1292
EVALUATION OF HARD PALATE DEPTH: CORRELATION
BETWEEN QUANTITATIVE AND QUALITATIVE METHOD
Avaliação da profundidade do palato duro:
correlação entre método quantitativo e qualitativo
Camila Mulazzani Maria (1), Ana Maria Toniolo da Silva (2), Angela Ruviaro Busanello-Stella (3),
Geovana de Paula Bolzan (4), Luana Cristina Berwig (5)
ABSTRACT
Purpose: to investigate the correlation between quantitative and qualitative methods of hard palate
depth evaluation. Method: 74 children participated in this study. They were in mixed dentition phase
and were evaluated by speech therapist and dentist, who made the plaster models of maxillary dental
arch used later for measure. The quantitative method was measurement of molar distance and molar
depth whose values were used to calculate the Palatal Height Index. The hard palate was classified
into low medium and high palate. Qualitative analysis was performed through visual inspection of
the plaster models by three speech therapists with experience in Orofacial Myology. The depth of
hard palate was classified as low, normal or increased. The result was the consensus of at least two
evaluators. For Data analysis the frequency of ratings was investigated and the Gamma Correlation
Test was applied. Results: qualitative method: medium palate (55,4%) followed by low palates (39,2%)
and high palate (5,4%). Quantitative method: high palates (51,4%) followed by medium palate (43,2%)
and low palates (5,4%). The Gamma Correlation Test resulted in 0,6212 (p<0,05) which indicates
moderate correlation. Conclusion: the correlation between quantitative and qualitative methods of
hard palate assessment was moderate. There was a trend in the qualitative evaluation to consider the
palates deeper than the quantitative method. Therefore, it is suggested that both forms of analysis to
be used in clinical practice.
KEYWORDS: Hard Palate; Evaluation; Measures; Morphology; Speech, Language and Hearing
Sciences
INTRODUCTION
The hard palate is the bony structure that forms
the division between the oral and nasal cavities1 and
maintains a close relationship with the functional
orofacial activities2-5.
The harmonious growth of the face and the
proper development of breathing, sucking, chewing,
(1)
Speech Language Pathologist graduated from the Federal
University of Santa Maria – UFSM, Santa Maria, Rio
Grande do Sul, Brazil.
(4)
(2)
Speech Language Pathologist, Professor from the
Department of Speech Language Pathology at the Federal
University of Santa Maria – UFSM, Santa Maria, Rio Grande
do Sul, Brazil; PhD in Human Communication Disorders by
the Federal University of São Paulo – UNIFESP.
Speech Language Pathologist, Master in Human
Communication Disorders by the Federal University of
Santa Maria – UFSM; PhD Student of the Postgraduate
Program of Human Communication Disorders, University
of Santa Maria – UFSM, Santa Maria, Rio Grande do Sul,
Brazil.
(5)
Speech Language Pathologist, Master in Human
Communication Disorders at the Federal University of Santa
Maria – UFSM; member of the Multidisciplinary Residency
Program in Management and Integrated Hospital Care
from the Public Health System, Federal University of Santa
Maria – UFSM, Santa Maria, Rio Grande do Sul, Brazil.
(3)
Speech Language Pathologist, Master in Human
Communication Disorders by the Federal University of
Santa Maria – UFSM; PhD Student of the Postgraduate
Program of Human Communication Disorders, University
of Santa Maria – UFSM, Santa Maria, Rio Grande do Sul,
Brazil.
Rev. CEFAC. 2013 Set-Out; 15(5):1292-1299
Conflict of interest: non-existent
Correlation between palate assessment
swallowing and speech depend on the balance
of the hard palate with the other structures of the
sensory-motor-oral system3,6,7, because the hard
tissues are closely related to function8.9.
The configuration of bone structures is genetically determined, but susceptible to the molding
action of the orofacial muscles. As the function
can adapt to the presence of altered shape, bone
structure can also be altered by inappropriate usual
positioning of the soft tissue in the performance of
a specific function and the moments of inactivity.
Accordingly, the detailed assessment of anatomical
structures helps in understanding the changed
functional behavior10.
Morphological analysis of the hard palate is
characterized as an important part of the evaluation
of Orofacial Motricity, it contributes to the structuring
of a therapeutic plan with strategies, prognosis
and appropriate referrals. When the depth of this
structure is altered, it can be expected that oral
functions and/or breathing will be impaired to a
greater or lesser degree4.
The qualitative method of evaluation of the
hard palate, i.e. intraoral visual inspection currently
shows up as the most used in clinical examination,
but without standardizing for the normal parameters or naming for their classification 3-5. In order
to enhance reliability of data of the miofunctional
examining it can be observed a trend of studies
in the area in suggesting methods for quantitative
analysis of combined data measured in qualitative
evaluation 5,11-14.
Obtaining these dimensions of the hard palate
can be performed by measuring with tridimensional
orthodontic compass (Korkhaus) in casts15 or in the
oral cavity of the patient16,17; through 18 millimeter
ruler; scanned tridimensional measurement19, or a
caliper in plaster models4,13,14,20.
The present study aimed to investigate the correlation between quantitative and qualitative methods
of evaluation of the depth of the hard palate.
METHOD
This study is characterized as quantitative and
transversal21.
The sample consisted of 74 children of both
genders, aged from seven to 11 years and 11
months old whose dentition present the first molars
erupted, classified as mixed. We excluded those
who had a history of speech therapy, previous and/
or current facial orthodontic and/or orthopedics,
as well as signs of neurological impairment and/
or syndromes, cognitive limitations or craniofacial
malformations.
In order to ascertain the suitability criteria for
inclusion and exclusion anamnesis was held with
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those responsible for the children. In this interview
it contained questions regarding the identification of
the subject, historical development, general health,
diet, oral habits, sleep, and previous treatments
and/or current.
It was also carried out a visual inspection of the
sensory-motor-oral system, in which there was the
usual positioning of the lips, tongue and jaw, as well
as the predominant breathing mode, according to
the protocol used at the home institution.
Subsequently, subjects underwent dental evaluation. The dentist noted teething period, dental
conservation, presence or absence of midline
shift and occlusal changes, as well as casted the
maxillary arch molding of children.
Later, the casts were properly identified and
those that did not allow visualization of the midline
palatal or all erupted teeth were replaced by a new
model. They served as the basis for both the quantitative assessment as to the qualitative.
In molding the maxillary dental arch trays were
used for printing polyamide orthodontic (Morelli ®)
and normal alginate setting type II (Seaweed
Gel ®), and type plaster cast stone to the roof of the
hard palate and plaster type for extra padding. This
process was conducted in a room with natural and
artificial lighting. The children remained seated with
hips, knees and ankles flexed at 90 degrees and
head driven Frankfurt plane.
Quantitative evaluation of the depth of the hard
palate
For this work it was considered that only the
aspect depth of the hard palate, since the plaster
models do not permit the viewing anthropometric
estafilino point necessary for measuring the length
of the hard palate and further obtaining of the index
width Palatine22.
Quantitative evaluation of the depth of the hard
palate was performed by obtaining the Palatine
Height Index, proximate relationship between the
height and width palate which classifies this structure
as camestafilino (low palate), ortoestafilino (medium
palate) or hipsiestafilino (high palate) 20.22.
To obtain this index was necessary to measure
the width and depth of the hard palate to the level
of the first molars20, with a digital caliper brand
Western ®, with a resolution of 0.01 mm and
accuracy of ± 0.02 mm, calibrated after each
measurement.
To measure the width of palatal landmarks were
marked on the plaster models at the level of the first
molars in the region corresponding to the union of
the edge palatal gingival sulcus20. The width corresponded to the palate transverse distance in millimeters between the points previously established
(Figure 1).
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Maria CM, Silva AMT, Busanello-Stella AR, Bolzan GP, Berwig LC
From these measurements we calculated the
index Palatine Height 20.22 according to the formula
below.
Index of Palatine’s Height = Palatine height x 100
Palatine width
The classification of the height/depth of the
palate was given by inserting the result of the calculation in one of the following tracks:
• Camaestafilino (low palate): values less than or
equal to 27.9 mm;
• Ortoestafilino (medium palate) values between
28.0 mm and 39.9 mm;
• Hipsiestafilino (high palate): values above 40.0
mm.
Figure 1 – Palate Width
To measure the height of the palate it was cut
a stainless steel wire with a length corresponding
to the transversal measurement (width of the hard
palate) and secured with red wax at the edges of the
gingival sulcus of the first molars. This wire served
as a support for the sliding of the rod of the caliper
for measuring the depth (Figure 2). The height corresponded to the palate as the perpendicular distance
between the palate and stainless steel wire, which
subtracted 0.05 mm, corresponding to the diameter
of the steel wire13.
Figure 2 – Palate Height
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The measurement of the height and width palate
was performed by a single researcher, who after 30
days from the first evaluation performed again the
measures in 30% of randomly chosen models to
verify the agreement between the first and second
measurement by calculating the intraclass correlation coefficient (ICC). The results showed significant correlation between the two measures for all
measurements of the hard palate.
Qualitative assessment of the depth of the
hard palate
The qualitative assessment of the depth of the
hard palate was performed by three experienced
Speech Language Pathologist in Orofacial Motricity,
through visual inspection of the 74 plaster models.
Similarly, as in the quantitative assessment, it was
analyzed only the deep aspect of the hard palate.
The three evaluators underwent prior visual
training conducted in joint way23, in order to
standardize the qualitative assessment that
considers the deep aspect of the hard palate
decoupled from other parameters such as width, as
proposed in the recent literature5,12,13. To this eight
plaster models were randomly selected training,
which constitutes approximately 10% of the sample.
In this step, the depth of the hard palate was
rated as low, normal or increased12 respectively
corresponding to the low, medium and high palate.
A visual inspection of the models and the marking
of the evaluation sheet were undertaken by three
evaluators concurrently but independently on the
presence of the researcher in charge. None of the
evaluators had access to the results of the quantitative method and the other evaluators.
As a result of qualitative assessment of each
model it was considered the predominant responses,
i.e. the concurrence of at least two evaluators. In
cases where there were three discordant responses
Correlation between palate assessment
it was considered consensus of the three examiners
after reevaluation24,25.
It is part of the research project approved by the
Ethics Committee of the Federal University of Santa
Maria, under number 0220.0.243.000-08. All participants had the Term of Free and Informed Consent
signed by the guardians.
Data analysis found the frequency of palates
considered low, medium and high in both evaluation methods and used the Gamma Correlation
Test, applied through the software Statistica 9.0,
1295
to obtain the value of the correlation between the
quantitative and qualitative methods, and values of
γ from 0 to 0.3 indicate weak correlation, from 0.3 to
0.7 indicate moderate correlation and values from
0.7 on indicate strong correlation.
RESULTS
Figure 3 shows the relative frequency of classifications of low, medium and high palate through
quantitative and qualitative methods of evaluation.
Figure 3 – Relative distribution of the frequency of the results of quantitative and qualitative methods
for assessing the depth of the hard palate
Table 1 shows the concordant and discordant
results of the classification of the depth of the hard
palate as to the results of quantitative and qualitative
methods of evaluation.
Table 2 explains the result of the correlation
between the two methods of assessing the depth
of the hard palate. The gamma value (γ) obtained
classifies this correlation as moderate.
Table 1 – Absolute and relative values for the intersection of the results of quantitative and qualitative
assessments of the depth of the hard palate
Quantitative method
Low palate (n=29)
Medium palate (n=41)
High/Deep palate (n=4)
Low palate
n
%
3
10,34
1
2,44
0
0,00
Qualitative method
Medium palate
n
%
17
58,62
15
36,59
0
0,00
High palate
n
%
9
31,03
25
60,98
4
100,00
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Maria CM, Silva AMT, Busanello-Stella AR, Bolzan GP, Berwig LC
Table 2 – Correlation between quantitative and qualitative methods to assess the depth of the hard
palate
Quantitative method
Qualitative method
γ*
0,6212
p
0,0007
* Index correlation by Gamma Correlation Test
p - significance level by Gamma Correlation Test (p <0.05)
DISCUSSION
Quantitative methods of evaluation in Orofacial
Motricity are increasingly suggested26 in order to
standardize the results, establish normal parameters and change, as well as standardize the classifications. Although the measurement of the hard
palate casts is considered a reliable method4.27,
there is disagreement as to the instruments and the
reference points used for measuring4,5,14,15.
In clinical practice it is observed that almost all
professionals use the qualitative method for evaluation of the hard palate, due to the convenience, low
cost and even the lack of knowledge of other forms
of analysis. The reliability of the qualitative method,
however, can be questioned, as the training and
experience of the evaluator are factors that influence
the analysis.
It is apparent, therefore, that the heterogeneity
evaluation methods of the hard palate as well as the
classification of this structure4,5 limit the diagnostic
of change and consequently the interdisciplinary
treatment plan and labor.
By comparing the quantitative and qualitative
methods for assessing the depth of the hard palate,
it was found that there was no full equivalence of the
results (Figure 3). Whereas the quantitative method
is shown to be more reliable, these data demonstrate that the forms of analysis are complementary
and not substitutes.
By the quantitative method it was found a higher
frequency of medium palates, followed by low and
high palates. Yet, in the qualitative assessment
audiologists felt that there were more high palates,
followed by medium and low.
The morphology of the hard palate is related
to the growth pattern of the face. In subjects with
medium facial type the depth of the palate tends to
show itself as medium28.29, in balance with other oral
structures. Thus, the medium hard palate hardly
entails functional impairment, being considered
normal. Similarly, the hard palate classified as low,
which is typically observed in individuals with short
face28,29, it may not significantly alter the vertical
dimension of the oral cavity as to induce adaptations of oral functions. The results of this study show
Rev. CEFAC. 2013 Set-Out; 15(5):1292-1299
that most palates classified as low by quantitative
method were considered average in the qualitative
evaluation, which possibly indicates a difficulty in
classifying the evaluative aspect alone and in depth
casts.
On the other hand, all palates classified as high
by quantitative method received the same rating in
the qualitative evaluation, seeming to be the most
easily identified morphology in visual inspection.
The hard palate with increased depth is characteristic of individuals who have long facial types28,29
and most frequently induces adaptations of breath,
chewing, swallowing and speech, as the increased
vertical dimension complicates the accommodation of this language structure both at rest and
in the execution of functions. Besides genetic
characteristics, two important factors contribute to
the increasing depth of the hard palate, which are
predominantly oral breathing mode and prolonged
sucking habits5,13,14.
Mouth breathing induces morphological change
by not allowing the tongue to exert its expander
action on the hard palate as to allow the entry of
air into the airway to keep open lips and tongue at
the floor of mouth30.31. The absence of a negative
pressure in the nasal cavity prevents the lowering
of the palate and the action of other bones and
muscles of the face assists in compressing the
outer maxillary dental arch, so that growth is more
pronounced in the vertical20.32. Mouth breathing
alters the vertical and transverse dimensions of the
hard palate mainly in the posterior hard palate5,13-16.
Oral habits cause atresia of the maxillary
dental arch, and the change is often reported as
the pressures of maintaining the habit alter the
morphology of the bone bases33.34. Children with
non-nutritive sucking habits have hard palate deeper
and narrower in anterior regions14.
The results presented also demonstrate that
there was a tendency of evaluators to rank the
palates as higher than they actually were. By the
qualitative method most of the low palates were
considered medium and the medium palates were
considered high. It was noted, therefore, that the
qualitative analysis diagnosed more morphological
Correlation between palate assessment
changes of the hard palate in regards to the increase
in the vertical dimension.
It is stressed that this diagnosis is extremely
important for establishing the correct behavior. In
cases where the hard palate presents high, there
may be some limitations to the therapeutic process,
such as difficulty in accommodating the palatal
papillae on the tongue to provide auxiliary nasal
breathing and swallowing33.35; articulation disorder,
once the hard palate supports the execution of rapid
and complex movements of the tongue36, among
others. In such cases the most appropriate action
is to refer patients for orthodontic evaluation, aiming
anatomical suitability prior to miofuncional therapy.
The correlation between the quantitative and
qualitative methods for assessing the depth of the
hard palate was moderately positive (Table 2),
which means that the results of both analyzes are
configured in a directly proportional manner.
Thus, it is indicated that in clinical practice the
two methods are used to evaluate the hard palate
as complementary for the diagnosis of morphological changes. While the quantitative analysis
provides a pre-established classification according
to numerical values, the qualitative considers the
relationship of structure to the soft tissues as well as
in the performance of orofacial functions.
The interdisciplinary approach of Speech
Language Pathology with orthodontics is essential
in cases of Orofacial Motricity. As the plaster
models are traditionally used by orthodontists for
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assessment of the occlusal without interference
from soft tissues of the mouth, the Speech Language
Pathologist can have in these devices a possibility of
analysis of the maxillary dental arch model to obtain
the measurements of the hard palate. It requires
integration among professionals, as it implies the
orthodontist providing orthodontic documentation
pertaining to the patient, including plaster models
for the analysis of the Speech Language Pathologist
and the discussion between them, with consequent
coordination of behaviors.
Some disadvantages are pointed out to the
use of the plaster cast of the dental evaluation, the
need for adequate space for storage and the risk of
breakage, even though they are indispensable as a
diagnostic means27, 37. We indicate that the Orofacial
Motricity professionals start considering the quantitative method and shared use of plaster models in
the clinic so that the evaluation of the hard palate
begins to establish itself as an evidence-based
practice.
CONCLUSION
The correlation between quantitative and qualitative methods to assess the depth of the hard
palate was presented as moderate.
The presented data showed that there was a
trend in the qualitative assessment to consider the
palates deeper than what the quantitative evaluation method.
RESUMO
Objetivo: verificar correlação entre método quantitativo e qualitativo de avaliação da profundidade do
palato duro. Método: participaram da pesquisa 74 crianças, com dentição mista, submetidas à avaliação fonoaudiológica e odontológica que incluiu moldagem do arco dental maxilar para confecção
dos modelos de gesso usados para posterior mensuração. Para análise quantitativa mediu-se largura
e profundidade do palato duro ao nível dos primeiros molares, cujos valores foram utilizados para o
Índice de Altura Palatina. Assim, os palatos duros foram classificados em baixo, médio ou alto. A avaliação qualitativa foi efetuada por inspeção visual dos modelos de gesso por três fonoaudiólogas com
experiência em Motricidade Orofacial. A profundidade dos palatos duros foi classificada em reduzida
(palato baixo), normal (palato médio) ou aumentada (palato alto). Como resultado considerou-se o
consenso de ao menos duas avaliadoras. Para análise dos dados verificou-se a frequência de classificações e aplicou-se o Teste de Correlação Gamma. Resultados: a partir da avaliação quantitativa
observou-se maior frequência de palatos médios (55,4%), seguidos de palatos baixos (39,2%) e
palatos altos (5,4%). Pelo método de avaliação qualitativo a maioria dos palatos duros foram considerados palatos altos (51,4%), seguidos de palatos médios (43,2%) e palatos baixos (5,4%). Teste de
Correlação de Gamma resultou em 0,6212 (p<0,05), indicando correlação moderada. Conclusão: a
correlação entre os métodos de avaliação da profundidade do palato duro apresentou-se moderada.
Na avaliação qualitativa houve tendência em considerar os palatos mais profundos do que indica o
método quantitativo. Sugere-se que ambas as formas de análise sejam utilizadas na prática clínica.
DESCRITORES: Palato Duro; Avaliação; Medidas; Morfologia; Fonoaudiologia
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Received on: January 20, 2012
Accepted on: May 22, 2012
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Rev. CEFAC. 2013 Set-Out; 15(5):1292-1299