Na mordida aberta anterior, as bordas incisais dos dentes anteriores pos suem Em razão da froux idão, a língua é projetada para frente (ceceio anterior) ou. 12 set. PLANEJAMENTO TERAPEUTICO EM M.O.. LAUREATE INTERNATIONAL UNIVERSITIES UNIVERSIDADE POTIGUAR – UnP. ESCOLA DA. ceceio é uma distorção na fala em decorrência de uma alteração na postura da A projeção pode ser anterior ou lateral e ocorre principalmente na produção.

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Occurrence of lisping in voiced and unvoiced fricatives in children with operated cleft lip and palate.

CECEIO – Definition and synonyms of ceceio in the Portuguese dictionary

Three Speech-Language-Pathologists judged perceptually audio recorded productions. There were significant differences between judgments for the fricatives [s] and [z], with higher prevalence of lisping in [s].

It is suggested that lisp is dependent of the phonetic-phonological context of the sentence and therefore must be considered for clinical and research purposes. Several studies report that occlusal alterations may cause disorders in the production of alveolar fricative consonants 1 – 6. Acoustically, voiced fricatives are characterized by the presence of two sources, the glottal source responsible for voicing and the noise source resulting from constriction of the vocal tractwhile unvoiced ceceoo are formed by ceceik single noise source 7.

Previous studies on individuals without craniofacial malformations indicated that occlusal changes may cause damage to the production of alveolar fricative consonants 18 – 12even though this relationship is not always observed 13 or even may not be directly related to the severity of occlusal alteration In general, the literature reports that, when the mandible is protruded in relation to the maxilla, the tongue may anterilr anteriorly positioned at rest, yielding changes in the airflow during production of alveolar fricatives, which would cause distortion in the production of these consonants.

In general, the literature evidences great interest in investigating the possible relationship between lisping and morphological alterations in the oral cavity in children with and without craniofacial deceio. Information on the acoustic and articulatory characteristics of voiced and unvoiced alveolar fricatives reported in naterior international literature indicate differences between these consonants, when produced by individuals with normal speech.

These acoustic descriptions indicate that voiced fricatives present lower intensity and shorter duration, as well as greater amplitude of friction interval compared to their unvoiced counterparts These differences are related with coupling of the glottal and frictional sources occurring in the production of voiced fricatives It is assumed that the vocal folds abducted during the production of cecwio fricatives allow a greater volume of ahterior to pass through the glottis toward the oral cavity.

Conversely, interruptions or restrictions of the airflow in voiced fricatives reduce the airflow volume and consequently the intensity of turbulence at the constriction point.

However, so far, it has not been investigated whether these acoustic characteristics may influence the auditory perceptual judgment of lisping in the speech of individuals with craniofacial malformations, making its identification less audible in voiced compared with unvoiced fricatives.

Also, articulatory descriptions resulting from electropalatography indicate differences between the production of alveolar fricatives [s] and [z] in cceeio with normal speech.

The literature reports that, in general, production of the fricatives [s] and [z] in normal conditions is characterized by lateral contact of the tongue along the palate, as well as incomplete contact of the tongue at the anterior portion of the alveolar ridge, yielding a groove at this region However, by electropalatography, investigators 21 have identified inter- and intra-individual variability in productions of [s] and [z] in adults with normal speech.

According to the investigators, a possible explanation for this difference would be the need of greater air volume for the production of [s], which would push the tongue laterally, in an attempt to create a wider passage for the airflow. Studies using magnetic resonance imaging also revealed differences in tongue positioning during the production of unvoiced and voiced fricatives. A preliminary study involving preschool children with malocclusion yet without craniofacial malformations indicated greater occurrence of lisping in fricative [s] compared with [z], when auditory perceptual judgment was used The hypothesis initially adopted in this study is that lisping, when present, presents differently in voiced and unvoiced fricatives, with greater occurrence for unvoiced compared with voiced alveolar fricatives.

Thus, this study investigated whether lisping, when present, differs between voiced and unvoiced alveolar fricatives produced by children with operated cleft lip and palate. This study was approved by the Institutional Review Board of the Hospital for Rehabilitation of Craniofacial Anomalies under protocol n.

This study had a prospective design in which speech samples saved in a databank, after selected, were judged by speech-language pathologists as to the occurrence of lisping in voiced and unvoiced fricatives. These samples were obtained from 32 children with operated complete unilateral cleft lip and palate, aged 6 to 11 years mean 8 years and 8 monthsof both genders.

Even though the Angle classification is among the most known and used for the evaluation of malocclusion in individuals without craniofacial malformations, this classification considers only the interarch tooth positioning in sagittal direction, besides being considered a qualitative rather than a quantitative malocclusion index This occlusal index has been applied in many craniofacial centers because it is reliable and easily reproduced; is able to distinguish the quality of intercenter surgical outcomes, allowing early diagnosis of dental arch relationship in both anteroposterior, vertical and transverse dimensions; and provides identification of the prognosis, which allows early changes in the surgical protocol without the need to wait up to the permanent dentition Conversely, score 5 is characterized by a negative overjet with buccally tipped incisors; b bilateral crossbite; and c poor maxillary dental arch morphology and palate anatomy Figure 2.


It should be emphasized that selection of occlusal scores 4 and 5 in this study was based on the greater involvement in expected interarch relationships poor or very poor prognosis in selected children, which might favor the identification of lisping in the fricatives of interest, whenever present. Note the poor interarch relationship with negative overjet and normal inclination of maxillary incisors, bilateral crossbite, tendency to open bite at the cleft area and face tending to Angle Class III, with evident maxillary deficiency.

Observe the very poor interarch relationship with markedly negative overjet, total crossbite, morphology of the maxillary dental arch and poor anatomy of the palate.

The face is excessively concave with very poor orthodontic-surgical prognosis. The study excluded children with history or presence of hypernasality, nasal air escape, weak intraoral pressure or compensatory articulation, at least to partially control the variables that might affect the identification of speech sound distortions.

None of the selected children had been submitted to orthodontic or orthopedic treatment before data collection. The speech productions analyzed were obtained from a databank. It was decided to use sentences with recurrence of the same phoneme, since this recurrence might favor the auditory perceptual identification of the presence or absence of speech distortion. This microphone was connected to an audio capture plate Sound Blaster Audigy 2 installed in a computer, in which the audio recordings were saved in files in WAV format, using the software Sony Sound Forge, version 8.

The recordings of interest for this study were edited using the same software Sony Sound Forge, version 8. The phrases produced by the 32 children were randomly stored in this DVD. Overall, phrases were initially selected for this study, being 64 corresponding to two consecutive repetitions of the phrase composed of fricative [s] and 64 corresponding to two consecutive repetitions of the phrase composed of fricative [z], produced by the 32 individuals.

Thereafter, judgments were independently performed by three speech-language pathologists experienced in the evaluation of speech disorders associated with cleft lip and palate, including those classified as dento-occlusal distortions, using the software Windows Media Player Microsoftin a personal computer and earphones.

The speech-language pathologists were asked to auditorily judge whether, during two consecutive repetitions of each phrase, at least one fricative segment inserted in these two repetitions was produced according to the target absence of lisping or if there was lisping i. At completion, a single judgment was obtained for each of the two consecutively repeated phrases, yielding a total of 64 judgments 32 related to the phrase composed of [s] and 32 related to the phrase composed of [z].

Examples of productions with and without lisping were offered to the speech-language pathologists before the study for calibration. After listening to each sentence, the speech-language pathologists indicated one alternative target or lisping for each speech sample analyzed, in a worksheet especially designed for that purpose. It should be highlighted that the speech-language pathologists were not asked to characterize the type of lisping, but rather to identify its presence or absence at least in one fricative segment that constituted each of the two phrases, based on the auditory judgment.

The judgments were then combined and a single judgment was obtained for each child, indicating the presence or absence of lisping in phrases with voiced and unvoiced fricatives, according to the agreement of most examiners. The binomial exact test was applied to verify differences between the employed categories of fricatives unvoiced x voiced produced by the total of children. Table 1 presents the occurrence of lisping in voiced and unvoiced alveolar fricatives in the children investigated.

When the judgments of lisping were compared between the fricatives produced, a significant increase in lisping was observed for the alveolar fricative [s] compared with the alveolar fricative [z]. In general, these findings indicate that dentofacial deformities favor the auditory perception of distortions lisping in the speech of children with operated cleft lip and palate, confirming previous descriptions for this population 15 These data confirm a previous study that revealed a lack of direct association between lisping and occlusal scores with variation in the degree of severity, i.

Goslon index between 1 and 5 during production of [s], when the auditory perceptual and visual simultaneous evaluations were used to investigate the speech of children mean age 8 years and 8 months with operated cleft lip and palate The present findings also agree with previous information in the literature 1014 for children without craniofacial malformations, in which lisping was not observed in all preschool children with malocclusion.

In these studies, the presence of morphological alterations malocclusion was considered a factor that favors the presence of lisping, yet it should not be considered determinant.

In general, the results observed for children with or without craniofacial malformations indicate that other factors, in addition to dentofacial alterations, should be considered when investigating the occurrence of lisping in the child population, including immaturity of the oral motor sensory system 26 ; reduced tongue tonus due to obstructive mouth breathing, in the case of cleft palate 27 ; sensorial differences due to tissue handling scars in the case of cleft lip and palate 28 and hearing losses frequently observed in the child population, especially those with history of cleft palate 29 Conversely, the possibility of efficient adaptation of children to the different structural conditions 31 may cause a less distorted speech, which would impair the auditory perception of lisping in the presence of facial deformity.


This study evidenced that the selection of fricative consonants interfered with the auditory perception of lisping, with greater occurrence of lisping in the alveolar fricative [s] compared to [z].

The same tendency was observed in a previous study involving preschool children with occlusal alterations, in whom lisping was more noticed for [s] in controlled speech conditions The greater occurrence of lisping in [s] based on the auditory perceptual evaluation may be explained by several factors.

First, acoustic descriptions indicate that voiced alveolar fricatives present lower intensity and duration than their unvoiced counterparts, due to coupling of the glottal and frictional sources It is assumed that the vocal folds abducted during production of unvoiced fricatives allow a greater volume of airflow to pass through the glottis toward the oral cavity. This may have contributed to the greater auditory identification of lisping in unvoiced alveolar fricatives.

Also, studies involving electropalatography indicate differences in lingual-palatal contact during the production of [s] and [z] in individuals with normal speech, with greater lingual-palatal contact in individuals with normal speech, with greater lingual-palatal contact for [z], as well as greater narrowing of the groove in [z] when produced at onset of the word Therefore, it may be suggested that articulatory differences between [s] and [z] may also occur in the presence of lisping, yet to a lower degree for [z], allowing greater auditory perception compared with [s].

Similar to electropalatography, data obtained by magnetic resonance imaging also indicated differences between unvoiced and voiced fricative consonants including alveolar fricativesproduced by North American adults with normal speech. This evaluation revealed a tendency of more anterior tongue root positioning in voiced fricatives compared to the unvoiced counterparts Considering the occurrence of differences in tongue root positioning between voiced and unvoiced fricatives in the production of normal speakers, this difference is also expected, though less marked, in the presence of lisping in which there is variability in the production of fricatives.

In general, comparison of the present findings with previous information is difficult due to the lack of studies in the national and international literature addressing the presence of lisping in individuals with cleft lip and palate.

However, a previous study involving preschool children with malocclusion yet without history of craniofacial malformations 19 revealed greater occurrence of lisping in [s] compared with [z].

Despite the different population preschool children without craniofacial malformationsthe findings of this preliminary study indicate the same tendency. Future studies are necessary to widen the knowledge on the presence of lisping in voiced and unvoiced fricatives in individuals with and without craniofacial malformations.

Therefore, it is observed that the fricative [s] favors the identification of lisping by the examiner and may be used both for screening and clinical speech evaluations. The results further indicate that words composed of unvoiced alveolar fricative may favor the onset of therapy because they allow greater perception of deviations in the productionwhile words composed of voiced alveolar fricative may be used at later periods, since they are syllable contexts that seem more difficult to monitor during therapy, because they minimize the auditory effect of lisping.

Also, selection of the phonetic-phonological context of the word may allow the patient a greater perception of lisping, which may favor the therapeutic process when searching for contrast between the presence and absence of this deviation in speech. In addition to the contributions derived from the present study, future investigations providing information on the production of unvoiced and voiced alveolar fricative consonants based on acoustic measurements may further expand the knowledge on the speech of children with lisping.

Previous studies demonstrated the importance of acoustic analysis to understand the pathological speech 22 The literature reports the importance of ultrasonography 32 and electropalatography 33 – 35 for better understanding of the pathological speech involving fricative consonants, including those related with cleft lip and palate The present findings suggest that unfavorable dentofacial conditions may favor the occurrence of lisping in voiced and unvoiced alveolar fricatives, when identified by auditory perceptual judgment.

This study also evidenced the influence of speech sample selection in the auditory perceptual judgment, since the fricative [s] tends to favor the identification of lisping when compared with its voiced counterpart [z]. In general, these findings present additional information on the influence of the phonetic-phonological context in the production and perception of alveolar fricative phonemes integrating the Brazilian Portuguese phonological system.

This information may contribute for clinical and research purposes in the field of orofacial motricity. Vertical interrincisal trespass assessment in children with speech disorders.

Correlations between malocclusions and dyslalias. Eur J Paediatr Dent. Rev Soc Bras Fonoaudiol. Speech defect and orthodontics: Universal parameters for reporting speech outcomes in individuals with cleft palate. Cleft Palate Craniofac J. Relationship between occlusion and lisping in children with cleft lip and palate. Kent RD, Read C. The acoust analysis of speech.

Meaning of “ceceio” in the Portuguese dictionary

Singular Publishing Group; The Goslon Yardstick in patients with unilateral cleft lip and palate: Cleft Palate Craniof J. Nasal airway dimensions of adults with cleft lip snterior palate: Abnormal patterns of tongue-palate contact in the speech individuals with cleft palate. A study of speech, language, hearing, and dentition in children with cleft lip only.