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There are many causes of impaired velopharyngeal valving that may occur in combination both in the presence and in the absence of overt or submucosal clefts of the palate. Moreover, there is a wide spectrum of severity of velopharyngeal dysfunction, and it is important to understand that such may be but one of several communication disorders that may contribute to impaired speech intelligibility in any given patient. Optimization of surgical outcome in each patient, therefore, requires both precision in diagnosis and careful selection of surgical technique.

There is certainly reason to be optimistic that we will come closer to making reasonable decisions about the best timing for palatal surgery, taking into account both maxillofacial growth and speech development. More options are now available in terms of surgical techniques that may help to protect growth. Significant palatal scarring and its subsequent effects on growth are not inevitable consequences just because palatal surgery is carried out early enough to protect normal communication development. With all the advances in physical management of clefts, the expectation for every otherwise-normal child should be normal speech development.

The prosthetic treatment of certain patients with cleft palate is an important part of the multidisciplinary approach to solving the many problems related to total health. Some of the cleft palate patients for whom speech aids can be made include those with a wide cleft of the palate with a deficiency of the soft palate, a wide cleft of the hard palate with a high vomer, a neuromuscular deficit (a sphincteric velopharyngeal action may not be attained even with a pharyngoplasty if the deficit is marked), and surgical failures. I strongly object to the use of remote extraoral flaps in cleft palate surgery, because a prosthesis seems to be more appropriate. The possibility of cancer being related to such a prosthesis is quite remote, and there has been no evidence of increased hearing loss in patients wearing a prosthesis. A prosthesis should not be used in a patient not competent to care for it or maintain proper hygiene. A prosthodontist engaged in treating patients with oral, facial, and speech deficits should be thoroughly familiar with the anatomic and physiologic deviations of the region involved and with the basic principles involved in prosthetic dentistry. He should always be willing to acquire further knowledge in this field.