双侧上颌骨部分缺损义颌修复前外科准备

:目的　阐明颧颊翼咽鼻突义颌修复双侧上颌骨部分缺损前的外科准备。方法　对 1992年以来的 7例患者实施了修复前外科手术 ,所有病例均存留部分上颌骨颧突及颧骨上颌突 ,进行口鼻道成形术以利于义颌前方固位 ,必要时在腭部行就位道成形术以利于义颌后方固位 ,在颧颊部进行颧颊承力区成形术为义颌创建承力支持部位。结果　各类手术均获得满意效果 ,术后义颌修复使病人的外形和咀嚼及发音等功能均有所改善。结论　颧颊翼咽鼻突义颌修复以部分硬腭存留和软腭保持连续者修复效果较好 ,而且可利用颧骨上颌突和上颌骨颧突的残留部分提供承力     

Prosthetic management of pharyngeal flap-related snoring.

OBJECTIVE: The obturating pharyngeal flap used in correcting velopharyngeal insufficiency has been implicated in creating difficulty in nasal breathing for some patients and/or in causing hyponasal speech, obstructive sleep apnea, and snoring. This is a case report of an individually designed removable prosthesis that positions an acrylic tube through each port lateral to the pharyngeal flap, with the goal of preventing the collapse of the ports during sleep and the consequent snoring. DESIGN: The acrylic tubes maintain an opening through both lateral ports preventing the soft tissues of the lateral walls from vibrating against the pharyngeal flap (causing the snoring sound) and allowing nasal breathing. RESULTS: The acrylic tubes effectively eliminated the patient's problem of snoring. CONCLUSIONS: This case study demonstrates that snoring associated with a pharyngeal flap can be controlled prosthetically by maintaining an opening through the two lateral ports, preventing the soft tissues of the walls of the lateral ports from vibrating against the flap.     

Silicone nasal prosthesis retained by an intranasal stent: A clinical report

Nasal defects after tumor excision can leave a patient functionally and esthetically impaired. Loss of nasal septal cartilage support causes the soft tissue to collapse or undergo stenosis, further compounding the problem. Intranasal stents can be used to maintain the patency of such nasal defects. This clinical report describes the use of an acrylic resin nasal stent bonded to a silicone nasal prosthesis to rehabilitate a patient with a nasal defect.     

Primary palatorraphy in the adult cleft palate patient. Surgical, prosthetic and logopaedic aspects

The treatment of 8 adults with untreated cleft palates is retrospectively discussed. A palatorraphy, consisting of a palatoplasty with pedicled palatal mucoperiosteal flaps and an intravelar veloplasty, is performed. A rib graft between the nasal and oral layer and a partial vestibuloplasty are used in a few patients to create a more favourable anatomical situation for the prosthetic appliance. The palatorraphy contributes to improved speech intelligibility however, combined with a pharyngeal flap as performed in 5 patients, an even better result can be achieved. According to the results, a surgical procedure in the adult still seems to be worthwhile.     

Three-Dimensional Comparison in Palatal Forms Between Modified Presurgical Nasoalveolar Molding Plate and Hotz's Plate Applied to the Infants With Unilateral Cleft Lip and Palate

The presurgical nasoalveolar molding plate appliance with stent (PNAM) extended from the palatal molding plate; to correct the nostril shape of infants with cleft lip and palate is well known. The PNAM appliance is based on the finding that a high degree of plasticity is maintained in the cartilage of infants during the first 6 weeks after birth. However, on the current PNAM protocol described by Grayson et al. the nasal stent is supposed to be an adjunct to the palatal molding plate after reducing the severity of the alveolar cleft width. We have used the modified Hotz's plate from the setup model and built up the nasal stent even before reducing the severity of the alveolar deformity. In this study we assess the effects of the modified Hotz's plate and the modified PNAM appliance for the alveolar and palatal form. The lateral deviation of the incisal point, the width of the palatal cleft, and the degree of curvature of the palatal vault were first evaluated on plaster models. The PNAM group is smaller on the lateral deviation of the incisal point than the modified Hotz's group. The decreased average width of the palatal cleft and curvature of the palate, was almost the same in both the modified Hotz's and PNAM groups. In comparison with the modified Hotz's plate, the modified PNAM appliance also improves the molding of the alveolar segments and reduces cleft width.     

A different design of palatal lift appliance: review and case reports

The problems of velopharyngeal incompetence and its treatment by a prosthetic device, the palatal lift appliance, are discussed. A new design of appliance and the technique for its fabrication is described in detail. Four case reports are given.
This design appears to have definite advantages over previously described designs, not the least of which is the simplicity of its fabrication both in the clinic and the laboratory.     

Morphological evaluation of changes in velopharyngeal function following maxillary distraction in patients with repaired cleft palate during mixed dentition.

OBJECTIVE: To describe the morphological changes of nasopharyngeal components after maxillary distraction and clarify whether the morphological characteristics are related to velopharyngeal function (VPF). DESIGN: Perceptual judgments of hypernasality and nasendoscopy were performed before and after treatment. Lateral cephalograms were obtained to describe the morphological changes. SETTING: Department of Oral and Maxillofacial Surgery, Miyazaki Medical College, Miyazaki, Japan. PARTICIPANTS: Nine patients with repaired cleft palate in the mixed dentition stage underwent maxillary distraction using a face mask and an intraoral fixed appliance system. OUTCOME MEASURES: The severity of hypernasality, velopharyngeal insufficiency, and measurements such as pharyngeal depth, velar length, and the rotation of the palatal plane were evaluated. RESULTS: Increase in pharyngeal depth was not always proportional to the amount of advancement. It depended on the posture of the posterior pharyngeal wall and the rotation of palatal plane. CONCLUSION: Cephalometric measurements of the nasopharynx before and after surgery confirmed subsequent changes in VPF. These were suggested to be useful in predicting future VPF. When performing maxillary distraction in patients with cleft palate in the mixed dentition stage, and when velopharyngeal closure is found to occur by velar contact against the hypertrophied adenoid, patients should be counseled about risks of subsequent deterioration in their speech before surgery.     

Interim palatal lift prosthesis as a constituent of multidisciplinary approach in the treatment of velopharyngeal incompetence

The velopharynx is a tridimensional muscular valve located between the oral and nasal cavities, consisting of the lateral and posterior pharyngeal walls and the soft palate, and controls the passage of air. Velopharyngeal insufficiency may take place when the velopharyngeal valve is unable to perform its own closing, due to a lack of tissue or lack of proper movement. Treatment options include surgical correction, prosthetic rehabilitation, and speech therapy; though optimal results often require a multidisciplinary approach for the restoration of both anatomical and physiological defect. We report a case of 56 year old male patient presenting with hypernasal speech pattern and velopharyngeal insufficiency secondary to cleft palate which had been surgically corrected 18 years ago. The patient was treated with a combination of speech therapy and palatal lift prosthesis employing interim prostheses in various phases before the insertion of definitive appliance. This phase-wise treatment plan helped to improve patient''s compliance and final outcome.     

Prosthetic Rehabilitation of Postsurgical Nasomaxillary Hypoplasia for a Patient Following Reconstructive Surgery: A Clinical Report

Repairs of the cleft nose, lip, and palatal deformity remain challenging endeavors for reconstructive surgeons. Postsurgical nasomaxillary hypoplasia is a common finding in patients with extensive clefts. This complex deformity has a pronounced impact on the social behavior and self image of the subject. Esthetic and functional rehabilitation of this postsurgical defect is scarcely reported in the literature. Support in the form of prostheses or stents to prevent tissue collapse is usually required in these patients following surgery. This clinical case presentation discusses the fabrication of an internal nasal stent for a cleft nose, lip, and palate patient following surgical reconstruction. Two prostheses using two prosthetic materials (Polymethyl methacrylate, flexible resin) were prepared to compare their efficacy. The final prostheses improved the patient's appearance, making the postsurgical defect less conspicuous.     

Effect of placement of a speech appliance on levator veli palatini muscle activity during speech.

OBJECTIVE: The purposes of this electromyographic study were to examine whether levator veli palatini muscle activity during speech can be changed with placement of a speech appliance and to clarify whether or not the change is related to the type of speech appliance used. DESIGN: Electromyography (EMG) was performed during production of speech samples in two conditions: with placement and with removal of a speech appliance. Speech samples were the vowel /omega/ and consonant-vowel (omega) syllables, including nasal, plosive, fricative, and affricate consonants. SETTING: Division for Oral-Facial Disorders, Faculty of Dentistry, Osaka University Dental Hospital, Japan. PARTICIPANTS: Subjects were six patients with repaired cleft palate and velopharyngeal inadequacy (VPI); three routinely wore a palatal lift prosthesis to correct borderline VPI, and the other three wore a speech appliance hybrid that consisted of a pharyngeal bulb and a palatal lift. INTERVENTIONS: Each patient was asked to produce each speech sample in both conditions of placement and removal of their respective appliances. MAIN OUTCOME MEASURES: Smoothed EMG signals of the levator veli palatini muscle were recorded with and without the appliance during five repetitions of each speech sample. The average value of peak smoothed levator EMG was compared between placement and removal conditions for all subjects and between the two subject groups in each experimental condition. RESULTS: With a speech appliance in place, the range of levator activity was distributed in a portion lower than that in the removed condition for subjects in both appliance groups. In addition, the intervals were smaller in the placement condition than in the removed condition. CONCLUSION: A speech appliance may prevent hypernasality, nasal emission of air, or both associated with VPI because of mechanical obturation of the velopharynx and an alteration in velopharyngeal function.     

Prosthetic Management of Post Surgical Nasal Skin Graft Contracture

The sequelae of trauma to the nose include nasal deformity and nasal obstruction that can have a long term negative impact on patient’s quality of life. Successful management of posttraumatic nasal obstruction relies on a detailed history, careful analysis, and accurate diagnosis. Treatment must balance the seemingly disparate goals of re-establishing structure, improving contour and esthetics, as well as restoring the nasal airway. Indications and technical steps for fabricating bilateral nasal stents are presented, for a case of surgical opening of bilateral nasal synechia necessitated due to failed initial corrective surgery, post contracture and collapse of skin grafts. The objective of nasal stent was to maintain patency of nasal passage post surgical intervention. This is achieved by support to graft and residual tissues and prevention of mouth breathing. The nasal stents were modified post insertion at regular intervals to ensure adaptation to changes in mucosal lining of nasal.     

上颌快速扩弓联合前方牵引治疗骨性Ⅲ类错牙合畸形对上气道影响的锥形束 CT 分析

目的：研究上颌快速扩弓联合前方牵引治疗骨性Ⅲ类错(牙合)畸形对上气道影响的三维变化。方法：选择53例伴上颌骨横向发育不足的骨性Ⅲ类错(牙合)畸形患者。所有患者先采用 Hyrax 矫治器进行上颌快速扩弓,然后前方牵引矫治。平均扩弓16 d,前方牵引平均5个月。分别于扩弓前（T0）、扩弓结束时（T1）及前方牵引结束时（T2）拍摄锥形束 CT 并进行三维重建和测量。结果：扩弓结束时鼻咽段最小截面积、最小截面积处冠状径和鼻咽段容积显著增大（P ＜0．05）;前方牵引矫治后鼻咽段4项指标与扩弓治疗前相比明显增大（P ＜0．05）。结论：上颌骨快速扩弓联合前方牵引可显著增加鼻咽段上气道容积。     

Modified nasal alveolar molding appliance for management of cleft lip defect

Nasal alveolar molding is used effectively to reshape the nasal cartilage and mold the maxillary arch before cleft lip repair and primary rhinoplasty. It provides aesthetic and functional benefits of nasal tip and alar symmetry and improved dental arch form. At The Craniofacial Center at the University of Illinois at Chicago, the authors have developed a modification of a nasal alveolar molding appliance previously described in the literature. The key modification is the use of an orthodontic wire from the palatal prosthesis with an acrylic bulb positioned inside the nose, underneath the apex of the alar cartilage, as the nasal stent. This modification allows easier adjustment of the position of the bulb during treatment to achieve a more symmetrical relationship between the nasal cartilages, columella, philtrum, and alveolar segments.     

Velopharyngeal changes after maxillary advancement in cleft patients with distraction osteogenesis using a rigid external distraction device: a 1-year cephalometric follow-up

The effect of maxillary advancement on speech may have benefits on articulation improvement but compromises velopharyngeal (VP) closure by increasing the nasopharyngeal distance. The purpose of this study was to evaluate the static VP anatomic changes on lateral cephalograms in patients who underwent maxillary advancement through distraction osteogenesis (DO) with a rigid external distraction device and to correlate these changes with clinical speech data. Twenty-two patients (5 female and 17 male) underwent maxillary advancement through DO utilizing a rigid external distraction device (age, 5.2 to 25.7 years) with various diagnoses, including 13 unilateral cleft lip and palate (CLP) patients, 5 bilateral CLP patients, 1 isolated cleft palate patient, 2 facial cleft patients, and 1 patient with craniosynostosis. Lateral cephalograms of preoperative, immediate postdistraction, and 1-year postdistraction were obtained for analysis. Speech evaluation was performed preoperatively, immediate postdistraction, and then at 6-month intervals, and included assessment of air pressure flow, hypernasality, and articulation. With an average amount of 8.9 mm maxillary forward advancement, 14% of patients (3 of 21) presented deterioration in hypernasality. However, 57% of patients (12 of 21) demonstrated improvement in articulation. The cephalometric analysis demonstrated an increase in nasopharyngeal depth by 8.5 mm (1:1 ratio with bony movement) and velar angle by 14.1 deg. The length of the soft palate remained unchanged. The need ratio (intersection of palatal plane and posterior pharyngeal wall-posterior nasal spine/posterior nasal spine--tip of uvula) worsens after distraction. The deterioration of hypernasality was related to the amount of forward distraction, especially in patients without a preexisting pharyngeal flap (PF). Speech evaluation is an important aspect concerning treatment planning for maxillary distraction. The increase in nasopharyngeal depth may compromise VP closure. The increase in velar angle was considered to be part of the compensation in the VP mechanism. An adverse effect of a preexisting PF on maxillary distraction was not observed; however, it prevented postoperative hypernasality.     

Effect of placement of a speech appliance on levator veli palatini muscle activity during blowing.

OBJECTIVE: We have observed clinically that some speakers wearing a speech appliance for correction of velopharyngeal incompetence can blow with variable intensity without nasal air escape. This clinical finding suggests that tightness of velopharyngeal closure may be regulated in accordance with oral air pressure during blowing. The purposes of this electromyographic study were (1) to examine whether levator vell palatini muscle activity can be changed in relation to oral air pressure during blowing when the speech appliance is removed, (2) to clarify whether or not the change is related to the severity of velopharyngeal incompetence, and (3) to examine whether placement of a speech appliance can alter levator muscle activity into the equivalent of that of normal speakers during blowing. DESIGN: Eight patients with repaired cleft palate, who routinely wear a palatal lift prosthesis (PLP) or a hybrid speech appliance of a pharyngeal bulb and palatal lift (bulb-PLP), served as subjects. Subjects were classified into one of two groups according to their speech appliance (PLP group and bulb-PLP group). Electromyography of the levator veli palatini muscle was recorded with a speech appliance in place and then with the speech appliance removed as the subject blew through a tube at three different effort levels. RESULTS: In the removed condition, the change in levator activity in relation to oral air pressure was variable across subjects in the bulb-PLP group, whereas levator activity changed in relation to oral air pressure change for all subjects in the PLP group. However, levator activity changed in relation to oral air pressure with either speech appliance in place for all subjects irrespective of their speech appliance types. CONCLUSION: The severity of velopharyngeal incompetence might be related in part to change in levator activity in association with oral air pressure. The effect of a speech appliance to correct velopharyngeal incompetence might consist not only of mechanical obturation of the velopharynx but also of alteration of velopharyngeal function to become similar to normal speakers. Moreover, it is likely that the velopharyngeal system could be well regulated so as to exhibit a consistent outcome of velopharyngeal function.     

Custom made alar stents for nostril stenosis: a 24-month evaluation

Nostril stenosis is an uncommon deformity and its aetiology is variable. The shape alteration and nostril asymmetry may have negative aesthetic and functional effects on nostril stenosis patients. Five patients were included in this study and followed up for 24 months; four of these had congenital nostril stenosis and one had an acquired deformity. Alar stent dilators were constructed from measured diameter of the affected nostril/s. The congenital nostril stenosis patients initially received a customised chairside soft nasal dilator (CCSND), which were later replaced with a customised laboratory rigid nasal dilators (CLRND). Treatment outcomes were evaluated using a questionnaire and a visual analogue scale to assess improvements in nostril breathing, comfort, appearance and satisfaction of the treatment provided by both types of dilators. There was improvement in nostril diameter with an average expansion of 7mm and this was stable at the desired diameter. The overall number of stents used to expand the tissues to the desired dimension ranged from 3 to 8 stents. Alar stent therapy is a conservative method to expand nostril tissues and has successfully maintained the nostril diameter for both acquired and congenital stenosis. This improvement in all parameters and the patients' satisfaction would make the custom-made nostril dilator in particular the CLRND a satisfactory treatment modality for congenital and acquired nostril stenosis.     

A Simplified Palatal Lift Prosthesis for Neurogenic Velopharyngeal Incompetence

Velopharyngeal incompetence is a contributing factor to speech disorders and implies the presence of hypernasality, inappropriate nasal escape, and decreased air pressure during speech. One prosthetic treatment is a rehabilitative procedure employing a palatal lift prosthesis (PLP), which reduces hypernasality by approximating the incompetent soft palate to the posterior pharyngeal wall and consists of two parts, the anterior denture base and the palatal lifting plate, which are connected with steel wires; however, it seems difficult to reproduce the mobility of the soft palate in speaking, and it is therefore likely that the palatal lifting plate stimulates or oppresses the tissue of the soft palate and hinders rather than assists articulatory function. To avoid these disturbances we devised an adjustable PLP with a flexible conjunction between the denture base and the palatal lifting plate to obtain the optimal vertical lifting angle. The palatal plate was adapted to conform in a passive manner to the soft palate with light‐cured resin. The designed PLP simplified the procedure and reduced the number of adjustments and visits.     

Long-term effects of mini-screw–assisted rapid palatal expansion on airway:: A three-dimensional cone-beam computed tomography study

ObjectivesTo evaluate the long-term effects on airway in patients with mini-screw–assisted rapid palatal expansion (MARPE), rapid palatal expansion (RPE), and controls with three-dimensional cone-beam computed tomography (CBCT) analysis.Materials and MethodsA total of 180 CBCTs of 60 patients were analyzed at different time points, such as pretreatment, postexpansion, and posttreatment. Patients were divided into three groups: mini-screw assisted rapid palatal expansion (MARPE), rapid palatal expansion (RPE), and controls. The nasal cavity, nasopharyngeal, oropharyngeal, and laryngopharyngeal airway volume and area were measured. Changes in total airway volume, total airway area, minimal cross-sectional area, maxillary intermolar width, external maxillary width, and palatal width were also evaluated.ResultsBoth MARPE and RPE caused a statistically significant increase in the airway after expansion as compared with the control group, but there was no statistically significant difference in the change in airway between MARPE, RPE, and the control group at posttreatment, except for nasopharyngeal volume, which was significantly increased in the MARPE group. There was no correlation between the amount of expansion and increase in total airway volume.ConclusionsThere was a significant increase in total airway volume, total airway area, and minimal cross-sectional area with MARPE and RPE immediately after expansion, but at posttreatment, the changes in the MARPE and RPE groups were similar to the change in the control group. However, MARPE led to a significant long-term increase in nasopharyngeal volume. The amount of expansion did not correlate with the increase in pharyngeal airway volume.     

Furlow palatoplasty to restore velopharyngeal competence following tonsillectomy avulsion of a pharyngeal flap.

OBJECTIVE: We report the successful use of a Furlow palatoplasty to salvage velopharyngeal competence following iatrogenic avulsion of a pharyngeal flap that had been previously established to treat velopharyngeal insufficiency associated with a submucous cleft palate. INTERVENTION: A tonsillectomy, conducted by a surgeon unaffiliated with a cleft palate team, was used to remove enlarged tonsils that had developed after pharyngeal flap surgery and extended into the lateral ports causing nasal obstruction and hypernasality because of mechanical interference with port closure. A posttonsillectomy evaluation revealed avulsion of the pharyngeal flap, which was successfully treated using a Furlow palatoplasty. CONCLUSIONS: To our knowledge, this is the first report of iatrogenic avulsion of a pharyngeal flap caused by tonsillectomy. Based on a review of the literature and this case experience, we would conclude that tonsillectomy should not be regarded as a routine procedure in patients previously treated with a pharyngeal flap. If required, it should be performed by a skilled otolaryngologist, preferably one affiliated with a multidisciplinary cleft palate team who is familiar with pharyngoplasty surgery. Finally, our experience would suggest that the Furlow palatoplasty is sufficiently robust to be used as a secondary salvage procedure to restore velopharyngeal sufficiency following iatrogenic avulsion of a pharyngeal flap.     

套筒冠固位加中空式赝复体修复老年人肿瘤术后单侧上颌骨缺损

目的:随访观察1-5年套筒冠固位加中空式赝复体修复老年人肿瘤术后的单侧上颌骨缺损的效果。方法:选择2005年1月至2010年1月门诊60岁以上老年人肿瘤术后的单侧上颌骨缺损伴牙槽骨缺失,口鼻相通伴发音差,健侧余留牙严重磨耗致咬合间隙小。采用套筒冠固位加中空式赝复体修复26例,随访观察1-5年复查修复体的密合性,美观与舒适,固位及稳定性,咬合关系和咀嚼功能,基牙牙周组织等。结果:随访观察1-5年套筒冠固位加中空式赝复体修复后效果:满意61.5%,基本满意34.6%,差3.8%,总满意率96.1%。结论:套筒冠固位加中空式赝复体修复老年人肿瘤术后的单侧上颌骨缺损效果较满意。