Separate clefts of the lip and the palate. A variant of cleft lip and palate

Separate clefts of the lip and of the palate (CL-CP) may belong to the same etiological class as the cleft lip with or without cleft palate CL(P), or a child may have two separate anomalies, CL and CP. This theory was tested in Finnish cleft patients. Among 2471 cleft cases, there were 66 CL-CP (2.7%). Adequate medical records were available for 62 children: 45 boys (73%) and 17 girls (27%). Familial occurrence was recorded in 6 cases (10%). Of the cleft cases among the near relatives, 5 were CL(P) and one CP. The prevalence of hypodontia was 37% among 38 subjects studied, as compared with 8.2% in the CL-, 29.8% in the CP- and 48.1% in the CLP controls. Conical elevations of the lower lip were observed in none, as compared with 0.8% of the CL(P)- and 39% of the CP controls. It was therefore assumed that the CL-CP belongs to the same etiological class as the CL(P).     

Oral clefts in the Sultanate of Oman

This is a retrospective study of the epidemiology of congenital clefts of the lip and palate in babies of Omani nationals born in the Sultanate of Oman between 1989 and 1995. Babies of non-Omani immigrants were excluded from the study. The data were collected from two sources. The first was the Centralized Plastic Surgery Service of Khoula Hospital at Muscat, the capital city of Oman between 1989 and 1995, which registers all oral cleft cases in the country. These data revealed the overall incidence of oral clefts (OC) to be 1.5 per 1000 live births, with incidences of 0.62 per 1000 for combined lip and palate (CLP) cleft, 0.34 per 1000 for cleft lip (CL), and 0.54 per 1000 for isolated cleft palate (CP). The second data source was national delivery records from maternity sections of all hospitals in the country from 1989 to 1995, which include oral clefts as congenital anomalies identified at birth. These statistics were similar to those from the first source for CL/CLP but underestimated the number of isolated cleft palates (CP). The histories of patients attending the Plastic Surgery Clinic of Khoula Hospital during the last year of the study period could be examined in detail. A study of the 177 OC cases registered in 1995 alone revealed associated congenital anomalies in 38.4%. A higher inbreeding coefficient of 0.0294 was noted among oral cleft cases than in the general population, which was calculated at 0.0198. Familial clefts accounted for 23% of all cases. Greater parental age and birth order were found to be associated with increased risk of oral cleft. High temperatures during the tropical desert summers in Oman (when temperatures reach 48°C) do not seem related to the incidence of oral clefts.     

The lack of isolated palatal clefts in Czech Gypsies

Orofacial clefts are usually divided into three basic types: isolated cleft lip (CL), cleft lip and palate (CLP) and isolated cleft palate (CP). The incidence of specific cleft types in a population and their relative numbers show specific differences between ethnic groups and races. However, there are no available data about the incidence and relative numbers of orofacial cleft types (CL, CLP, CP) in the gypsy ethnic group. The aim of this study was to compare relative numbers of specific types of orofacial clefts between the Czech gypsy and non-gypsy populations. We conducted a retrospective epidemiological study using a set of all living patients with orofacial clefts born in the Czech Republic from 1964 until 2002. The cleft patients were subdivided into three groups: 5304 non-gypsy children, both parents of whom were non-gypsies (NN), 98 gypsy children, both parents of whom were gypsies (GG) and 18 children with one parent non-gypsy and one parent gypsy (NG). The relative number of isolated CP was 37.1% in NN children. However, the relative number of CP was significantly reduced to 5.1% (P < 0.01) in the GG group. Conversely, the relative number of CLP was higher (P < 0.01) in the GG group (62.2%) in comparison to the NN group (39.2%). The tendency to decrease in the relative number of CP and increase in the relative number of CLP was also apparent in the NG group, but not so well expressed. We hypothesize that the decrease in CP and increase in CLP and CL in gypsies might be caused by their genetic predis-position to CL. Since the CP originates later than CL during embryonic development, some CP arise in embryos with already existing CL giving rise to CLP. Consequently, the missing isolated CP might be hidden in the group of CLP patients postnatally.     

Craniofacial cephalometric morphology in 6-year-old children with isolated cleft lip, isolated submucous cleft palate, and combined cleft lip and submucous cleft palate.

One hundred and twenty-one cleft children (67 with isolated cleft lip (CL), 32 with isolated submucous cleft palate (SMCP), and 22 with combined cleft lip and submucous cleft palate (CL + SMCP)) were compared retrospectively from lateral cephalograms taken at a mean age of 6.2 years (range 5.5-7.9). None of the children had had their palates repaired or been operated on to treat velopharyngeal insufficiency (VPI). The children with CL + SMCP and CL had similar morphology. They had greater maxillary length, greater maxillary and mandibular prominence, less vertical growth pattern, less deep nasopharyngeal airways, and thinner upper lips than those with isolated SMCP. After 6 years of age one patient with CL + SMCP, none with CL, and 16 with SMCP needed operations for VPI. This small series suggests that children with CL + SMCP and SMCP have different morphology. Although CL + SMCP is a combination of two types of clefts, it seems to be associated with similar morphology to CL.     

Craniofacial cephalometric morphology in 6-year-old children with isolated cleft lip,isolated submucous cleft palate,and combined cleft lip and submucous cleft palate

One hundred and twenty-one cleft children (67 with isolated cleft lip (CL), 32 with isolated submucous cleft palate (SMCP), and 22 with combined cleft lip and submucous cleft palate (CL + SMCP)) were compared retrospectively from lateral cephalograms taken at a mean age of 6.2 years (range 5.5–7.9). None of the children had had their palates repaired or been operated on to treat velopharyngeal insufficiency (VPI). The children with CL + SMCP and CL had similar morphology. They had greater maxillary length, greater maxillary and mandibular prominence, less vertical growth pattern, less deep nasopharyngeal airways, and thinner upper lips than those with isolated SMCP. After 6 years of age one patient with CL + SMCP, none with CL, and 16 with SMCP needed operations for VPI. This small series suggests that children with CL + SMCP and SMCP have different morphology. Although CL + SMCP is a combination of two types of clefts, it seems to be associated with similar morphology to CL.     

Birth weight and placental weight in cleft probands.

The mean birth weight of the 1,568 probands with clefts who were born in Finland between 1975 and 1985 was 3,346 g, which is lower than the mean of all live born babies in 1980 (3,541 g). The 345 who had an associated anomaly or syndrome had a mean birth weight of 3,027 g and placental weight of 538 g, compared with 3,435 g and 609 g, respectively, for those with solitary clefts. The more severe the cleft the lower the birth weight, but not the placental weight. The percentage of low birthweight (less than or equal to 2,500 g) infants was higher than in the general population (8.5% compared with 3.8%). The highest percentage of low birthweight infants was in the subgroup with bilateral cleft lip and palate (16.8%).     

Otitis media and feeding with breast milk of children with cleft palate.

The purpose of the present study was to analyse the incidence of acute and secretory otitis media (OM), and feeding with breast milk, and the use of a grommet in children with a cleft palate (CP/CLP) or cleft lip (CL), compared with controls. A total of 84 children between 6 and 10 years of age were studied. The CP/CLP group consisted of 48 children with an isolated cleft palate (n = 28), or a cleft lip and palate (n = 20). The CL group consisted of 15 children with an isolated cleft lip. The controls were 21 children without clefts. Children with CP/CLP had acute OM significantly more often than children without clefts (43/48 compared with 10/21), and secretory OM (40/48 compared with 4/21), despite the use of grommets. CP/CLP children were breast fed for a mean of 2.8 months (range 0-13), compared with 3.6 months (0-12) for CL, and 7.5 (0-24) months for controls. There was a significant correlation during the first 18 months of life between longer duration of feeding with breast milk and a lower incidence of acute and secretory OM in the three study groups combined. The incidence of otitis media was not affected by care in a day centre, having a sibling attending a day care centre, or by the family's medical history. Despite cleft repair and early treatment with grommets, both secretory and acute OM are common among children with cleft palate, presumably as a result of their eustachian tube dysfunction. The present study suggests that premature cessation of feeding with breast milk may contribute to an increased incidence of acute and secretory OM.     

Maxillary growth of adult patients with unoperated cleft: answers to the debates.

Maxillary growth of adult patients with unoperated cleft has long been studied, but results varied between different studies. The objectives of this study were to determine the growth potential of adult patients with unoperated clefts compared to the normal population and to differentiate the growth potential among types of clefts. METHODS: Subjects were from the same ethnic group, were more than 16 years of age with non-syndromic cleft and no associated anomalies. The types of cleft included unilateral complete cleft lip and palate (UCLP), bilateral complete cleft lip and palate (BCLP), unilateral cleft lip (UCL) and isolated cleft palate (CP). The sella-nasion-A point (SNA) angle from the cephalometry was measured, and a dental cast study using a three-dimensional imaging system was performed. RESULTS: SNA measurements showed significant differences among different groups, the BCLP group having larger values and the CP group having smaller values when compared with normal values. Dental cast analysis measuring palatal surface area showed a significantly smaller area in patients with cleft as compared to normal controls, but no difference among the different types of cleft. From the linear measurement it was found that the interdental distance was significantly more narrow in the anterior part up to the first premolar region as compared to the control group, especially in the complete cleft groups (UCLP and BCLP). Dentoalveolar arch was also deeper and longer in these complete cleft groups. CONCLUSION: There is an intrinsic tissue deficiency in all groups of patients with cleft; however, the sagittal development is still comparable to that of a normal population. Tissue deficiency mostly occurs in the anterior part. There is no difference in terms of the deficiencies among the different groups of cleft.     

Association between maternal diabetes mellitus and newborn oral cleft.

Diabetes mellitus has been implicated in several studies as a possible etiological factor of various congenital anomalies. Oral clefts are common congenital malformations that may severely affect the quality of life. The authors conducted a population-based case-control study using the 1996 National Center for Health Statistics United States Natality database to investigate whether maternal diabetes mellitus is a risk factor (p < 0.05) for having a newborn with an oral cleft. The patients consisted of 2,207 live births with cleft lip/palate, and the control subjects were 4,414 randomly selected live births, excluding those with other congenital defects. After adjusting for potential confounding variables, diabetic mothers were found to be 1.352 times (95% confidence interval, 1.004-1.821; p < 0.05) more likely than nondiabetic mothers to have a newborn with cleft lip/palate. In counseling expectant mothers, early glycemic control may be an important factor in decreasing the incidence of this congenital anomaly.     

A revised classification of the cleft lip and palate

BACKGROUND:

Submucous cleft palate is characterized by muscular diastasis of the velum in the presence of intact mucosa with variable combinations of bifid uvula and hard palatal defect. Submucous cleft palate is indicated as a separate entity in most previous classifications but it has never been properly classified on an anatomical basis.

OBJECTIVES:

To revise the Smith-modified Kernahan ‘Y’ classification of cleft lip and palate deformities, and to describe the different anatomical subtypes of submucous cleft palate.

METHODS:

The present study was conducted in Hayatabad Medical Complex, Abasin Hospital and Aman Hospital Peshawar, Pakistan, from November 2010 to December 2011. All patients who presented to the outpatient departments with cleft lip and palate, with the exception of previously operated cases, were included. All cases were described according to the Smith-modified Kernahan ‘Y’ classification and the authors’ revised Smith-modified Kernahan ‘Y’ classification. All of the data were organized and analyzed using SPSS version 17 (IBM Corporation, USA).

RESULTS:

A total of 163 cases of cleft lip and palate deformities were studied, of which 59.5% were male and 40.5% were female. Smith modification of the Kernahan ‘Y’ classification completely described the cleft deformities in 93.9% of patients. However, while the Kernahan ‘Y’ classification represented the submucous cleft palate, it did not describe its different anatomical subtypes in 6.13% of patients. The revised Smith-modified Kernahan ‘Y’ classification completely described the cleft deformities of the entire study population, including the different submucous cleft palate patients.

DISCUSSION:

The Smith alphanumeric modification of the Kernahan ‘Y’ classification of cleft lip and palate came into existence after a long search and a series of modifications over the past century. This classification system describes the cleft region, site of the cleft, degree of the cleft, rare and asymmetrical clefts, and are computer database friendly. However, this classification did not describe the different anatomical subtypes of submucous cleft palate that have variable relationships with velopharyngeal insufficiency.

CONCLUSION:

The revised Smith-modified Kernahan ‘Y’ classification described in the present study can describe all types of cleft lip and palate deformities in addition to the different types of submucous cleft palate deformities.     

Congenital heart disease and associated malformations in children with cleft lip and palate in Pakistan.

Children with cleft lip and palate often have other associated malformations. The reported incidence and types of associated malformations vary between different studies. There is a great paucity of literature on the subject from the region in general and none from Pakistan at all. The purpose of this study was to assess the frequency of associated malformations, particularly congenital heart disease, in children with cleft lip and palate presenting to the Aga Khan University (AKU) and Murshid Hospital (MH). From 1st October 1999 to 31st March 2002, all children with cleft lip and palate who presented to AKU and MH were prospectively enrolled in the study group. Socio-demographic characteristics and a number of other variables were documented. All children underwent a thorough clinical examination and an echocardiogram as part of the study protocol. 123 children formed the study group. Thirty-five (29%) of these children were found to have associated malformations. The most common of these was congenital heart disease, which accounted for 51% of all associated malformations. Thirty percent of cleft palate children had associated anomalies while 27% of cleft lip, with or without cleft palate, children had associated anomalies. There was a significant association between children born of a consanguineous marriage and the risk of associated malformations (p-value: 0.001). Consanguinity was present in 74% of children with associated anomalies as compared to 40% of children with no associated anomaly. Dysmorphic features and the presence of associated anomalies were also significantly associated (p-value: 0.009). Dysmorphic features were present in 46% of children with anomalies as compared to 21% of children with no associated anomaly. Fifty percent of children with associated anomalies had a low birth weight compared to 34% of children with no anomalies, but the difference was not statistically significant.The presence of consanguinity in a child with dysmorphic features should raise the suspicion of an associated anomaly. The likelihood of this being a cardiac defect is high and should be ruled out with a thorough clinical examination, supplemented with an echocardiogram in certain cases.     

Failure to thrive in babies with cleft lip and palate.

We established the frequency of failure to thrive (FTT) in children undergoing primary cleft procedures by using growth charts and standard-deviation scores. Initially, 147 babies with cleft lip and/or palate undergoing 186 primary lip-and-palate repairs were studied between 1993 and 1996. Rates of FTT were categorised according to cleft type. There was an increasing rate of FTT from 32% for unilateral cleft lip and palate to 38% for bilateral cleft lip and palate to 49% for cleft palate. There was a high incidence of FTT in palatal clefts, especially if these were associated with a syndrome or anomaly (P= 0.001). The incidence of FTT with the Pierre Robin sequence was 100%. In view of the high rates of FTT, two changes were instituted: a feeding-support nurse was appointed to supervise and monitor patients at risk and all patients with the Pierre Robin sequence had supervised airway management. Thereafter, the incidence of FTT was prospectively studied in 68 babies undergoing 84 primary procedures between 1997 and 1999. There was a decrease in the incidence of FTT in comparison with the earlier cohort (9% for unilateral cleft lip and palate, 20% for bilateral cleft lip and palate, 26% for cleft palate). There was a significant decrease in the incidence of FTT in the group with the Pierre Robin sequence, from 100% to 40%. As a result of the provision of a feeding-support nurse and airway management of patients with the Pierre Robin sequence, the incidence of FTT was reduced and the audit loop closed.     

Palatal fistulas after primary repair of clefts of the secondary palate

Our aim was to assess whether severity of cleft, age at the time of repair, and the operating surgeon's experience contributed to the development of fistulas in patients with clefts of the secondary palate. We studied 814 children born between 1960 and 1999 with clefts of the secondary palate who had had their primary operation at the Department of Plastic Surgery, Rikshospitalet University Hospital, Oslo, Norway. Data were collected retrospectively from the archives of the Oslo Cleft Team. Palatal fistulas developed in 36 patients (4%), among whom 17 patients required correction (2% of the total). The incidence of fistulas was not related to sex. Patients with clefts of the hard and soft palate developed fistulas more often than patients with clefts of the soft palate only (8% compared with 1%, p<0.001). Patients with submucous cleft palates developed fistulas significantly more often than patients with clefts of the soft palate only (5% compared with 1%, p=0.02). Among patients with clefts of the hard and soft palate, the incidence of fistulas increased significantly with increasing age at the time of palatal closure (p=0.005). The incidence decreased significantly the more experienced the operating surgeon was for treating clefts of the hard and soft palate (p<0.001) but not for submucous clefts. Among patients with clefts of the hard and soft palate who had the palate closed at 14 months of age or later, the incidence of fistulas decreased from 21% when the operating surgeon had little experience to 0 when the surgeon had much experience. The incidence of fistulas was related to severity of cleft, age at palatal closure, and the operating surgeon's experience.     

Nasal airflow and olfactory function after the repair of cleft palate (with and without cleft lip).

OBJECTIVE: The objective of this study was to examine nasal airflow and olfactory functions in patients with repaired cleft palate compared with matching normal controls. STUDY DESIGN: The all-cleft group consisted of 25 patients with hard palate cleft comprising 15 patients with unilateral cleft palate and lip (UCLP); 2 with CP but no cleft lip (UCLP subgroup) and 8 patients with bilateral cleft lip and palate (BCLP subgroup). All had had surgical correction of the palate in infancy. The control group consisted of 20 nonaffected orthodontic patients. The median age of both groups was 14 years. The tests included the following: (1) nasal airflow measured by anterior rhinomanometry, (2) smell threshold for isoamyl-acetate determined using a 3-way forced choice method, (3) a self-administered questionnaire regarding the subjective perception of smell sense function, and (4) orthonasal and retronasal smell identification (correct/incorrect) and hedonics using visual analog scale (VAS). RESULTS: The respective test results follow. (1) When compared with the control group, the total airflow in the UCLP subgroup was significantly lower especially on the affected side; while in the BCLP subgroup it was lower than in the control group bilaterally. No significant difference was found between the cleft side of UCLP and BCLP subgroups. (2) The smell threshold of the UCLP subgroup was significantly higher than that of the control group and BCLP subgroup. No significant differences were found between right and left nostrils within the BCLP patients and between them and the control group. (3) No difference was found between the groups regarding the subjective perception of smell. (4) No significant differences were found between the UCLP and BCLP subgroups and between the all-cleft group and the control group, except for one item, regarding orthonasal and retronasal smell identification and hedonics. CONCLUSION: Although nasal airflow is significantly lower and the smell threshold higher on the cleft side, the day-to-day function of the sense of smell of cleft patients is similar to that of normal controls.     

Cephalometric pharyngeal changes after Le Fort I osteotomy in different types of clefts

Fifty patients with clefts (30 unilateral cleft lip and palate (UCLP), 9 bilateral cleft lip and palate (BCLP), and 11 cleft palate only (CP), mean age 25 years) treated with Le Fort I osteotomy were compared retrospectively from cephalograms taken shortly before operation, and at six months and one year postoperatively. Patients with bimaxillary surgery or previous velopharyngoplasty, or both, were excluded. Maxillary advancement was moderate in all groups. One year postoperatively there was a significant change (73%–90% of the surgical advancement) in the sagittal depth of the nasopharyngeal airway but not in the depth of the oropharyngeal airway, the length of the soft palate or the position of the hyoid bone. The nasopharyngeal airway was largest in the CP group both preoperatively and postoperatively. Eleven patients (7 CP, 4 UCLP) had a velopharyngoplasty after the osteotomy to improve their speech. There was no difference in the nasopharyngeal airway in the patients treated by velopharyngoplasty compared with those not so treated, but they seemed to have the shortest maxillas and the greatest surgical changes vertically.     

Facial clefts involving the midline in combination with intracranial anomalies: Case studies illustrating surgical treatment and medical substitution

Abstract Malm? and Uppsala have been regional centres for the treatment of cleft lip and palate since the beginning of the 1950s. We have about 80 new cases every year and most patients have conventional oronasal clefts, either cleft lip and palate or isolated cleft palate. During a 10-year period we have come across four patients who have had varying degrees of midface dysplasia combined with intracranial anomalies. One child died at an early age, but the other three children were given medical substitution of hypopituitarism and have had their clefts reconstructed.     

单纯腭裂患儿心脏畸形的发生率与腭裂程度的关系

目的 研究单纯腭裂患儿合并先天性心脏病的特点,探讨腭裂的程度与心脏畸形发生率的关系.方法 收集2008年8月至2009年12月收治的416例单纯腭裂患儿的临床资料,对所有患儿进行心脏超声检查;将患儿分为完全性腭裂和不完全性腭裂组,每组再分为单侧和双侧亚组,不完全腭裂组进一步分为悬雍垂裂、软腭裂、软腭及部分硬腭裂3个亚组,统计各组患儿合并心脏畸形的例数和类型,计数资料用百分构成比表示,采用SPSS 13.0版软件包进行统计学处理,组间比较采用x2检验.结果 416例中共检出46例先天性心脏病,占11.1%;不完全性腭裂组心脏畸形检出率为9.9%(38/384),完全性腭裂组检出率为25%(8/32),明显高于不完全性腭裂组(F=6.852,P<0.05);在合并的心脏畸形中,房间隔缺损占52.2%(24/46),是最常见的心脏畸形.结论 与不完全性腭裂相比,完全性腭裂具有较高的发生心脏畸形的风险,应常规进行心脏超声检查,腭裂程度可作为腭裂合并先天性心脏病的预测因子之一.     

单纯腭裂患儿心脏畸形的发生率与腭裂程度的关系

目的 研究单纯腭裂患儿合并先天性心脏病的特点,探讨腭裂的程度与心脏畸形发生率的关系.方法 收集2008年8月至2009年12月收治的416例单纯腭裂患儿的临床资料,对所有患儿进行心脏超声检查;将患儿分为完全性腭裂和不完全性腭裂组,每组再分为单侧和双侧亚组,不完全腭裂组进一步分为悬雍垂裂、软腭裂、软腭及部分硬腭裂3个亚组,统计各组患儿合并心脏畸形的例数和类型,计数资料用百分构成比表示,采用SPSS 13.0版软件包进行统计学处理,组间比较采用x2检验.结果 416例中共检出46例先天性心脏病,占11.1%;不完全性腭裂组心脏畸形检出率为9.9%(38/384),完全性腭裂组检出率为25%(8/32),明显高于不完全性腭裂组(F=6.852,P<0.05);在合并的心脏畸形中,房间隔缺损占52.2%(24/46),是最常见的心脏畸形.结论 与不完全性腭裂相比,完全性腭裂具有较高的发生心脏畸形的风险,应常规进行心脏超声检查,腭裂程度可作为腭裂合并先天性心脏病的预测因子之一.     

Palatal Fistulae Following Cleft Palate Surgery

The occurrence and treatment of palatal fistulae have been studied in 1108 CLP patients who had their primary operations performed during the years 1954–69. No fistulae were recorded in 263 patients with incomplete cleft of the primary palate only. These patients were excluded, leaving 845 patients for analysis. The Le Mesurier or Millard technique had been used for the primary lip operation, and the von Langenbeck procedure for closure of the palate; in complete clefts, the anterior part of the palate had been closed using Veau's vomer flap operation simultaneously with lip closure. The observation period ranged from 7 to 22 years, during which time each patient was examined at least once and the majority on several occasions by members of the cleft palate team. The overall incidence of fistulae was 18%. Fistulae were recorded in 11.3% of all complete clefts of the primary palate, and in 36.1% of all complete total clefts. In cases of cleft palate only, fistulae were found in 3.5% of the incomplete clefts, and in 20% of the complete clefts. In patients with bilateral complete clefts, closure of both sides of the lip and anterior palate in one operation seemed to have greatly increased the risk of fistula formation. There was a much higher incidence of fistulae in patients operated on during the years 1954–61 than in those treated in the period 1962–69. Fistula symptoms requiring surgical intervention were recorded in 113 patients. Closure of the fistula was achieved in 84.1%. Of 18 patients with a residual fistula. 17 were asymptomatic or had symptoms so slight that they were considered insignificant and not justifying operation.     

Cephalometric pharyngeal changes after Le Fort I osteotomy in different types of clefts.

Fifty patients with clefts (30 unilateral cleft lip and palate (UCLP), 9 bilateral cleft lip and palate (BCLP), and 11 cleft palate only (CP), mean age 25 years) treated with Le Fort I osteotomy were compared retrospectively from cephalograms taken shortly before operation, and at six months and one year postoperatively. Patients with bimaxillary surgery or previous velopharyngoplasty, or both, were excluded. Maxillary advancement was moderate in all groups. One year postoperatively there was a significant change (73%-90% of the surgical advancement) in the sagittal depth of the nasopharyngeal airway but not in the depth of the oropharyngeal airway, the length of the soft palate or the position of the hyoid bone. The nasopharyngeal airway was largest in the CP group both preoperatively and postoperatively. Eleven patients (7 CP, 4 UCLP) had a velopharyngoplasty after the osteotomy to improve their speech. There was no difference in the nasopharyngeal airway in the patients treated by velopharyngoplasty compared with those not so treated, but they seemed to have the shortest maxillas and the greatest surgical changes vertically.