Le Fort I osteotomy in cleft patients: Maxillary advancement and velopharyngeal function

BackgroundMaxillary advancement may affect speech in cleft patients.AimsTo evaluate whether the amount of maxillary advancement in Le Fort I osteotomy affects velopharyngeal function (VPF) in cleft patients.MethodsNinety-three non-syndromic cleft patients (51 females, 42 males) were evaluated retrospectively. All patients had undergone a Le Fort I or bimaxillary (n = 24) osteotomy at Helsinki Cleft Palate and Craniofacial Center.Preoperative and postoperative lateral cephalometric radiographs were digitized to measure the amount of maxillary advancement. Pre- and postoperative speech was assessed perceptually and instrumentally by experienced speech therapists. Student's t-test and Mann–Whitney's U-test were used in the statistical analyses. Kappa statistics were calculated to assess reliability.ResultsThe mean advancement of A point was 4.0 mm horizontally (range: −2.8–11.3) and 3.9 mm vertically (range −14.2–3.9). Although there was a negative change in VPF, the amount of maxillary horizontal or vertical movement did not significantly influence the VPF. There was no difference between the patients with maxillary and bimaxillary osteotomy.ConclusionsThe amount of maxillary advancement does not affect the velopharyngeal function in cleft patients.     

上颌前徙术后腭咽闭合功能的临床观察

目的　临床观察评价上颌前徙术后腭咽闭合功能变化。方法　对 7例上颌发育不全患者及 3例唇腭裂继发上颌发育不全患者行LeFortI型截骨术前移上颌骨 ,术前术后行鼻咽纤维镜及发“i”音时的头颅侧位片检查 ,结合术前术后语音的评价 ,对上颌前徙术后腭咽闭合及发音的改变进行观察分析。结果　经统计学分析 ,软腭动度、腭咽闭合程度、语音清晰度等指标术前术后比较差异均无显著性。结论　患者术前腭咽闭合功能良好时 ,上颌前徙术后腭咽闭合功能无明显变化     

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 maxillary advancement on speech and velopharyngeal function of patients with cleft palate: Systematic Review and Meta-Analysis

This systematic review (SR) aimed to evaluate speech and velopharyngeal function (VPF) changes of patients with cleft palate (CLP) after maxillary advancement (MA) surgery. A two-phase PROSPERO-registered SR (CRD42019141370) was conducted following the PRISMA statements. Search strategies were developed for main databases (PubMed, Scopus, Web of Science, COCHRANE, LILACS, and EBSCOhost) and Grey literature information sources. The GRADE tool was used to evaluate the quality of evidence. From a total of 908 articles, 10 (205 men and 147 women; mean age ranging from 18.0 to 25.7 years) were selected for meta-analysis. Moderate to high risk of bias (Rob) was observed. The most common methods for outcomes evaluation were the Nasometer (speech) and nasoendoscopy (VPF). Speech changed from normal to hypernasal, and VPF worsening were reported in most studies. Comparing maxillary advancement interventions (osteogenic distraction versus Le Fort I), no statistically significant differences were found regarding benefit on speech and VPF. In summary, the effect of MA on speech and VPF remains controversial in CLP patients. The RoB, inconsistencies, and imprecisions severely affected the overall quality of evidence. Further adequately delineated clinical studies are necessary to investigate the potential effect of MA interventions on speech and VPF in CLP patients.     

A pilot study of the effects of transpalatal maxillary advancement on velopharyngeal closure in cleft palate patients

BACKGROUND AND AIMS: Impaired velopharyngeal closure function is sometimes a complication of a standard Le Fort I maxillary advancement in cleft palate patients. The transpalatal Le Fort I osteotomy has been suggested as an alternative technique that may avoid this problem. The aim of this pilot study was to examine the effects of the transpalatal approach on velopharyngeal function in a series of cleft palate patients. PATIENTS: Sixteen consecutive patients with a history of cleft palate exhibiting maxillary hypoplasia who underwent a transpalatal Le Fort I osteotomy. METHODS: All patients had a simultaneous audio/video speech recording and nasopharyngoscopy examination prior to maxillary advancement, followed by a repeat of the same examinations at least 1 year post-operatively. Velopharyngeal function was measured in two ways: by direct observation using nasopharyngoscopy, and indirectly by means of perceptual assessment. Reliability studies of the two measures were performed with satisfactory results. RESULTS: No statistically significant difference was found between the pre- and post-operative data in either the perceptual speech assessment or nasopharyngoscopy examination. CONCLUSION: These results indicate that maxillary advancement by transpalatal Le Fort I osteotomy does not adversely affect velopharyngeal closure function.     

Prediction of deterioration of velopharyngeal function associated with maxillary advancement using electromyography of levator veli palatini muscle.

OBJECTIVE: The purpose of the present study was to examine the possibility that postoperative velopharyngeal function following maxillary advancement could be predicted using preoperative electromyography of the levator veli palatini. DESIGN: Levator muscle electromyography was recorded preoperatively during speech and blowing. Levator activity was expressed as a percentage relative to the maximum value observed throughout the experiment. Postoperative velopharyngeal function was evaluated by means of perceptual judgment and nasoendoscopy. PARTICIPANTS: The subjects were four patients with repaired cleft palates who underwent maxillary advancement, two by osteotomy and two by distraction osteogenesis. None of the subjects presented with preoperative hypernasality, and nasoendoscopy demonstrated complete velopharyngeal closure in all subjects prior to maxillary advancement. RESULTS: Preoperative levator activity for speech of two subjects was similar to that for normal speakers (< 60% of total range), and postoperative nasality and nasoendoscopic findings revealed no detectible changes. For the other two subjects, levator activity for speech exceeded 60% of the total range, similar to that of speakers with velopharyngeal incompetence. These subjects showed increased hypernasality and deteriorated velopharyngeal closure following maxillary advancement. CONCLUSION: The deterioration of velopharyngeal function associated with maxillary advancement was demonstrated for subjects whose levator activity was at higher levels during speech in comparison with maximal activity observed during blowing, regardless of the amount of maxillary advancement. Preoperative levator muscle electromyography could be a predictor in identifying patients at higher risk of postsurgical deterioration of velopharyngeal function.     

Effect of maxillary distraction osteogenesis on velopharyngeal function: a pilot study

OBJECTIVE: The purpose of this study was to examine preoperative and postoperative changes of velopharyngeal function in cleft patients who underwent maxillary distraction osteogenesis using the Rigid External Distraction System. STUDY DESIGN: Six cleft patients followed for a minimum of 12 months after maxillary distraction were examined. Plain and contrast lateral-cephalograms were obtained preoperatively and postoperatively, and speech evaluation was performed by the same authorized speech therapist at the same time points. RESULTS: The mean distraction amount at the anterior nasal spine was 11.7 mm (range, 7.4 mm - 15.0 mm). Both the nasopharyngeal depth and velar length increased after maxillary distraction, but the need ratio (nasopharyngeal depth/velar length) also increased after distraction. Although scores for velopharyngeal closure dropped a few points after maxillary distraction, the rating for hypernasality remained unchanged in all patients but the patient whose distraction amount was 15.0 mm. CONCLUSION: These results suggest that maxillary distraction of less than 15 mm may not markedly affect velopharyngeal function in cleft patients.     

Alterations in velopharyngeal function after maxillary advancement in cleft palate patients

Velopharyngeal function was assessed aerodynamically prior to surgery and at least 1 year following surgery in 24 cleft palate patients who underwent maxillary advancement. In 5 patients (23%) deterioration and in 5 patients (23%) improvement of velopharyngeal function was observed. In those patients whose velopharyngeal function improved, a pharyngeal flap was in place at surgery. Of the 5 patients whose velopharyngeal function deteriorated, 4 had adequate and 1 borderline adequate velopharyngeal function prior to surgery. In the remaining 14 patients, velopharyngeal function was unchanged. No relationship between the amount of maxillary advancement or the "need ratio" and velopharyngeal function was observed.     

Anterior maxillary segmental distraction for correction of maxillary hypoplasia and dental crowding in cleft palate patients: a preliminary report

To evaluate the feasibility of anterior maxillary segmental distraction (AMSD) to correct maxillary hypoplasia and severe dental crowding in cleft lip and palate (CLP) patients, 7 patients (average age 16.4 years) with maxillary hypoplasia, shortened maxillary dental arch length and severe anterior dental crowding secondary to CLP were selected for this study. After anterior maxillary segmental osteotomy, 3 patients were treated using bilateral internal distraction devices, and 4 patients were treated using rigid external distraction devices. Photographs and radiographs were taken to review the improvement in facial profile and occlusion after distraction. An average 10.25 mm anterior maxillary advancement was obtained in all patients after 10–23 days of distraction and 9–16 weeks of consolidation. The sella–nasion–point A (SNA) angle increased from 69.5° to 79.6°. Midface convexity was greatly improved and velopharyngeal competence was preserved. The maxillary dental arch length was greatly increased by 10.1 mm (P < 0.01). Dental crowding and malocclusion were corrected by orthodontic treatment. These results show that AMSD can effectively correct the hypoplastic maxilla and severe dental crowding associated with CLP by increasing the midface convexity and dental arch length while preserving velopharyngeal function, and dental crowding can be corrected without requiring tooth extraction.     

The effects of Le Fort I osteotomy with maxillary movement on articulation, resonance, and velopharyngeal function

Articulation, resonance, and velopharyngeal function were evaluated before and after Le Fort I maxillary advancement in 16 patients (seven with cleft lip and palate, one with cleft lip only, and eight without clefts). On the postoperative evaluation, seven of 11 patients with preoperative articulation errors showed an improvement in articulation after surgery. Two patients without clefts showed slight changes in nasal resonance, and two patients (one with cleft lip and palate and one with cleft lip only) developed mild nasal emission. Nine patients showed diminished velopharyngeal contact during speech on videofluoroscopic studies. Compensatory changes in velopharyngeal function were also observed, which included velar stretching and lengthening and increased lateral pharyngeal wall movement.     

Skeletal,dental and facial aesthetic changes following anterior maxillary segmental distraction by tooth-borne device in patients with cleft lip and palate

Maxillary skeletal deficiency secondary to cleft lip and palate (CLP) remains a significant challenge. The aim of this study was to present the comprehensive skeletal, dental and facial aesthetic outcomes of anterior maxillary segmental distraction osteogenesis (AMSDO) for treatment of maxillary hypoplasia in patients with CLP. Twelve patients with maxillary hypoplasia treated with AMSDO by a customized tooth-borne distractor were included. Three-dimensional changes of anterior maxillary segment, upper incisor and pharyngeal space were measured by three-dimensional reconstruction derived from cone beam computed tomography (CBCT) data. Length and width of dental arch during distraction were determined in dental casts. Nasolabial angle, soft-tissue convexity and patient’s subjective satisfaction were assessed to evaluate facial aesthetic improvements. Nasopharyngoscopic evaluation and speech assessment were also performed before and after distraction. All patients successfully received AMSDO without serious complications. Following AMSDO, the anterior maxillary segments moved forward 5.56 ± 0.28 mm and slightly upward 1.15 ± 0.13 mm. AMSDO significantly lengthened maxillary dental arch, generated new bone to relieve dental crowding and improved patients’ facial aesthetic without worsening velopharyngeal closure and speech quality. AMSDO by tooth-borne distractor is an effective surgical alternative for the advancement in patients with cleft maxillary hypoplasia.     

Long-term skeletal stability after maxillary advancement with distraction osteogenesis in cleft lip and palate patients: A systematic review

Objective:To systematically review the long-term skeletal stability after maxillary advancement with distraction osteogenesis (DO) in cleft lip and palate (CLP) patients.Materials and Methods:Electronic databases, grey literature, and reference list searches were conducted. The inclusion criteria were stability of maxillary advancement with distraction osteogenesis assessed at the posttreatment follow-up ≥ 1 year in CLP patients. Full articles were retrieved from abstracts or titles that appear to meet the inclusion criteria or lacked sufficient detail for immediate exclusion. Once full articles were collected, they were again reviewed considering more detailed inclusion criteria for a final selection decision. A methodologic quality assessment tool was utilized.Results:Thirty abstracts/titles met the initial search criteria, and 13 articles were finally selected. Overall, methodologic quality scores were high in only one randomized clinical trial. After maxillary advancement with DO in CLP patients, the long-term horizontal relapse in A-point was less than 15% in eight studies and between 20% and 25% in four studies. The study that was judged as a high-quality study reported 8.2% horizontal relapse in A-point. The relapse rate was higher in DO with external distracter device than DO with internal distracter device.Conclusions:Current evidence suggests maxillary advancement with DO has good stability in CLP patients with moderate and severe maxillary hypoplasia.     

唇腭裂继发上颌骨发育不足牵引成骨后腭咽部功能变化

目的　通过颅外支架式上颌骨牵引成骨术 (RigidExternalDistraction ,RED)前后唇腭裂患者静止位和[i]发音位头颅定位侧位片腭咽部结构变化 ,拟评价上颌骨牵引成骨术对唇腭裂患者腭咽部结构功能的影响及其相关因素。方法　 1999～ 2 0 0 1年行颅外支架式上颌骨牵引成骨术的唇腭裂术后上颌发育不足患者 2 1名 ,平均年龄15 .0 5岁。所有患者RED术前后拍摄静止位及 [i]位头颅定位片 ,然后对腭咽部结构功能指标测量分析。结果　(1)RED术后PNS A、PNS PPW、NR、ASPHP、RVCR、EASP和MSP具有显著性变化 ;(2 )RVCR的变化与上颌骨前移幅度、PNS PPW增加幅度和NR增大程度呈正相关。上颌前移幅度还与软硬腭夹角增加呈正相关。结论　 (1)上颌骨牵引成骨术后腭咽腔深度增加 ,对唇腭裂患者腭咽闭合功能仍有一定负面影响 ,但同时腭咽部软组织有代偿性改变 ;(2 )上颌骨前移幅度与RED术后腭咽闭合功能变化有关 ;(3)咽后壁瓣的存在对防止和减少RED术后腭咽闭合功能不全产生有积极作用。     

The effects of Le Fort I osteotomy on velopharyngeal function in cleft patients

Introduction

Maxillary advancement may affect speech in cleft patients. The aim of this study was to evaluate whether preoperative velopharyngeal (VP) function and cleft type can predict VP function after a Le Fort I maxillary osteotomy.

The effect of cranio-maxillofacial osteotomies and distraction osteogenesis on speech and velopharyngeal status: a critical review.

OBJECTIVES: To review the impact of maxillary advancement by orthognathic surgery and distraction osteogenesis on speech and velopharyngeal status based on the literature of the past 30+ years, to review the methods employed in previous studies to explain discrepancies in results, and to make recommendations for future studies. METHOD: Thirty-nine published articles on the effect of cranio-maxillofacial osteotomies and distraction osteogenesis on speech and velopharyngeal status were identified and were systematically analyzed. A total of 747 cases of cleft and noncleft patients were selected, including craniofacial deformities and syndromes mainly involving maxillary hypoplasia. RESULTS: Findings varied. Many studies found that surgery had no impact on speech and velopharyngeal status. Some reported worsening only in patients with preexisting velopharyngeal impairment or those with borderline velopharyngeal function before surgery. There was no clear difference in outcome between distraction and conventional osteotomy, although there have been few systematic comparisons. There was great variation among reviewed studies in the number of subjects, speech sample, number and type of listeners, speech outcome measures, and timing of postoperative assessment. Few studies employed reliability measures. CONCLUSION: None of the 39 reviewed studies compared conventional osteotomy and distraction by including both groups in a single study. Randomized controlled trials with adequate number of subjects and follow-up duration are needed.     

Effects of orthognathic surgery on speech and breathing of subjects with cleft lip and palate: acoustic and aerodynamic assessment.

OBJECTIVE: To evaluate the impact of orthognathic surgery on acoustic nasalance of subjects with cleft and investigate the causes of possible changes by analyzing velopharyngeal function and nasal patency. DESIGN/PATIENTS: Nasalance was measured in 29 subjects with operated cleft palate +/- lip before (PRE) and 45 days (POST1) and 9 months (POST2) after surgery, on average. In 19 of the patients, the minimum velopharyngeal (VP) and nasal cross-sectional (N) areas were also determined. INTERVENTIONS: Le Fort I osteotomy with maxillary advancement in combination with procedures involving the nose, maxilla, mandible or all three. MAIN OUTCOME MEASURES: Nasalance, VP area, N area. RESULTS: We observed: (1) a significant (p < .05) increase in mean nasalance at POST1 and POST2, compared with PRE during the reading of oral sentences and nasal sentences; at POST2, high nasalance on the oral sentences was observed in 45% of the patients with normal nasalance at PRE, and 57% of patients with low nasalance on the nasal sentences at PRE no longer presented abnormal nasalance; (2) a significant increase in mean VP area at POST1; two borderline patients demonstrated deterioration of VP closure at POST2, compared with PRE; and (3) a significant increase in mean N area at POST2, with 73% of patients no longer presenting subnormal areas seen at PRE. CONCLUSIONS: On a long-term basis, orthognathic surgery modifies speech nasalance of some subjects with cleft, perhaps because of an increase in internal nose size. This may also improve nasal patency for breathing.     

Distraction osteogenesis in the management of severe maxillary hypoplasia in cleft lip and palate patients

The aim of this study was to systematically review literature reporting on the use of external distraction osteogenesis (DO) and internal DO in the treatment of severe maxillary hypoplasia in cleft and palate patients. Literature research has been performed using the PubMed database of the National Library of Medicine and National Institutes of Health from 1966 to August 2007. We used cleft lip and palate and distraction osteogenesis as key words. Of the 104 articles found, we only considered the Anglo-Saxon literature, which reported on the correction of the maxillary hypoplasia with DO techniques. A total of 32 studies reported on anteroposterior external DO (27 studies on rigid external device and 5 on face mask), 17 studies reported on anteroposterior internal DO, and 3 studies reported on transverse internal DO have been retained for this review. Despite the heterogeneity and methodological limitations of most of the studies, results showed that external DO with rigid external device and internal DO resulted to be a more reliable and accurate technique than the face mask in the management of severe maxillary hypoplasia in patients with cleft lip and palate. The current review demonstrated that external and internal DO in the treatment of severe maxillary hypoplasia in cleft and palate patients (1) is a reproducible and valuable alternative to standard orthognathic surgery procedures, (2) allows for a global improvement in facial aesthetic, (3) allows a maxillary correction in patients during the period of mixed dentition, and (4) allows either for an unchanged or better velopharyngeal function.     

Preoperative pharyngeal depth is associated with postoperative velopharyngeal function following primary cleft palate repair at the age of five and above

To determine prognostic factors for postoperative velopharyngeal function following the primary cleft palate repair at the age of five and above.This study reviewed patients with cleft palate who had undergone Furlow palatoplasty at age 5 or older from 2009 to 2014. We obtained intraoperative measurements, including velar length, pharyngeal depth, cleft width, maxillary width, cleft palate index (cleft width/maxillary width) and palatopharyngeal ratio (velar length/pharyngeal depth), as well as speech evaluation results at least 1 year after surgery. Logistic regression and retrospective analyses were performed to determine factors associated with speech performance after the primary cleft palate repair.Among the six intraoperative measurements of velopharyngeal morphology, only pharyngeal depth was incorporated into the regression model, and was found to have an inverse association with postoperative velopharyngeal function, Exp (B) 0.883 (95% CI 0.798-0.976). Moreover, a pharyngeal depth greater than 16 mm was significantly associated with a higher risk of postoperative velopharyngeal insufficiency (P < 0.01).Pharyngeal depth is potentially a prognostic indicator for the primary management of cleft palate in older patients. Pharyngoplasty may need to be considered when the pharyngeal depth is large and the patient’s access to surgery is limited.     

Velopharyngeal changes after maxillary distraction in cleft patients using a rigid external distraction device: A retrospective study

Objective:To evaluate early and late velopharyngeal changes in cleft lip and palate (CLP) patients after use of the Rigid External Distractor (RED) device and to correlate these changes to the amount of maxillary advancement.Materials and Methods:Thirty Class III CLP patients were included in the study. Maxillary advancement was performed using the RED device in combination with titanium miniplates and screws for anchorage. Lateral cephalograms, nasometer, and nasopharyngoscope records were taken before distraction, immediately after distraction, and 1 year after distraction. A paired t-test was used to detect differences at P < .05.Results:SNA angle and A point and ANS to Y axis were significantly increased after maxillary distraction (P  =  .0001). Statistically significant increases in nasopharyngeal and oropharyngeal depths, velar angle, and need ratio were also found (P  =  .0001). Nasalance scores showed a significant increase (P  =  .008 for nasal text and .044 for oral text). A significant positive correlation was observed between the amount of maxillary advancement and the increase in nasopharyngeal depth and hypernasality (P  =  .012 and .026, respectively).Conclusions:Nasopharyngeal function was deteriorated after maxillary advancement in CLP patients. There was a significant positive correlation between the amount of maxillary advancement and the increase in nasopharyngeal depth and hypernasality.     

Cephalometric pharyngeal changes after Le Fort I osteotomy in patients with unilateral cleft lip and palate

Pharyngeal changes after Le Fort I osteotomy were evaluated cephalometrically in 37 patients (27 M, 10 F; mean age 23.8 years) with unilateral cleft lip and palate (UCLP). Seven patients had previously undergone velopharyngeal (VPP) flap surgery to improve speech. One year postoperatively the patients without previous VPP showed a significant change (55%-85% of the surgical change) in the upper and lower sagittal depth of the nasopharyngeal airway, but not in the depth of oropharyngeal airway, length of soft palate, or position of hyoid bone. No significant changes were observed between 6 months and 1 year postoperatively. Mean surgical horizontal advancement was 4.7 mm and the mean vertical lengthening 4.7 mm anteriorly and 1 mm posteriorly. There was a correlation between the amount of horizontal advancement and the amount of change in the nasopharyngeal airway. The patients with previous VPP showed significant postoperative change (85% of the surgical change) only in the lower nasopharyngeal airway, although their surgical advancement was similar to that without previous VPP. Patients with previous VPP showed significantly smaller depths of upper nasopharyngeal airway postoperatively than the patients without previous VPP. Five patients (13%) needed VPP after the osteotomy. There was no difference in the nasopharyngeal airway in the patients with VPP after the osteotomy when compared to those without, but they seemed to have shortest maxillary lengths and largest mean surgical changes vertically both anteriorly (5.5 mm) and posteriorly (2.3 mm). Moderate maxillary advancement in UCLP patients results in significant changes in the nasopharyngeal airway.