Evaluation of 5-year-old children with complete cleft lip and palate: Multicenter study. Part 2: Functional results

The influence of three different primary treatment protocols on 5-year-old maxillary growth in patients with complete unilateral cleft lip and palate

The study evaluated the effects of three different primary treatment protocols on maxillary growth in patients aged 5 years with complete unilateral cleft lip and palate (UCLP). The secondary objective was to assess the influence of initial cleft severity, family history of class III, and status of permanent lateral incisor on maxillary growth. In total, 54 patients with non-syndromic complete UCLP were included and grouped as follows: group An underwent lip adhesion, cheilorhinoplasty associated with tibial periosteal graft for hard palate repair, and finally veloplasty; group B underwent lip adhesion, then cheilorhinoplasty with intravelar veloplasty, and finally a hard-palate repair; group C underwent cheilorhinoplasty with intravelar veloplasty and then a hard-palate repair. Five-year maxillary growth was assessed on dental models, both clinically and digitally. No difference was found with GOSLON-Yardstick scoring. Five-year measurements showed that group C tended to have the best maxillary arch morphology (p = 0.012). Initial cleft severity did not impact maxillary growth, but status of permanent lateral incisor and family history of class III did (p = 0.019 and p = 0.004, respectively). In patients aged 5 years, the two-stage approach appeared to be the least detrimental to growth development. Predictive factors for growth retardation included the absence of lateral incisor and a family history of class III.

Dermal Matrix Graft Effects on Facial Growth in a Veau-Wardill-Kilner Palatoplasty Model: An Experimental Study in Rats

The primary goal of palatoplasty is the restoration of normal speech, that can be aimed by, among many procedures, lengthening the palate through the pushback technique; one of its complications is abnormal maxillary growth. The main factor affecting facial growth in CLP patients is believed by many to be the palatoplasty-due to the large scar retraction resulting from some surgical techniques. The non-crosslinked two-layer bioabsorbable collagen matrix Mucograft™ (Geistlich Pharma AG, Wolhusen, Switzerland) is a potential tool to aid in wound closure in a second-intention healing situation.

The objective of this work was to test the use of an acellular dermal matrix (Mucograft®) in an experimental model of Veau-Wardill-Kilner palatoplasty, as a tool to reduce scar retraction of the denuded palatine mucosa.

Twenty-four 3-week-old male Wistar rats were used. The animals were randomly divided into two groups. In the control group, an excision was made with bone exposure in the palate, simulating the defect left in the Veau-Wardill-Kilner palatoplasty. In the intervention group, the same procedure was performed, and the area of denuded palatine bone was treated with a bioabsorbable collagen matrix (Mucograft®). For data collection, 9 weeks after surgery (12 weeks of life), the animals were euthanized by excessive anesthetic dosage. Maxillary growth, macroscopic appearance of the scar, pain, and bleeding were evaluated.

There were significant statistical differences between the groups for palate length growth (7.6 mm + -0.38 mm vs 5.5 mm + -0.36 mm, P = .009) and for palate width growth (1.47 mm + -0.8 mm vs -0.09 mm + -0.55 mm, P = .001), favoring dermal matrix group compared to controls. Whereas for pain and bleeding, there were no differences between the groups.

The use of dermal matrix in rats with an area of bone denudation on the palate increases maxillary length and width growth patterns. Besides, it does not increase pain, bleeding, or post-operative complications.

Cone Beam-CT-Based Bone Volume Assessments of Alveolar Synthetic Bone Graft GlassBONE™ in Cleft Lip and Palate Patients: A Retrospective Study

Background

Clefts of the lip and palate (CLP) are facial deformities that require multiple surgical procedures during childhood. One of these steps consists of filling the alveolar space with bone graft, traditionally removed from the iliac crest. However, this procedure could be invasive in children.

Aim

Here, we aimed to evaluate the outcomes of GlassBONE™ graft, a bioactive glass used as a bone substitute, as an alternative to the deleterious autologous bone graft in children.

Materials & methods

Retrospective monocentric study with 17 children aged 7.5 ± 2.2 yo [3.8-13.3 yo] carrying CLP. This technique has been established at La Timone Children hospital (Assistance Publique - Hôpitaux de Marseille) since 2011. Clinical (scar, graft rejection and periodontal status) and radiological (both panoramic radiographs and cone beam-CT) follow-up was conducted one year after the graft. The primary outcome was the reduction of the cleft volume, and secondary was the eruption of the adjacent tooth through the graft.

Results

GlassBONE™ permitted a significant reduction in the cleft volume by 42.4 ± 27.7% [0.6-81.1%] (p < 0.0001), corresponding to a filling of 57.6 ± 27.7% of the alveolar cleft. GlassBONE™ is well tolerated, ensuring satifactory clinical results (improvement in both scar and periodontal coverage), as well as the physiological evolution of the germs through the biomaterial. GlassBONE™ appears particularly suitable for small volumes, and we were able to determine a minimum volume of approximtely 0.259 + / - 0.155 cc required for a successful bone fusion.

Conclusion

The bioactive glass GlassBONE™ could be safely used in children with small CLP cases, providing satisfactory clinical and radiological results.

Influence of Lip Revision Surgery on Facial Growth in Patients With A Cleft Lip

Although patients with cleft lip and palate often present with poor maxillary growth because of intrinsic and iatrogenic factors, the surgical influence of lip revision surgery, palatal fistula repair, and pharyngeal flap procedures remains uncertain in contrast to that of primary cleft lip repair and palatoplasty. Therefore, this study aimed to reveal factors inhibiting maxillary growth and inducing later orthognathic surgery. A retrospective analysis was conducted on the data of patients with cleft lip and palate who underwent a series of treatments at Keio University Hospital from 1990 to 2000. We collected data on patient sex, cleft type, number and timing of lip revision surgery, the incidence of palatal fistulae, history of pharyngeal flap procedures, and timing of a repeat bone graft, and reviewed whether these patients underwent orthognathic surgery later in life. Multivariate analysis was conducted using binary logistic regression to extract factors affecting later orthognathic surgery. A total of 52 patients were included in this study. Results showed that revision surgery conducted more than twice was the highest statistically significant predictor of later orthognathic surgery in patients with a cleft lip and palate ( P <0.05, odds ratio=43.3), followed by palatal fistula occurrence after cleft palate repair ( P <0.05, odds ratio=22.3). Therefore, primary surgical procedure is most important for these patients.

Speech assessment following microsurgical soft palate repair

The aim of this study was to analyze speech intelligibility of children, who had undergone microsurgical soft palate repair according to Sommerlad. Cleft palate patients were treated by closure of the soft palate according to Sommerlad at about 6 months of age. At the age of 11, their speech was evaluated through automatic speech recognition. Word recognition rate (WR) was used as the outcome parameter of automatic speech recognition. To validate automatic speech results, an institute for speech therapy evaluated the speech samples for perceptual intelligibility. The results of this study group were compared to an age-matched control group. A total of 61 children were evaluated in this study, 29 in the study group and 32 in the control group. Study group patients had a lower word recognition rate (mean 43.03, SD 12.31) compared to the control group (mean 49.98, SD 12.54, p = 0.033). The magnitude of the difference was considered small (95% CI of the difference 0.6-13.3). The study group patients received significantly lower scores in the perceptual evaluation (mean 1.82, SD 0.58) compared to the control group mean (mean 1.51, SD 0.48, p = 0.028). Again, the magnitude of the difference was small (95% CI of the difference 0.03-0.57). Within the limitations of the study it seems that microsurgical soft palate repair according to Sommerlad at the age of 6 months might be a relevant alternative to other well established surgical techniques.

Otomicroscopic and functional outcomes after cleft palate repair via Sommerlad intravelar veloplasty vs. modified Veau-Wardill-Kilner push-back

OBJECTIVE

We aim to compare the modified Veau-Wardill-Kilner push-back technique (VWK) and the Sommerlad intravelar veloplasty (Sommerlad IVVP) in terms of middle ear outcomes and oronasal fistulae frequency in three years old children.

METHODS

For this retrospective cohort study, data were collected and anonymized from consecutive patients with cleft palate (with or without cleft lip) who underwent surgery in our hospital between January 2008 and December 2018. Patients with syndromic diagnoses and patients who underwent surgical treatment elsewhere were excluded. We collected data from 101 children (202 ears) regarding middle ear complications at the age of three, including acute otitis media, middle ear effusion, tympanic membrane retraction, tympanic membrane perforation, tympanic membrane atelectasis and chronic otitis media with cholesteatoma. In addition, the presence of oronasal fistulae and the number of ventilation tubes received by the age of three were recorded.

RESULTS

The odds of children having a normal middle ear evaluation were 3.07 (95% Confidence interval (95%CI): [1.52, 6.12]; p < 0.05) times higher when children received Sommerlad IVVP compared to modified VWK. With 40.7% compared to 26.7%, a significantly higher incidence of middle ear effusion was present in the modified VWK group compared to Sommerlad IVVP (X²(1) = 4.38, p < 0.05). Furthermore, this group needed significantly more ventilation tube reinsertions (X²(2) = 12.22, p < 0.05) and was found to have a significantly higher incidence of oronasal fistula (53.5% vs. 17.2%, X²(1) = 14.75, p < 0.05). The latter was significantly associated with a higher need for ventilation tube reinsertion (X²(1) = 7.34, p < 0.05).

CONCLUSION

This study shows superior middle ear outcomes and fewer oronasal fistulae after Sommerlad IVVP compared to modified Veau-Wardill-Kilner push-back at the age of three.

Criteria for early and late velopharyngoplasty in 61 children with cleft palate

BACKGROUND

Velopharyngeal insufficiency persists in 15 to 30% of children with cleft palate, despite early velar surgery. Pharyngoplasty using a superior pedicle flap is the most common secondary surgery to treat velopharyngeal insufficiency. This study aims to identify the criteria leading to indicate velopharyngoplasty in 3 groups of age.

MATERIALS AND METHODS

we conducted a retrospective single center study in the reference center for cleft palate in Paris from 2013 to 2016. We included 61 children with non-syndromic cleft operated on with a velopharyngoplasty for velopharyngeal insufficiency. Pre-operative speech and surgical assessments, as well as the operative reports of the children, were analyzed retrospectively using multivariate models.

RESULTS

We included 61 patients. The only criteria factor for an early velopharyngoplasty was the Pittsburgh Weighted Speech Scale (PWSS) score (OR 1.20, CI 95% 1.07 to 1.4 ; P=.006). Criteria for a late velopharyngoplasty were a degradation of the velopharyngeal function (OR 16.07, CI 95% 1.7 to 518.7 ; P=.041) and lost of follow-up (OR 5.78, CI 95% 3.9 to 4320 ; P=.017).

CONCLUSION

Criteria for early and late velopharyngoplasty were identified, and we demonstrated the insufficiency of Borel-Maisonny classification for scientific clinical study.

Primary cheilorhinoseptoplasty using the Talmant protocol in unilateral complete cleft lip: functional and aesthetic results on nasal correction and comparison with the Tennison-Malek protocol

Many surgical procedures used to treat patients with unilateral complete cleft lip do not include a complete primary rhinoseptoplasty, which is delayed until the end of growth as part of secondary surgery. Primary cheilorhinoseptoplasty using the Talmant technique has been performed at Lapeyronie University Hospital, Montpellier for 15 years. This retrospective study evaluated and compared the functional and aesthetic results obtained in such patients at 4-6 years after surgery with those obtained without primary rhinoseptoplasty in patients undergoing the Tennison-Malek technique. This study included a cohort of 60 children who presented a unilateral complete cleft lip: 29 were operated on with the Tennison-Malek technique and 31 with the Talmant technique. Three functional and 14 aesthetic criteria were evaluated. All functional criteria showed better results in the Talmant group: nocturnal nasal breathing (P < 0.001), incidence of closed rhinolalia (P = 0.0019), and presence of asymmetric nasal breathing (P < 0.001). Concerning the aesthetic results, all criteria evaluated on the frontal and basal photographs of each patient showed significantly better results in the Talmant technique group. The rate of satisfactory results was> 75% for 12 of the 14 criteria in the Talmant group, compared with none of the 14 criteria in the Tennison-Malek group.

Evaluation of cheiloplasty and palatoplasty on palate surface area in children with oral clefts: longitudinal study

This study evaluated the palatal surface area in children with different oral clefts after primary surgeries and at five years of age. This longitudinal study was composed by 216 digital models: unilateral complete cleft lip (UCL), unilateral complete cleft lip and palate (UCLP), and complete cleft palate (CP). The models were analysed at four time periods: T1 (before cheiloplasty), T2 (before palatoplasty), T3 (after palatoplasty); and T4 - (at five years of age). Area of the dental arches was measured through stereophotogrammetry software. Measurements evaluated with Student's test and ANOVA followed by the Tukey test (p<0.05) (AQ 1). In the UCL group, the palatal surface area significantly increased among phases. In the primary surgery periods, UCLP and CP significantly decreased (p<0.001). Palatal area in the UCLP group was significantly greater than the CP group. Overall, no statistically significant differences occurred among groups. At T4, the area of the palate in the UCL group was significantly greater than the UCLP group and no significant differences occurred between UCLP and CP groups. This study suggests that cheiloplasty did not inhibit the growth of the palatal surface area in children with UCL and UCLP. Palatoplasty significantly decreased the palatal area in children with UCLP and CP, demonstrating a significant negative effect of palatal repair on maxillary growth. At five years, children with UCLP and CP had a significantly smaller palate area than those with UCL.

Cleft Palate Repair: A History of Techniques and Variations

Orofacial clefting is a common reconstructive surgical condition that often involves the palate. Cleft palate repair has evolved over three centuries from merely achieving anatomical closure to prioritizing speech development and avoiding midface hypoplasia. Despite centuries of advancements, there is still substantial controversy and variable consensus on technique, timing, and sequence of cleft palate repair procedures. Furthermore, evaluating the success of various techniques is hindered by a lack of universal outcome metrics and difficulty maintaining long-term follow-up. This article presents the current controversies of cleft palate repair and details how the history of cleft palate repair has influenced current techniques commonly used worldwide. Our review highlights the need for a global consortium on cleft care to gather expert opinions on current practices and outcomes and to standardize technique classifications. An understanding of global protocols is crucial in an attempt to standardize technique and timing to achieve anatomical closure with optimal velopharyngeal competence, while also minimizing the occurrence of maxillary hypoplasia and palatal fistulae.

Quality of life and phonatory and morphological outcomes in cognitively unimpaired adolescents with Pierre Robin sequence: a cross-sectional study of 72 patients

Background

Pierre Robin sequence (PRS) is a heterogeneous condition involving retro(micro)gnathia, glossoptosis and upper airway obstruction, very often with posterior cleft palate. Patients with PRS, either isolated or associated with Stickler syndrome have good intellectual prognosis. Nevertheless, the quality of life in adolescence and the phonatory and morphological outcomes are rarely analysed. We assessed the phonatory and morphological outcomes of 72 cognitively unimpaired adolescents with PRS, studied their oral (COHIP-SF19), vocal (VHI-9i) and generic quality of life (QoL; KIDSCREEN-52), and searched for determinants of these outcomes.

Results

Two-thirds of our adolescents retained low or moderate phonation difficulties, but risk factors were not identified. For 14%, morphological results were considered disharmonious, with no link to neonatal retrognathia severity. Only one vs two-stage surgery seemed to affect final aesthetic results. The oral QoL of these adolescents was comparable to that of control patients and was significantly better than that of children with other craniofacial malformations (COHIP-SF19 = 17.5, 15.4 and 25.7, respectively). The oral QoL of the adolescents with non-isolated PRS was significantly worse (COHIP-SF19 = 24.2) than that of control patients and close to that of children with other craniofacial malformations. The vocal QoL of the adolescents (mean [SD] VHI-9i = 7.5 [5.4]) was better than that of patients with other voice pathologies and better when phonation was good. The generic QoL of the adolescents was satisfactory but slightly lower than that of controls, especially in dimensions concerning physical well-being, relationships and autonomy. QoL results were lower for adolescents with non-isolated than isolated PRS. Only non-isolated PRS and low oral QoL affected generic QoL.

Conclusion

Morphological or phonatory impairments remain non-rare in adolescents with PRS but do not seem to be directly responsible for altered QoL. These adolescents, especially those with non-isolated PRS, show self-confidence and social-relation fragility. We must focus on long-term functional and psychological results for PRS patients and improve therapy protocols and follow-up, notably those affecting the oral aspects of the disease.

Treatment Outcome in Bilateral Cleft lip and Palate Patients Evaluated With the Huddart-Bodenham Scoring System and the Bilateral Cleft lip and Palate Yardstick: A Systematic Review

Objectives

To assess treatment outcome (transversal and sagittal dental arch relationships) and its determinants in complete bilateral cleft lip and palate (BCLP) evaluated with the modified Huddart-Bodenham scoring system and the BCLP Yardstick.

Materials and methods

Multiple electronic databases were searched without time limitation. Randomized clinical trials, cohort and case control studies using BCLP Yardstick and/or modified Huddart-Bodenham system to judge treatment outcome of patients with BCLP were included. The Risk of Bias in Nonrandomized Studies of Interventions tool and Grading of Recommendations, Assessment, Development, and Evaluation was used.

Results

Of the 528 studies identified by the electronic search, only eight retrospective studies met the inclusion criteria and were included. A total of 12 cleft centers were represented. All treatment protocols differed and background information was underreported. The results for the BCLP yardstick showed that all except the centers in New Zealand had a mean score lower than 3, indicating good treatment results. However, these studies had a moderate to high risk of bias. The modified Huddart-Bodenham scores were negative in all studies. No further meta-analysis was done due to heterogeneity and high risk of bias. The quality of evidence was graded as very low.

Conclusion

Results for the dental arch relationship of studies in complete BCLP and possible determinants were not synthesized due to very low quality of evidence. Clinical research for patients with BCLP should focus on sound methodological designs to enable evidence-based decision making to improve treatment for patients with BCLP and thereby hopefully their quality of life.

The effect of intervelar veloplasty under magnification (Sommerlad's Technique) without tympanostomy on middle ear effusion in cleft palate patients

Objective

Different surgical techniques and management approaches have been introduced to manage the cleft palate (CP) and its complications, such as otitis media with effusion (OME) and auditory problems. The optimal method, as well as the ideal time for palatoplasty and ventilation tube insertion, are the subject of controversy in the literature. We aimed to evaluate The Effect of Intervelar Veloplasty under Magnification (Sommerlad’s Technique) without Tympanostomy on Middle Ear Effusion in Cleft Palate Patients.

Methods

non-syndromic cleft palate patients from birth to 24 months who needed primary palatoplasty from April 2017 to 2019 were enrolled in this study. intravelar veloplasty (IVVP) surgery under magnification has been done by the same surgeon. Likewise, Otoscopy, Auditory Brainstem Response (ABR), and tympanometry were performed for all the patients before and six months after palatoplasty.

Results

Tympanograms were classified into two categories according to shape and middle ear pressure, and it was done in 42 children (84 ears). Type B curve was seen in 40 cases (80 ears) before surgery which reduced significantly (P < 0.005) to 12 cases in the left ear and 14 cases in the right ear after surgery. So, after surgery, 70 % of the tympanogram of left ears and 66.6 % of the tympanogram of Rt ears were in normal condition (type A tympanometry). ABR was done for 43 patients (86 ears) before surgery and six months after palatoplasty. Data were shown that 40 of the patients had mild to moderate hearing loss before surgery, which reduced significantly (P < 0.005) to 9 in the left ear and 11 in the right ear after palatoplasty. So, after surgery, 79 % of ABR of left ears and 73.8 % of ABR of right ears were in normal status (normal hearing threshold).

Conclusions

Intervelar veloplasty under magnification (Sommerlad’s technique) significantly improved the middle ear effusion without the need for tympanostomy tube insertion.

Optimizing speech outcomes for cleft palate

PURPOSE OF REVIEW

Cleft lip with or without palate is one of the most common pediatric birth anomalies. Patients with cleft palate often have speech difficulties from underlying anatomical defects that can persist after surgery. This significantly impacts child development. There is a lack of evidence exploring, which surgical techniques optimize speech outcomes. The purpose of this update is to report on recent literature investigating how to optimize speech outcomes for cleft palate.

RECENT FINDINGS

The two-flap palatoplasty with intravelar veloplasty (IVVP) and Furlow double-opposing Z-plasty has the strongest evidence for optimizing speech. One-stage palatal repair is favored at 10-14 months of age, while delays are associated with significant speech deficits. For postoperative speech deficits, there is no significant difference between the pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation. Surgical management should be guided by closure pattern and velopharyngeal gap but few studies stratify by these characteristics.

SUMMARY

According to recent evidence, the two-flap palatoplasty with IVVP and Furlow palatoplasty result in the best speech. The pharyngeal flap, sphincter pharyngoplasty, and posterior pharyngeal wall augmentation are all viable techniques to correct residual velopharyngeal insufficiency. Future research should focus on incorporating standardized measures and more robust study designs.

Coverage, reporting degree and design of the Swedish quality registry for patients born with cleft lip and/or palate

Background

The objective of the Swedish cleft lip and palate (CLP) registry is to promote quality control, research and improvement of treatment, by comparison of the long-term results of surgery, orthodontics and speech from all six Swedish CLP centres. The purpose of the study was to investigate the coverage and reporting degree of the Swedish CLP registry, and to describe the design of the registry and discuss questions of reliability and validity of the data included.

Methods

All six Swedish CLP centres participate in the registry. All children in Sweden with cleft lip and/or cleft palate, born from 2009 onwards, are included in the registry. Baseline data such as cleft type (ICD-10 diagnosis), heredity, birth weight and additional deformities and/or syndromes, as well as pre-surgical treatment, are recorded at first visit. Data on surgical treatment are recorded continuously. Treatment outcome regarding dentofacial development and speech are recorded at follow-ups at 5, 10, 16 and 19 years of age. Data on dentofacial development are also recorded 1 year after orthognathic surgery. In addition, data on babbling and speech are recorded at 18 months of age. Coverage degree and reporting degree of surgery was assessed by comparison with registrations in the Swedish Central patient registry. Reporting degree of orthodontic and speech registrations at 5 years of age was assessed by comparison with registrations at baseline.

Results

The average coverage degree for children born 2009 to 2018 was 95.1%. For cleft-related surgeries, the average reporting degree was 92.4%. Average reporting degree of orthodontic registrations and speech registrations at age 5 years was 92 and 97.5% respectively.

Conclusion

In order to achieve valid and reliable data in a healthcare quality registry, the degree of coverage and reporting needs to be high, the variables included should be limited and checked for reliability, and the professionals must calibrate themselves regularly. The Swedish CLP registry fulfils these requirements.

Speech outcome after intravelar veloplasty

OBJECTIVE

Cleft lip and palate is the main craniofacial malformation in France. Many surgical techniques had been described to restore cleft palate. In this study, we evaluate phonation in a homogeneous series of patient with isolated unilateral non-syndromic cleft lip and palate before (and after) alveolar cleft closure, operated according to our surgical protocol.

METHODS

We included retrospectively 71 patients with isolated non-syndromic unilateral cleft lip and palate (UCLP), operated in our department from 2009 to 2013. All patients underwent the same surgical protocol: modified Millard cheilorhinoplasty (from 5 to 9-month-old); direct hard palatal closure (from 12 to 20-month-old); alveolar cleft closure with cancellous iliac bone graft (from 4 to 6-year-old). The phonation and clinical statute were evaluated before and after alveolar cleft closure. Fistula rate and speech evaluation were recorded.

RESULTS

The rate of oronasal fistula was 12.7%. About phonation, 76% and 86% of patients were competent or borderline competent respectively before and after gingivoperiostoplasty.

CONCLUSION

This surgical protocol provided speech results in patients with isolated unilateral non-syndromic cleft lip and palate. The gingivoperiostoplasty improved the speech intelligibility.

Benchmarking Speech, Velopharyngeal Function Outcomes and Surgical Characteristics Following the Sommerlad Protocol and Palate Repair Technique

Objective:

To report speech and velopharyngeal function (VPF) outcomes, and surgical characteristics, at age 5 following early complete palate closure using the Sommerlad protocol.

Design:

A retrospective, descriptive, cross-sectional consecutive series.

Setting:

A regional twin site center; a district general hospital and tertiary children’s hospital.

Participants:

Between 1993 and 2006, 877 participants underwent surgery; 712 (81%) were eligible for inclusion; 391 (55%) were included, 321 (45%) excluded. Thirteen percent had bilateral cleft lip and palate (CLP), 40% unilateral CLP, and 47% isolated cleft palate.

Intervention:

Lip and vomerine flap repair at 3 months of age (BCLP, UCLP) with soft palate closure using radical muscle dissection and retropositioning at a mean age of 6.6 months, range 4 to 23 months, as described and undertaken by Sommerlad.

Outcome Measures:

Velopharyngeal Composite (VPC) CAPS-A and articulation summary scores derived from analysis using the Cleft Audit Protocol for Speech-Augmented.

Results:

A VPC-SUM CAPS-A score of “0” was found in 97% reflecting adequate VPF; 73% had no cleft articulation difficulties. The BCLP group had the poorest articulation. Secondary speech surgery rate was 2.6% and 10.7% had fistula repair. Levator muscle quality and degree of retropositioning was associated with speech outcomes related to VPF. 2.6% had current features of VPI.

Conclusions:

Complete palate closure by around 6 months of age by the surgeon who described the technique led to excellent perceived VPF and very good speech outcomes at age 5, with less speech therapy and secondary speech surgery than commonly reported. These findings serve as a benchmark for the Sommerlad protocol and technique.

Facial profile and maxillary arch dimensions in unilateral cleft lip and palate children in the mixed dentition stage

Objectives:

The aim of this study was to evaluate the vertical and sagittal facial profile and maxillary arch width, depth, and length of patients with unilateral cleft lip and palate (UCLP) and to compare them with healthy noncleft children in the mixed dentition stage (7–13 years).

Materials and Methods:

This study is conducted at Hospital Universiti Sains Malaysia. UCLP group comprised 48 patients with nonsyndromic UCLP who have had the lip and palate repaired, whereas the control group comprised 48 healthy noncleft cases. The lateral cephalometrics measurements were used to determine the vertical height, sagittal depth of the face, and cranial base length and angle. Maxillary arch dimensions were measured on the study cast including arch width, depth, and length.

Results:

Vertical facial height and sagittal depth measurements showed a significant decrease (P < 0.05) in the mean growth pattern in UCLP group. The anterior cranial base length (S-N) was shorter in UCLP children (P < 0.001), while Ba-N length had no significant difference (P = 0.639). Nasion-Sella Tursica-Basion angle was significantly higher in the UCLP group (P = 0.016). Dental arch width with reference to canine-to-canine and first premolar-to- first premolar distance was significantly larger in control (P = 0.001).

Conclusion:

Mean vertical and sagittal facial dimensions in the UCLP children who do not undergo orthodontic treatment are significantly lesser in all directions of growth than healthy noncleft children. The maxillary dental arch had a normal depth but constricted in width and arch length.

The incidence of velopharyngeal insufficiency and oronasal fistula after primary palatal surgery with Sommerlad intravelar veloplasty: A retrospective study in Isfahan Cleft Care Team

OBJECTIVES

This study was designed to determine the incidence of velopharyngeal insufficiency (VPI), oronasal fistula development and facial grimace in patients seen by Isfahan Cleft Care Team (ICCT) after primary Sommerlad intravelar veloplasty (SIVV). Furthermore the association of gender, cleft type and age at primary surgery with the incidence of hypernasality and fistula is determined.

METHODS

A group of 40 patients with history of cleft palate with or without cleft lip were identified from the records of ICCT between 2011 and 2014. The main outcome measures were the incidence of hypernasality and fistula after primary palate repair with SIVV. Speech recordings were analyzed by consensus by two speech therapists according to the Cleft Audit Protocol for Speech- Augmented (CAPS-A), (Kappa = 82.4). Deciding whether or not to have a fistula was based on the oral examination videos.

RESULTS

Severe and moderate hypernasality was observed in 42.5% of patients. Normal resonance and mild/borderline hypernasality was observed in 37.5% and 20% of patients, respectively. The frequency of fistulas was 7.5%. There was a significant association between hypernasality with cleft type and the age at primary surgery (p < 0.05).

CONCLUSION

Significant progress has been made in the outcomes of the primary palate surgeries with the SIVV technique compared to the previous study in the ICCT.

Orofacial myofunctional evaluation in cleft lip and palate: an integrative literature review

ABSTRACT Purpose: to identify the focus of scientific publications in the field of orofacial motricity in individuals with cleft lip and palate, as well as validated protocols used in speech and language evaluation. Methods: a study conducted using the following databases: Medline, SciELO, Lilacs and Google Scholar, through keywords including: cleft palate + cleft lip + evaluation + speech therapy + stomatognathic system + speech + phonation + chewing + swallowing + breathing + validation studies, in Portuguese and English. Results: a total of 572 articles that addressed the evaluation of the stomatognathic system was selected. The articles were published between 2012 and 2017, and examined for year of publication, subject area, focus, instrument used for evaluation, and type of study. Of these, 90 articles met the inclusion criteria, but only 5 used validated protocols. The greatest number of articles was published in 2014. The studies covered broad age groups, using subjective and objective methods, and instruments were often non-standardized. Conclusion: speech was the prevalent theme, while other orofacial functions were poorly investigated, demonstrating that studies with other approaches were lacking.

Effect of palatoplasty on speech, dental occlusion issues and upper dental arch in children and adolescents with cleft palate: an integrative literature review

ABSTRACT Purpose: to compile acquired knowledge related to speech, maxillary growth, dental arch and dental occlusion issues of subjects with cleft palate (associated or not with cleft lip), relating them to the found structural and morphological changes, along with time of surgery and surgical technique employed in palatoplasty. Methods: a search was carried out on four databases, namely: PubMed, SciELO, LILACS and MEDLINE, between May and August, 2018. The following descriptors, in Portuguese and in their corresponding terms in English, were used: cleft palate, speech, oral surgery or palatoplasty, teeth or dental arch. Results: altogether, 92 articles were found in the four databases. Eleven articles met the established selection criteria, thus, included in this review. According to the findings, the palatoplasty surgical technique influences speech, maxillary growth and dental occlusal issues; however, it is still unclear which technique is more beneficial to the subjects with cleft palate. Conclusion: results found in these 11 studies are divergent in regard to the surgical technique which most favors the development of speech, dental arches and maxillary growth. Therefore, it is important that new researches be carried out relating the aspects of speech, facial growth, dental occlusion and dental arch in the subjects with cleft palate, to the technique and the time of palatoplasty.

Anthropometric Analysis of the Dental Arches of Five-Year-Old Children With Cleft Lip and Palate

This study aimed to analyze the dimensional alterations of the dental arches of 5-year-old children with cleft lip and palate and to compare these dimensions with children without oral clefts. One hundred twenty children were divided into the following groups: unilateral cleft lip (UCL), unilateral cleft lip and palate (UCLP), cleft palate (CP), and control (C). A specific software was used to digitize the dental casts and perform the anthropometric analyses through the measurement of transversal linear intercanine and intermolar distances on the maxilla and mandible. The intergroup comparisons of the maxillary dimensions exhibited that the intercanine distances of groups C and UCL were statistically greater than that of groups UCLP and CP. The intermolar distance was significantly smaller in group UCLP than in the other groups. No statistically significant difference occurred in the mandibular intercanine and intermolar distance among groups. The analysis of the superposition of the maxillary over the mandibular transversal distances showed statistically significant differences among groups. This study showed that at 5-year old, the children with cleft involving the palate had more maxillary dimensional alterations than those without cleft palate.

Transverse Maxillary Development in Complete Cleft Patients: Comparison of 2 Treatment Strategies by Longitudinal and Cross-Sectional Model Analysis

Objective:

This study aimed to compare differences in the maxillary transverse dimension following cleft repair using 2 protocols involving a 2-staged palatal closure with similar timing but different techniques.

Design:

Retrospective study. Two matched study samples, each containing 10 patients.

Setting:

Cleft center A is a university hospital. Cleft Center B is a general teaching hospital.

Patients:

Patients with cleft lip alveolus and palate (CLAP) were matched by cleft type, gender, age, and palatal morphology at the age of 1 month. Differences in the transverse dimension were measured at 4 ages in 2 matched groups (A and B from center A and B), each including 5 patients with unilateral CLAP (UCLAP) and 5 patients with bilateral CLAP (BCLAP).

Interventions:

Orthodontic/orthopedic expansion treatment began at 8 and 5 years of age at centers A and B, respectively.

Results:

The mean intercanine distance decreased by 8 mm (standard deviation [SD] = 1.6; P = .030) in group A patients with UCLAP between 1 and 5 years (SD = 1.6; P = .030) and by 6.3 mm (SD = 3.2; P = .016) in group B patients with BCLAP. The mean intermolar distance increased by 4 mm (SD = 3.4; P = .076) in patients with BCLAP. A trend toward improved canine positioning was observed in patients with BCLAP by 12 years of age, with improvement occurring between 4 and 12 years.

Conclusion:

The type of palatal closure (inducing scar tissue at the bony level) and the late installment of orthodontic/orthopedic expansion probably reduced the intercanine width in bilateral complete clefts.

Otologic Outcomes With Two Different Surgical Protocols in Patients With a Cleft Palate: A Retrospective Study

OBJECTIVE

To compare otologic outcomes in patients with cleft palate who underwent 2 different surgical protocols.

DESIGN

Monocentric retrospective analysis of medical reports.

PATIENTS, PARTICIPANTS

All consecutively treated patients affected by a cleft palate, born between January 1998 and December 2002 (group 1) and between January 2007 and December 2010 (group 2).

INTERVENTIONS

Patients in group 1 underwent Veau-Wardill-Kilner palatoplasty at 10 months and had ventilation tubes inserted in case of otitis media with effusion (OME) during surgery. Patients in group 2 underwent Sommerlad intravelar veloplasty at 5 months. Ventilation tubes were inserted only in case of persistent OME.

MAIN OUTCOME MEASURE(S)

The need for a second set of ventilation tubes to be inserted in case of persistent OME, the presence of OME at the age of 2 years, and tympanic abnormalities at the age of 5 years were analyzed.

RESULTS

There was no statistically significant difference either for the presence of OME at the age of 2 years (27 [45%] vs 32 [57.14%], respectively, in groups 1 and 2; P = .191) or for tympanic abnormalities at the age of 5 years (20 [33.33%] vs 15 [26.79%]; P = .433). Statistically significant difference was found for the need to insert a second set of ventilation tubes in case of persistent OME (29 [48.33%] vs 12 [21.42%], respectively; P = .02).

CONCLUSION

Early Sommerlad intravelar veloplasty may reduce persistent OME and consequently the need for ventilation tubes insertion, compared to later Veau-Wardill-Kilner palatoplasty.

Speech outcomes following Sommerlad primary palatoplasty: Results of the Ghent University Hospital

OBJECTIVE AND SUBJECTS

Speech outcomes were described for 16 patients with cleft palate (mean age: 5.4 years) following Sommerlad primary palatoplasty performed by a single surgeon of the Ghent University Hospital. These speech outcomes were compared with those of an age and gender matched control group without cleft palate (mean age: 5.3 years).

METHODS

Speech intelligibility/distinctiveness, resonance, nasal airflow and articulation, were perceptually evaluated. Additionally, nasalance values and the NSI 2.0 were determined.

RESULTS

In seven patients, speech intelligibility/distinctiveness was disordered. Hypernasality was present in twelve participants, whereas nasal emission and nasal turbulence were perceived in thirteen and five patients respectively. Both perceptual and instrumental speech evaluations were significantly poorer in the patient group in comparison to the control group.

CONCLUSIONS

Patients still present with both obligatory and compensatory speech disorders following Sommerlad's palatoplasty. In the future, a Dutch speech assessment protocol will be developed in order to standardize follow-up of these patients and to allow for within-center and inter-center comparisons.

Delayed primary palatal closure in resource-poor countries: Speech results in Ugandan older children and young adults with cleft (lip and) palate

AIMS

Unrepaired clefts still regularly occur in resource-poor countries as a result of limited health-care access. The purpose of the present study was to report resonance, airflow and articulation characteristics following delayed (≥8years) primary palatal closure.

METHODS

Fifteen Ugandan participants with cleft (lip and) palate (CP±L) were included as well as 15 age- and gender-matched Ugandan subjects without clefts. Palatal closure was performed at a mean age of 15;10 years using the Sommerlad technique. Speech evaluations were carried out on a single occasion postoperatively (mean age: 18;10 years). Resonance and nasal airflow were perceptually evaluated and detailed phonetic and phonological assessments were carried out. Additionally, nasalance values were determined.

RESULTS

Nasal emission occurred postoperatively in only 27% (4/15) of the patients, whereas resonance disorders and articulation errors were prevalent in 87% (13/15) of the patient group. Compared with the control group, a significantly higher prevalence of hypernasality and significantly higher nasalance values for all oral and oronasal speech samples were obtained in the CP±L group. Moreover, significantly smaller consonant inventories and significantly more phonetic and phonological disorders were observed.

CONCLUSIONS

Delayed palatal repair (≥8years) seems to be insufficient to eliminate nasal airflow errors, resonance abnormalities, and articulation disorders. In order to prevent patients' late presentation at specialized centers, the availability of high quality surgical cleft palate treatment should increase as well as people's awareness of the possibility and importance of early surgical intervention. Moreover, speech therapy following delayed palatal closure would be beneficial. Furthermore, a standardized and validated protocol for speech assessment in future studies is advocated.

Management of rare diseases of the Head, Neck and Teeth: results of a French population-based prospective 8-year study

BACKGROUND

In the last ten years, national rare disease networks have been established in France, including national centres of expertise and regional ones, with storage of patient data in a bioinformatics tool. The aim was to contribute to the development and evaluation of health strategies to improve the management of patients with rare diseases. The objective of this study has been to provide the first national-level data concerning rare diseases of the head, neck and teeth and to assess the balance between demand and supply of care in France.

METHODS

Centres of expertise for rare diseases record a minimum data set on their clinical cases, using a list of rare Head, Neck and Teeth diseases established in 2006. The present analysis focuses on 2008 to 2015 data based on the Orphanet nomenclature. Each rare disease RD "case" was defined by status "affected" and by the degree of diagnostic certainty, encoded as: confirmed, probable or non-classifiable. Analysed parameters, presented with their 95% confidence intervals using a Poisson model, were the following: time and age at diagnosis, proportions of crude and standardized RD prevalence by age, gender and geographical site. The criteria studied were the proportions of patients in Paris Region and the "included cases geography", in which these proportions were projected onto the other French Regions, adjusting for local populations.

RESULTS

In Paris Region, estimated prevalence of these diseases was 5.58 per 10,000 inhabitants (95% CI 4.3-7.1). At December 31st 2015, 11,342 patients were referenced in total in France, of whom 7294 were in Paris Region. More than 580 individual clinical entities (ORPHA code) were identified with their respective frequencies. Most abnormalities were diagnosed antenatally. Nearly 80% of patients recorded come to Paris hospitals to obtain either diagnosis, care or follow up. We observed that the rarer the disease, the more patients were referred to Paris hospitals.

CONCLUSIONS

A health network covering a range of aspects of the rare diseases problematic from diagnostics to research has been developed in France. Despite this, there is still a noticeable imbalance between health care supply and demand in this area.

Comparison of dental arch dimensions in models of preschool children with cleft lip/palate repaired by means of surgery alone versus controls

BACKGROUND

Cleft lip and palate (CLP) anomaly is one of the most prevalent congenital defects causing disturbances of dental arch dimensions. This study aimed at investigating differences in these dimensions between preschool children with cleft lip/palate and a matched control group representing healthy individuals with normal occlusion (NO).

MATERIALS AND METHODS

The sample of this cross-sectional analytical study consisted of 108 plaster models of children aged from 4 to 5.5 years. They were divided into five groups: the cleft lip group, the cleft palate (CP) group, the unilateral cleft lip and palate group, the bilateral cleft lip and palate group, and the NO group. The NO group was used as a control group. All cleft-affected children were treated only with surgery. Dental arch length and widths were measured.

RESULTS

The dental arch dimensions of the cleft lip group were nearly similar to those in the controls. Moreover, the mandibular transverse widths of the CP group were close to those in the controls. However, the mandibular arch length and all maxillary dimensions of the CP group were smaller than those in the controls. In the unilateral cleft lip and palate group, the arch lengths in both jaws and the maxillary transverse widths were smaller than those in the controls, whereas the mandibular transverse widths were similar to those in the controls. In the bilateral cleft lip and palate group, the arch lengths in both jaws were close to those in the controls, but both arches were narrower than those in the controls.

CONCLUSION AND RECOMMENDATIONS

The various types of CLP were found to be associated with differences in most maxillary and some mandibular arch dimensions. These data can be used for cleft patient counseling and treatment planning.

Five-year speech and language outcomes in children with cleft lip-palate

OBJECTIVE

To investigate 5-year speech and language outcomes in children with cleft lip/palate (CLP).

MATERIALS AND METHODS

Thirty-eight children aged 4-7 years and 8 months were recruited for this study. Speech abilities including articulation, resonance, voice, and intelligibility were assessed based on Thai Universal Parameters of Speech Outcomes. Language ability was assessed by the Language Screening Test.

RESULTS

The findings revealed that children with clefts had speech and language delay, abnormal understandability, resonance abnormality, and voice disturbance; articulation defects that were 8.33 (1.75, 22.47), 50.00 (32.92, 67.08), 36.11 (20.82, 53.78), 30.56 (16.35, 48.11), and 94.44 (81.34, 99.32).

CONCLUSIONS

Articulation errors were the most common speech and language defects in children with clefts, followed by abnormal understandability, resonance abnormality, and voice disturbance. These results should be of critical concern. Protocol reviewing and early intervention programs are needed for improved speech outcomes.