Pharyngeal Flap Is Effective Treatment for Post Maxillary Advancement Velopharyngeal Insufficiency in Patients With Repaired Cleft Lip and Palate

Secondary surgery techniques to optimise functional and aesthetic outcomes in orofacial clefting

Although the goal of primary surgery is to avoid the need for secondary surgery, in a proportion of patients this is not always possible. Secondary, or revisional, surgery is frequently undertaken in patients with orofacial clefts and may present a complex and challenging problem for the multidisciplinary team. There are a broad range of functional and aesthetic issues that secondary surgery might aim to address. These include palatal fistulae (that may be symptomatic for air, fluid or food), velopharyngeal insufficiency (typically manifesting with decreased intelligibility or nasal regurgitation), suboptimal cleft lip scars (that can significantly impact upon the psychosocial wellbeing of the patient), and nasal asymmetry (that is frequently accompanied by nasal airway concerns). Unilateral and bilateral clefts are each associated with a characteristic nasal deformity that requires a tailored surgical approach. Suboptimal maxillary growth in repaired orofacial clefts may impact negatively on both appearance and function; surgical correction through orthognathic surgery can be transformational for the patient. The general dental practitioner, cleft orthodontist and restorative dentist all play a critical role in this process.

A Preliminary Management Algorithm for Velopharyngeal Insufficiency in Cleft-Orthognathic Patients

PURPOSE

Patients born with a cleft palate often suffer from velopharyngeal insufficiency (VPI) due to the soft palate musculature's abnormal structure. Surgical correction of the palate at a young age can hinder maxillary growth, requiring surgical correction of the maxillomandibular discrepancy at skeletal maturity. Orthognathic surgery can then cause or further exacerbate VPI in these patients. The purpose of this paper is to assess cleft-orthognathic patients under the lens of persistent or newly-developed VPI, to understand outcomes and generate a targeted management algorithm.

METHODS

A retrospective study was performed inspecting cleft-orthognathic patients presenting to a single surgeon. Patients with sufficient follow-up were placed into predefined algorithmic cohorts by their VPI development pattern in relation to orthognathic surgery. They were further stratified into groups by level of adherence to our algorithm to evaluate VPI outcomes. Demographic factors, risk factors, and outcomes were compared between groups via Welch t test and Fisher exact test.

RESULTS

Fifty-one patients were examined, including 16 with VPI. Velopharyngeal insufficiency fully resolved amongst all algorithmically adherent patients and remained in nonadherent patients (P < 0.001).

CONCLUSIONS

Our targeted algorithm may improve symptoms and the management of VPI in cleft-orthognathic patients. Multi-centered studies with larger sample sizes and prospective studies are encouraged to validate our proposed treatment algorithm further.

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.

Evaluation of velopharyngeal function using high-speed cine-magnetic resonance imaging based on T2-weighted sequences: a preliminary study

The objective was to introduce a new technique for visualizing the three-dimensional (3D) movements of velopharyngeal-related muscles using high-speed cine-magnetic resonance imaging (MRI) based on T2-weighted sequences. The evaluation of phonation- and water swallowing-related events was performed in 11 healthy subjects. Specifically, whether cine-MRI could precisely visualize normal velopharyngeal function during these two events was examined. The 3D movements of the soft palate, superior pharyngeal constrictor muscles, and levator veli palatini muscles were visualized in all 11 subjects. A noteworthy finding was that the magnetic resonance signals of the superior constrictor pharyngeal muscles and the levator veli palatini muscles were significantly higher during phonation and during water swallowing than at rest. This initial study suggests that the 3D movements of velopharyngeal-related muscles can be successfully and precisely visualized without side effects. The magnetic resonance signal changes seen in the superior pharyngeal constrictor and levator veli palatini muscles using the technique described here should be useful to develop better methods of evaluation of velopharyngeal function.

Patient With Cleft Maxillary Hypoplasia Who Underwent Distraction Osteogenesis and Conservative Therapies to Postoperative Velopharyngeal Insufficiency

The authors performed distraction osteogenesis using The Maxillary Distractor System (SYNTHES) to maxillary hypoplasia patient with cleft lip palate, and consequently improved the aesthetic complexion of the patient. Velopharyngeal insufficiency developed after bone elongation; the authors improved the insufficiency with conservative therapies such as articulatory training using the bulb attached palatal lift prosthesis. The authors were successful and accepted postoperative speech outcome.