Effects of Orthognathic Surgery on Speech and Breathing of Subjects With Cleft Lip and Palate: Acoustic and Aerodynamic Assessment

The Impact of Maxillary Osteotomy on Fricatives in Cleft Lip and Palate: A Perceptual Speech and Acoustic Study

INTRODUCTION

Abnormal facial growth is a recognized outcome in cleft lip and palate (CLP), resulting in a concave profile and a class III occlusal status. Maxillary osteotomy (MO) is undertaken to correct this facial deformity, and the surgery can impact speech articulation, although the evidence remains limited and ill-defined for the CLP population.

AIMS

The aim of the study was to investigate the impact of MO on the production of the fricatives /f/ and /s/, using perceptual and acoustic analyses, and to explore the nature of speech changes.

METHODS

Twenty participants with CLP were seen 0-3 months pre-operatively (T1) and 3 months (T2) and 12 months (T3) after MO. A normal group (N = 20) was similarly recruited. Perceptual speech data was collected according to a validated framework and ratings made on audio and audio-video recordings (VIDRat). Spectral moments were centre of gravity (CG), standard deviation (SD), skewness (SK) and kurtosis (KU). Reliability studies were carried out for all speech analyses.

RESULTS

For the CLP group, VIDRat identified dentalization/interdentalization as the main type of pre-operative error for /s/ with a statistically significant improvement over time, χ2(2) = 6.889, p = 0.032. Effect sizes were medium between T1 and T3 (d = 0.631) and small between T2 and T3 (d = 0.194). For the acoustic data, effect sizes were similarly medium between T1 and T2 (e.g., SK, /f/ d = 0.579, /s/ d = 0.642) and small between T1 and T3 across all acoustic parameters. Independent t tests showed mainly statistically significant differences between both groups at all time points with large effect sizes (e.g., T2 CG, t = -4.571, p < 0.001, d =1.581), indicating that /s/ was not normalized post-operatively. For /f/, differences tended to be at T1 with large effect sizes (e.g., CG, t = -2.307, p = 0.028, d = 0.797), reflecting normalization.

CONCLUSIONS AND IMPLICATIONS

This is the first speech acoustic study on /f/ for individuals with CLP undergoing MO. The surgery has a positive impact on /f/ and /s/, which appear to stabilize 3 months post-operatively. Speech changes are an automatic and a direct consequence of the physical changes brought about by MO, effecting articulatory re-organization. The results of the study have direct clinical implications for the clinical care pathway for patients with CLP undergoing MO.

Le Fort I Osteotomy in Cleft Patients: Maxillary Advancement and Articulation

BACKGROUND

Maxillary advancement may affect speech in cleft patients.

AIMS

To examine whether the amount of maxillary advancement and preoperativecephalometric skeletal and dentoalveolar relationships are associated with articulation errors of the Finnish alveolar consonants /s/, /l/, and /r/ in cleft patients.

MATERIALS AND METHODS

Fifty-seven nonsyndromic cleft patients who underwent Le Fort I or bimaxillary osteotomies were evaluated retrospectively. Pre- and post-operative lateral cephalometric radiographs and standardized speech video recordings were analyzed. The Aspin-Welch unequal variance t test, Student t test sign test, intraclass correlation and Kappa statistics were used in the statistical analyses.

RESULTS

The mean advancement of the maxilla (point A) was 4.65 mm horizontally (range -2.80 to 11.30) and -3.82 mm vertically (range -14.20 to 3.90). The overall articulation (especially the sounds /s/ and /l/) improved significantly postoperatively, but the amount of maxillary advancement did not affect the articulation. The preoperative mean percentages of /s/, /l/, and /r/ errors were 32%, 33%, 46% and the postoperative percentages 23%, 19%, 40%, respectively. Preoperative articulation errors of /s/ were related to palatal inclination of the upper incisors.

CONCLUSIONS

Orthognathic surgery may improve articulation errors. The amount of maxillary advancement is not related to the improvement.

The impact of orthognathic surgery on quality of life in individuals with oral clefts

BACKGROUND/OBJECTIVES

To evaluate the relationships between individual, environmental, clinical factors and oral health-related quality of life (OHRQoL) in patients with cleft lip and palate (CLP) following orthognathic surgery.

MATERIALS AND METHODS

A follow-up study was conducted involving 69 adults with unilateral and bilateral CLP under orthodontic treatment. Interviews and oral examinations were conducted prior to orthognathic surgery (T0) to evaluate age, gender, psychological well-being, dental caries, malocclusion, social support, social networks, family income and education and OHRQoL. All participants were reviewed after 6 months (T1) to re-assess psychological well-being, malocclusion and OHRQoL. Structural equation modeling estimated the associations between the variables.

RESULTS

OHRQoL total scores reduced following orthognathic surgery, from 11.7 to 6.9 (P < 0.01). Occlusal characteristics and psychological well-being improved between T0 and T1. In the structural equation modeling, reduction of malocclusion (β = 0.02) between T0 and T1 directly predicted poor OHRQoL at T1. Improvement of psychological well-being between T0 and T1 was associated with better OHRQoL at T1 (β = -0.07). Dental caries and malocclusion at T0 were indirectly linked to poor OHRQoL at T1 (β = 0.02).

LIMITATIONS

The short follow-up period of 6 months after orthognathic surgery.

CONCLUSIONS/IMPLICATIONS

This represents the first prospective study examining the interrelationships of predictors of OHRQoL in patients with CLP after orthognathic surgery. OHRQoL and psychological well-being improved after orthognathic surgery. Clinical and psychological characteristics were important determinants of OHRQoL. These findings suggest the importance of the biopsychosocial model of health and the patient-centered approach in oral health care in individuals with CLP.

Preparation of a Protocol for Instrumental Assessment of Speech (PRAINF) based on psychometric and linguistic criteria

OBJECTIVE

Propose a protocol for instrumental assessment of adult speech considering psychometric and linguistic criteria.

METHODS

The choice of words was based on previously defined Brazilian Portuguese linguistic criteria after a search on the "Portal da Língua Portuguesa" database using the Portuguese Orthographic Vocabulary (VOP). The defined linguistic criteria considered grammatical class, vowel context, number of syllables, stress, and presence of words in the daily life of Brazilian adults. The choice of the images to represent the words considered the criteria of imageability, clearness, and cultural aspects. The words and images were rigorously evaluated by 13 non-specialist judges and six specialist judges. After being examined by the judges, the words were tested in adults through instrumental assessment.

RESULTS

The protocol was composed of 19 words and images, with prevalence of nouns over adjectives. Each word included one target sound in Onset Medial position, in the context precedent and following the vowel [a], trisyllabic and paroxytone words. The adults that attended the instrumental assessments succeeded in producing the list of words spontaneously. The data obtained through the assessments provided adequate analysis.

CONCLUSION

This study provided additional information on psychometric and linguistic criteria in addition to providing a protocol for instrumental assessment of adult speech.

Prosthodontic Rehabilitation of Arabic Speaking Individuals with Velopharyngeal Incompetence: A Preliminary Study

Background:

Hypernasality is a frequently encountered problem in the speech of individuals with velopharyngeal incompetence. The use of palatal lift appliance (PLA) is the main treatment option for correction of velopharyngeal incompetence. The literature on the outcomes of using prosthetics treatment for Arabic speaking patients is scarce.

Objective:

The aim of this study was to investigate the effect of using PLA on hypernasality of Arabic speaking patients with velopharyngeal incompetence.

Methods:

Six participants with age ranging from 9 to 61 years (4 males and 2 females) were recruited between October 2013 and August 2014. Written informed consents were taken from all the adult participants/the guardians of under-aged participants. All patients exhibited hypernasality with different etiologies for velopharyngeal incompetence (head injury, cerebrovascular accident, and neurological disorders). They were treated with PLAs which were constructed to elevate the dysfunctional soft palate. Nasalance scores and perceptual speech acceptability ratings were measured/evaluated in both situations; with and without appliances. Paired t-test was used to analyze the perceptual ratings and nasalance scores in order to detect any significant change in hypernasality pre and post insertion of PLA.

Results:

There was a statistically significant decrease (p>0.05) in nasalance scores (Pa, Pi, Ma, Mi, a, i) after PLA insertion. The subtest /u/ showed insignificant change (p= 0.056). Perceptual ratings showed significant reduction in hypernasality which was consistent with nasalance measurements.

Conclusion:

PLAs can reduce hypernasality in Arabic speaking patients who suffer from velopharyngeal impairment.

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.

Ressonância da fala após tratamento cirúrgico da insuficiência velofaríngea secundária à cirurgia ortognática

OBJETIVO:investigar o efeito da cirurgia corretiva da insuficiência velofaríngea sobre a ressonância da fala de indivíduos nascidos com fissura palatina que passaram a apresentar hipernasalidade, após a cirurgia ortognática.MÉTODOS:foram analisados os resultados da ressonância de 23 pacientes com fissura labiopalatina corrigida cirurgicamente que apresentavam ressonância oronasal equilibrada antes da cirurgia ortognática e foram submetidos à correção cirúrgica da insuficiência velofaríngea, devido ao aparecimento de hipernasalidade após a cirurgia ortognática. Os pacientes foram submetidos à avaliação perceptivo-auditiva da fala para classificação da hipernasalidade, em três situações: 3 dias antes e 5 meses, em média, após a cirurgia ortognática e, 13 meses, em média, após a cirurgia corretiva da insuficiência velofaríngea. A hipernasalidade foi classificada utilizando-se escala de 4 pontos: 1=ausência de hipernasalidade; 2=hipernasalidade leve; 3=moderada e 4=grave. Os escores de hipernasalidade nas três situações estudadas foram comparados por meio do teste de Friedman, com nível de significância de 5% e, posteriormente, pelo teste de Tukey para comparações múltiplas.RESULTADOS:do total de 23 pacientes, houve eliminação do sintoma de fala após a correção da insuficiência velofaríngea em 83% (19/23), sendo os escores médios de nasalidade antes da cirurgia ortognática=1, após a cirurgia ortognática=3 e após a correção da insuficiência velofaríngea=1. Houve diferença estatisticamente significante entre as três situações estudadas (p<0,001).CONCLUSÃO:a cirurgia corretiva da insuficiência velofaríngea foi um tratamento efetivo na grande maioria dos casos que apresentaram hipernasalidade secundária à cirurgia ortognática, com retorno à condição de normalidade.

Nasalance and nasality of tracheoesophageal speech in total laryngectomee

OBJECTIVES

The objective of this study was to determine the rates of nasalance for total laryngectomized users of a tracheoesophageal voice prosthesis and correlate them with the findings of auditory-perceptual assessment of nasality.

METHODS

In this study, 25 total laryngectomized users, including 20 men and five women, with a mean age of 63 years old participated. All the participants had a tracheoesophageal voice prosthesis and underwent treatment for the rehabilitation of tracheoesophageal communication. These patients were submitted to nasalance assessment using nasometry and auditory-perceptual evaluation of nasality and were rated by trained speech therapists.

RESULTS

The nasalance values obtained for nasal (59.92%) and oral (18.64%) sentences were within the normal limits for laryngeal speakers of Brazilian Portuguese language. It was possible to observe the presence of nasality in nasal sentences and its absence in oral sentences among most speakers. Specificity was found to be 100% for nasal sentences and sensitivity was 100% for oral sentences. It was not possible to calculate these values for the oral sentences.

CONCLUSIONS

Total laryngectomized patients with tracheoesophageal voice prostheses have adequate vocal nasality compatible with nasometry rates.

Effect of maxillary osteotomy on speech in cleft lip and palate: perceptual outcomes of velopharyngeal function

BACKGROUND

Abnormal facial growth is a well-known sequelae of cleft lip and palate (CLP) resulting in maxillary retrusion and a class III malocclusion. In 10-50% of cases, surgical correction involving advancement of the maxilla typically by osteotomy methods is required and normally undertaken in adolescence when facial growth is complete. Current evidence for the impact of the surgery on velopharyngeal function is weak and mixed.

AIMS

The first objective of the study was to investigate the nature of the effect of maxillary osteotomy on the perceptual outcomes of velopharyngeal function in CLP. The second objective was to establish if speech changes seen early at 3 months post-operation persisted for a year after/following surgery', when it is considered that the maxilla is relatively stable.

METHODS & PROCEDURES

Twenty consecutive patients with CLP undergoing maxillary osteotomy by a single surgeon were seen pre-operatively (T1), 3 months (T2) and 12 months (T3) post-operation. A non-cleft control group (NonCLP) undergoing surgery was also recruited. Speech data were collected using the Cleft Audit Protocol for Speech-Augmented (CAPS-A). A velopharyngeal composite score-summary (VPC-SUM) was derived from specific CAPS-A-rated parameters. An external CAPS-A-trained therapist, blinded to the study, rated the randomized samples and inter-rater reliability was established.

OUTCOMES & RESULTS

For the CLP group, hypernasality and nasal turbulence increased significantly post-operation. Planned comparisons were significant for T1-T2 only with a medium effect size. For hypernasality, the CLP group differed statistically from the NonCLP group at T2 and T3. For nasal turbulence, the CLP group differed statistically from the NonCLP group at T2. For VPC-SUM, there were statistically significant changes post-operatively between T1-T2 and T1-T3 only with medium effect sizes for the CLP group only.

CONCLUSIONS & IMPLICATIONS

This study provides evidence that maxillary osteotomy affects patients with and without CLP differently. In patients with CLP, surgery may impact negatively on velopharyngeal function for speech and changes seen early on at 3 months post-operatively appear to persist at 12 months postoperatively. The findings in this study have implications for the speech care pathway of patients with CLP undergoing maxillary osteotomy in terms of assessment, review and management.

Nasal symptoms and clinical findings in adult patients treated for unilateral cleft lip and palate

The aim of the study was to investigate self-experienced nasal symptoms among adults treated for UCLP and the association to clinical findings, and to evaluate whether palate closure in one-stage or two-stages affected the symptoms or clinical findings. All people with UCLP born between 1960-1987, treated at Uppsala University Hospital, were considered for participation in this cross-sectional population study with long-term follow-up. Eighty-three patients (76% participation rate) participated, a mean of 37 years after the first operation. Fifty-two patients were treated with one-stage palate closure and 31 with two-stage palate closure. An age-matched group of 67 non-cleft controls completed the same study protocol, which included a questionnaire regarding nasal symptoms, nasal inspection, anterior rhinoscopy, and nasal endoscopy. Patients reported a higher frequency of nasal symptoms compared with the control group, e.g., nasal obstruction (81% compared with 60%) and mouth breathing (20% compared with 5%). Patients also rated their nasal symptoms as having a more negative impact on their daily life and physical activities than controls. Nasal examination revealed higher frequencies of nasal deformities among patients. No positive correlation was found between nasal symptoms and severity of findings at nasal examination. No differences were identified between patients treated with one-stage and two-stage palate closure regarding symptoms or nasal findings. Adult patients treated for UCLP suffer from more nasal symptoms than controls. However, symptoms are not associated with findings at clinical nasal examination or method of palate closure.

Perceptual speech assessment after maxillary advancement osteotomy in patients with a repaired cleft lip and palate

Background

Maxillary hypoplasia refers to a deficiency in the growth of the maxilla commonly seen in patients with a repaired cleft palate. Those who develop maxillary hypoplasia can be offered a repositioning of the maxilla to a functional and esthetic position. Velopharyngeal dysfunction is one of the important problems affecting speech after maxillary advancement surgery. The aim of this study was to investigate the impact of maxillary advancement on repaired cleft palate patients without preoperative deterioration in speech compared with non-cleft palate patients.

Methods

Eighteen patients underwent Le Fort I osteotomy between 2005 and 2011. One patient was excluded due to preoperative deterioration in speech. Eight repaired cleft palate patients belonged to group A, and 9 non-cleft palate patients belonged to group B. Speech assessments were performed preoperatively and postoperatively by using a speech screening protocol that consisted of a list of single words designed by Ok-Ran Jung. Wilcoxon signed rank test was used to determine if there were significant differences between the preoperative and postoperative outcomes in each group A and B. And Mann-Whitney U test was used to determine if there were significant differences in the change of score between groups A and B.

Results

No patients had any noticeable change in speech production on perceptual assessment after maxillary advancement in our study. Furthermore, there were no significant differences between groups A and B.

Conclusions

Repaired cleft palate patients without preoperative velopharyngeal dysfunction would not have greater risk of deterioration of velopharyngeal function after maxillary advancement compared to non-cleft palate patients.

Cleft lip and/or palate and breathing during sleep

Cleft of the lip and/or palate (CL/P) is a common defect which is associated with changes in facial structures and a smaller upper airway. As a result, infants and children with CL/P have an increased risk of sleep disordered breathing (SDB). This paper will review the anatomical and functional factors which place infants and children with CL/P at increased risk of SDB as well as review the literature which defines the magnitude of this risk. The information available on treatment of SDB in infants and children with CL/P will be presented. Finally, outstanding issues relevant to SDB in children with CL/P are discussed with direction for future research.

Avaliação perceptiva e instrumental da função velofaríngea na fissura de palato submucosa assintomática

TEMA: a fissura de palato submucosa (FPSM) pode estar associada, ou não, a sintomas de disfunção velofaríngea (DVF). OBJETIVO: o presente estudo teve por propósito verificar se pacientes com FPSM diagnosticados como assintomáticos em uma avaliação perceptiva da fala apresentam ausência de hipernasalidade e fechamento velofaríngeo adequado em exame instrumental. MÉTODO: vinte pacientes com FPSM e sem sintomas de DVF, de ambos os gêneros, com idade entre 6 e 46 anos, foram submetidos à avaliação acústica da fala (nasometria), para a determinação da nasalância, o correlato acústico da nasalidade, e, à avaliação aerodinâmica da fala (técnica fluxo-pressão), para a determinação do fechamento velofaríngeo. A total concordância entre os resultados aferidos na avaliação perceptiva e nas avaliações instrumentais foi a hipótese de nulidade testada. RESULTADOS: a avaliação aerodinâmica confirmou integralmente as observações da avaliação perceptiva, ou seja, todos os 20 pacientes foram diagnosticados como tendo fechamento velofaríngeo adequado em ambas as modalidades de avaliação. Os resultados da nasometria, por sua vez, concordaram com os da avaliação perceptiva em apenas 15 dos 20 pacientes analisados (75% dos casos). Os 5 pacientes restantes (25%) apresentaram escores de nasalância sugestivos de hipernasalidade na nasometria, não constatada na avaliação perceptiva, levando, neste caso, à rejeição da hipótese de nulidade. CONCLUSÃO: os resultados mostram a importância do uso combinado de avaliação perceptiva e instrumental para o diagnóstico da DVF em casos de FPSM. Com base nos achados recomenda-se o acompanhamento periódico dos casos considerados assintomáticos em avaliação perceptiva da fala e que apresentem evidências de DVF em uma avaliação instrumental, como a nasometria, particularmente em se tratando de crianças, mais sujeitas ao desenvolvimento de sintomas com o avanço da idade.

A meta-analysis of cleft maxillary osteotomy and distraction osteogenesis

This meta-analysis aims to provide evidence-based data to assist surgeons to make an informed choice between distraction osteogenesis or conventional osteotomy for cleft lip and palate patients. A PUBMED search of the National Library of Medicine from 1966 to December 2003 was conducted. Keywords used in the search were 'cleft', 'distraction', 'maxilla', 'maxillary', 'advancement', 'osteotomy', and 'orthognathic surgery'. This study concluded that distraction osteogenesis tends to be preferred to conventional osteotomy for younger CLP patients with more severe deformities. In such cases it was feasible to use distraction to correct moderate to large movement of the maxilla by either complete or incomplete Le Fort I osteotomy, and a concurrent mandibular osteotomy was less frequently required. Intra-operative and post-operative complications were uncommon with either technique, and some of the traditional ischemic complications related to conventional osteotomy were replaced by infection of the oral mucosa due to the prolonged retention of the distractors. There is still no conclusive data on any differences in surgical relapse, velopharyngeal function and speech between the two techniques. Both distraction osteogenesis and conventional osteotomy can deliver a marked improvement in facial aesthetics.

Speech resonance in orthognathic surgery in subjects with cleft lip and palate

The main purpose of this study was to investigate the impact of maxillary advancement on speech resonance in subjects with cleft lip and palate. The study sample was composed of 42 subjects aged 16 to 41 years old with operated cleft palate ± lip submitted to maxillary advancement. Resonance was evaluated before and 3 to 12 months after surgery by perceptual analysis and graduated from absent to severe. It was observed that 47.5% of the subjects presented impairment of resonance after orthognathic surgery, with a confidence interval (at 95%) from 31.5% to 63.9%. These results suggest that orthognathic surgery in individuals with cleft palate may interfere in resonance, causing, or increasing the degree of hypernasality. Therefore, this highlights the importance of the orientation about the risks and benefits of maxillary advancement surgery and follow-up of these patients.

Cleft-orthognathic surgery

For the cleft patient presenting in adolescence with a jaw discrepancy and malocclusion, misinformation and limited available surgical and dental expertise often prevents a favorable facial reconstruction and dental rehabilitation. A major advantage of the modified Le Fort I osteotomy is its ability to simultaneously close cleft dental gap(s), resolve oronasal fistulas, manage skeletal defects, stabilize dentoalveolar segments, and correct jaw deformities. When a thoughtful staging of reconstruction is undertaken, individuals born with cleft lip and palate can reach adolescence after undergoing only a limited number of operations and interventions, without negative attention being drawn to their original malformation.