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

Does Distraction Lower Risk of VPI Compared to Conventional Maxillary Advancement? A Retrospective Cohort Study of Adolescents with Cleft Palate

OBJECTIVE

To determine whether method of maxillary advancement in adolescents with cleft palate with or without cleft lip (CP ± L) influences post-operative velopharyngeal function.

DESIGN

Retrospective cohort.

SETTING

Pediatric Tertiary Care Hospital.

PARTICIPANTS

One hundred and ninety-nine patients with CP ± L after LeFort I osteotomy for maxillary advancement at our institution between January 2007 and June 2019.

INTERVENTIONS

LeFort I osteotomy via distraction osteogenesis (DO) or conventional osteotomy (CO).

MAIN OUTCOME MEASURES

Patients who underwent DO or CO were compared for the presence of new velopharyngeal insufficiency (VPI), as measured by perceptual rating by a craniofacial speech-language pathologist.

Of the 199 patients who underwent maxillary advancement, 126 were available for analysis. The DO group was younger, male, and had more severe maxillary hypoplasia. Following surgery, 17/41 (41.5%) of the DO group had new VPI, compared to just 23/85 (27.1%) of the CO group. After adjusting for cleft type and predicted maxillary advancement, however, there was not sufficient evidence to reject the null hypothesis of no difference in risk of post-operative VPI between the two surgical groups (prevalence ratio [PR] 1.40, 95% CI 0.68-2.90). Increased prevalence of VPI after DO versus CO was primarily observed among patients with a pre-operative velopharyngeal need ratio < 0.8 (PR = 2.01, 95% CI 0.79-5.10) and patients with normal velopharyngeal function pre-operatively (PR = 2.86, 95% CI 0.96-8.50).

Our results suggest an increased rather than decreased risk of VPI following DO relative to CO. This association is primarily seen among those with a smaller velopharyngeal ratio or perceptually normal velopharyngeal function pre-operatively.

A 3-Dimensional Measurements of Bone and Airway Variables After Le Fort I Distraction Osteogenesis in Patients With Cleft Lip and/or Palate-Induced Midface Hypoplasia: A Retrospective Study

The authors retrospectively analyzed the effects of Le Fort I advancement with distraction osteogenesis on skeletal and airway variables in patients with midfacial hypoplasia induced by cleft lip and/or palate using 3-dimensional computed tomography reconstructions. The authors enrolled 23 subjects with moderate-to-severe midface hypoplasia induced by cleft lip and palate who were treated with Le Fort I distraction osteogenesis (mean age, 19.22±3.48 y; male/female ratio, 20/3); computed tomography images (1 before distraction and another at completion of distraction) were acquired. A 3-dimensional craniometric findings and airway volumes for the nasal cavity, nasopharynx, velopharynx, and upper and lower oropharynx were compared before and after distraction. The relationships between craniofacial morphology and changes in airway volume were also assessed ( P <0.05 was considered significant). Significant increases were observed in airway volumes for the nasal cavity (13.85%), nasopharynx (50.82%), velopharynx (29.57%), and upper oropharynx (36.92%) ( P =0.007, P <0.001, P =0.023, and P <0.001, respectively), whereas no significant changes were observed for the lower oropharynx ( P =0.117). Maxillary horizontal advancement was positively correlated with the airway volumes of the nasopharynx and upper oropharynx after distraction osteogenesis ( rs =+0.451, P =0.031; rs =+0.548, P =0.007); however, no significant correlations were observed for the nasal cavity and velopharynx. The authors' finding indicate that despite rotation of the mandible along with the maxilla, this change does not impact airway volume at the mandibular level. Le Fort I distraction osteogenesis can be feasible for patients with cleft lip and palate-induced midface hypoplasia, with satisfactory appearance and occlusion. Long-term detailed follow-up of the patients postdistraction osteogenesis is warranted.

Algorithm to the treatment of Crouzon syndrome

Clinical reports regarding the entire surgical sequence in Crouzon syndrome from the neonatal period to the adult age are rare. The purpose of this study is to trace an operative algorithm with a long term follow up in a homogenous group of patients affected by Crouzon syndrome. A retrospective review was conducted for all patients affected by Crouzon syndrome who completed the entire surgical sequence. 7 Crouzon patients (4 females, 3 males) completed the entire surgical sequence at different ages: fronto-orbital advancement (0.9 years), LF III distraction osteogenesis (11.5 years) and orthognathic surgery (18 years). The mean age at the last follow up was 19.3 years; normalization of the face was obtained in all cases with improvement of the respiratory problems. After orthognathic surgery, all patients had stable occlusion. A one-year postoperative CBCT scan revealed almost complete ossification of all osteotomy sites. Frontoorbital advancement and modified Le Fort III distraction osteogenesis are reliable surgical procedures. SARME and conventional orthognathic surgery with reductive genioplasty and fat grafting are performed at the end of the surgical sequence to enhance facial aesthetics.

Pre-treatment Factors Affecting Post-treatment Velopharyngeal Incompetency in Patients with Unilateral Cleft Lip and Palate Treated with Maxillary Rigid External Distraction

Introduction: Maxillary advancement (MA) with rigid external distraction (RED) to correct mid-face deficiency in adult cases with cleft lip and palate (CLP) may trigger velopharyngeal incompetency (VPI) post-surgically.

Aim and objectives: To determine pre-treatment factors affecting worsening of post-surgical VPI in patients with repaired unilateral CLP who underwent MA with RED.

Material and methods: Treatment records of 10 patients with unilateral CLP who underwent MA with RED were selected from institutional archives. All patients underwent clinical evaluation of velopharyngeal function at T1 (1 week before surgery) and T2 (3 months after surgery). Based on post-surgical VPI status, patients were divided into 2 groups: group 1 (no change in VPI) and group 2 (worsened VPI). Lateral cephalograms were manually traced at T1 and T2 to determine the changes in length of soft palate (LSP) and pharyngeal depth (PD) at T2. The information regarding amount of MA and presence of pre-surgical VPI was obtained from case sheets of patients.

Results: Mean LSP and PD at T2 were higher compared to T1 ( p-value < .001). No significant difference was observed in mean pre-surgical age, gender, pre-surgical LSP, and pre-surgical PD between the study groups ( p-value > .05 for all). The worsened VPI post-surgically was significantly associated with the presence of VPI pre-surgically and also with the amount of MA ( p-value < .05 for both).

Conclusions: Amount of MA and presence of pre-surgical VPI are most important factors affecting post-surgical VPI. Prospective studies are recommended to validate the findings of this study.

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

BACKGROUND

Maxillary advancement may affect speech in cleft patients.

AIMS

To evaluate whether the amount of maxillary advancement in Le Fort I osteotomy affects velopharyngeal function (VPF) in cleft patients.

METHODS

Ninety-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.

RESULTS

The 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.

CONCLUSIONS

The amount of maxillary advancement does not affect the velopharyngeal function in cleft patients.

Cephalometric changes in nasopharyngeal area after anterior maxillary segmental distraction versus Le Fort I osteotomy in patients with cleft lip and palate

OBJECTIVE

The present study was designed to compare the effects of two surgical methods, anterior maxillary segmental distraction (AMSD) versus conventional Le Fort I osteotomy, on cephalometric changes of velopharyngeal area of patients with cleft lip and palate.

MATERIALS AND METHODS

This study was conducted on 20 CLP in two groups. The first group had classic Le Fort I maxillary advancement and the second group had AMSD with a modified hyrax as an intraoral tooth-borne distractor. In the second group, 1 week after the surgery, activation of hyrax screw was started with the rate of 2 times a day for about 10 days. Initial and final lateral cephalograms were traced and analyzed by OrthoSurgerX software.

RESULTS

The changes in variables evaluating velopharyngeal status showed a significant difference between the two groups. In Group A (conventional), the mean of nasopharyngeal area and Nasopharynx floor length showed a significant increase (P < 0.05) after the surgery, while in Group B (DO), the trend of changes was vice-versa. The changes in SNA, overjet, and soft-tissue convexity were similar in both groups.

CONCLUSION

AMSD can improve facial profile, almost similar to the conventional Le Fort I advancement, while there is a significant decrease in nasopharyngeal; hereby there is no increase in the velopharyngeal sphincter.