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

Cleft Maxillary Hypoplasia: Comparison of Techniques and Proposal of a Novel Treatment Protocol for Management

This study was designed to compare different techniques of managing cleft maxillary hypoplasia and to propose a treatment protocol taking patient's age of presentation, amount of maxillary hypoplasia, and presence/absence of velopharyngeal insufficiency (VPI) into consideration. Five treatment modalities, viz. facemask therapy (Group I), anterior maxillary distraction (Group II), total maxillary distraction osteogenesis using rigid external distraction devices (Group III) and internal distraction devices (Group IV), and conventional orthognathic surgery (Group V), were assessed retrospectively using lateral cephalograms (taken at 3 intervals) and speech records (studied pre- and post-operatively). The results were subjected to statistical analysis. A P value of less than 0.05 was considered statistically significant. The mean advancement achieved in groups I, II, III, IV, and V was 4.2±1.54, 9.03±2.62, 11.82±1.18, 10.41±1.42, and 7.24±2.44 mm, respectively. The mean horizontal relapse noted in Groups I, II, III, IV, and V was 2.3 mm (n=8), 2.1 mm (n=14), 3.4 mm (n=10), 1.4 mm (n=5), and 2.4 mm (n=24), respectively. Compared to other groups, group II had fewer patients exhibiting relapse, a statistically significant observation. Similarly, statistically significant improvement in speech outcomes was found only in group II compared to other groups. Based on the results, a treatment protocol was proposed. The authors conclude that the proposed protocol would enable surgeons to decide the most appropriate treatment modality paying attention to not only the age of presentation and amount of advancement but also presence/absence of VPI which is instrumental in deciding upon the most appropriate treatment.

What Is the Effect of Maxillary Impaction Orthognathic Surgery on Voice Characteristics? A Quasi-Experimental Study

Background

Regarding the impact of orthognathic surgery on the airway and voice, this study was carried out to investigate the effects of maxillary impaction surgery on patients' voices through acoustic analysis and articulation assessment.

Methods

This quasi-experimental, before-and-after, double-blind study aimed at examining the effects of maxillary impaction surgery on the voice of orthognathic surgery patients. Before the surgery, a speech therapist conducted acoustic analysis, which included fundament frequency (F0), Jitter, Shimmer, and the harmonic-to-noise ratio (HNR), as well as first, second, and third formants (F1, F2, and F3). The patient's age, sex, degree of maxillary deformity, and impaction were documented in a checklist. Voice analysis was repeated during follow-up appointments at one and six months after the surgery in a blinded manner. The data were statistically analyzed using SPSS 23, and the significance level was set at 0.05.

Results

Twenty two patients (18 females, 4 males) were examined, with ages ranging from 18 to 40 years and an average age of 25.54 years. F2, F3, HNR, and Shimmer demonstrated a significant increase over the investigation period compared to the initial phase of the study (P <0.001 for each). Conversely, the Jitter variable exhibited a significant decrease during the follow-up assessments in comparison to the initial phase of the study (P< 0.001).

Conclusion

Following maxillary impaction surgery, improvements in voice quality were observed compared to the preoperative condition. However, further studies with larger samples are needed to confirm the relevancy.

Videofluoroscopic Findings as Predictors of Velopharyngeal Insufficiency After Orthognathic Surgery in Patients With Cleft Lip and Palate

BACKGROUND

Midface retrusion is a common problem in patients with cleft lip and palate owing to the lack of adequate growth of the maxilla. Midface advancement surgery is a definite treatment for midface retrusion; however, the subsequent oropharyngeal airway changes might result in velopharyngeal insufficiency (VPI) in affected patients. Determining the predictors of VPI beforehand and modifying the surgical procedure would be beneficial.

MATERIALS AND METHODS

A retrospective review of 42 patients with cleft lip and palate who underwent orthognathic surgery from 2013 to 2014 was performed. A total of 25 patients met the inclusion criteria and had undergone complete pre- and postsurgery videofluoroscopy, nasopharyngoscopy (NPS), and speech assessment. We compared 2 groups of patients, those who showed NPS finding changes of more than 0.1 (8 patients) and those without changes (17 patients), by measuring the distances of the contact point to the tip of the velum, gap size at maximum closure (MC) and rest, contact area length, lateral wall closure rate, closure velocity, and 2 angles (from the velum to the hard palate and genu) at MC and rest. The amount of maxillary advancement was also recorded.

RESULTS

Among the 8 patients with NPS finding changes, 3 underwent Furlow palatoplasty for VPI. No significant difference was found in the amount of maxillary advancement between the groups (5.8 vs 5.7 mm). Significant differences were found in the preoperative gap size at MC and angle at the genu at MC (P = 0.035 and .012). These could be considered as the predictors before surgery. After surgery, a significant difference was found in the contact area, lateral wall closure rate, and gap size at MC (P = 0.005, 0.018, and 0.01).

CONCLUSION

Videofluoroscopy is a relatively applicable method of determining dynamic changes in the velum function. By performing videofluoroscopy before midface advancement surgery in patients with cleft lip and palate, we may predict the risk of VPI and consider alternative surgical strategies.

The Effect of Bimaxillary Orthognathic Surgery on Nasalance, Articulation Errors, and Speech Intelligibility in Skeletal Class III Deformity Patients

BACKGROUND

We aimed to detect the changes in nasalance, articulation errors, and speech intelligibility after bimaxillary orthognathic surgery in skeletal class III patients.

METHODS

This double-blinded before and after quasi-experimental study was conducted in the Department of Maxillofacial Surgery, Qaem Hospital, Mashhad, Iran from Mar 2019 to Apr 2020. The main intervention was maxillary advancement with LeFort I osteotomy and mandibular setback surgery with bilateral sagittal split osteotomy (BSSO). The nasalance score, speech intelligibility, and articulation errors were evaluated one week preoperatively (T0), 1 and 6 months (T1, T2) postoperatively by a speech therapist. The significance level was set at 0.05 using SPSS 21.

RESULTS

Eleven women (55%) and 9 men (45%) with a mean age of 31.95 ± 4.72 yr were enrolled. The mean maxillomandibular discrepancy was 6.15 ± 1.53 mm. The mean scores of nasalance for the oral, nasal, and oral-nasal sentences were significantly improved postoperatively (P<0.001). Pre-operative articulation errors of consonants /r/, /z/, /s/ and /sh/ were corrected following the surgery. The percentage of speech intelligibility was significantly increased over time (P<0.001).

CONCLUSION

The patients might show a normal articulation pattern and a modified nasalance feature, following maxillary advancement plus mandibular setback surgery.

Occlusal and Functional Improvement of Patients With Midfacial Hypoplasia Corrected Using Intraoral Tooth-Borne Mid-Maxillary Osteodistractors at Teaching Hospital-Karapitiya, Sri Lanka

OBJECTIVE

Mid-maxillary osteodistraction (MMOD) is a novel technique. This study seeks to assess the occlusal and functional improvement of patients with midfacial hypoplasia secondary to cleft lip and palate.

DESIGN

This was done as a retrospective study at the Regional Cleft Centre of the Teaching Hospital-Karapitiya (THK).

PARTICIPANTS

A total of 81 patient records were accessed on those who underwent MMOD with a tooth-borne intraoral device from January 1, 2007, to December 31, 2016, at THK.

METHODS

Records of the patients included pre- and post-treatment lateral cephalograms, study models, speech assessments, and photographs.

RESULTS

An advancement ranging from 5 to 12 mm (mean, 8.14 mm) was achieved in all patients; 80% (n = 63) and 87.65% (n = 71) showed improvement in consonant production and quality of speech. These were statistically significant (P < .05). With regard to the Peer Assessment Rating score assessing the occlusal improvement, 97.6% showed an improvement whereas only 2 patients showed no improvement. There was a significant improvement in sella (S), nasion (N), and point A (SNA) angle; point A, the nasion, and point B (ANB) angle; and the maxillary length over the treatment period (P < .05). The change in the ANB angle and maxillary length significantly differed between genders with males having a comparatively higher improvement. The profile improvements were noteworthy on the profile photographs.

CONCLUSION

This relatively novel approach to maxillary advancement by maxillary distraction using a combined surgical and modified orthodontic technique has proven to be successful. This protocol and the technique have improved function, occlusion, and the 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.

Surgical maxillary advancement and speech resonance: comparison among cleft types

Purpose This study investigated the influence of the cleft type on the appearance of hypernasality after surgical maxillary advancement (MA). Methods Nasality was determined by measurement of nasalance (acoustic correlate of nasality) by nasometry. The study involved analysis of the nasalance scores of 17 individuals with isolated cleft palate (CP), 118 with unilateral cleft lip and palate (UCLP) and 69 with bilateral cleft lip and palate (BCLP), of both sexes, aged 18 to 28 years, after MA. Only individuals with normal nasalance scores indicating balanced resonance before MA were included in this study. Nasometry was performed 3 days before and 15 months after MA, on average. The proportion of patients who presented nasalance scores indicating hypernasality after surgery was calculated by the ANOVA test, and comparison among the different cleft types was evaluated by the chi-square test (p < 0.05). Results No significant difference was found in the proportions of individuals with hypernasality among the cleft types. Conclusion Nasometry showed that the appearance of hypernasality after MA in individuals with cleft palate with or without cleft lip occurred in similar proportions, regardless of the cleft type.

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.

Predictors of Velopharyngeal Dysfunction in Individuals With Cleft Palate Following Surgical Maxillary Advancement: Clinical and Tomographic Assessments

Objective:

To investigate whether morphofunctional velopharyngeal aspects may be considered predictors of appearance or worsening of hypernasality in patients with cleft palate after surgical maxillary advancement (MA).

Design:

Prospective.

Setting:

National referral center for cleft lip and palate rehabilitation.

Participants:

Fifty-two patients with repaired cleft palate, skeletal class III malocclusion, and normal speech resonance completed speech audio recordings and cone-beam computed tomography examination before (T1) and, on average, 14 months after (T2) MA.

Interventions:

Hypernasality was rated by 3 experienced speech-language pathologists using a 4-point scale and morphofunctional aspects on a 3-point scale. Cone-beam computed tomography image measurements were performed using Amira and Dolphin 3D software. For each velopharyngeal morphofunctional aspect analyzed, patients were compared according to the absence (G1) and presence (G2) of postoperative hypernasality.

Main Outcome Measures:

Comparison of hypernasality scores between T1 and T2 and association between hypernasality and each velopharyngeal morphofunctional aspect.

Results:

Significant difference was observed between T1 and T2 for hypernasality ( P = .031) and between G1 and G2 ( P = .015) for velar mobility, with significant association between this variable and hypernasality on T2 ( P = .041).

Conclusions:

Levator veli palatini mobility influenced the appearance of hypernasality after MA.