Objective: This study investigates the impact of maxillary advancement (Le Fort Iosteotomy) on consonant proficiency in patients with cleft lip and palate (CLP) and explores how these patients and ...

The Impact of Maxillary Advancement on Consonant Proficiency in Patients With Cleft Lip and Palate, Lay Listeners' Opinion, and Patients' Satisfaction With Speech

Purpose To evaluate the intra- and post-operative complications of tooth-borne anterior maxillary distraction in management of cleft maxillary hypoplasia over a 12-year period, and to establish whether the procedure involves a learning curve. Materials and methods All patients with cleft maxillary hypoplasia satisfying the inclusion and exclusion criteria and undergoing anterior maxillary distraction with a tooth-borne palatal distractor between June 2007 to June 2018 were retrospectively studied by retrieving their individual medical records, which included radiographic (lateral cephalogram analysis at three different intervals) and speech assessment records. The presence of intra- and post-operative complications developing in this study period was noted. Furthermore, the frequency of intra- and post-operative complications occurring from years 2007–2018 were evaluated to study whether there was a decrease in the frequency of complications with increasing time. This was done to establish whether there was a learning curve associated with the surgical procedure. The results thus obtained were tabulated using SPSS 25.0 (SPSS Inc., Chicago, IL) and subjected to statistical analysis using the chi-squared test. A p value of less than 0.05 was considered statistically significant. Results Out of the 458 patients included in the study, 78.82 % (n = 361) had no complications. In the remaining 97 patients, a total of 137 complications (46 intra-operative and 91 post-operative) were observed, making up for a complication rate of 21.17%. The intra-operative complications noted were appliance dislodgement (n = 19), palatal mucosal tears (n = 12), hemorrhage (n = 8), dental injuries (n = 6) and inadvertent fracture of the anterior segment (n = 1). The post-operative complications noted were anterior open bite (n = 24), gingival inflammation (n = 14), appliance dislodgement (n = 13), dental injuries (n = 10), relapse (n = 8), hemorrhage (n = 5), soft tissue infections (n = 4), palatal fistula (n = 3), speech impairment (n = 3), wound dehiscence not related to infection (n = 3), need for re-operation (n = 2), avascular necrosis of the anterior segment (n = 1) and maxillary sinusitis (n = 1). A statistically significant decrease (p  Conclusion Tooth-borne anterior maxillary distraction in managing cleft maxillary hypoplasia is associated with a wide range of complications: some avoidable and related to surgeon's experience; some related to the surgical procedure itself; and some unavoidable and related to the distractor appliance. Understanding potential complications allows the surgeon to ensure safe care through early intervention and to correctly inform the patient in the pre-operative discussion. The procedure involves a learning curve before it can be accomplished safely without many complications.

A retrospective analysis of complications associated with tooth-borne anterior maxillary distraction for managing cleft maxillary hypoplasia: A 12-year experience.

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Nasalidade de fala e nasometria nas fissuras labiopalatinas

Cleft lip and palate patients are born with a challenging deformity that requires multiple surgical interventions in order to reach functional and esthetic harmony. Mid face deficiency in cleft patients is a challenging clinical problem very often encountered in the management of this congenital defect. Cleft maxillary hypoplasia can be attributed to the inherited traits, acquired traits and Induced traits. CLP patients usually present with symptoms varying from malocclusion, retrusion of midface, and a narrow hard palate. A detailed evaluation and individualized treatment planning is of utmost importance in dealing with these patients. Treatment involves the contribution from both the orthodontist and the craniofacial team. The goals for the treatment for cleft maxillary hypoplasia are improvement of aesthetic deficits as well as correction of malocclusion.

/pdf/cleft-maxillary-hypoplasia-13m7gv0aox.pdf

Cleft Maxillary Hypoplasia

The authors present a 16-year-old patient with no known history of cleft palate who developed velopharyngeal insufficiency after a Le Fort I osteotomy performed for the correction of maxillary hypoplasia and a Class III malocclusion. Postoperative evaluation revealed the presence of velopharyngeal insufficiency and subtle findings of an occult submucous cleft palate. She had a pharyngeal flap 6 months later with successful correction of the velopharyngeal insufficiency. This case illustrates the need to screen for submucous cleft palate prior to orthognathic surgery.

Velopharyngeal Insufficiency After Le Fort I Osteotomy in a Patient With Undiagnosed Occult Submucous Cleft Palate.

This study reports on speech outcomes after maxillary advancements of cleft cases compared with non-cleft cases. Suggestions for further study and for helping with case management were introduced as well. Our society has produced few studies on this topic. Therefore, the authors' results have advanced our knowledge to the benefit of our plastic and maxillofacial surgeons.

There are many important factors in studying orthognathic surgery, velopharyngeal function, and their relationships. Among them, adequate case study selection, defining cephalometric analysis for structural evaluation, and optimal evaluation of velopharyngeal function should be well designed to produce acceptable results.

Considering the complexity of oral and maxillofacial structures, orthognathic surgery is a complicated procedure. The nature of the skin and subcutaneous tissue, muscles, ligaments, and hard tissue resilience differ a little in each case. In addition, cleft cases are far different from non-cleft cases because of operative scars, structural asymmetry of hard and soft tissues, and growth deformity. Most cleft maxillary movement vectors are three dimensional, and that results in frequent misdiagnosis. Therefore, adequate case selection is the most important factor in orthognathic surgery study, especially in cleft cases. Cases involving simple jaw movement such as pure advancement, those with simple definitions such as unilateral cleft lip and palate, and those involving one surgeon make the best subjects of study [1].

Delicate structural analysis can be made by defining cephalometric analysis because cephalometric analysis with a cephalogram has been evaluated for ninety years and many analytical methods and prediction mechanisms have been developed. However, mis-tracing as well as inter-observer and intra-observer biases can occur in assessing cephalograms. To reduce mis-tracing and biases, these studies would be better performed in conjunction with dental specialists such as orthodontists or oral surgeons. Two or more specialists trace the cephalograms and perform the trace at least twice with a time interval of at least one week. Special caution should be applied to cleft cases because of anatomical differences. For example, a posterior nasal spine is defined as the process formed by the united projecting ends of the posterior borders of the palatal process of the palatal bone. In cleft palate cases, both of the posterior borders of the palatal process make hardly unification. Therefore, a researcher should find that point using a pterygomaxillary fissure, which is the contour of the fissure projected onto the palatal plane. In addition, an A-point is widely used. An A-point is the point of greatest concavity on the anterior border of the maxilla. However, it is difficult to identify in cleft cases because of anterior nasal spine deviation and dentoalveolar abnormality. Therefore, a new A-point should be made for cleft cases. Follow-up cephalograms should be taken after at least a year to confirm the results [2,3].

Optimal evaluation of velopharyngeal function is essential for producing acceptable results. A recent review of speech outcomes recommends at least one instrumental measure such as naso-endoscopy, multiview videofluoroscopy, nasometry, pressure-flow analysis, and perceptional speech analysis. A follow-up of at least 6 months is essential [4,5].

In conclusion, stable and reproducible surgery, reliable cephalogram analysis after at least one year, and at least 6 months follow-up using multiple measurements of speech outcomes can produce acceptable results for orthognathic-velopharyngeal function research.

/pdf/perceptual-speech-assessment-after-maxillary-advancement-3aeo5ormlw.pdf

Perceptual Speech Assessment after Maxillary Advancement Osteotomy in Patients with a Repaired Cleft Lip and Palate

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Perceptual Speech Assessment after Maxillary Advancement Osteotomy in Patients with a Repaired Cleft Lip and Palate