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

Abstract

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.

Measurement Matters: MRI Analysis of Differing Anatomic Measurement Techniques for Velar Length and the Velopharyngeal Needs Ratio

“…This is particularly relevant, given that recent studies have noted that small quantitative differences (<1 mm) have been reported to influence velopharyngeal function, and these differences may be correlated with the perception of hypernasality. 56,57 For example, in patients that demonstrate velopharyngeal insufficiency, use of the curvilinear measurement provides more accurate quantitative assessment of the velar morphology and likelihood for postoperative VP function, particularly as it relates to distraction osteogenesis 30 and obstructive sleep apnea. 58 Furthermore, functional differences may also be observed when assessing velar length during phonation due to patient-specific anatomy postpalatoplasty, again highlighting the need to precisely measure this structure using a curvilinear measurement.…”

“…6,10,17,20,[27][28][29] Thus, the VP needs ratio has been supportive as an anatomic indicator for the ability to achieve VP closure during speech. 12,13,23,[30][31][32] Notably, within these seminal works, a measure of linear velar length is often described and measured as a straight line from the posterior maxillary point (PMP) or posterior nasal spine (PNS) to the uvular tip. This is common in clinical settings.…”

Função velofaríngea após avanço cirúrgico da maxila em pacientes com fissura labiopalatina: 20 anos de experiência no HRAC-USP

“…A repercussão da cirurgia ortognática com avanço de maxila sobre a função velofaríngea de indivíduos com fissura labiopalatina tem sido objeto de estudo nos últimos anos. A literatura já demonstrou que a deterioração dessa função não está diretamente relacionada à quantidade de avanço maxilar 4,12,13 . Atualmente, os estudos estão sendo direcionados na busca pela identificação dos fatores preditivos do aparecimento e/ou agravamento da disfunção velofaríngea após a cirurgia ortognática.…”

“…No entanto, não houve correlação entre o aparecimento da disfunção velofaríngea e a quantidade de avanço maxilar, constatando-se que a piora da função velofaríngea foi mais evidente nos casos em que o palato mole apresentava menor extensão. Mais recentemente, Kinter et al (2022) 13 mostraram que pacientes que realizaram o avanço de maxila por meio de distração osteogênica apresentaram maiores escores de hipernasalidade em relação aos tratados com avanço de maxila convencional.…”