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

Abstract

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.

Avanço cirúrgico de maxila e ressonância de fala: comparação entre os tipos de fissura

“…However, in individuals with cleft lip and palate, worsening of the velopharyngeal function has been reported after this surgical procedure. Several studies investigated the effect of MA on the speech of individuals with repaired cleft palate, using perceptual (13)(14)(15)(17)(18)(19) and instrumental (11,17,18) evaluations for that purpose.…”

“…It is known that, in isolation, the extent of maxillary advancement in millimeters does not directly influence the speech outcomes in individuals with CLP (17)(18)(19)(20) ; however, the literature is controversial concerning the possible causes that lead to worsening of velopharyngeal function after Le Fort I osteotomy (17) . Aiming to investigate the morphofunctional aspects of the velopharyngeal region that may be considered predictors of the appearance or worsening of hypernasality after surgical maxillary advancement, a recent study investigated the speech outcomes of 52 patients with repaired CLP submitted to Le Fort I osteotomy.…”

“…The authors observed that 21% (11/52) of individuals analyzed started to present speech symptoms, and this result was correlated to regular or poor mobility of the velum. That is, the worse the velum movement to complete the VPC, the worse is the speech outcome after MA (19) .…”

“…However, this was not demonstrated in the present study. It is believed that, in individuals presenting the speech symptom after MA, the functional conditions of the palate may be inadequate as a consequence of primary palatoplasty, and may indicate the population that presents regular or poor mobility of the velum, which has been demonstrated to lead to the appearance or worsening of hypernasality after MA, regardless of the cleft type involving the palate (19) . Other explanation for this result is that the appearance of hypernasality may be related to differences in the shape of the velopharyngeal region.…”

“…Studies emphasized that MA, by reestablishing the maxillomandibular balance and consequently adjusting the positioning of tongue and teeth, promotes a beneficial effect for speech production (15,16) . However, even though it has been confirmed that the extent of maxillary advancement, in millimeters, does not directly influence the speech results in individuals with CLP (17)(18)(19) , the forward movement of hard and soft palate achieved during MA surgery may change the pattern of VCP, contributing to the appearance of hypernasality as a consequence of dysfunction of the velopharyngeal mechanism (VPD) (11,20) .…”