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  • Title: Velopharyngeal changes after maxillary advancement in cleft patients with distraction osteogenesis using a rigid external distraction device: a 1-year cephalometric follow-up.
    Author: Ko EW, Figueroa AA, Guyette TW, Polley JW, Law WR.
    Journal: J Craniofac Surg; 1999 Jul; 10(4):312-20; discussion 321-2. PubMed ID: 10686880.
    Abstract:
    The effect of maxillary advancement on speech may have benefits on articulation improvement but compromises velopharyngeal (VP) closure by increasing the nasopharyngeal distance. The purpose of this study was to evaluate the static VP anatomic changes on lateral cephalograms in patients who underwent maxillary advancement through distraction osteogenesis (DO) with a rigid external distraction device and to correlate these changes with clinical speech data. Twenty-two patients (5 female and 17 male) underwent maxillary advancement through DO utilizing a rigid external distraction device (age, 5.2 to 25.7 years) with various diagnoses, including 13 unilateral cleft lip and palate (CLP) patients, 5 bilateral CLP patients, 1 isolated cleft palate patient, 2 facial cleft patients, and 1 patient with craniosynostosis. Lateral cephalograms of preoperative, immediate postdistraction, and 1-year postdistraction were obtained for analysis. Speech evaluation was performed preoperatively, immediate postdistraction, and then at 6-month intervals, and included assessment of air pressure flow, hypernasality, and articulation. With an average amount of 8.9 mm maxillary forward advancement, 14% of patients (3 of 21) presented deterioration in hypernasality. However, 57% of patients (12 of 21) demonstrated improvement in articulation. The cephalometric analysis demonstrated an increase in nasopharyngeal depth by 8.5 mm (1:1 ratio with bony movement) and velar angle by 14.1 deg. The length of the soft palate remained unchanged. The need ratio (intersection of palatal plane and posterior pharyngeal wall-posterior nasal spine/posterior nasal spine--tip of uvula) worsens after distraction. The deterioration of hypernasality was related to the amount of forward distraction, especially in patients without a preexisting pharyngeal flap (PF). Speech evaluation is an important aspect concerning treatment planning for maxillary distraction. The increase in nasopharyngeal depth may compromise VP closure. The increase in velar angle was considered to be part of the compensation in the VP mechanism. An adverse effect of a preexisting PF on maxillary distraction was not observed; however, it prevented postoperative hypernasality.
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