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Cleft and Craniofacial Surgery. J Oral Maxillofac Surg 2023; 81:E120-E146. [PMID: 37833020 DOI: 10.1016/j.joms.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
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Mink van der Molen AB, van Breugel JMM, Janssen NG, Admiraal RJC, van Adrichem LNA, Bierenbroodspot F, Bittermann D, van den Boogaard MJH, Broos PH, Dijkstra-Putkamer JJM, van Gemert-Schriks MCM, Kortlever ALJ, Mouës-Vink CM, Swanenburg de Veye HFN, van Tol-Verbeek N, Vermeij-Keers C, de Wilde H, Kuijpers-Jagtman AM. Clinical Practice Guidelines on the Treatment of Patients with Cleft Lip, Alveolus, and Palate: An Executive Summary. J Clin Med 2021; 10:jcm10214813. [PMID: 34768332 PMCID: PMC8584510 DOI: 10.3390/jcm10214813] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 10/06/2021] [Accepted: 10/10/2021] [Indexed: 11/16/2022] Open
Abstract
Significant treatment variation exists in the Netherlands between teams treating patients with cleft lip, alveolus, and/or palate, resulting in a confusing and undesirable situation for patients, parents, and practitioners. Therefore, to optimize cleft care, clinical practice guidelines (CPGs) were developed. The aim of this report is to describe CPG development, share the main recommendations, and indicate knowledge gaps regarding cleft care. Together with patients and parents, a multidisciplinary working group of representatives from all relevant disciplines assisted by two experienced epidemiologists identified the topics to be addressed in the CPGs. Searching the Medline, Embase, and Cochrane Library databases identified 5157 articles, 60 of which remained after applying inclusion and exclusion criteria. We rated the quality of the evidence from moderate to very low. The working group formulated 71 recommendations regarding genetic testing, feeding, lip and palate closure, hearing, hypernasality, bone grafting, orthodontics, psychosocial guidance, dentistry, osteotomy versus distraction, and rhinoplasty. The final CPGs were obtained after review by all stakeholders and allow cleft teams to base their treatment on current knowledge. With high-quality evidence lacking, the need for additional high-quality studies has become apparent.
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Affiliation(s)
- Aebele B. Mink van der Molen
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (J.M.M.v.B.); (L.N.A.v.A.)
- Correspondence: ; Tel.: +31-88-7554-004
| | - Johanna M. M. van Breugel
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (J.M.M.v.B.); (L.N.A.v.A.)
| | - Nard G. Janssen
- Department Maxillo Facial Surgery and Dentistry, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (N.G.J.); (D.B.)
| | - Ronald J. C. Admiraal
- Department of Oto-Rhino-Laryngology, Radboud University Medical Center, 6500 HB Nijmegen, The Netherlands;
| | - Leon N. A. van Adrichem
- Department of Plastic and Reconstructive Surgery, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (J.M.M.v.B.); (L.N.A.v.A.)
| | | | - Dirk Bittermann
- Department Maxillo Facial Surgery and Dentistry, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands; (N.G.J.); (D.B.)
| | | | - Pieter H. Broos
- Knowledge Institute of the Federation of Medical Specialists, 3528 BL Utrecht, The Netherlands; (P.H.B.); (A.L.J.K.)
| | | | | | - Andrea L. J. Kortlever
- Knowledge Institute of the Federation of Medical Specialists, 3528 BL Utrecht, The Netherlands; (P.H.B.); (A.L.J.K.)
| | - Chantal M. Mouës-Vink
- Department of Plastic and Reconstructive Surgery, Medical Center Leeuwarden, 8934 AD Leeuwarden, The Netherlands;
| | | | | | - Christl Vermeij-Keers
- Dutch Association for Cleft Palate and Craniofacial Anomalies, 3643 AE Mijdrecht, The Netherlands;
| | - Hester de Wilde
- Department of Speech Therapy, University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands;
| | - Anne Marie Kuijpers-Jagtman
- Department of Orthodontics, University Medical Center Groningen, University of Groningen, 9713 GZ Groningen, The Netherlands;
- Department of Orthodontics and Dentofacial Orthopedics, School of Dental Medicine, Medical Faculty, University of Bern, CH-3010 Bern, Switzerland
- Faculty of Dentistry, Universitas Indonesia, Jakarta 10430, Indonesia
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Steinberg B, Caccamese J, Costello BJ, Woerner J. Cleft and Craniofacial Surgery. J Oral Maxillofac Surg 2019; 75:e126-e150. [PMID: 28728728 DOI: 10.1016/j.joms.2017.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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Abstract
BACKGROUND Reconstruction of the levator musculature during cleft palate repair has been suggested to be important in long-term speech outcomes. In this study, we compare the need for postoperative speech therapy between 2 intravelar veloplasty techniques. METHODS Chart review was performed for patients with nonsyndromic cleft palate who underwent either primary Kriens or overlapping intravelar veloplasty before 18 months of age. All subjects completed a follow-up visit at approximately 3 years of age. Data obtained included documentation of ongoing or recommended speech therapy at age 3 years and reasons for speech therapy, which were categorized as cleft-related and non-cleft-related by a speech-language pathologist. RESULTS One surgeon performed all Kriens procedures (n = 81), and the senior author performed all overlapping procedures (n = 25). Mean age at surgery (Kriens = 13.5 ± 1.4 months; overlapping = 13.1 ± 1.5 months; P = 0.188) and age at 3-year follow-up (Kriens = 3.0 ± 0.5 years; overlapping = 2.8 ± 0.5 years; P = 0.148) were equivalent in both groups. Cleft severity by Veau classification (P = 0.626), prepalatoplasty pure tone averages, (P = 0.237), pure tone averages at 3-year follow-up (P = 0.636), and incidence of prematurity (P = 0.190) were also similar between the 2 groups. At 3 years of age, significantly fewer overlapping intravelar veloplasty patients required cleft-related speech therapy (Kriens = 47%; overlapping = 20%; P = 0.015). The proportions of patients requiring non-cleft-related speech therapy were equivalent (P = 0.906). CONCLUSIONS At 3 years of age, patients who received overlapping intravelar veloplasty were significantly less likely to need cleft-related speech therapy compared with patients who received Kriens intravelar veloplasty. Cleft severity, hearing loss, and prematurity at birth did not appear to explain the difference found in need for speech therapy.
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Modified Palatoplasty Method (Busan Modification) for Incomplete Type Cleft Palate. J Craniofac Surg 2015; 26:1203-6. [PMID: 26080158 DOI: 10.1097/scs.0000000000001716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
To achieve ultimate goals of cleft palate repair, levator muscle's appropriate reapproximation is viewed more importantly as of now, rather than simple palatal lengthening. Authors have developed modified version of 2-flap palatoplasty technique for incomplete type cleft palate and conducted follow-up study, including its early complications, speech evaluation, and facial growth measurement. Of the entire patients receiving a surgery from 2002 to 2012, the authors surveyed consecutive 100 cases of nonsyndromic incomplete cleft palate receiving our modified surgeries, and their early postoperative complication occurrence and the progress were monitored. Of them, the authors performed speech evaluation (n = 36) and facial growth measurement (n = 28) for the patients who the authors could follow-up until at least the age of 4.The medical record review has found no single, early postoperative complication requiring immediate treatment. A total of 10 cases showed delayed wound healing, but 7 of them recovered without a special problem and the other 3 showed residual fistula, recording 3% fistula formation rate. Of the 36 pronunciation evaluation cases, average score was 64.2, reaching almost to the full score of 66, but 1 case with the lowest point was found to need a corrective surgery for the clinical velopharyngeal dysfunction. Cephalometric measurement receiving 28 cases showed sella-nasion-A point angle (SNA) of 82.8° ± 3.4°, sella-nasion-B point angle (SNB) of 78.9° ± 3.9°, and a point-nasion-B point angle (ANB) of 3.9° ± 1.9°. In all range of the measurements, no significant statistical difference was found between normal population at that age and the sample group. The authors consecutively performed this modified method (Busan modification) for patients with incomplete cleft palate and consequentially found a lower rate of early postoperative complications. Moreover, relatively excellent long-term results including speech evaluation score and facial growth outcome were proved during 4 years of postoperative follow-up period.
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Extent of palatal lengthening after cleft palate repair as a contributing factor to the speech outcome. Ann Plast Surg 2013; 74:330-2. [PMID: 23903079 DOI: 10.1097/sap.0b013e31829d2244] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Operative techniques in performing cleft palate repair have gradually evolved to achieve better speech ability with its main focus on palatal lengthening and accurate approximation of the velar musculature. The authors doubted whether the extent of palatal lengthening would be directly proportional to the speech outcome. Patients with incomplete cleft palates who went into surgery before 18 months of age were intended for this study. Cases with associated syndromes, mental retardation, hearing loss, or presence of postoperative complications were excluded from the analysis. Palatal length was measured by the authors' devised method before and immediately after the cleft palate repair. Postoperative speech outcome was evaluated around 4 years by a definite pronunciation scoring system. Statistical analysis was carried out between the extent of palatal lengthening and the postoperative pronunciation score by Spearman correlation coefficient method. However, the authors could not find any significant correlation. Although the need for additional research on other variables affecting speech outcome is unequivocal, we carefully conclude that other intraoperative constituents such as accurate reapproximation of the velar musculature should be emphasized more in cleft palate repair rather than palatal lengthening itself.
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Spruijt N, Widdershoven J, Breugem C, Speleman L, Homveld I, Kon M, Van Der Molen AM. Velopharyngeal Dysfunction and 22q11.2 Deletion Syndrome: A Longitudinal Study of Functional Outcome and Preoperative Prognostic Factors. Cleft Palate Craniofac J 2012; 49:447-55. [DOI: 10.1597/10-049] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To describe the effect of time after velopharyngoplasty on outcome and to search for preoperative prognostic factors for residual hypernasality in patients with 22q11.2 deletion syndrome. Design Retrospective chart review. Setting Tertiary hospital. Patients Patients with 22q11.2 deletion syndrome and velopharyngeal dysfunction who underwent a primary (modified) Honig velopharyngoplasty between 1989 and 2009. Main Outcome Measures Clinically obtained perceptual and instrumental measurements of resonance, nasalance, and understandability before and after velopharyngoplasty. Results Data were available for 44 of 54 patients (81% follow-up), with a mean follow-up time of 7.0 years (range, 1.0 to 19.4 years). During follow-up, 24 (55%) patients attained normal resonance and 20 (45%) had residual hypernasality or underwent revision surgery. Mean postoperative nasalance and understandability scores were closer to the norm than mean preoperative scores were (2.0 versus 5.5 standard deviations for the normal passage, 1.3 versus 8.1 standard deviations for the nonnasal passage, and score 2.3 versus 4.1 understandability). Serial measurements revealed that hypernasality only resolved an average of 5 years after surgery, and three patients whose resonance initially normalized later relapsed to hypernasality. Gender, age at surgery, lateral pharyngeal wall adduction, velar elevation, presence of a palatal defect, previous intravelar veloplasty, nasalance, understandability, adenoidectomy, hearing loss, and IQ were not able to predict poor outcome following primary velopharyngoplasty (all p > .05). Conclusions In this chart review of patients with 22q11.2 deletion syndrome and velopharyngeal dysfunction, residual hypernasality persisted in many patients after velopharyngoplasty. None of the preoperative factors that were studied had prognostic value for the outcome.
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Affiliation(s)
- N.E. Spruijt
- Department of Plastic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - J.C.C. Widdershoven
- Department of Otolaryngology, Head and Neck Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - C.C. Breugem
- Department of Plastic Surgery, University Medical Center Utrecht
| | - L. Speleman
- Department of Otolaryngology, Head and Neck Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - I.L.M. Homveld
- Department of Otolaryngology, Head and Neck Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M. Kon
- Department of Plastic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
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Nyberg J, Westberg LR, Neovius E, Larson O, Henningsson G. Speech Results after One-Stage Palatoplasty with or without Muscle Reconstruction for Isolated Cleft Palate. Cleft Palate Craniofac J 2010; 47:92-103. [DOI: 10.1597/08-222.1] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Objective To investigate speech outcome between children with isolated cleft palate undergoing palatoplasty with and without muscle reconstruction and to compare speech outcomes between cleft and noncleft children. The number of subsequent velopharyngeal flaps was compared with respect to surgical techniques and cleft extent. Design Cross-sectional retrospective study. Participants One hundred four children aged 4 years, 0 months to 6 years, 0 months, 33 with isolated cleft of the soft palate, 53 with isolated cleft of the hard and soft palate, and 18 noncleft children. Interventions Two primary palate repair techniques: minimal incision technique (MIT) and minimal incision technique including muscle reconstruction (MITmr). Main Outcome Measures Perceptual judgment of seven speech parameters assessed on a five-point scale. Results No significant differences in speech outcomes were found between MIT and MITmr surgery groups. The number of velopharyngeal flaps was significantly lower after MITmr surgery compared to MIT surgery. The number of flaps was also significantly lower in children with cleft of the soft palate compared to children with cleft of the hard and soft palate. Children with cleft of the soft palate had significantly less glottal articulation and weak pressure consonants compared to children with cleft of the hard and soft palate. Conclusions The MITmr surgery technique was not significantly superior to the MIT technique regarding speech outcomes related to velopharyngeal competence, but had fewer velopharyngeal flaps, which is contradictory. Until a larger sample can be studied, we will continue to use MITmr for primary palate repair.
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Affiliation(s)
- Jill Nyberg
- Department of Speech Pathology, Karolinska University Hospital Solna, Sweden
| | - Liisi Raud Westberg
- Department of Speech Pathology, Karolinska University Hospital Huddinge, Sweden
| | - Erik Neovius
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital Solna, Sweden
| | - Ola Larson
- Department of Reconstructive Plastic Surgery, Karolinska University Hospital Solna, Sweden
| | - Gunilla Henningsson
- Division of Speech and Language Pathology, Department for Clinical Science, Intervention and Technology, Karolinska Institutet, Karolinska University Hospital Huddinge, Sweden
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Gbaguidi C, Vazquez MP, Devauchelle B. Les séquelles vélopharyngées des fentes labioalvéolopalatovélaires. Les pharyngoplasties dynamiques types orticochea. ACTA ACUST UNITED AC 2007; 108:343-51. [PMID: 17681571 DOI: 10.1016/j.stomax.2007.06.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2007] [Accepted: 06/15/2007] [Indexed: 11/21/2022]
Abstract
Sphincter pharyngoplasty is one of the treatments for velopharyngeal insufficiency, in cleft palate patients. After Hynes, Orticochea described a procedure which became the reference. After studying 2 series of patients treated by two different surgical procedures, it appeared that the speech improvement was nearly the same. Improvement of the results was obtained when the surgical procedure took into account the physiopathology of the velopharyngeal insufficiency. When the velar mobility was weak or absent, but with an effective mobility of lateral pharyngeal walls, a pharyngoplasty with a pharyngeal flap and a superior pedicle was chosen. On the opposite, with an effective velar mobility, sphincter pharyngoplasty was chosen. When both were poor (velar and lateral pharyngeal walls), it seems that using a pharyngeal flap with a velum pushback gave the best result. If hypernasality persisted after pharyngoplasty, a second procedure had to be performed.
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Affiliation(s)
- C Gbaguidi
- Service de chirurgie maxillofaciale et stomatologie, CHU Hôpital-Nord, place Victor-Pauchet, 80054 Amiens cedex 01, France.
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