Influence of the Furlow palatoplasty for patients with submucous cleft palate on facial growth

A comparison of maxillofacial growth in Chinese children with isolated cleft palate treated with two different palatoplasty techniques without relaxing incisions: a preliminary study

OBJECTIVE

To assess the maxillofacial growth of patients with isolated cleft palate following the Sommerlad-Furlow modified technique and compare it with the effect of the Sommerlad technique.

STUDY DESIGN

A Retrospective Cohort Study.

METHODS

A total of 90 participants, 60 patients with non-syndromic isolated soft and hard cleft palate (ISHCP) underwent primary palatoplasty without relaxing incision (30 patients received the Sommerlad-Furlow modified (S-F) technique and 30 received Sommerlad (S) technique). While the other 30 were healthy noncleft participants with skeletal class I pattern (C group). All participants had lateral cephalometric radiographs at least 5 years old age. All the study variables were measured by using stable landmarks, including 11 linear and 9 angular variants.

RESULTS

The means age at collection of cephalograms were 6.03 ± 0.80 (5-7 yrs) in the S group, 5.96 ± 0.76 (5-7 yrs) in the S-F group, and 5.91 ± 0.87 (5-7 yrs) in the C group. Regarding cranial base, the results showed that there were no statistically significant differences between the three groups in S-N and S-N-Ba. The S group had a significantly shortest S-Ba than the S-F & C groups (P = 0.01), but there was no statistically significant difference between S-F and C groups (P = 0.80). Regarding skeletal maxillary growth, the S group had significantly shorter Co-A, S- PM and significantly less SNA angle than the C group (P =  < 0.01). While there was no significant difference between S-F & C groups (P = 0.42). The S group had significantly more MP-SN inclination than the C group (P =  < 0.01). Regarding skeletal mandibular growth, there were no statistically significant differences in all linear and angular mandibular measurements between the three groups, except Co-Gn of the S group had a significantly shorter length than the C group (P = 0.05). Regarding intermaxillary relation, the S-F group had no significant differences in Co-Gn-Co-A and ANB as compared with the C group. The S group had significantly less ANB angle than S-F & C groups (P = 0.01 & P =  < 0.01). In addition, there were no significant differences in all angular occlusal measurements between the three groups.

CONCLUSION

As a preliminary report, Sommerlad-Furlow modified technique showed that maxillary positioning in the face tended to be better, and the intermaxillary relationship was more satisfactory than that in Sommerlad technique when compared them in healthy noncleft participants.

A retrospective cephalometric study on the craniofacial morphology of adult patients with unoperated submucous cleft palate

This retrospective cross-sectional study reviewed adult patients with unrepaired SMCP, OCP and normal control and performed comprehensive skeletal and soft tissue morphological analyses basing on lateral cephalometric radiographs. One way-ANOVA and rank-sum tests detected potential intergroup differences. 32 subjects with unrepaired SMCP, 42 with unrepaired OCP and 28 noncleft normal controls were enrolled. Both the SMCP and OCP groups were significantly different from the normal controls in sagittal maxillary length, jaw relationship, facial profile angle, nasal base and nasal tip prominence, upper lip position, and lower lip protrusion. S-N-A angle in the control group (82.25 ± 2.74°) was significantly greater than in the SMCP (77.96 ± 4.05°, p<0.001) and OCP (78.55 ± 2.93°, p<0.001) groups. Nasolabial angle in the control group (99.18 ± 8.76°) was significantly greater than in the SMCP (91.75 ± 8.93°, p = 0.002) and OCP (93.69 ± 7.24°, p = 0.020) groups. No significant difference was detected between the SMCP and the OCP group in other measurements except upper facial height. Within the limitations of the study it seems that craniofacial growth is impaired in patients with submucous clefts to the same extent as in patients with a conventional cleft palate.

Does Notching Along the Nasal Velar Surface During Nasopharyngoscopy Predict Discontinuity of the Underlying Levator Veli Palatini Muscle?

To determine the sensitivity and specificity of velar notching seen on nasopharyngoscopy for levator veli palatini (LVP) muscle discontinuity and anterior positioning.

Nasopharyngoscopy and MRI of the velopharynx were performed on patients with VPI as part of their routine clinical care. Two speech-language pathologists independently evaluated nasopharyngoscopy studies for the presence or absence of velar notching. MRI was used to evaluate LVP muscle cohesiveness and position relative to the posterior hard palate. To determine the accuracy of velar notching for detecting LVP muscle discontinuity, sensitivity, specificity, and positive predictive value (PPV) were calculated.

A craniofacial clinic at a large metropolitan hospital.

PARTICIPANTS

Thirty-seven patients who presented with hypernasality and/or audible nasal emission on speech evaluation and completed nasopharyngoscopy and velopharyngeal MRI study as part of their preoperative clinical evaluation.

Among patients with partial or total LVP dehiscence on MRI, presence of a notch accurately identified discontinuity in the LVP 43% (95% CI 22-66%) of the time. In contrast, the absence of a notch accurately indicated LVP continuity 81% (95% CI 54-96%) of the time. The PPV for the presence of notching to identify a discontinuous LVP was 78% (95% CI 49-91%). The distance from the posterior edge of the hard palate to the LVP, known as effective velar length, was similar in patients with and without notching (median 9.8 mm vs 10.5 mm, P = 1.00).

The observation of a velar notch on nasopharyngoscopy is not an accurate predictor of LVP muscle dehiscence or anterior positioning.

Surgical indication of Furlow palatoplasty to treat submucous cleft palate

This study investigated the effects of Furlow palatoplasty on children with submucous cleft palate (SMCP) and identified surgical indications by comparing SMCP and control patients. Twenty-three SMCP children (average age 28.9 months) who were nonsyndromic and underwent surgery between April 2010 and December 2016 were included. Facial computed tomography (CT) was performed preoperatively and at least 1 year postoperatively after a language test. Facial CT measurements were taken for 140 children aged 0-6 years without deformities (control group). Later surgery was associated with more severe nasality. In the coronal view, the difference in the maxillary tuberosity before and after surgery was 3.8 mm (p < 0.05). The height and width of the palatal arch (HNP and WNP) were well maintained (p > 0.05), whereas the angle of the levator veli palatini muscle (ALM) increased (p < 0.05). The nasopharynx was close to normal postoperatively. The distance between the medial pterygoid plates, the HNP, and the WNP were larger in SMCP patients preoperatively (p < 0.05), but these differences disappeared after surgery (p > 0.05). The ALM in SMCP patients was narrower preoperatively, but became flatter postoperatively (p < 0.05), indicating the repositioning of the levator muscle, with improvement of the velopharyngeal function. Furlow palatoplasty is indicated if the HNP and WNP values are larger, and the ALM value is less, in patients with SMCP than in those without.

Speech outcome after early repair of cleft soft palate using Furlow technique

OBJECTIVE

The earlier closure of palatal cleft is the better the speech outcome and the less compensatory articulation errors, however dissection on the hard palate may interfere with facial growth. In Furlow palatoplasty, dissection on the hard palate is not needed and surgery is usually limited to the soft palate, so the technique has no deleterious effect on the facial growth. The aim of this study was to assess the efficacy of Furlow palatoplasty technique on the speech of young infants with cleft soft palate.

METHODS

Twenty-one infants with cleft soft palate were included in this study, their ages ranged from 3 to 6 months. Their clefts were repaired using Furlow technique. The patients were followed up for at least 4 years; at the end of the follow up period they were subjected to flexible nasopharyngoscopy to assess the velopharyngeal closure and speech analysis using auditory perceptual assessment.

RESULTS

Eighteen cases (85.7%) showed complete velopharyngeal closure, 1 case (4.8%) showed borderline competence, and 2 cases (9.5%) showed borderline incompetence. Normal resonance has been attained in 18 patients (85.7%), and mild hypernasality in 3 patients (14.3%), no patients demonstrated nasal emission of air. Speech therapy was beneficial for cases with residual hypernasality; no cases needed secondary corrective surgery.

CONCLUSION

Furlow palatoplasty at a younger age has favorable speech outcome with no detectable morbidity.

Repair of submucous cleft palate with Furlow palatoplasty

OBJECTIVE

Submucous cleft palate is a congenital anomaly caused by abnormal insertion of the levator veli palatini muscles to the posterior border of the hard palate, normally these muscles unite together to form the levator sling. Velopharyngeal insufficiency (VPI) may occur in about 10% of cases, our previous treatment protocol was pharyngeal flap that may result in obstructive breathing. Furlow technique seems to be a more physiologic solution as it reconstructs the levator sling. The aim of this study was to determine the efficacy of Furlow palatoplasty in treatment of submucous cleft palate cases presented with VPI.

METHODS

This prospective study was conducted on 15 children with symptomatic submucous cleft palate. All cases were treated by Furlow double opposing Z-plasty technique for repositioning of levator muscles, preoperative and postoperative speech evaluation was done using auditory perceptual assessment and nasometry, while velopharyngeal closure was assessed with flexible nasopharyngoscopy.

RESULTS

Significant improvement of speech and overall nasalance score were achieved. Flexible nasopharyngoscopy showed complete velopharyngeal closure of 13 cases (86.7%), while one case needed secondary pharyngoplasty for correction of residual VPI and the parents of the other case refused secondary surgery as the speech improvement of their child was satisfactory.

CONCLUSIONS

Furlow palatoplasty technique is an effective method in treatment of VPI in cases of submucous cleft palate as it has high success rate with no morbidity.

Furlow's Palatoplasty for Cleft Palate Repair

BACKGROUND

The major drawbacks of standard procedures of palatoplasty have been inadequate palatal lengthening, velopharyngeal incompetence, impaired maxillary growth with mid-face retrusion and high fistula rates. The Furlow's double opposing Z-plasty is accepted as one of the better procedures for treating cleft palates.

METHODS

This paper compared Furlow's procedure to Veau Kilner Wardill's procedure performed on 63 patients from July 2000 till February 2005.

RESULTS

The results were compared in terms of the fistula rates, palatal lengthening, nasal regurgitation, velopharyngeal incompetence, improvement in speech, hearing and maxillary growth.

CONCLUSIONS

The Furlow's technique offered better results irrespective of the age, type and extent of the cleft in the palate.

Early Two-Stage Palatoplasty Using Modified Furlow's Veloplasty

Objective

To achieve sufficient velopharyngeal function and maxillary growth for patients with unilateral cleft lip and palate (UCLP), the authors have designed a new treatment protocol for palate closure involving early two-stage palatoplasty with modified Furlow veloplasty. Details of the surgical protocol and the outcomes of the dental occlusion of patients at 4 years of age are presented.

Design and Setting

This was an institutional retrospective study.

Patients

Seventy-two UCLP patients were divided into two groups based on their treatment protocols: patients treated using the early two-stage palatoplasty protocol (ETS group; n = 30) and patients treated using Wardill-Kilner push-back palatoplasty performed at 1 year of age (PB group; n = 42).

Interventions

The features of the ETS protocol are as follows: The soft palate is repaired at 12 months of age using a modified Furlow technique. The residual cleft in the hard palate is closed at 18 months of age. Lip repair is carried out at 3 months of age with a modified Millard technique for all subjects.

Results

The ETS group showed a significantly better occlusal condition than the PB group. The incidence of normal occlusion at the noncleft side central incisor was 7.1% in the PB group; whereas, it was 66.7% in the ETS group.

Conclusion

The results indicate that the early two-stage protocol is advantageous for UCLP children in attaining better dental occlusion at 4 years of age.

Treatment of submucous cleft palate by pharyngeal flap as a primary procedure

OBJECTIVE

(a) Palatal repair is the standard surgical method for correction of velopharyngeal incompetence due to submucous cleft, but some patients may need further narrowing of velopharynx by pharyngeal flap. (b) The purpose of this study is to evaluate the efficacy of a pharyngeal flap as a single surgical procedure in the treatment of symptomatic cases.

METHODS

Nine cases of symptomatic submucous cleft palate were subjected to treatment by pharyngeal flap only as a primary and single procedure after failure of speech therapy. Preoperative flexible nasopharyngoscopy was carried out for all children to determine the width of the velopharyngeal gap; the results were recorded on videotape and reviewed in the operating theatre for determination of the width of the pharyngeal flap. Postoperative follow-up by flexible nasopharyngoscopy and parent's questionnaire were used to assess the success rate.

RESULTS

Follow-up flexible nasopharyngoscopy showed complete closure of the lateral ports in eight cases (89%) while one case (11%) showed incompetence. Hypernasality was improved in all cases witnessed by parent's questionnaire and this improvement was satisfactory in seven cases (78%) but not satisfactory in two cases (22%). One of the last two cases reached to satisfactory level after speech therapy, while the other case showed no further improvement.

CONCLUSIONS

Speech therapy alone cannot correct hypernasality in presence of anatomical defect. Pharyngeal flap is a useful procedure monitored by flexible nasopharyngoscopy. When pharyngeal flap is used, the need for adjunctive procedure is absent.

Management of the Black Hole in Velopharyngeal Incompetence: Combined Use of a Furlow Palatoplasty and Sphincter Pharyngoplasty

BACKGROUND

Patients with velopharyngeal incompetence may have a combination of a large velopharyngeal gap and poor lateral wall motion on phonation, simulating a "black hole" on nasendoscopy. Pharyngeal flaps for treatment of velopharyngeal incompetence in these patients are of questionable efficacy, because poor lateral wall motion necessitates such a wide flap that nasal airway obstruction is likely.

METHODS

Thirteen patients with velopharyngeal incompetence were managed between 1994 and 2003 with a combined Furlow palatoplasty and sphincter pharyngoplasty by a single surgeon. A diagnosis of velopharyngeal incompetence was established by means of perceptual speech evaluation performed by a trained speech pathologist using a standardized speech/voice rating scale (0 to 13); scores of 4 or higher indicated an incompetent velopharyngeal valving mechanism. Surgical inclusion criteria were a large velopharyngeal gap (> or =7 mm) and poor lateral wall motion (1 or 2 of 5, with 3 being rated as average) measured by multiview videofluoroscopy and nasendoscopy.

RESULTS

The mean preoperative score on the speech and voice rating scale was 10.5 (range, 4 to 13), with a mean postoperative score of 1.9 (range, 0 to 8) following Furlow palatoplasty and sphincter pharyngoplasty in 13 patients. Two patients required an additional surgical procedure to achieve complete correction of velopharyngeal incompetence without nasal airway obstruction, to achieve a final mean score of 0.8 (range, 0 to 2) among the 12 patients who completed surgical management, achieving a highly significant reduction in nasality (p < 0.0001).

CONCLUSIONS

Patients with velopharyngeal incompetence who have a black hole on nasendoscopy consisting of a large velopharyngeal gap and poor lateral wall motion are at high risk for recurrent velopharyngeal incompetence or nasal airway obstruction following surgical management. Initial treatment with a Furlow palatoplasty and sphincter pharyngoplasty has a high rate of success in these patients and does not preclude further surgical correction if needed, with minimal risk of nasal airway compromise.