|Year : 2016 | Volume
| Issue : 2 | Page : 96-101
Effect of two-flap palatoplasty on growth and speech in patients with a cleft palate
Alaa A Altaweel1, Ashraf Abdelkader2, Rana S Mohamed3
1 Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Al-Azhar University, Cairo, Egypt
2 Department of Paediatric Medicine, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
3 Department of Phoniatrics, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
|Date of Submission||02-Apr-2016|
|Date of Acceptance||04-Apr-2016|
|Date of Web Publication||23-Aug-2016|
Alaa A Altaweel
Department of Oral and Maxillofacial Surgery, Faculty of Dental Medicine, Al-Azhar University, Cairo, PO. 11571
Source of Support: None, Conflict of Interest: None
This study aimed to evaluate the outcomes of two-flap palatoplasty in improving the growth rate and repairing speech abnormalities in patients with an isolated cleft palate.
Patients and methods
In 30 patients with an isolated cleft palate, two-flap palatoplasty was used for correction. The immediate postoperative gain in palatal length was assessed and the incidence of postoperative oronasal fistula was also observed. All patients received speech and nutritional therapy. Speech parameters were obtained preoperatively and at 6, 18 and 30 weeks postoperatively. Patients' height was recorded 6 months preoperatively, at the time of surgery and 6 months postoperatively, whereas patients' weight was recorded 6 and 3 months preoperatively, at the time of surgery, and 3 and 6 months postoperatively.
There was a significant increase in palatal length (the mean palatal length gain was 6.09 ± 0.15 mm). The incidence of oronasal fistula was reported in three patients. A significant improvement was recorded in speech outcome at different follow-up periods. There was a significant gain in children's weight and height postoperatively.
Two-flap palatoplasty is a reliable technique for correction of an isolated cleft palate, with a limited incidence of oronasal fistula. Palatoplasty combined with proper nutrition has a positive effect on the catch-up growth rate. Speech therapy after palatoplasty is essential to achieve good speech outcomes.
Keywords: cleft palate, growth, speech, two.-flap palatoplasty
|How to cite this article:|
Altaweel AA, Abdelkader A, Mohamed RS. Effect of two-flap palatoplasty on growth and speech in patients with a cleft palate. Tanta Dent J 2016;13:96-101
|How to cite this URL:|
Altaweel AA, Abdelkader A, Mohamed RS. Effect of two-flap palatoplasty on growth and speech in patients with a cleft palate. Tanta Dent J [serial online] 2016 [cited 2018 Mar 20];13:96-101. Available from: http://www.tmj.eg.net/text.asp?2016/13/2/96/188912
| Introduction|| |
Orofacial cleft is one of the most common congenital anomalies in humans; it has considerable medical, psychological, social and financial implications on the affected individuals and families . It affects about 1.5/1000 live births worldwide (250 000 new cases per year) , with an incidence of 1.66/1000 live births in Egypt .
The mechanism for the development of orofacial cleft is not fully clear. The genetic factor plays an important role in its development; the high rates of familial occurrences and elevated concordance rates in monozygotic twins provide evidence for a strong genetic component in nonsyndromic orofacial cleft. It has been suggested that the development of nonsyndromic orofacial cleft occurs as a result of the interaction between different genetic and environmental factors ,.
In addition to the aesthetic disfigurement, a child with an orofacial cleft suffers functional morbidities such as restricted maxillofacial growth, speech disorders, hearing loss and recurrent ear infections . Furthermore, an orofacial cleft is often associated with swallowing impairment and decreased growth rate, secondary to children's inability to feed appropriately .
According to the literature, children with an orofacial cleft have a short rapid uncoordinated and inefficient intraoral suction. Also, the entry of milk into the nasal cavity may result in asphyxia . The cleft is considered the main anatomic factor leading to these dysfunctions. In fact, previous studies reported that children with clefts have lower height and weight compared with normal children ,.
Orofacial clefts may involve structures around the oral cavity and may extend to the surrounding facial structures, resulting in extensive craniofacial deformity. The main types of orofacial cleft are an isolated cleft palate and a cleft lip with or without a cleft palate. Both categories may present either isolated or as part of a syndrome ,.
The primary aims of palatoplasty are to achieve normal growth , speech and deglutition without affecting normal maxillofacial growth . Thus, establishment of a competent velopharyngeal mechanism and separation of the nasal and oral cavities are essential for achieving these goals .
The investigators hypothesized that two-flap palatoplasty may improve the growth rate and speech disorders in patients with an isolated cleft palate.
| Patients and Methods|| |
Thirty patients with a nonsyndromic isolated cleft palate were included in this study. The patients' age ranged from 12 to 18 months. Eighteen patients were females, whereas 12 were males. The parents of all patients were informed about the study and signed an informed consent form.
Before the surgery, all patients were subjected to a thorough clinical examination including parents' height, patients' height and weight, chest, cardiac, abdominal and neurological examination and presence or absence of other associated dysmorphisms. Also, language assessment was performed by comparing the result of children's receptive and expressive language with the normal language profile to exclude any language disorder .
Intelligence quotient evaluation
The intelligence quotient of the children was determined [Vineland Adaptive Behaviour Scales, 2nd ed. (Vineland-II)] .
Preoperative speech assessment was performed by recording the degree of nasality, audible nasal emission of air and overall unintelligibility of speech of the patients.
Palatal length evaluation
Immediately preoperatively after induction of general anaesthesia, the palatal length was measured using a paper ruler by measuring the straight-line distance from the free gingival margin of the central incisors to the posterior border of the uvula.
Patients were included in this study if they had an isolated cleft palate (involving the uvula, soft and secondary hard palate, with the primary palate and alveolar process intact), had no previous attempts at repair had been made, and were with normal parent's height, normal clinical examination, without associated dysmorphic features. Also, they had to have normal intellectual abilities (adequate level of intelligence according to Vineland-II score 85–115) and average language development. The children had to be capable of uttering at least single words.
All patients were provided dietary support during the period of 6 months before and 6 months after surgery in the form of 120–150 KCl/kg/day of energy, with 50% carbohydrate, 30% fat and 20% protein, 5 mg elemental iron/kg/day, 5 mg/day zinc and daily maintenance doses of vitamin A, vitamin B6 and vitamin B12 to fulfil all nutritional and vitamins requirements.
During this period, all patients were followed up according to the weight and height gained. The results obtained were compared with normal weight and height values of the same sex and age groups obtained from normal WHO growth curves .
All patients underwent two-flap palatoplasty under general anaesthesia with oral endotracheal intubation and under completely aseptic conditions. All surgeries were performed by the same surgeon.
After the mouth was opened by a Dingman mouth gag, adrenaline saline 1: 200 000 concentrations were injected along the edges of the cleft. The incision was placed along the edges of the cleft. A lateral incision was performed at the palatal margin just medial to the free gingival margin, starting from the maxillary tuberosity and extending anteriorly to join the anterior edge of the cleft. The nasal and oral mucosa layers were dissected from underlying tissues. At this point, two oral mucoperiosteal flaps based on the greater palatine artery were developed. The palatal muscles were separated from the posterior edge of the hard palate ([Figure 1]).
After completing the flap on both sides, the nasal mucosa was sutured with interrupted inverted 5/0 vicryl sutures, the palatal muscles were sutured by 4/0 vicryl sutures, which would enable mobilization of the flap posteriorly, and water tight suturing of the oral mucosa was performed using 5/0 vicryl interrupted sutures. A periodontal pack was placed to support the flap and protect the surgical field from the oral environment.
All patients were followed up for 6 months after the surgery, during which they received speech therapy and nutritional support.
Postoperative follow-up and evaluation
Gain in palatal length
After surgery, the straight-line length of the palate was recorded before recovery from general anaesthesia.
One week after surgery, the pack was removed and signs and symptoms of infection, inflammation and incidence of oronasal fistula were recorded.
Postoperative speech evaluation
Six weeks after surgery, all children received speech therapy sessions at a frequency of three sessions per week, each of 20 min duration. During the sessions of speech therapy, children were taught first to avoid forceful production of different sounds.
Audiovisual activities were introduced to the children to make them aware of the oral direction of air together with experiencing an oral stream of air by introducing (f) sound simultaneously with blowing and phonation. Also, clenching nares were performed to direct air stream through the mouth. The focus was on the production of the correct consonant articulation first in isolation, then in syllables, then at the beginning and middle of words and then at the end of words, with correction of stop sounds, especially bilabials (b, p) . It was important to reward the children so that they were motivated to continue the therapy and work as best as they could.
Six, 18 and 30 weeks after surgery, speech assessment was performed, which included reporting of the degree of nasality, audible nasal emission of air and overall unintelligibility of speech. All the above elements were graded along a five-point scale starting with grade 0 (normal) to grade IV (severely affected) . This auditory perceptual assessment was performed throughout the study by matching the findings of three evaluators who had 10 years' experience in phoniatrics and speech pathology and reaching a consensus on the grading according to Fleiss's ᴋ coefficient.
A speech sample was prepared for each child for evaluation through auditory perceptual assessment (APA) by recording the speech of the child throughout 24 h over 2 days (12 h/day).
Postoperative growth evaluation
Follow-up of patients' weight was performed at 3 and 6 months preoperatively and postoperatively, whereas follow-up of patients' height was performed at 6 months preoperatively and postoperatively.
Statistical analysis was carried out using SPSS computer package, version 17.0 (SPSS Inc., Chicago, Illinois, USA). The mean±SD was used for quantitative variables, whereas number and per cent were used for qualitative variables. To assess differences in the frequency of qualitative variables, the x2-test was used. To assess differences in the means of quantitative variables, a paired-samples t-test was used to compare the means of a variable observed at two different time points (before and after surgery) of a single group, whereas a repeated-measures analysis of variance test was used to detect differences in the related means over three or more time points. The statistical methods were verified, assuming a significance level of P less than 0.05 and a high significance level of P less than 0.001.
| Results|| |
A total of 30 patients underwent two-flap palatoplasty for closure of their palatal cleft. The mean age of the patients at the time of the surgery was 15.3 ± 2.61 months. Eighteen (60%) patients were females, whereas 12 (40%) were males. During the second week postoperatively, the healing was uneventful, with no incidence of oronasal fistula, except in three (10%) patients.
Gain in palatal length
The mean palatal length was 38.2 ± 1.31 mm preoperatively and increased to 44.29 ± 1.46 mm; the mean gain in palatal length was 6.09 ± 0.151 mm. Statistical analysis of these results indicated a highly significant increase in palatal length immediately after the surgery.
In terms of speech outcomes including the degree of nasality, audible nasal emission of air and overall unintelligibility, the x2-test showed a highly significant improvement (P < 0.001) in speech outcomes during the postoperative follow-up periods ([Figure 2],[Figure 3],[Figure 4]).
|Figure 2: Estimation of the degree of nasality at different follow-up periods.|
Click here to view
|Figure 3: Evaluation of the degree of nasal emission of air at different follow-up periods.|
Click here to view
|Figure 4: Estimation of the degree of unintelligibility of speech during different follow-up periods.|
Click here to view
There were significant improvements in the weight and height of all patients throughout all follow-up time points, with the rate of increase in the patients' weight and height being 19.85 and 9.25%, respectively, during the 6-month preoperative period. The rate of increase in patients' weight and height was 20.22 and 11.82%, respectively, during the 6-month postoperative period ([Table 1] and [Table 2]).
|Table 1: Comparison of patients' weights and heights 6 months before and at the time of surgery|
Click here to view
|Table 2: Comparison of patients' weights and heights at surgery and 6 months after surgery|
Click here to view
The mean difference in patients' weight before and at surgery was 1.36 ± 0.34 kg and increased to 1.66 ± 0.34 kg (P < 0.001) in the period from the time of surgery to 6 months after surgery. The mean difference in the patients' height before and at surgery was 6.20 ± 1.76 cm and increased to 7.90 ± 1.25 cm (P = 0.001) in the period from the time of surgery to 6 months after surgery.
There was a highly significant increase (P < 0.001) in the mean difference in the patients' weights during the 6-month period after surgery compared with the 6 months preceding surgery.
| Discussion|| |
No actual consensus exists on the optimum time frame for cleft palate repair. The balance between avoiding restriction in facial growth after early surgery and speech development, which requires an intact palate, should be considered. Most children will need an intact palate to produce definite speech sounds at the age of 18 months. There is little evidence to suggest any benefit of palatoplasty before the age of 9 months. Surgical repair before this time point is associated with a higher incidence of maxillary hypoplasia later in life and leads to no improvements in speech. For these reasons, cleft palate repair is usually performed at ~ 9–18 months of age ,.
Children with cleft palate have a high rate of malnutrition secondary to suctioning impairment. This actually interferes with the growth rate and weight gain . The most effective solution to this problem is palate corrective surgery. Also, one of the most important objectives of cleft palate repair is development of normal speech, which requires separation of the nasal and oral cavities to create intelligible speech . Thus, improvements in the growth rate and speech can be considered important parameters on the basis of which the technique of palatoplasty can be assessed ,.
Velopharyngeal competence is the cornerstone in speech production. To achieve a competent valve, the length of the soft palate as well as the integrity of its muscular sling are crucial. Also, muscle reconstruction in a separate layer is advocated .
In the current study, three patients developed oronasal fistula after the surgery, whereas the healing was uneventful in the other patients. The limited incidence of oronasal fistula may be because of atraumatic surgery and careful multilayer closure of the cleft without tension. A lower incidence (5.2%) of oronasal fistula was reported in the study of Bardach . Murthy et al.  reported that eight of 332 patients developed oronasal fistula; the author concluded a decrease in the incidence of oronasal fistula was seen with surgeon experience as seven of eight fistula occurred in the first 10 years of practice, and only one occurred in the last 10 years. Also, Lee et al. , in their study, reported that two-flap palatoplasty can be used to close the cleft palate with minimal exposure of palatal bone, with a reduction in the incidence of fistula formation.
In this study, the mean gain in palatal length immediately after palatoplasty was 6.09 ± 0.15 mm. The gain in palatal length may be because of the backward movement of the flap after suturing the palatal muscles that separated from the posterior edge of the hard palate. This result is in agreement with that of Bae et al. ; in their study, the gain in palatal length using two-flap palatoplasty was 6.7 mm (17.2%).
The length of the palate was measured preoperatively and immediately postoperatively. No long-term assessment of palatal length was performed to determine whether the soft palate continued to lengthen or shorten following surgery. This can be attributed to the difficulty in obtaining reproducible measurements of palatal length in the subsequent follow-up periods as, for an accurate study, the patients should be asleep in the supine position so that the measurements can be obtained again.
Children were subjected to an evaluation of intelligence quotient and language assessment to ensure the presence of an adequate level of intelligence and language skills to facilitate the training manoeuvres during speech therapy. As it was difficult to instruct children 12–18 months of age to say and repeat words spoken by the therapists at the time of evaluation, a speech sample for each child was recorded throughout 24 h over 2 days (12 h/day) to obtain about 2 h of speech sample for an auditory perceptual assessment.
The present study found a slight improvement in speech parameters at 6 weeks postoperatively; this may have been because of the surgical correction of anatomical defects. Further improvement occurred after the commencement of speech therapy. The improvement achieved in the speech parameters may be attributed to blowing exercises, which involved directing air from the nose to the mouth during speech. Also, strengthening of the palatal muscles was achieved, together with better articulation of phonemes and improvement in unintelligibility accompanying nasality. These results are in agreement with those of Bardach , Morris et al.  and Salyer et al. .
In an attempt to assess the growth recovery of patients after palatoplasty, the inclusion criteria were a normal clinical examination, normal height of parents and absence of any other dysmorphism (absence of genetic factors). Also, all patients' weights and heights during the period of the study were compared with normal weight and height values of same sex and age groups obtained from normal WHO growth curves developed by obtaining growth patterns of well-fed, healthy children from diverse ethnic backgrounds and consequently are applicable for children of all races and ethnicities .
The weight and length of all patients were affected before surgery and this can be attributed to a structural defect of the cleft, which interferes with proper feeding also because of frequent aspiration.
Follow-up of the patients over 6 months before surgery, ensuring adequate nutritional support and provision of vitamins, resulted in significant improvements in weight and height, with the rate of increase in patients' weight being 19.85% and the rate of increase in patients' height being 9.25%. Despite this increased growth rate, the patients failed to achieve the weight and length of same age and sex groups of normal children according to WHO growth curves because of the presence of cleft palate.
The follow-up of the patients between the time of surgery and 6 months after surgery, with the same nutritional support and provision of vitamins, resulted in significant improvements in weight and height, with the rate of increase in patients' weight being 20.2% and the rate of increase in patients' height being 11.8%. By the end of this period, the patients achieved a normal growth rate comparable with that of age and sex groups of normal children obtained from WHO growth curves, and this improvement may have been because of nutritional support and correction of palatal defects.
By comparing the mean differences in patients' weights and heights before and after the surgery, we found a highly significant increase (P < 0.001) in the patients' weights during the period of 6 months after surgery compared with the 6 months preceding the surgery, but the increase in height was not significant and this may have been because the follow-up period of 6 months after surgery was short and a longer follow-up period may be required to assess the rate of increase in height.
These results are in agreement with those of the study of Lee et al. , who reported a rapid recovery in growth following surgical repair, with no residual growth deficit because of the creation of a proper oral environment.
| Conclusion|| |
The results of this study suggest that two-flap palatoplasty is a reliable technique for the correction of an isolated cleft palate, with a limited incidence of oronasal fistula. Palatoplasty combined with proper nutritional supply exerts a positive effect on the catch-up growth rate. Speech therapy after palatoplasty is essential to achieve good speech outcomes.
The authors thank speech therapist Kawsar Abdelrahman for her effort during the rehabilitation sessions.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sinno H, Tahiri Y, Thibaudeau S, Izadpanah A, Christodoulou G, Lin SJ, Gilardino M. Cleft lip and palate: an objective measure outcome study. Plast Reconstr Surg 2012; 130:408–414.
Allam E, Windsor LJ, Stone C. Cleft lip and palate: etiology, epidemiology, preventive and intervention strategies. Anat Physiol 2014; 4:150–156.
Temtamy SA, Abdel Meguid N, Mazen I, Ismail SR, Kassem NS, Bassiouni R. Genetic epidemiological study of malformations at birth in. East Mediterr Health J 1998; 4:252–259.
Mitchell LE, Risch N. Mode of inheritance of nonsyndromic cleft lip with or without cleft palate: a reanalysis. Am J Hum Genet 1992; 51:323–332.
Carinci F, Pezzetti F, Scapoli L, Martinelli M, Avantaggiato A, Carinci P, et al.
Recent developments in orofacial cleft genetics. J Craniofac Surg 2003; 14:130–143.
Mossey PA, Little J, Munger RG, Dixon MJ, Shaw WC. Cleft lip and palate. Lancet 2009; 374:1773–1785.
Haberg C, Larson O, Milerad J. Incidence of cleft lip and palate and risks of additional malformations. Cleft Palate Craniofac J 1998; 35:40–45.
Mizuno K, Ueda A, Kani K, Kawamura H. Feeding behaviour of infants with cleft lip and palate. Acta Paediatr 2002; 91:1227–1232.
Ize-Iyamu IN, Saheeb BD. Feeding intervention in cleft lip and palate babies: a practical approach to feeding efficiency and weight gain Int J Oral Maxillofac Surg 2011; 40:916–919.
Zarate AY, Martin LJ, Hopkin RJ, Bender PL, Zhang X, Howard M, et al.
Evaluation of growth in patients with isolated cleft lip and/or cleft palate. Pediatrics 2010; 125:543–549.
Wong FW, King NM. The oral health of children with clefts – a review. Cleft Palate Craniofac J 1998; 35:248–254.
Hunt O, Burden D, Hepper P, Johnston C. The psychosocial effects of cleft lip and palate: a systematic review. Eur J Orthod 2005; 27:274–285.
Lee J, Nunn J, Wright C. Height and weight achievement in cleft lip and palate. Arch Dis Child 1997; 76:70–72.
Rohrich RJ, Love EJ, Byrd HS, Johns DF. Optimal timing of cleft palate closure. Plast Reconstr Surg 2000; 106:413–421.
Leow AM, Lo LJ. Palatoplasty: evolution and controversies. Chang Gung Med J 2008; 31:335–345.
Rifaie N, Hegazi M, Hassan S, Shoeib R, Dawood A. Screening for language development skills during infancy. J Al-Azhar Med Faculty (Girls) 2006; 27:517–533.
Sparrow SS, Cicchetti DV, Balla DA. Vineland-II adaptive behavior scales: survey forms manual
. Circle Pines, MN: AGS Publishing; 2005.
Kummer AW. Cleft palate and craniofacial anomalies: the effects on speech and resonance
. Cincinnati, OH: WB Saunders; 2005. 401–424.
Kotby MN, Abdel Haleem EK, Hegazi M, Safe E, Zaki M. Aspects of assessment and management of velopharyngeal dysfunction in developing countries. Folia Phoniatr Logop 1997; 49:139–146.
Dorf DS, Curtin JW. Early cleft palate repair and speech outcome: a ten year experience. In: Bardach J, Morris HL, editors. Multidisciplinary management of cleft lip and palate
. Philadelphia, PA: WB Saunders; 1990. 341–348.
Copeland M. The effect of very early palatal repair on speech. Br J Plast Surg 1990; 43:676–682.
Mcheik NJ, Levard G. Growth in infants in the first two years of life after neonatal repair for unilateral cleft lip and palate. Int J Pediatr Otorhinolaryngol 2010; 74:465–468.
Kirschner R, Wang P, Jawad AF, Duran M, Cohen M, Solot C, et al
. Cleft-palate repair by modified Furlow double-opposing Z-plasty: the children's hospital of Philadelphia experience. Plast Reconstr Surg 1999; 104:1998–2010.
Randal P, LaRossa D. Cleft palate. In: McCarthy J, editor. Plastic surgery
. Philadelphia, PA: WB Saunders; 1990. 2723–2725.
Bardach J. Two-flap palatoplasty: Bardach's technique. Oper Tech Plast Surg 1995; 2:211–214.
Murthy AS, Parikh PM, Cristion C, Thomassen M, Venturi M, Boyajian MJ. Fistula after 2-flap palatoplasty. A 20-year review. Ann Plast Surg 2009; 63:1–4.
Lee JH, Sohn HS, Lee KC, Park JM, Kim SK. The two flap palatoplasty by Bardach compared with the other methods in cleft palate. J Korean Soc Plast Reconstr Surg 2003; 30:378–383.
Bae YC, Kim JH, Lee J, Hwang SM, Kim SS. Comparative study of the extent of palatal lengthening by different methods. Ann Plast Surg 2002; 48:359–362.
Morris HL, Bardach J, vanDemark DR, Jones DL, Sharkey SG. Results of two-flap palatoplasty with regard to speech production. Eur J Plast Surg 1989; 12:19–24.
Salyer KE, Sng KW, Sperry EE. Two-flap palatoplasty: 20-year experience and evolution of surgical technique. Plast Reconstr Surg 2006; 118:193–204.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2]