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Nasolabial Angle Modifications Following Maxillary Surgery
Oral Abstract Track 2 approximately 20-25% of patients with cleft palate (McComb et al, 2011). Advancing and /or repositioning the maxilla surgically results in the soft palate being carried forward and this can negatively impact velopharyngeal functioning, leading to hypernasal speech and excessive nasal air emission in at risk patients. Speech-Language Pathologists play an integral role in determining the potential effects maxillary advancement may have on velopharyngeal functioning (resonance) and speech sound production (articulation). This presentation will outline the pre-operative speech evaluation used at The Hospital for Sick Children, Toronto, Canada to provide valuable information to patients regarding expected speech outcomes following maxillary advancement. Audio and videotape samples of perceptual ratings of resonance, articulation analysis, the use of acoustic analysis (Nasometry) and relevant components of the oral peripheral examination will be reviewed. The Hospital for Sick Children modified its assessment protocol in 2005 based on a retrospective clinical audit of cleft palate patients undergoing Le Fort I maxillary advancement over a 3 year period. Pre-operative nasopharyngoscopy is no longer a standard pre-requisite test to ascertain risk for velopharyngeal insufficiency (VPI). Results supported the use of perceptual evaluations by specially trained Speech-Language Pathologists to predict post-operative VPI risk and nasopharyngoscopy did not significantly increase predictive values (Phillips et al, 2005). Patients undergoing maxillary advancement need to be counseled regarding potential increase in hypernasality after maxillary advancement if they pre-operatively present with borderline or inadequate velopharyngeal functioning. A retrospective chart review over a 2 year period at The Hospital for Sick Children revealed that 14 (7 males, 7 females) out of 54 patients (25.9%) with repaired cleft palate required secondary surgery to manage VPI after maxillary advancement. Of the 14 patients, 8 had bilateral cleft lip/palate, 4 were unilateral cleft lip/palate and 2 patients were syndromic with cleft palate (Apert’s Syndrome, Treacher Collins Syndrome). Thirteen patients presented with some degree of hypernasality pre-operatively and were counselled regarding their increased risk of VPI. Four patients presented with unchanged resonance ratings post-advancement, 9 experienced an increase in hypernasality and for 1 patient there was no pre-operative data for comparison. On average, surgical management for VPI was completed one year postadvancement. Eleven patients were managed with a superiorly based pharyngeal flap, 2 had secondary Furlow palatoplasty and the patient with Treacher Collins Syndrome required a pharyngeal flap revision. Explaining the underlying mechanics of velopharyngeal movement and speech production physiology to patients can help them better understand potential speech outcomes and alleviate anxiety. The protocol for postoperative speech assessment for patients who experience e-22
VPI will be addressed with emphasis on the timing for additional testing and the role of nasopharyngoscopy to determine surgical/prosthetic management options to treat VPI. Nasopharyngoscopy samples will illustrate the role of ratings of gap size and closure pattern to determine management options. These include posterior pharyngeal flaps, sphincter pharyngoplasties, velar lengthening procedures (e.g. secondary Furlow palatoplasty ), pharyngeal wall augmentation and palatal obturator prosthesis. References: 1. McComb RW, Marrinan EM, Nuss RC, LaBrie RA, Mulliken JB, Padwa BL: Predictors of velopharyngeal insufficiency after Le Fort 1 maxillary advancement in patients with cleft palate. J Oral Maxillofac Surg 69:2226-2232, 2011. 2. Phillips JH, Klaiman PG, Delorey R, MacDonald DB. Predictors of velopharyngeal insufficiency in cleft palate orthognathic surgery. Plast Reconstr Surg 115:681-686, 2005.
Nasolabial Angle Modifications Following Maxillary Surgery A. Bunnell: University of Florida Health Science Center, T. Fattahi The nasolabial angle is the angle formed by a line tangent to the upper lip and a line tangent to the columella. A value of 90 to 120 degrees is considered normal in adults.1 The nasolabial angle is determined by several factors including the anteroposterior position of the maxilla, the anteroposterior position of the maxillary incisors, the vertical position or rotation of the nasal tip, which can result in a more obtuse or acute nasolabial angle, and by the soft tissue thickness of the maxillary lip that contributes to the nasolabial angle. A thin upper lip favors a flatter angle, while a thicker upper lip favors an acute angle.2 Therefore this angle is a common parameter that is considered when treatment planning for maxillary surgery. While there is a general consensus within the literature on these values, there appears to be inconsistencies in describing changes to the nasolabial angle that occur following maxillary surgery. Previous reports have described changes as acute, more acute, more obtuse, less obtuse, open vs. closed, leading to confusion among the readers in determining if the angle actually increases or decreases in size.3,4 This study aims to evaluate the changes to this angle that occur following maxillary surgery, including whether the angle decreases or increases and clarify the terminology that is used to describe the changes found. This retrospective chart review evaluated twenty patients who underwent maxillary surgery for correction of dentofacial abnormalities from July 2009 to December 2013 at the Department of Oral and Maxillofacial Surgery, University of Florida Health Science Center, Jacksonville, Florida. Lateral cephalograms and lateral profile photographs taken in the pre and post-operative period for each patient were obtained for analysis and processed using Dolphin Imaging Software. Analysis AAOMS 2014
Oral Abstract Track 2 of these films included measurement of the amount of anteroposterior movement of the maxilla and measurement of nasolabial angle changes following maxillary surgery. Subjective analysis has shown that the nasolabial angle increases in the majority of subjects evaluated at our institution. These increases in the nasolabial angle were also found to correlate with the amount of anteroposterior advancement of the maxilla.By clarifying the terminology, it allows for a consistent method of defining post-operative changes to the nasolabial angle and avoids confusion among practitioners when communicating treatment plans with one another. References: 1. Defining the ideal nasolabial angle.Armijo BS1, Brown M, Guyuron B. Plast Reconstr Surg. 2012 Mar;129(3):759-64. 2. The Aesthetic Dentofacial Analysis David Sarver, Ronald S. Jacobson Clinics in Plastic Surgery - July 2007 (Vol. 34, Issue 3, Pages 369-394) 3. Changes in facial profile after maxillomandibular advancement surgery for obstructive sleep apnea syndrome. Cohen-Levy J1, Petelle B, Vieille E, Dumitrache M, Fleury B. Int Orthod. 2013 Mar;11(1):71-92. 4. An evaluation of the nasolabial angle and the relative inclinations of the nose and upper lip. Fitzgerald JP1, Nanda RS, Currier GF. Am J Orthod Dentofacial Orthop. 1992 Oct;102(4):328-34.
Maxillary Advancement and the presence of pre-operative pharyngeal flap in cleft palate patients: Speech and Relapse Implications P. G. Klaiman: The Hospital for Sick Children, S. J. Fischbach, B. Tompson, C. R. Forrest, J. H. Phillips Patients with cleft palate have a 20-30% rate of developing velopharyngeal insufficiency (VPI). VPI is characterized by nasal sounding speech (hypernasality) and audible/turbulent nasal escape during speech related to inadequate functioning of the soft palate musculature. Confirmed VPI is typically managed through secondary surgery and a superiorly based pharyngeal flap is the most commonly used procedure. Patients with cleft palate are also at risk for maxillary hypoplasia requiring orthognathic surgery. The effects of having a pre-existing pharyngeal flap on orthognathic surgical planning and subsequent speech outcome have not been well documented. Isolated cases have been described as part of a larger series of studies evaluating speech outcomes after maxillary osteotomy (Maegawa et al. 1998, Watzke et al. 1990). As a result of a small number of subjects, firm conclusions about changes in velopharyngeal functioning, flap status and relapse are difficult to make. A retrospective chart review of patients with non-syndromic cleft lip and/or palate with pharyngeal flaps who underwent maxillary advancement between the 10 year period from January 1, 2003 to December 31, 2013 was conducted. Demographic information, diagnosis, speech and surgical outcomes were collected
AAOMS 2014
pre-operatively and where appropriate post-operatively. To evaluate relapse rates, patients with and without pre-existing pharyngeal flap were matched for diagnosis, gender and amount of advancement. Standardized cephalograms were hand traced and digitized. Paired t-tests were used to compare relapse rates between the two matched groups at pre and at least 6 months post- maxillary advancement. Nineteen cleft lip and/or palate patients (8 females, 11 males) were included. Nine patients had unilateral cleft lip and palate and 10 had bilateral cleft lip and palate. The age range at the time of maxillary advancement was 15.5 to 24.5 years (mean 19.5). The age range at the time of pharyngeal flap surgery was 3.5 to 17.2 years (mean 8.1). Two patients required takedown of the pharyngeal flap at the time of advancement. One patient had an obstructing pharyngeal flap and documented OSA which was managed by BiPap. After takedown, resonance remained acceptable. The other patient required the largest advancement in the series (14 mm) which could not be achieved with the flap in place and pre-operatively mildly hypernasal was documented. Pre-advancement, 11 patients presented with normal resonance, 4 with mixed slight/inconsistent hypernasality and hyponasality, 2 were hyponasal, and 2 patients had mild hypernasality. Patients were only referred for a post-advancement speech assessment if they reported increased hypernasality after surgery. None of the patients who presented with either normal or mixed resonance were referred for follow up. Resonance remained unchanged in one of the patients with pre-operative mild hypernasality. The other patient required flap takedown and became moderately hypernasal after surgery. A repeat pharyngeal flap pharyngoplasty 17 months after advancement was completed with a successful speech outcome. The amount of maxillary advancement ranged from 3 to 14 mm. There was no difference in relapse rates between the two groups, likely as a result of the use of rigid internal fixation. Patients with an adequately functioning pharyngeal flap prior to advancement can expect their resonance to remain unchanged after surgery and this is consistent with the findings reported for non-syndromic cleft lip/palate patients without pharyngeal flaps. Patients who require significant advancements may require takedown of a pharyngeal flap which likely will result in increased hypernasality. Patients should be counseled accordingly. References: 1. Maegawa J, Sells RK, David DJ: Pharyngoplasty in patients with cleft lip and palate after maxillary advancement. J Craniofac Surg. 9:4:330-335, 1998. 2. Watzke I, Turvey TA, Warren DW, Dalston R: Alterations in velopharyngeal functioning after maxillary advancement in cleft palate patients. J Oral Maxillofac Surg. 48: 685-689, 1990.
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VPI will be addressed with emphasis on the timing for additional testing and the role of nasopharyngoscopy to determine surgical/prosthetic management options to treat VPI. Nasopharyngoscopy samples will illustrate the role of ratings of gap size and closure pattern to determine management options. These include posterior pharyngeal flaps, sphincter pharyngoplasties, velar lengthening procedures (e.g. secondary Furlow palatoplasty ), pharyngeal wall augmentation and palatal obturator prosthesis. References: 1. McComb RW, Marrinan EM, Nuss RC, LaBrie RA, Mulliken JB, Padwa BL: Predictors of velopharyngeal insufficiency after Le Fort 1 maxillary advancement in patients with cleft palate. J Oral Maxillofac Surg 69:2226-2232, 2011. 2. Phillips JH, Klaiman PG, Delorey R, MacDonald DB. Predictors of velopharyngeal insufficiency in cleft palate orthognathic surgery. Plast Reconstr Surg 115:681-686, 2005.
Nasolabial Angle Modifications Following Maxillary Surgery A. Bunnell: University of Florida Health Science Center, T. Fattahi The nasolabial angle is the angle formed by a line tangent to the upper lip and a line tangent to the columella. A value of 90 to 120 degrees is considered normal in adults.1 The nasolabial angle is determined by several factors including the anteroposterior position of the maxilla, the anteroposterior position of the maxillary incisors, the vertical position or rotation of the nasal tip, which can result in a more obtuse or acute nasolabial angle, and by the soft tissue thickness of the maxillary lip that contributes to the nasolabial angle. A thin upper lip favors a flatter angle, while a thicker upper lip favors an acute angle.2 Therefore this angle is a common parameter that is considered when treatment planning for maxillary surgery. While there is a general consensus within the literature on these values, there appears to be inconsistencies in describing changes to the nasolabial angle that occur following maxillary surgery. Previous reports have described changes as acute, more acute, more obtuse, less obtuse, open vs. closed, leading to confusion among the readers in determining if the angle actually increases or decreases in size.3,4 This study aims to evaluate the changes to this angle that occur following maxillary surgery, including whether the angle decreases or increases and clarify the terminology that is used to describe the changes found. This retrospective chart review evaluated twenty patients who underwent maxillary surgery for correction of dentofacial abnormalities from July 2009 to December 2013 at the Department of Oral and Maxillofacial Surgery, University of Florida Health Science Center, Jacksonville, Florida. Lateral cephalograms and lateral profile photographs taken in the pre and post-operative period for each patient were obtained for analysis and processed using Dolphin Imaging Software. Analysis AAOMS 2014
Oral Abstract Track 2 of these films included measurement of the amount of anteroposterior movement of the maxilla and measurement of nasolabial angle changes following maxillary surgery. Subjective analysis has shown that the nasolabial angle increases in the majority of subjects evaluated at our institution. These increases in the nasolabial angle were also found to correlate with the amount of anteroposterior advancement of the maxilla.By clarifying the terminology, it allows for a consistent method of defining post-operative changes to the nasolabial angle and avoids confusion among practitioners when communicating treatment plans with one another. References: 1. Defining the ideal nasolabial angle.Armijo BS1, Brown M, Guyuron B. Plast Reconstr Surg. 2012 Mar;129(3):759-64. 2. The Aesthetic Dentofacial Analysis David Sarver, Ronald S. Jacobson Clinics in Plastic Surgery - July 2007 (Vol. 34, Issue 3, Pages 369-394) 3. Changes in facial profile after maxillomandibular advancement surgery for obstructive sleep apnea syndrome. Cohen-Levy J1, Petelle B, Vieille E, Dumitrache M, Fleury B. Int Orthod. 2013 Mar;11(1):71-92. 4. An evaluation of the nasolabial angle and the relative inclinations of the nose and upper lip. Fitzgerald JP1, Nanda RS, Currier GF. Am J Orthod Dentofacial Orthop. 1992 Oct;102(4):328-34.
Maxillary Advancement and the presence of pre-operative pharyngeal flap in cleft palate patients: Speech and Relapse Implications P. G. Klaiman: The Hospital for Sick Children, S. J. Fischbach, B. Tompson, C. R. Forrest, J. H. Phillips Patients with cleft palate have a 20-30% rate of developing velopharyngeal insufficiency (VPI). VPI is characterized by nasal sounding speech (hypernasality) and audible/turbulent nasal escape during speech related to inadequate functioning of the soft palate musculature. Confirmed VPI is typically managed through secondary surgery and a superiorly based pharyngeal flap is the most commonly used procedure. Patients with cleft palate are also at risk for maxillary hypoplasia requiring orthognathic surgery. The effects of having a pre-existing pharyngeal flap on orthognathic surgical planning and subsequent speech outcome have not been well documented. Isolated cases have been described as part of a larger series of studies evaluating speech outcomes after maxillary osteotomy (Maegawa et al. 1998, Watzke et al. 1990). As a result of a small number of subjects, firm conclusions about changes in velopharyngeal functioning, flap status and relapse are difficult to make. A retrospective chart review of patients with non-syndromic cleft lip and/or palate with pharyngeal flaps who underwent maxillary advancement between the 10 year period from January 1, 2003 to December 31, 2013 was conducted. Demographic information, diagnosis, speech and surgical outcomes were collected
AAOMS 2014
pre-operatively and where appropriate post-operatively. To evaluate relapse rates, patients with and without pre-existing pharyngeal flap were matched for diagnosis, gender and amount of advancement. Standardized cephalograms were hand traced and digitized. Paired t-tests were used to compare relapse rates between the two matched groups at pre and at least 6 months post- maxillary advancement. Nineteen cleft lip and/or palate patients (8 females, 11 males) were included. Nine patients had unilateral cleft lip and palate and 10 had bilateral cleft lip and palate. The age range at the time of maxillary advancement was 15.5 to 24.5 years (mean 19.5). The age range at the time of pharyngeal flap surgery was 3.5 to 17.2 years (mean 8.1). Two patients required takedown of the pharyngeal flap at the time of advancement. One patient had an obstructing pharyngeal flap and documented OSA which was managed by BiPap. After takedown, resonance remained acceptable. The other patient required the largest advancement in the series (14 mm) which could not be achieved with the flap in place and pre-operatively mildly hypernasal was documented. Pre-advancement, 11 patients presented with normal resonance, 4 with mixed slight/inconsistent hypernasality and hyponasality, 2 were hyponasal, and 2 patients had mild hypernasality. Patients were only referred for a post-advancement speech assessment if they reported increased hypernasality after surgery. None of the patients who presented with either normal or mixed resonance were referred for follow up. Resonance remained unchanged in one of the patients with pre-operative mild hypernasality. The other patient required flap takedown and became moderately hypernasal after surgery. A repeat pharyngeal flap pharyngoplasty 17 months after advancement was completed with a successful speech outcome. The amount of maxillary advancement ranged from 3 to 14 mm. There was no difference in relapse rates between the two groups, likely as a result of the use of rigid internal fixation. Patients with an adequately functioning pharyngeal flap prior to advancement can expect their resonance to remain unchanged after surgery and this is consistent with the findings reported for non-syndromic cleft lip/palate patients without pharyngeal flaps. Patients who require significant advancements may require takedown of a pharyngeal flap which likely will result in increased hypernasality. Patients should be counseled accordingly. References: 1. Maegawa J, Sells RK, David DJ: Pharyngoplasty in patients with cleft lip and palate after maxillary advancement. J Craniofac Surg. 9:4:330-335, 1998. 2. Watzke I, Turvey TA, Warren DW, Dalston R: Alterations in velopharyngeal functioning after maxillary advancement in cleft palate patients. J Oral Maxillofac Surg. 48: 685-689, 1990.
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