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Pharyngeal flap extension as an adjunct to maxillary advancement in patients with cleft palate
J Oral Maxillofac Surg 41:411.1983
Pharyngeal Flap Extension as an Adjunct to Maxillary Advancement in Patients with Cleft Palate THOMAS W. BRAUN, DMD, PHD,· AND GEORGE C. SOTEREANOS, DMD, MSt A significant number of patients with cleft palate have velopharyngeal incompetency. Significant incompetency is frequently improved by placement of pharyngeal flaps. The flaps serve as permanent soft tissue partitions between the nasopharynx and oropharynx. During speech, less movement is required between the velum and the pharyngeal wall to obtain a more competent mechanism with a pharyngeal flap. In patients with maxillary hypoplasia as well as velopharyngeal incompetence , a dilemma is encountered. The preferred treatment of the skeletal, dental, and soft tissue deformity is frequently maxillary advancement. The net result of such treatment, however, is an increase in pharyngeal depth of both the nasopharynx and the oropharynx. This can create a relapse or return of velopharyngeal incompetence in those patients in whom compensation through a pharyngeal flap has been achieved. On the other hand, the flap can be a hindrance to unencumbered maxillary mobility for advancement or vertical repositioning. Although each surgical case must be considered individually, the alternatives in surgical management generally include no interference with the flap; release of the flap at surgery, with secondary reattachment; or extension of the flap at its pharyngeal base. The final alternative, of course , depends on the amount and direction of maxillary movement. We have found that in most cases of advancement up to 15 mm , extension of the base is frequently possible and an intact pharyngeal flap can be maintained.' The procedure of flap extension is readily performed after completion of the maxillary oste-
FIGURE 1. Lateral view of pharyngeal flap extension through the tran snasal approach. The Metzenbaum scissors are placed over the downfractured maxilla with their tips at the junction of the pharyngeal flap and the posterior wall of the pharynx. By submucosal dissection, the flap can then be extended. A similar procedure is performed for superiorly based flaps by a transoral approach.
otomy. Superiorly based flaps can be extended from below through the oral cavity. Inferiorly based flaps are extended transnasally (Fig. I). With the flap extended , adequate maxillary mobility can be achieved while velopharyngeal contact is maintained. It should be noted, however, that maintenance of the velopharyngeal attachment does not necessarily guarantee a speech mechanism unaltered from the preoperative state. A true evaluation of the preoperative and postoperative speech mechanism must be performed by a speech pathologist and , when possible, enhanced by videofluorography.
* Chief, Oral and Maxillofacial Surgery, Western Pennsylvania Hospital; Assistant Profes sor of Anatomy and Oral and Maxillofaci al Surgery, University of Pittsburgh and PresbyterianUn ivers ity Hospital, Pittsburgh. t Chairman, Department of Dentistry, Western Pennsylvania Hospital; Director, Oral and Maxillofacial Surgery, Presbyterian-University Hospital, Pittsburgh . Address correspondence and reprint requests to Dr. Braun: Mellon Pavilion, 4815 Liberty Ave., Pittsburgh, PA 15224.
References 1. Braun TW, Sotereanos GO : Orthognathic surgical reconstruction of cleft palate deformities in adolescents. J Oral Surg 39:255, 1981
411
Pharyngeal Flap Extension as an Adjunct to Maxillary Advancement in Patients with Cleft Palate THOMAS W. BRAUN, DMD, PHD,· AND GEORGE C. SOTEREANOS, DMD, MSt A significant number of patients with cleft palate have velopharyngeal incompetency. Significant incompetency is frequently improved by placement of pharyngeal flaps. The flaps serve as permanent soft tissue partitions between the nasopharynx and oropharynx. During speech, less movement is required between the velum and the pharyngeal wall to obtain a more competent mechanism with a pharyngeal flap. In patients with maxillary hypoplasia as well as velopharyngeal incompetence , a dilemma is encountered. The preferred treatment of the skeletal, dental, and soft tissue deformity is frequently maxillary advancement. The net result of such treatment, however, is an increase in pharyngeal depth of both the nasopharynx and the oropharynx. This can create a relapse or return of velopharyngeal incompetence in those patients in whom compensation through a pharyngeal flap has been achieved. On the other hand, the flap can be a hindrance to unencumbered maxillary mobility for advancement or vertical repositioning. Although each surgical case must be considered individually, the alternatives in surgical management generally include no interference with the flap; release of the flap at surgery, with secondary reattachment; or extension of the flap at its pharyngeal base. The final alternative, of course , depends on the amount and direction of maxillary movement. We have found that in most cases of advancement up to 15 mm , extension of the base is frequently possible and an intact pharyngeal flap can be maintained.' The procedure of flap extension is readily performed after completion of the maxillary oste-
FIGURE 1. Lateral view of pharyngeal flap extension through the tran snasal approach. The Metzenbaum scissors are placed over the downfractured maxilla with their tips at the junction of the pharyngeal flap and the posterior wall of the pharynx. By submucosal dissection, the flap can then be extended. A similar procedure is performed for superiorly based flaps by a transoral approach.
otomy. Superiorly based flaps can be extended from below through the oral cavity. Inferiorly based flaps are extended transnasally (Fig. I). With the flap extended , adequate maxillary mobility can be achieved while velopharyngeal contact is maintained. It should be noted, however, that maintenance of the velopharyngeal attachment does not necessarily guarantee a speech mechanism unaltered from the preoperative state. A true evaluation of the preoperative and postoperative speech mechanism must be performed by a speech pathologist and , when possible, enhanced by videofluorography.
* Chief, Oral and Maxillofacial Surgery, Western Pennsylvania Hospital; Assistant Profes sor of Anatomy and Oral and Maxillofaci al Surgery, University of Pittsburgh and PresbyterianUn ivers ity Hospital, Pittsburgh. t Chairman, Department of Dentistry, Western Pennsylvania Hospital; Director, Oral and Maxillofacial Surgery, Presbyterian-University Hospital, Pittsburgh . Address correspondence and reprint requests to Dr. Braun: Mellon Pavilion, 4815 Liberty Ave., Pittsburgh, PA 15224.
References 1. Braun TW, Sotereanos GO : Orthognathic surgical reconstruction of cleft palate deformities in adolescents. J Oral Surg 39:255, 1981
411