Speech evaluation and dental arch shape following pushback palatoplasty in cleft palate patients: Supraperiosteal flap technique versus mucoperiosteal flap technique

ARTICLE IN PRESS Journal of Cranio-Maxillofacial Surgery (2006) 34, 135–143 r 2006 European Association for Cranio-Maxillofacial Surgery doi:10.1016/j.jcms.2005.11.006, available online at http://www.sciencedirect.com

Speech evaluation and dental arch shape following pushback palatoplasty in cleft palate patients: Supraperiosteal flap technique versus mucoperiosteal flap technique Shizuyo ITO1, Makoto NOGUCHI1,, Yoshiyuki SUDA1, Akira YAMAGUCHI1, Geniku KOHAMA1, Etsuhide YAMAMOTO2 1

Department of Oral Surgery (Chairman: Hiroyoshi Hiratsuka), Sapporo Medical University and School of Medicine, Sapporo, Japan; 2Department of Oral Surgery (Chairman: Etsuhide Yamamoto), School of Medicine, Kanazawa University, Kanazawa, Japan

Background: The aim of this study was to evaluate and compare the maxillary dental arch shape and speech of cleft palate patients following pushback palatoplasty using either the supraperiosteal flap technique or the mucoperiosteal flap technique. Patients: Sixty-two patients (29, cleft palate only; 33, unilateral cleft lip, alveolus and palate) operated on by the supraperiosteal technique and 47 patients (23, cleft palate only; 24 unilateral cleft lip, alveolus and palate) by the mucoperiosteal technique were reviewed in this study. Study design: Dental arch shape and speech proficiency at preschool and school age were evaluated in all patients. Results: Dental arch shapes were classified as U type (good dental arch shape) and V type (narrow dental arch shape). In cleft palate only patients, U type was observed in 90% of the supraperiosteal group and 83% of the mucoperiosteal group. In unilateral cleft lip, alveolus and palate patients, U type was observed in 85% of the supraperiosteal group, while only in 33% of the mucoperiosteal group. In cleft palate only patients, normal speech at school age was observed 100% of the supraperiosteal group and 83% of the mucoperiosteal group. In unilateral cleft lip, alveolus and palate patients, normal speech at school age was observed in 97% of the supraperiosteal group and 75% of the mucoperiosteal group. Misarticulation was frequently found in patients with the V type of dental arch shape. Conclusion: It is suggested that pushback palatoplasty using the supraperiosteal technique is more advantageous for speech development compared with the mucoperiosteal technique. r 2006 European Association for Cranio-Maxillofacial Surgery

SUMMARY.

Keywords: cleft palate, palatoplasty, speech results, dental arch shape, supraperiosteal flap technique, mucoperiosteal flap technique

types of palatal surgery: the supraperiosteal flap technique (SP technique) described by Kohama (1991) without denudation of bone, and the classical pushback technique described by Wardill in 1937 resulting in denuded bone (MP technique). In that study it was found that the palatal length in the deciduous dentition following SP technique was better than following MP technique. Noguchi et al. (2003) compared dento-alveolar development in the permanent dentition between patients who had received either one of those two types of palatal surgery, and reported also that dento-alveolar development following the SP technique was superior to the MP technique regarding palatal length and palatal height. They concluded that the technique that leaves no denuded bone in the alveolar region was considered to be advantageous for the development of the alveolar processes of the maxilla. The purpose of this study was to evaluate the maxillary dental arch shape and speech of cleft palate patients at preschool and school ages following palatal repair using either the SP or the MP technique.

INTRODUCTION Pushback palatoplasty has been widely used as a most reliable procedure to generate velopharyngeal competence for cleft palate patients. However, the issue of articulation errors in patients with good velopharyngeal closure still remains (Green, 1960; Musgrave et al., 1975; Ainoda, 1981; Yoshimasu et al., 1986). On the other hand, it is well known that pushback palatoplasty can often cause disturbances in maxillary growth as well as malposition of the teeth due to scar tissue formation at the denuded bone area (Ross and Johnston, 1972). Various types of palatoplasty have been designed to diminish the negative influence of surgery on the growth of the hard palate and the maxillary alveolar process (Perko, 1974, 1979; Kohama, 1991). Leenstra et al. (1996) evaluated the peri- and postoperative course and the dento-alveolar development of the deciduous dentition in patients with unilateral clefts of the lip, alveolus and palate, and isolated cleft palate up to 5 years of age following two 135

ARTICLE IN PRESS 136 Journal of Cranio-Maxillofacial Surgery

MATERIAL AND METHODS Patients One-hundred and nine patients born between 1974 and 1991 with isolated cleft palate including cleft of the soft palate only (ICP, 52), and patients with unilateral clefts of lip, alveolus and palate (UCLAP, 57) were evaluated. The patients were treated at the Department of Oral Surgery, Sapporo Medical University School of Medicine, Japan (Table 1). Patients with other congenital anomalies, mental retardation, serious hearing problems, or emotional disturbances were excluded from this study. The surgical procedure for cleft palate was a pushback palatoplasty, but the method of elevating the palatal flaps differed as either a SP technique or a MP technique had been used. The MP group was performed according to Wardill’s method (1937). In the SP group, the palatal flaps were raised so that the periosteum remained on the palatal side of the alveolar region: A no. 11 blade was advanced nearly parallel the alveolar crest, and soft tissue was left in the alveolar region. On the palatal process, a mucoperiosteal flap was raised in such a manner that the neurovascular bundle was enclosed within the flaps. An early evaluation of the results of the pushback palatoplasty using the MP flap technique led us to adopt the SP flap technique around 1980. This was based on the impression that scar formation on the palatal side of the alveolus inhibited the development of the alveolar process. The purpose of this study is to present patients who have had either a pushback palatoplasty before or after we changed our technique. Among 52 ICP patients, 29 (m, 11; f, 18) were treated using the SP technique, and 23 patients (m, 10; f, 13) using the MP technique. Among 57 UCLAP patients, 33 (m, 23; f, 10) were treated using the SP technique and 24 patients (m, 15; f, 9) using the MP technique. Patients with UCLAP did not receive

preoperative orthopaedic treatment before lip closure. Lip closure was performed at a mean age of 3 months. Palatoplasty was performed at a mean age of 16 months. Orthodontic management began during the mixed dentition and maxillary dental arch shape was evaluated annually (on the dental casts). Postoperative care and long-term observations were performed simultaneously by oral surgeons and a speech pathologist. The patients were observed longitudinally from the time of palatoplasty for between 2–11 years at intervals of 6 months to 1 year. Speech and language development, development of language skills and articulation errors as well as velopharyngeal closure were checked as were the dentition, maxillary growth and development, occlusion and tongue function. All patients had undergone speech– language therapy focusing on parent education; a school speech clinic was started after surgery with the objective of attaining normal speech and language development and development of good oral function: blowing, sucking, swallowing, chewing, licking, clicking tongue, and folding tongue. Evaluation of the dental arch shape Maxillary dental arch shapes were monitored annually in all patients using plaster cast models from 2 years until 5 years after surgery, and categorized into U type (good dental arch shape) or V type (narrow dental arch shape). Assessment of velopharyngeal function Velopharyngeal closure from the time of palatoplasty was monitored at intervals of 3 months to 6 months. Velopharyngeal function was measured postoperatively by oral examination, acoustic judgement (hypernasality, distorted consonants associated with nasal emission ) and blowing exercises by a speech pathologist and oral surgeons from before 3 years of

Table 1 – Patients’ data Surgical technique SP

MP

Cleft type

n

ICP

29

UCLAP

33

ICP

23

UCLAP

24

Age at surgery

Age at evaluation (mean age) Preschool

School-age

1 year 1 month–1 year 8 months (1 year 4 months) 1 year 2 months–1 year 11 months (1 year 4 months)

3 years 6 months–5 years 11 months (5 years 3 months) 3 years 5 months–5 years 11 months (5 years 1 month)

7 years 0 months–12 years 8 months (9 years 7 months) 7 years 0 months–12 years 3 months (9 years 1 month)

1 year 2 months–1 year 9 months (1 year 4 months) 1 year 3 months–1 year 11 months (1 year 4 months)

3 years 2 months–5 years 9 months (5 years 2 months) 5 years 3 months–5 years 11 months (5 years 4 months)

7 years 0 months–12 years 7 months (10 years 7 months) 7 years 3 months–12 years 2 months (9 years 5 months)

ICP: Isolated cleft palate. UCLAP: Unilateral cleft of lip, alveolus, and palate. SP: Supraperiosteal flap technique. MP: Mucoperiosteal flap technique.

ARTICLE IN PRESS Speech evaluation and dental arch shape following pushback palatoplasty in cleft palate patients 137

age until 12 years of age. Results were graded as competent (no problem in all examinations), incompetent (having problems in all examinations) or slight incompetence (having problems in some examinations). All patients associated with velopharyngeal incompetence underwent insertion of a palatal lift prosthesis (Lang, 1967) at 2 years 8 months to 3 years of age. At the time of speech evaluation in preschool childhood, none of the patients showed hypernasality or distorted consonants resulting from velopharyngeal incompetence.

the teeth or alveolar ridge and tongue-tip, and are now produced by articulatory movement of the palate and central portion of the tongue (Okazaki et al., 1991).

RESULTS Dental arch shape after palatoplasty Maxillary dental arch shape was classified as U type (good shape) or V type (narrow shape). In isolated cleft palate (ICP) children, U type was observed in 90% of the SP group (26 patients), and in 83% of the MP group (19 patients). In children with unilateral clefts of lip, alveolus and palate (UCLAP), U type was observed in 85% of the SP group (28 patients), and only in 33% of the MP group (8 patients). The MP group had a statistically significant greater number of V types. Statistically significant differences were found between ICP and UCLAP children within the MP group and also between the SP and the MP groups among the UCLAP patients (po0:01; Table 2).

Speech evaluation Speech proficiency consisting of auditory and visual assessment was evaluated by a speech–language pathologist who has had more than 30 years of clinical experience with cleft palate patients in the postoperative period at intervals of 6 months to 1 year in free conversation. Patients were assessed for articulation development in simple sounds, words and connected sentences at preschool childhood between 3 years 2 months and 5 years 11 months of age and at school age between 7 years and 12 years 8 months of age. Speech proficiency at preschool age was evaluated before articulation therapy was started. In all patients with velopharyngeal incompetence, the assessment of articulation was performed during use of the palatal prosthesis in childhood and when at school age. Each patient was examined to see whether hypernasality and misarticulation were present or not, and what types of articulation errors existed. Speech results were classified into normal speech or articulation disorders. Articulation disorders were palatalized articulation, lateral articulation, glottal stop, weak consonants associated with nasal emission and substitutions. Palatalized articulation is an articulation disorder in which dental sounds and alveolar consonants are systematically found, these sounds being normally produced using

Velopharyngeal function During preschool years, velopharyngeal incompetence was observed in 4 patients of the SP groups among the ICP patients (14%), and in one case of the MP group (4%). In UCLAP patients (at preschool ages), velopharyngeal incompetence was found in 2 patients of the SP group (6%), and in 2 patients of the MP group (8%). Both pushback techniques almost always obtained good velopharyngeal closure. A palatal lift prosthesis was constructed for 9 patients with velopharyngeal incompetence, and all of these patients ultimately showed completely recovered velopharyngeal closure at 8 years. In one ICP patient of the SP group the palatal lift prosthesis was

Table 2 – Dental arch shapes following palatoplasty using the SP technique or the MP technique for isolated cleft palate and unilateral cleft lip, alveolus and palate

ICP

Dental arch shapes

U type

V type

U CLAP

SP (n=29)

MP (n=23)

SP (n=33)

MP (n=24)

26

19

28

8

3

4

5

16 *

* U type: Good dental arch shape. V type: Narrow dental arch shape. SP: Supraperiosteal flap technique. MP: Mucoperiosteal flap technique.*po0:01:

ARTICLE IN PRESS 138 Journal of Cranio-Maxillofacial Surgery Table 3 – Velopharyngeal function at preschool and school ages following 2 types of palatoplasty Surgical technique

Cleft type

SP

ICP ðn ¼ 29Þ UCLAP ðn ¼ 33Þ

MP

ICP ðn ¼ 23Þ UCLAP ðn ¼ 24Þ

a

Time at evaluation

Velopharyngeal function Competence

Slight incompetence

Incompetence

Preschool School age Preschool School age

25 26a 31 31

0 0 0 0

4 3 2 2

Preschool School age Preschool School age

22 22 22 22

0 1b 0 0

1 0 2 2

Palatal lift prosthesis could be removed after speech therapy. Palatal lift prosthesis was rejected by 1 patient.

b

Table 4 – Speech results at preschool and school ages following 2 types of palatoplasty

Speech proficiency Surgical

Time at

technique

Cleft type

ICP (n=29) SP UCLAP (n=33)

Articulation

evaluation

Normal speech

Preschool

25

4

School age

29

0

Preschool

23

10

disorders

UCLAP (n=24)

*

po0:05;

**

po0:02;

** ***

School age

32

1

Preschool

18

5

School age

19

4

Preschool

12

12

School age

18

6

ICP (n=23) MP

*

**

***

po0:01:

removed after therapy because good velopharyngeal function and normal articulation were obtained. In another ICP patient (belonging to the MP group), however, slight velopharyngeal incompetence still existed at school age due to rejection of the palatal lift prosthesis (Table 3). Speech results Speech results at preschool and school ages were classified either as normal speech or as with articulation disorders (Table 4). In the SP group, normal speech was observed in 86% of ICP patients (25 patients) of preschool and in all ICP patients (100%) of school age. In UCLAP patients, normal speech was found in 70% of patients of preschool (23 patients), and in 97% of patients of school age (32 patients). In the MP group, on the other hand, normal speech was observed in 78% of ICP patients of preschool (18 patients) and in 83% of patients of school age

(19 patients). In UCLAP patients, normal speech was observed in 50% of patients of preschool (12 patients) and in 75% of patients of school age (18 patients). Thus, there was a higher incidence of normal speech in both groups of cleft patients within the SP group than in their counterparts in the MP group– both at preschool and school ages. The incidence of normal speech was also much greater in ICP than in UCLAP patients at preschool and at school age in both surgical groups. Among the articulation errors, palatalization was the most common type in preschool children of the SP (24%) and MP (42%) group of UCLP patients. In the preschool phase, the incidence of palatalized articulation was significantly higher in UCLAP compared with ICP patients in both surgical groups, and lower in UCLAP patients of the SP than those of the MP group. Palatalized articulation was improved at school age compared with preschool childhood in ICP patients of the SP group, in UCLAP patients of the MP group and to a significantly greater extent in UCLAP patients of the SP group.

ARTICLE IN PRESS Speech evaluation and dental arch shape following pushback palatoplasty in cleft palate patients 139 Table 5 – Articulation errors at preschool and school ages following 2 types of palatoplasty

Articulation errors Surgical technique

Cleft type

ICP (n=29) SP UCLAP (n=33)

Time at palatalized lateral glottal evaluation articulation articulation stop Preschool

1

School age

0

Preschool

8a

*

others

Normal speech (%)

0

2

1

25 (86)

0

0

0

29 (100)

3a

1

0

23 (70)

1b *** 2

0

0

32 (97)

1

0

18 (78)

1

0

1

19 (83)

0

2

0

12 (50)

0

0

18 (75)

** School age

1b

Preschool

2

School age

2

Preschool

10

ICP (n=23) MP UCLAP (n=24)

School age

6

***

b

b

1

SP: Supraperiosteal flap technique. MP: Mucoperiosteal flap technique. * po0:05; **po0:02; ***po0:01: a Two cases had patalized and lateral articulation. b One case had palatalized and lateral articulation.

Lateral articulation was found in 2 ICP patients of the MP group, and in no UCLAP patient at preschool age. Glottal stops were deleted in 2 patients of ICP and one UCLAP patient of the SP group, and in one patient of the ICP and 2 patients with UCLAP in the MP group in preschool ages. However, all of them had learned normal speech at school age. An ICP patient of the MP group presented weak consonants after rejection of the palatal lift prosthesis at school age. Substitutions occurring in an ICP child of the SP group improved spontaneously (Table 5). The link between speech proficiency and dental arch shape at preschool age following palatoplasty by the SP technique was also evaluated (Fig. 1). All patients had normal speech at school age except for one and almost all of the patients who underwent the SP technique had a good dental arch shape. Speech proficiency and dental arch shape at preschool age following palatoplasty by the MP technique are shown in Fig. 2. Most of the ICP patients in preschool ages with normal speech had a U-shaped dental arch. Normal speech was observed in 6 UCLAP patients of preschool childhood with good shape and also in 6 with narrow shape. Most of the patients exhibiting misarticulation had a V-type arch shape and the incidence of this narrow arch shape was particularly high among UCLAP patients with palatalized articulation. At school age, 4 of 5 patients with palatalized articulation had a V-shaped dental arch. DISCUSSION In the present study, maxillary dental arch shapes following palatoplasty were classified into U-type

(normal arch shape) or V-type (narrow arch shape). In ICP patients there was no significant difference between the SP and the MP group and almost all of ICP patients had U-type. However, in UCLAP patients, the U-type palate was found in significantly more of the SP group compared with the MP group. Leenstra et al. (1996) also investigated the dentoalveolar development of the deciduous dentition in ICP and UCLAP patients up to 5 years after palatoplasty using either the SP or the MP technique, and reported that the arch depths of SP groups were significantly larger than the MP groups. Moreover, Noguchi et al. (2003) indicated that palatal length and height in the permanent dentition was superior in the SP group than in MP group. All these results suggest that the SP technique is advantageous for development of the maxillary alveolar process using the pushback palatoplasty. Velopharyngeal competence within the SP group at preschool age was 86% for ICP patients, 94% for UCLAP patients, and in the MP group 96% and 92%, respectively. Both techniques, when employed with a significant pushback and constructing a muscle sling, attained good results in terms of velopharyngeal competence. Wardill, who designed the V–Y pushback technique in 1937, stated that his surgical technique ensures formation of a functional nasopharyngeal valve. Data on the V–Y pushback procedure performed before 2 years of age showed a success rate of 95% (Ainoda, 1981) and 89% (Yoshimasu et al., 1986). Musgrave et al. (1975) had a success rate of 89% for the V–Y technique and of 73% for the von Langenbeck technique in children with soft palate cleft only. On the other hand, Suzuki et al. (1989), reporting on

ARTICLE IN PRESS 140 Journal of Cranio-Maxillofacial Surgery

Fig. 1 – Speech proficiency and dental arch shape at preschool and school age following palatoplasty by the supraperiosteal flap technique: (a) for ICP and (b) for UCLP. O: U type (good dental arch shape), n: V type (narrow dental arch shape), (n): number of patients.

velopharyngeal function after palatoplasty using an improved palatal mucosal flap technique, found a success rate of 84%. From these findings, the V–Y technique and the palatal mucosal flap technique yielded somewhat better results than the von Langenbeck method. The SP technique achieved equally good velopharyngeal function as was obtained by the V–Y pushback using palatal mucosal flap techniques. In the treatment of patients with velopharyngeal incompetence velopharyngeal incompetence following cleft palate repair, secondary surgical techniques and speech appliances are used. The two most common prosthetic devices for the treatment of velopharyngeal incompetence are palatal lift prostheses and the speech bulb (Lang 1967; Golding-

Kushner et al., 1995). In the present study, all of the 9 patients with velopharyngeal incompetence after palatoplasty were treated with a palatal lift prosthesis as it may be useful for patients in whom the incompetence is due to inadequate velar elevation but in whom there is sufficient lateral pharyngeal wall motion to meet the raised palate, and the palate is of sufficient length and thickness to contact the posterior pharyngeal wall when elevated (Golding–Kushner et al., 1995). The SP and the MP techniques with a significant pushback and muscle sling construction can result in sufficient length and thickness of the soft palate to achieve contact with the posterior pharyngeal wall when it is elevated in blowing and sound production. Palatals lift prostheses were employed in order to eliminate velopharnygeal incompetence after

ARTICLE IN PRESS Speech evaluation and dental arch shape following pushback palatoplasty in cleft palate patients 141

Fig. 2 – Speech proficiency and dental arch shape at preschool and school age following palatoplasty by the mucoperiosteal flap technique: (a) for ICP and (b) for UCLP. O: U type (good dental arch shape), n: V type (narrow dental arch shape), (n): number of patients.

palatoplasty and were remarkably effective for improving velopharyngeal function and speech in these patients. In the present study, a greater incidence of normal speech was observed in ICP patients compared with UCLAP patients, and in the SP group compared with the MP group, as well as at school age compared with preschool age. In the SP group at school age, normal speech was observed in all ICP patients and in all except one of UCLAP patients. In the MP group in particular, palatalized articulation and lateral articulation were errors that were difficult to eradicate. Palatalized articulation was the most common type of disorder in the UCLAP patients in this study. Palatalized articulation, however, was observed significantly more often in the MP group than in the SP

group at preschool age. There are some studies evaluating speech up to school age subsequent to palatoplasty before 2 years of age by either the V–Y or the von Langenbeck technique. Witzel et al. (1979) and Dreyer and Trier (1984) found no differences between the two techniques. Musgrave et al. (1975) reported that the differences between the V–Y and the von Langenbeck techniques in terms of adequacy of articulation were negligible at early preschool years and at 10 years of age. They showed that articulation errors were usually mild distortions of sibilants with both techniques, but that the incidence of articulation errors related to the dentition was high. Ainoda (1981) and Yoshimasu et al. (1986) who evaluated speech outcomes in childhood after the V–Y surgery performed before 2 years of age found that normal articulation was observed significantly

ARTICLE IN PRESS 142 Journal of Cranio-Maxillofacial Surgery

more in ICP than in UCLAP children. They noted that the incidence of palatalized articulation was significantly higher in UCLAP than in ICP children and a majority of the patients with palatalized articulation had good velopharyngeal function. Suzuki et al. (1989), who studied speech results after the palatal mucosal flap technique, reported that palatalized articulation was the most common error among articulation disorders and the occurrence was correlated with cleft type. Green (1960) who analysed the speech of 263 cleft palate patients following palatoplasty using the V–Y technique noted that the degree of collapse of the maxillary arch differed between patients who have normal speech and those who have lateral articulation. From these findings, it was suggested that the articulation errors were less common in ICP patients than in UCLAP patients, and the occurrence of the poor articulation, including palatalized articulation, was associated with cleft type and maxillary collapse. In the present study, speech proficiency in relation to dental arch shape at preschool age and at school age was also evaluated. All patients of the SP group at school age had normal speech except for one UCLAP patient. In both ICP and UCLAP patients, speech improved significantly between preschool and school ages. Almost all of the ICP patients (90%) and the UCLAP patients (85%) had a good dental arch shape. In the MP group, on the other hand, normal speech was observed in 78% of ICP patients at preschool childhood and in 83% at school age, and a good dental arch shape was observed in 83%. On the other hand, in UCLAP patients, normal speech was observed only in 50% at preschool ages and in 75% at school age, and a good dental arch shape was only found in 33%. Palatalized articulation was the most common type of misarticulation in UCLAP patients, and was observed in patients with V-type narrow dental arch shape. Okazaki et al. (1991) reported that children with palatalized articulation were characterized by small palatal volume, and, in particular, there was a narrowing and shortening of the anterior palate. They concluded that morphology might be one cause of palatalized articulation. LeBlanc and Cisneros (1995) indicated that the dental arches (dentition and skeletal arch) act as structural boundaries for lingual placement, are directly involved in the production of phonemes /t,d,n,l/, assist in the production of many linguopalatal phonemes, and provide a grooving mechanism for production of continuants /s,z, ,t ,d /. Although the speech mechanism is highly adaptable and it cannot always be assumed that there is a one-to-one relationship between structural defects and a given articulation problem, it was concluded from the results of this study, that the narrow dental arch shape with consequent reductions in tongue space and speech sound production, and the resting position of tongue, could be a significant cause of palatalized articulation.

CONCLUSION This study indicated that speech development in the supraperiosteal group was more favourable than that of the mucoperiosteal group. Occurrence of articulation errors in cleft palate patients has been considered to be strongly relevant to the dental arch shape or palatal morphology. From this viewpoint, pushback palatoplasty using the supraperiosteal technique was more advantageous to speech development when compared with the mucoperiosteal technique. ACKNOWLEDGEMENTS

We would like to acknowledge Dr. Ryoichi Genba for his assistance with data collection and analysis. We would further like to acknowledge Dr. Naohiro Matsuzawa and Miss Michiyo Shirahata who have supported this work. References Ainoda N: Articulation following primary cleft palate surgery performed between the ages of 12 and 23 months. Jpn J Soc Plast Reconstr Surg 1: 49–63, 1981 Dreyer TM, Trier WC: A comparison of palatoplasty techniques. Cleft Palate J 21: 251–253, 1984 Golding-Kushner KJ, Cisneros G, EleBlanc E: Speech bulbs. In: Shprintzen RJ, Bardach J (Eds.), Cleft Palate Speech Management: A Multidisciplinary Approach. St Louis, Mosby, pp. 352–363, 1995 Green MCL: Speech analysis of 263 cleft palate cases. J Speech Hear Disord 25: 43–48, 1960 Kohama G: Comparison of a modified mucosal flap-, with a mucoperiosteal flap push-back technique in palatal repair. Jpn Cleft Palate J 16: 151–160, 1991 Lang BR: Modification of the palatal lift speech aid. J Prosthet Dent 6: 620–626, 1967 LeBlanc EM, Cisneros GJ: The dynamics of speech and orthodontic management in cleft lip and palate. In: Shprintzen RJ, Bardach J (Eds.), Cleft Palate Speech Management: A Multidisciplinary Approach. St Louis, Mosby, pp. 305–326, 1995 Leenstra TS, Kohama G, Kuijpers-Jagtman AM, Freihofer HPM: Supraperiosteal flap technique versus mucoperiosteal flap technique in cleft palate surgery. Cleft Palate Craniofac J 33: 501–506, 1996 Musgrave RH, McWilliams BJ, Matthews HP: A review of the results of two different surgical procedures for the repair of clefts of the soft palate only. Cleft Palate J 12: 281–290, 1975 Noguchi M, Suda T, Itoh S, Kohama G: Dento-alveolar development in unilateral cleft lip, alveolus and palate. J Cranio-Maxillofac Surg 31: 137–141, 2003 Okazaki K, Kato M, Onizuka T: Palate morphology in children with cleft palate with palatalized articulation. Ann Plast Surg 26: 156–163, 1991 Perko MA: Primary closure of the cleft palate using a palatal mucosal flap: an attempt to prevent growth impairment. J Maxillofac Surg 2: 40–43, 1974 Perko MA: Two- stage closure of cleft palate. J Maxillofac Surg 7: 76–80, 1979 Ross RB, Johnston MC: Facial growth in surgically repaired cleft lip and palate. In: Ross RB (Ed.), Cleft Lip and Palate. Baltimore, Williams & Wilkins, pp. 158–205, 1972 Suzuki K, Okamoto A, Hara Y, Hasegawa K, Niimi S, Torigai K, Shioya N, Kamiishi H: Speech results of the palatal mucosal flap method. Jpn Cleft Palate J 14: 123–131, 1989 Wardill WEM: The technique of operation for cleft palate. Brit J Surg 25: 117–130, 1937

ARTICLE IN PRESS Speech evaluation and dental arch shape following pushback palatoplasty in cleft palate patients 143 Witzel MA, Clarke JA, Lindsay WK, Thomson HG: Comparison of results of push back or von Langenbeck repair of isolated cleft of the hard and soft palate. Plast Reconstr Surg 64: 347–352, 1979 Yoshimasu H, Ohira A, Shioda S, Hashimoto K, Amagasa T, Sato K, Ishii J, Tomizuka K, Kdowaki N, Oyama T, Ito S: A followup study of children with cleft palates after primary palatoplasty, Part 1: speech results on cases repaired at age 1 and 2 years. Jpn Cleft Palate J 11: 62–69, 1986

MAKOTO NOGUCHI, DDS, Ph.D. Dept. of Oral Surgery, School of Medicine Toyama University 2630 Sugitani Toyama 930-0194 Japan Paper received 16 December 2003 Accepted 22 November 2005