General Clinical Data
Forty patients with nonsyndromic incomplete cleft palate aged 5 to 25 were included and all of them received treatment at the Stomatological Hospital of Zunyi Medical University between January, 2014 and September, 2015. The patients were comprised of 14 female patients and 26 male patients and the average age is 15.25 years old.
According to specific conditions of each patient, different surgical methods were applied to them on the basis of morphology and function of their soft palates. Patients in group A received modified Z-plasty palatoplasty. In group B, 12 patients had DOZ, while 8 patients underwent Sommerlad palatoplasty. Patients's velopharyngeal function and speech intelligibility were compared before and 3 months after operation.
Test of Speech Intelligibility
Consonant articulation was figured out via quantitative evaluation (formula of consonant articulation: correct consonant syllables/total consonant syllables × 100%). The speech recovery was regarded to be good, when the outcome of the test ≥ 70%.5
The evaluators assessment was categorized in 4 grades (grade 0—normal, 1—mild, 2—moderate, and 3—severe hypernasality) as proposed by an international working.6
Assessment Criteria of Nasal Air Leakage
We selected /i/ out of Chinese pinyin (Fig. 1).
Grade 0: when a subject pronounces /i/, there is no water vapor on the surface of a fog filter.
Grade 1: when a subject pronounces /i/, the length of water vapor on the surface of a fog filter is within 2 cm.
Grade 2: when a subject pronounces /i/, the length of water vapor on the surface of a fog filter is more than 2 cm.
Lateral Cephalometric Pharyngeal Radiographs
Fixed points: A: the intersection point of the extended line of BC and the posterior pharyngeal wall; B: the still knee-point of nasal soft palate; and C: the knee-point of nasal soft palate during pronunciation of /i/.The length of AC, namely the depth of the pharyngeal cavity, was measured.
Evaluation criterion:4 normal velopharyngeal closure: AC<4 mm; Incomplete velopharyngeal closure: AC≥4 mm.
Voice Spectrum Analysis
The VS-99 Speech Workstation was applied to record the pronunciation of all subjects. In our special speech laboratory, subjects were required to pronounce/a/ and /i/ for recording on a single track with sampling frequency of 10,000 Hz, 16 units. Upper and lower limit values of frequency of first 3 resonance peaks (F1, F2, and F3) were detected and averaged as the resonance peak value of vowels. Speech analyses on pronunciation were carried out respectively before and after operation in the experimental and the control group. Statistical analyses of first 3 resonance peaks (F1, F2, and F3) of the 2 pure vowels were conducted with statistical software respectively (Fig. 3).
All surgical wounds of the 40 patients met the standard of clinical healing by first intention without perforation or infection of both soft and hard palates and no perforation or cleft relapse of suture was observed after operation.
Evaluation of Speech Intelligibility
Patient evaluation was carried out according to the speech intelligibility evaluation sheet offered by the Stomatological Hospital of Zunyi Medical University. After operation, 85% patients in the experimental group showed speech intelligibility above 70%, while only 80% patients showed speech intelligibility above 70% in the control group, and the difference in the 2 groups was statistically significant (P < 0.05, Table 1).
Evaluation of Nasal Resonance
After operation, compared with patients in the control group, more patients had normal or mild nasals in the experimental group with statistical significance (P < 0.05, Table 2).
With assessment of nasal air leakage by a fog filter, there were more patients of Grade 0 in the experimental group with statistical significance (P < 0.05, Table 3).
In the experimental group, 17 patients had normal velopharyngeal closure with a postoperative normal velopharyngeal closure rate of 85%, while in the control group, there were 14 patients showing normal velopharyngeal closure with a postoperative rate of normal velopharyngeal closure of 70%. The distributional difference of comparison of postoperative X-ray films between the 2 groups was of statistical significance (P < 0.05) (Table 4).
Voice Spectrum Analysis
Through the VS-99 Speech Workstation, speech analyses on pronunciation of /a/ and /i/ before and after operation were carried out respectively (Tables 5 and 6). Resonance peak values of the first 3 resonance peaks (F1, F2, and F3) of the 2 pure vowels in experimental and control group were compared. Results showed that during pronunciation of /a/ and /i/, F1 of the 2 groups were similar (P > 0.05) and F2 and F3 showed significant difference (P < 0.05). Values in the experimental group were higher than those in the control group.
Most studies on velopharyngeal function merely focus on postoperative recovery of velopharyngeal closure and ignore the recovery of coordination of velopharyngeal muscular movement. However, Velopharyngeal closure cannot reflect the velopharyngeal function completely.7 In the clinical, though some patients show incomplete velopharyngeal closure, according to fibronasopharyngoscopy, they can form complete velopharyngeal closure when they pronounce certain sounds. These patients meet anatomical conditions of formation of complete velopharyngeal closure. Hence, surgeons tend to pursue recovery of anatomical structure of palatal muscles.8 It is undeniable that the defects of the operation design can have a significant impact. For example, regarding Sommerlad palatoplasty, although it reconstructs levator veli palatini and enhances the effective length of a soft palate, it may also cause great damage to levator veli palatini and leave severe scars, which limits normal function of reconstructed levator veli palatini to some extent.9 Meanwhile, with no extension of the soft palate on the nasal mucosal level, the surgery impacts postoperative velopharyngeal closure.10 According to a comparative study on the soft palate and body muscles of rats, muscles of the head have fewer Satellite cells (SatCs) than muscles of limbs. So after the same crush or trauma, regeneration of muscles in the head is much slower, forming fibrous connective tissues.11 Therefore, in soft palate surgery, muscle injury should be minimized. Otherwise, it would be difficult for the soft palate muscle to recover function. Considering the opposing Zs on the oral mucosa and the nasal mucosa in DOZ,12 DOZ is not suitable for patients who suffer from complete cleft palate or require bilateral relief incisions. Because relief incisions could affect blood supply for mucosal flaps of a soft palate and the Z-shaped incision may cause extensive scars, leading to lengthening failure of the soft palate.13 Excessive overlapping suture of levator veli palatini and the velopharyngeal muscle on the median line of a soft palate and the malposed uvularis after DOZ break the normal anatomical structure, forming asymmetric velopharyngeal closure and leading to insufficient rotation and displacement for nasal cleft sutures.8,14 In modified Z-plasty palatoplasty, after cutting open edges of the soft palate, anatomy is conducted in amid mucous glands and muscles, which exposes muscles above the nasal mucosa completely. An incision is then made on the outer side of levator veli palatini near the free-end along the trend of its muscle fibers, intersecting the incision that cuts apart the muscle. As a result, the shape of the whole incision is like the Chinese character
. After rotation and suture of flaps, the trend of muscle fibers of levator veli palatini on both sides becomes normal with opposite broken ends. By this new operation method, the trend of levator veli palatini is corrected without anatomy. Meanwhile, the soft palate on the level of the nasal cavity is lengthened and the pharyngeal cavity is shrunk, laying a good foundation for normal pronunciation in the future.
Postoperative speech and velopharyngeal function recovery are the important indexes of postoperative effect monitoring. Good velopharyngeal function is critical for good pronunciation.15 Assessments on postoperative phonetic effects include subjective and objective assessments.16 Subjective evaluation by professionals is still a gold standard for assessments of phonetic effects, while objective evaluation can confirm the results of subjective evaluation.16,17
In this study, through preoperative evaluation of speech intelligibility of cleft palate patients, it was found that all 40 patients showed certain high nasals, nasal air leakage, compensatory articulation, etc. By using the evaluation sheet of speech intelligibility offered by the Stomatological Hospital of Zunyi Medical University, patients in group A showed better speech intelligibility than those in group B after operation. In respect of nasal resonance and nasal air leakage, the group A also displayed better performance than group B, indicating the velopharyngeal function in group A was greatly improved after operation. X-ray lateral pharyngeal radiography can reflect velopharyngeal closure in some degree. The experiment results showed the velopharyngeal closure in group A was better compared with group B. Through the voice spectrum analysis, postoperative effects were evaluated objectively. According to the present study, the first 3 resonance peaks are of high significance for research on speech of cleft palate patients.18 In this study, values of the first 3 resonance peaks of /a/ and /i/ were used as observation indexes and the results indicated that group A had better performance than group B in terms of improvement of tongue retraction and velopharyngeal function.
In conclusion, reconstruction of velar muscles is accomplished well in this method and the velar muscles are repositioned more transversely and posteriorly, which establishes an anatomic arrangement closer to the normal palate. This modified Z-plasty palatoplasty for cleft palate repair can become an optional surgical method for cleft palate clinically. Personalized therapies should be formulated in accordance with conditions of different patients to improve the postoperative velopharyngeal function. However, any improvement needs to be clinically tested. Although some elder patients with cleft palate obtained satisfactory phonetic effects and velopharyngeal function after modified Z-plasty palatoplasty, the long-term effect is still unknown, which requires larger sample research and long-term follow-up.
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Keywords:© 2019 by Mutaz B. Habal, MD.
Articulation; cephalometric lateral radiographs; cleft palate; modified Z-plasty palatoplasty for cleft palate repair; primary palatoplasty; velopharyngeal