Orthognathic Consequences of Sphincter Pharyngoplasty in Cleft Patients: A 2-Institutional Study

Abstract

Background:Understanding long-term sequelae of cleft treatment is paramount in the refinement of treatment algorithms to accomplish optimized immediate and long-term outcomes. In this study, we reviewed sphincter pharyngoplasties as a method of velopharyngeal insufficiency (VPI) treatment in relationship to orthognathic surgery.Methods:Cleft lip/palate and cleft palate patients, 15 years of age and older, were reviewed for demographics, VPI surgery, revisions, and subsequent orthognathic surgery at 2 institutions. Chi-square test, Student’s t test, and logistic regression analyses were performed.Results:In 214 patients reviewed (mean age, 19.5 years), 61.7% were male, 18.2% had isolated cleft palate, 61.2% had unilateral cleft lip and palate, and 20.6% had bilateral cleft lip and palate. A total of 33.6% were diagnosed with VPI and received a sphincter pharyngoplasty (mean age, 11.9 years). When subsequent orthognathic surgery was examined, sphincter pharyngoplasty was not associated with maxillary advancement (P = 0.59) but did correlate with an increase in mandibular surgery from 2.8% to 11.1% (P = 0.02). The indications for mandibular surgery in the pharyngoplasty population were related to congenital micrognathia. When cephalometric analyses were evaluated, sphincter pharyngoplasty resulted in a decreased sella-to-nasion-to-B point angle (mean, 79.0–76.3 degrees, P = 0.02) and a higher incidence of normal to class II maxillomandibular relationships as defined by A point-to-nasion-to-B point angles >0.5 (P = 0.02).Conclusions:Sphincter pharyngoplasty decreases anterior mandibular growth and the discrepancy between maxillomandibular skeletal relationships because of the frequent predisposition of cleft patients to maxillary hypoplasia. In patients with congenital mandibular micrognathia, a small increase in mandibular surgeries may occur.

Orthognathic Surgery Rate in Cleft Care

“…This was intuitively expected as a greater number of palatal surgeries should result in increased palatal scar burden. With respect to surgery for VPI, both pharyngeal flap and sphincter pharyngoplasty have been implicated in decreased anteroposterior maxillary growth in patients with CL/P 20,21 ; however, this has been disputed. 22 Timing of palatal repair has also been hypothesized to play a role in the development of midface hypoplasia and the optimal age for palatoplasty continues to be a topic of much debate.…”

A Preliminary Management Algorithm for Velopharyngeal Insufficiency in Cleft-Orthognathic Patients

“…In cleft patients requiring orthognathic surgery, VPI can worsen following necessary maxillary advancement. There is a paucity of literature and little consensus on the management of VPI in cleft-orthognathic patients 12,24–29 . Additionally, in some cleft patients requiring orthognathic surgery, an already placed PPF may pose a challenge for anesthesia intubation and optimal maxillary advancement.…”

“…A literature review was performed to find and compare all management options for this condition. This search revealed only 1 alternative for post-orthog-nathic VPI in CP patients: dynamic sphincter pharyngoplasty (DSP) 25,26 . When used to treat more traditional VPIs (not induced by orthognathic surgery), DSP and PPF are 2 equally safe and efficient surgical techniques 39 .…”

“…25,26 When used to treat more traditional VPIs (not induced by orthognathic surgery), DSP and PPF are 2 equally safe and efficient surgical techniques. 39 Yoshikane et al 25 utilized DSP by engaging superiorly-based flaps involving the palatopharyngeus and superior constrictor muscles. Similar to our study, Dentino et al 26 investigated the efficacy of PPF for VPI after orthognathic surgery.…”

“…This search revealed only 1 alternative for post-orthognathic VPI in CP patients: dynamic sphincter pharyngoplasty (DSP). 25,26 When used to treat more traditional VPIs (not induced by orthognathic surgery), DSP and PPF are 2 equally safe and efficient surgical techniques. 39 Yoshikane et al 25 utilized DSP by engaging superiorly-based flaps involving the palatopharyngeus and superior constrictor muscles.…”