J. Cranio-Max.-Fac.Surg. 18 (1990) J. Cranio-Max.-Fac.Surg. 18 (1990) 141-146 © GeorgThiemeVerlagStuttgart • NewYork

Primary Palatorraphy in the Adult Cleft Palate Patient Surgical, Prosthetic and Logopaedic Aspects Theo J. M. Hoppenreijs Dept. of Oral and Maxillo-FacialSurgery(Head: Prof. H. P. M. Freihofer, M.D., D.M.D.),UniversityHospitalNijmegen,The Netherlands Submitted 22.8.89; accepted 4.10. 89

141

Summary The treatment of 8 adults with untreated cleft palates is retrospectively discussed. A palatorraphy, consisting of a palatoplasty with pedicled palatal mucoperiosteal flaps and an intravelar veloplasty, is performed. A rib graft between the nasal and oral layer and a partial vestibuloplasty are used in a few patients to create a more favourable anatomical situation for the prosthetic appliance. The palatorraphy contributes to improved speech intelligibility however, combined with a pharyngeal flap as performed in 5 patients, an even better result can be achieved. According to the results, a surgical procedure in the adult still seems to be worthwhile.

Keywords Cleft palate - Adult - Palatorraphy - Intravelar veloplasty - Rib graft - Pharyngeal flap - Speech - Obturator - Overlay denture

Introduction Cases of hare-lip or cleft palate attaining maturity without undergoing surgery in infancy or childhood are seldom seen in the more advanced countries of Europe and America (Innis, 1962). Nowadays, the number of untreated adult cleft palate patients being presented to the cleft palate teams is ever decreasing; however, new patients are still encountered. Compared with the number of newborn cleft palate patients it is an insignificant figure. Several different operative procedures have been described. Hatzifotiadis and Iakovidis (1985) repair the cleft palate in edentulous adults in two steps, first using a yon Langenbeck sliding flap from the hard palate and nasal mucosa, and later an oral mucoperiosteal flap from the buccal vestibule of the alveolar process. Schwenzer (1973) uses palatal flaps to close the hard palate and three months later the soft palate is repaired, sometimes in combination with a pharyngeal flap. Obwegeser and Freihofer (1973) prefer a one step procedure. They close the hard palate with mucoperiosteal flaps and use, in some cases, a rib graft to bridge the palatal defect. In a few patients a pharyngeal flap is added to improve speech. Most of the untreated patients wear a prosthetic appliance to accomplish a separation between the oral and nasal cavity. Sometimes an obturator is fixed additionally. This mechanical device improves voice quality by supporting the velopharyngeal musculature. Hochstein (1981) reported that the stomatological care of the adult cleft palate patient is inferior to that of non-cleft patients. Premature loss of abutment teeth will reduce retention of the prosthesis. The inability to masticate with an ill-fitting obturator prosthesis, severe speech problems, and less frequently poor aesthetics, were reasons for the request for surgical intervention. The purpose of the surgery is: 1. To close the palatal cleft with soft tissues from the surrounding tissue. 2. To improve speech.

3. To create a more favourable anatomical situation in order to improve retention, stability and aesthetics of the prosthetic appliance. This retrospective study describes our experience in the treatment of a small group of adult cleft palate patients. We feel it is proper to shed light on this rarely-reported group of individuals.

SurgicalTechnique The technique is basically the same as that described by Obwegeser and Freihofer (1973). The epithelium near the margin of the cleft is stripped. A sharp dissection is carried out to free the oral layer from the nasal mucous membrane up to the edges of the hemiuvula. A marginal incision is extended to the tuberosity of the maxilla. Mucoperiosteal pedicled flaps according to Veau (1931) are prepared from the underlying palatine processes until the greater palatine artery can be identified. The neurovascular bundle is isolated by blunt dissection. In order to allow for enough medial displacement of the flap it is advisable to prepare up to the posterior edge of the palate. In the soft palate the nasal mucous membrane, the oral and muscular layer are carefully dissected. The nasal mucous membrane is elevated and approximated to the mucous flap of the vomer. After separation from the attachment of the posterior border of the maxilla, the muscles of the soft palate have to be realigned and retrodisplaced. The mucoperiosteal flaps are approximated with mattress sutures. Whenever possible a reconstruction of the uvula is performed. It is essential that any degree of tension between the flaps is avoided. Depending on the width of the bony defect and the requirements of a firm palate, a reconstruction with an autogenous rib transplant is performed. A piece of rib is split, bent a little and perforated. The perforations are used to suture the oral and nasal layer against the rib graft, to achieve a reasonable adaptation. To prevent haematoma,

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]. Cranio-Max.-Fac. Surg. 18 (i990)

Fig. 1 a

,~.

Fig.1 Case 8. Unilateral cleft lip and palate with a wide palatal defect preoperatively (a).

Th. J. M. Hoppenreijs

Fig. 1 b

Fig. 1 c

Palate one month after palatorraphy (b).

Inferiorly based pharyngeal flap 7 months postoperatively (c).

to protect the suture and to cover deperiosteum-ed bone of the palate a gauze pack with vaseline iodoform is of value, and can be fixed to remaining teeth or sutured to the mucosa of the alveolar process. If the cleft passes through the alveolar process, the oro-nasal communication is closed by using a vestibular mucosal transposition flap according to Burian (1963), or a vestibular sliding flap. A superiorly or inferiorly based pharyngeal flap can be added simultaneously. The size of the lateral channels is controlled by means of 18-Charri&re catheters.

Table 1

Material and Methods

UCLP=Unilateral Cleft Lip and Palate, BCLP=Bilateral Cleft Lip and Palate, CP=Cleft Palate.

The series consists of adult patients, with an untreated cleft palate, presenting to the cleft palate team at Nijmegen. Most of the patients had already consulted the department of Maxillo-Facial Prosthetics, referred by a dentist asking for advice concerning malfunctioning of the prosthetic appliance. During the first consultation a multidisciplinary analysis was started. The lip closure, the form of the nose, the position of the maxilla in the facial skeleton, the dental arch and the palatal cleft, the condition of the remaining teeth and the prosthetic appliance were evaluated. The otorhinolaryngological examination was performed by an ENT specialist. However, an audiological examination was not done routinely. The speech was analysed by a speech therapist. Between December 1980 and January 1988, 8 patients, with an average age of 49 years and 10 months (range 12 years 3 months to 71 years 6 months) were operated upon, 5 males and 3 females. The cases included 2 isolated cleft palates, 4 unilateral and 2 bilateral cleft lips and palates (Table 1). In none of the cases had a previous attempt been made to close the palate. Nevertheless in all patients the lip had been repaired, as could be expected. The dental state and the prosthetic appliance are listed in Table 2. All five obturators were of a fixed or immobile type. In all patients a primary palatoplasty including a veloplasty was performed. The nasal mucous membrane was closed directly, the oral mucoperiosteum was closed using mucoperiosteal flaps and in 2 patients a rib graft was interposed. In one patient an osteotomy of the premaxilla was performed in the same session (Table 3). In 5 cases, 7 oro-nasal communications situated on the vestibular side in the alveolar process, were simultaneously closed by a vestibular mucosal flap, 1 of which was according to Burian (1963). In case 7 a defect in the alveolar process was left untreated.

Synopsis of cases and cleft types

No.

Sex

Age

Cleft type

1 2 3 4 5 6 7 8

m m f m m m f f

71 12 47 30 56 60 62 58

CP BCLP UCLP UCLP CP BCLP UCLP UCLP

Table 2 No.

1 2 3 4 5 6 7 8

Dentition mutilated edentulous

none

Prosthetic appliance partial complete obturator

2

5

0 0 0 0 0 0 0 0

Total 6

2

Table 3 No.

Overview of dental and prosthetic condition pre-operatively

1

5

Synopsis of additional procedures

Burian flap

©steotomy premaxilla

Rib graft Pharyngeal flap superior/inferior

Primary Palatorraphy in the Adult Cleft PalatePatient

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J. Cranio-Max.-Fac. Surg. 18 (1990)

Fig.2a

Fig.2b

Fig. 2 c

Fig,2 Case 3. Unilateral cleft lip and palate with a wide palatal defect, small defect in the alveolar process and multiple full crowns with cervical carious lesions (a).

Palate 18 months after palatorraphy. Retention of the overdenture is achieved by telescopic crowns (b),

Superiorly based pharyngeal flap 18 months postoperatively (c).

Five patients underwent simultaneously an additional pharyngoplasty one of which was inferiorly based (Fig. 1). Subjective listening evaluations were used for assessing speech and velopharyngeal function. The speech and its intelligibility is compared postoperatively with the preoperative starting point without wearing an obturator. A good result means that the speech was passable or the patient occasionally had hypernasal speech. A fair result means that speech was considerably improved postoperatively, intelligibility acceptable, but some degree of hypernasility was still present. A poor result means that the surgery did not improve speech to any great extent. The firmness of the hard palate, the mobility of the soft palate, the retention and stability of the prosthetic appliance were evaluated clinically.

by glottal and pharyngeal articulation. In 2 patients, who underwent a palatoplasty and a pharyngeal flap simultaneously, the results were adjudged good. In 5 cases a fair and in one case a poor result was achieved (Table 5). Nevertheless not a single patient in this series has an excellent speech result, that is perfectly intelligible speech and without nasal vowels. The realisation of consonants is still a problem but only two patients underwent additional speech therapy. Even so, all patients reported an immediate improvement in speech. This gave them more confidence. All 8 patients felt the operative discomfort was justified by the result, and they would all have been willing to go through the same procedure again to achieve such an improvement.

Results

All patients were treated by the same surgeon. No difficulties were encountered during the operations and no complications developed postoperatively. The main follow-up was 5 years and 1 month. In 2 patients a fistula developed behind the alveolar process directly postoperatively, this closed spontaneously. In patients 5 and 8, a small fistula, 1 - 2 mm in diameter developed behind the hard/soft palate junction. The hard palate was much more resilient in cases with a palatoplasty without the interposition of a rib graft. The soft palate had a satisfactory mobility. The veloplasty and pharyngeal flap permitted dispensation with the obturator. Postoperatively, one patient received a partial and 4 a complete denture, and 2 an overdenture (Fig. 2, Table 4). In case 2 the dental arch was restored by an osteotomy of the premaxilla followed by orthodontic treatment. Therefore, the partial prosthesis was no longer required. In case 6, a local vestibuloplasty with secondary epithelialisation was performed later on, under local anaesthesia. All prosthetic appliances had adequate stability and retention. Although several patients had initial postoperative nasal obstruction, one patient complained of late postoperative nasal breathing difficulty. Four months after the operation, the pedicle of the superiorly based pharyngeal flap was divided. The ultimate result is not impaired by this intervention. All unoperated adult patients spoke hypernasally, and compensated their inability to produce acceptable speech

Table 4 No.

1 2 3 4 5 6 7 8

Overview of dental and prosthetic condition post-operatively

Dentition mutilated edentulous

none

Prosthetic appliance partial complete overdenture

1

1

0 0 0 0 0 0 0 0

Total 4

Table 5

4

4

2

Postoperative speech results related to surgery

Operation

No.

Results Good Fair Poor

Palatorraphy without pharyngeal flap Palatorraphy with pharyngeal flap

3 5

0 2

2 3

1 0

Total

8

2

5

1

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J. Cranio-Max.-Fac.Surg. 18 (1990)

Discussion

Law and Fulton (1959), Ortiz-Monasterio et al. (1966) and Pitanguy and Franco (1967) presented observations with unoperated cleft palates. Balan and Stellmach (1973) investigated the literature and reported a group of 135 untreated adult patients. Nevertheless, they underlined the rarety of publications dealing with the surgical treatment in the adult. Obwegeser and Freihofer (1973) reported the results of 38 patients treated during 15 years, and Schwenzer (1973) reported on 28 cases, 22 of whom had primary treatment of the palate at least. In both aforementioned studies, the operation technique and some results were published. In addition to the surgical technique, the prosthetic and logopaedic aspects are discussed more in detail in this paper. The shortage of comparable studies and the small number of patients cannot justify far-reaching conclusions. Evaluation of the profile and oral examination indicated that generally no obvious ma,xillary retrognathism was present. A formal cephalometric analysis was not done. The arch form was maintained reasonably with a small defect in the alveolar process and a wide defect in the palate. These findings can be explained by the fact that the development of the maxilla was not influenced by surgery. The anatomical situation of the alveolar process may be the result of an early lip repair. Its influence on the profile appears to be minor. The wide palatal cleft may be reinforced by the action of the tongue (Hotz and Gnoinski, 1979). An optimal closure of the nasal layer as well as the oral layer without tension is an important goal of the palatorraphy. Notwithstanding the wide defect, it is generally possible to achieve the desired approximation. Special care should be exercised at the anterior end of a narrow cleft, just behind the alveolar process, and at the point situated behind the vomer, at the junction of the hard and soft palate (Trauner, 1973). Luhr et al. (1973) reported 48 of all fistulae to be situated in the anterior third and 29 in the posterior third of the hard palate. In this study, in 2 patients a wound dehiscence occurred in the anterior part of the palate, resulting in a small fistula. Nevertheless, secondary repair (Schwenzer, 1986) was not necessary because of spontaneous closure in the late postoperative period. The fistulae behind the hard/soft palate junction in cases 5 and 8 had no influence on the retention of the prosthetic appliance and no leakage of liquid into the nose was noticed. Due to favourable experience in treating all kinds of cleft palates, a palatoplasty with monopedical flaps (Veau, 1931; Obwegeser and Freihofer, 1973), is preferred to a yon Langenbeck (1861) procedure, employing bipedicled flaps (Trier, 1985a; Dreyer and Trier, 1984). It is generally acknowledged that the levator veli palatini muscles play an important role in velopharyngeal closing movements. Detachment of these muscles from their abnormal insertion into a cleft palate has been shown to increase lateral pharyngeal wall movement as evaluated by electrical stimulation (Honjo et al., 1980). The palatoglossus and the superior pharyngeal constrictor show activity in positioning the velum during speech (Kriens, 1970; Fara and Dvorak, 1970; Seaver and Kuehn, 1980), the musculus uvulae in modifying rigidity and velar extension (Kuehn et al., 1988) and the palatopharyngeus is primarily concerned with swallowing (Trigos et al., 1988). The muscles may be quite small, difficult to separate from the other velar muscles, quite friable and consequently difficult to suture. Not-

Th. J. M. Hoppenreijs withstanding, it is a fundamental part of the palate repair to free the levatores veli palatini from their abnormal attachment on the posterior medial aspect of the hard palate and the posterior nasal spine, rotate them, including the rest of the velar muscles medially and posteriorly, and reconstruct an anatomical velum sling. As a result of tension, the palatorraphy will result in a shortening of the soft palate. Also traction of scar tissue results in an undesirably anterior position of the velum and consequently the soft palate will no longer be able to achieve tight closure against the posterior pharyngeal wall. As Dalston and Warren (1985) described how adequate velopharyngeal closure following primary palatoplasty varies from less than 50 up to 95,8 of the cases, it is advisable to perform a pharyngeal flap when a questionable velopharyngeal mechanism is anticipated. The pharyngeal flap operation (Trier, 1985b) is preferred to the pushback palatoplasties (Millard, 1962), the sphincter pharyngoplasties (Jackson, 1985), and posterior wall augmentation. The number of 5 pharyngeal flaps performed in 8 patients in this study is comparable with 27 pharyngeal flaps indicated in 38 patients as reported by Obwegeser and Freihofer (1973). There has been active discussion in the literature as to whether the pharyngeal flap should be based inferiorly or superiorly (Bloom, 1975; Millard, 1980). The essential point is that the base be located at the point of potential contact between velum and pharyngeal wall when the levator veli palatini muscles are activated. This action can be assisted by a superiorly based flap. The inferiorly based flap is technically relatively easy to achieve, the width of the lateral openings is more predictable, and the base is positioned at the side of maximal lateral movement of the pharyngeal wall. In this study, an inferiorly based pharyngeal flap is performed in one case because of a wide cleft, and a short soft palate with inadequate mobility. On the basis of research establishing the port size for velopharyngeal incompetence (Warren, 1964), the premise was accepted that competence would be established when the velopharyngeal port during connected speech fell below 20 mm 2 in area. Hogan (1973) achieved a 97 velopharyngeal competence by using catheters with a diameter of 4 mm. Smith et al. (1985) reported an incidence of 35 nasal obstruction, and Hogan (1973) mentioned 3 hyponasality. Jarvis and Trier (1988) reported an 8 to 16 incidence of moderate-tosevere hyponasality and, therefore, suggested an increased port size. In our procedure, 18-Charri&re catheters (diameter 6.00mm.) are used. In 3 of the 5 patients some degree of hypernasality is still noticed. This can be attributed to shrinkage of the pharyngeal flap postoperatively, resulting in an increase in orifice size. On the other hand, in case 5, catheters with a diameter of 4 mm. were used and this patient complained of persistent nasal obstruction so that we had to divide the base of the pharyngeal flap after four months. One has to consider that the untreated adult patients became accustomed to a wide oro-nasal communication and may have more difficulty in adapting to the small lateral ports. Taking the different aspects into consideration, catheters with a diameter of between 4 and 6 mm. would be preferable. The 14-Charri&re (diameter 4.66 mm.) or the 16-Charri&re (diameter 5.33mm.) catheters are expected to be satisfactory.

Primary Palatorraphy in the Adult Cleft Palate Patient Comparison of speech evaluation in the group of 3 patients who underwent a palatorraphy without a pharyngeal flap, with the group of 5 patients who underwent a palatorraphy with a pharyngeal flap, demonstrated possibly better results in the latter group. This would be in accordance with the opinions promulgated by Obwegeser and Freihofer (1973), and Schwenzer (1973) in the primary treatment of adult cleft patients. Success or failure of pharyngeal flap surgery has primarly been defined in terms of speech assessment, specifically reduction or elimination of hypernasal voice quality. This, however, does not guarantee normal speech. Adults have to eliminate a variety of indirect compensating speech behaviour patterns. Surgery made the sophisticated, bulky obturator redundant. The retention and stability problems of these obturators increases because of loss of abutment teeth and maxillary resorption. Securing adequate retention in the edentulous cleft palate is often a problem (Adisman, 1971). Therefore, the preservation of teeth is of utmost importance for the retention of prostheses. Even roots, if they are still firmly embedded in bone, can be saved by means of endodontic therapy. Regarding stability, a firm palatal base is thought to be desirable. Indeed the use of a bone transplant, as suggested by Obwegeser and Freihofer (1973), provides a firm palate with less resilience compared to a palatoplasty performed without an interposed bone graft. However, the stability of complete dentures in the latter group was fair. The relation between palatal firmness and stability of the denture is not obvious. In only one case was a rib graft utilized in an edentulous maxilla. Within a few years a firm palate may become more important, in a more atrophic maxilla. Retention and stability are most commonly used by clinicians to evaluate subjectively the efficiency of the prosthesis. Occlusal forces do not appear to be suitable measurements (Shipman, 1987). In the mutilated maxillary dentition, a full-coverage overlay denture is a relatively successful prosthetic method (Rothenberg, 1977). The fact that the prosthesis is both tooth and tissue borne and is comparatively stable improves the prognosis. In the edentulous maxilla, the available base-tissue area must be used optimally. Prostheses should be extended well into the alveolar sulci, and should cover the hard palate to its junction with the soft palate. Additional pre-prosthetic surgery may be indicated to improve the poor anatomical condition. A partial vestibuloplasty was performed for one patient to deepen the labial sulcus. Nwoteu (1973) described the buccal inlay technique, vestibuloplasties with secondary epithelialisation, and vestibuloplasties with mucosal or skin grafts. Generally, first the bony defect has to be restored with an autogenous bone graft and then the labial sulcus can be corrected at a later stage by a vestibuloplasty. This is in accordance with Chausse (1973) and Freiborer and Obwegeser (1973) who respectively described the repair of residual clefts and the complications. Conclusions Although this report consists of only 8 cases with a mean follow-up of 61 months some conclusions can already be drawn: 1. Technically, even in palatal clefts more than 20mm. wide, it is possible to perform a complete palatorraphy, with the available soft tissue of the palate, in one session.

J. Cranio-Max.-Fac. Surg. 18 (1990)

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The closure of the nasal and oral layer is considered rather simple. 2. An intravelar veloplasty may improve velopharyngeal sufficiency, resulting in reasonable speech. An additional pharyngeal flap seems to contribute to even better speech. 3. Palatoplasty eventually combined with a vestibuloplasty creates a more favourable anatomical situation for the prosthetic appliance. A tooth-supported overlay denture, possessing good stability and retention, is preferred. In the case with an edentulous cleft maxilla an additional rib graft transplant should be considered. 4. Positive response of the patients seems to justify our opinion that even in the adult, a surgical operation is worthwile.

References Adisman, I. K.: Cleft palate prosthetics. In: W. C. Grabb, S. W. Rosenstein, K. R. Broch (ed.): Cleft lip and palate; surgical, dental and speech aspects. Little, Brown, Boston first ed. (1971) 617-642 Balan, E., R. Stellmach: Beobachtungen an erwachsenen, unoperierten Spalttrfigernmit Konsequenzen fiir die Frage der Sekund~irbehandlung. In: K. Schuchardt (ed.): Fortschr. Kiefer- u. Gesichtschir., Thieme, Stuttgart 16/17 (1973) 209-213 Bloom, H. J.: Surgical repair of the cleft palate. In: W. H. Archer (ed.): Oral and Maxillo-Facial Surgery. Saunclers 5th ed. Vol. 2 (1975) 1849-1859 Burian, F.: Chirurgie der Lippen- und Gaumenspalten. Verlag Volk und Gesundheit, Berlin, 1963 Chausse, J.: Ergebnisse des Verschlusses von Restspahen. In: K. Schuchardt (ed.): Fortschr. Kiefer-u. Gesichtschir.,Thieme, Stuttgart 16/17 (1973) 314-316 Dalston, R. M., D. W. Warren: The diagnosis of velopharyngealinadequacy. Clin. Plast. Surg. 12 (1985) 685 Dreyer, T. M., W. C. Trier: A comparison of palatoplasty techniques. Cleft palate J. 21 (1984) 251 Fara, M., J. Dvorak: Abnormal anatomy of the muscles of palatopharyngeal closure in cleft palates. Plast. Reconstr. Surg. 46 (1970) 488 Freihofer, H. P. M., H. Obwegeser: Verschtutg grotger Gaumendefekte durch Weichteil- und Knochenplastik. In: K. Schuchardt (ed.): Fortschr. Kiefer- u. Gesichtschir., Thieme, Stuttgart 16/17 (1973) 311-314 Hatzifotiadis, D., D. Iakovidis: Cleft-palate repair in edentulous adults. In: E. Hjorting-Hansen (ed.): Proceedings from the 8th International Conference on Oral and Maxillofacial Surgery. Quintessence, Chicago (1985) 520-523 Hochstein, H.: Zur Rehabilitation ~iltererSpalttr~igerunter besonderer Berficksichtung chirurgischer und stomatologischer Gesichtspunkte. Stomatol. DDR 31 (1981) 863 Hogan, V. M.: A clarification of the surgical goals in cleft palate speech and the introduction of the lateral port control pharyngeal flap. Cleft Palate J. 10 (1973) 331 Honjo, I., H. Hisatoshi, U. Nobuhiro: Significance of the levator muscle sling formation in cleft palate surgery: evaluation by electrical stimulation. Plast. Reconstr. Surg. 65 (1980) 443 Hotz, M. M., W. M. Gnoinski: Effects of early orthopaedics in coordination with delayed surgery for cleft lip and palate. J. Max.-Fac. Surg. 7 (]979) 201 Innis, C. I.: Some preliminary observations on unrepaired hare-lips and cleft palates in adult members of the Dusan tribes of North Borneo. Br. J. Plast. Surg. 15 (1962) 173 Jackson, I. T.: Sphincter pharyngoplasty. Clin. Plast. Surg. 12 (1985) 711 Jarvis, B .J., W. C. Trier: The effect of intravelar veloplasty on velopharyngeal competence following pharyngeal flap surgery. Cleft Palate J. 25 (1988) 389

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Kuehn, D. P., J. W. Folkins, R. N. Linville: An electromyographic study of the musculus uvulae. Cleft Palate J. 25 (1988) 348 Kriens, O. B.: Fundamental anatomic findings for an intravelar veloplasty. Cleft Palate J. 7 (1970) 27 Law, F. E., J. T. Fulton: Unoperated oral clefts at maturation; 1. Study design and general consideration. Am. Publ. Hlth. 49 (1959) 1517 Luhr, H., W. H61tje, U. Hammer: Ober den Verschlufg von Rest16chern im Ganmenbereich. In: K. Schuchardt (ed.): Fortschr. Kiefer- u. Gesichtschir., Thieme, Stuttgart 16/17 (1973) 293-298 Millard, D. R.: Wide and/or short cleft palate. Plast. Reconstruct. Surg. 29 (1962) 40 Millard, D. R.: Superior versus inferior base. In: Cleft craft; the evolution of its surgery. III. Alveolar and palatal deformities, Little, Brown, Boston, first ed. (1980) 633-638 Nwoku, A. L.: Pr/iprothetische Chirurgie bei erwachsenen Spaltpatienten. In: K. Schuchardt (ed.): Fortschr. Kiefer- u. Gesichtschir., Thieme, Stuttgart 16/17 (1973) 344-347 Obwegeser, H., H. P. M. Freihofer: Probleme des Verschlusses prim/irer Gaumenspalten beim Erwachsenen. In: K. Schuchardt (ed.): Fortschr. Kiefer- u. Gesichtschir., Thieme, Stuttgart 16/17 (1973) 160-163 Ortiz-Monasterio, F., A. F. Serrano, G. P. Barrera, H. RodriguesHoffmann, E. Vinageras: A study of untreated adult cleft palate patients. Plast. Reconstr. Surg. 38 (1966) 36 Pitanguy, I., T. Franco: Nonoperated facial fissures in adults. Plast. Reconstr. Surg. 39 (1967) 569 Rothenberg, L. I. A.: Overlay dentures for the cleft-palate patient. J. Prosthet. Dent. 37 (1977) 327 Schwenzer, N.: Prim~iroperation bei erwachsenen Spaltpatienten. In: K. Schuchardt (ed.): Fortschr. Kiefer- u. Gesichtschir., Thieme, Stuttgart 16/17 (1973) 154-159 Schwenzer, N.: Korrekturoperationen nach operativer Prim/irversorgung yon Spaltpatienten. Fortschr. Kieferorthop. 47 (1986) 540

Seaver, E. J., D. P. Kuehn: A cineradiographic and electromyographic investigation of velar positioning in non-nasal speech. Cleft PalateJ. 17 (1980) 216 Shipman, B.: Evaluation of occlusal force in patients with obturator defects. J. Prosthet. Dent. 57 (1987) 81 Smith, B. E., Z. Skef, M. Cohen, D. S. Doff: Aerodynamic assessment of the results of pharyngeal flap surgery: a preliminary investigation. Plast. Reconstr. Surg. 76 (1985) 402 Trauner, R.: Lippen-I(iefer-Gaumenspalten. In: R. Trauner (ed.): Kiefer- und Gesichtschirurgie, Urban und Schwarzenberg, Mfinchen-Berlin-Wien, second, ed., Vol. 2 (1973) 1-162 Trier, W. C.: Primary palatoplasty. Clin. Plast. Surg. 12 (1985 a) 659 Trier, W. C.: The pharyngeal flap operation. Clin. Plast. Surg. 12 (1985 b) 697 Trigos, I., A. Ysunza, D. Vargas, M. Del Carmen Vazquez: The San Venero Roselli pharyngoplasty: an electromyographic study of the palatopharyngeus muscle. Cleft Palate J. 25 (1988) 385 Veau, V.: La division palatine; anatomie, chirurgie, phon~tique. Masson, Paris, 1931 Von Langenbeck, B.: Operation des angeborenen totalen Spaltes des batten Gaumens nach einer neuen Methode. Dtsch. Klin. 8 (1861) 231 Warren, D. W.: Velopharyngeal orifice size and upper pharyngeal pressure-flow patterns in normal speech. Plast. Reconst. Surg. 33 (1964) 148

Th. J. M. Hoppenreijs, D. M. D. Afdeling Mond- en Kaakchirurgie University Hospital Geert Grooteplein zuid 14 Postbus 9101 NL-6500 HB Nijmegen The Netherlands

Primary palatorraphy in the adult cleft palate patient. Surgical, prosthetic and logopaedic aspects.

The treatment of 8 adults with untreated cleft palates is retrospectively discussed. A palatorraphy, consisting of a palatoplasty with pedicled palata...
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