Oral Maxillofacial Surg Clin N Am 14 (2002) 525 – 537

Secondary cleft surgery and speech

Étoile M. LeBlanc, MS, CCCa,b,c,d,*
a
Private Practice, Speech Science Centre, 75 South Broadway, 4th Floor, White Plains, NY 10601, USA
b
Craniofacial Speech Disorders Center, New York Presbyterian Hospital, 3959 Broadway, New York, NY 10032, USA
c
Babies and Children’s Hospital of New York, USA
d
Department of Plastic and Reconstructive Surgery, Albert Einstein College of Medicine, 1300 Morris Park Avenue,
Bronx, NY 10461, USA

The craniofacial-cleft surgeon searches continu-
ally for the combination of treatment regimens that
secure successful aesthetics, dental-skeletal form, and
speech results in patients with cleft lip and palate.
Recent developments in innovative surgical proce-
dures, such as osetodistraction, neuroradiographic
and video imaging, and robotic and minimally inva-
sive surgical technology [1], have been welcomed
additions to the field. We anticipate how they may
translate into cleft surgery protocols, yet we are still in
pursuit of practices that will enhance speech out-
comes after primary and secondary cleft surgery.
Many children have successfully developed nor-
mal intelligible speech after surgical repair; however,
a review of the literature represents not only what we
do know but also what must be learned to ensure
desired speech outcomes. The reported incidence
of speech problems in cleft lip and palate after
primary repair ranges from 5% to 89% depending
on the criteria applied [2 – 10]. This variability in
results leaves levels of confidence of effect and out-
come modest at best. The literature also is replete with
conflicting reports on which surgical procedures are
the most effective in primary palatoplasty [11 – 13], at
which age surgery provides the desired speech out-
come [14 – 17], what effects maxillary advancement
and distraction have on resonance [18 – 25], and
which secondary pharyngoplasty procedure provides
* Speech Science Center, 75 South Broadway, 4th Floor,
White Plains, NY 10601, USA
E-mail address: craniofacial@msn.com
(E.M. LeBlanc).
the best surgical speech outcome [26 – 32]. Divergent
results may lead to evolution of the field but also
lends to confusion, misdirection and subsequent mis-
management of many patients. The variability in
current practices and research has been marred by
methodologic flaws (Table 1). In the past 10 years,
from 1992 to 2002, only 13 randomized clinical trial
studies were performed in clefting disorders world-
wide [33]. A retrospect look at the literature reveals
that researchers continue to conduct and publish
research based on less than optimal scientific design
and have yet to harness the multitude of variables that
affect speech outcomes in clefting disorders.
Acknowledging and understanding the variables
that influence speech outcomes and limitations
in controlling these variables have a great effect on
our ability as surgeons and speech pathologists to
provide better management protocols that lead to
optimized speech.
Variable I. The speech matrix
The processes and mechanisms that function to
carry out speech are virtually multifactorial, with
numerous variables directly and indirectly affecting
its integrity (Table 2).
Should any one determinant of the speech matrix
become inoperative, other morphologic components
(epigenetically determined and nondeterministic pro-
cesses) have the capacity to compensate and provide
obligatory responses temporally and operationally,
as the demands require [34]. They can provide an al-
ternative means in an attempt to achieve more or less
the same developmental and functional result, al-

1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 4 1 - 9
526 E.M. LeBlanc / Oral Maxillofacial Surg Clin N Am 14 (2002) 525–537

Table 1
Methodical flaws in research of speech outcomes in cleft lip and palate
Methodologic design
Lack of interexaminer and
intraexaminer reliability
Small number of subjects
lack of randomized sampling
Large propensity of
retrospective studies
Decreased use of matched
control group studies
Reliance on one-time
assessment accepted
Lack of consistency in
subject pools
Uneven subject distribution
across independent variables
Lack of double blind studies
Limited number of randomized
clinical trials
Speech parameters Surgical parameters
Need for operational definitions Age of surgery
Lack of objective speech data Type of surgery
Comparison of speech results Age at assessment
across wide age ranges Multiple surgeons
Inconsistent methods of Differing surgical modifications
defining VPI in surgical procedure
Lack of objective measures of Do not operationally define criteria
velopharyngeal function of acceptability
Lack of consistency in preoperative Differing criteria on successful
and postoperative assessment tools surgical results
Do not operationally define what
speech criteria should be accepted
Differing criteria on successful
speech results

though perhaps with some degree of anatomic and
physiologic change in function.
The capability to speak originates from a genomic
makeup, anatomic structure, and internal and external
functional demands. Facets that maintain the drive to
speak include environmental and communicative
needs (ie, communicative intent, social needs, expec-
tations). Conversely, anatomic limitations and envi-
ronmental facets (ie, educational services, quality of
rehabilitative services, poor social esteem, lack of
familial support) have the potential to discourage what
level of speech integrity is possible in an individual.
Speech represents the internal functional demand
on the craniofacial scaffold and its soft tissue envel-
ope. If velopharyngeal, laryngeal, palatal, maxillary,
or mandibular segments are missing, unstable, or in
poor anatomic relationship with one another, as typi-
cally presented in clefting, the functions of breathing,
swallowing, and speaking can be impaired [35]. Un-
derstanding how speech manifests in an individual
with a cleft lip and palate requires understanding the
dynamic speech matrix.
Speech is made up of the systems of resonance,
articulation, and voice. The ‘‘potential’’ primary
speech disorders associated with cleft lip and palate
are hypernasality (resonance disorder), compensatory
articulation disorder secondary to velopharyngeal
insufficiency (VPI), and obligatory articulation or den-
tal adaptations (articulation disorders). The underlying
cause of obligatory articulation errors is related to den-
tal and skeletal anomalies, whereas hypernasality and a
compensatory articulation disorder are directly related
to dysfunction of the velopharyngeal mechanism.
Each of these systems may interact with one another
and many other abnormal speech processes (second-
ary speech disorders such as developmental articu-
lation errors, neurologically based articulation
disorders), which results in greatly compromised
speech and a complicated paradigm for the craniofa-
cial-cleft surgeon.
Compensatory articulation disorder secondary to
VPI is the typical articulation disorder associated with
cleft palate. It involves production of sounds in an
aberrant location of the vocal tract (posterior oral
cavity, hypopharyngeal and supralaryngeal area).
Sound production in this disorder reinforces abnormal
placement and inappropriate manipulation of airflow
and air pressure, which results in less-than-optimal
velar and lateral pharyngeal wall movement of the
velopharynx. It is possible that VPI is, in part, related
and exacerbated by the presence of compensatory
articulation disorders.
Velopharyngeal insufficiency may be, in part,
‘‘articulatory based.’’ The child ‘‘learns’’ that velo-
pharyngeal movement is not necessary. The use of the
velopharyngeal mechanism may be avoided, although
closure may be anatomically possible in these pa-
tients. The child also may use other anatomic struc-
tures to facilitate velopharyngeal closure, such as
lingual, pharyngeal muscular, and epiglottic valving
[36,37]. These maladaptive gestures directly affect
perceived resonance quality. Phoneme-specific VPI
is another example in which hypernasality is per-
ceived and velopharyngeal dysfunction is docu-
mented; however, it is purely an articulation disorder
and, if assessed correctly, can be treated successfully
 E.M. LeBlanc / Oral Maxillofacial Surg Clin N Am 14 (2002) 525–537 527

Table 2
Factors affecting speech outcomes in cleft lip and palate
Genetic Anatomy/Physiology
DNA integrity Cleft type
Chromosomal Severity and extent of
integrity original defect
Type of underlying
syndrome
Cognitive/IQ status
Hearing status
Language status
Psychosocial status
Velopharyngeal integrity
Size of velopharyngeal
gap
Movement of velar/
lateral musculature
Type of velophryngeal
closure
Etiology of insufficiency
Cranial base angle
Adenoid/tonsillar integrity
Dental-skeletal integrity
Neurologic integrity
Presence of other
medical issues
Growth rates
Environmental Speech Surgical
Quality of Appropriate Age of surgery
educational services development Type of procedure
Cultural diversity Timely Experience of surgeon
Family and peer support preventative services Integrity of preoperative
Family and Articulation integrity assessment
peer interaction Resonance integrity Presence of fistulas
Cultural origin Type of articulation Success in primary
Quality of disorder palate closure
rehabilitative services Type of Use of
Presence of inter- resonance disorder preorthopedic devices
multidisciplinary Neurologic integrity Use of nasal
team care Hearing integrity molding devices
Experience of Feeding/Voice integrity Postoperative healing
team members swallowing status and scarring
Stimulating environment Types of objective Length of time
for development speech measures between surgery and
Age at time speech assessment
of assessment Amount of short- and
Quality of management long-term follow-up
History of therapeutic Presence of postoperative
intervention complications
Amount of therapeutic One-stage versus
intervention two-stage procedures
Primary or secondary repair
Orthodontic treatment
Use of nasopharyngoscopy
and procedures
Multiview videoflouroscopy

by speech therapy only. Marginal or touch closure of
the velopharyngeal mechanism is often remediated by
nonsurgical, and/or nonprosthetic management.
Articulation and velopharyngeal function are
inversely related, and a craniofacial speech assess-
ment that includes at least nasopharyngoscopy is
imperative to the decisions being made preoperatively
and postoperatively. The act of speech requires ele-
ments from various dimensions of the matrix. Its
dysfunction, compensatory nature, and rehabilitation
depend highly on many factors.
Variable II. Isolated versus syndromic clefting
Isolated clefting versus syndrome-related clefting
is an important variable to take into account when
discussing speech and surgical outcomes. The attri-
butes of the speech disorder in isolated cleft lip and
palate have the potential to differ significantly as
compared to a syndrome-related cleft lip and palate
[38 – 40]. The speech matrix changes in the presence
of a syndrome, which depends highly on the natural
history, genotypic and phenotypic characteristics of
the syndrome. For example, a child with an isolated
cleft lip and palate may potentially present with
varying degrees of hypernasality, varying types and
degrees of severity of compensatory articulation sec-
ondary to VPI, obligatory errors, and transient com-
promised hearing acuity caused by otitis media. A
child with Treacher Collins syndrome may potentially
present with varying degrees of hyponasality accom-
panied by possible VPI secondary to asymmetry [31]
or cleft palate, varying types and degree of severity of
obligatory errors or compensatory articulation second-
ary to VPI, and hoarseness, pitch, and loudness
problems (voice disorders) caused by laryngeal asym-
metry [41]. A child diagnosed with 22q11.2 micro-
deletion syndrome presents with hearing, cognitive,
language, and voice problems and increased use of
compensatory articulation errors (as compared to
isolated cleft palate). A child diagnosed with Trisomy
21 however, presents with mental retardation, upper
airway issues, oral structural anomalies that affect
speech in a varying manners [38], and VPI related
to clefting or neurologic impairment. The surgeon
528 E.M. LeBlanc / Oral Maxillofacial Surg Clin N Am 14 (2002) 525–537
may increase the chances of appropriate speech and
surgical outcome after surgery if the child’s speech
profile is well delineated in a manner that determines
which component of the disordered speech is directly
related to the velopharyngeal mechanism, dental skel-
etal anomalies, neurologic impairment, learned behav-
ior, and other nonstructural speech issues.
Variable III. The preoperative assessment
The successful surgeon understands the existence
of the speech matrix effect and seeks out the appro-
priate speech diagnostic assessment. The use of per-
ceptual speech assessment and direct visualization of
the velopharyngeal mechanism by means of naso-
pharyngoscopy and multiview videofluoroscopy in-
creases the frequency of desired speech outcomes and
decreases the chance of postoperative complications.
Indirect instrumentation, such as nasometry and aero-
dynamic pressure flow studies, provides objective
measures on airflow and pressure; however, on their
own they provide minimal utility in diagnostic etiol-
ogy and determination of abnormal physiology of the
velopharyngeal structure and do not provide distinct
information on management.
Perceptual speech assessment should be conducted
by a well-trained craniofacial speech pathologist who
is able to decipher the speech matrix and provide the
surgeon with vital information in the following areas:
1. The type and severity of the resonance dis-
order present
2. The type and severity of the articulation
disorder
3. Whether therapeutic intervention is needed
4. Whether therapeutic intervention should be
conducted before surgery, in combination with
surgery, or after surgery
5. The anticipated speech outcome after surgery.
Direct visualization of the velopharyngeal mech-
anism should provide the surgeon with the follow-
ing information:
1. The cause of insufficiency
2. To what degree structure contributes to closure
or dysfunction (ie, adenoids, tonsils, lin-
gual valving)
3. To what degree movement of the velar, lateral
pharyngeal walls, posterior pharyngeal wall,
and lingual structure is present
4. To what degree the dysfunction noted is related
to learned behavior
5. Which surgical procedure is appropriate for the
relative dimensions in the velopharynx
6. Delineation of abnormal structure, such as
carotid pulsations associated with 22q11.2
microdeletion syndrome
7. Anticipation of the affect of the intended
surgical procedure on desired speech outcome.
The relationship between the surgeon and the
craniofacial speech pathologist is pivotal for success.
The surgeon who cultivates this relationship and is
willing to take a transdisciplinary role in surgical
management undoubtedly increases the results of
desired outcome. The craniofacial-cleft palate special-
ist, whether a surgeon or a speech pathologist, cannot
ignore the significance and impact of a comprehensive
diagnostic evaluation. Many erroneous assumptions
have been made about velopharyngeal structure and
function and sound production based on less than
adequate diagnostic regimens, often producing less
than adequate treatment outcomes. One cannot pro-
vide successful management of hypernasality without
a comprehensive articulation assessment and a com-
prehensive assessment of the velopharyngeal mech-
anism, which involves at least a nasopharyngoscopy
or multiview videofluoroscopic study.
Variable IV. The effects of primary palatoplasty
Secondary cleft surgery encompasses a category
that is wide and varied. It includes procedures to
improve the appearance of the lip and nose, move
and stabilize the mandible and maxilla, and improve
the function of speech (Table 3). The more severe the
initial cleft problem, the more likely the need for
secondary or revisional surgery. The individual who
needs secondary cleft surgery is affected by many
more potential variables that affect desired speech
outcome than the person who faces initial primary
surgery (Table 4).
The infant who needs a primary lip or palate repair
presents to the surgeon with significantly fewer
demands on the surgeon: (1) the type of unrepaired
cleft lip and palate (laterality and severity), (2) status
of premaxilla and anterior palate and need for presur-
gical molding devices, (3) possibility of contributing
phenotypic characteristics of an underlying syndrome
(ie, airway, cardiac, gastrointestinal anomalies), and
(4) the possibility of hearing and feeding issues.
The individual who faces secondary cleft surgery
(1) generally is much older, (2) may present with less-
than-optimal primary surgical repair with scarring and
dehiscence, (3) may present at a much later age than
 E.M. LeBlanc / Oral Maxillofacial Surg Clin N Am 14 (2002) 525–537 529

Table 3
Potential speech issues after primary cleft surgery
Speech symptom
Clinical sign Resonance Articulation Voice
Nose
Severe septal deviations, Hyponasal, hypernasal No known effect No known effect
Reduced nasal patency cul de sac resonance

Lip
Tissue deficiency, poor Perceived hypernasality Weak articulatory contact, No known effect
differentiation from weak contact caused by adaptive changes
maxilla asymmetry,
short upper lip, whistle
tip deformity

Hard palate
Fistula repair Hypernasality, nasal rustling, Weak articulatory contact, No known effect
nasal emission, grimacing, middorsal palatal stops,
nasal regurgitation, lingual backing,
nasal emission obligatory errors
Alveolar cleft No known effect

Velum
Velopharyngeal Hypernasality, nasal rustling, Compensatory articulation Hoarseness,
dysfunction nasal emission, nasal turbulence low volume
Marginal closure Mild hypernasality Weak articulatory contact Hoarseness,
low volume
Learned VPI Hypernasality, nasal rustling, Compensatory articulation Hoarseness,
nasal emission, nasal turbulence low volume

surgically desired, (4) presents with dental occlusal
and skeletal anomalies, (5) presents with the possibil-
ity of learned maladaptive speech behavior, (6) has
other speech problems that may interact and influence
speech disorders related to the clefting, (7) has a
dysfunctional velopharyngeal mechanism or one at
high risk for dysfunction, (8) may contribute pheno-
typic characteristics of an underlying syndrome, (9)
possibly may have hearing, language, and cognitive
issues, and (10) may have affected social-emotional
integrity. The surgeon who performs secondary cleft
procedures faces an increased number of concerns that
affect surgical outcome.
Secondary procedures of the nasal deformity
deformities do not affect sound production or voice.
Depending on the degree of nasal deformation, how-
ever, there could be an effect on resonance. The
individual may present with a hyponasal, hypernasal,
or cul de sac resonance quality. Nasal tip and nostril
revision is possible in early childhood, although
septal and bony surgery to straighten the nose totally
should be postponed until full or near full growth of
the facial features has occurred. Secondary surgery,
such as straightening the nasal septum, is expected to
have a positive effect on the elimination of hypona-
sality (if septal deviation and nasal deformities are the
primary sources of the hyponasality perceived). Tran-
sient resonance issues, such as hyponasality, may be
caused by postsurgical edema, which is expected to
dissipate during the healing process.

Primary repair of a complete or incomplete cleft

lip with its associated nasal deformity presents with a
potential effect on certain aspects of speech. In the
unilateral cleft lip, the patency of the nasal cavity may
be affected by nasal collapse, broad flaring nostrils,
asymmetry, shortened columella, and a concomitant
septal deviation. These anomalies affect the patency
of the nasal cavity and might affect speech. Nasal
Secondary procedures of lip deformity
Major revisional procedures on the lip are not un-
common. With a wide range of procedures, repair may
occur at almost any age. Secondary correction of the
cleft lip unilaterally or bilaterally has minimal effect
on speech sound production. Primary repair of the lip
530 E.M. LeBlanc / Oral Maxillofacial Surg Clin N Am 14 (2002) 525–537
Table 4
Potential speech issues after secondary cleft surgery
Speech symptom
Clinical sign Resonance
Lip/nose revisions No known effect
Hard Palate
Oronasal fistula repair Hypernasality, nasal
emission, nasal
regurgitation, foul odor
Alveolar bone graft Nasal regurgitation,
foul odor
Velum
Secondary pharyngoplasty Hypernasality, nasal
emission, nasal
regurgitation, hyponasality
Le Fort I advancement Hypernasality, nasal emission
Maxillary osteodistraction Transient hypernasality
Mandibular osteodistraction No known effect
has marginal effects on sound production. Resonance
and voice are rarely—if ever—affected directly or in-
directly. Clefting of the lip results in tissue deficiency,
poor differentiation from the maxilla, asymmetry, and
retropositioning of the maxilla from the mandible.
Depending on the type of cleft (unilateral versus bi-
lateral), severity of the cleft, surgical procedure used,
and experience of the surgeon, surgical repair may
result in scarring, infection, and dehiscence.
A repaired short upper lip, a whistle tip deformity,
lip incompetence, and immobility caused by scarring,
small prolabium, and an underlying pseudo Class III
malocclusion may affect production of certain sounds
[m, p, b, f, v, w] [41,42]. The effect is often a
maladaptive change, so the intended sounds actually
may be produced with the dental edge and the lower
lip, which results in a [p] or [b] being perceived as
having weak articulatory contact, or ‘‘sounding soft.’’
Weak articulatory contact limits the amount of
increased intraoral air pressure behind the lips because
the lips do not achieve a tight seal for the necessary
duration of time that allows for air pressure to build
behind them, which provides the possible perception
of increased nasality.
Production of [f, v] may be affected by a shortened
upper lip and may affect the phonemes because of
difficulty in maintaining the correct placement of the
maxillary dentition on the lower lip (labiodental).
Production of [w] and some vowels may be affected
by a tight or short upper lip. This effect may be
marginal to the untrained ear. Growth and secondary
lip revisions of adding bulk and length to the upper
Articulation Voice
No known effect No known effect
Middorsal palatal stops No known effect
Obligatory errors No known effect
Compensatory articulation No known effect
Improved obligatory No known effect
No known effect
No known effect No known effect
lip, age of the child, and how habitual the articulatory
adaptation becomes may have positive effects on
these sound errors. Superior retropositioning of the
maxilla and mandibular and maxillary advancements
reportedly has an effect of stretching the lip and
increasing lip tension. Offering the tissue changes of
that nature allows lips to approximate in a more
normalized position for sound production [43]. The
sound errors found in clefts of the lip are considered to
be attempts to balance the relationship between a
functional need (sound production) and insufficient
soft and bony structure. Often this equalization is
maladaptive in nature.
Secondary correction of the palate
Oronasal fistula and unrepaired alveolar clefts
An oronasal fistula is noted in 5% to 30% of all
primary palate repairs [44]. There are differences in
incidence depending on the type of palatoplasty
performed, the degree of cleft severity, and the sur-
geon’s experience. In some cases the fistula is left
intentionally, which is called initial fistulas (secondary
to intravelar pharyngoplasties); in other cases, fistulas
develop because of poor healing (recurrent fistulas)
[45]. It is critical to delineate between fistulas asso-
ciated with unrepaired alveolar clefts and oronasal
palatal fistulas. The differentiation is important from a
speech perspective. Fistulas caused by an unrepaired
alveolar cleft rarely have a direct effect on resonance,
 E.M. LeBlanc / Oral Maxillofacial Surg Clin N Am 14 (2002) 525–537
articulation, or voice. Conversely, the size and extent
of the alveolar cleft may have the potential for indirect
speech effects, such as concomitant nasal emission,
weak articulatory contact, and nasal regurgitation.
Nasal regurgitation, foul odor, and difficulty in eating
in public are often noted as secondary effects [46].
Oronasal fistulas have a direct effect on speech.
The effects of an oronasal fistula depend on the
location, size, and length of time during sound devel-
opment and length of time in which the fistula was
present. Hypernasality, nasal emission, and articu-
lation errors, such as mid-dorsal palatal stops (com-
pensatory articulation disorder secondary to VPI),
have been associated with oronasal fistulas [39,
47,48]. Oronasal fistulas are often the site of resistant
sound errors, which may have direct and indirect
effects on velopharyngeal closure [48 – 50]. Leblanc
and Eisig [39] noted that long-standing history of
oronasal fistula was found to have a direct effect on
the velopharyngeal closure in patients who underwent
a Le Fort I advancement. The presence and effect of
fistulas on maxillary osteodistraction are currently
unknown. Paying attention to the integrity of speech
sounds during the elicited speech sample (with the
fistula occluded) provides information on the pres-
ence of articulation errors and how hypernasality is
masking the extent of the sound errors as well as
provides information as to the possible contributions
of velopharyngeal dysfunction on the hypernasality
being heard.
Management of fistulas, especially oronasal fistu-
las, is important to undertake as soon as possible if it
has been determined that they have detrimental effects
on speech. Management may include temporary
occlusion by use of prosthetic obturators [41] and
adhesive patches that adhere to the oral mucosa [51].
In the case of a small fistula (no matter how affected
the speech may be), surgical management may be
delayed until fistula repair can be performed at the
same time as other surgical procedures to reduce the
number of times one undergoes general anesthesia.
Large fistulas that directly contribute to hypernasality,
nasal emission, articulation errors, and nasal regur-
gitation often require immediate surgery. Surgical
closure of oronasal fistulas is common, however its
success is often tenuous because of the presence of
scar tissue, location, and size [44,52].
There have been few systematic investigations into
the effects of the following procedures and the desired
speech outcomes: local turnover flaps, modifications
of the mucoperiosteal palatal flaps, buccal flaps, and
tongue flaps, and the use of pharyngeal flap (a sec-
ondary pharyngoplasty procedure) in the presence of
posteriorly placed oronasal fistulas [26,44,53]. The
531
positive effects of fistula repair on speech far out-
weigh the negatives.
Velopharyngeal insufficiency
All too often the first question asked when hyper-
nasality is heard concerns the integrity of the velo-
pharyngeal musculature. For successful management
of hypernasality, however, the first question asked
should be how much of the nasality heard is related to
VPI and how much—if at all—is it related to ‘‘learned
maladaptive sound compensations.’’ Many complicat-
ing factors contribute to the perception of hyperna-
sality. The surgeon who achieves the desired speech
outcome successfully (1) identifies which contrib-
utory speech factors exist, (2) provides a compre-
hensive structural and physiologic assessment, (3)
determines when to manage the patient surgically,
and (4) develops an ‘‘haute couture’’ surgical plan
(surgery specifically designed for the patient based on
in-depth preoperative assessment).
Management of VPI depends greatly on the trans-
disciplinary diagnostic assessment. This assessment
involves the use of direct visualization techniques,
such as nasopharyngoscopy and multiview video-
fluoroscopy, measurements of airflow and air pressure
through the use of aerodynamic studies, and a cranio-
facial speech assessment.
The debates expressed in the literature and during
professional forums that revolve around the issue of
which secondary surgical procedure provides the most
desired outcome are misplaced. Each procedure has
the potential to result in positive outcomes. The debate
over which procedure is most effective more appro-
priately revolves around issues of postoperative man-
ifestations of nasal and airway obstruction. To date, the
pharyngeal flap presents with a 10% to 13% increased
risk of postoperative airway issues as compared to the
sphincter pharyngoplasty [29,54]. There have been
several reports of airway obstruction and death asso-
ciated with posterior pharyngeal flap surgery and
obstructive sleep apnea after such surgery [55].
Many surgeons who use the pharyngeal flap pro-
cedure do not experience these results. Differences in
opinion still exist as to whether hyponasality beyond
the postoperative healing process is considered to be
normal. Hyponasality does not represent normal res-
onance [5,9,36,56].
The surgical approaches currently available consist
of augmentation of the velum (ie, Furlow double-
reversing Z-plasty) and altering the structure and
physiology of the pharyngeal musculature (ie, supe-
riorly based pharyngeal flaps, sphincter pharyngoplas-
ties, and augmentation pharyngoplasties).
532 E.M. LeBlanc / Oral Maxillofacial Surg Clin N Am 14 (2002) 525–537
Sphincter pharyngoplasty
The sphincterplasty acts on the velopharynx by
advancing the posterior pharyngeal wall (dissection of
the posterior faucial pillars, with insertion into the
posterior pharyngeal wall), reducing the lateral pha-
ryngeal wall dimensions (reducing the overall dia-
meter), and providing a dynamic sphincter action
(simulating the natural physiologic action of the velo-
pharynx) [29,35,57 – 59]. Riski et al [58] and Witt
et al [59] noted that preexisting and persistent com-
pensatory articulation errors, low lateral flap place-
ment, flap dehiscence, and reduced experience of
the surgeon accounted for sphincterplasty failures in
the patients who did not demonstrate an improve-
ment in their resonance quality. Pensler et al [60]
reported a 4% occurrence of sleep apnea. The sphinc-
ter pharyngoplasty has gained an ever-increasing
attractiveness by its ease of procedure, favored
speech outcomes, and significantly reduced postop-
erative complications.
Pharyngeal flap
The pharyngeal flap as a procedure to eliminate
hypernasality has been reported in the literature with
the most vigor and frequency because of its long
history. It has been in use in one form or another
since 1876 [61]. The success of the pharyngeal flap
depends on more factors to ensure resonance integrity
than that of the sphincterplasty. The pharyngeal flap
relies in part on the mesial movement of the lateral
pharyngeal walls, the appropriate width of the flap, the
superior placement of the flap, insertion of the free
flap into the velum, the size of the lateral ports, flap
tissue atrophy, and surgeon experience [62]. In addi-
tion to concerns of airway obstruction after pharyn-
geal flap, questionable resonance results have raised
concern about transient changes in facial growth
patterns in patients who undergo pharyngeal flaps,
particularly maxillary arch changes, mandible angle
changes, and increased anterior facial height [63].
Furlow double opposing Z-plasty
The Furlow-plasty has enjoyed much use and
success with submucous and occult submucous cleft
palates. It also has become increasingly popular as a
secondary surgical procedure in the presence of status
postprimary palatal repair and documented VPI. The
success depends on the size of the insufficiency, the
movement excursion of the lateral pharyngeal walls,
and the presence of compensatory articulation errors.
Secondary correction of the maxilla and mandible
Secondary alveolar bone graft
Alveolar bone grafts (primary and secondary) are
designed to stabilize the segments of the maxilla and
replace missing bone. Alveolar bone grafting typically
occurs between 9 and 11 years of age, when the
permanent lateral incisor or the canine tooth roots
are approximately one-third developed. The presence
of appliances (rapid palatal expansion devices) before
bone grafting may affect articulation and resonance
indirectly because of the obstructive nature of the
appliances affecting lingual placement (affecting spa-
tial relationships) and aerodynamics of airflow and
pressure for sound production. This is typically a
transient effect [64]. Before the bone graft; a child
with a cleft lip presents with dental and occlusal
anomalies that have the potential to affect speech
(obligatory sound errors, weak articulatory contact
of sound, possible nasal emission).
Maxillary and mandibular osteodistraction
Osteodistraction of the mandible has been used for
a decade, since it was first introduced in 1992 by
McCarthy et al [65]. Osteodistraction is still relatively
new to the flora of utility research endeavors, espe-
cially when related to speech. To date, few studies have
examined the effects of speech after distraction
[21,22,66]. The current data indicate that maxillary
distraction of no more than 10 to 15 mm resulted in
VPI occurring in transient manner with resolution to
predistraction status at least 3 to 6 months after surgery
[21]. These results are consistent with the reported
literature on Le Fort I advancements. Theoretically, the
gradual advancement of the maxilla may allow for
progressive adaptation in the velopharyngeal mech-
anism, although this has not been well researched.
Of the scant literature and personal communica-
tions available on speech outcomes and maxillary
distraction, it is believed that an advancement of
10 mm or more may result in increased velopharyn-
geal function. Satoh et al [22] noted that seven of eight
patients who presented with normal velopharyngeal
function and normal articulation before distraction
were unchanged after distraction. The average ad-
vancement ranged from 4.5 to 7.6 mm in 9- to
11-year-old children, with six subjects presenting with
hypertrophic adenoidal tissue. The patient who pre-
sented with borderline velopharyngeal closure before
distraction exhibited increased VPI after distraction.
Satoh et al [22] also noted that the ratio of velar length
to pharyngeal depth decreased in all eight subjects
 E.M. LeBlanc / Oral Maxillofacial Surg Clin N Am 14 (2002) 525–537
(1.06 – 1.76 before distraction and 0.79 – 1.19 after
distraction). Guyette [21] reported on the positive
change in sound production after distraction. This
finding is supported by several studies on the effect
of Le Fort I advancement and articulation [24].
Distraction osteogenesis is a term used to denote
several different types of surgical and movement
techniques for moving hard and soft tissue in varying
directions into more normal positions. Because of this,
one is cautioned to make assumptions that the effect
on speech would be similar to that noted in Le Fort I
advancements. One also is reminded that the literature
on speech effects after Le Fort I advancements con-
tinues to cause debate because of numerous methodo-
logic flaws in the research. The research conducted to
date gave minimal rigor to reliably discussing the
short- and long-term effects of maxillary distraction
on resonance and articulation.
Le Fort I advancement
Although maxillary distraction has gained increas-
ing popularity as the procedure to be used for maxillary
hypoplasia and retrusion, the Le Fort I advancement
continues to be used actively in many surgeons’
protocols. The goal of maxillary repositioning with ap-
propriate movement of osteotomized units includes
achieving normal occlusion, normal sized and func-
tioning oral and pharyngeal resonance cavities, and
improved facial proportions. Orthognathic surgery re-
quires careful coordination among the surgeon, speech
pathologist, and orthodontist. Much debate has oc-
curred over the Le Fort I osteotomy’s effect on speech.
Articulation
Crowding of the maxillary teeth, increased spaces
that result from alveolar fistulas, missing incisors,
crossbites, and pseudoprognathism in cleft lip may
lead to articulation errors (obligatory disorder) known
as distortions (frontal and lateral lisping [s, z, sh, ch,
j], lingual retraction [t, d, n], and maladaptive produc-
tion [p, b, f, v]). Dental-skeletal anomalies have
greater potential to effect sound production if they
exist before or during the period of sound devel-
opment (9 months to 4 years) [56]. Correction of
Class III malocclusion often improves or resolves
obligatory sound errors. Published reports on advan-
cing the maxilla forward, with or without simulta-
neous sagittal split osteotomies, repeatedly have
demonstrated that obligatory errors were eliminated
if present in most of the reported cases [23,65,67 – 69].
Le Fort I advancements have minimal to no effect
(negative or positive) on compensatory articulation
533
disorder secondary to VPI or secondary articulation
disorders, such as developmental or phonologic pro-
cessing feature disorder.
Velopharyngeal function
Advancement of the maxilla results in three-
dimensional changes of the velopharynx, nasophar-
ynx, and hypopharynx. Le Fort I advancement has the
potential of impacting the integrity of the function of
the velopharyngeal mechanism by modifying its kin-
ematic dynamics. One area of relative agreement in
the literature is that postoperative hypernasality is
likely to occur in patients with maxillary advance-
ments of 10 mm or more. This is a reported finding in
one dimension only, however. Adaptive or maladap-
tive effects or no effects at all on resonance have been
reported [20,39,56 – 74]. Schwarz et al [75] summa-
rized the following findings:
1. No changes in the normal oral-nasal reso-
nance balance
2. Changes from normal resonance to hyper-
nasality
3. Increase in the severity of hypernasality
4. Decrease in the degree of severity of hyper-
nasality
5. Changes from hypernasality to hyponasality
6. Increase in the degree of hyponasality
7. Decrease in the degree of hyponasality
8. Elimination of hyponasality.
The following patient profile has been noted to
increase the potential for undesirable changes in
velopharyngeal function after Le Fort I advancement
[17,39]:
1. Status after primary pharyngoplasty
2. Status after secondary pharyngoplasty (based
on pharyngeal flap procedure)
3. Presence or history of marginal or touch
velopharyngeal closure
4. Status after long-standing history of oronasal
palatal fistula
5. Presence of or suspicion of submucous or
occult submucous cleft palate
6. Presence of hypertrophic adenoid tissue
7. History of hypernasality after adenoidectomy
or tonsillectomy
8. Presence of compensatory articulation disorder
secondary to VPI
9. Presence of cranial base anomalies, such as
Apert, Crouzon, Pfeiffer, and Treacher Collins
syndromes.
534 E.M. LeBlanc / Oral Maxillofacial Surg Clin N Am 14 (2002) 525–537
Little attention has been paid in the literature to
the effects of Le Fort I advancement on sphincter
pharyngoplasty and furlow pharyngoplasty, the site of
placement (inferior versus superior) and width of the
pharyngeal flap, or whether there is a concomitant
relapse in velopharyngeal function (with or without
secondary pharyngoplasty) in patients who dem-
onstrate a dental-skeletal relapse. To date, there has
been no attempt to assess all the potential factors and
their predictive value in velopharyngeal outcome.
One aspect is ensured: extensive preoperative per-
ceptual and direct visualization (via nasopharyngo-
scopy) is vital to the success of Le Fort I advancement.
Documentation of the risk for velopharyngeal dys-
function does not change the potential undesired
resonance outcome. It does lend to appropriate expec-
tations of surgical and speech outcomes, however,
with the realization that revision or secondary pharyn-
goplasty is a possibility in 6 to 9 months after
advancement. It is important that such patients be
closely monitored longitudinally. The most recent
study by Sabry et al [76] noted a low risk of velopha-
ryngeal dysfunction in 12 patients who previously
underwent a secondary pharyngoplasty. Six of 9 sub-
jects presented with a degree of VPI (‘‘bubbling’’)
before advancement. Three subjects reportedly
improved velopharyngeal function, whereas 1 pre-
sented with increased VPI, as compared to the pre-
operative state. The researchers failed to comment on
the relationship of velopharyngeal function after
advancement and type of secondary pharyngoplasty.
A small sample and a poorly delineated mix of non-
syndromic and syndromic patients make the results
difficult to interpret.
Oronasal fistula
The presence or long-standing history of palatal
oronasal fistula has been noted to have an impact on
velopharyngeal function after maxillary advancement.
LeBlanc and Eisig [39] and Poole et al [77] noted that
patients who presented with velopharyngeal dysfunc-
tion after maxillary advancement exhibited the pres-
ence or history of fistula. The deleterious effect of the
fistula on the kinematics of the velopharyngeal mech-
anism has been supported by the work of Isberg and
Henningsson [34].
Discussion
For the surgeon who performs secondary proce-
dures on clefting disorders, there is a need for careful
balancing of occlusal, aesthetic, and speech consid-
erations. Historically, we have learned from the
growth of our professions and have moved closer to
providing optimized surgical and speech outcomes for
patients. We have learned that enhancing surgical
procedures, technique and the learning curve do not
ensure optimized speech outcomes alone. Speech
represents a dynamic matrix of elements that interact
with each other and the surgical components. Con-
trolling many of the variables to ensure an optimized
outcome is the responsibility of the cleft team. The
team is ideally made up of cleft-experienced disci-
plines that work with each other for the benefit of the
patient. The American Cleft Palate-Craniofacial Asso-
ciation [78] has established minimal criteria on the
parameters of cleft team care.
Based on what we do know at the beginning of the
twenty-first century, a comprehensive preoperative
speech assessment is fundamental to any cleft surgery.
Universal standards have been recently proposed for
speech assessment in clefting [5,79], including a
rigorous perceptual assessment, nasopharyngoscopy,
and multiview videofluoroscopy by a trained cranio-
facial-cleft speech specialist.
The type of articulation disorder presented by the
patient has a direct effect on velopharyngeal function,
the outcome of secondary pharyngoplasties, maxillary
distractions, and Le Fort I advancements. Compen-
satory articulation disorder secondary to VPI—in the
sheer nature of the sound disorder—directly affects the
kinematics of velar and lateral pharyngeal wall move-
ment, which results in less than optimal mobility. In
many cases, optimizing sound production before sec-
ondary pharyngeal cleft surgery changes the physio-
logic mechanism of the velopharynx and necessitates a
different surgical approach. If optimal speech is dif-
ficult to obtain at the time that surgery is considered,
having appropriate expectations of velopharyngeal
function and speech postoperatively is imperative.
This is especially important because many secondary
pharyngoplasties result in concomitant edema, which
leads to hyponasality. This may have a false-positive
effect, because when the transient edema resolves, one
may perceive hypernasality caused by the presence of
the type of articulation errors.
Postprimary pharyngoplasties have the potential
to place the palate and its function at risk for res-
onance and articulation disorders. Fistulas, regarded
by many surgeons as having minimal effect on speech,
have the potential to impact articulation, velopha-
ryngeal function, eating, and the outcomes of second-
ary pharyngoplasties, maxillary advancements via
osteodistraction, and Le Fort I osteotomy.
Secondary pharyngoplasties are best used when an
‘‘haute couture’’ approach of assessment and surgery
 E.M. LeBlanc / Oral Maxillofacial Surg Clin N Am 14 (2002) 525–537
approach is adopted. Surgical proficiency on the
furlowplasty, sphincterplasty, and pharyngeal flap is
increasing in the team-centered approach. The criteria
for the timing and need for surgery require further
development. Each procedure has merits, and under
the right hands each procedure has proved to achieve
the desired outcomes. In other words, one should
do what works, as long as one knows when it is
not working.
Maxillary and mandibular advancements have the
potential to affect the function of the velopharyngeal
mechanism. We do know that an anteroposterior
direction of movement of more than 10 mm increases
the occurrence of perceived hypernasality. There is so
much more that we do not know, however. What other
movement directions affect velopharyngeal function
and in what manner? More clinical research is needed
in examining the effects of oronasal fistula, the type
and presence of articulation disorders, and the inci-
dence of relapse and velopharyngeal dysfunction.
What we do know is that any velopharyngeal
mechanism in an individual with a palatal cleft or
craniofacial syndrome is at risk for compromise and a
comprehensive speech assessment is imperative. This
assessment includes direct visualization of the velo-
pharyngeal mechanism via nasopharyngoscopy.
The more one knows about clefting and its impact
on speech production, oropharyngeal anatomy, and
physiology and the basic regimens used in dental and
surgical management, the greater the contribution to
the successful management process.
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