The Cleft Palate–Craniofacial Journal 00(00) pp.

000–000 Month 0000

Ó Copyright 2015 American Cleft Palate–Craniofacial Association

ORIGINAL ARTICLE

Perceptual-Speech, Nasometric, and Cephalometric Results After Modified

V-Y Palatoplasties With or Without Mucosal Graft
Kentaro Oyama, D.D.S., Kazuhide Nishihara, D.D.S., Ph.D., Kazuhide Matsunaga, D.D.S., Ph.D., Naoko Miura,
S.L.T., B.A., Toshiro Kibe, D.D.S., Ph.D., Norifumi Nakamura, D.D.S., Ph.D,

Objective: Although the goal of cleft palate (CP) repair is to achieve normal speech, no
standard procedure ensures that patients’ speech will be at the same level as speech in children
without CP. In this study, postoperative speech outcomes following primary CP repair combined
with or without a mucosal graft was analyzed in comparison with that of control subjects without
CP.
Participants: Eighty-two patients who underwent modified V-Y palatoplasty with a mucosal
graft on the nasal side for symmetrical muscular reconstruction during 2006–2012 (MG group)
and 109 patients who previously underwent modified V-Y palatoplasty without a mucosal graft
(non-MG group) were enrolled in this study. Speech data on 37 Japanese subjects without CP
were used as a control.
Main Outcome Measures: Perceptual rating of resonance and nasal emission and nasometry
were carried out for all participants. Furthermore, cephalometric analyses were performed to
assess postoperative velopharyngeal morphology and velar movement.
Results: Normal resonance was achieved at a significantly higher rate (90.3% of patients) in
the MG group than in the non-MG group (68.8%) (P , .01). The mean nasalance scores in the MG
group were significantly lower (P , .01) and were almost at the same level as in controls.
Cephalometric analyses revealed a greater velar length and velar elevation angle during
phonation in the MG group (P , .01 and P , .05, respectively).
Conclusions: Modified V-Y palatoplasty combined with a mucosal graft on the nasal side of
the velum for symmetrical muscular reconstruction facilitates speech outcomes for children with
cleft palate that are comparable with those for peers without CP.

KEY WORDS: cleft palate, nasometry, speech

Dr. Oyama is Postgraduate Student, Department of Oral and

Maxillofacial Surgery, Field of Oral and Maxillofacial Rehabilitation,
Kagoshima University Graduate School of Medical and Dental
Sciences
Dr. Nishihara is Associate Professor, Department of Oral and
Maxillofacial Functional Rehabilitation, Graduate School of Medi-
cine, University of the Ryukyus, Nishihara, Japan. Dr. Matsunaga is
Research Associate, Department of Oral and Maxillofacial Surgery,
Field of Oral and Maxillofacial Rehabilitation, Kagoshima University
Graduate School of Medical and Dental Sciences, Kagoshima, Japan.
Ms. Miura is Speech-Language Hearing Therapist, Division of
Rehabilitation, Division of Clinical Technology, Kagoshima Univer-
sity Medical and Dental Hospital, Kagoshima, Japan. Dr. Kibe is
Research Associate, Department of Oral and Maxillofacial Surgery,
Field of Oral and Maxillofacial Rehabilitation, Kagoshima University
Graduate School of Medical and Dental Sciences, Kagoshima, Japan.
Dr. Nakamura is Professor, Department of Oral and Maxillofacial
Surgery, Field of Oral and Maxillofacial Rehabilitation, Kagoshima
University Graduate School of Medical and Dental Sciences,
Kagoshima, Japan.
No funding or grant was received for this study.
This study was presented orally at the 58th Annual Meeting of
Japanese Oral and Maxillofacial Surgeons, Fukuoka, Japan, October
11, 2012, and received the Best Oral Presentation Award.
Submitted May 2014; Revised December 2014, March 2015;
Accepted September 2015
Address correspondence to: Dr. Norifumi Nakamura, Department
of Oral and Maxillofacial Surgery, Field of Oral and Maxillofacial
Rehabilitation, Graduate School of Medical and Dental Sciences,
Kagoshima University, 8-35-1 Sakuragaoka, Kagoshima 890-8544,
Japan. E-mail nakamura@dent.kagoshima-u.ac.jp.
The surgical goals of primary repair for cleft palate (CP)
include closing the anatomic defect of the hard and soft
palate and achieving normal speech based on a complete
velopharyngeal (VP) closure mechanism. It is also impor-
tant to minimize or avoid disturbing maxillary growth
caused by surgical intervention for the hard palate during
palatoplasty in infancy. Patients and family members
always desire the patient’s speech to sound like that of
healthy children. However, approximately 40% of patients
will have a persistent, often lifelong, speech disorder related
to CP (Stengelhofen, 1989). It is well recognized that
achieving a sufficient VP closure mechanism is the core of
treatment for patients with CP. Since the soft palate plays
an important role in the VP closure mechanism, which
allows a speaker to differentiate between nasal and oral
speech sounds, patients with an insufficient VP closure
mechanism may sound hypernasal and experience nasal air
emission (Bressmann et al., 2011). Furthermore, the patient
may subsequently find it difficult to produce pressure
DOI: 10.1597/14-141

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0 Cleft Palate–Craniofacial Journal, Month 0000, Vol. 00 No. 00
consonant sounds, and many patients develop compensa-
tory misarticulations.
The surgical modalities for primary CP repair have
developed over a long period. V-Y palatoplasty using the
Wardill-Kilner technique (Millard, 1980) has been widely
used because of the relatively high rate of achieving
favorable postoperative VP closure and flexibility to treat
various degrees of wide clefts and short palates. However,
since the problem of maxillary growth disturbance
following primary CP repair have been indicated by
orthodontists (Pruzansky, 1955; Ross, 1987), palatoplasty
has shifted to less invasive procedures focusing on maxillary
growth. Furlow (1986) reported a new concept of double
opposing Z-plasty for the soft palate that could maintain
hard palate tissues as intact. After Furlow’s report, many
surgeons reported their own modifications and techniques
for Furlow palatoplasty, expecting a new standard for CP
repair to achieve successful results on treating wide,
complete clefts (LaRossa et al., 2004; Bindingnavele et al.,
2008; Gupta et al., 2011).
Over the past few decades, a large number of surgeons
have developed surgical procedures for palatal repair that
ensure favorable VP closure, result in normal speech, and
minimize the adverse surgical effects on maxillary growth
(Dorrance and Bransfield, 1943; Ruding, 1964; Kreins,
1970; Edgerton and Dellon, 1971; Kaplan, 1975; Millard,
1980; Jackson et al., 2004; Nishio et al., 2010). In previous
reports, the success rates for achieving favorable VP closure
or no hypernasality varied from 50.4% to 100% (Furlow,
1986; Grobbelaar et al., 1986; Horswell et al., 1993;
Brothers et al., 1995; Kirshner et al., 1999; von Lierde et
al., 2004; Nishio et al., 2010; Nyberg et al., 2010). Furlow
palatoplasty provided relatively favorable postoperative
results on resonance of around 75% to 96% (Furlow, 1986;
Horswell et al., 1993; Kirshner et al., 1999) and achieved
better results than the minimally invasive technique
(Nyberg et al., 2010), von Langenbeck procedure (Williams
et al., 2011), and two-stage palatoplasty using Perko’s
technique (Terao et al., 2013). On the other hand, in reports
comparing the surgical outcomes using objective measure-
ments, Brothers et al. (1995) observed that the success rates
for VP closure after Furlow palatoplasty and the modified
Wardill-Kilner procedure were 64.0% and 70.0%, respec-
tively, using pressure-flow testing, and they concluded that
there was no difference between the two procedures. Van
Lierde et al. (2004) also compared Furlow palatoplasty and
the Wardill–Kilner procedure using nasometry and ob-
served significantly better results in those treated with the
Wardill-Kilner procedure. Although there were several
differences in the postoperative results between the surgical
procedures, to date there has been no standard procedure
that can ensure complete VP closure in patients with CP.
In 2006, the Department of Oral and Maxillofacial
Surgery, Kagoshima University Medical and Dental
Hospital (Kagoshima University Hospital), changed the
surgical protocol for primary palatoplasty with the goal of
improving VP closure for speech. The concept of our
strategy for CP repair was to approach each anatomical
and pathological abnormality that may cause postoperative
velopharyngeal incompetence (VPI)—short palate, asym-
metric palate, insufficient velar elevation, and a midline
defect of the velum—to establish CP repair that can ensure
VP closure (Table 1). The aforementioned factors were
identified based on our experiences of treating patients with
persistent VPI after CP repair. Therefore, our procedures
for CP repair consisted of the following: (1) presurgical
orthopedics using a Hotz plate as much as possible to
minimize the cleft space; (2) modified V-Y palatoplasty,
allowing conservation of the periosteum in the anterior part
of the maxilla and minimizing maxillary growth distur-
bance; (3) lengthening of the nasal layer using large Z-plasty
and a free mucosal graft; (4) muscular reconstruction
producing a symmetrical levator sling and pharyngeal arch
(posterior faucial pillars); and (5) two-layered suture of the
palatal muscles.
In this study, we evaluated postoperative speech-related
outcomes, including presence/ severity of hypernasality,
nasal emission, and nasalance scores, as well as anatomical
characteristics, including VP morphology and velar motion
following palatal repair. We then compared these with the
outcomes using our previous palatal repair protocol
without a mucosal graft. Furthermore, we also compared
them with the nasalance scores of Japanese children
without CP.
PATIENTS
The data were collected from the records of the
Department of Oral and Maxillofacial surgery and the
CLP Clinic at Kagoshima University Hospital. This study
was approved by the Clinical Research Ethical Review
Boards of Kagoshima University Medical and Dental
Hospital (#337).
Eighty-two consecutive patients with CP with or without
cleft lip (CP6CL) who underwent primary CP repair from
2006 to 2012 using modified V-Y palatoplasty, which
allowed conservation of part of the periosteum in the
anterior part of the hard palate, veloplasty with muscle
repositioning, large Z-plasty, and a free mucosal graft on
the nasal side of the velum (MG group), were enrolled in
this study. The patients included 45 boys and 37 girls, and
the age at palatal repair varied from 15 to 109 months, with
a median age of 19 months. Thirty-seven patients had
unilateral cleft lip and palate (UCLP), 18 had bilateral cleft
lip and palate (BCLP), and 27 had cleft palate only (CPO).
For comparison, 109 patients with CP6CL who had
previously received palatal repair in our department using
modified V-Y palatoplasty with Z-plasty without a free
mucosal graft for velar extension between 1995 and 2005
(non-MG group) were also enrolled. We tried to recall all
114 patients who underwent palatal repair through
telephone calls, and 109 (95.6%) patients responded and
 Oyama et al., SPEECH RESULTS AFTER PALATOPLASTY WITH OR WITHOUT A MUCOSAL GRAFT 0

TABLE 1 Surgical Strategy for Palatal Repair Approaching Each Anatomical and Pathological Abnormality and Possible Causes of VPI*

Possible Causes of VPI Anatomical Pathological Abnormalities Surgical Procedures in Palatal Repair

Short palate
Asymmetric velopharynx
Insufficient velar elevation
Midline defect of the velum
* Problems of hearing loss and mental retardation were not included in this surgical strategy.
Wide cleft palate
Growth deficiency of the soft palate
Insufficient retropositioning of the palatal muscles
Anteroposterior discrepancy between the maxillary
segments
Discrepancy in the velar length between the segments
Malpositioning of the palatal muscles
Insufficient release of the palatal muscles from the palatal
bone
Muscular pooling in the soft palate
Wide scar in the soft palate
Unsatisfactory repair or defect of musculus uvulae
Presurgical orthopedics for narrowing the cleft space
using a Hotz plate, as much as possible
Sufficient retropositioning of the palatal muscle
Presurgical orthopedics improving the positional gap
using a Hotz plate, as much as possible
Extension of the nasal mucosa by large Z-plasty with a
free mucosal graft
Symmetrical reconstruction of the palatal muscle
referencing the anatomical landmarks
Freeing the palatal muscle in a single layer on the tensor
aponeurosis
Sufficient retropositioning of the palatal muscle
Sufficient extension of the oral and nasal mucosa
Two-layer suture of the palatal muscles in the midline of
the velum

returned to the hospital. The patients included 60 males and
49 females; the age at palatal repair varied from 16 to 31
months, with a median of 18 months. Fifty-eight patients
had UCLP, 26 had BCLP, and 25 had CPO. There were no
significant differences in sex or age at time of surgery
between the MG and non-MG groups. All patients in both
groups were Japanese and had no syndromic diseases;
patients with mental retardation and hearing problems
were excluded from this study. No patients in either group
had previously received adenoidectomy, re-pushback
surgery, or pharyngeal flap surgery. Patients with submu-
cosal cleft palate were excluded because testing for 22q11.2
deletion syndrome was not fully available in our depart-
ment. Palatal repair was performed by multiple oral
surgeons in both the MG and non-MG groups.
The postoperative speech data from perceptual analyses,
data from nasometry conducted by speech-language
hearing therapists (SLTs), and lateral cephalograms at rest
and on phonation were analyzed and compared between
the MG and non-MG groups.
Furthermore, nasometry data for 37 Japanese children
without CP (control group), who showed normal resonance
in the perceptual assessment by SLT were used as controls.
The control group included 21 boys and 16 girls, and their
age varied from 5 to 14 years, with a median of 6 years.
TREATMENT PROTOCOL FOR CP AT KAGOSHIMA UNIVERSITY
HOSPITAL
Patients with cleft lip and palate were treated by an
integrated team of various specialists. Patients with a wide
CP6CL received presurgical orthopedic treatment using
the Hotz plate (Hotz and Gnoinski, 1976) and managed by
pediatric dentists. An oral impression was taken at the first
examination, within 2 weeks after birth in most patients,
and the Hotz plate was set approximately 1 week later.
Physical and mental development were checked by oral
surgeons and SLTs from the cleft lip and palate team every
3 months, and the presence of otitis media was checked by
an otorhinolaryngologist every 6 months.
In subjects with cleft lip, primary lip repair was
performed at 3 to 4 months (if weight was more than 6
kg) using a triangular flap technique, and palatal repair was
carried out at around 1.5 years of age. Postoperatively,
speech development and VP closure were assessed and
facilitated periodically by 2 SLTs. Speech assessment was
performed at around 4 years of age, and when VPI was
recognized, speech therapy and a prosthesis (e.g., a fistula
obturator or speech bulb) were recommended. If VPI
remained after the nonsurgical speech management,
subsequent secondary palatal repair, including re-pushback
surgery (Nakamura et al., 2003) and pharyngeal flap
surgery, were carried out at approximately 10 and 17 years
of age, respectively.
SURGICAL PROCEDURES FOR PALATAL REPAIR
MG Group
The surgical strategy and procedures of palatal repair
for the MG group are shown in Table 1 and Figure 1,
respectively. Palatal repair was performed with a
modified V-Y palatoplasty, which allowed conservation
of the periosteum in the anterior part of the maxilla. On
designing the incision line, anatomical landmarks at the
velopharynx were marked using 0.05% Toluidine blue
solution (Fig.1a). The marked points included the tip
and base of the uvula (nos.1 and 2), the point at which
the extension line of the palatoglossal arch crossed the
cleft edge (no.3), the posterior edge of the hard palate
(no.4), and the midpoint between nos. 3 and 4 (no.5).
The palatal flaps were elevated while preserving the
periosteum in the anterior and lateral parts of the hard
palate, and the palatal muscles—including the levator
veli palatini muscle, palatopharyngeal muscle, and
musculus uvulae, although these muscles were not
clearly identified—were bluntly dissected along the
0 Cleft Palate–Craniofacial Journal, Month 0000, Vol. 00 No. 00

FIGURE 1 Surgical steps in palatal repair for UCLP in the MG group. The figure demonstrates anatomical landmarks and the incision line. A:
Elevation of the palatal flaps conserving the periosteum in the anterior and lateral parts of the hard palate and a large Z-plasty on the nasal side (dotted
line). B: A free mucosal graft on the nasal side. C: Symmetrical muscular reconstruction producing a levator sling while referring to D: the anatomical
landmarks.
 Oyama et al., SPEECH RESULTS AFTER PALATOPLASTY WITH OR WITHOUT A MUCOSAL GRAFT
surface of the tensor aponeurosis and nasal mucosa in a
single layer. Muscles were sufficiently retropositioned as
the direction was turned sideways. Neither fracture nor
exposure of the hamular process occurred.
For extension of the nasal mucosa of the soft palate,
large Z-plasty was performed in the nasal surface of the
soft palate (Fig.1b). The mucosal incision for the large
Z-plasty was extended until the surgeon could confirm
contact between the nasal side of the soft palate and
posterior pharyngeal wall without any tension. The
mucosal defect was closed using the mucosal flaps
produced by large Z-plasty; however, when the velar
length became shorter on complete closure of the Z-
plasty, the mucosal defect that remained on the nasal
side was filled using a free mucosal graft donated from
the buccal area (Fig.1c). This was because the shortened
velar length caused an asymmetric VP form and closure
motion due to complete closure.
Palatal muscles were then sutured in the midline of the
soft palate by a two-layered suture (nasal and oral sides)
using a nonabsorbable thread (5-0 nylon) (Fig.1d).
Palatal muscle was sutured carefully on producing a
symmetrical levator sling and also the symmetrical
palatopharyngeal and palatoglossal arches and uvula,
while referencing five anatomical landmarks, as de-
scribed previously. The raw area of the hard palate was
dressed using a collagen-based artificial dermis and
covered using an acrylic plate for 1 week.
Non-MG Group
The concept of palatal repair of the non-MG group,
which included a modified V-Y palatoplasty preserving
the periosteum and Z-plasty of the nasal side, was
basically the same as that of the MG group. The levator
veli palatini muscle was sutured in an edge-to-edge
manner to produce a levator sling. However, the
surgical procedures differed from those of the MG
group as follows: the mucoperiosteal tissue in the
anterior maxilla, which covered the first palate, was
used as an incisal flap, and the axial flap was donated
from the incisal branch. The incisal flap was elevated
and turned to cover the anterior cleft palate. Further-
more, mucosal defects caused by Z-plasty on the nasal
side were completely closed without a mucosal graft.
SPEECH ASSESSMENT
Postoperatively, subjects were followed by 2 SLTs with
14 and 5 years of clinical experience, respectively. The SLTs
saw patients every 3 months until they were around 4 years
old. Because one of the SLTs had moved, in this study,
perceptual rating of hypernasality and nasal emission was
carried out by one SLT for all participants using the
preserved sound sources. In perceptual rating, hyper-
nasality and nasal emission were classified into four
0
categories: none, slight/mild, moderate, and severe. Artic-
ulation was also evaluated using the articulation test of the
Japan Society of Logopedics and Phoniatrics and then
converted to International Phonetic Alphabet 2005 pho-
netic symbols so that all abnormalities could be diagnosed
and transcribed in the International Phonetic Alphabet.
Nasometry scores were obtained for all patients using the
Kay 6200 Nasometer II (Kay Elemetics, Lincoln Park, NJ).
For speech stimuli, the low-pressure vowel /i:/ and low-
pressure sentence /yooi wa ooi/ and the high-pressure
consonant-vowel syllable /tsu/ and high-pressure sentence /
kitsutsuki ga kiwotsutsuku/ (Ogata et al., 2013) were used.
We selected /i:/ extending the verbalization of /i/ among the
all low-pressured vowels based on our previous study on
the relationship between nasalance score and the perceptual
rating of resonance in Japanese subjects with and without
(Ogata et al., 2003). In this study, we found that the
nasalance score during phonation of /i:/ was correlated with
perceptual rating of resonance and subjects with normal
resonance, with or without cleft, demonstrated mean
nasalance score less than 20% during phonation of /i:/.
During speech ratings and nasometry, fistula obturator was
used in 8 patients in the MG group and 7 patients in the
non-MG group, and no other speech appliances were used
in the groups.
Means and SDs were measured and compared between
the MG, non-MG, and control groups. Since nasometer
use began at Kagoshima University Hospital in 2007,
patients who previously underwent palatal repair in our
department (non-MG group) were recalled for speech
assessment. Therefore, the ages at speech assessment in the
non-MG group (5 to 15 years with a mean of 8 years) were
higher than those of the MG group (4 to 11 years with a
mean of 5 years).
MEASUREMENTS OF CEPHALOMETRIC RADIOGRAPHS TO
ASSESS VELOPHARYNGEAL MORPHOLOGY AND VELAR
MOTION
Lateral cephalometric radiographs at rest and during
phonation of /i:/ were used for analysis of VP morphology
and velar motion in 65 subjects from the MG group and 98
subjects from the non-MG group. During cephalometric
analysis, no patients wore any prosthesis, such as fstula
obturator and speech bulb, in either group. Dimensions of
the velopharynx were measured by a single examiner
(postgraduate student who was not a surgeon) to eliminate
interoperator errors and any operator-based bias. Mea-
surement of cephalometric radiographs were repeated three
times, and the mean value was used for statistical analyses.
Skeletal landmarks and measurements made from the
cephalograms at rest and during phonation of /i:/
included the velar length, velar thickness, pharyngeal
depth (Fig.2a), ratio of velar length to pharyngeal depth
3 100 (the length/depth ratio), and the velar elevation
angle, which was the gap caused by velar angles between
0 Cleft Palate–Craniofacial Journal, Month 0000, Vol. 00 No. 00
FIGURE 2 Cephalometric landmarks and velopharyngeal measures. S
¼ sella, the midpoint of the sella turcica; N ¼ nasion, the most anterior
point of the nasofrontal suture; ANS ¼ anterior nasal spine; the tip of the
anterior nasal spine; PNS ¼ posterior nasal spine, the tip of the posterior
nasal spine; PPW ¼ posterior pharyngeal wall, the margin of the
posterior pharyngeal wall at the junction of the palatal plane; Ptm ¼ the
lower edge of the pterygoid plate. The velar length (PNS-U), velar
thickness (widest point of soft palate), and pharyngeal depth (PPW-
PNS) were measured in A: the resting position and B: the velar thickness
(widest point of soft palate) and pharyngeal velar elevation angle (PPT-
PNS-U) were measured on phonating /i:/.
the resting position and the position during phonation
of /i:/ (Fig.2b). Because the age distribution (and hence,
cranial size) was uneven in the study and previous
groups, all velopharyngeal dimensions were standard-
ized relative to the anterior cranial base length (S-N),
which was given a value of 100 (S-N revision).
Table 2 Comparison of Ratings of Hypernasality and Nasal
Emission Between the MG and Non-MG Groups
P
None Slight/Mild Moderate Severe Value*
Hypernasality
MG group
(n ¼ 82) 74 (90.3%) 5 (6.1%) 2 (2.4%) 1 (1.2%)
Non-MG group
(n ¼ 109) 75 (68.8%) 17 (15.6%) 4 (3.7%) 13 (11.8%) ,.01
Nasal emission
MG group
(n ¼ 82) 74 (90.3%) 5 (6.1%) 2 (2.4%) 1 (1.2%)
Non-MG group 13 (11.9%)
(n ¼ 109) 75 (68.8%) 18 (16.5%) 3 (2.8%) ,.01
* Mann-Whitney U test: P , .05.
STATISTICAL ANALYSIS
To evaluate the difference in speech outcomes following
the two different veloplasties, ratings of hypernasality and
nasal emission in the MG and non-MG groups were
compared using the Mann-Whitney U test. Nasalance
scores for the MG, non-MG, and control groups were
compared using analysis of variance. Furthermore, ceph-
alometric measures of velopharyngeal structures and velar
movement were compared between the MG and non-MG
groups using Student’s t test. Significance was defined as P
, .05.
RESULTS
Comparison of Speech Results Between MG and Non-
MG Groups
Table 2 shows a comparison of ratings of hyper-
nasality and nasal emission between MG and non-MG
groups. Hypernasality was classified as none in 74
(90,3%), slight/mild in five (6.1%), moderate in two
(2.4%), and severe in one (1.2%) patient in the MG
group. Alternatively, they were classified as none in 75
(68.8%), slight/mild in 17 (15.6%), moderate in four
(3.7%), and severe in 13 (11.9%) patients in the non-
MG group. The rate of achieving the absence of
hypernasality was significantly higher in the MG group
than in the non-MG group (P , .01).
When comparing the rate of achieving normal
resonance in each cleft type (Table 3, Fig. 3), normal
resonance was achieved in 35/37 (94.6%) with UCLP,
15/18 (83.3%) with BCLP, and 24/27 (88.9%) with CPO
in the MG group. Severe hypernasality was observed in
one patient with BCLP. On the other hand, normal
resonance was achieved in 40/57 (70.2%) with UCLP,
16/25 (64.0%) with BCLP, and 19/27 (70.3%) with CPO
in the non-MG group. Successful achievement of
normal resonance was obtained more reliably in all
types of CPO in the MG group, but there were
 Oyama et al., SPEECH RESULTS AFTER PALATOPLASTY WITH OR WITHOUT A MUCOSAL GRAFT 0

Table 3 Comparison of Ratings of Hypernasality of Each Cleft Type Between the MG and Non-MG Groups

MG Group (n¼82) Non-MG Group (n¼109)

None Slight/Mild Moderate Severe None Slight/Mild Moderate Severe P Value*

Hypernasality
UCLP 35 1 1 0 40 7 2 8 ,.05
BCLP 15 2 0 1 16 5 1 3 .27
CPO 24 2 1 0 19 5 1 2 .23
Total 74 5 2 1 75 17 4 13
* Mann-Whitney U test: P , .05.

significant differences in only UCLP between the two
groups (P , .05).
Regarding nasal emission, emission absence was
achieved in 90.3% of the patients in the MG group
and 68.8% of patients in the non-MG group. Only a
small percentage of patients were rated as having
significant nasal emission rate in the MG group
(1.2%) compared with the non-MG group (11.9%),
and there was a significant difference in nasal emission
between the two groups (P , .01) (Table 2).
Regarding articulation, five patients with delayed
articulation (three in the MG group and two in the
non-MG group) were excluded, and 186 were assessed
perceptually (Fig. 4). Normal articulation was ob-
tained in 54/79 (68.4%) patients in the MG group and
45/107 (42.1%) patients in the non-MG group.
Regarding the type of articulation disorder, eight
(10.1%)patients in the MG group demonstrated
lateralized distortions, seven (8.9%) demonstrated
palatal/velar backed articulation, one (1.2%) demon-
strated pharyngeal fricatives, and four (5.1%) demon-
strated glottal stops. On the other hand, of the patients
in the non-MG group, 16 (15.9%) demonstrated
lateralized distortions, 17 (15.9%) demonstrated pala-
tal/velar backed articulation, and 11 (10.3%) demon-
strated glottal stop. The portion of glottal stop was
markedly smaller in the MG group.
Comparison of Nasalance Scores Between the MG, Non-
MG, and Control Groups
The means and SDs of the nasalance scores in each
speech task of the MG, non-MG, and control groups
are shown in Table 4. The mean nasalance scores in
the MG group were 19.9% 6 13.1% on phonating the
low-pressure vowel /i:/, 16.6% 6 12.2% on phonating
the high-pressure consonant /tsu/, 19.8% 6 13.2% on
phonating the low-pressure sentence, and 19.1% 6

FIGURE 3 Postoperative hypernasality of each cleft type in the MG and non-MG groups.
0 Cleft Palate–Craniofacial Journal, Month 0000, Vol. 00 No. 00

FIGURE 4 Postoperative articulation in the MG and non-MG groups.

11.8% on phonating the high-pressure sentence. The
mean nasalance scores in the non-MG group were
33.3% 6 23.3% on phonating /i:/, 22.2% 6 18.7% on
phonating /tsu/, 23.9% 6 16.6% on phonating the
low-pressure sentence, and 23.3% 6 17.9% on
phonating the high-pressure sentence. There were
significant differences in the average nasalance scores
during phonating /i:/ and /tsu/ between the two
groups (P , .01 and P , .05, respectively). When
comparing the nasalance scores between the MG,
non-MG, and control groups, those in the non-MG
group were significantly higher on phonating /i:/ and
the low-pressure sentence than those in the control
group (P , .05 and P , .01, respectively). However,
there was no significant difference between the MG
and control groups. In other words, the nasalance
scores in the subjects of the MG group recovered to
almost the same levels as those of Japanese children
without cleft.
Comparison of Velopharyngeal Morphology and Velar
Motion Between MG and Non-MG Groups
and P values are shown in Table 5. Regarding
velopharyngeal morphology at rest, the mean velar
length was 47.9 6 6.7 mm, velar thickness was 17.5 6
4.4 mm, pharyngeal depth was 23.9 6 6.1 mm, and
length/depth ratio was 210.1% 647.3% in the MG
group. On the other hand, the mean velar length was
43.2 6 6.7 mm, velar thickness was 17.7 6 4.0 mm,
pharyngeal depth was 23.8 6 6.3 mm, and length/depth
ratio was 192.9% 6 48.1% in the resting position in the
non-MG group. There were significant differences in the
velar length and length/depth ratio between the two
groups (P , .01 and P , 0.5, respectively).
Regarding assessment of the velar motion during
phonation of /i:/ position, velar thickness was 17.4 6
4.9 mm and velar elevation angle was 11.98 66.08 in the
MG group, while they were 19.0 6 4.4 mm and 9.48
68.38 in the non-MG group, respectively. There were
significant differences in the velar thickness and velar
elevation angle during phonation between the two
groups (P , .05, respectively).
DISCUSSION

The means and SDs of the cephalometric measure- When one considers the reasons for postoperative VPI
ments of velopharyngeal morphology and velar motion following CP repair, there are several main causes,

Table 4 Mean 6 SD of the Nasalance Score in the MG, Non-MG, and Control Groups

Nasalance Score (%) P Value*

Nasalance Score MG (n ¼ 82) Non-MG (n ¼ 109) Controls (n ¼ 37) MG vs. Non-MG MG vs. Controls Non-MG vs. Controls

/i:/ 19.9 6 13.1 33.3 6 23.3 22.7 6 14.4 ,.01 NS ,.05

/tsu/ 16.6 6 12.2 22.2 6 18.7 15.2 6 8.5 ,.05 NS NS
/youi wa ooi/ 19.8 6 13.2 23.9 6 16.6 13.0 6 9.7 NS NS ,.01
/kitsutsuki ga kiwo tsutsuku/ 19.1 6 11.8 23.3 6 17.9 17.5 6 9.8 NS NS NS
* Analysis of variance: P , .05; NS ¼ no significance.
 Oyama et al., SPEECH RESULTS AFTER PALATOPLASTY WITH OR WITHOUT A MUCOSAL GRAFT
TABLE 5 Mean 6 SD of Velopharyngeal Morphology and Velar
Motion in Cephalometric Analysis†
MG Group Non-MG Goup
(n ¼ 65) (n ¼ 98) P Value
At rest
Velar length (mm) 47. 9 6 6.7 43.2 6 6.7**
Celar thickness (mm) 17.5 6 4.4 17.7 6 4.0
Pharyngeal depth (mm) 23.9 6 6.1 23.8 6 6.3
Length/depth ratio 210.1 6 47.3 192.9 6 48.1*
During phonation
Velar thickness (mm) 17.4 6 4.9 19.0 6 4.4*
Velar elevation angle (degree) 11.9 6 6.0 9.4 6 8.3*
† All velopharyngeal dimensions were standardized relative to the anterior cranial
base length (S-N) of 100 (S-N revision).
* Student’s t test P , .05; ** Student’s t test P , .01.
including wide cleft, short palate, deep pharynx, and
unsatisfactory muscle reconstruction when syndromic
conditions, hearing loss, and mental retardation are
excluded. Furthermore, in the authors’ experience during
endoscopic examination and re-pushback surgery in
patients with persistent VPI, an asymmetric pharyngeal
form or movement of the velopharynx and the midline
defect of the velum might be a critical cause of VP closure
dysfunction.
The preoperative portion between the velar length and
pharyngeal depth bilaterally often differed, especially in
subjects with UCLP, whose major and minor segments
dislocated anteroposteriorly. During palatal repair, Z-
plasty was usually utilized for adjusting the velar length;
however, complete closure of the mucosal defect by large Z-
plasty sometimes moved the uvula forward remaining
asymmetry of the uvula position and pharyngeal arches.
The authors believe these asymmetries in the velopharyn-
geal form may disturb the symmetrical muscular approx-
imation and cause different sizes of the velopharyngeal
orifice, resulting in persistent VPI following palatal repair.
Therefore, it is thought to be useful to add a mucosal graft
on the nasal side to fill the mucosal defect and to avoid an
asymmetric VP form that may facilitate symmetrical velar
motion in the VP closure mechanism.
Furthermore, regarding the midline defect of the velum,
Kuehn and Perry (2009) also reported their experience of it
as a midline defect often observed endoscopically in
patients with cleft palate, and they suggested the presence
of a deficiency or lack of musculus uvulae tissue or
unsatisfactory surgical repair of this muscle. The anatomy
and functional significance of the musculus uvulae
(sometimes called the uvular muscle) for VP closure was
described by Kuehn et al. (1982). The musculus uvulae
courses posteriorly from its origin along the midline of the
velum near the nasal surface of the velum. It is in its most
cohesive form in the area overlying and cradled by the
levator sling. The musculus uvulae adds bulk to the dorsal
aspect of the velum, thereby helping to fill the area between
the velum and posterior pharyngeal wall. Without such
0
bulk, the dorsal region would be concave, rather than
convex, demonstrating a midline defect in the velum. In
these cases, complete VP closure would not be achieved
(Kuehn and Perry, 2009).
Considering the aforementioned, to ensure complete VP
closure on CP repair, it is important to construct a
,.01
.757 symmetrical and functional velopharynx. Therefore, the
.957 authors have established a surgical strategy for palatal
.026 repair focusing on sufficient lengthening of the nasal
mucosa, retropositioning the palatal muscles to produce a
.031 symmetrical levator sling, and using a two-layer suture to
.039
unionize the palatal muscles with a certain width in the
midline of the velum. This investigation was performed to
analyze the postoperative speech results and velar move-
ment following palatal repair based on our surgical strategy
and to elucidate if our CP repair restored the VP
mechanism to achieve a sufficient degree of VP closure
that would result in normal resonance.
This study had several limitations that should be taken
into consideration when interpreting our results. First, since
the patients in the MG and non-MG groups were separated
historically, surgeons and surgical closure in the anterior
palate with or without an incisal flap and the closure of the
nasal mucosa with or without a free mucosal graft were not
the same, although the basic principle for modified V-Y
palatoplasty, allowing conservation of the periosteum in
the anterior part of the maxilla, minimizing maxillary
growth disturbance, and retropositioning palatal muscles
to produce the levator sling were the same between the two
groups. Thus, it is more reasonable to think that the results
of this study were due to the differences in surgical
procedures rather than a specific surgeon’s skill. Second,
the ages at speech assessment of the MG and non-MG
groups were different because patients in the non-MG
group were recalled to the hospital to objectively assess
their postoperative VP closure using nasometry and
cephalometric examination. It is well recognized that VPI
may increase with the shrinkage of adenoids and changes in
the configuration of the pharynx in older patients
(Peterson-Falzone et al., 2010). However, Subtelny and
Koepp-Baker (1956) reported that the age at peak adenoid
size was as young as 9 to 10 years. VP closure is generally
maintained as the patient grows in childhood. When
considering that the mean ages of the MG and non-MG
groups were 5 and 8 years, respectively, the different
distribution of subjects’ ages might not have been as
favorable for the MG group.
Several conclusions can be made based on our data. A
major one is that modified V-Y palatoplasty with a large Z-
plasty and a mucosal graft for symmetrical muscular
reconstruction facilitates acceptable resonance outcomes in
patients with CP. The rate of achieving normal resonance
or slight/mild hypernasality, thought of as acceptable
resonance, was 96.3% (79/82) in the MG group. The rate
of achieving normal resonance by cleft type was 94.6% for
patients with UCLP, 83.3% for patients with BCLP, and
0 Cleft Palate–Craniofacial Journal, Month 0000, Vol. 00 No. 00
FIGURE 5 Representative cephalometric features of MG and non-MG groups in the resting position and on phonating /i:/. In the MG group, the
physiological and pliant movements of the soft palate ensured A: complete VP closure. In the non-MG group, the muscle bulkiness disturbed velar
movement, resulting in B: VPI.
88.9% for patients with CP, and acceptable resonance rates
were 97.2%, 94.4%, and 96.3%, respectively. Severe
hypernasality was recognized in only one subject with
BCLP. These results were much more favorable than those
for patients treated without mucosal grafts.
Additional evidence of the favorable speech outcome
achieved in our patient cohort is also shown through the
nasalance scores, which were similar to those for children
without CP. The mean nasalance scores for all speech
stimuli were around 20%, and they were similar to the
mean scores of the control group. Regarding the nasalance
scores in patients with CP, van Lierde et al. (2004) reported
long-term speech outcomes based on subjective and
objective assessments of Wardill-Kilner palatoplasty and
two-stage Furlow palatoplasty, and they found that
patients who underwent two-stage Furlow palatoplasty
showed significant hypernasality and higher nasalance
scores in comparison with those who underwent one-stage
Wardill-Kilner palatoplasty.
Previous reports demonstrated the usefulness of the
buccal flap for achieving good speech quality (Kaplan,
1975; Jackson et al., 2004). Jackson et al. (2004) divided the
nasal mucosa horizontally and utilized the buccal mucosal
flap to lengthen the soft palate on primary palatal repair in
156 nonsyndromic patients with CP. They reported that a
favorable speech quality was obtained in 89% and normal
articulation in 97.9% of subjects. In this series, VPI
occurred in 10/156 (8.8%) patients, and a higher rate of
VPI was observed in patients with BCLP (35.0%). They
concluded that palatal repair using a buccal mucosal flap
was effective and has the advantages of palatal closure
without tension, satisfactory muscular reconstruction,
lengthening of the nasal layer, and palatal closure with no
wound left uncovered by the soft tissue on the bone surface.
These results suggest that the recruitment of buccal mucosal
 Oyama et al., SPEECH RESULTS AFTER PALATOPLASTY WITH OR WITHOUT A MUCOSAL GRAFT
tissue with or without a pedicle in the nasal layer is useful to
lengthen the soft palate and provide symmetrical muscular
reconstruction, resulting in successful VP closure.
The next major finding was that the differences in the
speech outcome between MG and non-MG groups might
be related to the velopharyngeal morphology and velar
motion. Cephalometric analyses demonstrated a greater
velar length and length/depth ratio in the resting position as
well as smaller velar thickness and greater velar elevation
angle during phonation in the MG group compared with
the non-MG group.
Figure 5 shows representative cephalometric findings in
both the MG and non-MG groups. In the MG group, the
morphology of the soft palate was longer and thinner and
the one-third posterior portion of the soft palate was
flexibly elevated on phonation (Fig.5a). However, in the
non-MG group, the soft palate was bulkier, and its
bulkiness became more marked at the center of the soft
palate, hindering velar movement on phonation (Fig. 5b).
From these findings, we speculate that sufficient mucosal
extension by large Z-plasty and a free mucosal graft and the
successful recovery of symmetrical muscular approxima-
tion led to pliant and wider-ranging velar movement.
However, due to insufficient mucosal extension in the non-
MG group, palatal muscles may aggregate and lose their
anatomical arrangement in the narrow space of the soft
palate, resulting in the disturbance of velar movement.
It has been well recognized that the retropositioning of
palatal muscle, especially the levator veli palatini muscle, is
key for veloplasty on palatal repair (Kreins, 1970; Millard,
1980). Sommerlad (2003) introduced the concept of radical
levator retropositioning to achieve favorable VP closure
following palatal repair. When we consider the mechanism
of velar movement, as well as the retropositioning of the
levator veli palatini muscle, sufficient lengthening of the
nasal mucosa and symmetrical palatal muscle approxima-
tion while maintaining the anatomical muscle arrangement
in the soft palate are also important for primary CP repair.
Although CP repair with a mucosal graft led to favorable
resonance similar to that of control subjects without cleft,
normal articulation was observed in only 68.4% of the MG
group. Since VP closure was better in the MG group, the
rate of glottal stops was markedly less compared with that
in the non-MG group. However, lateral articulation and
palatal/velar backed articulation were still recognized in
around 10% of patients with CP, respectively. The causes
of articulation disorders might be related to the younger age
of the present subjects. Furthermore, several other factors
have been described as causes of lateralized distortion and
palatal/velar backed articulation, such as palatal fistula
(Hoch et al., 1986; Golding-Kushner, 1995), an abnormal
palatal morphology or dental arch (Laine, 1986; Okazaki et
al., 1991; Nishikubo et al., 2009), and velopharyngeal
insufficiency (VPI) (Peterson-Falzone, 1986). In the present
series, we could assess the position and incidence of the
residual palatal fistulae following the palatal repair in only
0
the MG group. The palatal fistulae was observed in the
anterior part of the hard palate, and the incidence of fistulae
in subjects with palatal/velar backed articulation (71.4%, 5/
7) was much higher than that in subjects with other
misarticulation or normal articulation (22.0%, 13/75),
suggesting the association of fistulae as a possible cause
of backed articulation.
Additionally, maxillary growth following modified V-Y
palatoplasty, which facilitated conservation of the perios-
teum in the anterior part of the maxilla, to minimize the
maxillary growth disturbance, has been investigated. Long-
term follow-up will be necessary to clarify the effects on
maxillary growth as well as changes in the long-term speech
outcome of patients in this series.
CONCLUSIONS
Modified V-Y palatoplasty combined with a mucosal
graft on the nasal side of the velum for symmetrical
muscular reconstruction facilitates better resonance out-
comes than a similar procedure without mucosal grafting.
Acknowledgments. We express our thanks to Dr. Tamotsu Mimura,
emeritus professor of Kagoshima University, and the staff of the Cleft Lip
and Palate Clinic at Kagoshima University Hospital for managing patients
with CP6CL. We also express our thanks to Ms. Yuko Ogata, a former
SLT, for speech assessment and data correction, and Drs. Narihiro
Hirahara and Akinori Gomi for their cooperation in the recall of patients
in this study.
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