clinical study dimensions of velopharyngeal space...

Clinical StudyDimensions of Velopharyngeal Space following MaxillaryAdvancement with Le Fort I Osteotomy Compared to ZisserSegmental Osteotomy A Cephalometric Study

Furkan Erol Karabekmez1 Johannes Kleinheinz2 and Susanne Jung2

1Department of Plastic Reconstructive and Aesthetic Surgery Faculty of Medicine Abant Izzet Baysal University Golkoy14280 Bolu Turkey2Oral and Maxillofacial Surgery Clinics Central Hospital University Hospital Munster Albert Schweitzer Campus 148149 Munster Germany

Correspondence should be addressed to Furkan Erol Karabekmez drfurkanerolyahoocom

Received 21 October 2014 Accepted 26 December 2014

Academic Editor Antonio Ysunza

Copyright copy 2015 Furkan Erol Karabekmez et al This is an open access article distributed under the Creative CommonsAttribution License which permits unrestricted use distribution and reproduction in any medium provided the original work isproperly cited

The objectives of this study are to assess the velopharyngeal dimensions using cephalometric variables of the nasopharynx andoropharynx as well as to compare the Le Fort I osteotomy technique to Zisserrsquos anterior maxillary osteotomy technique based onpatientsrsquo outcomes within early and late postoperative follow-ups 15 patients with severe maxillary deficiency treated with Le Fort Iosteotomy and maxillary segmental osteotomy were assessed Preoperative early postoperative and late postoperative follow-uplateral cephalograms patient histories and operative reports are reviewed with a focus on defined cephalometric landmarks forassessing velopharyngeal space dimension and maxillary movement (measured for three different tracing points) A significantchange was found between preoperative and postoperative lateral cephalometric measurements regarding the distance between theposterior nasal spine and the posterior pharyngeal wall in Le Fort I osteotomy cases However no significant difference was foundbetween preoperative and postoperative measurements in maxillary segmental osteotomy cases regarding the samemeasurementsThe velopharyngeal area calculated for the Le Fort I osteotomy group showed a significant difference between the preoperativeand postoperative measurements Le Fort I osteotomy for advancement of upper jaw increases velopharyngeal space On the otherhand Zisserrsquos anterior maxillary segmental osteotomy does not alter the dimension of the velopharyngeal space significantly

1 Introduction

Patients with cleft lip and palate have changes of the maxillaconcerning anatomical dimension position and functionwith diverse prevalence of these changes which are causedby genetic developmental and treatment-associated deter-minants [1 2] In planning secondary orthognathic surgerythe jaw and occlusal relations must be considered in additionto the functional aspects of the pathology [3 4]

(1) Velopharyngeal Function Length and position of thevelummay lead to speech impairment or borderline compen-sated speech [5]

(2) Reduced Maxillary Length (Shortened Maxilla) It lacksspace in the dentate area for prosthodontic treatment(bridges implants) [6]

(3) Maxillary Retrognathia It may lead to esthetical andfunctional complaints [7]

(4) Velopharyngeal Flap (Velopharyngoplasty) It completedat an early stage of growth may result in a reduced anteriorgrowth of the maxilla [8]

Frequency of maxillary osteotomy for advancement iscorrelated with the spectrum of severity of labiopalatalclefting [9] Advancement of the maxilla by a Le Fort I

Hindawi Publishing CorporationBioMed Research InternationalVolume 2015 Article ID 389605 9 pageshttpdxdoiorg1011552015389605

2 BioMed Research International

osteotomy carries the risk of increased velopharyngeal spaceand deterioration of speech function ending up in hyper-nasal resonance [10ndash12] advancement of a short maxillawithout gaining new space for prosthodontic treatment andprevention of sufficient anterior movement caused by thevelopharyngeal flap

Maxillary segmental osteotomy first described by Zisser(1969) [13 14] advances the anterior maxillary segmentwithout disturbing nasopharyngeal function Several mod-ifications of segmental osteotomy such as transpalatal orsegmental osteotomy have been described for the maxilla [1516] It seems that using a segmental osteotomy may preventforeseen problems of conventional maxillary osteotomy foradvancement such as disturbance of nasopharyngeal func-tion However it is important to define specific indicationsfor when each treatment should be utilized

In this study a cephalometric analysis was conducted toevaluate and compare the position of the maxilla the lengthof the maxilla and dimension of the velopharyngeal spaceafter Le Fort I and segmental osteotomy

2 Patients and Methods

After having an approval from local ethics committee in 2013patient charts were reviewed with the key words ldquomaxillaryosteotomyrdquo between 1997 and 2012 in the surgical records ofone surgeon in order to make comparison between differentsurgical procedures without any effect of surgeonrsquos personalpreferences After exclusion of syndromic cases patientswho had maxillary osteotomy previously and had additionalsystemic disorders 38 maxillary osteotomy patients wereidentified initially Subsequently 15 were excluded due tolack of records four patients were excluded due to a setbackprocedure and five patients were excluded due to less than4mmof advancement ormultiple pieces of osteotomyThere-fore seven patients who had the Zisser operation (namedthe Zisser group) and seven patients who underwent LeFort I osteotomy (named the Le Fort group) were includedin the study Patientrsquos characteristics and lateral cephalo-grams were recorded digitally and numbered by a differentauthor (Susanne Jung) to deidentify cephalograms and ensureblinded measurements by the observer (another authorFurkan Erol Karabekmez) Preoperative cephalograms takenat the closest date to the surgical procedure were usedfor preoperative evaluation and were grouped as T1 Earlypostoperative cephalograms taken at closest date to thesurgical procedure were named T2 The late postoperativecephalograms taken on the latest follow-up of the patientwere named T3 Complications and date of the removal ofelastics were also recorded

21 Cephalometric Evaluation The standard lateral cephalo-metric radiographs were transferred to digital images usinga digital camera (DSC-W90 Sony Corp Tokyo Japan) Thelandmarks on the lateral cephalometric radiographic imageswere traced using Image J software (National Institutes ofHealth httprsbwebnihgov USA) After calibration withthe scale the following were measured using the ldquomeasurerdquotools of the program posterior nasal spine (PNS) to posterior

pharyngeal wall (PPW) distance parallel to the palatal plane(PP) PNS to PPW distance perpendicular to the PPW tipof the uvula (U) to PPW distance parallel to the PP U toPPWdistance perpendicular to the PPW anterior nasal spine(ANS) to PNS distance (for the maxillary dental arch length)PNS to U distance sella-nasion plane (SN) PP angle (SN-PP) ANS to SN distance and PNS to SN The area locatedsuperior to the U-PPW line parallel to the PP was calculatedPoints distances and areas used in the study are showed inFigure 1 Eachmeasurement was calculated for T1 T2 and T3time points by the same blinded observer Different authorperformed the cephalometric tracings and the surgery

22 Surgery For Le Fort I surgery patients are induced withnasotracheal hypotensive general anaesthesia and preparedfor a standard intraoral Le Fort I procedure Rigid skeletalfixation using a couple of 20mm miniplates and screws toboth sides was performed in all patients

For surgery with the Zisser technique presurgicalorthodontic treatment includes the preparation of space forvertical interdental osteotomies between the secondpremolarand first molar on the upper jaw (between 15-16 and 25-26 according to the Palmer Notation Method) Surgery wasperformed following the standard procedure

In the case of the distractor application after the Le Fort Ior segmental osteotomy fixation was performed by usinga bone born distractor (Medartis Modus MDO 20 BaselSwitzerland) (Figure 2) The maxilla was advanced at a rateof 05mm twice a day after a five-day latency period Thevector of the distractor was planned according to the verticaldeficiency if it existed The amount of distraction was alsodetermined according to the need of each patient

23 Statistical Analysis The angular linear and area mea-surements were compared using a Wilcoxon signed rankstest to assess the changes between T1 and T2 (as the surgicalchange) T2 and T3 (as the postsurgical change) and T1and T3 in both Le Fort I and Zisser groups Differencesbetween surgical and postsurgical movements of the Le Fort Iand Zisser groupsrsquo measurements were also compared withMann-Whitney tests Distractions versus nondistraction andcleft versus noncleft comparisons were also completed withMann-Whitney tests

Correlations between cleft palate history distractionand the measured parameters were investigated with theSpearman correlation coefficient test

The intraobserver reliability was tested with the intraclasscorrelation coefficient test Measurements were repeated 1month later by the same observer Statistical analyses wereperformed with PASW (version 18) software (SPSS IncChicago IL) The results are shown as the mean and thestandard deviation 119875 lt 005 was considered as significant

3 Results

Mean follow-up time for the late postoperative lateral ceph-alogram (T3) was 205 months T1 cephalograms wereobtained mean 283 days preoperatively T2 cephalogramswere obtained mean 195 days postoperatively Of the

BioMed Research International 3

N

U

S

ANSPNSPPWPPW90

Area of the velopharyngeal space

PPW90998400

PPW998400

Figure 1 Variables used for cephalometric evaluations points ANS most anterior point of anterior nasal spine PNS posterior nasal spinePPW posterior pharyngeal wall U tip of the uvula S midpoint of hypophyseal fossa N most anterior point of frontonasal suture PlanesSN sella-nasion plane PP palatal planeDistances PNS-PPW distance measured parallel to the PP from PNS to PPW PNS-PPW90 distancemeasured with line drawn perpendicular from PNS to PPW90 U-PPW1015840 distance measured parallel to the PP from U to PPW1015840 U-PPW901015840distance measured with line drawn perpendicular from U to PPW901015840 ANS-PNS distance measured ANS to PNS (for the maxillary dentalarch length) PNS-U distance measured from PNS to U ANS-SN distance measured with line drawn perpendicular from ANS to SN PNS-SN distance measured with line drawn perpendicular from PNS to SN Angle SN-PP angle between SN and PP Area area of the airwaylocated above the line drawn parallel to the PP and passing through U point

Figure 2 Vertical interdental osteotomies between second premolar and first molar on upper jaw according to Zisser technique followed bydistractor application and activation

14 patients 8 were females and 6 were males The age at thetime of surgery was 15ndash36 years (mean 21 years) Six of theseven patients in the Zisser group and three of the sevenpatients in the Le Fort group have cleft lip palate Four of theseven patients in the Le Fort group and three of the sevenin the Zisser group had distraction osteogenesis Patientsrsquocharacteristics were summarized in Table 1 Variables used

for cephalometric evaluations including velopharyngeal softtissue points are shown in Figure 1

Comparisons between T1 and T2 within the Zissergroup for all measurements with Wilcoxon signed ranks testrevealed no significant difference except PNS-ANS distance(119875 = 002) (Table 2 Figure 3) Comparisons between T1 andT2 within the Le Fort I group for all measurements with


Table 1 Patient characteristics

Group Age Advancement (leftright) Distraction Cleft Follow-up (month) Mandibular setbackLe Fort 16 11mm + + 21 minus

Le Fort 23 5mm minus minus 1 minus

Le Fort 36 75mm95mm minus minus 11 +Le Fort 20 95mm + minus 13 minus

Le Fort 15 10mm + + 24 minus


Le Fort 32 4mm minus minus +Zisser 16 55mm + minus 1 minus

Zisser 21 4mm minus + 1 minus

Zisser 19 9mm7mm + + 62 minus




Zisser 16 95mm105mm + + 28 +

lowast

lowast

lowast

SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

T3T2T1

Time pointsZisser cases (n = 7)

Figure 3 A statistically significant difference found between pre-operative (T1) and postoperative (T2) ANS-PNS distances andpostoperative (T2) and late postoperative (T3) PNS-U distancesin the Zisser group (Box plots show the median interquartilerange 95 percentile and outliers as circles lowast indicates significantdifference)

the Wilcoxon signed ranks test revealed significant differ-ences concerning PNS-PPW distance PNS-PPW90 distanceand velopharyngeal area (119875 = 003 003 and 003 resp)(Table 2 Figure 4)

Comparisons between T2 and T3 within the Zisser groupfor all measurements with the Wilcoxon signed ranks test

SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

321

Time points

minus10

lowastlowast

Le Fort cases (n = 7)

Figure 4 A statistically significant difference was found betweenT1 and T2 measurements for PNS-PPW and PNS-PPW90 in the LeFort group (Box plots show the median interquartile range 95percentile and outliers as circles lowast indicates significant difference)

revealed no significant difference except PNS-U distance(119875 = 003) (Table 3 Figure 3) The comparison betweenT2 and T3 within the Le Fort group for all measurementswith the Wilcoxon signed ranks test revealed no significantdifferences (Table 3 Figure 4)

Le Fort I grouprsquos patientsrsquo velopharyngeal area measure-ments however showed a significant change between T1 andT2 but not between T2 and T3 (119875 = 003 and 10 resp)


Table 2 Surgical movements of all points and area for the Zisserand the Le Fort groups Wilcoxon signed ranks test was used for thecomparison

Surgical movements (T2-T1) Mean SD 119875

PNS-PPWZisser (119873 = 7) minus02 07 045Le Fort (119873 = 7) 65 36 003lowast

PNS-PPW90Zisser (119873 = 7) minus01 09 052Le Fort (119873 = 7) 61 27 003lowast

U-PPWZisser (119873 = 7) 06 15 027Le Fort (119873 = 7) 19 24 014

U-PPW90Zisser (119873 = 7) 10 12 008Le Fort (119873 = 7) 12 17 014

PNS-ANSZisser (119873 = 7) 58 29 002lowast

Le Fort (119873 = 7) 15 20 007PNS-U

Zisser (119873 = 7) 10 16 014Le Fort (119873 = 7) 21 30 012

SN-ANS90Zisser (119873 = 7) 23 59 035Le Fort (119873 = 7) 19 23 012

SN-PNS90Zisser (119873 = 7) 05 27 050Le Fort (119873 = 7) 30 48 012

SN-PP angleZisser (119873 = 7) minus09 41 072Le Fort (119873 = 7) 10 22 029

AreaZisser (119873 = 7) 104 219 018Le Fort (119873 = 7) 664 622 003lowast

lowastSignificant difference

(Figure 5) On the other hand Zisser grouprsquos measurementsshowed no significant change This supports that conven-tional Le Fort I osteotomy increases velopharyngeal spaceand may cause velopharyngeal insufficiency but Zisserrsquososteotomy does not

The Le Fort I group versus Zisser group relationshipregarding the T2-T1 (surgical changes) values with theMann-Whitney tests revealed no significant differences between thedifferences at all time points except PNS-PPW PNS-PPW90and PNS-ANS distances and the measured area (119875 = 0003119875 = 0003 119875 = 002 and 119875 = 002 resp) (Figure 6) Thisalso supports that there is a significant difference betweenLe Fort osteotomy and Zisser osteotomyrsquos sagittal pharyngealtracings

The comparison of all measured parameters on T1 timepoints between the Zisser and Le Fort groups showed

Table 3 Postsurgicalmovements of all points and area for the Zisserand the Le Fort groups Wilcoxon signed ranks test was used for thecomparison

Postsurgical movements (T3-T2) Mean SD 119875

PNS-PPWZisser (119873 = 7) 20 54 10Le Fort (119873 = 7) minus16 39 059

PNS-PPW90Zisser (119873 = 7) 27 37 069Le Fort (119873 = 7) minus17 30 029

U-PPWZisser (119873 = 7) minus10 21 030Le Fort (119873 = 7) minus03 21 059

U-PPW90Zisser (119873 = 7) minus09 22 060Le Fort (119873 = 7) 03 15 10

PNS-ANSZisser (119873 = 7) minus02 08 041Le Fort (119873 = 7) minus03 75 066

PNS-UZisser (119873 = 7) minus27 18 003lowast

Le Fort (119873 = 7) minus16 21 029SN-ANS90Zisser (119873 = 7) 03 31 089Le Fort (119873 = 7) 28 14 011


SN-PP angleZisser (119873 = 7) minus03 14 058Le Fort (119873 = 7) minus30 36 018

T3areaZisser (119873 = 7) 30 327 092Le Fort (119873 = 7) 10 524 10


a significant difference in the evaluation of the U-PPWdistance (119875 = 003) (Figure 7) Additionally the resultsof the PNS-PPW PNS-PPW90 and PNS-U distances onthe T2 time points between the Zisser and Le Fort groupswere significantly different (119875 = 002 004 and 004 resp)(Figure 8)

Distraction versus nondistraction comparison withMann-Whitney tests at the T1 time point revealed no signi-ficant difference for all parameters measured at the threetime points

Cleft versus noncleft comparison with Mann-Whitneytests at the T1 time point revealed no significant differenceexcept the velopharyngeal area of T1 (119875 = 004)

There is a negative correlation between the amount ofmaxillary advancement and area of velopharyngeal spacemeasured at T1 (119875 = 0004) and cleft palate and area ofthe velopharyngeal space measured at T1 (119875 = 003) for allpatients A positive correlation was found between maxillary


lowast

+ +

+

Groups

700

600

500

400

300

200

100

0Zisser (n = 7)

Time points

T3T2T1

Are

a (m

m2)

Le Fort (n = 7)

Figure 5 A statistically significant difference was found between T1and T2 measurements for the area of velopharyngeal space in theLe Fort group (Box plots show the median interquartile range 95percentile and outliers as circles and extreme values as plus signslowast indicates significant difference)

advancement and SN-PP angle measured on T2 (119875 = 0049)Other correlations revealed no significant relationship

Intraobserver reliability was ge095 for all representativemeasurements

4 Discussion

Velopharyngeal insufficiency and hypernasality are seriousproblems commonly observed in cleft lip palate patientsThese patients have increased risk of speech deteriorationespecially after maxillary advancement procedures [17ndash19]Velopharyngeal closure is a complex mechanism affected bymultiple factors such as the soft palatersquos length function andposture the dimensions of the nasopharynx and the activityof the posterior and lateral pharyngeal walls according toMazaheri et al [20] There is no single method to assess all ofthese factors affecting velopharyngeal function Static mea-surement on lateral cephalograms gives information for themorphological changes in the velopharyngeal anatomy [21]Based on the previous literature related to velopharyngealevaluation the cephalometric landmarks used in this studywere chosen [21 22]

Different authors provided clear evidence showing thedeleterious effect of maxillary advancement and clearly doc-umented that the forward shift of the maxilla producedvelopharyngeal inadequacy and hypernasal resonance [10ndash12 23] There was a significant increase in the measurements

lowastlowastlowast

+

+

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

15

10

5

0

Le FortZisser

Groups

SN-P

P∘

minus10

minus5

(mm

)Surgical movements (T2-T1) in all measurements

Figure 6 Statistically significant differences were found betweenZisser and Le Fort groupsrsquo surgical changes (T2-T1) regarding thePNS-PPW PNS-PPW90 and ANS-PNS distances (Box plots showthe median interquartile range 95 percentile and outliers ascircles and extreme values as plus signs lowast indicates significantdifference)

of PNS-PPW U-PPW and the area of the velopharyngealspace which may have a potential role in velopharyngealinsufficiency with one-segment maxillary advancement inthe current study as well

Zisserrsquos approach was described especially for retrusivehypoplastic maxilla cases such as patients with cleft lip palate[14] Osteotomy between the second premolar and firstmolaras well as advancement of the anterior segment providesmaxillary advancement without a deleterious effect on thevelopharyngeal space in theory The main advantage of thetechnique is that the position of the soft palate is not changedsubstantially and it is expected that speech impediments suchas those possibly arising following Le Fort I osteotomy arepossibly obviated Another positive effect of Zisser maxillaryadvancement is the effective closure of the anterior openbite However no study in the current literature revealed anyquantitative measurement for the evaluation of Zisser maxil-lary advancement regarding the velopharyngeal structure andfunctionality It is shown that Le Fort group patients showsignificant increase regarding PNS-PPW and velopharyngealarea on the lateral cephalogram (Table 2 Figure 6) On theother hand the Zisser group showed no significant changein the mentioned measurements Therefore we suggest that


lowast lowast

lowast

SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

Groups

Le FortZisser

Comparison of postoperative (T2) measurements

Figure 7 A statistically significant difference was found betweenthe Zisser and Le Fort groupsrsquo measurements of T1 regarding the U-PPWdistance (Box plots show themedian interquartile range 95percentile and outliers as circles and extreme values as plus signslowast indicates significant difference)

maxillary segmental advancement with Zisser osteotomywillnot compromise velopharyngeal function

Some authors claimed that maxillary advancement mightimprove or worsen certain aspects of speech in patients [1824] Different authors suggest that maxillary advancementmay improve articulation due to correction of the occlusionbut cause hypernasal speech It is shown that assessment ofpalatal length and pharyngeal depth on cephalometric radio-graphs is helpful in predicting postoperative velopharyn-geal insufficiency development [19 25] Therefore we usedcephalometric parameters showing pharyngeal depth as apredictor of velopharyngeal insufficiency and compared twomaxillary advancement techniques with these parameters

Zisser osteotomynot only has the advantage of preventingrisk of increased velopharyngeal space but also helps toincrease the sagittal length of the maxilla which is impor-tant for gaining extra space for prosthodontical treatmentin patients with short maxilla Significant increase in thedistance of ANS-PNS with Zisser osteotomy in the currentstudy also showed Zisser osteotomyrsquos effect on maxillarylengthening (Table 2 Figure 6)

One limitation of the present study is the small samplesize Since the indication for Zisser osteotomy is rare setbackand three-piece osteotomies are excluded and only patientswith advancement of more than 4mm were included in

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

(mm

)

50

40

30

20

10

0

Groups

Le FortZisser

minus10

Comparison of preoperative (T1) measurements

SN-P

P∘

lowast

Figure 8 Statistically significant differences were found betweenthe Zisser and Le Fort groupsrsquo measurements of T2 regarding thePNS-PPW PNS-PPW90 and PNS-U distances (Box plots show themedian interquartile range 95 percentile and outliers as circlesand extreme values as plus signs lowast indicates significant difference)

the study Thus we had relatively few cases Another limi-tation of the study is the lack of functional evaluation suchas video fluoroscopy However the main aim of our studywas to file the changes of the static cephalometric parametersregarding the morphology of the velopharyngeal structuresIt is already shown in the literature that increased velopharyn-geal space is associated with increased risk of velopharyngealinsufficiency after the maxillary advancement procedures[12 19 23 26 27] The Zisser osteotomy group revealedno significant changes in PNS-PPW and U-PPW distanceswhereas the Le Fort I osteotomy group evidenced significantchanges in the same distances including an extension of theupper airways and an increase in the velopharyngeal space

5 Conclusion

Zisserrsquos anterior segmental osteotomy is a reliable procedurefor advancement of maxilla with respect to morphologicalchanges in the velopharyngeal structures especially sagittalmeasurements and measurements of area of velopharyn-geal space on lateral cephalograms Zisserrsquos osteotomy maybecome the best solution in selected cases such as cleftpatients who have anterior open bites and increased risk ofpostoperative velopharyngeal insufficiency


Ethical Approval

This study was approved (accepted as exempt) by local ethicscommittee (Ethics Committee of the Medical Association ofWest Falen-Lippe and Medical Faculty of the University ofMunster)

Disclosure

Names of the authors in the front matter are orderedaccording to the order of the authorship The study wasaccomplished in the University Hospital Munster Oral andMaxillofacial Surgery Clinics

Conflict of Interests

The authors declare that they have no competing interests

Authorsrsquo Contribution

Furkan Erol Karabekmez Johannes Kleinheinz and SusanneJung have made substantial contributions to conception anddesign of the study Furkan Erol Karabekmez JohannesKleinheinz and Susanne Jung have been involved in draftingthe paper All authors have given final approval of the lastversion

References

[1] Y Li B Shi Q-G Song H Zuo and Q Zheng ldquoEffects of liprepair on maxillary growth and facial soft tissue developmentin patients with a complete unilateral cleft of lip alveolus andpalaterdquo Journal of Cranio-Maxillofacial Surgery vol 34 no 6pp 355ndash361 2006

[2] R B Ross ldquoTreatment variables affecting facial growth incomplete unilateral cleft lip and palaterdquoCleft Palate Journal vol24 no 1 pp 5ndash77 1987

[3] Y Lu B Shi Q Zheng W Xiao and S Li ldquoAnalysis ofvelopharyngeal morphology in adults with velopharyngealincompetence after surgery of a cleft palaterdquo Annals of PlasticSurgery vol 57 no 1 pp 50ndash54 2006

[4] J P Reyneke ldquoPrinciples of orthognathic surgeryrdquo in Essentialsof Orhognathic Surgery J P Reyneke Ed Quintessence Pub-lishing Carol Stream Ill USA 2003

[5] M-L Haapanen M Kalland A Heliovaara J Hukki and RRanta ldquoVelopharyngeal function in cleft patients undergoingmaxillary advancementrdquo Folia Phoniatrica et Logopaedica vol49 no 1 pp 42ndash47 1997

[6] B Johanson A Ohlsson H Friede and J Ahlgren ldquoA follow upstudy of cleft lip and palate patients treated with orthodonticssecondary bone grafting and prosthetic rehabilitationrdquo Scandi-navian Journal of Plastic and Reconstructive Surgery vol 8 no1-2 pp 121ndash135 1974

[7] A Gaggl G Schultes andH Karcher ldquoAesthetic and functionaloutcome of surgical and orthodontic correction of bilateralclefts of lip palate and alveolusrdquo The Cleft Palate-CraniofacialJournal vol 36 no 5 pp 407ndash412 1999

[8] B G Keller R E Long Jr E D Gold and M D RothldquoMaxillary dental arch dimensions following pharyngeal-flapsurgeryrdquo Cleft Palate Journal vol 25 no 3 pp 248ndash257 1988

[9] P M Good J B Mulliken and B L Padwa ldquoFrequency of LeFort I osteotomy after repaired cleft lip andpalate or cleft palaterdquoCleft Palate-Craniofacial Journal vol 44 no 4 pp 396ndash4012007

[10] J Scheuerle ldquoCommentary on velopharyngeal changes aftermaxillary advancement in cleft patients with distraction osteo-genesis using a rigid external distraction device a 1-yearcephalometric follow-uprdquo Journal of Craniofacial Surgery vol10 no 4 pp 321ndash322 1999

[11] K Okazaki K Satoh M Kato M Iwanami F Ohokubo andK Kobayashi ldquoSpeech and velopharyngeal function followingmaxillary advancement in patients with cleft lip and palaterdquoAnnals of Plastic Surgery vol 30 no 4 pp 304ndash311 1993

[12] I Watzke T A Turvey D W Warren and R Dalston ldquoAlter-ations in velopharyngeal function after maxillary advancementin cleft palate patientsrdquo Journal of Oral and MaxillofacialSurgery vol 48 no 7 pp 685ndash689 1990

[13] G Zisser ldquoSurgical correction of alveolar malpositionrdquoDeutsche Zahn- Mund- und Kieferheilkunde mit Zentralblattfur die Gesamte vol 59 no 3 pp 68ndash83 1972

[14] G Zisser ldquoSurgical treatment of maxillary retrusionrdquo Zah-narztliche Praxis vol 20 no 18 pp 205ndash206 1969

[15] D R James and K Brook ldquoMaxillary hypoplasia in patientswith cleft lip and palate deformitymdashthe alternative surgicalapproachrdquo The European Journal of Orthodontics vol 7 no 4pp 231ndash247 1985

[16] D Sell L Ma D James M Mars and M Sheriff ldquoA pilotstudy of the effects of transpalatal maxillary advancementon velopharyngeal closure in cleft palate patientsrdquo Journal ofCranio-Maxillofacial Surgery vol 30 no 6 pp 349ndash354 2002

[17] L K Cheung H D P Chua and M B Hagg ldquoCleft maxillarydistraction versus orthognathic surgery clinical morbiditiesand surgical relapserdquo Plastic and Reconstructive Surgery vol 118no 4 pp 996ndash1009 2006

[18] J Janulewicz B J Costello M J Buckley M D Ford JClose and R Gassner ldquoThe effects of Le Fort I osteotomies onvelopharyngeal and speech functions in cleft patientsrdquo Journalof Oral and Maxillofacial Surgery vol 62 no 3 pp 308ndash3142004

[19] R W McComb E M Marrinan R C Nuss R A Labrie JB Mulliken and B L Padwa ldquoPredictors of velopharyngealinsufficiency after le Fort I maxillary advancement in patientswith cleft palaterdquo Journal of Oral and Maxillofacial Surgery vol69 no 8 pp 2226ndash2232 2011

[20] MMazaheri A E Athanasiou and R E Long Jr ldquoComparisonof velopharyngeal growth patterns between cleft lip andorpalate patients requiring or not requiring pharyngeal flapsurgeryrdquoThe Cleft Palate-Craniofacial Journal vol 31 no 6 pp452ndash460 1994

[21] K Satoh T Wada T Tachimura and R Shiba ldquoThe effect ofgrowth of nasopharyngeal structures in velopharyngeal closurein patients with repaired cleft palate and controls without cleftsa cephalometric studyrdquo British Journal of Oral andMaxillofacialSurgery vol 40 no 2 pp 105ndash109 2002

[22] H Yu X Wang B Fang and S G Shen ldquoComparativestudy of different osteotomymodalities in maxillary distractionosteogenesis for cleft lip and palaterdquo Journal of Oral andMaxillofacial Surgery vol 70 no 11 pp 2641ndash2647 2012

[23] M A Witzel and I R Munro ldquoVelopharyngeal insufficiencyafter maxillary advancementrdquo Cleft Palate Journal vol 14 no2 pp 176ndash180 1977


[24] I E Voshol K G H Van Der Wal L N A Van Adrichem EMOngkosuwito andM J Koudstaal ldquoThe frequency of Le FortI osteotomy in cleft patientsrdquo Cleft Palate-Craniofacial Journalvol 49 no 2 pp 160ndash166 2012

[25] L L DrsquoAntonio B J Eichenberg G J Zimmerman et alldquoRadiographic and aerodynamic measures of velopharyngealanatomy and function following Furlow Z-plastyrdquo Plastic andReconstructive Surgery vol 106 no 3 pp 539ndash549 2000

[26] A W Kummer J L Strife W H Grau N A Creaghead and LLee ldquoThe effects of Le Fort I osteotomy with maxillary move-ment on articulation resonance and velopharyngeal functionrdquoCleft Palate Journal vol 26 no 3 pp 193ndash199 1989

[27] S A Schendel M Oeschlaeger L MWolford and B N EpkerldquoVelopharyngeal anatomy andmaxillary advancementrdquo Journalof Maxillofacial Surgery vol 7 no 2 pp 116ndash124 1979

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Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


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EndocrinologyInternational Journal of



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Immunology ResearchHindawi Publishing Corporationhttpwwwhindawicom Volume 2014

Journal of

ObesityJournal of



Computational and Mathematical Methods in Medicine

OphthalmologyJournal of


Diabetes ResearchJournal of



Research and TreatmentAIDS


Gastroenterology Research and Practice


Parkinsonrsquos Disease

Evidence-Based Complementary and Alternative Medicine

Volume 2014Hindawi Publishing Corporationhttpwwwhindawicom


osteotomy carries the risk of increased velopharyngeal spaceand deterioration of speech function ending up in hyper-nasal resonance [10ndash12] advancement of a short maxillawithout gaining new space for prosthodontic treatment andprevention of sufficient anterior movement caused by thevelopharyngeal flap

Maxillary segmental osteotomy first described by Zisser(1969) [13 14] advances the anterior maxillary segmentwithout disturbing nasopharyngeal function Several mod-ifications of segmental osteotomy such as transpalatal orsegmental osteotomy have been described for the maxilla [1516] It seems that using a segmental osteotomy may preventforeseen problems of conventional maxillary osteotomy foradvancement such as disturbance of nasopharyngeal func-tion However it is important to define specific indicationsfor when each treatment should be utilized

In this study a cephalometric analysis was conducted toevaluate and compare the position of the maxilla the lengthof the maxilla and dimension of the velopharyngeal spaceafter Le Fort I and segmental osteotomy

2 Patients and Methods

After having an approval from local ethics committee in 2013patient charts were reviewed with the key words ldquomaxillaryosteotomyrdquo between 1997 and 2012 in the surgical records ofone surgeon in order to make comparison between differentsurgical procedures without any effect of surgeonrsquos personalpreferences After exclusion of syndromic cases patientswho had maxillary osteotomy previously and had additionalsystemic disorders 38 maxillary osteotomy patients wereidentified initially Subsequently 15 were excluded due tolack of records four patients were excluded due to a setbackprocedure and five patients were excluded due to less than4mmof advancement ormultiple pieces of osteotomyThere-fore seven patients who had the Zisser operation (namedthe Zisser group) and seven patients who underwent LeFort I osteotomy (named the Le Fort group) were includedin the study Patientrsquos characteristics and lateral cephalo-grams were recorded digitally and numbered by a differentauthor (Susanne Jung) to deidentify cephalograms and ensureblinded measurements by the observer (another authorFurkan Erol Karabekmez) Preoperative cephalograms takenat the closest date to the surgical procedure were usedfor preoperative evaluation and were grouped as T1 Earlypostoperative cephalograms taken at closest date to thesurgical procedure were named T2 The late postoperativecephalograms taken on the latest follow-up of the patientwere named T3 Complications and date of the removal ofelastics were also recorded

21 Cephalometric Evaluation The standard lateral cephalo-metric radiographs were transferred to digital images usinga digital camera (DSC-W90 Sony Corp Tokyo Japan) Thelandmarks on the lateral cephalometric radiographic imageswere traced using Image J software (National Institutes ofHealth httprsbwebnihgov USA) After calibration withthe scale the following were measured using the ldquomeasurerdquotools of the program posterior nasal spine (PNS) to posterior

pharyngeal wall (PPW) distance parallel to the palatal plane(PP) PNS to PPW distance perpendicular to the PPW tipof the uvula (U) to PPW distance parallel to the PP U toPPWdistance perpendicular to the PPW anterior nasal spine(ANS) to PNS distance (for the maxillary dental arch length)PNS to U distance sella-nasion plane (SN) PP angle (SN-PP) ANS to SN distance and PNS to SN The area locatedsuperior to the U-PPW line parallel to the PP was calculatedPoints distances and areas used in the study are showed inFigure 1 Eachmeasurement was calculated for T1 T2 and T3time points by the same blinded observer Different authorperformed the cephalometric tracings and the surgery

22 Surgery For Le Fort I surgery patients are induced withnasotracheal hypotensive general anaesthesia and preparedfor a standard intraoral Le Fort I procedure Rigid skeletalfixation using a couple of 20mm miniplates and screws toboth sides was performed in all patients

For surgery with the Zisser technique presurgicalorthodontic treatment includes the preparation of space forvertical interdental osteotomies between the secondpremolarand first molar on the upper jaw (between 15-16 and 25-26 according to the Palmer Notation Method) Surgery wasperformed following the standard procedure

In the case of the distractor application after the Le Fort Ior segmental osteotomy fixation was performed by usinga bone born distractor (Medartis Modus MDO 20 BaselSwitzerland) (Figure 2) The maxilla was advanced at a rateof 05mm twice a day after a five-day latency period Thevector of the distractor was planned according to the verticaldeficiency if it existed The amount of distraction was alsodetermined according to the need of each patient

23 Statistical Analysis The angular linear and area mea-surements were compared using a Wilcoxon signed rankstest to assess the changes between T1 and T2 (as the surgicalchange) T2 and T3 (as the postsurgical change) and T1and T3 in both Le Fort I and Zisser groups Differencesbetween surgical and postsurgical movements of the Le Fort Iand Zisser groupsrsquo measurements were also compared withMann-Whitney tests Distractions versus nondistraction andcleft versus noncleft comparisons were also completed withMann-Whitney tests

Correlations between cleft palate history distractionand the measured parameters were investigated with theSpearman correlation coefficient test

The intraobserver reliability was tested with the intraclasscorrelation coefficient test Measurements were repeated 1month later by the same observer Statistical analyses wereperformed with PASW (version 18) software (SPSS IncChicago IL) The results are shown as the mean and thestandard deviation 119875 lt 005 was considered as significant

3 Results

Mean follow-up time for the late postoperative lateral ceph-alogram (T3) was 205 months T1 cephalograms wereobtained mean 283 days preoperatively T2 cephalogramswere obtained mean 195 days postoperatively Of the


N

U

S

ANSPNSPPWPPW90


PPW90998400

PPW998400



















Zisser 16 95mm105mm + + 28 +

lowast

lowast

lowast

SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

T3T2T1





SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

321

Time points

minus10

lowastlowast













Le Fort (119873 = 7) 15 20 007PNS-U

Zisser (119873 = 7) 10 16 014Le Fort (119873 = 7) 21 30 012



























lowast

+ +

+

Groups

700

600

500

400

300

200

100

0Zisser (n = 7)

Time points

T3T2T1

Are

a (m

m2)

Le Fort (n = 7)




4 Discussion



lowastlowastlowast

+

+

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

15

10

5

0

Le FortZisser

Groups

SN-P

P∘

minus10

minus5

(mm






lowast lowast

lowast

SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

Groups

Le FortZisser







PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

(mm

)

50

40

30

20

10

0

Groups

Le FortZisser

minus10


SN-P

P∘

lowast



5 Conclusion



Ethical Approval


Disclosure






References


































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















N

U

S

ANSPNSPPWPPW90


PPW90998400

PPW998400



















Zisser 16 95mm105mm + + 28 +

lowast

lowast

lowast

SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

T3T2T1





SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

321

Time points

minus10

lowastlowast













Le Fort (119873 = 7) 15 20 007PNS-U

Zisser (119873 = 7) 10 16 014Le Fort (119873 = 7) 21 30 012



























lowast

+ +

+

Groups

700

600

500

400

300

200

100

0Zisser (n = 7)

Time points

T3T2T1

Are

a (m

m2)

Le Fort (n = 7)




4 Discussion



lowastlowastlowast

+

+

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

15

10

5

0

Le FortZisser

Groups

SN-P

P∘

minus10

minus5

(mm






lowast lowast

lowast

SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

Groups

Le FortZisser







PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

(mm

)

50

40

30

20

10

0

Groups

Le FortZisser

minus10


SN-P

P∘

lowast



5 Conclusion



Ethical Approval


Disclosure






References


































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





























Zisser 16 95mm105mm + + 28 +

lowast

lowast

lowast

SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

T3T2T1





SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

321

Time points

minus10

lowastlowast













Le Fort (119873 = 7) 15 20 007PNS-U

Zisser (119873 = 7) 10 16 014Le Fort (119873 = 7) 21 30 012



























lowast

+ +

+

Groups

700

600

500

400

300

200

100

0Zisser (n = 7)

Time points

T3T2T1

Are

a (m

m2)

Le Fort (n = 7)




4 Discussion



lowastlowastlowast

+

+

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

15

10

5

0

Le FortZisser

Groups

SN-P

P∘

minus10

minus5

(mm






lowast lowast

lowast

SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

Groups

Le FortZisser







PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

(mm

)

50

40

30

20

10

0

Groups

Le FortZisser

minus10


SN-P

P∘

lowast



5 Conclusion



Ethical Approval


Disclosure






References


































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
























Le Fort (119873 = 7) 15 20 007PNS-U

Zisser (119873 = 7) 10 16 014Le Fort (119873 = 7) 21 30 012



























lowast

+ +

+

Groups

700

600

500

400

300

200

100

0Zisser (n = 7)

Time points

T3T2T1

Are

a (m

m2)

Le Fort (n = 7)




4 Discussion



lowastlowastlowast

+

+

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

15

10

5

0

Le FortZisser

Groups

SN-P

P∘

minus10

minus5

(mm






lowast lowast

lowast

SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

Groups

Le FortZisser







PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

(mm

)

50

40

30

20

10

0

Groups

Le FortZisser

minus10


SN-P

P∘

lowast



5 Conclusion



Ethical Approval


Disclosure






References


































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















lowast

+ +

+

Groups

700

600

500

400

300

200

100

0Zisser (n = 7)

Time points

T3T2T1

Are

a (m

m2)

Le Fort (n = 7)




4 Discussion



lowastlowastlowast

+

+

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

15

10

5

0

Le FortZisser

Groups

SN-P

P∘

minus10

minus5

(mm






lowast lowast

lowast

SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

Groups

Le FortZisser







PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

(mm

)

50

40

30

20

10

0

Groups

Le FortZisser

minus10


SN-P

P∘

lowast



5 Conclusion



Ethical Approval


Disclosure






References


































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















lowast lowast

lowast

SN-P

P

PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

60

50

40

30

20

10

0

Groups

Le FortZisser







PNS-

SN

AN

S-SN

PNS-

U

AN

S-PN

S

U-P

PW90

U-P

PW

PNS-

PPW

90

PNS-

PPW

(mm

)

50

40

30

20

10

0

Groups

Le FortZisser

minus10


SN-P

P∘

lowast



5 Conclusion



Ethical Approval


Disclosure






References


































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















Ethical Approval


Disclosure






References


































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of


























of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















clinical study dimensions of velopharyngeal space...

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