Speech Outcome Evaluation After Two-Flap Palatoplasty In Plastic Surgery Division Cipto Mangunkusumo Hospital: A Retrospective study

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Latar Belakang: Salah satu tujuan utama operasi sumbing palatum adalah untuk memperbaiki mekanis-
me artikulasi agar proses pembentukan suara dapat berjalan normal. Studi ini bertujuan mengevaluasi ha-
sil kemampuan bicara pada pasien dengan sumbing palatum yang menjalani operasi two-ap palatoplasti
sebelum usia 2 tahun.
Metode: Studi restrospektif dilakukan terhadap 22 anak dengan sumbing palatum unilateral komplit (de-
ngan atau tanpa sumbing bibir) yang menjalani two-ap palatoplasti antara tahun 2002 hingga 2006 di Ru-
mah Sakit Cipto Mangunkusumo. Penilaian dilakukan oleh seorang ahli terapi wicara, yang mencakup
pola artikulasi, hipernasalitas, inteligibilitas, dan kompentensi velofaring.
Hasil: Sebelas pasien menjalanni palatoplasi sebelum usia 2 tahun, dan 11 lainnya setelah usia 2 tahun.
Kemampuan bicara ke-22 pasien pascapalatoplasti dinilai secara perseptif dari rekaman suara yang di-
standarisasi. Kompetensi velofaring pada pasien yang menjalani palatoplasti sebelum dan sesudah usia 2
tahun dibandingkan, dengan hasil 72.7% baik, 18.2% cukup, dan 9.1% buruk, versus 54.5% baik, 9.1%
cukup baik, dan 36.4% buruk secara restrospektif.
Kesimpulan: Melakukan two-ap mukoperiosteal palatoplasti pada anak dengan sumbing palatum
sebelum usia 2 tahun menunjukkan hasil kemampuan bicara yang lebih baik, meskipun makna statistik
belum signikan. Studi prospektif lanjut dengan jumlah sampel lebih besar diperlukan untuk mendukung
hasil studi ini.
Kata kunci: cleft palate, palatoplasty, speech outcome
Backgrounds: One of the primary goal of cleft palate repair is to provide an intact mechanism for normal
speech production. The purpose of this study is to evaluate the two-ap mucoperiosteal palatoplasty pro-
cedure on speech outcomes in patients undergoing surgical repair before the age of 2 years.
Methods: A retrospective analysis study was done on 22 children with complete unilateral cleft palate
(with or without cleft lip) who underwent two-ap palatoplasty between year 2002 to 2006 at Cipto Ma-
ngunkusumo Hospital. Evaluation was performed by a speech pathologist for pattern of articulation, hy-
pernasality, intelligibility, and velopharyngeal competence.
Results: Palatoplasty were performed after 2 year-old in 11 patients and before 2 year-old in 11 patients.
Speech of the 22 children postpalatoplasty was evaluated perceptually from standardised tape recordings.
Velopharyngeal competence in patients who underwent palatoplasty before 2 year-old compared to after 2
year-old were 72.7% good, 18.2% fair and 9.1% poor versus 54,5% good, 9,1% fair and 36,4% poor respec-
tively.
Conclusion: Two-aps mucoperiosteal palatoplasty performed before the age of 2 years old shows better
speech outcome in all parameters, although the numbers are not statistically signicant. Further prospec-
tive study with larger sample is needed.
Keyword: cleft palate, palatoplasty, speech outcome
Intania Djoenaedi, Siti Handayani, Luh Karunia Wahyuni, Kristaninta Bangun
Jakarta, Indonesia
left lip and palate are the most common
congenital craniofacial anomalies encoun
tered by plastic surgeons1. The incidence
of cleft lip and palate is 46%, followed by isola-
ted cleft palate at 33%, and isolated cleft lip at
21%. Unilateral clefts are nine times more com-
mon than bilateral clefts1. Individuals born with
cleft lip and or palate require care from multi-
ple specialties to optimize treatment outcome1-3.
The techniques of palatoplasty have
changed considerably from the ancient times to
date2,4,5. The 19th century witnessed a great evo-
lution in palatoplasties, allowing higher success
C
From Division of Plastic Surgery, Department of
Surgery, Cipto Mangunkusumo Hospital, Universitas
Indonesia
Presented in The Fifteenth Annual Scientic Meeting of
Indonesian Association of Plastic Surgeon, Semarang,
Central Java, Indonesia
Speech Outcome Evaluation After Two-Flap
Palatoplasty In Plastic Surgery Division Cipto
Mangunkusumo Hospital: A Retrospective study
CRANIOFACIAL
Disclosure: The authors have no nancial interest to
declare in relation to the content of this article.
www.JPRJournal.com 153

of cleft palate closure and more optimal outco-
mes4. Renements in the basic principles of re-
pair and greater attention to the anatomic and
functional details marked the beginning of a
modern cleft palate treatment. Treatment objec-
tive in palatoplasty has not only been the sim-
ple anatomic closure of the palate but also to
create an adequately functioning velophary-
ngeal mechanism for normal speech produc-
tion, and avoidance of abnormal maxillofacial
growth after repair2,4-6. Speech quality remains
the most important output by which to assess
the surgical success3. The most effective techni-
que for the surgical repair of palatal clefts conti-
nues to provoke controversy2,4.
One of the factors that has been iden-
tied to inuence speech outcome for children
with cleft palate is the timing of primary palatal
surgery. The majority of studies suggested that
earlier surgery was associated with better
speech, better articulation, and production of a
more normal resonance to minimize the deve-
lopment of compensatory articulations6. It is
generally thought that speech are improved by
early cleft palate repair (before 24 months of
age) and that delayed closure (after 4 years) is
associated with less retardation of midfacial
growth5,7.
The Division of Plastic Surgery in Cipto
Mangunkusumo Hospital utilizes the two-ap
mucoperiosteal palatoplasty technique with
mscle realignment to treat a unilateral or bila-
teral complete cleft palate. Primary cleft palate
surgical repair is recommended between 18
months-old up to ≤ 2 years old8. This study eva-
luates how primary palatal surgery timing affe-
ct speech outcome and how it can be used as a
guideline for the ideal time in treating complete
cleft palate in our division.
METHODS
This retrospective analytic study was
performed at the Division of Plastic Surgery
and Medical Rehabilitation Department,
Faculty of medicine University of Indonesia
Cipto Ma-ngunkusumo Hospital Jakarta during
June-July 2010. Patients with complete cleft
palate with or without cleft lip, who underwent
palatoplasty at the Division Plastic Surgery
Cipto Mangun-kusumo hospital between 2002
and 2006 are included. All patients underwent
two-ap mu-coperiosteal palatoplasty repair
for soft and hard palate with repositioning of
the muscle (intravelar veloplasty), regardless of
the cleft severity and operator. All patients
already had prior cleft lip repair. Patients with
associated syndromic malformation, oronasal
stulas, mental disorder, redo palatoplasty, the
need for secondary velopharyngeal surgery,
and loss of follow up were excluded from this
study.
Patients were divided into two groups
based upon timing of palatoplasty: those re-
paired between ≤ 2 years old and > 2 years old.
Eleven patients were included in each group for
analysis. A perceptual analysis will be perfor-
med from audio recordings of the patients. The
recordings are done by one resident of plastic
surgery using a high quality digital recorder in
a noise-free room. The microphone will be pla-
ced 15 cm away from the mouth of the patient
with the articulation samples will stored in a se-
parate audio cassette tape for each patient.
Each child articulates 13 sentences in
Bahasa Indonesia, including words predomi-
nantly consisted of nasal and oral consonant,
with phonation emphasis of the vowels “a”, “i”,
and “u”. The words are listed in Table 1. Patie-
nts also count numbers from 1 to 10 in Bahasa.
Speech samples of the patients will be blindly
analyzed by a speech pathologist who is experi-
enced in the assessment of cleft palate speech,
using headphones in a noise-free room. Percep-
tual analysis of intelligibility, articulation, and
resonance are analyzed following the Murthy
rating criteria for speech parameters16. Based on
the scoring obtained from these parameters, the
velopharyngeal competence level is divided
into either good, fair, or poor. Good result
would refer to denite and probable adequate
velopharyngeal competency. Fair result means
marginal velopharyngeal competency, whilst
poor score means a probable or denite
inadequate velopharyngeal compeetency. The
data is statistically analyzed using SPSS 16.0 for
window.
RESULTS
Twenty-two patients with unilateral co-
mplete cleft lip and palate who underwent the
154
Jurnal Plastik Rekonstruksi - March 2012

intravelar veloplasty are included in the study.
Informed consents are obtained from the paren-
ts to participate in this study. Patients ranged
between 3.5 to 13 year-old (mean 8.2 year) at
time of speech evaluation. Palate repair were
done between 1 to 8 year-old (mean 29.1 mon-
ths). 15 patients are male, 7 female. Based on
Saphiro-Wilk normality test, this data has nor-
mal distribution (p= 0.716). Eleven patients un-
derwent palatoplasty at ≤ 2 years old (aged 12
to 24 months, mean 18.4 months), and eleven
others at >2 years old (aged 30 to 96 months,
mean 39.8 months). Only two of the 22 patients
received speech therapy, one and two sessions
each. Patient demography is listed in Table 2.
An overall assessment of articulation,
resonance, and intelligibility, as well as velo-
pharyngeal competence post palatoplasty in all
patients shows that 68.2% of patient has normal
phonemes production, 63.6% has normal nasa-
lity, 77.3% has intelligibile speech, and 63.6% of
them has good velopharyngeal comptetence.
155
Volume 1 - Number 2 - Speech Outcome Evaluation After Two-Flap Palatoplasty
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Other distributions of abnormal phonemes, hy-
pernasality and speech untelligibility is summa-
rized in Table 3.
Speech outcomes are then assessed ba-
sed on the timing of primary palatal surgery in
regards to articulation, hypernasality, and
speech intelligibility. Articulation and hyper-
nasality criteria in Table 3 are further grouped
to either normal or abnormal. Intelligibility are
either normal or requiring listener’s attention,
and velopharyngeal competence are either
good, fair, or poor. In all accounts, the group of
patient who underwent primary palate repair
before the age of two shows a higher propor-
tion of having normal articulation, normal
nasality, and inteligible speech as shown in
Table 4. Velopharyngeal competence of the
early versus later-repair group shows a
tendency of those repaired before the age 2
years to have fewer poor competence (9.1%
versus 36.4%) shown in Table 5. However, these
gures are not found to be statistically signi-
cant.
DISCUSSION
The ideal surgical technique for the re-
pair of unilateral palatal cleft is an ongoing de-
bate. However, the primary goals of palatal
repair remain to provide a functional velo-
pharyngeal mechanism for the development of
normal speech and to minimize any detrimental
effects on maxillofacial growth by achieving a
tension-free multilayer closure of the palatal
defect with minimal dissection and a succesful
reconstruction of the levator muscle sling2-5,17.
Although the two-ap palatoplasty was rst
156
Jurnal Plastik Rekonstruksi - March 2012
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popularized more than 25 years ago in world,
there are several modication to the original
technique. In this study, all samples underwent
two ap mucoperiosteal palatoplasty modied
by di-ssection of the abnormal attachments of
the velar muscles and suturing them without
ten-sion, as intravelar veloplasty. All subjects
have had their lips repaired.
Dynamically, speech is characterized by
ordered maintenance and release of intra oral
pressure, producing phonemes (high pressure
consonants and vowels) controlled at the level
of the lips, tongue, palate, and larynx18.
Children under 4 years of age have generally
not yet reached the level of maturity required to
cooperate enough to allow for the appropriate
perceptual test to accurately asses articulation,
resonance and velopharyngeal competence19.
This perceptual assessment is conducted bet-
ween the age of 3.5 and 13 years. The age of one
of our samples is 3,5 years, but the patient coo-
perate enough to follow the test and the sample
sound can be assessed well by speech patholo-
gist. Males predominance is found in the cleft
lip and palate population. In this study, male is
twice as many as the female sample1.
The timing of palatal closure is critical,
and the best time to achieve this is before the
development of palate-related sounds, or the
phonemic stage of development. Early palatal
repair and its benecial effects on speech have
been reported by several authors13. Meanwhile,
in our study, 50% of our samples had palate
repair at the age of more than 2 years old. This
may be due to the lack of knowledge or econo-
mic difculties to get appropriate treatment.
McWilliams et al.21, performed Furlow palato-
plasty in 63 patient, and non Furlow (Von
Langenback, four ap Wardill) in 20 patients.
Furlow patients had better speech outcome than
non Furlow, with normal nasal resonance for
Furlow patients around 79%, moderate
hypernasality was 4.76%, and 98% of Furlow
patients showed normal articulation. Susam
park et al20 had 56 patients with unilateral cleft
lip and palate repaired using the push-back
technique, 80.1% had normal and good velo-
pharyngeal competence. The Salyer et al19 study
performed modied two ap palatoplasty at
younger age patients, regardless the type of
cleft, 91% shows normal and mildly impaired
hypernasality, 63.2 normal to mildly impaired
articulation. In our study, all patients who
underwent two ap palatoplasty and intravelar
veloplasty by several surgeons, shows 77.3% to
have a normal to mildly impaired articulation,
77.3% has normal to mild hypernasality, 77.3%
has normal intelligibility, and 63.6% good
velopharyngeal competence.
Current developmental research has
shown that speech develops between 18 to 24
months of age. Dorf and Curtin13 used 12
months of age as an arbitrary dividing point
between early and late palatal repair and found
better speech, specically, with fewer compen-
satory articulations, in those who had early
palatal repair. Salyer et al operated at approxi-
mately 8 months of age, which is the ideal time
to perform the two-ap palatoplasty. In this
study, the cut-off point of the early and late
palatoplasty is 2 years old. All of the samples
are divided into two groups. The group who
had early palatoplasty has 90.9% normal articu-
lation and only 63.6% of the sample who perfor-
med late palatoplasty has normal articulation.
The group who had early palatoplasty has
90.9% normal and mildly nasal resonance, 90.9
% normal intelligibility and 72.7% good velo-
pharyngeal competence, compare with 63.6%,
63.6% and 54.5% in group who had late pala-
toplasty. In our study, there is a patient who
had palatoplasty at age 8 years old and gives
good velopharyngeal competence. However,
this difference was not statistically signicant
by Fischer test. Although we are unable to show
statistically that the palatoplasty before 2 years
old is superior to the palatoplasty more than 2
years, a trend toward this conclusion has been
demonstrated.
CONCLUSION
According to this study, the manage-
ment of cleft palate that has been implemented
in our center: by two ap mucoperiosteal tech-
nique and surgery timed around 2 years of age
is still applicable because the rate of good
speech outcome is acceptable (72.7%). In the fu-
ture, we propose to conduct a more thorough
research with bigger samples and better design
to have a more reliable result.
157
Volume 1 - Number 2 - Speech Outcome Evaluation After Two-Flap Palatoplasty

of cleft palate closure and more optimal
outcomes4. Renements in the basic principles
of re-pair and greater attention to the anatomic
and functional details marked the beginning of
a modern cleft palate treatment. Treatment
objective in palatoplasty has not only been the
sim-ple anatomic closure of the palate but also
to create an adequately functioning velophary-
ngeal mechanism for normal speech produc-
tion, and avoidance of abnormal maxillofacial
growth after repair2,4-6. Speech quality remains
the most important output by which to assess
the surgical success3. The most effective techni-
que for the surgical repair of palatal clefts conti-
nues to provoke controversy2,4.
One of the factors that has been iden-
tied to inuence speech outcome for children
with cleft palate is the timing of primary palatal
surgery. The majority of studies suggested that
earlier surgery was associated with better
speech, better articulation, and production of a
more normal resonance to minimize the deve-
lopment of compensatory articulations6. It is
generally thought that speech are improved by
early cleft palate repair (before 24 months of
age) and that delayed closure (after 4 years) is
associated with less retardation of midfacial
growth5,7.
The Division of Plastic Surgery in Cipto
Mangunkusumo Hospital utilizes the two-ap
mucoperiosteal palatoplasty technique with
muscle realignment to treat a unilateral or bila-
teral complete cleft palate. Primary cleft palate
surgical repair is recommended between 18
months-old up to ≤ 2 years old8. This study eva-
luates how primary palatal surgery timing affe-
ct speech outcome and how it can be used as a
guideline for the ideal time in treating complete
cleft palate in our division.
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158
Jurnal Plastik Rekonstruksi - March 2012
Luh Karunia Wahyuni, M.D.
Cleft Craniofacial Center. Plastic Surgery Division
Cipto Mangunkusumo General National Hospital
Jalan Diponegoro.No.71, Gedung A