ObjectiveDevelop and apply novel data visualization techniques to analyze longitudinal cleft surgical care and to identify patterns in treatment timing and procedural burden across 2 cleft teams.DesignRetrospective cohort study of operative data using novel data visualization methods.SettingTwo cleft teams in the United States.Patients and ParticipantsPatients with cleft lip and/or palate with operative clinical encounters between 2018 and 2023. Team A had 228 patients and team B had 355.InterventionsVisualization of primary cleft-related surgical procedures which were cleft lip and palate repair, fistula repair, alveolar bone grafting, correction of velopharyngeal insufficiency, orthognathic surgery, and rhinoplasty.Main Outcome Measure(s)Visual interpretation of surgical timing, frequency, volume, and distribution using novel timelines, stacked-bar charts, and ridgeplots.ResultsTimeline visualizations clarified procedural sequencing and highlighted variation in treatment timing by team and phenotype but were too dense for interpretation for a large volume of patients. Stacked-bar charts illustrated procedural volume but lacked temporal insight. Ridgeplots demonstrated both timing of procedures and aggregate team volume.ConclusionsIndividual patient timelines can effectively depict deviation from "ideal" care protocols, but aggregate data may be best depicted by a ridgeplot. These tools may support quality improvement initiatives by transforming raw data into actionable insights and enhancing multidisciplinary team reflection.

Long-Term Velopharyngeal Insufficiency–Related Quality of Life in Cleft Palate Patients: Speech and Surgical Factors

Microscopic transoral approach (TOA) has been considered as the gold standard for anterior decompression of the cranio-vertebral junction (CVJ). The progress in endonasal endoscopic procedures has made it possible to perform odontoidectomy via a minimally invasive transnasal route. The aim is to critically analyze our cases of odontoid subluxation and those described in the literature that were treated by the endonasal endoscopic odontoidectomy (EEA). Seven consecutive patients that failed conservative treatment and other surgical procedures of atlanto-axial dislocation, were managed surgically by endonasal endoscopic odontoidectomy at our institution. There were 4 patients with basilar invagination, Chiari malformation, and atlanto-axial dislocation, and one patient each with a tumor of the odontoid process, retropharyngeal abscess, and osteomyelitis. None of our patients developed velopharyngeal insufficiency, respiratory distress, speech disturbances, or CSF leak after surgery. Transoral odontoidectomy, tracheostomy, gastrostomy, or prolonged ventilation was not required in any patients. One patient developed transient swallowing difficulty postoperatively which improved after a few weeks. The endonasal endoscopic odontoidectomy is a safe and effective procedure for patients with non-reducible atlanto-axial dislocation. The technique allows optimal viewing when using angulated instruments and angled endoscopes.

ObjectiveTo systematically review advances in surgical techniques for secondary cleft palate repair, emphasizing their impact on velopharyngeal function, speech outcomes, and the methodological validity of speech assessments used in published studies.DesignFollowing PRISMA 2021 guidelines, six electronic databases were searched for articles from January 2012 to February 2025 using MeSH terms related to secondary cleft palate repair, velopharyngeal insufficiency, palatoplasty, and speech outcomes. Eligible studies included clinical reports with ≥10 patients undergoing secondary repair. Data on surgical methods, outcomes, and complications were extracted and qualitatively synthesized due to heterogeneity across studies.SettingAll published clinical studies evaluating secondary cleft palate repair outcomes.Patients/ParticipantsIndividuals presenting with residual velopharyngeal insufficiency, recurrent fistula, or speech dysfunction following primary palatoplasty.Main Outcome MeasuresSpeech resonance and intelligibility, velopharyngeal closure rate, fistula recurrence, donor-site morbidity, and obstructive sleep apnea risk.ResultsFourteen studies met the inclusion criteria. Palate-based re-repair with Furlow double-opposing Z-plasty and buccal myomucosal flaps improved resonance and closure in small to moderate gaps. Pharyngeal flap and sphincter pharyngoplasty achieved satisfactory closure in larger defects but increased the risk of airway obstruction. However, most studies lacked validated speech protocols or controlled for articulatory errors and fistula effects, limiting confidence in the interpretation of outcomes.ConclusionsWhile secondary repairs often improve resonance and velopharyngeal competence, evidence remains constrained by heterogeneity and non-validated assessment methods. Future multicenter research integrating standardized, speech pathologist-verified protocols is essential to establish evidence-based algorithms for secondary cleft palate repair.

Artificial intelligence (AI) is rapidly reshaping craniofacial surgery, extending well beyond 3D printing. This domain has long been challenged by anatomic variability and subjective assessment, frequently relying on expert opinions and experience. Across key areas, such as cleft lip and palate, craniosynostoses, orthognathic deformities, velopharyngeal insufficiency, and auricular anomalies, AI systems are revolutionizing diagnosis and management strategies by providing automated, objective insights. These capabilities can strengthen diagnosis and risk stratification, personalize surgical planning and timing, and enable standardized postoperative outcome assessment. Beyond the operating room, educational applications span readability enhancement of patient materials and trainee assessment tools, while telemedicine models expand access to specialist-level diagnosis. Key challenges include data scarcity and bias, privacy, workflow fit, and evolving regulatory expectations. Overall, AI is converting experience-dependent and subjective processes into transparent and scalable pathways, with the potential to improve accuracy, efficiency, and equity of craniofacial care.

Congenital palatal fistula associated with submucous cleft palate: Surgical outcomes and insights from a case series of 27 patients.

ObjectiveThe purpose of this study was to determine factors predicting communication-related quality of life in children with cleft palate with or without cleft lip (CP ± L) or congenital velopharyngeal insufficiency (VPI).DesignCross-sectional design.SettingOutpatient pediatric craniofacial anomalies clinic.PatientsTwo-hundred and seventy-one children <18 years of age, diagnosed with CP ± L or congenital VPI.Main Outcome MeasureVelopharyngeal Insufficiency Quality of Life (VELO) scores as well as articulation, speech intelligibility, resonance, and voice outcomes were extracted from the electronic medical record in order to characterize communication-related quality of life. Total VELO score, as well as speech limitations, situational difficulty, emotional impact, perception by others and swallow subscores, were collected. Demographic factors, economic deprivation, medical history, and history of palatoplasty/pharyngoplasty were considered. Linear regression identified predictors of VELO total and subscores.ResultsPoorer speech intelligibility and increased hypernasality significantly predicted lower (worse) total VELO scores (P < .01), as well as more severe speech limitations (P < .01), situational difficulty (P < .01), emotional impact (P < .01), and perception by others (P < .01). The presence of glottal stop substitutions also predicted more severe emotional impact (P < .01). A comorbid behavioral health condition predicted significantly lower total VELO scores (P < .01), and children living in neighborhoods experiencing greater socioeconomic deprivation presented with worse swallow section scores (P < .01).ConclusionsHypernasality and decreased speech intelligibility primarily influenced the communication-related quality of life in children with velopharyngeal dysfunction. Additional research is warranted to determine how intervention can best mitigate VPI-related challenges in order to improve social interaction and quality of life.

Assessment of levator veli palatini muscle morphology and its correlation with velopharyngeal function using dynamic magnetic resonance imaging in children with repaired cleft palate.

Do Pharyngeal Flaps Have a Greater Risk of Obstructive Sleep Apnea Than Other Speech Procedures? A Systematic Review and Meta-Analysis.

Wide cleft palate repair poses a considerable challenge due to the potential for closure under tension, and an elevated risk of postoperative oronasal fistula and velopharyngeal insufficiency (VPI). Preoperative cleft width and Cleft Palate Index (CPI) are recognized as key predictors of outcome. This study presents Cleft Lip And Palate Association of Pakistan's (CLAPP) institutional experience with wide cleft palate repair, analyzing the influence of anatomical severity, surgical technique, and other variables on fistula formation and speech outcomes. A retrospective review was conducted of patients undergoing repair at CLAPP Hospital between January 2015 and December 2023. Data collected included demographics, cleft width, palatal shelf width, CPI, surgical technique, fistula location and rate, speech outcomes, and need for secondary speech-correcting surgery. Cleft width and CPI were stratified into predefined categories. Univariate and multivariate logistic regression were performed to identify predictors of postoperative fistula formation. A total of 293 patients (mean age 8 years, range 9 months-48 years) were included. Nearly one-third (35.5%) had cleft widths greater than the combined right and left palatal shelf widths. CPI distribution revealed progressive fistula rates from 12.1% in the narrowest group to 28.2% in the widest. The overall postoperative fistula rate was 21.2%, most frequently at the soft palate (27.4%) and hard-soft junction (12.9%). In univariate analysis, left palate width ≥ 1.1 cm and von Langenbeck repair were associated with significantly lower fistula rates, although only the latter remained significant in multivariate analysis (adjusted odds ratio = 0.34; 95% confidence interval = 0.16-0.72; P = 0.004). Bardach repair was preferentially performed in more severe, wider clefts, accounting for its higher unadjusted fistula rate. Preoperative and postoperative speech assessments (N = 173) showed a mean composite score improvement of 13.4%, with 8.9% requiring secondary speech-correcting surgery. Wide cleft palate repair outcomes are strongly influenced by cleft morphology, with CPI emerging as a key prognostic tool. While von Langenbeck repair demonstrated lower adjusted fistula rates, technique selection remains contingent on preoperative assessment, with Bardach repair favored in severe cases. Long-term monitoring for VPI is crucial, with early repair and tailored technique selection critical for optimizing functional outcomes in this challenging subset.

Custom-made patient-specific nasal devices for speech and swallow rehabilitation in patients with velo-pharyngeal insufficiency

ObjectiveAssess the patient compliance rate for nasopharyngoscopy as documented in clinical reports.DesignCross-sectional.SettingThirteen cleft teams in North America.PatientsPatients aged 3 to 21 years old with a repaired cleft palate.InterventionsNasopharyngoscopy.Main Outcome MeasurePatient compliance rate for nasopharyngoscopy.ResultsPatient compliance was documented in 128 of 158 reports (81%). Of the 128 reports, patient compliance was reported as "good/excellent" in 65% (n = 83), "marginal/fair" across 10% (n = 13), "poor" in 16% (n = 20), and "other" in 9% (n = 12). Patients with "poor" compliance had lower rates of documented imaging ratings, however 55% (n = 11) of reports included a surgical recommendation.ConclusionsAmong children completing nasopharyngoscopy for velopharyngeal insufficiency surgery planning, at least one-fourth of reports indicate significant compliance issues that limits velopharyngeal port imaging. These findings suggest that some cleft teams and surgeons may be proceeding with surgical management of velopharyngeal insufficiency without adequate visualization or ratings of velopharyngeal anatomy.

ObjectiveTo assess the relationship in ratings of velopharyngeal closure between connected speech and sustained speech, as visualized on nasopharyngoscopy.DesignProspective observational study.SettingCraniofacial clinics in the United States and Canada.ParticipantsFifty-two participants with velopharyngeal insufficiency (VPI) who underwent nasopharyngoscopy and produced both connected speech and sustained speech of either /i/or /s/ during the procedure.Main outcome measure(s)Correlations and differences between connected speech and sustained speech for velopharyngeal closure percentage, velar movement, lateral pharyngeal wall movement, and velopharyngeal closure pattern.ResultsThere were moderate to very strong correlations observed between connected speech and sustained /i/ for velopharyngeal closure percentage (P < .01); extent of velar movement (P < .01), and left (P < .01) and right (P < .01) lateral pharyngeal wall movement. Findings were similar between connected speech and sustained /s/. Differences between ratings made during connected and sustained speech were small: for velopharyngeal closure percentage, there was a 5% difference in the mean between connected speech and sustained /i/ (77.5% vs 72.5%) and a 7% difference for /s/ (79.3% vs 86.7%). Overall differences across ratings ranged from 2% to 12%. Closure pattern was rated the same for both connected speech and sustained /i/ in 90% of videos (n = 44/49; P = .38) and the same for connected speech and sustained /s/ in 95% of videos (n = 42/44; P = 1.00).ConclusionsRatings of velopharyngeal movement during nasopharyngoscopy are similar between connected speech and sustained /i/ and /s/ suggesting elicitation of only sustained /i/ and /s/ may be adequate in most cases when assessment of connected speech is not possible.

The purpose of this study was to compare the height of velopharyngeal (VP) closure in relation to the palatal plane between individuals with velopharyngeal insufficiency (VPI) with or without cleft palate and individuals without cleft palate and with normal speech, considering the effects of age and sex. Magnetic resonance imaging was used to analyze the height of VP closure in the midsagittal view during phonation of /i/ and /s/ sounds among 105 individuals with VPI and 45 individuals without cleft palate and normal speech. Independent-samples t tests demonstrated that individuals with VPI display a significantly lower mean height of VP closure (3.7 mm) compared to individuals without cleft palate and normal speech during phonation of /i/ and /s/ sounds (p < .001). Analysis of variance was used to evaluate the impact of age and sex on the height of VP closure. Significant differences were observed between the height of VP closure in individuals with VPI and those without cleft palate and normal speech across the age span during the production of /i/ and /s/ sounds. However, nonsignificant differences were found between the height of VP closure in males and females of the VPI group and those without cleft palate and normal speech during the production of these sounds. The results revealed the variations of the height of VP closure in relation to the palatal plane. These findings provide insights into the presurgical planning for individuals with VPI undergoing palatal surgeries, especially the location of pharyngeal flap insertion.

The use of buccal myomucosal flaps during primary palatoplasty have gained popularity, yet their impact on surgical outcomes remains debated. This study evaluates whether using buccal flaps in primary Furlow palatoplasty for children with cleft lip/palate (CLP) decreases the likelihood of developing velopharyngeal insufficiency (VPI). A retrospective cohort study of children with CLP who underwent primary palatoplasty (2015-2022) at a single institution. Patients < 2 years old at surgery who had primary Furlow alone (FA) or Furlow with buccal flap (FB) and had speech-language pathology (SLP) evaluation for VPI were included. Bayesian multivariable logistic regression assessed the posterior probability of VPI after FB. Seventy-nine patients were included (68% FA vs 32% FB). Median age at palatoplasty was 12 months (IQR: 11.25-13). Baseline characteristics were similar between groups. The median age of SLP assessment was 5 (3-7) years. VPI rates were higher in FA (26.4%) versus FB (8.0% FB) (p=0.08). Fistula rates were higher in FA (9.4%) compared to FB (0.0%) (p=0.17). Patients with VPI had a higher fistula rate (25.0% vs 1.6%, p<0.01). After adjusting for Veau class and fistula, buccal flaps had an odds ratio of 0.4 (95% credible interval: 0.1-1.6) in VPI, with an 89% likelihood of decreasing the odds of VPI. Buccal flaps in primary Furlow palatoplasty were associated with lower VPI and fistula rates, supporting their role in optimizing speech outcomes. While they offer advantages as vascularized, autologous tissue, multi-institutional, randomized studies are needed to confirm these findings.

Although injection pharyngoplasty (IP) has been well described as a treatment for velopharyngeal insufficiency (VPI) in the pediatric population, there are far fewer studies on its safety and effectiveness in adults with acquired VPI. Our study aims to characterize the safety and efficacy of IP as a treatment for acquired VPI in adults while identifying underlying VPI etiologies and injection characteristics that are associated with positive outcomes. We conducted a retrospective analysis of 30 adult patients with acquired VPI who were treated with IP. We collected data on patient demographics, etiology of acquired VPI, and IP procedural characteristics for analysis. Descriptive statistics are provided for patient demographic and IP procedural characteristics. In our cohort, 16 patients had a history of radiation and/or chemotherapy while 14 patients had acquired VPI due to other etiologies. A majority of patients (n = 16) in our study had their VPI resolved with a single injection. Of all 61 injections recorded in our cohort, the most frequent injection agent was calcium hydroxyapatite (n = 35) followed by autologous fat (n = 15). We found that 27 of the patients in our cohort reported improvement in their acquired VPI after IP with only 9 reporting temporary minor complications that were resolved without intervention. Our study further establishes IP as a safe and effective procedure for adult patients with acquired VPI.

Obstructive sleep disordered breathing (oSDB), including obstructive sleep apnea (OSA), frequently coexists with cleft lip and palate, velopharyngeal insufficiency (VPI), and other craniofacial conditions. Moreover, oSDB is often a key factor in decisions for primary or revision cleft palate or velpharyngeal surgery. Due to the frequency with which cleft and craniofacial team members care for patients with oSDB, this article provides a primer for OSA evaluation and management for team members.oSDB can have a significant impact on quality of life, health outcomes, surgical planning, and global development for all children, especially those with cleft and craniofacial conditions. In this review, oSDB screening and testing methods are discussed, including interpretation of OSA testing. Considerations for specific craniofacial populations are included, such as those with 22q11.2 deletion syndrome and Pierre-Robin sequence. The impact of VPI surgery on OSA is discussed. Finally, approaches to OSA management are reviewed, with attention to how standard management approaches may shift in children with cleft and craniofacial conditions.As awareness of oSDB in children has increased, including increased access to diagnostic testing, studies have shown certain patient populations are more likely to have OSA and would benefit from screening. Children with craniofacial conditions, including cleft palate and velopharyngeal insufficiency, have altered risk profiles which impact management considerations for OSA. This article provides an introduction to key concepts in oSDB screening, diagnositics, and management, which can be valuable for any professional assisting in the care of children with a cleft or craniofacial condition.

Having nasal speech due to velopharyngeal insufficiency (VPI) remains one of the most difficult complications to manage after cleft palate repair. Over early childhood, persistent hypernasality can impede the psychosocial and communicative development of a child. The purpose of this study was to assess the results of secondary soft palate lengthening surgery on children older than five years with a history of primary palatoplasty and persistent nasal speech. In this study, 60 non-syndromic patients with cleft palate whose nasal speech was persistent after cleft palate repair were included from January 2018 to December 2024 at Misurata Medical Center, Libya. Each of them underwent soft palate lengthening, most by intravelar veloplasty, and some by posterior pharyngeal flap. All the patients had preoperative and 12-month postoperative speech evaluation from both perceptual (Pittsburgh Weighted Speech Scale) and instrumental (nasometry) analysis. For statistical analysis, paired t-tests were used, with P &lt; 0.05 considered significant. Of the total, 80% of patients had complete hypernasality correction, and 13.3% had partial correction. There was a significant improvement postoperatively on nasalance scores (48.5 ± 9.2% to 24.1 ± 6.8%, P &lt; 0.001). 85% of the patients had improved speech intelligibility, with more than 86% of parents satisfied with the overall results. 10% had transient snoring and 5% had wound dehiscence, both classified as minor complications and were conservatively managed. For patients older than five years, soft palate lengthening is a secondary procedure that is both safe and effective for persistent nasal speech after cleft palate repair. It shows remarkable positive outcomes in resonance, intelligibility, and psychosocial confidence

Velopharyngeal insufficiency (VPI) following oncologic resection of the soft palate in edentulous patients presents a major clinical challenge, often leading to hypernasal speech, nasal regurgitation, and impaired swallowing. Advances in digital technology have enabled the fabrication of precise and functionally efficient prostheses through computer-aided design/computer-aided manufacturing (CAD/CAM) and three-dimensional (3D) printing. This report describes the prosthodontic rehabilitation of a 68-year-old male with post-radiotherapy soft palate resection using a fully digital workflow to fabricate a 3D-printed complete denture with an integrated speech bulb. Following a conventional preliminary impression, the definitive cast was digitised, and all subsequent stages --including custom tray design, virtual denture base modelling, and prosthesis fabrication --were performed using CAD software and additive manufacturing. The speech bulb extension was digitally contoured to achieve functional velopharyngeal closure. At insertion and during the three-month follow-up, the prosthesis demonstrated excellent adaptation, retention, and comfort, with significant improvement in speech intelligibility, swallowing, and overall quality of life. This case highlights the clinical advantages of integrating digital workflows and 3D printing in maxillofacial prosthetic rehabilitation, providing a reproducible, minimally invasive, and patient-centred approach for managing velopharyngeal insufficiency following oncologic resection.

Sound Decisions: Optimizing Speech Through Collaborative Team Care.