Effect of Cleft Palate Closure Technique

on Speech and Middle Ear Outcome: A

Systematic Review
Sofie Teblick,* Maarten Ruymaekers,y Elke Van de Casteele, MSc, PhD,z and
Nasser Nadjmi, MD, DDS, PhD, EFOMFSx
Purpose: Otitis media with effusion and disturbed speech are highly prevalent in children after cleft
palate repair. Although many techniques for palatal closure have been described, no consensus has
been reached on the most effective technique for these issues. The aim of this systematic review was to
provide evidence-based information related to the effectiveness of different palatal closure techniques
on middle ear and speech outcomes.
Materials and Methods: A literature search in multiple electronic databases was performed: National
Guidelines Clearinghouse, Trip Database, Cochrane Library, and Medline (PubMed). Potentially relevant
articles were selected according to title and abstract and full-text eligibility. Then, quality control on the
included articles was executed.
Results: Twenty-three retrospective and prospective cohort studies were included in this systematic re-
view. These studies compared at least 2 of the following techniques: von Langenbeck palatoplasty, 2-flap
palatoplasty, Veau-Wardill-Kilner V-to-Y pushback technique, Kriens intravelar veloplasty, Sommerlad tech-
nique, Furlow double-opposing Z-plasties, and the Nadjmi modification of the Furlow palatoplasty. Their
outcomes on the prevalence of otitis media with effusion, number of tympanostomy tubes placed, rates of
hearing loss, and speech development were compared.
Conclusions: The Sommerlad and Furlow palatoplasties were associated with the lowest prevalence of
otitis media with effusion and the smallest number tympanostomy tubes needed. For hearing outcomes,
the Furlow palatoplasty generated the best audiometric outcome. For speech outcomes, the Sommerlad
and Furlow palatoplasties were more beneficial than the 2-flap palatoplasty, the Veau-Wardill-Kilner
V-to-Y pushback technique, and the von Langenbeck palatoplasty. Additional randomized controlled trials
are recommended to obtain evidence that can support these findings.
Ó 2018 The Authors. Published by Elsevier Inc. on behalf of the American Association of Oral and
Maxillofacial Surgeons. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
J Oral Maxillofac Surg 77:405.e1-405.e15, 2019

*Medical Master Student, Faculty of Medicine and Health
Sciences, University of Antwerp, Antwerp, Belgium.
yMedical Master Student, Faculty of Medicine and Health
Sciences, University of Antwerp, Antwerp, Belgium.
zPostdoctoral Researcher, Faculty of Medicine and Health
Sciences, University of Antwerp, Antwerp; All for Research vzw,
Antwerp; Department of Craniomaxillofacial Surgery, Antwerp
University Hospital, Edegem, Belgium.
xProfessor and Coordinating Program Director for Oral and
Maxillofacial Surgery, Faculty of Medicine and Health Sciences,
University of Antwerp, Antwerp; Director of Team for Cleft and
Craniofacial Anomalies, Department of Craniomaxillofacial
Surgery, Antwerp University Hospital, Edegem; Department of
Maxillofacial Surgery, ZMACK, AZ Monica Antwerp, Antwerp,
Belgium.
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Nadjmi:
Department of Maxillofacial Surgery, ZMACK, AZ Monica Antwerp,
Harmoniestraat 68, 2018 Antwerp, Belgium; e-mail: nasser@
nadjmi.com
Received August 20 2018
Accepted September 21 2018
Ó 2018 The Authors. Published by Elsevier Inc. on behalf of the American
Association of Oral and Maxillofacial Surgeons. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
0278-2391/18/31099-1
https://doi.org/10.1016/j.joms.2018.09.027

405.e1
405.e2
Cleft palate (CP) is one of the most frequent congenital
malformations, with an incidence of 1 per 650 live
births.1,2 Closure of the cleft focuses primarily on 5
targets: normal maxillary growth, no fistula
formation, normal speech, normal eustachian tube
(ET) function, and good esthetic results. Palatal
surgery is already associated with satisfactory
cosmetic results, but disturbed speech and persistent
ET dysfunction remain concerns.3 The tensor and leva-
tor veli palatini muscles, with their insertion in the soft
palate, play an important role in this matter. Contrac-
tion of these muscles produces tension in the soft pal-
ate, which accordingly moves upward and backward.
The result of this action is velopharyngeal closure and
dilatation of the ET.4 Velopharyngeal closure is a
requirement for normal speech production. Dilatation
of the ET is needed for equilibration of middle ear pres-
sure and drainage of fluids that might have accumu-
lated in an acute or chronically inflamed middle ear.
In children with CP, there is an abnormal point of inser-
tion of these muscles because of the absence of palatal
fusion during fetal development.5 In consequence,
active dilatation of the ET is impaired, which leads to
frequent episodes of otitis media with effusion
(OME) and an increased need for tympanostomy
tubes. Without intervention, middle ear effusion
causes conductive hearing loss.6,7 In addition,
impaired velopharyngeal closure has consequences
on speech development.
An important factor that could affect the outcome of
CP repair in relation to middle ear function and speech
is the technique of palatoplasty. Unfortunately, this re-
mains a major point of contention.
Many techniques for palatal closure have been
described, but the most effective surgical technique
continues to be undetermined. Bernard von Langen-
beck described the von Langenbeck palatoplasty in
18611 and it is currently in use. This technique involves
straight-line closure of the palatal cleft and does not
correct muscle abnormalities of the soft palate. A disad-
vantage is that the von Langenbeck technique does not
lengthen the soft palate. The 2-flap palatoplasty,
described by Bardach,8 is a refinement of the von Lan-
genbeck palatoplasty. The theory is similar, but this
technique can lengthen the soft palate by pushback.
The Veau-Wardill-Kilner (VWK) V-Y repositioning
technique also lengthens the soft palate by pushback.9
In 1970, the intravelar veloplasty (IVVP) was proposed
by Kriens.10 This technique restores the levator sling
and palatal musculature at the midline, where they
would normally meet. This is accomplished by dissec-
tion of the anteriorly malpositioned bundles from the
posterior edge of the hard palate and repositioning
them in the midline. This technique was popularized
by Sommerlad,11 with radical muscle dissection
and posterior repositioning performed under the
SPEECH AND HEARING OUTCOME AFTER CLEFT CLOSURE
operating microscope. Based on the theory that the
abnormal position and structure of the levator veli
palatini muscle must be corrected, Leonard Furlow de-
signed the double-opposing Z-plasties in 1986.12,13
Two opposing Z-plasties are performed on the oral
and nasal mucosa. The Z-plasties lead to palatal
lengthening without pushback. In addition, it avoids
straight-line closure and thus subsequent contracture.
This technique is less appropriate for wide palatal
clefts, because tension-free closure is hard to achieve.
This disadvantage has inspired surgeons to modify
the technique. Nadjmi et al14 made 2 modifications.
First, the levator muscle is reunited with minimal over-
lap of the myomucosal flaps, instead of complete over-
lap. Second, in wider clefts, a buccal myomucosal flap
is used to achieve a tension-free oral layer closure and
avoid exposure of raw surfaces.
The purpose of this systematic review was to re-
view the research performed in this field, because
there is no clear overview of all independent
studies. The aim was to determine which palatal
closure technique is associated with the best results
for speech and middle ear outcomes in children
with CP.
Materials and Methods
ELIGIBILITY CRITERIA
This systematic review focused on a patient popula-
tion defined as children and adults (age, birth to 28 yr)
with CP with or without cleft lip. Unilateral and bilat-
eral clefts were included. Only patients with isolated
cleft lip or submucosal CP were excluded. The inter-
vention was primary CP closure, with the main focus
on the surgical technique used. For outcome, all
long- and short-term clinical outcomes for speech, lan-
guage, and middle ear function were included. No
restrictions were made for language or publication
date. The goal of this systematic review was to
compare middle ear and speech outcomes and to
reach conclusions on the most beneficial surgical tech-
nique. No ethical approval was required for this
systematic review.
INFORMATION SOURCES
A search through multiple electronic databases was
performed, including the National Guidelines Clear-
inghouse, the Trip Database, the Cochrane Library,
and Medline (PubMed). The literature published until
March 2018 was screened. The search yielded 367 ar-
ticles. Ten additional articles were included through a
manual reference search. These were included
because they were referred to in articles of the present
systematic literature search or were recommended
by experts.
 BLICK ET AL
TE
SEARCH TERMS
The following search terms were used: cleft palate,
cleft palate surgery, soft palate closure, soft palate
reconstruction, palate closure technique, palatoplasty,
von Langenbeck, Furlow, V-to-Y pushback, intravelar
veloplasty, Sommerlad, auditory tube function, eusta-
chian tube, middle ear, middle ear effusion, middle
ear infection, hearing loss, and speech.
STUDY SELECTION
After removal of duplicates, potentially relevant arti-
cles were selected from the initial publications by
reading the title and abstract. This was performed
separately by 2 authors to augment reliability. Dis-
agreements in selected articles were settled after a
discussion. Reasons for exclusion were studies based
on patients with unrepaired clefts, patients with only
cleft lip, and a topic that largely deviated from the
topic being investigated. Additional studies (n = 10)
were obtained from the references of the selected arti-
cles or suggested by experts on this topic.
The remaining full-text articles were assessed for
eligibility. Type of CP, outcome parameters, primary
or secondary CP surgery, and a comparison between
different types of surgery were the main criteria to
evaluate eligibility.
ASSESSMENT OF QUALITY AND STRENGTH OF
STUDIES
The quality evaluation of the selected articles was
performed with the use of an 11-item standardized
checklist of predefined criteria. The criteria are pre-
sented in Table 1. If an item met the inclusion criteria,
Table 1. CRITERIA FOR ASSESSING METHODOLOGIC
QUALITY OF STUDIES
1. Description of research design (randomized controlled
trials or observational studies, prospective or
retrospective design)
2. Well-defined description of consecutive samples
3. Well-formulated inclusion and exclusion criteria
4. Validated method of assessing OME, hearing loss, or
speech
5. Appropriate control groups
6. Assessing whether a study is powered adequately to
detect the expected difference
7. Degree of selection of the patient sample is clearly
described
8. Type of cleft palate surgery is reported
9. Type of cleft palate is described
10. Observers are blinded
11. Follow-up rate is >80%
Abbreviation: OME, otitis media with effusion.
Teblick et al. Speech and Hearing Outcome After Cleft Closure.
J Oral Maxillofac Surg 2019.
405.e3
then it was assigned 1 point. Items that were not
adequately described or did not meet the inclusion
criteria were assigned 0 point. In consequence, quality
assessment scores ranged from 0 to 11. Studies scoring
9 to 11 points were rated as high quality. Studies
scoring 6 to 8 points were considered moderate qual-
ity. Studies scoring 0 to 5 points were rated as
low quality.
The strength of studies was classified according to
the Oxford Centre for Evidence-Based Medicine
(https://www.cebm.net/wp-content/uploads/2014/
06/CEBM-Levels-of-Evidence-2.1.pdf). A systematic re-
view of randomized trials or single-patient trials was
graded level 1. Level 2 was defined as a randomized
trial or observational study with dramatic effects. A
nonrandomized controlled cohort or follow-up study
was classified as level 3. Level 4 was defined as case se-
ries, case-and-control studies, or historically controlled
studies. Level 5 was defined as mechanism-based
reasoning. The levels could be downgraded based on
study quality, imprecision, indirectness, inconsistency
between studies, or because the effect size was
very small.
DATA EXTRACTION
Data were extracted from the included studies by
one author and then checked by a second author
before being collected in a database. Disagreements
were settled after a discussion between the 2 authors.
Description of the included patients (eg, type of cleft,
ethnicity) was extracted, as were age and duration of
follow-up, age at palatal closure, and surgical tech-
nique used. In addition, the outcome parameters of
the studies and their related outcomes were extracted.
Results
STUDY SELECTION
In the National Guideline Clearinghouse, Trip Data-
base, and Cochrane Library databases, the search term
‘‘cleft palate surgery’’ yielded 3, 1,240, and 3 results,
respectively. The filter ‘‘evidence-based synopses’’
was applied in the Trip Database to guaranty high qual-
ity. This narrowed the results to 11 publications in
this database.
In PubMed, multiple searches were performed. The
first search for ((soft palate closure OR soft palate
reconstruction OR palate closure technique) AND
(auditory tube function OR middle ear effusion OR
middle ear infection OR hearing loss)) yielded 49
initial results without a restriction on publication
date. The second search was performed with the
following search terms: ((cleft palate AND palato-
plasty) AND (middle ear OR speech OR eustachian
tube OR hearing loss)); this yielded 209 results with
405.e4
a publication date starting from 2006. Another search
was narrowed to terms more specific to palate surgical
techniques: ((von Langenbeck) AND (Furlow OR V-to-
Y pushback)) and ((Furlow OR von Langenbeck) AND
(auditory tube function OR middle ear effusion OR
middle ear infection OR hearing loss)); this yielded
20 and 14 results, respectively. ((Sommerlad OR intra-
velar veloplasty) AND (auditory tube function OR mid-
dle ear effusion OR middle ear infection OR hearing
loss OR ventilation tubes)) and ((Sommerlad OR intra-
velar veloplasty) AND (velopharyngeal function))
yielded 15 and 43 results, respectively.
A total of 367 records were identified (Fig 1) and 10
additional records were obtained by a manual refer-
ence search. After removal of duplicates (n = 45),
332 articles were screened by title and abstract. Of
these, 290 records that were clearly irrelevant were
eliminated. The remaining 42 full-text articles were as-
sessed for eligibility and quality. Nineteen articles were
excluded for the following reasons: no full-text article
was obtainable (n = 8), studies had a low grade of
evidence (n = 2), a forced response test result was
FIGURE 1. Flow diagram of study retrieval and selection. Abbreviation: CP, cleft palate.
Teblick et al. Speech and Hearing Outcome After Cleft Closure. J Oral Maxillofac Surg 2019.
SPEECH AND HEARING OUTCOME AFTER CLEFT CLOSURE
the outcome parameter (n = 1), hospitalization time
and surgery time were outcome parameters (n = 1),
patients with submucosal clefts were included
(n = 1), secondary palatal surgery was an intervention
after failed primary palatal surgery (n = 5), and chil-
dren with and without CP were compared (n = 1).
Therefore, 23 studies were included in this systematic
review.
STUDY CHARACTERISTICS
Most eligible studies (91.3%) were published in the
past 2 decades4,6,7,12,14-32 (Table 2). Most studies
were conducted in Europe (43.5%) and 26.2% were
conducted in the United States. Quality assessment
showed that 12 studies were of high quality and 10
were of moderate quality. Only 1 study was of low qual-
ity. For level of evidence, all studies were level 2 (n = 3)
or 3 (n = 20). The designs of the included studies were
retrospective (n = 19) and prospective (n = 4) cohort
studies. In total, 1,684 patients (age range, 2 to 28 yr)
were evaluated in this systematic review. In most cases,
follow-up was conducted for at least 1 year.
 TE
BLICK ET AL
Table 2. SUMMARY OF STUDY CHARACTERISTICS

Study Design Quality LOE Year Country Intervention and Comparisons Sample Size, N Mean Age Follow-Up

Guneren et al4 PC High 3 2000 Turkey VWK vs FP 26 3.2 yr 27.3 mo

Hassan and Askar15 PC High 2 2007 Egypt VWK vs Kriens technique with 70 N/M 2 yr
3-layer palatoplasty
Spauwen et al16 PC High 2 1992 Netherlands FP vs VLP 20 2.8-3.2 yr 3 yr
Wilson et al17 RC Moderate 3 2017 USA FP vs straight-line repair N/M N/A 1 yr
Antonelli et al18 PC High 2 2011 Brazil FP vs VLP 370 5-6 yr >5 yr
Smith et al19 RC Moderate 3 2008 USA 2-flap palatoplasty vs FP 100 3 yr >2 yr
Kappen et al20 RC Moderate 3 2017 Netherlands 2-stage palatoplasty 48 21 yr 1 yr
Kappen et al6 RC Moderate 3 2017 Netherlands 2-stage palatoplasty 48 21 yr 1 yr
Lithovius et al21 RC Moderate 3 2015 Finland Palatoplasty with different 90 3-9 yr 6 yr
surgical techniques
Carrol et al7 RC High 3 2013 USA FP vs VWK vs 2-flap 138 N/A 6 yr
palatoplasty vs VLP
Musgrave et al22 RC Moderate 3 1975 USA VLP vs VWK N/M 10 yr 1 yr
Dayashankara et al23 RC High 3 2011 India VWK vs Kriens technique with 24 18-36 mo 6 mo
3-layer palatoplasty
Dong et al12 RC High 3 2012 China FP vs 2-flap palatoplasty 88 2-28 yr 6 mo
Funayama et al24 RC High 3 2014 Japan 1-stage FP vs 1-stage VWK vs 2- 38 4 and 8 yr 8 yr
stage FP
Vokurkova et al25 RC Low 3 2000 Czech Republic FP vs VLP 15 6 yr 1 yr
Yamanishi et al26 RC Moderate 3 2011 Japan FP vs VWK 72 4 yr 3 yr
Yu et al27 RC High 3 2001 Taiwan FP vs VLP 96 2.5 yr 1 yr
D’Andrea et al28 RC Moderate 3 2018 France VWK vs Sommerlad IVVP 116 N/M 5 yr
Brgoch et al29 RC Moderate 3 2015 USA Straight-line IVVP vs FP vs 94 N/M 2 yr
straight-line without IVVP
Dissaux et al30 RC High 3 2016 France VWK vs straight-line vs 80 5 yr N/A
Malek + IVVP vs
Talmant + IVVP
Doucet et al31 RC High 3 2013 France Malek without IVVP vs Talmant 40 3.3 yr 4 yr
with IVVP
Gunther et al32 RC Moderate 3 1998 USA FP vs straight-line + IVVP 119 3 yr N/M
Nadjmi et al14 RC High 3 2013 Belgium FP vs modified FP 40 23.9 mo 6 yr

Abbreviations: FP, Furlow double-opposing Z-plasties; IVVP, intravelar veloplasty; LOE, level of evidence; N/A, not applicable; N/M, not mentioned; PC, prospective cohort study;
RC, retrospective cohort study; VLP, von Langenbeck palatoplasty; VWK, Veau-Wardill-Kilner 2-flap palatoplasty.

405.e5
Teblick et al. Speech and Hearing Outcome After Cleft Closure. J Oral Maxillofac Surg 2019.
405.e6 SPEECH AND HEARING OUTCOME AFTER CLEFT CLOSURE

COMPARATIVE EFFECTIVENESS OF CP CLOSURE Tympanostomy Tubes

TECHNIQUES
Otitis Media With Effusion
OME is characterized by a mucoid or serous effusion
of the middle ear. OME is a condition with high preva-
lence in childhood; approximately 30 to 40% of chil-
dren develop OME at least once,33,34 but the
incidence reaches 90% in children with CP younger
than 1 year and up to 97% in children with CP
younger than 2 years.35,36 During palate
reconstruction, innervation and vascularization of
the palatal muscles are injured; in consequence, ET
function is not completely restored. According to
this theory, it is logical to assume that the
palatoplasty technique might play a role in the
prevalence of OME after palatoplasty.
Five cohort studies in this review (2 retrospec-
tive17,28 and 3 prospective4,15,16) included
comparisons of OME prevalence in children who
underwent different surgical techniques (Table 3).
Four studies reported no relevant difference in preva-
lence between their study groups, thus concluding
surgical technique has no influence on the prevalence
of OME postoperatively.4,15,17,28 However, in the study
by Hassan and Askar,15 IVVP using the Kriens was asso-
ciated with a lower incidence of OME compared with
the VWK palatoplasty.
As described earlier, children with CP with or
without cleft lip have problems with ventilation of
the middle ear and drainage of middle ear fluids. The
most common treatment to restore middle ear ventila-
tion is the placement of tympanostomy tubes.37 Place-
ment of tympanostomy tubes prevents the
development of negative pressure in the middle ear
and thus the accumulation of fluid. Approximately
half the children with CP (39 to 53%) in the 4- to 6-
year-old group underwent ventilation tube insertion
on at least 1 occasion. However, approximately 30%
received tubes twice and even 3% of children with
CP received tubes a third time.18 What is the associa-
tion between the surgical palatal closure technique
and the frequency of tympanostomy tube insertion?
Comparisons of incidence and prevalence of ventila-
tion tube placement between different palatal closure
techniques were performed in 6 retrospective cohort
studies7,17,19,21,28,29 and 1 prospective randomized
controlled trial18 (Table 4). Antonelli et al18 reported
no difference in the need for tympanostomy tubes at
5 to 6 years of age between the Furlow and von Lan-
genbeck palatoplasties. In 2 retrospective cohort
studies, no difference in need for tympanostomy
tube placement was found.17,21 However, D’Andrea
et al28 reported a lower incidence of ventilation tube

Table 3. PREVALENCE AND INCIDENCE OF OME AFTER PALATOPLASTY

Outcome: Prevalence of
Study, Year (Country) Design Intervention Participants OME

Guneren et al,4 2000
(Turkey)
Hassan and Askar,15 2007
(Egypt)
Spauwen et al,16 1992
(Netherlands)
Wilson et al,17 2017
(USA)
D’Andrea et al,28 2018
(France)
PC Gp I, VWK; Gp II, FP
PC Gp I, VWK; Gp II, Kriens
IVVP technique with
3-layer palatoplasty
PC Gp, I, FP; Gp II, VLP
RC Gp I, FP; Gp II, straight-
line palatoplasty
RC Gp I, VWK; Gp II,
Sommerlad IVVP
26 (Gp I, 13; Gp II, 13); 77% in Gp I, 62% in Gp II;
mean F/U, 27.3 mo no relevant difference
(6-56 mo)
70 (Gp I, 32; Gp II, 38) Lower incidence of OME
in Gp II
20 (Gp I, 10; Gp II, 10); 70% in Gp I, 70% in Gp II;
age at examination, no relevant difference
2.8-3.2 yr
F/U interval 1, <6 mo; AB for OME: interval 1,
F/U interval 2, 6 mo 23.5% in Gp I and
to 1 yr 22.2% in Gp II; interval
2, 30% in Gp I and
33.3% in Gp II; no
relevant difference
116 (Gp I, 60; Gp II, 56); 45% in Gp I, 57% in Gp II;
age at examination, no significant
2 yr difference (P = .191)

Abbreviations: AB, antibiotics; F/U, follow-up; FP, Furlow double-opposing Z-plasties; Gp, group; IVVP, intravelar veloplasty;
OME, otitis media with effusion; PC, prospective cohort study; RC, retrospective cohort study; VLP, von Langenbeck
palatoplasty; VWK, Veau-Wardill-Kilner 2-flap palatoplasty.
Teblick et al. Speech and Hearing Outcome After Cleft Closure. J Oral Maxillofac Surg 2019.
 TE
BLICK ET AL
Table 4. INCIDENCE OF TYMPANOSTOMY TUBE PLACEMENT AFTER PALATOPLASTY

Study, Year (Country) Design Intervention Participants Outcome: Tympanostomy Tubes

Antonelli et al,18 2011 (Brazil)
Smith et al,19 2008 (USA)
Wilson et al,17 2017 (USA)
Kappen et al,6 2017 (Netherlands)
Lithovius et al,21 2015 (Finland)
Carrol et al,7 2013 (USA)
D’Andrea et al,28 2018 (France)
Brgoch et al,29 2015 (USA)
Abbreviations: AB, antibiotics; F/U, follow-up; FP, Furlow double-opposing Z-plasties; Gp, group; IVVP, intravelar veloplasty; UCLP, unilateral cleft lip and palate; VLP, von Langen-
beck palatoplasty; VWK, Veau-Wardill-Kilner 2-flap palatoplasty.
Teblick et al. Speech and Hearing Outcome After Cleft Closure. J Oral Maxillofac Surg 2019.
Prospective Gp I, FP; Gp Ia at 9-12 mo old, Gp 370 with UCLP; examination at 5- Need for tympanostomy tubes: Gp
randomized, Ib at 15-18 mo old; Gp II, VLP; 6 yr old I, 9.8%; Gp II, 12.3%; no relevant
controlled study Gp IIa at 9-12 mo old, Gp IIb at difference between groups
15-18 mo old
Retrospective cohort Gp I, 2-flap palatoplasty; Gp II, FP 100 (Gp I, 60; Gp II, 40); F/U time Need for >2 sets of tympanostomy
study >2 yr (at 6-mo intervals) tubes: Gp I, 53%; Gp II, 18%; Gp
II had lower incidence of
tympanostomy tube placement
Retrospective cohort Gp I, FP; Gp II, straight-line repair F/U interval 1, <6 mo; F/U interval Need for tympanostomy tubes:
study 2, 6 mo to 1 yr interval 1, 11% in Gp I and 0% in
Gp II; interval 2, 20% in Gp I and
27.8% in Gp II; no relevant
difference
Retrospective cohort 2-stage palatoplasty 49 with UCLP; F/U at 17 yr old Tympanostomy tubes were placed
study $1 time in 78.7% of patients
Retrospective cohort Cleft palate closure with different 90; F/U at 3-9 yr old Surgical technique was not a
study techniques relevant factor related to
number of tympanostomy tubes
Retrospective cohort Gp I, FP; Gp II, VWK; Gp III, 2-flap 138 (Gp I, 24; Gp II, 24; Gp III, 70; Tympanostomy tubes required 6 yr
study palatoplasty; Gp IV, VLP Gp IV, 20); F/U at 3 and 6 yr after after repair: Gp I, 2.5; Gp II, 4.0;
palatoplasty Gp III, 2.0; Gp IV, 3.0 (P = .001,
Gp II vs Gp III; P = .003, Gp II vs
Gp IV; no significant difference,
Gp I vs Gp II)
Retrospective cohort Gp I, VWK; Gp II, Sommerlad IVVP 116 (Gp I, 60; Gp II, 56); F/U until Need for 2 sets of tympanostomy
study 5 yr of age tubes: Gp I, 48%; Gp II, 21%
(P = .02)
Retrospective cohort Gp I, straight-line with IVVP; Gp II, 94 (Gp I, 41; Gp II, 34; Gp III, 19) Mean number of tympanostomy
study FP; Gp III, straight-line without tubes placed: Gp I, 0.60; Gp II,
IVVP 0.85; Gp III, 1.47 (P = .0065)

405.e7
405.e8
placement after the Sommerlad IVVP compared with
the VWK palatoplasty. At 2 years of age, 48% of chil-
dren in the VWK group already had 2 sets of tympanos-
tomy tubes placed compared with only 21% of
children in the Sommerlad IVVP group. Brgoch
et al29 compared straight-line palatoplasty with IVVP,
straight-line without IVVP, and the Furlow palato-
plasty. At 2 years of age, straight-line palatoplasty
with IVVP was associated with an average of 0.60
tube placed compared with 1.47 tubes for the same
surgery without IVVP. The Furlow group showed
similar results as the Sommerlad group, with an
average of 0.85 tube placed. They concluded palatal
muscle reconstruction by IVVP or Furlow double-
opposing Z-plasties could improve ET function and
lessen the need for tympanostomy tubes.
Smith et al19 pointed out the beneficial effects of the
Furlow palatoplasty on the need for ventilation tubes.
They found a lower incidence of ventilation tube
placement after Furlow double-opposing Z-plasties
(group A) compared with 2-flap palatoplasty (group
B). Two years postoperatively, 53% of patients in group
B had at least 3 sets of ventilation tubes placed
compared with only 18% of patients in group A.
They concluded the Furlow palatoplasty has a better
outcome on ET function and thus children have fewer
OME episodes that need ventilation tubes. Carrol et al7
investigated the impact of surgical technique on the
need for ventilation tubes later in life. Six years after
palatal reconstruction, children who underwent the
von Langenbeck technique had an average of 3.0 tubes
placed compared with 4.0 tubes in children who un-
derwent the VWK technique. These numbers were
statistically larger than for the Furlow and 2-flap palato-
plasty groups (2.5 and 2.0 tubes placed, respectively).
Hearing Loss
A major negative long-term outcome in children with
CP is hearing loss, even after palatal reconstruction.
Because all surgical techniques have their differences
in reconstructing the CP, they also would have differ-
ence effects on the hearing capabilities of children.
Hearing loss after palatoplasty was estimated by 3
retrospective cohort studies7,21,22 and 1 prospective
randomized controlled trial18 (Table 5). In general,
the Furlow palatoplasty was associated with the best
audiometric outcomes. Antonelli et al18 reported a
mean pure tone audiometry (PTA) threshold of
14.7 dB at 5 to 6 years of age with the Furlow palato-
plasty compared with 17.5 dB in patients who under-
went the von Langenbeck palatoplasty with IVVP
(P = .048). Carrol et al7 confirmed these results,
because they found a mean PTA hearing threshold of
10.0 dB with the Furlow palatoplasty at 6 years of
age, which is considerably lower than with the 2-flap
palatoplasty (11.7 dB) and the VWK and von Langen-
SPEECH AND HEARING OUTCOME AFTER CLEFT CLOSURE
beck palatoplasties (15.0 dB). Type of repair tech-
nique was seen to significantly influence PTA score
(P = .027). Musgrave et al22 examined hearing levels
at 10 years of age and found that children who under-
went the VWK technique had higher rates of hearing
loss compared with those who underwent the von
Langenbeck technique. Lithovius et al21 reported
that surgical technique was not a relevant factor
related to hearing loss.
Speech
In the normal situation, no air passes through the
nose during the production of non-nasal speech
sounds. This is accomplished by an elevation of the
soft palate, which closes off the nasal cavity. In chil-
dren with an unrepaired CP, this action is impossible
because the oral and nasal cavities compose a contin-
uum. Even after palatal closure, total velopharyngeal
closure can remain inadequate, which hinders normal
speech development.
Disturbances of speech mostly seen in children with
CP are deviant consonant production, audible nasal air
emission, hypernasality, and malarticulation. Concerning
the pronunciation of consonants, the sounds/s/,/r/,/l/
and explosive consonants/t/and/d/are the most difficult
for children with CP.38,39
According to the literature, approximately 50% of
patients born with CP develop problems with speech
at 3 years of age, even if they underwent palato-
plasty.20,40 Eleven studies (10 retrospective cohort
studies12,14,23-27,30-32 and 1 prospective cohort
study16) examined the association between speech
and palatal closure technique (Table 6). Dissaux
et al30 compared the VWK straight-line palatoplasty
with the Sommerlad IVVP. The worst speech out-
comes (intelligibility, nasal air emission, hypernasality)
were seen in the VWK group. The best outcomes were
observed in the Sommerlad IVVP group. The benefi-
cial results of the Sommerlad IVVP are supported by
Doucet et al.31 Three years postoperatively, children
who underwent IVVP using the Sommerlad technique
had better speech outcomes than children who
underwent the Malek protocol without IVVP. Only
15% of children who underwent the Sommerlad pro-
cedure with IVVP had a delay in speech articulation
compared with 55% of children who underwent the
Malek protocol without IVVP. Concerning intelligi-
bility, 30% of children who did not undergo IVVP
had good intelligibility compared with 75% who un-
derwent the Sommerlad IVVP. Gunther et al32
compared IVVP with the Furlow palatoplasty. The re-
sults were in favor of the Furlow palatoplasty, because
these children had lower incidences of hoarseness,
nasal escape, and hypernasality at 3 years of age. Yama-
nishi et al26 compared the Furlow palatoplasty with
the VWK palatoplasty and concluded that there was
 BLICK ET AL
TE 405.e9

Table 5. AUDIOMETRIC OUTCOMES AFTER PALATOPLASTY

Study, Year Outcome:

(Country) Design Intervention Participants Audiometric

Antonelli et al,18 Prospective Gp I, FP; Gp Ia at 370 with UCLP; PTA air conduction
2011 (Brazil) randomized, 9-12 mo old; Gp Ib audiologic F/U thresholds slightly
controlled study at 15-18 mo old; Gp assessment at 6- to better in right ears
II, VLP with IVVP; 12-mo intervals of Gp I (14.7 dB) vs
Gp IIa at 9-12 mo until 5-6 yr old Gp II (17.5 dB;
old; Gp IIb at P = .048);
15-18 mo old otherwise no
significant
difference between
groups
Musgrave et al,22 Retrospective cohort Gp I, VLP; Gp II, VWK Age at surgery: Gp I, Gp I had greater
1975 (USA) study 23 mo; Gp II, hearing loss
20 mo; examination
at 10 yr of age
Carrol et al,7 Retrospective cohort Gp I, FP; Gp II, VWK; 69; F/U at 3 and 6 yr Median PTA hearing
2013 (USA) study Gp III, 2-flap after palatoplasty thresholds at 6 yr of
palatoplasty; Gp IV, age: Gp I, 10.0 dB;
VLP Gp III, 11.7 dB; Gp
II + IV, 15.0 dB;
Furlow palatoplasty
resulted in better
hearing outcome
Lithovius,21 2015 Retrospective cohort Cleft palate closure 90; F/U at 3-9 yr of age Surgical technique
(Finland) study with 1-stage palatal, was not a relevant
3-layer closure, and factor related to
Kriens IVVP hearing loss
Abbreviations: AB, antibiotics; F/U, follow-up; FP, Furlow double-opposing Z-plasties; Gp, group; IVVP, intravelar veloplasty;
PTA, pure tone audiometry; UCLP, unilateral cleft lip and palate; VLP, von Langenbeck palatoplasty; VWK, Veau-Wardill-
Kilner 2-flap palatoplasty.
Teblick et al. Speech and Hearing Outcome After Cleft Closure. J Oral Maxillofac Surg 2019.

no relevant difference in articulation and velopharyng-
eal function between the 2 groups. Three studies
compared the Furlow double-opposing Z-plasties
with the von Langenbeck technique. All agreed that
the Furlow palatoplasty showed better speech out-
comes.16,25,27 Yu et al27 reported the prevalence of
adequate velopharyngeal function at 2.5 years of age,
because this is the most important condition for
normal speech development. After the Furlow palato-
plasty, 98% of children had adequate velopharyngeal
closure compared with 70% of children who under-
went the von Langenbeck technique. Spauwen
et al16 compared speech assessment at 2.8 to 3.2 years
of age and found hypernasality in 50% of children oper-
ated on by the von Langenbeck technique versus 0% of
children operated on by the Furlow technique. The
results of nasal emission also were beneficial for the
Furlow group, with a prevalence of 10% compared
with 50% in the von Langenbeck group. There was
no relevant difference found for articulation. Vokur-
kova et al25 compared these techniques at an older
age (6 years), when the Furlow palatoplasty is still
the most beneficial technique for nasality, nasal emis-
sion, and articulation. Dong et al12 compared the Fur-
low palatoplasty with the 2-flap palatoplasty for
speech assessment 6 months postoperatively. Overall,
children who underwent the Furlow procedure had
better outcomes for nasal resonance and intelligibility.
Only 2% had severe hypernasality compared with
17.5% of patients who underwent the 2-flap palato-
plasty. The average score for intelligibility was 84.34
in the Furlow group compared with 76.26 in the
2-flap palatoplasty group. There was no relevant differ-
ence in nasal emission. Funayama et al24 performed a
retrospective cohort study comparing 1-stage Furlow
palatoplasty (group A) with 1-stage VWK pushback
(group B) and 2-stage Furlow palatoplasty (group C)
at 4 years of age. The results were in favor of the
1-stage Furlow palatoplasty and least beneficial for
the 2-stage Furlow palatoplasty. The prevalence of
nasal emission at 4 years of age was 0% in group A,
35.3% in group B, and 72.7% in group C.
 405.e10
Table 6. SPEECH OUTCOME AFTER PALATOPLASTY

Study, Year
(Country) Design Intervention Participants Outcome: Speech

Dayashankara Retrospective Gp I, VWK; Gp II, 3-layer 24 (Gp I, 12; Gp II, 12); Nasal resonance better in Gp II than in Gp I (P = .02); no
et al,23 2011 cohort study palatoplasty (Kriens 6-mo postoperative relevant difference in articulation or intelligibility, but the 2
(India) technique) F/U groups performed considerably better postoperatively than
preoperatively, which indicates that the 2 techniques
improved speech quality; Gp II had higher incidence of
postoperative fistula
Dong et al,12 2012 Retrospective Gp I, FP; Gp II, 2-flap 88 (Gp I, 48; Gp II, 40); Nasal resonance scores better in Gp I than in Gp II (severe
(China) cohort study palatoplasty >6 mo postoperative hypernasality, 2 vs 17.5% of patients); intelligibility better in
F/U Gp I than in Gp II (84.34  11.75 vs 76.26  12.93; P = .003);
nasal emission showed no relevant difference
Funayama et al,24 Retrospective Gp I, 1-stage FP; Gp II, 38 with UCLP (Gp I, 10; Nasal emission prevalence at 4 yr: 0% in Gp I, 35.3% in Gp II,
2014 (Japan) cohort study 1-stage VWK Gp II, 17; Gp III, 11); 72.7% in Gp III; malarticulation prevalence: 10% in Gp I,
pushback; Gp III, speech assessment at 35.3% in Gp II, 63.6% in Gp III; but with a relevant correlation
2-stage FP 4 and 8 yr of age between these outcomes and oronasal fistula (0% in Gp I, 47%
in Gp II, 100% Gp III)
Spauwen et al,16 Prospective Gp I, FP; Gp II, VLP 20 (Gp I, 10; Gp II, 10); Nasal resonance prevalence: 0% in Gp I, 50% in Gp II; nasal
1992 cohort study speech assessment at emission prevalence: 10% in Gp I, 50% in Gp II; articulation:
(Netherlands) 2.8-3.2 yr of age no relevant difference

SPEECH AND HEARING OUTCOME AFTER CLEFT CLOSURE

Vokurkova et al,25 Retrospective Gp I, FP; Gp II, VLP 15; speech assessment at Better speech results in Gp I than in Gp II
2000 (Czech cohort study 6 yr of age
Republic)
Yamanishi et al,26 Retrospective Gp I, 2-stage palatoplasty 72 with UCLP (Gp I, 30; No relevant difference between groups in velopharyngeal
2011 (Japan) cohort study (Furlow); Gp II, 1-stage Gp II, 42); examination competence and articulation
palatoplasty (VWK) at 4 yr of age
Yu et al,27 2001 Retrospective Gp I, FP; Gp II, VLP 96 (Gp I, 46; Gp II, 50); Prevalence of adequate velopharyngeal function: 98% in Gp I,
(Taiwan) cohort study speech assessment at 70% in Gp II; better speech outcome with Furlow method
2.5 yr of age
Dissaux et al,30 Retrospective Gp I, VWK; Gp II, 80 (Gp I, 20; Gp II, 20; Gp Gp I had worst speech outcomes (intelligibility, audible nasal air
2016 (France) cohort study straight-line III, 20; Gp IV, 20); emission, hypernasality); best outcomes in Gp III and IV; no
palatoplasty; Gp III, examination at 4-6 yr relevant difference in nasal air emission with
Malek + Sommerlad of age Aerophonoscope
technique; Gp IV,
Talmant + Sommerlad
technique
Doucet et al,31 Retrospective Gp I, Malek without 40 (Gp I, 20; Gp II, 20); Children with delay in speech articulation: 55% in Gp I, 15% in
2016 (France) cohort study IVVP; Gp II, 3.3-yr postoperative Gp II (P = .019); children with good intelligibility: 30% in Gp I,
Sommerlad F/U 75% in Gp II (P = .01); nasal air emission: more in Gp I
(P = .007)
 BLICK ET AL
TE 405.e11

Abbreviations: AB, antibiotics; F/U, follow-up; FP, Furlow double-opposing Z-plasties; Gp, group; IVVP, intravelar veloplasty; UCLP, unilateral cleft lip and palate; VLP, von
Malarticulation was seen in 10% of children in group A,
Better speech quality (based on Bzoch test; P = .04), nosometry
Higher incidence of hoarseness, nasal escape, hypernasality in

(P = .002), hypernasality (P = .015) in Gp II; hypernasality

35.4% in group B, and 63.6% in group C. In this study,
the 2-stage Furlow palatoplasty showed the worst
speech outcomes, but these results are in contrast to
all the studies cited earlier. Funayama et al noticed
this and added the prevalence of oronasal fistulas in
each group to their analysis. They found a strong cor-
relation between speech outcomes and prevalence
prevalence: 50% in Gp I, 10% in Gp II

of oronasal fistula, which made the association with

surgical technique unclear. Thus, they concluded
that the results showed that a postoperative fistula at
4 years of age has a marked negative influence on
speech development, regardless of surgical technique.
Several studies reported on the beneficial effects of
the Furlow palatoplasty on speech and language devel-
opment. However, this technique is not suitable for
wider clefts. Concerning this issue, Nadjmi et al14
modified this technique to make it more applicable
Gp II

for wider clefts. This modification was compared

with the standard Furlow palatoplasty. In children
with clefts wider than 9 mm, the modification by
Nadjmi et al generated less hypernasality, less nasal
emission, and better velopharyngeal closure measured
119; examination at 3 yr

by nosometry. This led to better speech quality

(Gp I, 10; Gp II, 30)
40 with cleft >9 mm

compared with the classic Furlow palatoplasty.

Velopharyngeal Function
Adequate velopharyngeal function is the most
of age

important factor for speech outcomes. After primary

Teblick et al. Speech and Hearing Outcome After Cleft Closure. J Oral Maxillofac Surg 2019.

cleft surgery, 20 to 40% of children still complain about

hypernasality. This is typically seen when velophar-
yngeal inadequacy (VPI) is present. VPI is the incom-
petence to completely close the velopharyngeal
Gp I, FP; Gp II, modified
Gp I, FP; Gp II, straight-

port, which is needed during speech or while eating.

Langenbeck palatoplasty; VWK, Veau-Wardill-Kilner 2-flap palatoplasty.

Children with VPI develop compensatory errors,

such as glottal stops, nasal resonance, nasal emission,
and distorted articulation.41 Because this is the basis of
line + IVVP

later speech problems, it is important to know

whether the technique used in primary cleft surgery
FP

plays a causal role. Five retrospective cohort studies

investigated this issue12,14,16,24,26,27,31 (Table 7). Dou-
cet et al31 described the beneficial effects of the Som-
merlad IVVP compared with soft palate repair without
cohort study

cohort study
Retrospective

Retrospective

IVVP. With the Sommerlad technique, velopharyngeal

closure was achieved in 85% of patients who under-
went IVVP and in only 45% of patients who did not.
Yamanishi et al26 examined the differences between
the Furlow palatoplasty and the VWK palatoplasty
but found none. Two studies compared the Furlow
palatoplasty with the von Langenbeck palatoplasty.
2013 (Belgium)

At 2.5 years of age, Yu et al27 found that the prevalence

Gunther et al,32

Nadjmi et al,14
1998 (USA)

of adequate velopharyngeal function was 98% in the

Furlow group compared with 70% in the von Langen-
beck group. Spauwen et al16 supported these results at
2.8 to 3.2 years of age, with a 90% prevalence of velo-
pharyngeal closure after the Furlow palatoplasty
 405.e12
Table 7. SPEECH OUTCOME AFTER PALATOPLASTY: VELOPHARYNGEAL CLOSURE

Outcome: Velopharyngeal
Study, Year (Country) Design Intervention Participants Competence

Dong et al,12 2012 (China)
Spauwen et al,16 1992
(Netherlands)
Yamanishi et al,26 2011 (Japan)
Yu et al,27 2001 (Taiwan)
Retrospective Gp I, FP; Gp II, 2-flap palatoplasty 88 (Gp I, 48; Gp II, 40); >6-mo Prevalence of velopharyngeal
cohort study postoperative F/U closure: 89.5% in Gp I, 72.5% in
Gp II (P = .045)
Prospective Gp I, FP; Gp II, VLP 20 (Gp I, 10; Gp II, 10); Prevalence of velopharyngeal
cohort study examination at 2.8-3.2 yr of age closure: 90% in Gp I, 50% in Gp
II
Retrospective Gp I, 2-stage palatoplasty (Furlow); 72 with UCLP (Gp I, 30; Gp II, 42); No relevant difference in
cohort study Gp II, 1-stage palatoplasty examination at 4 yr of age prevalence of velopharyngeal
(VWK) competence
Retrospective Gp I, FP; Gp II, VLP 96 (Gp I, 46; Gp II, 50); speech Prevalence of adequate
cohort study assessment at 2.5 yr of age velopharyngeal function: 98% in
Gp I, 70% in Gp II; better speech

SPEECH AND HEARING OUTCOME AFTER CLEFT CLOSURE

outcome with FP
Doucet et al,31 2013 (France) Retrospective Gp I, Malek without IVVP; Gp II, 40 (Gp I, 20; Gp II, 20); 3.3-yr Prevalence of velopharyngeal
cohort study Talmant + IVPP (Sommerlad) postoperative F/U closure: 45% in Gp I, 85% in Gp
II (P = .019)
Nadjmi et al,14 2013 (Belgium) Retrospective Gp I, FP; Gp II, modified FP 40 with cleft >9 mm (Gp I, 10; Better speech quality (based on
cohort study Gp II, 30) Bzoch test; P = .04), nosometry
(P = .002), hypernasality
(P = .015) in Gp II; prevalence of
velopharyngeal closure by
nosometry: 50% in Gp I, 93.3%
in Gp II
Abbreviations: AB, antibiotics; F/U, follow-up; FP, Furllow double-opposing Z-plasties; Gp, group; IVVP, intravelar veloplasty; UCLP, unilateral cleft lip and palate; VLP, von Lan-
genbeck palatoplasty; VWK, Veau-Wardill-Kilner 2-flap palatoplasty.
Teblick et al. Speech and Hearing Outcome After Cleft Closure. J Oral Maxillofac Surg 2019.
 BLICK ET AL
TE
compared with 70% after the von Langenbeck palato-
plasty. Dong et al12 compared the Furlow palatoplasty
with the 2-flap palatoplasty and also found results that
favored the Furlow palatoplasty. They reported a prev-
alence of 89.5% of children with adequate velophar-
yngeal function 6 months after the Furlow
palatoplasty versus 72.5% after the 2-flap palatoplasty.
As mentioned earlier, Nadjmi et al14 compared the Fur-
low palatoplasty with their modification in children
with wider clefts (>9 mm); 93.3% of children with
the Nadjmi modification achieved velopharyngeal
closure compared with only 50% after the Furlow pal-
atoplasty, making this modification more beneficial for
speech development in wider clefts.
Discussion
The ideal surgical technique for CP reconstruction
continues to be a source of great controversy, because
not all studies agree that surgical technique has an
impact on speech and middle ear outcomes. Of the
studies that noted marked differences between surgi-
cal techniques, the Sommerlad and Furlow palato-
plasty techniques seemed to generate the best
outcomes for middle ear function and speech.
For OME, 4 of 5 studies concluded that the Furlow
palatoplasty, von Langenbeck palatoplasty, VWK pala-
toplasty, and Sommerlad IVVP had no relevant effect
on OME prevalence. Only 1 study15 reported a lower
incidence of OME after the Kriens IVVP compared
with the VWK palatoplasty.
For the number of tympanostomy tubes placed after
palatal reconstruction, 3 studies concluded that surgi-
cal technique was not a relevant factor related to the
number of ventilation tubes needed after palate repair.
However, 4 studies claimed the opposite. D’Andrea
et al28 pointed out the beneficial effects of the Som-
merlad technique compared with the VWK palato-
plasty. Carrol et al7 reported that the von
Langenbeck and VWK palatoplasties were associated
with a higher incidence of ventilation tube placement
compared with the Furlow and 2-flap palatoplasties.
Smith et al19 further investigated the difference be-
tween the Furlow palatoplasty and the 2-flap palato-
plasty; they concluded children needed fewer
ventilation tubes after the Furlow palatoplasty than af-
ter the 2-flap palatoplasty. Brgoch et al29 compared the
Furlow palatoplasty with the Sommerlad technique
and stated that their effects on the need for ventilation
tubes were similar.
For hearing outcomes, Musgrave et al22 reported
that a higher rate of hearing loss was seen 10 years af-
ter the von Langenbeck palatoplasty compared with
the VWK palatoplasty. Antonelli et al18 concluded
that after a von Langenbeck palatoplasty children
had higher PTA thresholds but these were compared
405.e13
with those after a Furlow palatoplasty. Along the
same line, Lithovius et al21 reported the lowest rates
of hearing loss after the Furlow palatoplasty. The
median PTA thresholds increased with the 2-flap pala-
toplasty and the highest rates were seen after the von
Langenbeck and VWK palatoplasties.
Another point of interest in children with CP is their
speech development. Three studies concluded that
the Furlow palatoplasty generated better speech out-
comes than the von Langenbeck palatoplasty. At
2.5,27 2.8 to 3.2,16 and 625 years of age, these children
had less hypernasality, nasal emission, and VPI. Dong
et al12 compared the Furlow palatoplasty with the
2-flap palatoplasty and found that children had the
best speech outcomes (nasal resonance and intelligi-
bility) after the Furlow palatoplasty. For wider clefts,
better speech outcomes were seen with the modifica-
tion of the Furlow palatoplasty by Nadjmi et al.14
Dayashankara et al23 stated that the Kriens IVVP
technique led to less nasal resonance than the VWK
palatoplasty. Two studies30,31 concluded the
Sommerlad technique has beneficial effects on
speech and language development, with less
hypernasality and better intelligibility, compared
with straight-line palatoplasty without IVVP30,31 and
the VWK palatoplasty.30
For velopharyngeal function, 2 studies16,27
compared the Furlow and von Langenbeck
palatoplasties and reported the positive influence of
the Furlow palatoplasty on velopharyngeal closure.
Dong et al12 also stated that the Furlow palatoplasty
generated a higher prevalence of adequate velophar-
yngeal competence compared with the 2-flap palato-
plasty. For wider clefts, a higher prevalence of
velopharyngeal closure was seen after the modifica-
tion of the Furlow palatoplasty by Nadjmi et al.14
LIMITATIONS
This systematic review had some limitations. First,
there were no studies that compared children with
CP with children in the normal population. Therefore,
it is not clear how these values are related to the
‘‘normal population.’’ For example, is the prevalence
of OME after a specific palatal surgical technique
equivalent to the prevalence of OME in children
without CP?
Second, in the section on OME, 3 of the 5 articles
were published more than a decade ago.4,15,16 With
ever-advancing medical practices, these results might
be too outdated to make any conclusions.
Third, slightly more than half the included studies
were of high quality and none had a level of evidence
higher than 2. This means there is a shortage of high-
quality randomized controlled trials about the effects
of CP closure techniques. Fourth, some studies were
405.e14
well designed and well executed but had small sam-
ples. Of the included studies, 5 had samples with
fewer than 40 patients. This could imply that the statis-
tical power of these studies is too low to detect differ-
ences. Fifth, all the studies in this systematic review
were cohort studies with heterogeneous methods,
making them unsuitable for meta-analysis. Therefore,
no attempt was made to perform pooled analysis,
and the evidence was summarized qualitatively.
FUTURE RESEARCH NEEDS
For future research, randomized controlled trials
with high power will be needed to verify the conclu-
sions of this study, because some included studies
were underpowered cohort studies. Ideally, future
studies would follow a standardized method,
removing the barrier to evidence synthesis that is
currently present.
Some very well-designed and well-executed studies
have searched for the ideal surgical technique for CP
closure. Because of the different findings, the authors’
question remains partly unanswered. Some studies re-
ported no relevant differences in outcome between
surgical techniques, making it difficult to draw overall
conclusions. Based on studies that did report a differ-
ence in CP closure technique, the Sommerlad and Fur-
low palatoplasties showed the best impact on ET
function. Compared with the 2-flap, VWK, and von
Langenbeck palatoplasties, the Sommerlad and Furlow
palatoplasties resulted in fewer OME episodes that
required tympanostomy tubes. For the Furlow palato-
plasty, this statement is supported by audiometric find-
ings. Hearing loss in children with CP is mainly caused
by repetitive damage from frequent otitis media epi-
sodes. Overall, lower PTA thresholds were described
after the Furlow palatoplasty compared to the 2-flap,
VWK, and von Langenbeck palatoplasties. These last
2 palatoplasties were associated with the highest rates
of hearing loss. For speech outcomes, some studies re-
ported no association between speech development
and surgical technique. The studies that did report
an association were in favor of the Sommerlad and Fur-
low palatoplasties. These techniques led to the lowest
prevalences of nasal emission, hypernasality, and VPI.
These prevalences were higher after CP closure with
the 2-flap, VWK, and von Langenbeck palatoplasties.
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