SP45. Understanding Velopharyngeal Insufficiency: Predictive Factors After Orthognathic Surgery in Adolescents With Cleft Palate

PURPOSE: Orthognathic surgery is often advised for adolescents with a repaired cleft palate to address midface hypoplasia. While these surgical interventions can improve facial structure, they may also result in velopharyngeal insufficiency (VPI) due to alterations in the anatomy of the soft palate and surrounding areas. Although the factors contributing to VPI post-palatoplasty in infants have been well-documented, there is a gap in understanding the determinants of VPI in patients undergoing orthognathic surgery. This study seeks to explore the predictors of VPI in adolescents who have previously undergone cleft palate repair and are undergoing orthognathic procedures. METHODS: We conducted a retrospective analysis of non-syndromic adolescents who had undergone orthognathic surgery for repaired cleft palates at a prominent children’s hospital from 1991 to 2024. Patients with follow-up periods shorter than six months were excluded. Data on demographics, surgical interventions, nasopharyngoscopic evaluations, and speech assessments by licensed speech and language professionals were collected. Both univariate and multivariate regression analyses were employed to evaluate the predictive significance of various factors related to post-operative VPI. RESULTS: Among 185 patients with cleft palate who received orthognathic surgery, 127 were included in the final analysis. The average age at surgery was 16.3 years. A majority (63%) underwent Le Fort I maxillary advancement, while 28.6% had distraction osteogenesis. The extent of advancement ranged from 2 to 14 mm (mean 6.65 ± 1.96) for the Le Fort I group and 5 to 30 mm (mean 13.54 ± 8.51) for the distraction group. Univariate analysis indicated a significant correlation between the length of maxillary advancement and post-operative VPI in the Le Fort I group (p = 0.001), but no such correlation was found for the distraction group (p = 0.852). The occurrence of VPI was similar in one-piece and segmental advancements (p = 0.286). Multivariate analysis identified several significant predictors of post-operative VPI, including the presence of bilateral cleft palate (p = 0.045), Veau class IV (p = 0.014), and a history of recurrent palatal fistulas (p = 0.011). Factors that did not significantly predict VPI included prior speech surgeries (p = 0.053), the presence of a single palatal fistula (p = 0.27), time elapsed since palatoplasty to surgery (p = 0.125), and age at follow-up (p = 0.354). CONCLUSION: This investigation highlights several important predictors of velopharyngeal insufficiency (VPI) following orthognathic surgery in adolescents with a history of cleft palate repair. Key factors include the length of maxillary advancement, the complexity of the cleft (bilateral or Veau class IV), and previous occurrences of palatal fistulas. These insights emphasize the necessity for comprehensive pre-surgical evaluations and tailored surgical strategies to reduce the likelihood of VPI, particularly in patients with intricate medical histories. Future research should focus on refining surgical techniques and post-operative care to improve outcomes in this vulnerable population.