Speech following Le Fort I Maxillary Advancement in Cleft Maxillary hypoplasia - an objective and subjective outcome analysis.

PURPOSE: To objectively evaluate the effect of maxillary advancement on speech and VPI using video-fluoroscopy (VFS), direct nasoendoscopy, and speech evaluation and subjectively assess patients and their peer's perception regarding their speech outcome. MATERIALS AND METHODS: 27 cleft patients who underwent Lefort 1 maxillary advancement were divided into 2 groups- Group A with 4-7 mm of advancement and Group B with 8-13 mm advancement. VFS in lateral view, nasoendoscopy, and speech recordings were performed pre and 6 months postoperatively. VFS assessed the relative position of velum in relation to the pharyngeal wall, speech was evaluated for changes in nasal emission, resonance, and articulation along with nasal endoscopy to assess the overall function of the velopharyngeal valve. Subjective speech evaluation was done with a Patient-Reported Outcome Measure [PROM] questionnaire. RESULTS: As per VFS, for every 1 mm maxillary advancement, the velopharyngeal gap at rest increased by 1.75 mm in group A and 1.58 mm in group B. The compensatory changes in group B were more pronounced. Post-operative VFS showed velar closure remained the same as preoperative closure in 86.7%, and worsened in 13.3% in group A whereas it remained unchanged in 66.7%, improved in 25%, and worsened in 8.3% in group B. In nasoendoscopy, the closure pattern showed no change in 86.6%, improved in 6.7%, and deteriorated in 8.3% in group A while there was no change in 83.4%, improved in 8.3%, and deteriorated in 8.3% in group B. Dental and labiodental articulation statistically improved [p < 0.05] after surgery. PROM reported 85.7% of patients with improved speech, 82.1% improved sound quality along with 89.3% improvement in articulation. CONCLUSION: The primary cause for functional impairment and poor aesthetics in cleft deformity is the maxillary hypoplasia and therefore, should be the focus during correction. The pre-operative VP status or the amount of maxillary advancement could not predict the postoperative VP status. Maxillary advancement over 10 mm did not seem to significantly affect the final VP status. Articulation improves due to increased tongue space and favorable dental segment positioning. Mild to moderate immediate post op changes in nasality improves or even reverts to their preoperative status in the majority of the cases in about six months.

Mitochondrial apoptosis is amplified through gap junctions.

The death of one cell can precipitate the death of nearby cells in a process referred to as the bystander effect. We investigated whether mitochondrial apoptosis generated a bystander effect and, if so, by which pathway. Microinjection with cytochrome c mimicked function of the mitochondrial apoptosis-induced channel MAC and caused apoptosis of both target and nearby osteoblasts. This effect was suppressed by inhibiting gap junction intercellular communication. A bystander effect was also observed after exogenous expression of tBid, which facilitates MAC formation and cytochrome c release. Interestingly, in connexin-43 deficient osteoblasts, microinjection of cytochrome c induced apoptosis only in the target cell. These findings indicate that a death signal was generated downstream of MAC function and was transmitted through gap junctions to amplify apoptosis in neighboring cells. This concept may have implications in development of new therapeutic approaches.