Original Article

Velopharyngeal changes after maxillary distraction in cleft patients using

a rigid external distraction device:
A retrospective study
Mahasen Tahaa; Yasser M. Elsheikhb
ABSTRACT
Objective: To evaluate early and late velopharyngeal changes in cleft lip and palate (CLP) patients
after use of the Rigid External Distractor (RED) device and to correlate these changes to the
amount of maxillary advancement.
Materials and Methods: Thirty Class III CLP patients were included in the study. Maxillary
advancement was performed using the RED device in combination with titanium miniplates and
screws for anchorage. Lateral cephalograms, nasometer, and nasopharyngoscope records were
taken before distraction, immediately after distraction, and 1 year after distraction. A paired t-test
was used to detect differences at P , .05.
Results: SNA angle and A point and ANS to Y axis were significantly increased after maxillary
distraction (P 5 .0001). Statistically significant increases in nasopharyngeal and oropharyngeal
depths, velar angle, and need ratio were also found (P 5 .0001). Nasalance scores showed
a significant increase (P 5 .008 for nasal text and .044 for oral text). A significant positive
correlation was observed between the amount of maxillary advancement and the increase in
nasopharyngeal depth and hypernasality (P 5 .012 and .026, respectively).
Conclusions: Nasopharyngeal function was deteriorated after maxillary advancement in CLP
patients. There was a significant positive correlation between the amount of maxillary
advancement and the increase in nasopharyngeal depth and hypernasality. (Angle Orthod.
2016;86:962968.)
KEY WORDS: Hypoplasia; Distraction; Velopharyngeal; Nasometer

INTRODUCTION

advancement can trigger or worsen velopharyngeal

insufficiency (VPI),37 which is one of the most important
problems affecting speech in CLP patients.8
Recently, distraction osteogenesis (DO) has been
recognized as a widely accepted method to correct
maxillary hypoplasia in CLP patients, with predictable
and stable results. 912 DO aids in prevention of
velopharyngeal deterioration after maxillary advancement, in addition to enhancing bone stability, where
slow movement of the maxillary bone allows the
surrounding soft tissues as the facial envelop, soft
palate, and pharynx to adapt to the structural changes
and reduce skeletal relapse.13 Changes in speech and
velopharyngeal function (VPF) after maxillary distraction have been detailed in a few studies and have
yielded different results. Some investigators1416 have
reported VPF deterioration in 14% and 16.7% of their
patients after maxillary distraction. They identified the
degree of distraction at which VPF is compromised as
15 mm. Another study17 reported that the deterioration
of hypernasality was not always proportional to the

Maxillary hypoplasia is a common deformity in repaired

cleft lip and palate (CLP) patients. This hypoplasia is
related to a combination of congenital reduction in
midfacial growth and the surgical scar from the repair of
the cleft palate.1,2 About 25% of these patients require
orthognathic surgery for the correction of this deformity.2
Le Fort I maxillary advancement offers significant
improvement in terms of esthetic, functional, and psychosocial benefits. However, this immediate surgical
a
Associate Professor, Orthodontic Department, Faculty of
Dentistry, Mansoura University, Mansoura, Egypt.
b
Assistant Professor of Plastic Surgery, Faculty of Medicine,
Menuofyia University, Menuofyia, Egypt.
Corresponding author: Dr Mahasen Taha, Mansoura University,
Faculty of Dentistry, Mansoura 35516, Egypt
(e-mail: anbortho@hotmail.com)

Accepted: February 2016. Submitted: January 2016.

Published Online: March 23, 2016.
G 2016 by The EH Angle Education and Research Foundation,
Inc.
Angle Orthodontist, Vol 86, No 6, 2016

962

DOI: 10.2319/011216-33.1

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VELOPHARYNGEAL CHANGES AFTER MAXILLARY DISTRACTION

amount of advancement. It depended on the position of

the posterior pharyngeal wall and the rotation of the
palatal plane.
Therefore, the impact of DO on the status of the
velopharynx remains unclear, and the question of
a possible correlation between degree of maxillary
advancement and velopharyngeal deterioration remains unanswered. The aim of this study was to
evaluate early and late velopharyngeal changes in CLP
patients after using of a Rigid External Distractor (RED)
and to correlate these changes to the amount of
maxillary advancement.
MATERIALS AND METHODS
Patients
This study was approved by the Ethics Committee
of Alexandria University. This retrospective study was
conducted on 30 CLP patients who underwent maxillary DO at the Maxillofacial Surgery Department,
Faculty of Dentistry, Alexandria University, Egypt.
The patients had mean age of 17.13 6 4.9 years.
Among the 30 patients, 20 patients were females and
10 patients were males. Twenty-four patients had
a diagnosis of unilateral cleft lip and palate; the other
six patients had a diagnosis of bilateral cleft lip and
palate. Eight patients exhibited predistraction pharyngeal flaps. All patients had severe maxillary hypoplasia
and remarkable negative overjet.

Figure 1. Cephalometric parameters for the evaluation of skeletal

changes. Landmarks: S: Sella; N: Nasion; A: point A; B: point B;
ANS: anterior nasal spine; PNS: posterior nasal spine; Go: Gonion;
Me: Menton; Po: Porion; Or: Orbitale; References planes: S-N plane;
FH plane; palatal plane; mandibular plane; X-axis: 7u below the SN
line; Y-axis: the perpendicular line on the SN passing through the S
point. Linear and angular parameters: SNA; SNB; ANB; palatal plane
to SN angle; FMA; mandibular plane to SN angle; A, ANS and PNS
points to X- and Y-axes.

Surgery
A complete high-level Le Fort I osteotomy was
made, then the maxilla was downfractured softly
to ensure its mobility. Maxillary advancement was
performed using a RED device10 (KLS-Martin L.P.,
Tuttlingen, Germany) in combination with titanium
miniplates and screws for anchorage. Two titanium
miniplates were fixed with screws at both sides of
the anterior maxillary wall to be used for traction.
The RED device was applied immediately after
surgery using scalp screws. After a latency period of
5 days, distraction was performed at a rate of 1 mm/day
until a positive overjet was achieved. The distraction
device was left in place for 4 weeks for rigid retention.
Lateral cephalograms, nasometer, and nasopharyngoscopy were used for evaluating the patients at
three stages: preoperatively (T0), postdistraction (T1),
and 1 year after distraction (T2).
Cephalometric Analysis
All lateral cephalograms were manually traced.
Reference points were marked, yielding 22 linear and
seven angular measurements (Figures 1 and 2).14,18

To estimate the method error, 15 randomly selected

radiographs were traced and measured twice within
a week by the same person. The mean values from the
first tracing together with the mean values of the
second tracing were applied
p
Dahlbergs
P to the
formula,19 thus: (ME ~ d 2 =2n). For linear
measurements, 0.47 mm was set as the method error,
and for angular measurements it was 0.5u.
Nasometric Analysis
A Nasometer 6200-2 IM (30-02 software, 1.7
version; Kay Elemetrics, Pinebrook, NJ), a
microcomputer-based system manufactured by Kay
Elemetrics, was used. Nasalance scores were recorded during the reading of two sets of sentences,
one consisting of sentences containing predominantly
nasal sounds (nasal text), such as mama betnayem
manal, for the identification of reduced nasalance, the
other consisting of sentences with no nasal sounds
(oral text), such as as ?ali rah jel?b kura. The
resultant signal is a ratio of nasal to nasal plus oral
acoustic energy. This ratio is multiplied by 100 and
expressed as a nasalance score.20,21 Hypernasality
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TAHA, ELSHEIKH

Velopharyngeal valve movements were recorded

while the patient repeating the word / ? mbar/;
vowels /a/, /e/, and /u/; and syllables /pa/, /ta/, and
/ka/ for a repeated number of times. Movements of
the velum and lateral and posterior pharyngeal walls
were traced on the monitor. The movement of each
component was given a score (04), where 0 is
a resting (breathing) position, 2 is half the distance
to the corresponding wall, and 4 is the maximum
movement reaching and touching the opposite
wall.22
Statistics
Data were analyzed using the computer program
SPSS, version 17.0. Descriptive statistics were calculated in the form of mean 6 standard deviation
(SD).The significance of difference was tested using
the Students t-test (paired) to compare between
the means of two related groups of numerical
(parametric) data. The Pearson correlation coefficient test was used to correlate different parameters.
A P value of ,.05 was considered statistically
significant.
Figure 2. Cephalometric parameters for the pharyngeal airway
passage and soft tissue. Landmarks: ad1: the intersection of the
PNS-Ba line and the posterior pharyngeal wall; ad2: the intersection
of a perpendicular line from PNS to Ba-S line with the posterior
pharyngeal wall; H: the point of intersection of a perpendicular line
from PNS to Ba-S with the cranial base; Ptm: pterygomaxillary
fissure; UPW (upper pharyngeal wall): the intersection of the pp
and posterior pharyngeal wall; MPW (middle pharyngeal wall): the
intersection of the line from point U to the posterior pharyngeal wall;
LPW (lower pharyngeal wall): the intersection of the line from V with
the posterior pharyngeal wall;. U: tip of uvula; T: the tip of the tongue;
V: the intersection of the epiglottis and the base of the tongue. Linear
and angular parameters. Lower airway thickness: PNS to ad1; lower
adenoid thickness: ad1 to Ba; total lower sagittal depth of the bony
nasopharynx: PNS to Ba; upper airway thickness: PNS to ad2; upper
adenoid thickness: ad2 to H; total upper airway thickness: PNS to
H; posterior sagittal depth of the bony nasopharynx: Ptm to Ba;
vertical airway length: PNS-V; nasopharyngeal depth: PNS to UPW;
oropharyngeal depth: U to MPW; the lower pharyngeal depth:
V to LPW; velar length: distance from PNS to U; velar thickness:
represents the maximal thickness of the soft palate measured
perpendicular to the PNS-U line; tongue length: T to V; tongue
height: the perpendicular distance from the most superior point of
the tongue to the V-T line; velar angle: ANS-PNS-U; need ratio:
nasopharyngeal depth/velar length.

and hyponasality were judged using separate

five-point scales, where 0 5 normal, 1 5 mild, 2 5
moderate, 3 5 severe, and 4 5 very severe.17

RESULTS
Cephalometric Measurements
The parameters pertaining to the sagittal maxillary
changes were 9.67u at the SNA angle, 8.5 mm at A
point, 11 mm at ANS, and 9.5 mm at PNS.
The vertical treatment changes in the maxilla, at the
position of A, ANS, and PNS points relative to the
X-axis, were increased significantly (P 5 .0001, .0001,
and .017, respectively), whereas the mean increases
in SNB angle, FMA, MP to SN, and PP to SN angles
were not statistically significant (P 5 .900, .749, .538,
and .493, respectively; Table 1). Significant increases
were observed in the nasopharyngeal and oropharyngeal dimensions (P 5 .0001), while the hypopharynx
(V-IPW) showed a nonsignificant change (P 5 .878).
Statistically significant results were recorded for the
velar angle and the need ratio (P 5 .0001). However,
the soft palate revealed no significant changes
(Table 2). Regarding the follow-up cephalometric
changes from T1 to T2, there were no significant
changes during this period except for the velar angle
(P 5 .005).
Nasometer

Nasopharyngoscope
The Karl Storz fibroptic naso-pharyngo-laryngoscopy model 11001 RP was used. Commenting on the
video record reply of all assessment aspects was done
with three judges.
Angle Orthodontist, Vol 86, No 6, 2016

During the reading of oral text, there was a significant

increase in the mean nasalance score (P 5 .044;
Table 3). In the analysis of the five-point scales of
hypernasality, 14 patients exhibited deterioration in
hypernasality. Twelve patients had the same scores,

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VELOPHARYNGEAL CHANGES AFTER MAXILLARY DISTRACTION

Table 1. Changes in the Skeletal Measurements
T0

SNA
SNB
ANB
FMA
MP to SN
PP to SN
A-X
ANS-X
PNS-X
A-Y
ANS-Y
PNS-Y

T1

T2

Mean

6 SD

Mean

6 SD

Mean

6 SD

P1

P2

71.33
75.33
24.42
33.83
42.92
11.83
50.92
43.58
41.58
58.42
61.67
17.33

3.85
2.90
3.50
3.41
4.85
2.59
6.01
5.07
4.38
6.86
9.32
4.42

81.00
75.42
5.58
34.17
43.83
12.50
57.00
48.75
43.67
66.92
72.67
26.83

4.26
3.42
3.60
4.63
4.47
3.63
5.03
5.50
3.20
8.66
8.18
4.80

78.67
74.22
5.67
34.11
44.22
13.11
56.22
47.78
44.00
64.78
71.67
24.89

4.58
4.06
2.87
3.72
4.09
3.41
6.91
4.55
3.46
7.40
6.42
4.26

.0001
.900
.0001
.749
.538
.493
.0001
.0001
.017
.005
.012
.0001

.134
.202
.915
.105
.233
.844
.831
.824
.629
.094
.535
.419

T0 indicates before distraction; T1, after distraction; T2, after retention; P, probability test used: paired t-test; P1, significance between T0 and
T1; and P2, significance between T1 and T2.

and four patients showed some improvement in the

hypernasality (Table 4).
In the reading of the nasal text, a significant
increase in mean nasalance score was observed
(P 5 .008 and .787) at T1 and T2, respectively (Table 3).
Four out of six patients showed a postoperative decrease in hyponasality. The other two patients with
unchanged mild hyponasality had a pharyngeal flap
(Table 4).
Nasopharyngoscope
The mean increases in the grade of motion of the
palate and right and left pharyngeal walls between T0
and T1 time intervals were not statistically significant
(P 5 .104, .272, and .671, respectively). In addition,
no statistically significant changes were observed
between T1 and T2 (Table 5).

DISCUSSION
Lateral cephalometric films and computed tomography are used to assess velopharyngeal status, providing observation of soft and hard tissues, although
the reliability of the two-dimensional image has been
questioned as a valid representation of the actual
nasopharyngeal anatomy. Some studies23 have shown
that pharyngeal airway space measured by cephalograms offers good agreement with a three-dimensional
computed tomography scan.
Cephalometric analysis of the sagittal and vertical
positions of the maxilla showed significant changes,
which were expected as a result of distraction. When
the maxilla was brought forward by DO, the depth of
the nasopharynx and oropharynx were increased
significantly (13.75 mm and 3.5 mm, respectively).
This is due to the forward movement of the posterior

Table 2. Changes in the Pharyngeal Airway Passage and Soft Tissue

T0

PNS-ad1
ad1-Ba
PNS-Ba
PNS-ad2
Ad2-H
PNS-H
Ptm-Ba
PNS-UPW
U-MPW
V- IPW
PNS-U
SPT
ANS-PNS-U
PNS-V
T-V
TGH
Need ratio

T1

T2

Mean

6 SD

Mean

6SD

Mean

6 SD

P1

P2

20.83
23.00
45.08
17.08
12.83
29.92
44.83
20.58
14.83
15.50
29.33
7.83
125.00
65.58
76.58
34.42
.70

3.41
4.13
4.23
3.96
3.69
4.32
4.61
3.03
3.10
3.15
2.02
1.19
3.88
8.24
2.50
2.54
.13

34.25
22.83
57.00
29.75
12.17
41.92
44.58
34.33
18.33
15.33
30.58
6.67
140.25
66.92
76.75
34.58
1.14

3.05
2.33
3.95
4.33
2.92
4.10
3.68
3.20
4.01
4.25
2.07
.98
5.22
8.69
3.02
2.39
.13

32.78
23.22
56.00
29.89
10.89
40.67
44.33
33.00
17.33
13.56
30.00
6.33
136.67
64.89
76.56
34.11
1.06

1.99
2.95
3.46
4.88
2.32
4.50
4.80
2.00
4.69
3.84
2.92
1.00
4.39
8.08
4.50
3.02
.13

.0001
.877
.0001
.0001
.526
.0001
.855
.0001
.0001
.878
.183
.06
.0001
.358
.854
.867
.0001

.094
.650
.012
.763
.855
.700
.877
.184
.305
.531
.763
.195
.005
.894
.928
.912
.157

T0 indicates before distraction; T1, after distraction; T2, after retention; P, probability test used: paired t-test; P1, significance between T0 and
T1; and P2, significance between T1 and T2.
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TAHA, ELSHEIKH

Table 3. Changes in the Nasometer Measurements Before Distraction (T0), After Distraction (T1), and After Retention (T2)

Nasal text
Oral text

T0

T1

T2

P1

P2

54.86 6 15.94
35.10 6 15.54

67.13 6 9.62
44.03 6 17.15

67.84 6 12.05
42.10 6 13.54

.008
.044

.787
.348

P1 indicates t-test between T0 and T1; P2, t-test between T1 and T2.

nasal spine and soft palate along with the maxilla

during DO. Ko et al.14 observed an increase in the
nasopharyngeal depth by a 1:1 ratio with the bone
movement after maxillary distraction in cleft patients.
The length of the soft palate remained unchanged.
This is parallel to the increase in the need ratio (1.14),
suggesting borderline VPI (the average need ratio in
normal patients was reported to be 0.87). This finding
is also reported in other studies. 14,17 However,
other studies24,25 reported 0.4 mm of lengthening of
the soft palate per millimeter of maxillary advancement. This diversity among results might be due to
different degrees of advancement, different types of
patients (cleft vs noncleft and unilateral vs bilateral
cleft), operation techniques, assessment methods, and
observation periods.

One of the prominent findings was the change in

the velar angle. We found 15.25u increases in the
inclination of the soft palate following 8.5 mm of
maxillary advancement. Schendel et al.25 found a velar
angle change of 2u per millimeter of maxillary
advancement in cleft patients and after conventional
osteotomy for maxillary advancement. Ko et al.14 found
an increase in the velar angle of 1.6u per millimeter of
advancement.
In our study, before distraction, 87% (26/30) of
the patients had nasalance values for the reading of
the oral text above the normal limit. This finding is
consistent with the high prevalence of VPI reported for
subjects with palatal clefts.8
Fourteen of 30 patients (46.6%) experienced
deterioration in hypernasality after distraction, which

Table 4. Judgments of Nasal Resonance Using a 5-Point Scale (0 5 Normal; 1 5 Mild; 2 5 Moderate; 3 5 Severe; 4 5 Very Severe)
Hypernasality

Hyponasality

Patient No.

T0

T1

T2

Direction

T0

T1

T2

Direction

1
2*
3
4*
5
6
7
8
9
10
11*
12*
13
14
15
16*
17*
18
19
20*
21
22
23
24*
25
26
27
28
29
30
Mean

3
0
1
2
1
2
3
3
3
0
3
1
2
1
2
2
3
0
1
0
0
3
3
1
3
1
1
2
2
1
1.8

3
0
3
2
4
1
3
4
4
4
3
2
2
4
1
2
3
0
2
0
4
4
4
2
3
4
3
1
1
1
2.4

3
0
3
2
4
1
3
4
4
4
3
2
2
4
1
2
3
0
2
0
4
4
4
2
3
4
3
1
1
1
2.4

Same
Same
Deteriorated
Same
Deteriorated
Improve
Same
Deteriorated
Deteriorated
Deteriorated
Same
Deteriorated
Same
Deteriorated
Improve
Same
Same
Same
Deteriorated
Same
Deteriorated
Deteriorated
Deteriorated
Deteriorated
Same
Deteriorated
Deteriorated
Improve
Improve
Same

3
1
0
0
0
0
0
0
0
3
0
0
0
0
0
3
0
0
0
1
0
0
0
0
0
3
0
0
0
0
0.46

0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0.06

0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0.06

Improve
Same
Same
Same
Same
Same
Same
Same
Same
Improve
Same
Same
Same
Same
Same
Improve
Same
Same
Same
Same
Same
Same
Same
Same
Same
Improve
Same
Same
Same
Same

T0 indicates before distraction; T1, after distraction; and T2, after retention.
* : patient with pharyngeal flap.
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VELOPHARYNGEAL CHANGES AFTER MAXILLARY DISTRACTION

Table 5. Changes in Nasopharyngoscopy Before Distraction (T0), After Distraction (T1), and After Retention (T2)

Palate
Right pharyngeal wall
Left pharyngeal wall

T0

T1

T2

P1

P2

2.43 6 0.43
2.43 6 0.62
2.48 6 0.55

2.71 6 0.62
2.64 6 0.77
2.57 6 0.47

2.64 6 0.14
2.62 6 0.43
2.53 6 0.47

.104
.272
.671

.189
.67
.165

P1 indicates t-test between T0 and T1; P2, t-test between T1 and T2.

indicated decreased speech intelligibility and subsequent speech worsening. This effect might be
attributed to the greater increase in the pharyngeal
depth than the velar length resulting in compromised
VP closure and coupling between the oral and nasal
cavities. An increase in hypernasality after maxillary
distraction in cleft patients was reported in other
studies as well.1416 In agreement with our results,
previous studies4,6 also reported a similar deterioration
of hypernasality in the patients who experienced
abnormal preoperative hypernasality before advancement. This indicates that maxillary advancement as
performed in this study may contribute to the worsening of a previously existing hypernasality in subjects
with cleft.
It was very obvious that the presence of a predistraction pharyngeal flap decreased the degree of
resultant postdistraction hypernasality, and these
findings were found to coincide with the results of Ko
et al.,14 Guyette et al.,15 and Harada et al.,16 in whose
studies the flap is a soft tissue obturator of the
pharyngeal space.
Twelve patients maintained the same degree of
hypernasality, and four patients showed some
improvement, from moderate to mild hypernasality;
thus, compensation in the VF mechanism might be
assumed in these patients. The small, consistent
increase in velar length and the significant increase
in velar angle achieved some form of muscular
compensatory activity in these patients. The increase
in the velar angle was the result of stretching of the soft
palate, which is aided in maintaining the vertical
position of the soft palate and is considered to be
a part of the compensation occurring in the VP
mechanism.14 Through a gradual bone distraction
procedure, the surrounding soft tissues may have
a better chance to adapt to the structural changes,
in contradiction to the sudden changes elicited by
the Le Fort I osteotomy.
Warren and Drake26 reported that 60% of their
subjects with cleft had nasal airway obstruction. In our

cases, 20% (6/30) of the patients analyzed presented

nasalance values for the reading of the nasal text
below the normal limit before distraction. Hyponasality
was found to be improved in 67% (4/6) of the patients.
No patient experienced an increase in hyponasality as
a result of DO. This finding is partially supported by
other studies27,28 whose authors suggested that maxillary advancement increases the nasopharyngeal
space, widens the nasal valve (thus favoring nasal
respiration), and reduces nasal resistance.
Regarding the nasopharyngoscopic results, all of the
patients had VPI preoperatively. This is may be due to
the cicatrization from previous palatal repair surgery.
After DO, there was no significant increase in the soft
palate or lateral pharyngeal wall movements. These
findings were documented by Satoh et al.,17 who found
a widening of the gap between the posterior pharyngeal wall and the velum after DO in the patients with
borderline closure before distraction. It is likely that
once a loss of contact between the posterior pharyngeal wall and the velum occurs, patients cannot adapt
to the changes to maintain the VPC. On the other
hand, some studies15 suggested that it is possible for
the maxillary distraction to encourage velopharyngeal
movement. As the palate is advanced in small
increments (approximately 1 mm per day), the patient
has time to adapt to the change before the maxilla is
advanced another 1 mm. However, the authors did not
image palatal movement before or after the distraction
procedure. They mentioned this observation only as
a suggestion after pre- and postdistraction oral
examination. They realize that intraoral observation is
not sufficient to make judgments of velar movement,
and they mentioned this observation only as a hypothesis for further research using appropriate imaging
procedures.15
In agreement with our correlation results, another
study14 has found a significant positive correlation
between the amount of forward skeletal movement
and postdistraction hypernasality and pharyngeal
depth (Table 6).

Table 6. Correlation Between A-Y and Other Variables

A-Y
r
P

PNS-UPW

U-MPW

V-IPW

PNS-U

SPT

ANS-PNS-U

Hyper

Endos

.695
.012

2.021
.947

2.404
.193

2.526
.079

2.056
.863

.361
.249

.587
.026

2.080
.806

r indicates Pearsons correlation coefficient; P, probability; Hyper, postdistraction hypernasality; and Endos, postdistraction endoscopic
results.
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968
A comprehensive speech evaluation is an important
component of treatment planning for maxillary DO,
especially if done in cleft patients. If VP closure
cannot be compensated for, pharyngoplasty and
pharyngeal flap procedures should be considered to
correct the VPI.
CONCLUSIONS
N The maxilla was moved forward by gradual distraction, causing an increase in nasopharyngeal depth
and compromising VPF.
N There was a positive correlation between the amount
of maxillary advancement and the increase in
hypernasality and pharyngeal depth.
N No significant relapse was encountered in maxillary
skeletal position, nasopharyngeal measurements, or
function during the follow-up period.

TAHA, ELSHEIKH

12.

13.

14.

15.

16.

17.

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