The Eurocleft project 1996-2000: overview

Timeliness of surgical care in children with special health care needs: delayed palate repair for publicly insured and minority children with cleft palate

BACKGROUND/PURPOSE

Disparities in access to health care are known to exist for the most vulnerable pediatric population, children with special health care needs. Timely access to surgical care in this population is critical, yet poorly studied.

METHODS

A national database of pediatric hospitals in the United States was searched for nonsyndromic, healthy patients younger than 24 months who underwent cleft palate repair from 2003 to 2008. A multivariate, linear regression model was constructed to determine the relationship of public payer status and race with age at palatal repair.

RESULTS

Age at palate repair was significantly delayed for patients who were publicly insured (1.2 weeks, P = .01), were of nonwhite race/ethnicity (1.5-3.5 weeks, P = .009), and had a diagnosis of cleft lip in addition to cleft palate (3.4 weeks, P = .006) compared to their counterparts in a sample of 2995 patients with cleft palate.

CONCLUSION

There is a small but significant delay in age at repair for patients who are publicly insured or of nonwhite race/ethnicity. These results may herald broader access disparities that could adversely affect clinical outcomes and should be investigated further.

A two-centre study on facial morphology in patients with complete bilateral cleft lip and palate at nine years of age

The aim of this study was to compare craniofacial morphology and soft tissue profiles in patients with complete bilateral cleft lip and palate at 9 years of age, treated in two European cleft centres with delayed hard palate closure but different treatment protocols. The cephalometric data of 83 consecutively treated patients were compared (Gothenburg, N=44; Nijmegen, N=39). In total, 18 hard tissue and 10 soft tissue landmarks were digitized by one operator. To determine the intra-observer reliability 20 cephalograms were digitized twice with a monthly interval. Paired t-test, Pearson correlation coefficients and multiple regression models were applied for statistical analysis. Hard and soft tissue data were superimposed using the Generalized Procrustes Analysis. In Nijmegen, the maxilla was protrusive for hard and soft tissue values (P=0.001, P=0.030, respectively) and the maxillary incisors were retroclined (P<0.001), influencing the nasolabial angle, which was increased in comparison with Gothenburg (P=0.004). In conclusion, both centres showed a favourable craniofacial form at 9-10 years of age, although there were significant differences in the maxillary prominence, the incisor inclination and soft tissue cephalometric values. Follow-up of these patients until facial growth has ceased, may elucidate components for outcome improvement.

Sagittal maxillary growth in children with unilateral cleft of the lip, alveolus and palate at the age of 10 years: an intercentre comparison

OBJECTIVE

Aim of this intercentre study was to compare sagittal facial growth in children with unilateral cleft lip and palate treated with different surgical protocols. A first evaluation had been carried out at the age of 6 years, now the patients have been re-evaluated at the age of 10 years.

MATERIAL AND METHOD

22 patients had been analyzed in centre 1, 32 patients in centre 2. All patients had presurgical orthopaedics. Centre 1 had lip repair at the age of 3 months and one-stage palatal closure with 1 year. Centre 2 had lip repair with 6 months, soft palate repair at 12 and hard palate repair at the age of 30 months. Sagittal growth was evaluated on lateral cephalograms. As control, data of 35 non-cleft children were used. Statistical analysis was carried out with student's t-test, multiple comparisons with Bonferroni.

RESULTS

There was considerably normal sagittal facial growth in centre 1, with tendency of forward growth of the mandible. In centre 2 there was a slight decrease in sagittal maxillary and mandibular growth with unchanged intergnathic relation. There was no statistically significant difference in sagittal growth between the centres. A re-evaluation has to be carried out after the final growth spurt.

Facial surface changes after cleft alveolar bone grafting

PURPOSE

The aim of this study was to assess the 3-dimensional facial surface changes after cleft alveolar bone grafting with digital surface photogrammetry.

PATIENTS AND METHODS

In a prospective study, 22 patients with cleft lip and palate underwent alveolar bone grafting. Before the procedure and 6 weeks postoperatively and before the continuation of orthodontic treatment, 3-dimensional images were taken with digital surface photogrammetry. Seven standard craniofacial landmarks on the nose and the upper lip were identified. Their spatial change because of bone grafting was assessed. Statistical analysis was performed with analysis of variance and t test.

RESULTS

A significant increase in anterior projection on the operative side (P < .05) was found for the labial insertion points of the alar base (subalare). No significant changes were detected for the position of the labial landmarks.

CONCLUSION

Our results show 3-dimensionally that there is a positive influence of the alveolar bone graft on the projection of the alar base on the cleft side.

Survey of management of children with cleft lip and palate in teaching and specialist hospitals in Nigeria

OBJECTIVE

A national survey was conducted to obtain an overall view of the current management of children with cleft lip and/or palate in Nigeria.

METHOD

Questionnaires were sent to 44 identified cleft surgeons in all teaching and specialist hospitals in Nigeria.

RESULTS

A total of 38 respondents returned completed questionnaires. The findings are as follows: (1) a majority of the surgeons (68.4%) are "low-volume operators," undertaking 10 or fewer new cleft repairs annually; (2) 86.8% of the surgeons repair cleft lip at 3 to 4 months of age, and the most common (71%) unilateral cleft lip repair method is the rotation-advancement technique; (3) 50% of the surgeons use straight line repair for bilateral cleft lip; (4) a majority (79%) of the respondents close the soft and hard palates as a single procedure; 47.3% of respondents use the von Langenbeck technique, 21.1% use the double-opposing Z-plasty and 21.1%, the palatal pushback; (5) in the management of protruding premaxilla, 52.6% of the respondents choose adhesive tape; (6) procedures such as alveolar bone grafting, rhinoplasty, and surgical treatment for velopharyngeal incompetence are rarely done as part of cleft management; and (7) the interdisciplinary team approach is practiced by 21% of respondents.

CONCLUSIONS

Issues are raised regarding the current organization of cleft services. We hope the findings of this study will provide preliminary information needed for the eventual establishment of standard cleft management for children with cleft lip and palate deformity in Nigeria.

Craniofacial morphological outcome following treatment with three different surgical protocols for complete unilateral cleft lip and palate: a premilinary study

This study compared craniofacial morphology between three groups of children with complete unilateral cleft lip and palate, treated with different surgical protocols. The study included 66 10-year-old children (42 boys and 20 girls) with a complete unilateral cleft lip and palate (22 patients in each of the three groups). Children aged 7 months underwent one-stage surgery, performed by a single surgeon. During surgery, the soft and hard palate and the lip underwent correction. The difference between the groups depended on the hard palate closure. Group I patients had the mucoperiosteal flap elevated on both sides of the cleft. Group II patients had the mucoperiosteal flap elevated on the non-cleft side, and had only a minimal 2-3mm mucoperiosteal flap elevated on the cleft side. Group III patients had mucoperiostium elevated from the septum vomer to create a single-layered caudally pedicled flap, and had only a minimal 2-3mm palatal flap elevated on the cleft side. Craniofacial morphology was defined using lateral cephalometric analysis. Significant craniofacial morphological differences were identified between groups I, II and III. Group III demonstrated the most favourable morphology. This indicates that the technique of hard palate closure has significant influence on craniofacial growth and development.

Cleft lip and palate

Clefts of the lip and palate are generally divided into two groups, isolated cleft palate and cleft lip with or without cleft palate, representing a heterogeneous group of disorders affecting the lips and oral cavity. These defects arise in about 1.7 per 1000 liveborn babies, with ethnic and geographic variation. Effects on speech, hearing, appearance, and psychology can lead to longlasting adverse outcomes for health and social integration. Typically, children with these disorders need multidisciplinary care from birth to adulthood and have higher morbidity and mortality throughout life than do unaffected individuals. This Seminar describes embryological developmental processes, epidemiology, known environmental and genetic risk factors, and their interaction. Although access to care has increased in recent years, especially in developing countries, quality of care still varies substantially. Prevention is the ultimate objective for clefts of the lip and palate, and a prerequisite of this aim is to elucidate causes of the disorders. Technological advances and international collaborations have yielded some successes.

Dental Arch Relationship in Children with Complete Unilateral Cleft Lip and Palate following Warsaw (One-Stage Repair) and Oslo Protocols

Objective:

To compare the dental arch relationship following one-stage repair of unilateral cleft lip and palate (UCLP) in Warsaw with a matched sample of patients treated by the Oslo Cleft Team.

Material:

Study models of 61 children (mean age, 11.2; SD, 1.7) with a nonsyndromic complete UCLP consecutively treated with one-stage closure of the cleft at 9.2 months (range, 6.0 to 15.8 months; SD, 2.0) by the Warsaw Cleft Team at the Institute of Mother and Child, Poland, were compared with a sample drawn from a consecutive series of patients with UCLP treated by the Oslo Cleft Team and matched for age, gender, and soft tissue band.

Methods:

The study models were given random numbers to blind their origin. Four examiners rated the dental arch relationship using the GOSLON Yardstick. The strength of agreement of rating was assessed with weighted Kappa statistics. An independent t-test was carried out to compare the GOSLON scores between Warsaw and Oslo samples, and Fisher's exact tests were performed to evaluate the difference of distribution of the GOSLON scores.

Results:

The intrarater and interrater agreements were high (K ≥ .800). No difference in dental arch relationship between Warsaw and Oslo groups was found (mean GOSLON score  =  2.68 and 2.65 for Warsaw and Oslo samples, respectively). The distribution of the GOSLON grades was similar in both groups.

Conclusions:

The dental arch relationship following one-stage repair (Warsaw protocol) was comparable with the outcome of the Oslo Cleft Team's protocol.

An Evaluation of Health-Related Quality of Life (HRQoL) in a group of 4-7 year-old children with cleft lip and palate

BACKGROUND AND OBJECTIVE

Cleft lip and palate (CLP) is the most common congenital craniofacial abnormality. The interventions' intensity and psychosocial burden of the cleft may have a lasting impact on the child. The aim of this study was to assess the psychosocial functioning of 4 to 7-year-old children with non-syndromic CLP.

MATERIAL AND METHODS

Health-Related Quality of Life (HRQoL) was assessed using the revised German KINDL HRQoL questionnaire, a five-point, 24-Likert-item questionnaire covering six domains (physical well-being, emotional well-being, self-esteem, family life, friends and school). The total score is the sum of all item scores. In addition, a chronic generic module consisting of six items, and a specific parent module consisting of 22 items have been added to the core KINDL questionnaire. Higher scores indicate better HRQoL. All the parents of 4 to 7-year-old children with non-syndromic CLP treated at the interdisciplinary CLP center at Cologne University Hospital were invited to participate in the study.

RESULTS

A total of 74 families were contacted, 61 of whom agreed to study participation (82% response). The 61 children (32 boys and 29 girls) had a mean age of 5.39 years. The mean values for the total scale were slightly lower for children with CLP, but when compared, CLP and non-CLP children revealed no statistically significant difference in HRQoL levels.

CONCLUSION

This study demonstrated that 4 to 7-year-old children with CLP do not appear to experience major psychosocial problems when compared with their non-CLP peers.

Cleft lip and palate treatment of 530 children over a decade in a single centre

OBJECTIVE

We sought to evaluate the process of care and the outcomes of cleft lip and palate operations carried by a multidisciplinary team at a centre of craniofacial anomalies with a high patients' volume.

METHODS

A retrospective review of all cleft lips and/or palates cases treated in the centre from 1995 to 2007 was performed. Direct and long term complication rates, clinical, audiologic, speech intelligibility and dental arch assessments were analyzed.

RESULTS

A total of 530 children have been operated this period in the centre (64 isolated cleft lip closures). A detailed presentation of the outcomes is performed in relation to the various types of cleft lip and palates. The majority of parents (70%) reported very good or excellent results 2-5 years after the lip closure with the Millard technique, although those with bilateral clefts were significantly less satisfied (P<0.002). Forty-two percent of children with cleft palate and otitis media with effusion were self-improved 2-8 months after palate reconstruction and 83.3% of children treated with the two flaps palatoplasty technique had a rather high or very high intelligibility score. Muscles' retropositioning had a significant effect on intelligibility (P=0.04).

CONCLUSIONS

Children with cleft lips and palates have a variety of conditions and functional limitations even after the surgical correction of their problem that need to be evaluated and treated by several specialists. The treatment protocol utilized by the multidisciplinary team of our centre is efficient with a relative low percentage of complications and unfavorable results.

The nasal alar elevator: a new device that may reduce the need for primary operation of the nose in patients with cleft lip

To improve the shape of the cleft lip nose preoperatively, we have developed the nasal alar elevator. This has been used routinely since 1996 on all our cleft lip patients who have an asymmetrical nose, from the first week after birth until the date of primary lip surgery. We present our 11-year-long experience of using the device on patients born with complete, unilateral cleft lip. In this study 56 children, born between 1996 and 2006 inclusive, with complete unilateral cleft lip, had preoperative treatment with the elevator. During this 11-year period, continuous evaluation during the preoperative period, and its effects on the cleft lip nose, were evaluated, both preoperatively and postoperatively. Our results show that the preoperative use of the device has led to less need for primary nasal surgery. Instead of having to have a primary rhinoplasty (McComb) together with a lip plasty, as a routine, now only about 30% of the patients need primary surgical correction of the nose. If nasal correction is needed, a rather limited undermining of skin over the ala on the cleft side will often be sufficient. The use of a nasal elevator reduces both the length and the extent of the primary intervention, without compromising the final result.

Current practice of distraction osteogenesis for craniofacial anomalies in Europe: a web based survey

Aim of the study was to get more insight into the opinion of European surgeons and orthodontists on the use of distraction osteogenesis (DO) for patients with different diagnoses and treatment protocols. A web based survey was set up, showing records of four patients with different conditions: hemifacial microsomia (case 1), bilateral mandibular deficiency (case 2), cleft lip and palate (case 3) and Crouzon syndrome (case 4). Respondents from 181 Eurocleft centres were asked to fill out a questionnaire for each patient. Most of the respondents considered case 1 (80%), case 3 (81%) and case 4 (86%) suitable for DO, while only 31% were considering case 2 for DO. There was lack of consensus among the respondents about many aspects of DO. Out of six different treatment parameters, an acceptable degree of agreement was only seen in two: a latency period of 3-7 days and a distraction rate of 1mm per day. Furthermore, there was noticeable disagreement on the ideal age for treatment, surgical technique, distraction device, and retention period. Our results showed that there is a wide variety in treatment approaches for craniofacial anomalies in Europe. There is disagreement on essential steps in the distraction procedures.

Evaluation of Craniofacial Care outside the Brazilian Reference Network for Craniofacial Treatment

Objective:

To describe health care provided outside the Brazilian Reference Network for Craniofacial Treatment, and to inform the debate about craniofacial health care policy in Brazil.

Design:

Observational, retrospective cohort.

Methods:

Craniofacial care providers completed the same questionnaire previously used to evaluate the Brazilian Reference Network for Craniofacial Treatment (RRTDCF).

Results:

Units outside the RRTDCF are mainly located in the southeast region of Brazil and in universities. They comprise 56 independent clinics, 22 combined clinics, and four parental associations. Services provided are variable from unit to unit and just six of them meet the American Cleft Palate-Craniofacial Association minimum team standard. Genetic evaluation and counseling is provided by clinical geneticists in 35 units; whereas, in 30 units, it is undertaken by untrained professionals.

Conclusion:

A significant number of craniofacial units work in parallel and overlap the RRTDCF. They are funded by the government but not recognized as craniofacial teams. Regional disparities and lack of coordination within and between cleft lip and/or cleft palate (CL/P) teams are unsolved problems. Non-RRTDCF units are heterogeneous concerning configuration, service provided, areas of treatment, and composition of the teams. A nationwide and voluntary database on orofacial clefts is a proposed strategy to address some of these problems. Anticipated benefits include strengthening the collaboration within and between healthcare teams and supplying health authorities with a comprehensive and population-specific source of information on this prevalent and potentially preventable group of birth defects.

Evaluation of secondary functional cheilorhinoplasty during growth of cleft patients with residual lip and nasal deformities

PURPOSE

The aim of the study was to evaluate the clinical outcomes of secondary functional cheilorhinoplasty of residual lip and nasal deformities caused by muscular deficiency in cleft patients.

PATIENTS AND METHODS

During a 4-year period, 31 patients underwent cheilorhinoplasty, including complete reopening of the cleft borders and differentiated mimic muscle reorientation. In 21 patients, remarkable residual clefts of the anterior palate were also closed. Simultaneous alveolar bone grafting was performed in 15 patients. The minimum follow-up was 1 year. Cosmetic features evaluated were spontaneous facial appearance and changes in position of the nasal floor and the philtrum. The width of the alar base was measured. For functional outcomes, deficiency during mimic movements was evaluated, using standardized photographs taken preoperatively and postoperatively. The final results, judged according to defined criteria with several clinical factors, were compared.

RESULTS

Cosmetic and functional improvement was achieved in all patients. In young patients (aged 4 to 9 years), the improvements were noteworthy. There were no differences in outcomes between the groups with and without simultaneous grafting, except for unilateral cases with minor muscular deficiency, in whom bone grafting before cheilorhinoplasty led to better results.

CONCLUSION

In cases of major muscular deficiency, early cheilorhinoplasty should be performed at age 7 years, without waiting for the usual timing of bone grafting. In minor and moderate cases, the operation can ideally be done in combination with bone grafting.

Sagittal growth of the facial skeleton of 6-year-old children with a complete unilateral cleft of lip, alveolus and palate treated with two different protocols

OBJECTIVE

The purpose of the study was to compare sagittal growth of the facial skeleton of 6-year-old children treated in two cleft centres with different surgical protocols.

MATERIAL AND METHODS

Each group consisted of 20 consecutive non-syndromic children with complete unilateral cleft lip, alveolus and palate. They all had presurgical orthopaedics with a passive plate and external strapping until lip repair. Centre 1 had lip repair at the age of 3 months and one stage palatal closure at the age of 1 year. Closure of the alveolar cleft was planned at 9 years with bone grafting. In centre 2 lip repair was performed at the age of 6 months, soft palate repair at 12 months and hard palate repair together with mucoperiosteal closure of the alveolar cleft at the age of 30 months. At the time of investigation, the children from both centres had not received any postoperative orthodontic treatment. Sagittal growth was evaluated on lateral cephalograms using the angles SNA, SNB, ANB and SNPg. For control, Droschl standards were used. The Mann-Whitney U test was used for statistical analysis.

RESULTS

There was no statistically significant difference in SNA, SNB, ANB and SNPg between the centres at the age of 6 years. There were no children with a class III jaw relationship. The sagittal dimensions were close to the values of non-cleft control persons (Droschl standards).

CONCLUSION

There was considerable similar sagittal growth of the facial skeleton in both centres which has not been affected by the different surgical protocols so far. A final evaluation should be delayed until the growth of the facial skeleton is complete.

[Maxillary sequelae in cleft patients. Causes of maxillary hypoplasia and possible prevention]

Maxillary hypoplasia is frequently observed in cleft patients. Although maxillary retrusion can be a syndromic outcome, the growth failure is also a consequence of the primary surgery of the palate, alveolar cleft, or lip. In this article the authors analyze the impact of primary surgery on the maxillary growth failure and discuss on how to prevent this complication.

[Oronasal fistula in sequels of labialalveolarvelopalatine clefts]

Labial and palatine maxillary clefts are treated by surgery, as for oronasal fistula. One of the most important parts of management is the timing of primary surgery in order to avoid growth disturbance. The authors describe the various possibilities to close secondary oronasal fistula. The timing and choice of surgical techniques are still debated and being improved. Various surgical techniques are available, from mucoperiosteal palatal flap to a free flap. Nevertheless, the mucoperiosteal palatal flap is the most commonly used. In some cases mucoperiosteal flaps are impossible to perform, so other options for extreme cases are discussed.

Evaluation of patient satisfaction after therapy of unilateral clefts of lip, alveolus and palate

INTRODUCTION

Cleft lip, alveolus and palate (CLAP) is a craniofacial abnormality and is one of the most frequent human developmental anomalies. Therapy of clefts does not only comprise surgical closure of the cleft, but rather aims at an aesthetically and functionally optimal result at adult age.

MATERIAL AND METHODS

Thirty-three cleft patients with total clefts of lip, alveolus and palate were enrolled in this study. Osseous bridging of the alveolar cleft (osteoplasty) was performed in all patients followed by different types of subsequent treatment. All patients answered a questionnaire to assess their satisfaction with the treatment result and their facial appearance. Patient satisfaction was correlated to the type of alveolar cleft repair.

RESULTS

The returned questionnaires revealed varying patient satisfaction with their appearance, occlusal conditions, and dental aesthetics depending on the type of dental treatment in the alveolar cleft area. Questionnaire analysis by gender revealed clear gender-dependent differences in self-rated satisfaction.

CONCLUSION

Aesthetics gain increasing importance for self-perception. Therefore, patient satisfaction with her facial appearance should move even more into focus of therapy of clefts.

Comparison of facial morphology in two populations with complete unilateral cleft lip and palate from two different centers

OBJECTIVE

To identify differences in craniofacial morphology of two populations with a history of complete unilateral cleft lip and palate (UCLP) treated under different protocols.

DESIGN

Retrospective longitudinal cohort study.

SETTING

Cleft Center of the University of Nijmegen, The Netherlands, and the Cleft Lip and Palate Program, The Hospital for Sick Children, Toronto, Canada.

SUBJECTS

Nineteen patients (16 male, 3 female) from Nijmegen and 19 patients (16 male, 3 female) from Toronto. Each patient was matched for sex and age with a patient from the other group. The mean ages at which lateral cephalometric radiographs were available for the Nijmegen group were 5.5, 9.9, and 18.3 years, while for the Toronto group these were available at mean ages of 5.3, 10.1, and 18.3 years, respectively. Eighteen patients from the Nijmegen group received an alveolar bone graft at a mean age of 9.5 years (range 8.2 to 13.5 years). None of the patients from Toronto received bone grafts.

MAIN OUTCOME MEASURES

Eighteen cephalometric variables per radiograph were calculated at each time registration, using Dentofacial Planner cephalometric software. Statistical evaluation was performed with repeated-measures analysis of variance.

RESULTS

No differences were seen in the maxillary measurements. The patients in the Toronto group had significantly larger mandibles at all three time registrations.

CONCLUSIONS

The Nijmegen and Toronto protocols resulted in similar maxillary projections in patients with UCLP. Comparison of data from other studies supports the contention that the larger profile convexity of the Nijmegen group is a reflection of a genetically determined smaller mandibular size in the Dutch population.

The management of ectodermal dysplasia and severe hypodontia. International conference statements

An international conference on ectodermal dysplasias and hypodontia, held in London in 2004, featured a session devoted to the management of the ectodermal dysplasias and severe hypodontia. This paper presents a set of statements prepared by an international specialist panel, including representatives of patient support groups, who presented and subsequently debated a series of papers on this subject. The following topics were explored: potential roles of patient support groups; core care standards, including the roles and composition of medical and dental multidisciplinary teams for treating these conditions; the format of a baseline data set for patients with an ED; and priorities for research in ectodermal dysplasias, with particular regard to laboratory and clinical studies, and research methodology. The statements are intended to form an international framework for developing patient care pathways, and collaborative research in this field.

Anomalias craniofaciais: descrição e avaliação das características gerais da atenção no Sistema Único de Saúde

A primeira iniciativa para incluir a atenção às anomalias craniofaciais no SUS ocorreu em 1993. Um importante avanço foi a criação da Rede de Referência no Tratamento de Deformidades Craniofaciais (RRTDCF), atualmente com 29 centros credenciados. Os objetivos deste estudo foram descrever e avaliar as características gerais da atenção às anomalias craniofaciais nos centros que integram a referida rede. Foi utilizado questionário semi-estruturado, remetido por correio. Obteve-se 86,2% de respostas. Os resultados demonstram agregação de centros no Sudeste, em universidades e na área de fissuras labiopalatais; financiamento predominantemente público; equipes constituídas principalmente de acordo com parâmetros norte-americanos; atendimento de rotina em cerca de 90% e utilização de protocolos em cerca de 70% dos centros. A denominação da RRTDCF não parece corresponder à sua abrangência. Os achados sugerem necessidade de revisão da definição, objetivos e abrangência da RRTDCF e dos critérios de credenciamento de centros.

Standards for digital photography in cranio-maxillo-facial surgery – Part I: Basic views and guidelines

Clinical photography is an essential facility to support the work of cranio-maxillo-facial surgical departments. This paper highlights the requirements to ensure the highest quality and consistency of photographs taken and provides a standardized set of both facial and intra-oral views that fit the needs of accurate digital photo-documentation in cranio-maxillo-facial surgery. Furthermore it gives assistance in the selection of equipment, archival storage and error avoidance. These guidelines have been approved in November 2005 by the Council of the European Association for Cranio-Maxillo-Facial Surgery and are to be understood as a proposal to all our colleagues in Maxillofacial Surgery.

Treatment outcome in unilateral cleft lip and palate evaluated with the GOSLON yardstick: a meta-analysis of 1236 patients

BACKGROUND

The goal of this study was to assess determinants for treatment outcome in unilateral cleft lip and palate, evaluated according to the Great Ormond Street London and Oslo (GOSLON) Yardstick and 5-year-index ratings by means of a meta-analysis.

METHODS

Multiple databases were searched for publications in which patient groups were evaluated by GOSLON ranking or the GOSLON-like 5-year index. From the 15 selected publications, the following background variables could be extracted and were evaluated as determinants for treatment outcome in unilateral cleft lip and palate: year of birth, average age of the patient at the time of GOSLON classification, racial background, presence of Simonart's band, infant orthopedics, palatal closure before the age of 3 versus palatal closure at a later age, bone graft, and number of surgeons.

RESULTS

The total number of patients included in the meta-analysis was 1236. Patients whose soft and hard palate were closed before the age of 3 presented significantly poorer (p = 0.003) GOSLON scores (mean score, 2.9; SD 0.4) than patients whose palate was closed at a later age (mean GOSLON score, 2.3; SD 0.2).

CONCLUSIONS

Delayed palatal closure generally results in better dental arch relationships than early palatal closure. Well-designed, randomized clinical trials are required for further investigation of the optimal timing for palatal closure.

Part 2. Physical assessment of the infant with cleft lip and/or palate

Cleft lip and cleft palate (CL/CP) are the most commonly occurring craniofacial birth defects. Although some CL/CPs are detected on prenatal ultrasound, the majority are immediately recognized in the delivery room. Part 1 of this 2-part article, "Understanding the Embryology and Genetics of Cleft Lip and Palate," presented the embryology of the face, lip, and palate to help the clinician understand the timing, complexity, and factors that may influence the development of these defects. Part 2 provides clinicians with the tools needed to obtain a detailed family and pregnancy history to evaluate for known associated risk factors. It provides a guide for a systematic physical assessment of the infant with CL/CP along with key areas of assessment for other midline defects or physical findings consistent with associated syndromes. Pictures of a variety of types of CL/CP are included to enhance understanding of these defects. Treatment and long-term complications of CL/CP are reviewed with an emphasis on family support, identifying educational resources, and counseling.

Ethical and scientific decision making in distraction osteogenesis

OBJECTIVE

To propose a prospective registry for distraction osteogenesis research.

RESULTS

The search strategy identified 82 reports, of which 11 were review articles, 17 were animal studies, 5 were theoretical models, and 49 were case reports/series.

CONCLUSIONS

So far, the literature concerning distraction osteogenesis does not allow reliable choices to be made on the most appropriate form of distraction osteogenesis in different clinical decisions or whether it is superior to osteotomy or nontreatment. A prospective registry is proposed to hasten critical appraisal of distraction osteogenesis.