Twenty-Year Follow-Up of 50 Consecutive Patients Born with Unilateral Complete Cleft Lip and Palate Treated by the Oslo Cleft Team, Norway

Four-year follow-up comparison of three pre-surgical infant orthopedic methods on mandibular arch morphology in unilateral cleft lip and palate: A retrospective study

OBJECTIVE

To evaluate the impact of presurgical infant orthopedics (PSIO) on mandibular dimensions and inter arch relation at 4 years follow-up comparing three different PSIO methods (modified Grayson's technique, Dynacleft nasal elevator, OrthoAligner NAM with Dynacleft nasal elevator) to no-nasoalveolar molding (NAM) in infants with unilateral cleft lip and palate (UCLP).

METHODOLOGY

A retrospective cohort study was conducted on non-syndromic UCLP patients treated with either PSIO or no-PSIO between 2018 and 2019, with a 4-year follow-up. The cohort was divided into four groups of 13 patients each: group 1 received PSIO with the modified Grayson's technique, group 2 received PSIO with the Dynacleft nasal elevator, group 3 was treated with OrthoAligner NAM combined with Dynacleft nasal elevator, and group 4 received no PSIO. Mandibular transverse width and interarch relation were assessed using the Modified Huddart and Bodenham (MBH) index. Descriptive statistics, ANOVA, and the Chi-square test were used to compare mandibular dimensions and interarch relationships across the groups.

RESULTS

A total of 52 patients (29 boys, 23 girls) were included in the study. Mandibular arch dimensions showed no significant differences across groups (P>0.05), with inter-canine (Grayson: 26.31mm, Dynacleft: 27.42mm, OrthoAligner: 28.27mm, no-NAM: 27.15mm), anterior arch (33.36-33.50mm), inter-molar (36.50-36.77mm), and posterior arch widths (42.36-42.61mm). Crossbite and interarch occlusal relationships showed comparable distribution among all groups, with no significant variations (P>0.05).

CONCLUSION

The study found no significant differences in mandibular transverse arch dimensions or inter arch occlusal relationships among different PSIO modalities, indicating that the choice of PSIO modality did not substantially impact arch width or occlusion interarch relation.

What Does Cleft Lip and Palate Care Cost? The Time and Economic-Associated Burden of Care From Birth to Maturity

Introduction: This study aims to describe the burden of care (BoC) for the management of patients with nonsyndromic cleft lip and palate (CLP) by identifying provider burden, characterizing an interaction burden, and calculating an economic burden associated with their health system interactions. Methods: A retrospective chart review was conducted of patients with nonsyndromic CLP treated at a pediatric tertiary hospital between January 1, 1999, and April 30, 2021. Healthcare utilization data for inpatient and outpatient interactions were extracted. Community outpatient data were obtained from affiliated specialists. Bottom-up microcosting was utilized for hospital costing, the provincial tariff guide for provider reimbursement, and zip code for calculating patient costs. Results: In total, 58 patients identified with CLP had a median of 148.5 healthcare interactions (consults/follow-ups/surgeries) between the ages of 0 and 18 years. Patients had a median of 10.5 surgical procedures, and a median 135.8 outpatient interactions. The most used specialty service was orthodontics, with a median of 71.5 orthodontic interactions per patient. The median cost of care, including direct hospital costs, physician costs, community healthcare costs, and indirect costs, was $73,398. Conclusions: Patients born with nonsyndromic CLP have a very high frequency of healthcare encounters, out of proportion to cost associated with healthcare, suggesting an overall significant BoC.

The Early Operative Burden for Children Born with Cleft lip and Palate

OBJECTIVES

to audit the surgical management of infants born with non-syndromic cleft lip and palate (CLP) at an Australian cleft unit in a large tertiary paediatric hospital.

DESIGN

Retrospective cohort study.

SETTING

A tertiary Cleft centre.

PATIENTS

193 infants born with non-syndromic CLP were referred to the centre and underwent primary repair of their CLP between 2009 and 2020.Main Outcome Measures: (1) The timing and surgical repairs performed; (2) the frequency of postoperative complications; (3) the frequency of secondary Cleft surgery; and (4) the total Cleft-related operations performed for infants born with CLP.

RESULTS

Four different surgical repair techniques were performed by six surgeons, and postoperative complications were uncommon (n = 14). Rates of oronasal fistula surgery (10.5% at five years of age; 14.3% at eight years of age) and velopharyngeal insufficiency surgery (8.7% at five years of age; 14.3% at eight years of age) were not significantly different across the surgical repair groups (p-value >0.05) and were comparable to international Cleft centres. Children underwent an average of four operative procedures in this audit period, including primary Cleft repair, ear, nose and throat surgery, and dental care. Surgery for managing Eustachian tube dysfunction was the most common surgical intervention following primary Cleft repair.

CONCLUSIONS

Children born with non-syndromic CLP have a high early operative burden, with outcomes similar across the spectrum of techniques and surgeons.

Long-term follow-up of mandibular dental arch changes in patients with complete non-syndromic unilateral cleft lip, alveolus, and palate

BACKGROUND

Treatment of cleft lip and palate (CLP) requires a comprehensive interdisciplinary approach and long-term follow-up. Only a few studies are available that reported on changes after treatment, which showed that in particular the transverse dimension, in patients with CLP is prone to changes after treatment. However, those studies did not pay attention to concomitant changes in the mandibular arch that occur after treatment.

OBJECTIVES

To evaluate mandibular transverse dental arch dimensions and interarch transverse changes in patients with complete non-syndromic unilateral cleft lip, alveolus, and palate (CUCLAP) up to five years after treatment.

MATERIAL AND METHODS

Retrospective longitudinal study in 75 consecutive patients with CUCLAP directly after comprehensive treatment (T0), two (T2), and 5 years after treatment (T5). Great Ormond Street, London and Oslo (GOSLON) scores were available for all patients. Three-dimensional scans of all dental casts were made. Inter premolar and intermolar distances between the mandibular contralateral teeth were measured. The modified Huddart Bodenham (MHB index) was applied to assess the transverse interarch relationship. Paired t-tests and ANOVA were used to analyze transverse and interarch transverse changes. Linear regression analysis was done to define contributing factors.

RESULTS

Paired t-tests showed a significant decrease of the mandibular inter first and second premolar distances (p < 0.05) and an increase of the inter second molar distance, whilst the MHB Index deteriorated at all time points for all segments and for the total arch score (p < 0.05). Linear regression showed no significant contributing factors on the decrease of the transverse distances. However, inter arch transverse relationship was significantly affected by age at the end of treatment, missing maxillary lateral incisor space closure, and the GOSLON Yardstick score at the end of treatment (p < 0.05), especially during the first two years after treatment.

CONCLUSIONS

Changes occurred in the mandibular arch expressed as changes in the transverse dimensions and interarch relationship measured by the MHB Index. A younger age at the end of treatment, space closure for a missing maxillary lateral incisor and a higher GOSLON score at the end of treatment negatively influence the interarch transverse deterioration especially in the first two years after treatment. For the transverse dimensional changes in the mandibular arch such influencing factors could not be determined.

A novel success scale for evaluating alveolar cleft repair using cone-beam computed tomography

PURPOSE

Radiographic scales, based on plain radiographs, for the evaluation of alveolar cleft repair, have certain weaknesses and are thought to overestimate to some degree the success of the surgical intervention. The aim of this study was the presentation of a novel success scale for evaluating alveolar cleft repair using cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

Patients treated with secondary osteoplasty for unilateral or bilateral alveolar cleft were evaluated using the Bergland and Enemark scales, as well as the novel success scale, which measures the bone height, the bone width and the level of the nasal floor.

RESULTS

A total of 44 patients with a total of 53 alveolar cleft sites were included. According to the new scale, 60% of the cases were defined as successful, with moderate (kappa = 0.511) or substantial (kappa = 0.718) agreement, between the new scale and the Bergland or Enemark scale, respectively. Statistically significant correlation was reported between the new success scale and the closure of space of the lateral incisor, the patient's age at surgery, the graft revision and the presence of residual fistula.

CONCLUSIONS

The novel success scale for evaluating alveolar cleft repair using CBCT takes into consideration all dimensions of the bony bridge. Future application is necessary for validation of its potential value.

Eighteen-Year Follow-Up of 160 Consecutive Individuals Born With Unilateral Cleft Lip or Cleft Lip and Alveolus Treated by the Oslo Cleft Lip and Palate Team

OBJECTIVE

Describe patients born with unilateral cleft lip with or without cleft alveolus (CL±A) in relation to cleft severity and laterality, gender, associated anomalies and syndromes, number and type of lip- and nose operations, and time of alveolar bone graft (ABG) treatment in relation to dental status in cleft area.

MATERIALS AND METHODS

Patients included 220 children born with unilateral CL±A, born between 1988 and 1997 referred to the Oslo Cleft Lip and Palate Team. The data were collected retrospectively. All patients were followed up until 18 years of age.

RESULTS

Among all CL±A, 3.6% had recognized syndromes, 6.8% had associated anomalies, and in 89.6% CL±A was the only malformation. CL±A was more common, but not more severe, on the left side. Among the 160 individuals with CL±A without syndromes and associated anomalies, 66.9% had an isolated soft tissue CL, and 33.1% were diagnosed with a CL alveolus (CL+A). Male predominance was observed. Children with CL+A had more severe soft tissue clefts of the lip and underwent more lip and nose surgeries than children born with CL. The time of ABG was found to be at a younger age when the patient had a lateral incisor in the cleft area than when this tooth was missing.

CONCLUSION

Findings provide a reference for morphologic variations in CL±A, and insight into the surgical burden of care until the age of 18 years.

Facial Growth of Patients With Complete Unilateral Cleft Lip and Palate Treated With Alveolar Bone Grafting at 6 Years

Objective:

To investigate the effect that alveolar bone grafting (ABG) around 6 years of age has on facial growth by assessing craniofacial growth outcomes.

Design:

Retrospective cohort study.

Setting:

North American cleft centers.

Participants:

A total of 33 children with complete unilateral cleft lip and palate who were consecutively treated with secondary ABG around 6 years of age were compared to 148 participants from 4 centers with late secondary ABG.

Methods:

Preorthodontic standardized lateral cephalometric radiographs were analyzed and traced according to the Americleft Study protocol. Sixteen angular and 2 proportional measurements were performed. The outcomes of all ABG were assessed using the Standardized Way to Assess Graft scale. Measurement means from the study center (SC) were compared to 4 North American centers using analysis of variance and Welch modified t tests, and P < .05 was considered statistically significant.

Results:

For the SC, the mean age (SD) at the time of bone graft was 5.85 (0.71) years and the mean age at the time of the lateral cephalogram was 13.4 (1.8) years. The sagittal maxillary prominence of the SC was comparable to the 4 other centers. The mean SNA (78.1 [4.3]) for the SC was significantly higher compared to one center that used primary bone grafting ( P = .03). The soft tissue mean ANB (3.52 [4.09]) for the SC was significantly lower compared to 3 of the centers.

Conclusions:

Early secondary ABG around 6 years of age did not result in reduced midface projection as assessed by SNA and thus did not compromise anterior maxillary growth.

Comparison of Reliability of Categorical and Continuous Scales for Radiographic Assessments of Bone Infill Following Secondary Alveolar Bone Grafting

OBJECTIVES

To investigate examiner reliability of scoring intraoral radiographs of bone infill following secondary bone grafting using a categorical scale (modified Kindelan Index) and a 10-cm visual analog scale (VAS). To investigate the level of clinical experience on the reliability of these assessments.

DESIGN

Retrospective study involving 10 clinicians of varying clinical experience who were blind to the patient's identity.

SETTING

All grafting was carried out within the New Zealand public hospital service.

PATIENTS

Fifty-eight grafts (48 UCLP and 5 BCLP) were assessed with 14 duplicated radiographs randomly added to the sample, making a total of 72 radiographs for assessment.

MAIN OUTCOME MEASURES

Weighted kappa was used for intra- and interrater examiner reliability for the categorical scale and correlations for the VAS.

RESULTS

Relatively poor intrarater examiner agreement for categorical scoring (median 0.46) was found. Clinicians with greater experience generally recording higher intrarater weighted kappa. The intrarater correlations for the continuous scale (median 0.89) suggest better consistency regardless of the level of experience. The interrater relationships were generally low, with an average of weighted kappa of 0.25 while the overall average VAS correlation was 0.49. For the majority of scorers, there was a relationship between the VAS and the Kindelan Index, with lower VAS scores related to worse Kindelan scores.

CONCLUSIONS

The use of a VAS produced better intra- and interexaminer reliability than the categorical Kindelan Index and was more consistent despite the level of clinical experience. Further evaluation of the validity of the VAS for the assessment of bone infill is warranted.

Assessment of Orthodontic Burden of Care in Patients With Unilateral Complete Cleft Lip and Palate

Objective:

To assess the orthodontic burden of care of patients from a Brazilian rehabilitation center (Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo [HRAC-USP]).

Design:

Retrospective.

Setting:

Hospital for Rehabilitation of Craniofacial Anomalies, University of São Paulo.

Interventions:

One hundred files of unilateral complete cleft lip and palate patients who had consecutively finished orthodontic rehabilitation at HRAC-USP were evaluated from January 2011 to January 2013. The duration of orthodontic treatment, number of visits, kilometers traveled, number of appliances and surgical procedures performed were recorded. The sample was divided into 2 subgroups according to severity the interarch relation (Goslon Yardstick score) at the beginning of orthodontic treatment. Mann-Whitney test was applied for intergroup comparison ( P < .05).

Results:

For the total sample (n = 100), the mean time of orthodontic treatment was 140.2 months, the mean number of orthodontic appointments was 61.8, the mean number of appliances was 10, the mean number of surgical procedures was 6.2, and the mean distance traveled to attend the center for orthodontic appointments was 38,978.5 km. The subgroup with the most severe malocclusion (Goslon yardsticks scores 4 and 5) showed a longer orthodontic treatment length, greater number of surgical procedures, and longer distance traveled than those presenting Goslon yardstick scores 1, 2, and 3.

Conclusion:

Patients with greater severity of the initial malocclusion experienced a higher burden of care than patients with less severity of the initial malocclusion. To reduce the burden of care, research and efforts should focus on minimizing maxillary growth deficiency related to primary surgery.