Reference photographs for nasolabial appearance rating in unilateral cleft lip and palate

Correlation Between the Initial Severity of Oral Clefts at Birth in Patients With Complete Unilateral Cleft Lip and Palate and Craniofacial Morphology, Dental Arch Relationship, and Nasolabial Aesthetics During Pre-Adolescence

STUDY OBJECTIVES

To comprehensively evaluate the correlations between the severity of oral clefts at birth and the treatment outcomes during pre-adolescence in patients with complete unilateral cleft lip and palate (CUCLP).

MATERIAL AND METHODS

Records of 21 consecutive patients with CUCLP from a cleft/craniofacial centre were obtained. All subjects were treated with nasoalveolar moulding, followed by cheiloplasty and palatoplasty. The severity was measured by anterior cleft width, anterior and posterior arch width, arch circumference and arch length on scanned plaster models taken after birth. Craniofacial morphology, dental arch relationship and nasolabial aesthetics were assessed with cephalometric measurements, GOSLON score and Asher-McDade rating (AMR), respectively. Pearson and Spearman's rank correlation tests were performed to determine correlations between initial severity parameters and the treatment outcomes.

RESULTS

Pearson correlation showed negative correlations between posterior arch width at birth and maxillary position (SNA; r = -0.573, p < 0.01), mandibular position (SNB; r = -0.452, p < 0.05) and nasal prominence (N'-UNT/SN; r = -0.478, p < 0.05). A positive correlation was also found between posterior arch width at birth and maxillary inclination (SN/ANS-PNS; r = 0.454, p < 0.05). The ratio between anterior cleft width to arch length (G-L/Arch Length) demonstrated negative correlations with soft tissue facial height ratio (N'-Sn/Sn-Me'; r = -0.470, p < 0.05) and soft tissue vertical proportions (N'-Sn/N'-Gn'; r = -0.495, p < 0.05). Spearman's rank tests revealed no significant correlation between the initial severity parameters and GOSLON score and AMR.

CONCLUSIONS

The initial severity parameters were correlated with some craniofacial characteristics but not with dental arch relationships and nasolabial aesthetics during pre-adolescence.

Development of a Core Outcome Set for the Audit of Cleft Care in Malaysia

OBJECTIVE

To develop a core outcome set for the audit of cleft care in Malaysia.

DESIGN

To generate a core outcome set for patients dealing with cleft lip and/or palate within Malaysia, a combination of scholarly research reviews and consensus-driven methodologies, such as questionnaires and collaborative discussions, were utilized to guide the development process.

SETTING

Multicenter study. Feedback obtains via face-to-face and online interaction.

PARTICIPANTS

Cleft Clinicians, Cleft Lip and Palate Association of Malaysia members, hospitals, and government bodies personal.

MAIN OUTCOME MEASURE

Participants provide their feedback and suggestions of each outcome measure.

RESULTS

Through a deliberative process, agreement was established on a uniform set of outcome measures selected from an initial list of 108 potential outcomes. These agreed-upon measures were classified into 12 primary domains: demographic, cleft detail, pregnancy, general pediatric, otolaryngology/audiology, speech, surgical, orthodontics, pediatric dentistry, radiology, photographs, and study models.

CONCLUSION

A specialized core outcome set has been successfully developed for patients with cleft lip and/or palate, aiming to facilitate its implementation within the Malaysian healthcare system.

Association of Clinical, Biomechanical, and Psychosocial Factors with Smile Dynamics in Unilateral Cleft Lip: A Multicenter Observational Study

OBJECTIVE

To investigate the association between clinical, biomechanical, and psychosocial factors and smiling behavior in individuals with treated unilateral cleft lip with or without cleft palate (UCL ± P) compared to non-cleft controls.

DESIGN

Multicenter observational study in New Zealand.

PARTICIPANTS

Individuals aged ≥15 (N = 42) comprised 2 study groups: a UCL ± P group (N = 21) and a non-cleft control group (N = 21).

METHODS

Participants viewed an amusing video while their facial expressions were recorded. Smile features were automatically detected via software. A clinical outcome, nasolabial esthetics, was scored using the Asher-McDade system. Perioral biomechanical properties were measured via myotonometry. Smile Esthetics-related Quality of Life (SERQoL), Orofacial Esthetics Scale (OES), and personality (IPIP-NEO-60) questionnaires were completed.

RESULTS

Smile features and personality traits did not differ between the groups. Participants with UCL ± P exhibited higher stiffness (+44.2%; Cohen's d = 1.6) and tone (+22.6%; Cohen's d = 1.9) at the cleft scar site, and higher decrement (or lower elasticity, +8.5%; Cohen's d = 0.8) adjacent to the scar. Nasolabial esthetics and elasticity of the scar correlated with the duration of smiles and relative smile time (-0.50 < R < -0.44; p < .05). Participants in the UCL ± P group had lower scores for the OES and higher impacts on SERQoL for social contacts and dental self-confidence.

CONCLUSIONS

Adolescents and adults with UCL ± P exhibit similar smile behavior as their cleft-free peers-at least in non-social settings. Nasolabial esthetics and perioral biomechanical properties are associated with propensity to smile. UCL ± P is negatively associated with smile-related quality of life and an individual's perception of their facial appearance.

Effects of nasoalveolar molding on nasolabial aesthetics in patients with cleft lip and palate during pre-adolescence: A systematic review and meta-analysis of retrospective studies

This study aims to analyze long-term effects of nasoalveolar molding (NAM) as a part of cleft primary management protocols on nasolabial aesthetics for patients with non-syndromic cleft lip and palate by conducting a systematic review and meta-analysis. Six electronic databases and two journals were searched up to July 2023. Studies comparing nasolabial outcomes between NAM and non-NAM protocols were selected for further analysis. Nasolabial aesthetics were the outcome of interest. Data extraction, methodological quality assessment, risk of bias assessment, meta-analysis and subgroup analysis were performed. Seven retrospective cohort studies were selected for a qualitative review and four for a quantitative analysis. The risk of bias assessment was moderate for most studies. Only studies utilizing the Asher-McDade rating (AMR) were included for meta-analyses. The protocols with NAM exhibited a significantly lower AMR score for vermillion border than other protocols. AMR scores for nasal form and nasal symmetry from protocols with NAM were significantly lower than protocols without any pre-surgical infant orthopaedics (PSIO) but not significantly different from protocols with other PSIO techniques. The AMR score for nasolabial profile from protocols with NAM was not significantly different from other protocols. However, subgroup analysis demonstrated that protocol combining NAM and primary rhinoplasty significantly lowered AMR scores for nasal form, nasal symmetry and nasolabial profile. For patients with unilateral cleft lip with or without palate (UCLP), this study found that a protocol combining NAM and primary rhinoplasty improved nasolabial outcomes while a protocol with NAM alone offered only limited benefits. For patients with BCLP, the available evidence remains inconclusive. Performing NAM in combination with primary rhinoplasty improves nasolabial aesthetics in patients with UCLP. PROSPERO (CRD4202128384).

Reliability of the novel cleft lip and palate smile esthetic index (CLP-SEI)

BACKGROUND/OBJECTIVES

The aim of this research was to determine the reliability of a novel index for the assessment of smile esthetics in patients with cleft lip and/or palate (CL ± P) at the end of their multidisciplinary treatment, for use in clinical and academic settings.

MATERIALS AND METHODS

Five orthodontists, five periodontologists, five general practitioners, five dental students, and five laypeople rated the smiles of 10 patients with CL ± P twice at a 2 weeks interval. The rating scale consisted of four main categories: 1. nasolabial esthetics, 2. gingival esthetics, 3. dental esthetics, and 4. overall esthetics. A total of 15 parameters were rated. Intra- and inter-rater agreements were calculated using SPSS.

RESULTS

The inter-rater agreement varied between good and excellent whereby the orthodontists, periodontists, general practitioners, dental students, and laypeople obtained agreement scores of 0.86, 0.92, 0.84, 0.90, and 0.89, respectively. The intra-rater agreement was good with agreement scores of 0.78, 0.84, 0.84, 0.80, and 0.79, respectively.

LIMITATIONS

Smile esthetics were rated on static pictures, not in real life or by video recordings in a young adult population.

CONCLUSIONS/IMPLICATIONS

The cleft lip and palate smile esthetic index is a reliable tool for the assessment of smile esthetics in patients with CL ± P.

Comparative evaluation of nasolabial appearance of unilateral cleft lip and palate patients by professional, patient and layperson using 2 aesthetic scoring systems: A cross sectional study

OBJECTIVE

To compare the perspective of healthcare providers (orthodontists), cleft patients and laypersons in judging nasolabial aesthetics in patients with complete unilateral cleft lip, with or without cleft palate (UCL ± P) using 2 scoring systems.

DESIGN

This cross-sectional study was conducted in a tertiary care government hospital.

PATIENTS

Photographic records of 100 patients with complete UCL ± P from the age group of 5-18 years (mean age-12.2 ± 3.93 years) were included in this study.

METHOD

Photographic records of 100 patients with complete UCL ± P from the age group of 5-18 years were included. A panel of 3 orthodontists, 3 laypersons and 3 cleft patients rated nasolabial aesthetics using 2 scoring systems i.e. Asher-McDade index (AMAI) and Cleft Aesthetic Rating Scale (CARS). Spearman's split-half reliability, Intra-class correlation coefficient and Cronbach's alpha were computed to measure internal consistency and reliability. Inter-panel agreement between pair of groups was determined by means of Spearman correlation coefficient.

RESULTS

Estimated reliability of CARS for 3 raters in each panel was in moderate agreement for orthodontists and cleft patients (0.849 and 0.810). Good repeatability and agreement were recorded with moderate to high intra-panel reliability for all parameters of both AMAI and CARS. Overall inter-panel agreement was moderate for both AMAI and CARS. Pair-wise inter-panel agreement showed a moderately positive correlation in both scales (AMAI and CARS) by cleft patients and professionals.

CONCLUSION

CARS index can be reliably used for assessment of nasolabial aesthetics by cleft patients, professionals and lay persons on 2D facial photographs. Patients were more critical than clinicians and laypersons using both indices (CARS and AMAI) as they are more self-aware and conscious. Thus, a clear communication between clinician and patient regarding expectations, perception and satisfaction with surgical results is strongly recommended.

Nasolabial appearance in unilateral cleft lip and palate patients: A comparison of aesthetics using two scoring systems: A cross-sectional study

OBJECTIVE

The objective of the study was to assess nasolabial aesthetics in patients with complete unilateral cleft lip, with or without cleft palate (UCL ± P) using two scoring systems.

DESIGN

A cross-sectional study conducted in a tertiary care government hospital.

PATIENTS

Photographic records of 91 patients with complete UCL ± P from the age group of 5-18 years (mean age = 13.2 ± 3.14 years) were included.

METHOD

A panel of three orthodontists with varying experience in cleft management rated nasolabial aesthetics using two scoring systems, that is Asher Mc-Dade index (AMAI) and Cleft Aesthetic Rating Scale (CARS). Intraclass correlation coefficient, Fleiss' kappa and Cronbach's alpha were used to measure the internal consistency amongst three raters and Spearman-Brown formula was used for measuring overall reliability. Time required for assessment of each photograph was compared with ANOVA.

RESULTS

Overall, both AMAI and CARS showed high reliability and outcome assessment with good inter-rater reliability and internal consistency, when used independently by orthodontists having varied experience. Statistically significant difference was present in time taken for assessment of nasolabial aesthetics with CARS index (8.75 ± 1.65 seconds) as compared to AMAI (18.62 ± 3.49 seconds).

CONCLUSION

Asher Mc-Dade index and CARS are equally reliable and consistent for the assessment of nasolabial aesthetics in patients with UCL ± P. However, considerably less time was taken for the assessment using CARS index as compared to AMAI. The use of CARS index is recommended for the initial assessment and screening of patients by orthodontists using two dimensional photographs.

Photometric Evaluation of Adult Patients With Bilateral Cleft Lip and Palate Treated With Nasoalveolar Molding and Primary Columella Lengthening

OBJECTIVE

The aim of this study was to assess the nasal shape of young adults with BCLP treated with primary surgical columella lengthening and nasoalveolar molding (NAM).

SETTING AND PATIENTS

A group of 28 young adult patients with BCLP (mean age: 19.1±1.4 years) was compared through normalized photogrammetry to a control of 28 age- and sex-matched noncleft young adults.

RESULTS

Nasal protrusion and length of the columella were not different from noncleft young adults. On the other hand, nasolabial angle, columellar width, interalar, and nasal tip width were significantly wider than the noncleft controls. Thus, 27% of the patients have requested at this time secondary correction of the excessive nasal width.

CONCLUSIONS

Both NAM and primary rhinoplasty in patients with BCLP resulted in a near normal length of the columella and nasal projection until young adulthood. Nevertheless, width of all nasal features was significantly wider than the noncleft population and required secondary nasal correction in one-third of the sample.

Validity of the combined use of two esthetic rating systems, the infant index and 5-point aesthetic index, for pre- and postsurgical evaluation of cleft lip repair

OBJECTIVE

The present study was designed to investigate the usefulness of combining two different ordinal scaling indices, infant index (I-I) and 5-point aesthetic index (5-PAI), for the assessment and prediction of esthetic outcome of primary lip repair for patients with unilateral cleft lip.

MATERIALS AND METHODS

The nasolabial appearance of the patients was evaluated before primary lip repair and at 5 years of age using cropped facial photographs with frontal and oblique views. The I-I and 5-PAI employ expanded reference photographs and objective esthetic variables for judgment.

RESULTS

The inter- and intrarater Kappa values of both I-I and 5-PAI demonstrated good to very good agreement (range: 0.74-0.84 for I-I and 0.62-0.77 for 5-PAI). Furthermore, both the declination of the columella and the deformity of the alar cartilage in I-I showed a correlation with nasal rating score of 5-PAI and were identified as predictable independent parameters (declination of the columella: Rs = 0.37, P = 0.04; deformity of the alar cartilage: Rs = 0.35, P = 0.02).

CONCLUSION

The combined use of I-I and 5-PAI with expanded reference photographs and objective variables could be useful for obtaining greater accuracy of the esthetic assessment and predicting postsurgical nasolabial esthetics at infancy.

Perth scoring system for assessment of the cleft lip

Background: Currently, there is no standardised assessment tool to assess facial aesthetics in cleft lip and palate surgery. Inter-centre comparison is hampered by the use of different aesthetic indices with low intra- and inter-rater reliability. Aim: The Perth scoring system is a new assessment tool for unilateral cleft lip which scores four key components of the cleft lip/nose repair: lip length, white roll, alar insertion point and vermillion. The aim of this study was to validate the Perth scoring system as a reliable and useful new assessment tool and to demonstrate the use of the scoring system to measure improvements after cleft lip revision. Method: Nineteen patients who underwent cleft lip revision by the senior author were selected. Pre- and postoperative photos were presented to a panel of raters to score. Scores were analysed to determine the intra-and inter-rater reliability and to compare outcomes. Results: Almost all patients (15/16) had improvement in scores (range 1.09–5.59) after cleft lip revision. Intra raters’ agreement scores from lowest to highest were: lip length (0.65), white roll (0.7), alar insertion point (0.78) and vermillion (0.78). The total intra-class correlation coefficient was 0.96 (0.94–0.98, 95% CI, P<0.000). Conclusion: This new scoring system is a valid and useful tool for assessment of the unilateral cleft lip. The high rate of intra- and inter-rater reliability allow it to serve as a useful tool to compare surgical outcomes both within and between centres. Further field testing with a larger cohort of patients is required.

Evaluation of nasolabial aesthetics by different groups in operated unilateral cleft lip and palate

AIM

The aim of this study is to evaluate and to compare the perception of nasolabial aesthetic by experienced professionals, inexperienced professionals, cleft patients and laypersons in children with unilateral cleft lip and palate (UCLP) using the Asher-McDade Scoring System.

MATERIALS AND METHODS

In this retrospective study, 75 patients who applied to Ege University, Faculty of Dentistry, Department of Orthodontics and whose primary surgery operations were completed in Ege University, Faculty of Medicine Department of Plastic and Reconstructive Surgery, were evaluated from the extra-oral and profile photographs. All photographs were arranged according to Asher-McDade Scoring System and evaluated by 4 different groups. 5 people were evaluated in each group consisting of experienced professionals, inexperienced professionals, cleft patients and the laypersons. Nasal form, nasal deviation, vermilion border and nasal profile were evaluated in 5 different categories according to Asher-McDade Scoring System. Statistical analyzes were performed using STATA 11 and MEDCALC software. G Power, Fleiss Kappa, Weighted Kappa and Friedman statistical analyzes were performed for determination of number of individuals, interobserver and intraobserver reliability and comparison of scoring between groups, respectively.

RESULTS

In this study, the interobserver agreement was found to be between 0.75 and 0.80 that shows a high degree of reliability. In the comparision made between the groups; experienced professionals and inexperienced professionals; there was moderate agreement in nasal profile scoring (WK 0.2857) (-0.9673/0.6596). There was agreement between experienced professionals and cleft patients in mostly vermilion border (WK 0.5454) (-0.1643/1.0000). There was no agreement between vermilion border between inexperienced professionals and cleft patients (WK 0.9230) (-1.0000/-0.2878), and compliance with the nasal profile mostly (WK 0.5454) (-0.1643/1.0000). There was a similar insignificant agreement between experienced and inexperienced professionals, cleft patients among the laypersons, at all values (WK 0,0000) (-0.0000/0.0000). According to the scoring results of the photographs for experienced professionals; nasal form, nasal deviation, vermilion border and nasal profile were evaluated as bad and close the bad (4.00±0.00, 3.80±0.44, 3.80±0.44, 3.60±0.54); it was found fair and near the bad for inexperienced professionals (3.00±0.00, 3.00±0.00, 3.40±0.54 3.20±0.44) and close the bad for cleft patients (3.60±0.54, 3.80±0.44, 3.80±0.44, 3.40±0.54). But it was found to be acceptable and good for laypersons (2.00±0.00, 2.00±0.00, 2.40±0.54, 1.40±0.54). Laypersons showed statistically significant difference in the evaluation of nasal form, nasal deviation and nasal profile from the cleft patients (P<0.05), while they showed statistically significant difference in all the score from the experienced professionals (P<0.05, P<0.01).

CONCLUSION

The aesthetic appearance of nasolabial region is one of the important tools to evaluate the success of the treatment in patients with CLP. The success of primary surgery has one of the most important effects for nasolabial aesthetics on patients with clefts. As a result of the study, the evaluation of cleft patients was found to be similar to that of experienced professionals and lower than that of inexperienced professionals and the laypersons. This result shows us that patients with CLP have higher awareness of self-perception, but these patients may have psychosocial problems ranging from low self-esteem to social isolation risk.

Is There a Correlation Between Nasolabial Appearance and Dentoalveolar Relationships in Patients With Repaired Unilateral Cleft Lip and Palate?

OBJECTIVE

To determine whether a relationship exists between the aesthetic scores given to photographic records of the nasolabial region of patients with repaired unilateral cleft lip and palate (UCLP) and the 5-Year Olds' Index scores of study models for the same participants.

DESIGN

Retrospective study.

SETTING

University of Bristol Dental Hospital, United Kingdom.

PARTICIPANTS

Patients with nonsyndromic UCLP previously enrolled in the Cleft Care UK (CCUK) Study.

METHODS

The CCUK participants, who had both study models and photographs (frontal and worm's eye view), were identified and their records retrieved. These were rated by 2 consultants and 2 senior registrars in orthodontics. The 5-Year Olds' Index was used to score the study models, and at a separate sitting, a 5-point Likert scale was used to score the cropped frontal and worm's eye view photographs of the same children. The results were analyzed using intraclass correlation coefficients and Cohen κ.

MAIN OUTCOME MEASURES

Correlation between the aesthetic scores of the photographic views and the concordant 5-Year Olds' Index scores of the study models.

RESULTS

The intraclass correlation coefficient scores showed very poor agreement between the photographic views and their concordant study models. The level of inter- and intra-rater reliability was strongest when scoring the study models.

CONCLUSIONS

There was no agreement between the scores given to various photographic views and their corresponding study models. Scoring the study models using the 5-Year Olds' Index was the most reliable outcome measure for this age-group.

Nasolabial Aesthetics Following Cleft Repair: An Objective Evaluation of Subjective Assessment

OBJECTIVE

Assess the weight and contribution of each of the parameters of the Asher-McDade Scale to overall subjective assessment of nasolabial aesthetics following cleft lip repair.

DESIGN

Retrospective cohort evaluation.

SETTING

Cleft and craniofacial center.

PARTICIPANTS

Forty-one patients who underwent unilateral cleft lip repair.

INTERVENTIONS

Unilateral cleft lip repair.

MAIN OUTCOME MEASURES

Nasolabial rating using the Asher-McDade scale and overall subjective assessment of nasolabial aesthetics using a rank score following unilateral cleft lip repair.

RESULTS

Strong interrater reliability was observed between the 3 raters. Significant association was determined on bivariate analysis between nasal form score (β = 27.06; P < .001), nasal symmetry score (β = 26.41; P < .001), nasal profile score (β = 28.75; P < .001), vermilion border score (β = 13.40; P = .012), and the ranking score. Adjusted β coefficients obtained from multivariate regression analysis were used to develop a modified nasolabial appearance score (over 5), that is, weighted for each of the 4 parameters: nasal form (over 8, adjusted β = 14.33), nasal symmetry (over 5, adjusted β = 7.96), nasal profile (over 5, adjusted β = 9.44), and vermilion (over 2, adjusted β = 3.31). Regression analysis between our modified nasolabial appearance score and patient ranking score demonstrated superior goodness of fit when compared to the Asher-McDade overall nasolabial appearance score (R² = .80; P < .001 vs R² = .69; P < .001).

CONCLUSION

The parameters evaluated in the Asher-McDade scale have different weights and contribute differently to overall subjective assessment of nasolabial aesthetic outcomes following cleft lip repair. Adjusting for their weights results in a modified score that demonstrates superior correlation with overall subjective assessment of nasolabial aesthetic outcomes.

Canine edge width and height affect dental esthetics in maxillary canine substitution treatment

Background

To investigate the effect of canine edge width and height on dental esthetics in maxillary canine substitution treatment.

Methods

A total of 127 canine substitution treatment cases were screened and evaluated by a panel of orthodontic experts and laypersons in the pilot study. The top five subjects with the esthetically most pleasant canine substitution were included in the study, resulting in 140 computerized images displaying only the upper dentition, with different canine edge widths (0%, 12.5%, 25%, 37.5%, 50%, 62.5%, and 75% of the central clinical width) and heights (− 0.5 mm, 0 mm, 0.5 mm, and 1.0 mm vertically relative to the central incisor edge) finally used for the esthetic evaluation by 101 observers (41 orthodontists and 60 laypersons). The ordered logistic regression analysis, the univariate analysis of variance, the chi-square, and Fisher’s exact tests were used for statistical analyses.

Results

The most esthetic canine shape for canine substitution was found to be a shape with the edge width of 62.5% of the central incisor width and the edge height of 0.5 mm gingival to the central incisor edge (P < 0.05). The canine edge width of 50–75% and height of 0.5–0 mm gingival to the central incisor edge were generally considered to be esthetic by all observers. Orthodontists and laypersons had the same ranking on the top two most esthetic canine shapes (edge width and height 62.5% and 0.5 mm gingival; 50% and 0 mm incisal) as well as the bottom two most unesthetic canine shape (0% and 0.5 mm gingival; 75% and 1 mm incisal). Male and female observers generally had similar esthetic grades and rankings on the canine shapes (P > 0.05).

Conclusions

The most esthetic canine shape for canine substitution is a shape with the canine edge width of 62.5% of the central incisor width and the edge height of 0.5 mm gingival to the central incisor edge. The different collocations of the canine edge width and height affect dental esthetics of the canine during canine substitution treatment.

Columella Elongation Surgery Outcome in Complete Bilateral Cleft Lip and Palate

Background:

The evaluation of surgical outcomes is needed to achieve excellence in nasal reconstruction of patients with complete bilateral cleft lip and palate (BCLP). The study objective is to evaluate the quality of nasal aesthetics after the columella elongation surgery.

Methods:

The sample of this study consisted of 70 patients with complete BCLP, operated on columella elongation surgery and analyzed at 6 to 12 years. The system for evaluation of nasal appearance after the columella elongation surgery was performed by objective and subjective analyses.

Anthropometric Measurements:

Four anthropometric nose measurements were performed directly on the faces, and the same was performed in control group (60 children without oral clefts), paired by age and sex with the experimental group. The measurements were repeated 3 times (triplicate).

Subjective Analysis:

Scores to evaluate nasal width, nasal tip projection, and length of the columella were applied before and after the columella elongation surgery by 5 raters from the rehabilitation team. Interrater and intrarater agreement was calculated by means of the kappa test.

Results:

Nasal width in BCLP group was higher when compared to the control group (P < 0.05). Nasal tip projection (subnasal–pronasal) and columella length (subnasal–columella) were decreased in BCLP group compared to that of the controls (P < 0.05). Columella width was similar in both study groups (P > 0.05). All scores of nasal aesthetics significantly improved after the columella elongation surgery.

Conclusions:

Nose of the patients with BCLP is wider, is less projected, and has the shorter columella compared to that of the noncleft subjects. After secondary columella elongation surgery in BCLP, nasal width, nasal projection, and columella length significantly improved.

Reliability of Americleft Yardstick Nasolabial Appearance Assessment With/Without Basal View for Japanese Children With Unilateral Complete Cleft Lip and Palate

OBJECTIVE

There is debate on the reliability of the Americleft Yardstick (AY) global nasolabial appearance assessment method. The objective was to analyze the effect of the additional basal view (BV) feature on the reliability of the AY method for Japanese children with complete cleft lip and palate (CUCLP).

DESIGN

Blind retrospective analysis of clinical records on 43 patients (5- to 7-year-old) with nonsyndromic CUCLP who underwent primary lip repair from 2005 to 2011.

MAIN OUTCOME MEASURE

Color pictures published in AY and Rubin's studies were used as reference pictures. Patients' photographs were cropped and rated on a 5-point scale for the vermilion border (VB), nasolabial frontal (NLF), and nasolabial profile (NLP) according to AY with/without BV assessment by Rubin's methods. Rating was performed twice by 3 oral surgeons. Intra- and inter-rater reliabilities were analyzed using weighted κ, and correlations between BV and other features were analyzed.

RESULTS

Overall average assessment scores were 2.742 (0.573) with AY and 2.702 (0.489) with AY+BV methods (P = .728). Average intra-rater reliabilities were 0.605 and 0.611 and average inter-rater reliabilities were 0.525 and 0.48 with AY and AY+BV, respectively. Inter-rater reliability was the lowest for NLP. ρ scores between BV versus VB, NLF, and NLP were 0.025, 0.659, and 0.092, respectively.

CONCLUSIONS

Present study demonstrates moderate intra- and inter-rater reliabilities obtained with the AY assessment method for Japanese children with CUCLP. Nasolabial profile standard ambiguity may lead to the poor reliability of AY assessment. Addition of the BV feature does not improve overall reliability.

Development of the Submental Nasal Appearance Scale for the Assessment of Repaired Unilateral Complete Cleft Lip: A Pilot Study

Objective:

To develop the “Submental Nasal Appearance Scale” (SNAS), which is an easy-to-use objectified tool to represent a cleft surgeon’s standard for assessment of the nasal appearance from the submental perspective.

Design:

Eighty-five photographs of patients with unilateral complete cleft lip and palate were selected and cropped, displaying the submental view. Sixty-one photographs were used to develop 5 sets of reference photographs. Three cleft surgeons graded 24 photographs with these sets and subjectively graded the overall nasal appearance as well. Internal agreement for both methods was calculated, as well as correlation between them. The SNAS was created, by only using the combination of sets that showed the highest reliability and correlation.

Setting:

Boston Children’s Hospital, Boston, Massachusetts.

Patients:

Six- to 9-year-old patients with unilateral complete cleft lip and palate.

Results:

The intrarater and interrater reliability was 0.84 and 0.79, respectively, for the SNAS and 0.76 and 0.62, respectively, for the overall appearance assessment. The correlation was 0.74 between the methods.

Conclusions:

The SNAS is a reliable tool that reflects a cleft surgeon’s standard and could be used independently or in combination with existing rating scales using the frontal and/or lateral view, for assessment after cleft lip repair.

Defining the Aesthetic Range of Normal Symmetry for Lip and Nose Features in 5-Year-Old Children Using the Computer-Based Program SymNose

Objective:

To provide a normal comparison group against which to judge symmetry results after cleft surgery and to introduce the thin lip correction (TLC) feature in SymNose. A lip–aspect ratio algorithm has been added to the latest version of SymNose to compensate for the higher degree of overlap in thicker lips when compared to thin lips.

Design:

Retrospective analysis of symmetry in healthy participants, using the computer-based program SymNose on both anteroposterior (AP) and base view images. Photographs of 91 noncleft children were traced twice by 3 independent investigators experienced with SymNose.

Participants:

Five-year-old healthy participants from a local state school in Tavistock (West Devon, United Kingdom).

Main Outcome Measure:

Asymmetry expressed as the perimeter mismatch percentage for nose and lip features on AP view images and for nose features on base view images.

Results:

The perimeter mismatch reference range for the nose (AP view) was 2.65% to 30.91%, for the lip 2.13% to 15.44%, for the nose (base view) 1.69% to 14.84%, for the nostrils 4.68% to 26.6%, and for the width–height ratio 1.15% to 1.80%. The perimeter mismatch percentage for the lip without TLC was significantly higher compared to the perimeter mismatch percentage with TLC (P < .001).

Conclusion:

This article provides a noncleft reference range for all perimeters drawn from SymNose against which to compare results after cleft surgery at 5 years of age. Furthermore, it shows the importance of correcting for variance in lip volume per child.

Nasolabial aesthetics of patients with repaired unilateral cleft lip and palate: A comparison of three rating methods in two countries

OBJECTIVES

The study aimed to compare nasolabial aesthetics of patients with unilateral cleft lip and palate (UCLP) treated in Vietnam and Estonia using three rating methods: five-point aesthetic index, a visual analogue scale (VAS), and reference scores method.

METHODS

A total of 56 patients with repaired UCLP (23 from Vietnam and 33 from Estonia) were included in this cross-sectional study. Patients' facial and profile photographs were cropped to reveal the nasolabial region and coded. Five examiners rated nasolabial aesthetics of the patients using three methods: five-point aesthetic index, 100 mm VAS, and reference scores method. Intraclass correlation coefficients were used to evaluate intrarater and interrater reliabilities.

RESULTS

The five-point aesthetic index had a higher reliability than VAS and reference scores method. The least aesthetic feature among Vietnamese and Estonian patients was nasal symmetry and nasolabial profile respectively. No differences in nasolabial aesthetics were found between Vietnamese and Estonian patients regardless of the rating methods (p > 0.05) except for nasal symmetry.

CONCLUSIONS

The five-point aesthetic index seems to produce more reproducible results. There were no significant differences in nasolabial aesthetics between the two countries. Overall average nasolabial appearance results were obtained using different treatment protocols in the two countries.

The Americleft Project: A Modification of Asher-McDade Method for Rating Nasolabial Esthetics in Patients With Unilateral Cleft Lip and Palate Using Q-sort

The purpose of this study was to investigate ways to improve rater reliability and satisfaction in nasolabial esthetic evaluations of patients with complete unilateral cleft lip and palate (UCLP), by modifying the Asher-McDade method with use of Q-sort methodology. Blinded ratings of cropped photographs of one hundred forty-nine 5- to 7-year-old consecutively treated patients with complete UCLP from 4 different centers were used in a rating of frontal and profile nasolabial esthetic outcomes by 6 judges involved in the Americleft Project's intercenter outcome comparisons. Four judges rated in previous studies using the original Asher-McDade approach. For the Q-sort modification, rather than projection of images, each judge had cards with frontal and profile photographs of each patient and rated them on a scale of 1 to 5 for vermillion border, nasolabial frontal, and profile, using the Q-sort method with placement of cards into categories 1 to 5. Inter- and intrarater reliabilities were calculated using the Weighted Kappa (95% confidence interval). For 4 raters, the reliabilities were compared with those in previous studies. There was no significant improvement in inter-rater reliabilities using the new method. Intrarater reliability consistently improved. All raters preferred the Q-sort method with rating cards rather than a PowerPoint of photos, which improved internal consistency in rating compared to previous studies using the original Asher-McDade method. All raters preferred this method because of the ability to continuously compare photos and adjust relative ratings between patients.

Facial and Nasolabial Aesthetics of Complete UCLP Submitted to 2-Stage Palate Repair With Vomer Flap

OBJECTIVE

To evaluate the aesthetics of nasolabial appearance and facial profile of children with unilateral cleft lip and palate (UCLP) submitted to 2-stage palate repair with vomerine flap.

DESIGN

Retrospective.

SETTING

Single center.

PATIENTS

Forty patients with UCLP, mean age of 7.81 years of both sexes, rehabilitated at a single center by 1 plastic surgeon.

INTERVENTIONS

Lip and anterior palate repair with nasal alar repositioning was performed at 3 to 6 months of age by Millard technique and vomer flap, respectively. Posterior palate was repaired at 18 months by Von Langenbeck technique.

MAIN OUTCOME MEASURE(S)

Four cropped digital facial photographs of each patient were evaluated by 3 orthodontists to score the nasolabial aesthetics and profile. Frequencies of each score as well means and medians were calculated. Kappa test was used for evaluating inter- and intrarater reproducibility.

RESULTS

The nasal form and deviation was scored as good/very good in 70%, fair in 22.5%, and poor in 7.5% of the sample. The nasal-subnasal aesthetic was considered good/very good in 55%, fair in 30%, and poor in 15% of the sample. The lip vermilion border and the white part of surgical scar aesthetics were good/very good in 77.5% and 80%, fair in 17.5% for both categories, and poor in 5% and 2.5% of the cases, respectively. In all, 67.5% showed convex facial profile, 20% was straight, and 12.5% was concave profile.

CONCLUSIONS

Two-stage palatoplasty presented an adequate aesthetical results for the majority of patients with UCLP in the mixed dentition.

Burden of Care of Various Infant Orthopedic Protocols for Improvement of Nasolabial Esthetics in Patients With CUCLP

OBJECTIVES

1. To evaluate the orthodontic burden of care of nasoalveolar molding (NAM) and modified McNeil for the treatment of patients with complete unilateral cleft lip and palate (CUCLP). 2. To compare the esthetic outcomes of each with those of centers not utilizing infant orthopedics (IO).

DESIGN

Retrospective cohort study.

SETTING

Institutional.

PARTICIPANTS

Four cohorts with repaired CUCLP (n = 149) from 3 centers.

INTERVENTIONS

Two cohorts were treated in the same center and had either traditional infant orthopedics (TIO) or NAM and 2 were treated in centers not employing IO.

MAIN OUTCOME MEASURES

Burden of care data for the IO groups were compared using t tests. Frontal and profile photographs at approximately age 5 were collected for ratings of nasolabial esthetics, using a modification of the Asher-McDade method. Intrarater and interrater reliabilities were determined using weighted κ statistics. Median ratings were compared using a Kruskal-Wallis test.

RESULTS

The burden of care of NAM was significantly greater than TIO for both the number of visits (9.9 vs 6.6, [ P < .001]); and treatment duration (127 vs 112 days, [ P < .05]). Significant differences in nasolabial esthetic ratings were noted among the 3 centers. No significant differences were observed in the nasolabial esthetic outcomes between the NAM and TIO groups.

CONCLUSIONS

1. NAM required more visits and longer overall duration compared with TIO. 2. The center employing IO showed favorable nasolabial esthetics compared to those not utilizing IO. 3. No significant differences were found in the nasolabial esthetics of patients who have received NAM compared with TIO.

Comparison of the Basal View and a Previously Standardized Cleft Lip Rating Scale

OBJECTIVES

Numerous scales assessing the aesthetics of cleft lip repair exist. Most, including the Asher-McDade scale, use frontal and lateral views, while neglecting a basal view. We believe this view is important for properly assessing the aesthetics of repair. In this study, we evaluate the basal view in comparison to the Asher-McDade scale.

METHODS

This scale was based on progressive columellar shortening and alar flaring/slumping. A panel of 4 plastic surgeons applied the basal and Asher-McDade scales to pictures of patients with repaired unilateral cleft lip in 56 multiethnic participants aged 5 years to 18 years; images were scored from 1 to 5 (best). Statistical analysis was done via Spearman correlation.

RESULTS

Scores from plastic surgeons correlated strongly for each view. There was moderate correlation for the basal view with both nasal form and deviation scores ( P < .05). As expected, there were no strong correlations between the basal view and vermillion border or profile.

DISCUSSION

The Asher-McDade scale has been used to evaluate cleft lift repairs but is limited due to its subjective nature. The basal view scale grades these repairs by using a scale of progressive columellar shortening and alar flaring/slumping, which provides an opportunity for quantification and standardization. Our results show that the basal view correlates with the Asher-McDade scale among raters, thus providing an objective and validated measure of cleft lip repair.

Determinants of Health-Related and Oral Health–Related Quality of Life in Adults With Orofacial Clefts

Objectives:

To investigate the structural and intermediary determinants of health-related quality of life (HRQoL) and oral health–related quality of life (OHRQoL) among adults with cleft lip and/or palate (CL/P).

Design and Participants:

A cross-sectional study was conducted with patients enrolled at the referral center for craniofacial anomalies in Manaus, Brazil. Adults aged 18 years or more with nonsyndromic CL/P were selected.

Main Outcome Measures:

Both HRQoL and OHRQoL were assessed using the 36-item Short-Form Health Survey and the Oral Impacts on Daily Performance, respectively. Individual interviews and oral examinations were conducted to collect data on socioeconomic and demographic characteristics, social ties, health-related behaviors, compliance of CL/P protocol, chronic diseases, type of CL/P, oral clinical measures, and CL/P-related measures. Poisson regression was used to test the association of independent variables with HRQoL and OHRQoL outcomes.

Results:

The mean age of the 96 participants was 29.4 ± 9.1 years. Low family income, female sex, low social support, type of CL/P, and dental caries were associated with poor HRQoL and poor OHRQoL ( P < .05). Poor HRQoL was also associated with chronic diseases ( P < .05). Adults with low education, low social network, and smokers were more likely to have worse OHRQoL ( P < .05).

Conclusions:

Structural and intermediary determinants were related to HRQoL and OHRQoL in adults with CL/P, suggesting the need for interdisciplinary approaches to improve the management of CL/P and intersectoral actions to reduce the impact of social inequalities.

The Cleft Aesthetic Rating Scale for 18-Year-Old Unilateral Cleft Lip and Palate Patients: A Tool for Nasolabial Aesthetics Assessment

OBJECTIVE

To develop a reliable and easy-to-use method to assess the nasolabial appearance of 18-year-old patients with unilateral cleft lip and palate (CLP).

DESIGN

Retrospective analysis of nasolabial aesthetics using a 5-point ordinal scale and newly developed photographic reference scale: the Cleft Aesthetic Rating Scale (CARS). Three cleft surgeons and 20 medical students scored the nasolabial appearance on standardized frontal photographs.

SETTING

VU University Medical Center, Amsterdam.

PATIENTS

Inclusion criteria: 18-year-old patients, unilateral cleft lip and palate, available photograph of the frontal view.

EXCLUSION CRITERIA

history of facial trauma, congenital syndromes affecting facial appearance. Eighty photographs were available for scoring.

MAIN OUTCOME MEASURES

The interobserver and intraobserver reliability of the CARS for 18-year-old patients when used by cleft surgeons and medical students.

RESULTS

The interobserver reliability for the nose and lip together was 0.64 for the cleft surgeons and 0.61 for the medical students. There was an intraobserver reliability of 0.75 and 0.78 from the surgeons and students, respectively, on the nose and lip together. No significant difference was found between the cleft surgeons and medical students in the way they scored the nose ( P = 0.22) and lip ( P = 0.72).

CONCLUSIONS

The Cleft Aesthetic Rating Scale for 18-year-old patients has a substantial overall estimated reliability when the average score is taken from three or more cleft surgeons or medical students assessing the nasolabial aesthetics of CLP patients.

An Intercenter Comparison of Nasolabial Appearance Including a Center Using Nasoalveolar Molding

OBJECTIVE

To compare nasolabial appearance outcomes of patients with complete unilateral cleft lip and palate (CUCLP) in preadolescence from 4 cleft centers including a center using nasoalveolar molding (NAM) and primary nasal reconstruction.

DESIGN

Retrospective cohort study.

SETTING

Four cleft centers in North America.

PATIENTS

135 subjects with repaired CUCLP.

METHODS

Frontal and profile facial pictures were assessed using the Asher-McDade rating scale. Intra- and interrater reliability were tested using weighted Kappa statistics. Median scores by center were compared with Kruskal-Wallis statistics.

RESULTS

Intrarater reliability scores were moderate to good. Interrater reliability scores were moderate. Significant differences ( P < .05) among centers were found. For nasal form, center G (median = 2.83) had better scores than centers C and D (C median = 3.33, D median = 3.17). For nose symmetry, center G had better scores (median = 2.33) than all other centers (B median = 2.67, C median = 2.83, D median = 2.83). For vermillion border, center G had better scores (median = 2.58) than centers B and C (B median = 3.17, C median = 3.17). For nasolabial profile, center G (median score = 2.67) had better scores than center C (median = 3.00). For total nasolabial score, center G (median = 2.67) had better scores than all other centers (B median = 2.83, C median = 3, D median = 2.83).

CONCLUSION

The protocol followed by center G, the only center that performed NAM and primary nasal reconstruction, produced better results in all categories when compared to center C, the only center that did not perform presurgical orthopedics or lip/nose revisions. When compared to centers that performed traditional presurgical orthopedics and surgical revisions (B and D), center G was not consistently better in all categories. As with other uncontrolled, retrospective intercenter studies, it is not possible to attribute the outcomes to a specific protocol component.

Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 8. Assessing naso-labial appearance in 5-year-olds - a preliminary study

BACKGROUND AND AIM

Facial appearance is one of the most relevant measures of success in cleft lip and palate treatment. The aim was to assess nasolabial appearance at 5 years of age in all children in the project. In this part of the project the local protocol for lip closure continued to be used because the primary lip and nose operations were not part of the randomisation. The great majority of the surgeons used Millard's technique together with McComb's technique for the nose. One center used Tennison-Randalls technique and in one center the centers own technique as well as nose plugs were used.

METHODS

Three hundred and fifty-nine children participated in this part of the project. Standardised photos according to a specific protocol developed for the Scandcleft project were taken. Only the nasolabial area was shown, the surrounding facial features were masked. Three components were scored using a 5-point ordinal scale. A new developed Scandcleft Yardstick was used.

RESULTS

The reliability of the method was tested using the weighted kappa statistics. Both the interrater and intrarater reliability scores were good to very good. There were statistically significant differences between the three trials.

CONCLUSION

The Millard procedure combined with McComb technique had been used in the majority of the cases in all three trials. There were statistically significant differences between the three trials concerning upper lip, nasal form, and cleft side profile.

TRIAL REGISTRATION

ISRCTN29932826.

Crowdsourcing as a Novel Method to Evaluate Aesthetic Outcomes of Treatment for Unilateral Cleft Lip

BACKGROUND

Lack of convenient and reliable methods to grade aesthetic outcomes limits the ability to study results and optimize treatment of unilateral cleft lip. Crowdsourcing methods solicit contributions from a large group to achieve a greater task. The authors hypothesized that crowdsourcing could be used to reliably grade aesthetic outcomes of unilateral cleft lip.

METHODS

Fifty deidentified photographs of 8- to 10-year-old subjects (46 with unilateral cleft lip and four controls) were assembled. Outcomes were assessed using multiple pairwise comparisons that produced a rank order (Elo rank) of nasal appearance and, on a separate survey, by Asher-McDade ratings. Both surveys were repeated to assess reliability. A group of expert surgeons repeated the same tasks on a smaller subset of photographs.

RESULTS

The authors obtained 2500 and 1900 anonymous, layperson evaluations by means of crowdsourcing on each Elo rank and Asher-McDade survey, respectively. Elo rank and Asher-McDade scores were highly reproducible (correlation coefficients, 0.87 and 0.98), and crowd evaluations agreed with those by expert surgeons (0.980 and 0.96 for Elo rank and Asher-McDade score, respectively). Crowdsourcing surveys were completed within 9 hours, whereas the expert surgeons required 3 months. On further analysis of their cleft subject sample set, the authors found that greater initial cleft severity was associated with worse aesthetic outcome.

CONCLUSIONS

Outcomes assessed by crowds were reliable and correlated well with expert assessments. Crowdsourcing allows acquisition of massive numbers of layperson assessments on an unprecedented scale, and is a convenient, rapid, and reliable means of assessing aesthetic outcome of treatment for unilateral cleft lip.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, IV.

Facial Aesthetic Outcomes of Cleft Surgery: Assessment of Discrete Lip and Nose Images Compared with Digital Symmetry Analysis

BACKGROUND

High-quality aesthetic outcomes are of paramount importance to children growing up after cleft lip and palate surgery. Establishing a validated and reliable assessment tool for cleft professionals and families will facilitate cleft units, surgeons, techniques, and protocols to be audited and compared with greater confidence. This study used exemplar images across a five-point aesthetic scale, identified in a pilot project, to score lips and noses as separate units and compared these human scores with computer-based SymNose symmetry scores.

METHODS

Forty-five assessors (17 cleft surgeons nationally and 28 other cleft professionals from the UK South West Tri-centre units), scored 25 standardized photographs, uploaded randomly onto a Web-based platform, twice. Each photograph was shown in three forms: lip and nose together, and separately cropped images of nose only and lip only. The same images were analyzed using the SymNose software program.

RESULTS

Scoring lips gave the best intrarater and interrater reliabilities. Nose scores were more variable. Lip scoring associated most closely with the whole-image score. SymNose ranking of the lip images related highly to the same ranking by humans (p = 0.001). The exemplar images maintained their established previous ranking.

CONCLUSIONS

Images illustrating the aesthetic outcome grades are confirmed. The lip score is reliable and seems to dominate in the whole-image score. Noses are much harder to score reliably. It appears that SymNose can score lip images very effectively by symmetry. Further use of SymNose will be investigated, and families of children with cleft will trial the scoring system.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

An anatomical subunit-based outcome assessment scale for bilateral cleft lip and palate

As there is currently no internationally accepted outcome measurement tool available for complete bilateral cleft lip and palate (CBCLP), the goal of this prospective study was to develop a numerical evaluation scale that allows reliable scoring of this cleft deformity. Our cohort comprised 121 Indian subjects with CBCLP who underwent surgical repair (mean age at time of surgery 6.53 months) using a modified Millard technique. A panel of three professionals evaluated each subject's outcome of bilateral cleft lip repair 6 months postoperatively on two-dimensional (2D) full-face photographs in the frontal view and worm's eye view. A simple two-point rating system was applied to separately analyse a total of 12 components of lip, nose, and scar. The results and mean scores for the analysed anatomical areas were 2.2±1.01 (max=3) for nose, 5.4±1.54 (max=8) for lip, and 1.9±1.3 (max=3) for scar, with a total score 7.7±2.21 (max=12) indicating a good surgical outcome. The inter-examiner ICC for nose, lip, scar, and total score was calculated at 0.836, 0.889, 0.723, and 0.927 respectively and indicated a strong level of repeatability and reliability that was highly significant (P<0.001). In conclusion, we were able to develop and test a scoring system for measuring outcomes in CBCLP that warrants simplicity of use, reliability and reproducibility.

A novel computer system for the evaluation of nasolabial morphology, symmetry and aesthetics after cleft lip and palate treatment. Part 1: General concept and validation

PURPOSE

The need for a widely accepted method suitable for a multicentre quantitative evaluation of facial aesthetics after surgical treatment of cleft lip and palate (CLP) has been emphasized for years. The aim of this study was to validate a novel computer system 'Analyse It Doc' (A.I.D.) as a tool for objective anthropometric analysis of the nasolabial region.

MATERIALS AND METHODS

An indirect anthropometric analysis of facial photographs was conducted with the A.I.D. system and Adobe Photoshop/ImageJ software. Intra-rater and inter-rater reliability and the time required for the analysis were estimated separately for each method and compared.

RESULTS

Analysis with A.I.D. system was nearly 10-fold faster than that with the reference evaluation method. The A.I.D. system provided strong inter-rater and intra-rater correlations for linear, angular and area measurements of the nasolabial region, as well as a significantly higher accuracy and reproducibility of angular measurements in submental view. No statistically significant inter-method differences were found for other measurements.

CONCLUSIONS

The hereby presented novel computer system is suitable for simple, time-efficient and reliable multicenter photogrammetric analyses of the nasolabial region in CLP patients and healthy subjects.

Comparison of Three Methods of Rating Nasolabial Appearance in Cleft Lip and Palate

OBJECTIVE

To investigate which of three methods of rating nasolabial appearance-esthetic index, visual analogue scale (VAS), or numerical scale with reference photographs-is optimal.

DESIGN

Experimental study.

SETTING

Radboud University Medical Centre, The Netherlands and University of Bern, Switzerland.

SUBJECTS AND METHODS

Cropped photographs of 60 patients with complete unilateral cleft lip and palate (mean age = 10.8 years) were used for rating. A panel of eight raters rated four components of nasolabial morphology (nasal shape, nose deviation, vermillion border, and profile view) using three methods: 5-point esthetic index, 100 mm VAS, and 0 to 200 numerical scale with reference photographs (reference scores method). Method reliability was assessed by re-evaluation of 20 images after >1 month. Intraclass correlation coefficients were calculated to evaluate consistency of each method.

RESULTS

Overall reference scores method always produced more reproducible results (i.e., higher ICCs) than did VAS or the esthetic index. However, statistically significant differences were found between reference scores and esthetic index in rating nasal shape, nose deviation, and vermillion border only (P < 0.001, <0.001, and 0.012, respectively) and between reference scores and VAS in rating nose deviation and vermillion border (P < 0.001 and 0.017, respectively).

CONCLUSION

We recommend the use of reference photographs along with the VAS or numerical (from 0 to 200) semi-continuous scale. The esthetic index, based on a Likert-type scale, seems to produce the most variable results and, therefore, is not preferred.

The Development of the Cleft Aesthetic Rating Scale: A New Rating Scale for the Assessment of Nasolabial Appearance in Complete Unilateral Cleft Lip and Palate Patients

OBJECTIVE

The development of the Cleft Aesthetic Rating Scale, a simple and reliable photographic reference scale for the assessment of nasolabial appearance in complete unilateral cleft lip and palate patients.

DESIGN

A blind retrospective analysis of photographs of cleft lip and palate patients was performed with this new rating scale.

SETTING

VU Medical Center Amsterdam and the Academic Center for Dentistry of Amsterdam.

PATIENTS

Complete unilateral cleft lip and palate patients at the age of 6 years.

MAIN OUTCOME MEASURES

Photographs that showed the highest interobserver agreement in earlier assessments were selected for the photographic reference scale. Rules were attached to the rating scale to provide a guideline for the assessment and improve interobserver reliability. Cropped photographs revealing only the nasolabial area were assessed by six observers using this new Cleft Aesthetic Rating Scale in two different sessions.

RESULTS

Photographs of 62 children (6 years of age, 44 boys and 18 girls) were assessed. The interobserver reliability for the nose and lip together was 0.62, obtained with the intraclass correlation coefficient. To measure the internal consistency, a Cronbach alpha of .91 was calculated. The estimated reliability for three observers was .84, obtained with the Spearman Brown formula.

CONCLUSION

A new, easy to use, and reliable scoring system with a photographic reference scale is presented in this study.

Surgeon's and Caregivers' Appraisals of Primary Cleft Lip Treatment with and without Nasoalveolar Molding: A Prospective Multicenter Pilot Study

BACKGROUND

Despite the increasing use of nasoalveolar molding in early cleft treatment, questions remain about its effectiveness. This study examines clinician and caregiver appraisals of primary cleft lip and nasal reconstruction with and without nasoalveolar molding in a nonrandomized, prospective, multicenter study.

METHODS

Participants were 110 infants with cleft lip/palate (62 treated with and 48 treated without nasoalveolar molding) and their caregivers seeking treatment at one of six high-volume cleft centers. Using the Extent of Difference Scale, standard photographs for a randomized subset of 54 infants were rated before treatment and after surgery by an expert clinician blinded to treatment group. Standard blocked and cropped photographs included frontal, basal, left, and right views of the infants. Using the same scale, caregivers rated their infants' lip, nose, and facial appearance compared with the general population of infants without clefts before treatment and after surgery. Multilevel modeling was used to model change in ratings of infants' appearance before treatment and after surgery.

RESULTS

The expert clinician ratings indicated that nasoalveolar molding-treated infants had more severe clefts before treatment, yet both groups were rated equally after surgery. Nasoalveolar molding caregivers reported better postsurgery outcomes compared with no-nasoalveolar molding caregivers (p < 0.05), particularly in relation to the appearance of the nose.

CONCLUSIONS

Despite having a more severe cleft before treatment, infants who underwent nasoalveolar molding were found by clinician ratings to have results comparable to those who underwent lip repair alone. Infants who underwent nasoalveolar molding were perceived by caregivers to have better treatment outcomes than those who underwent lip repair without nasoalveolar molding.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Facial aesthetic outcome analysis in unilateral cleft lip and palate surgery using web-based extended panel assessment

BACKGROUND AND AIM

The reproducible measurement of aesthetic outcomes after cleft lip and palate (CLP) surgery remains elusive, and there is no internationally recognised system. The aim of this pilot study was to better understand how humans rate post-operative aesthetic outcome after unilateral cleft lip and palate (UCLP) repair using a novel web-based rating platform with an extended panel of surgeon raters.

METHODS

Cropped images of 5-year-old UCLP patients were arranged in a randomly generated sequence within a web-based aesthetic scoring tool as part of an agreement/reliability study. Assessors rated the appearances of patients using a five-point Likert-type scale on two occasions. A mixed-effect statistical model was adopted to analyse the effects of rater, image and timing.

RESULTS

Images of 76 patients were scored by 29 UK-based cleft surgeons. Intra-rater variability was found, and the linear weighted kappa was 0.56. This allowed identification of the most and least consistent raters. The random image effect (p < 0.001) suggested that a broad range of aesthetic outcomes were included in the current study. Surgeon raters in this study were likely to score the images more preferably at the second assessment.

CONCLUSIONS

A web-based scoring system provides extended data capture, and mixed-effect statistical modelling reveals the effect that time, image and rater have on the scorings. The selection and training of raters, in combination with an exemplary yardstick, might improve inter- and intra-rater agreement. The development of objective measures based upon digital facial recognition can replace the highly variable subjective human influence on rating the aesthetic outcome.

Basal View Reference Photographs for Nasolabial Appearance Rating in Unilateral Cleft Lip and Palate

The Asher-McDade system is a 5-point ordinal scale frequently used to rate the components of nasolabial appearance, including nasal form and nasal symmetry, in unilateral cleft lip and palate. Although reference photographs illustrating this scale have been identified for the frontal and right profile view, no reference photographs exist for the basal view. The aim of this study was to identify reference photographs for nasal form and nasal symmetry from the basal view to illustrate this scale and facilitate its use. Four raters assessed nasolabial appearance (form and symmetry) on basal view photographs of 50 children (average age 8 years) with a repaired cleft lip. Intraclass correlation coefficients show fair to moderate inter-rater reliability. Cronbach α indicated strong agreement between raters (0.77 nasal form; 0.78 nasal symmetry; 0.80 overall), along with low duplicate measurement error and strong internal consistency between the measures. The photographs with the highest agreement among raters were selected to illustrate each point on the 5-point scale for nasal form and for nasal symmetry, resulting in the selection of 10 reference photographs. The basal view reference photograph set developed from this study may complement existing reference photograph sets for other views and facilitate rating tasks.

The Americleft Project: A Proposed Expanded Nasolabial Appearance Yardstick for 5- to 7-Year-Old Patients with Complete Unilateral Cleft Lip and Palate (CUCLP)

Objective

To develop a yardstick of reference photographs for nasolabial appearance assessments of 5- to 7-year-old patients with complete unilateral cleft lip and palate (CUCLP).

Design

Blind retrospective analysis of clinical records and comparison to historical controls.

Patients

Subjects were two groups of 6- to 12-year-olds (n = 124 and n = 135) and one group of 5- to 7-year-olds (n = 149) with nonsyndromic CUCLP from three previous Americleft studies, including cohorts from seven different cleft/craniofacial centers.

Interventions

All patients received the infant management protocols of their respective centers. Eleven trained and calibrated judges (five participated in all three studies) did blind ratings of nasolabial appearance using the Asher-McDade method.

Main Outcome Measures

Patients receiving the most consistent ratings between judges, selected first from the groups of 6- to 12-year-olds, were used to create a pilot yardstick for eventual use in the third study of 5- to 7-year-olds. For each of the Asher-McDade categories, 8 of the 5- to 7-year-old patients receiving the most consistent scores between raters were ranked by 10 judges for a final elimination to leave three per category.

Results

Using this method of successive changes in rating methods, a new reference yardstick for nasolabial appearance rating was established and linked to the original Asher-McDade method as well as the single examples in a previously published yardstick for patients with CUCLP. Pilot testing using the yardstick improved reliabilities.

Conclusions

Use of an expanded nasolabial yardstick of reference photographs representative of the range of possibilities of each of the five Asher-McDade categories is now available to see if reliability of these ratings can be improved.

Developing a visual rating chart for the esthetic outcome of unilateral cleft lip and palate repair

INTRODUCTION

Aesthetic impairment is a major concern for the cleft lip/palate patient. Thus, auditing of postsurgical esthetic outcome needs to be further explored as till date no universally accepted protocol exists. The study objective was to propose a new visual rating chart (VRC) for the aesthetic outcome of cleft lip and palate (CLP) surgery.

MATERIALS AND METHODS

In a retrospective review of 200 repaired clefts, the common esthetic deficiencies were identified, categorized and ranked in the order of severity. A chart of the illustrative diagram with textual description of the defects was produced and used as a basis for rating outcome by two groups of raters (familiar raters and recruited raters). Intra- and inter-raters reliability was estimated using Cohen's kappa statistics and intra-class correlation coefficient (ICC). Comparison between mean group coefficient was achieved with Kendall's correlation coefficient of concordance.

RESULTS

The intra- and inter-rater reliability for familiar raters was found to be strong with kappa values range of 0.80-0.87 (P < 0.001). Similarly, inter-raters' reliability by recruited judges was very strong using ICC at both single (0.768) and average measures (0.982).

CONCLUSION

The VRC is a reliable tool for assessing the esthetic outcome of CLP repairs.

Judgment of Nasolabial Esthetics in Cleft Lip and Palate Is Not Influenced by Overall Facial Attractiveness

OBJECTIVE

To determine whether judgment of nasolabial esthetics in cleft lip and palate (CLP) is influenced by overall facial attractiveness.

DESIGN

Experimental study.

SETTING

University of Bern, Switzerland.

SUBJECTS AND METHODS

Seventy-two fused images (36 of boys, 36 of girls) were constructed. Each image comprised (1) the nasolabial region of a treated child with complete unilateral CLP (UCLP) and (2) the external facial features, i.e., the face with masked nasolabial region, of a noncleft child. Photographs of the nasolabial region of six boys and six girls with UCLP representing a wide range of esthetic outcomes, i.e., from very good to very poor appearance, were randomly chosen from a sample of 60 consecutively treated patients in whom nasolabial esthetics had been rated in a previous study. Photographs of external facial features of six boys and six girls without UCLP with various esthetics were randomly selected from patients' files. Eight lay raters evaluated the fused images using a 100-mm visual analogue scale. Method reliability was assessed by reevaluation of fused images after >1 month. A regression model was used to analyze which elements of facial esthetics influenced the perception of nasolabial appearance.

RESULTS

Method reliability was good. A regression analysis demonstrated that only the appearance of the nasolabial area affected the esthetic scores of fused images (coefficient = -11.44; P < .001; R(2) = 0.464). The appearance of the external facial features did not influence perceptions of fused images.

CONCLUSION

Cropping facial images for assessment of nasolabial appearance in CLP seems unnecessary. Instead, esthetic evaluation can be performed on images of full faces.

Evidence-based medicine: The cleft lip nasal deformity

LEARNING OBJECTIVES

After studying this article, the participant should be able to: (1) Describe the components of unilateral and bilateral secondary cleft lip nasal deformity. (2) Discuss current methods of assessing the deformity and outcomes. (3) Discuss primary treatment options including the use of preoperative orthopedics, nasal molding techniques, and the primary cleft rhinoplasty. (4) Design a treatment plan for cleft patients that will optimize the outcome of nasal appearance and function. (5) Discuss the evidence regarding outcomes of current practices, and describe areas where more research is needed.

SUMMARY

This is the third Maintenance of Certification article on the secondary cleft lip nose deformity. In the first article, Guyuron defined the deformities and described techniques for the definitive (adult) rhinoplasty. The second article, by Zbar and Canady, presented evidence regarding the assessment, surgical treatment, and outcomes from the literature published between 1999 and 2009. In this article, the authors summarize important points from the first two articles and then concentrate on the evidence for the following topics: (1) methods currently used in evaluating the severity of the deformities; (2) methods used in evaluating outcomes of different treatments; (3) benefits of rhinoplasty performed at the time of the lip repair and evidence for the effect of rhinoplasties performed after infancy but before maturity; (4) presurgical orthopedics and nasoalveolar molding; (5) common surgical techniques used in primary cleft rhinoplasties; and (6) impact of the nasal deformity on quality of life. Overall, there is little high-level evidence regarding the outcomes of cleft nasal deformity treatment, leaving much room for future study.

The effects of lip revision surgery on nasolabial esthetics in patients with cleft lip

OBJECTIVES

1) To determine the concordance among surgeons on subjective assessments of nasolabial esthetics in children with repaired cleft lip; and 2) to evaluate longitudinal changes in nasolabial esthetics in relation to cleft lip revision surgery.

SETTING AND SAMPLE POPULATION

School of Dentistry at University of North Carolina, Chapel Hill. Children with repaired unilateral cleft lip: 32 had lip revision surgery and 27 did not have surgery.

MATERIALS AND METHODS

Retrospective observational study from a non-randomized clinical trial. Ratings of nasolabial esthetics performed by six surgeons using the Asher-McDade scale at baseline and 12-month follow-up.

RESULTS

Concordance among surgeons ranged from poor to acceptable. Nasolabial ratings at follow-up were better in the Revision group than in the Non-Revision group, although differences were small. The most prevalent change in the Revision Group was improvement in one or more units on the scale, while 'no change' was most prevalent in the Non-Revision group. Participants in the Revision group were more likely to receive a 'no' in relation to the need for lip or nose revision at the follow-up visit.

CONCLUSION

There were mild esthetic improvements observed in relation to lip revision surgery, which should be interpreted with caution given the subjectivity of the rating method used.

Scoring systems of cleft-related facial deformities: a review of literature

Objective :  There is a need for an internationally agreed objective method of assessing cleft-related deformities in order to compare the results of individual surgeons and different surgical techniques or to determine the optimal timing for primary lip closure. To assess the current methods, an overview of the recent developments in postoperative scoring systems of cleft-related deformities was made. Methods :  A Medline search from June 2003 through July 2011 was conducted, and references in the selected articles were checked. This search yielded 428 articles, and after application of the inclusion and exclusion criteria, 40 articles were included in this review. Results :  Twenty-five studies used two-dimensional (2D) photographs for the assessment of cleft-related deformities. Fourteen of these studies used a subjective method for the assessment and 11 performed anthropometric measurements. Good reliability has been found for subjective assessments and measurements from 2D photographs. Fifteen studies assessed three-dimensional (3D) imaging. Conclusions :  Although there is a wide variety in study design, 3D imaging seems most reliable in assessing cleft-related facial deformities. However, scoring on 2D photographs is easier to perform and more applicable in daily practice because all cleft patients are photographed through the course of their treatment.

Outcomes in facial aesthetics in cleft lip and palate surgery: a systematic review

BACKGROUND

While there are internationally validated outcome measures for speech and facial growth in cleft lip and palate patients, there is no such internationally accepted system for assessing outcomes in facial aesthetics.

METHOD

A systematic critical review of the scientific literature from the last 30 years using PUBMED, Medline and Google Scholar was conducted in-line with the PRISMA statement recommendations. This encompassed the most relevant manuscripts on aesthetic outcomes in cleft surgery in the English language.

RESULTS

Fifty-three articles were reviewed. Four main means of determining outcome measures were found: direct clinical assessment, clinical photograph evaluation, clinical videographic assessment and three-dimensional evaluation. Cropped photographs were more representative than full face. Most techniques were based on a 5-point scale, evolving from the Asher-McDade system. Multiple panel-based assessments compared scores from lay or professional raters, the results of which were not statistically significant. Various reports based on cohorts were poorly matched for gender, age, clinical condition and ethnicity, making their results difficult to reproduce.

CONCLUSIONS

The large number of outcome measure rating systems identified, suggests a lack of consensus and confidence as to a reliable, validated and reproducible scoring system for facial aesthetics in cleft patients. Many template and lay panel scoring systems are described, yet never fully validated. Advanced 3D imaging technologies may produce validated outcome measures in the future, but presently there remains a need to develop a robust method of facial aesthetic evaluation based on standardised patient photographs. We make recommendations for the development of such a system.

Reliability and validity testing for the Child Oral Health Impact Profile-Reduced (COHIP-SF 19)

OBJECTIVES

This study assessed the reliability and validity of the Child Oral Health Impact Profile-Short Form 19 (COHIP-SF 19) from the validated 34-item COHIP.

METHODS

Participants included 205 pediatric, 107 orthodontic, and 863 patients with craniofacial anomalies (CFAs). Item level evaluations included examining content overlap, distributional properties, and use of the response set. Confirmatory factor analysis identified potential items for deletion. Scale reliability was assessed with Cronbach's alpha. Discriminant validity of the COHIP-SF 19 was evaluated as follows: among pediatric participants, scores were compared with varying amounts of decayed and filled surfaces (DFS) and presence of caries on permanent teeth; for orthodontic patients, scores were correlated with anterior tooth spacing/crowding; and for those with CFA, scores were compared with clinicians' ratings of extent of defect (EOD) for nose and lip and/or speech hypernasality. Convergent validity was assessed by examining the partial Spearman correlation between the COHIP scores and a standard Global Health self-rating. Comparisons between the COHIP and the COHIP-SF 19 were completed across samples.

RESULTS

The reduced questionnaire consists of 19 items: Oral Health (five items), Functional Well-Being (four items), and a combined subscale named Socio-Emotional Well-Being (10 items). Internal reliability is ≥ 0.82 for the three samples. Results demonstrate that the COHIP-SF 19 discriminates within and across treatment groups by EOD and within a community-based pediatric sample. The measure is associated with the Global Health rating (P < 0.05), thereby indicating convergent validity.

CONCLUSIONS

Reliability and validity testing demonstrate that the COHIP-SF 19 is a psychometrically sound instrument to measure oral health-related quality of life across school-aged pediatric populations.

Evaluating aesthetics of the nasolabial region in children with cleft lip and palate: professional analysis and patient satisfaction

Cleft lip and palate is one of the most common deformities of the craniofacial region, and treatment of this deformity is essential for social reintegration. One of the major goals of surgery and treatment of craniofacial deformities is to improve the aesthetic appearance of the face, and thereby improve the patient's social acceptability. Here, we present a critical review of the criteria for aesthetic evaluation of the nasolabial region in cleft patients by assessing publications with the highest level of evidence, including professional evaluation, and patient satisfaction. The findings indicate treatment of this condition represents a major challenge for multidisciplinary team care.