Occlusal and Cephalometric Outcomes of Cleft Orthognathic Surgery: A Retrospective Cohort Study

OBJECTIVES

Aberrant facial growth in individuals affected by orofacial clefts can result in maxillary retrusion and class III malocclusion, with a proportion requiring surgical correction at cessation of growth. This study aimed to evaluate occlusal and cephalometric outcomes of combined orthodontic-orthognathic treatment.

MATERIAL AND METHODS

Retrospective cohort study in a United Kingdom cleft center. Participants included twenty-seven patients (20 males, 7 females) with cleft (n = 16 UCLP :7 BCLP :4 ICP) who consecutively underwent combined surgical treatment for Class III malocclusion between January 2013 and December 2017. Records were collected pre-treatment (T0), pre-surgery (T1) and at debond (T2). Models were scored using the Peer Assessment Rating (PAR) index and cephalometric radiographs were traced and analyzed. Outcomes were assessed by an independent rater.

RESULTS

Mean age at surgery was 21.4 years (SD 4.9). Le Fort 1 advancement (mean 6.1 mm, SD 4.0) was performed in all cases. Additional procedures included mandibular setback (n = 2), cortico-cancellous bone grafting (n = 6) and genioplasty (n = 1). Mean T0 PAR score was 44.8 (SD 11.7), reducing to 3.6 (SD 2.0) at T2, indicating a mean % PAR score reduction of 91.6% (SD 4.7). Class III skeletal profiles improved from a mean T0 ANB of -2.1º (SD 2.2), to 2.8º (SD 1.6) at T2. Mean T0 overjet was -3.3 mm (SD 2.3), increasing to 2.6 mm (SD 1.3) at T2.

CONCLUSION

Cleft orthognathic surgery differs in complexity and approach to routine orthognathics, however, these results demonstrate that occlusal outcomes can still be comparable with non-cleft populations. Outcome data can be used for comparison with other centers providing cleft orthognathic treatment.

Scoping review of outcome measures in cleft care used in research and reports

Treatment outcome measures are critical in the decision making of best practices in the OFC field. OFC consortium working groups provided standardization of outcome measures based on previous treatment outcome studies. However, the implementation of such standardization in OFC centres worldwide is unknown. This study presented mapped outcome measures in cleft care using a structured review method complemented by quantitative overview of the relevant published research to provide initial guidelines for the implementation of treatment outcome standardization. A scoping review of the literature of treatment outcomes in cleft care following Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines was performed. The selected indexed paper in outcome measures mapped following the international consortium in standard set of outcome measures in cleft care. Three hundred and sixty-five articles were filtered. The most discussed domains of cleft care were dental and oral health, appearance and speech/communication. Overall, the majority of publications were produced in high-income countries. The current review indicates that there are inequalities of treatment outcome studies among the domain of cleft care. In addition, there are also inequalities of published articles from HIC versus LMIC in treatment outcomes. This information can be used to develop targeted interventions aimed at encouraging cleft centres worldwide to adapt standardized outcome measures.

Long-term Outcome for Two-Stage Palatal Closure With Different Timings for Hard Palate Surgery: Craniofacial Growth and Dental Arch Relation

OBJECTIVE

The aim was to evaluate dental arch relation and craniofacial growth for individuals born with unilateral cleft lip and palate (UCLP), who had two-stage palatal surgery, with hard palate closure (HPC) at the ages of 3 or 8 years.

DESIGN

Longitudinal cohort study.

SETTING

Ceft lip and palate team in Gothenburg, Sweden.

PATIENTS

The inclusion criteria were nonsyndromic individuals born with complete UCLP who were consecutively operated according to two different surgical protocols; soft palate closure at 6 months followed by hard palate closure at the age of 3 years (HPC3) or at the age of 8 years (HPC8). In this evaluation, 28 individuals had HPC3 and 59 individuals had HPC8.

INTERNVENTIONS

The main outcome, longitudinal series of dental casts and lateral radiographs from the ages of 5, 10, 16, and 19 years, were evaluated using GOSLON Yardstick and cephalometric analysis.

RESULTS

At the age of 10 years, 78% of the individuals with HPC3 demonstrated GOSLON scores of 1 and 2 and 86% in HPC8. At the age of 19 years, 54% of the individuals exhibited GOSLON scores of 1or 2 when compared with 74% in HPC8. A statistical significant difference for SNA was observed at the age of 5 years (P  =  .004), with a lower SNA in HPC3, but not at the ages of 10, 16 and 19 years. At the final age, SNA was 75.2° for HPC3 and 76.8° for HPC8.

CONCLUSIONS

The decrease in age for HPC did not have an adverse effect on long-term dental arch relationship or craniofacial growth.

Neurodevelopmental trajectories in children with cleft lip and palate: A longitudinal study based on the Japan Environment and Children's Study

Cleft lip and/or palate (CL/P), the most prevalent congenital anomaly, is understood to negatively affect a wide range of child development. Since the concept remains controversial, because most published work is from cross-sectional studies, we examined the neurodevelopmental trajectories in participants with CL/P through a longitudinal comparison with the general population during early childhood using data from a nationwide birth cohort study in Japan. The linear mixed models for each domain of the Ages and Stages Questionnaire, third edition (ASQ-3), were used to detect differences in standardised mean scores between groups. The ASQ-3 is a general neurodevelopmental screening tool comprising communication, gross motor, fine motor, problem-solving, and personal-social domains. Participants' neurodevelopment was determined semi-annually from 6 to 36 months of age. The trajectories of standardised mean scores in each domain showed several significant differences between the control and CL/P groups, with the maximum difference at 24 months of age in the communication domain. Indeed, CL/P was associated with significantly lower scores in the communication (coefficient: -3.31, 95% CI: -5.09 to -1.14), problem-solving (coefficient: -3.13, 95% CI: -5.07 to -1.18), and personal-social domains (coefficient: -1.99, 95% CI: -3.87 to -0.11). Trajectories of ASQ-3 scores suggest neurodevelopmental delays in children with CL/P.

Speech Outcomes of a National Cohort of Children with Orofacial Cleft at 5 and 10 Years of age

OBJECTIVE

To assess speech outcomes at five and ten years of age in a nationwide study of children with orofacial cleft.

DESIGN

Prospective study.

PARTICIPANTS

Children born with orofacial cleft and having primary surgery in New Zealand. Speech samples were available for 151 five-year-old, and 163 ten-year-old children.

MAIN OUTCOME MEASURES

Intelligibility, Acceptability, Velopharyngeal function, Hypernasality, Hyponasality, severity of airflow evaluated by perceptual speech assessment (using the standardised Rhinocleft assessment), and overall assessment of requirement for clinical intervention.

RESULTS

A large proportion of five-year-old children had speech that was considered to be not completely intelligible, was not acceptable, and had inadequate velopharyngeal function. The noted deficiencies led to a clinical judgement that further speech and/or surgical intervention was required in 85% with cleft lip and palate, 65% with cleft palate and 26% with cleft lip. The proportion of children with poor speech outcomes in the ten-year-old children was lower, though of clinical importance, further intervention required for 25% with CLP, 15% with CP and 3% with CL. The number of sound production errors in both age groups followed the same pattern with fewest in those with CL and most in those with CLP.

CONCLUSIONS

A significant proportion of children with orofacial cleft were found to have poor speech outcomes requiring further treatment. The outcomes are poor compared to centres reported in the UK and Scandinavia. New Zealand requires a review of the current services for individuals born with cleft to improve speech outcomes and interdisciplinary care.

Peer Assessment Rating (PAR) scoring of cleft patients treated within a regional cleft centre in the United Kingdom

OBJECTIVE

To assess static occlusal outcomes for patients with cleft lip and/or palate (CLP) and cleft palate (CP) managed within a UK Regional Cleft Service and to compare with previously published Peer Assessment Rating (PAR) scores from a non-cleft population of patients treated within a UK consultant-led hospital service.

DESIGN

Retrospective multicentre study.

SETTING

Eight orthodontic hospital units within the Spires Cleft Service, UK.

PARTICIPANTS

Patients born with CLP or CP between 1985 and 1995 treated within the service.

METHODS

Patients were assigned to groups by cleft type and whether they were treated by orthodontics only or a combination of orthodontics and orthognathic surgery. PAR was recorded before and after treatment from study models.

RESULTS

Data were collected for 171 patients included in the study. Median pre-treatment PAR was 42 and post-treatment 11. Median percentage change in PAR for all patients was 73%, although 12% of cleft patients had a PAR improvement that was worse or no different. Median change in PAR score was 71% for those treated with orthodontics only and 83% for those who had an osteotomy. Median PAR improvement for those treated with orthodontics only was 73% in the cleft lip group, 77% in the CP group, 66% in the unilateral CLP group and 53% in the bilateral CLP group. Median pre- and post-treatment PAR for the cleft group was higher and PAR reduction lower than those published for non-cleft patients.

CONCLUSION

These data demonstrate high severity of malocclusion, complexity of orthodontic treatment and difficulty in achieving an ideal static occlusion for cleft patients. If PAR is to be used to assess orthodontic outcomes in cleft patients the findings of this study should be considered. A higher proportion of cases are likely to be classed as 'worse or no different', and a lower percentage change will be expected.

Radiographic outcome of secondary alveolar bone grafting in patients with alveolar clefts

OBJECTIVE

To determine the outcome of secondary alveolar bone grafting (SABG) in a series of consecutive patients with clefts involving the alveolus.

DESIGN AND SETTING

Retrospective cohort study of consecutive operations performed between June 2011 and September 2016 by a single surgeon at a single United Kingdom cleft center.

PARTICIPANTS

A total of 160 patients with a cleft/s involving the alveolus, inclusive of syndromic patients and those with atypical facial clefts.

INTERVENTIONS

A standard protocol involved an oral hygiene program, pre-surgical orthodontics where necessary and autologous bone grafting from the iliac crest.

MAIN OUTCOME MEASURE(S)

The Kindelan bone-fill index was used to evaluate success using occlusal radiographs. Weighted Cohen's kappa coefficient was used as a measure of intra- and inter-rater agreement. Fisher's exact test was used to examine the effects of type of cleft, pre-surgical orthodontics or age at time of SABG on radiographic outcome.

RESULTS

There were 200 SABGs assessed. Mean age at time of SABG was 9.1 years old (SD 1.1) with 99% (n = 198) of grafts deemed successful. There were two failures where re-graft was performed successfully during the study period. A grade 1 outcome was achieved for 92.5% (n = 185) of grafts and this did not appear to be affected by type of cleft (P = .290), pre-surgical orthodontics (P = .380) or age at time of SABG (P = .081).

CONCLUSIONS

The high success rate reported in this study supports the favorable outcomes of a high-volume cleft surgeon. These findings can be used for comparative audit with similar units providing cleft care.

Occlusal Outcome of Orthodontic Treatment for Patients With Complete Cleft Lip and Palate

AIM

To assess occlusal outcomes of orthodontic treatment for patients with complete cleft lip and palate.

DESIGN

Retrospective assessment using the Peer Assessment Rating (PAR) index.

SETTING

Consecutive patients treated by one consultant orthodontist at a tertiary care cleft center.

PARTICIPANTS

One hundred twenty-seven patients with either complete unilateral cleft lip and palate (UCLP) or bilateral cleft lip and palate (BCLP) consecutively treated with fixed appliances.

INTERVENTION

Fixed orthodontic appliance treatment and orthognathic surgery when required.

OUTCOMES

The PAR index assessment was carried out by a calibrated-independent assessor. Treatment duration, the number of patient visits, and data on dental anomalies were drawn from patient records and radiographs.

RESULTS

One hundred two patients' study models were assessed after exclusions. Mean start PAR score for UCLP (n = 71) was 43.9 (95% CI, 41.2-46.6, SD 11.5), with a mean score reduction of 84.3% (95% CI, 81.9-86.7, SD 10.1). The UCLP mean treatment time was 23.7 months with 20.1 appointments. Mean start PAR score for BCLP (n = 31) was 43.4 (95% CI, 39.2-47.6, SD 11.4), with a mean score reduction of 80.9% (95% CI, 76.3-85.5, SD 12.5). The BCLP mean treatment time was 27.8 months with 20.5 appointments.

CONCLUSION

These results compare well with other outcome reports, including those for patients without a cleft, and reflect the standard of care provided by an experienced cleft orthodontist. As with high-volume surgeons, orthodontic treatment for this high need group is favorable when provided by a high-volume orthodontist. These findings may be used for comparative audit with similar units providing cleft care.

Occlusal and Functional Improvement of Patients With Midfacial Hypoplasia Corrected Using Intraoral Tooth-Borne Mid-Maxillary Osteodistractors at Teaching Hospital-Karapitiya, Sri Lanka

OBJECTIVE

Mid-maxillary osteodistraction (MMOD) is a novel technique. This study seeks to assess the occlusal and functional improvement of patients with midfacial hypoplasia secondary to cleft lip and palate.

DESIGN

This was done as a retrospective study at the Regional Cleft Centre of the Teaching Hospital-Karapitiya (THK).

PARTICIPANTS

A total of 81 patient records were accessed on those who underwent MMOD with a tooth-borne intraoral device from January 1, 2007, to December 31, 2016, at THK.

METHODS

Records of the patients included pre- and post-treatment lateral cephalograms, study models, speech assessments, and photographs.

RESULTS

An advancement ranging from 5 to 12 mm (mean, 8.14 mm) was achieved in all patients; 80% (n = 63) and 87.65% (n = 71) showed improvement in consonant production and quality of speech. These were statistically significant (P < .05). With regard to the Peer Assessment Rating score assessing the occlusal improvement, 97.6% showed an improvement whereas only 2 patients showed no improvement. There was a significant improvement in sella (S), nasion (N), and point A (SNA) angle; point A, the nasion, and point B (ANB) angle; and the maxillary length over the treatment period (P < .05). The change in the ANB angle and maxillary length significantly differed between genders with males having a comparatively higher improvement. The profile improvements were noteworthy on the profile photographs.

CONCLUSION

This relatively novel approach to maxillary advancement by maxillary distraction using a combined surgical and modified orthodontic technique has proven to be successful. This protocol and the technique have improved function, occlusion, and the aesthetics.

Reliability and Predictive Validity of Dental Arch Relationships Using the 5-Year-Olds’ Index and the GOSLON Yardstick to Determine Facial Growth

Aims:

To determine reliability and predictive validity of the 5-year-olds’(5YO) Index and GOSLON Yardstick in 119 patients born with unilateral cleft lip and palate at 5, 7/8, 10, 15/16, and 19 years.

Methods:

Five hundred thirty-four dental study models were appraised by 2 teams in 2 centers, twice in each center. Intrateam and interteam reliability in scoring the models was calculated using κ. Dental arch prediction rates were calculated as the proportion of models remaining in the same category (good–scores 1 and 2; fair–score 3; poor–scores 4 and 5) over time.

Results:

Intrateam and interteam κ statistics ranged from 0.74 to 0.89 and from 0.74 to 0.81, respectively. The 5YO Index and GOSLON Yardstick at 5 years produced almost identical results. The prediction rate of 19-year-old (n = 106) outcome was >80% for those in groups 1 and 2 at 5 years, while for those in groups 4 and 5 prediction was poor (<40%). Prediction of groups 4 and 5 remained poor until 10 years when it increased to 77%. At 15/16 years prediction rate was 93% for those in groups 4 and 5. Prediction of cases in group 3 was very poor at all ages.

Conclusions:

These results question the predictive value of “poor” dental arch relationships before 10 years of age. However, the predictive value of “good” dental arch relationship scores over time is good in all age groups. This has implications for audit policies to predict facial growth outcomes.

Validating the Asher-McDade score to assess facial aesthetic outcomes in 22 consecutive complete bilateral cleft lip repairs

Most scoring systems used to assess facial aesthetics in cleft patients tend to lack consistency, and the absence of an internationally agreed system makes comparison challenging. The most widely used and validated tool is the five-point Asher-McDade index. We note that there are currently no reports (to our knowledge) of its use for scoring outcomes after bilateral cleft lip repair. To validate it for this use, the aim was to describe the outcomes of 22 consecutive bilateral cleft lip repairs assessed using this scale. A retrospective review was undertaken of 22 consecutive patients with bilateral cleft lip repairs performed at our centre. Each patient underwent bilateral advancement rotation repair with a vomer flap on one side at three months followed by repair of the remaining hard palate and an intravelar veloplasty three months later. Standardised photographs were taken five years after repair and were cropped to isolate the nasolabial component. Eleven members of the cleft multidisciplinary team were asked to rate each image on a five-point Likert scale. Statistical analysis was performed using a two-way ANOVA test and intraclass correlation coefficient to interrogate intraobserver and interobserver variance. A total of 22 consecutive patients with complete bilateral cleft lips were photographed. The overall mean (range) score for the repairs was 3.2 (4.3 - 1.8). Two-way ANOVA demonstrated that inter-rater variability accounted for just over 10% (11.23% of the total variance, p < 0.0001). As predicted, the single biggest factor affecting score variability was the patient's appearance, which accounted for 44.51% of the total variance between scores (p < 0.0001). Intraobserver variance was not found to be significant, accounting for 0.33% of the total variance (p = 0.0006). We demonstrate that the Asher-McDade scoring system is a valid tool to use when assessing bilateral cleft lip repairs. Variance in the patient's score was significantly related to a true difference in appearance, with only a small percentage of differences being due to intraobserver and interobserver variation.

Long-Term Outcomes for Adult Patients With Cleft Lip and Palate

The purpose of this study was to evaluate a single center's experience with adult patients who had cleft lip, cleft palate, or both. The authors aimed to identify common long-term needs in this patient population and evaluated the relationship of team-based care in meeting those needs. To do so, the authors retrospectively reviewed chart records from a single private practice and tertiary referral cleft center for all patients who were ≥15 years of age and who had a history of clefts of the lip or palate, or both, from January 1, 2013, to June 30, 2014. The authors compared the concerns of the patients who received cleft-team-based care by a single, multidisciplinary cleft team; multiple multidisciplinary cleft teams; or no formal cleft team. The authors analyzed data for 142 patients. The most common patient concerns were lip aesthetics (64%), nose aesthetics (61%), septal deviations (47%), nasal obstruction (44%), malocclusion (32%), oronasal fistulas (29%), and speech (21%). Oronasal fistulas were more commonly reported in the group of patients who had care by multiple teams (42.9%; P < .001). Malocclusion was more commonly reported in the group of patients who had care by multiple teams (50%; P = .001). The authors found that adult patients who have undergone rehabilitation for cleft lip and palate appear to have a common set of long-term needs. Multidisciplinary cleft-team-based care appears to be the most effective way to address these needs.

Further construct validation of the CLEFT-Q: Ability to detect differences in outcome for four cleft-specific surgeries

BACKGROUND

The CLEFT-Q is a patient-reported outcome measure developed for use in patients with cleft lip and/or palate. A significant indicator of the CLEFT-Q's validity relates to its ability to detect differences between the impact of specific aspects of clefting before and after surgery. This study compares relevant sub-scale scores of the CLEFT-Q for patients requiring four specific surgical treatments against those who either have had surgery or never needed surgery.

METHODS

CLEFT-Q scores and clinical information regarding the past and future need for jaw surgery, lip revision, rhinoplasty, and speech surgery were obtained from the CLEFT-Q field-test data. Eight one-way analysis of variance (ANOVA) models were developed to compare mean scores of relevant CLEFT-Q scales between those who needed surgery, those who have had surgery, and those who never needed surgery. Only patients from high-income countries were included to minimize the impact of any economic confounders that could result in treatment variation. In the rhinoplasly and lip revision models, patients without a cleft lip were excluded. In the jaw surgery and speech surgery models, patients without a cleft palate or alveolus were excluded.

RESULTS

The CLEFT-Q field test included 1938 participants from high-income countries. Participants who needed surgery scored significantly lower (worse) than those who have had surgery in each of the eight relevant CLEFT-Q scales (p < 0.001 in each ANOVA).

CONCLUSION

The ability of the CLEFT-Q to detect differences between groups based on surgical status further supports its validity.

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 outcomes in a nationwide study of orofacial cleft in New Zealand

OBJECTIVES

To (a) assess nasolabial outcomes across four main cleft subgroups, (b) assess agreement using a categorical and a continuous scoring measure and (c) compare outcomes to international studies.

SETTINGS AND SAMPLE POPULATION

Analysis of 470 images of which 218 was unilateral cleft lip and palate (UCLP), 128 unilateral cleft lip (UCL), 90 bilateral cleft lip and palate (BCLP) and 34 bilateral cleft lip (BCL). Images were taken around five (n = 279) and eight-ten (n = 191) years of age.

MATERIALS & METHODS

Cropped images were assessed using the Asher-McDade (AM) and a 100 mm visual analogue scale (VAS) by a panel of six raters. Scoring was undertaken for vermillion border and nasal form, symmetry and profile. Analysis was undertaken for each subscore, a total score with sensitivity analysis using a total score based on the subscores for each patient. AM intra- and inter-rater reliability was assessed using weighted kappa and for the VAS components reliability was assessed using Pearson correlation.

RESULTS

The AM intra-rater reliability was moderate/substantial, whilst inter-rater reliability was fair. The VAS intra-rater correlations were high, and inter-rater correlations were moderate. Better outcomes were found with cleft lip (CL) vs cleft lip and palate (CLP). No differences were found for sex, ethnicity, age and cleft laterality (unilateral). The AM found no difference between unilateral or bilateral. The VAS found bilateral scored worse than unilateral for both CL and CLP.

CONCLUSIONS

The nasolabial outcomes differ by cleft type. The correlation was relatively high for the VAS whilst the AM had relatively poor reliability.

Dental arch relationship outcomes for children with complete unilateral and complete bilateral cleft lip and palate in New Zealand

OBJECTIVES

To evaluate dental arch relationships of patients with complete unilateral and complete bilateral cleft lip and palate (CUCLP/CBCLP) in New Zealand.

SETTING AND SAMPLE POPULATION

Retrospective nationwide observational outcomes study involving 100 CUCLP and 32 CBCLP non-syndromic patients.

MATERIAL AND METHODS

Four calibrated assessors, blinded to the origin of the randomized digital models, used the GOSLON (UCLP) and the Bauru-BCLP (BCLP) Yardsticks and a 100 mm visual analogue scale (VAS) (UCLP&BCLP) to assess dental arch relationships. Weighted Kappa statistics were used to determine the intra- and inter-rater reliability for the GOSLON/Bauru-BCLP Yardsticks and correlations for the VAS.

RESULTS

Intra-rater reliability ranged from 0.57 to 0.88 (GOSLON), 0.62-0.84 (Bauru-BCLP) and 0.45-0.93 (VAS). Inter-rater reliability ranged from 0.62 to 0.86, (GOSLON), 0.48-0.75 (Bauru-BCLP) and 0.64-0.93 (VAS). Of the 100 CUCLP models, 46% had poor/very poor, 28% fair and 26% had good/very good dental arch relationships. Of the 32 CBCLP models, 37.5% were poor/very poor, 40.6% fair and 21.9% had good/very good dental arch relationships. The mean CUCLP VAS score was 50.5 mm (SD 19.9 mm) whilst the mean CBCLP VAS score was 40.0 mm (SD 22.0 mm) and both showed a strong relationship with their respective Yardstick scorings.

CONCLUSION

The dental arch relationships of children in New Zealand with CUCLP are similar to those centres in the Eurocleft and Americleft studies which had less favourable outcomes. Those with CBCLP are inferior to those reported elsewhere. Continued monitoring will allow for tracking of improvement in outcomes.

Dentoalveolar Effects of Early Orthodontic Treatment in Patients With Cleft Lip and Palate

No agreement exists on the most appropriate timing of orthodontic treatment in patients with cleft lip and palate. The aim of this study is to investigate the effect of early orthodontic treatment on development of the dental arches and alveolar bone.A dental casts analysis was performed on 28 children with cleft lip and palate before orthodontic treatment (T0; mean age, 6.5 ± 1.7) and at the end of active treatment (T1; mean age, 9.2 ± 2.1 years). The considered variables were: intercanine and intermolar distances; dental arch relationships, evaluated according to the modified Huddart/Bodenham system.The study group was divided into 2 samples according to the age at T0: Group A (age < 6 years) and Group B (age ≥ 6 years). A statistical comparison of the treatment effects between the 2 samples was performed.Patients in Group A exhibited a greater increase of intercanine distance (8 mm versus 2.7 mm; P<0.001), intermolar distance (7.2 mm versus 5 mm; P = 0.06), and Huddart/Bodenham score (7.1 versus 3; P < 0.05) when compared with patients in Group B.Early orthodontic treatment strongly improved the dental arch relationship, since subjects starting the therapy before the age of 6 had a better response in terms of anterior maxillary expansion.

Comparing Modified Huddart-Bodenham Scoring System and GOSLON Yardstick to Assess Dental Arch Relationships in Unilateral Cleft Lip and Palate Patients

OBJECTIVE

To test the reliability of the modified Huddart-Bodenham (MHB) numerical scoring system and its agreement with the GOSLON Yardstick categorization for assessing the dental arch relationships in unilateral cleft lip and palate (UCLP) cases.

DESIGN

A retrospective study.

SETTING

Faculty of Dentistry, The University of Hong Kong.

PATIENTS

Forty-one nonsyndromic UCLP consecutive patients attending the Joint Cleft Lip/Palate Clinic at Faculty of Dentistry in the University of Hong Kong were selected.

INTERVENTIONS

Study models at 8 to 10 years old (T1) and 10 to 12 years old (T2) were obtained from each patient.

MAIN OUTCOME MEASURES

Models were rated with the MHB scoring system and GOSLON Yardstick index. The intra- and interexaminer reliabilities as well as correlation of both scoring systems were evaluated. Furthermore, to investigate the outcome measurements consistency, the MHB scoring system and GOSLON Yardstick were independently used to compare the dental arch relationships from T1 to T2, with the samples split into intervention and nonintervention groups.

RESULTS

The MHB scoring system presented good intra- and interexaminer agreement, which were comparable to those of the GOSLON Yardstick. The correlation between the MHB scoring system and GOSLON Yardstick scores was good. Both scoring systems showed similar results when assessing the change in the dental arch relationships from T1 to T2.

CONCLUSIONS

The MHB scoring system can be used as an alternative method to the commonly used GOSLON Yardstick for assessing dental deformities in UCLP patients. Both scoring systems showed similar results in assessing the improvement in dental arch relationships.

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.

Use of the Sphenoid Flap in Repair of the Wide Cleft Palate

Objective:

In wide palatal defects, closure of the nasal layer can prove a considerable challenge. Mobilizing nasal flaps posteriorly usually facilitates soft palate closure. However, the defect is often too wide within the hard palate; hence, bilateral vomerine flaps are frequently required. Despite this, there is often a small defect in the nasal layer at the posterior septum (typically equating to the hard-soft palate junction), which has to be left to heal by secondary intention with the resulting increased risk of fistula formation and the potential deleterious long-term effect on speech due to cicatricial migration of the reconstructed levator sling anteriorly. We describe our experience in the use of the sphenoid flap to obtain tension-free primary closure of the nasal layer.

Methods:

A retrospective multi-center study assessing all sphenoid flap procedures undertaken at both Birmingham Children’s Hospital and Great Ormond Street Hospital. Key demographic and medical data was collected pre-, peri-, and postoperatively across the 2 sites.

Results:

A total of 66 patients underwent the use of a sphenoid flap to aid closure of the nasal layer. The average age at time of repair was 9.7 months. More than half (55%, n = 36) were isolated cleft palates, and 35% (n = 23) were BCLPs. Forty-two percent of all patients had Robin sequence. The average cleft width was 14.4 mm. The overall fistula rate was 25.8% (n = 17).

Conclusions:

We describe the operative technique, indications, and our experience in the use of the sphenoid flap in wide cleft palate repair.

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.

A scoping review of outcomes related to orthodontic treatment measured in cleft lip and palate

The aim of this study was to identify and summarize the outcomes measured in orthodontic studies of children with cleft lip and/or palate. The objectives were to categorize the outcomes into pre-determined domains and to explore whether any domains were under-represented. Electronic databases and grey literature were searched until December 2016 to identify all studies of orthodontic treatment interventions in children and adolescents with cleft lip and palate. Abstracts and subsequently eligible full-text articles were screened independently and in duplicate by two reviewers. All reported outcome measures were identified and categorized into six predetermined outcome domains. The search identified 833 abstracts. The majority of studies did not assess orthodontic interventions and were therefore not eligible for inclusion. Consequently, following screening 71 eligible articles were retrieved in full, of which 40 met the inclusion criteria. Morphological features of malocclusion were measured in 27 studies (68%) and adverse effects of orthodontic treatment in 10 (25%). Functional status (n=4; 10%), physical consequences of malocclusion (n=3; 7.5%), quality of life (n=3; 7.5%) and health resource utilization (n=2; 5%) were rarely considered. Relatively few studies concerning patients with cleft lip and palate focused on orthodontic interventions. Most of the identified outcomes were concerned with measuring morphological treatment-related changes and do not reflect patient perspectives.

Treatment outcome after neonatal cleft lip repair in 5-year-old children with unilateral cleft lip and palate

INTRODUCTION

The aim of this study was to assess speech outcomes and dental arch relationship of 5-year-old Czech patients with unilateral cleft lip and palate (UCLP) who have undergone neonatal cleft lip repair and one-stage palatal closure.

METHODS AND MATERIALS

Twenty-three patients with UCLP, born between 2009 and 2010, were included in the study. Three universal speech parameters (hypernasality, articulation and speech intelligibility) have been devised for speech recordings evaluation. Outcomes of dental arch relationship were evaluated by applying the GOSLON Yardstick and subsequently compared with the GOSLON outcome of other cleft centers.

RESULTS

Moderate hypernasality was present in most cases, the mean value for articulation and speech intelligibility was 2.07 and 1.93, respectively. The Kappa values for inter-examiner agreement for all the three speech outcomes ranged from 0.786 to 0.808. Sixty-three percent of patients were scored GOSLON 1 and 2, 26% GOSLON 3, and 10% GOSLON 4. GOSLON mean score was 2.35. Interrater agreement was very good, represented by kappa value of 0.867.

CONCLUSION

The treatment protocol, involving neonatal cleft lip repair and one-stage palatal repair performed up to the first year of UCLP patient's life, has shown good speech outcomes and produced very good treatment results in regard to maxillary growth, comparable with other cleft centers.

Which index should be used to measure primary surgical outcome for unilateral cleft lip and palate patients?

OBJECTIVE

To determine the optimal dentoalveolar measure to assess unilateral cleft lip and palate (UCLP) patient plaster models.

DESIGN

The models of 34 patients with UCLP taken at 5, 10, and 15-20 years of age were scored by two examiners on two separate occasions using five indices: the 5 Year Olds' (5YO), GOSLON, Modified Huddart/Bodenham (MHB), EUROCRAN, and Overjet. Reliability, validity, and ease of use were recorded for each index/examiner.

SETTING

All models were scored in either Bristol Dental Hospital or Derriford Hospital, Plymouth, United Kingdom by senior orthodontic clinicians.

RESULTS

Highest overall reliability was seen with MHB (Kappa = 0.56-0.97). Predictive validity was similar for MHB, GOSLON, and 5YO with a 50-65 per cent prediction of final outcome from 5 and 10 years. EUROCRAN palatal index showed no clear predictive validity (Spearman's correlation = 0.20-0.21). Agreement to the gold standard 5YO score at the 5-year age group was high for MHB (Kappa = 0.83) and moderate for GOSLON (Kappa = 0.59). Agreement to the gold standard GOSLON score at 10 years was highest for 5YO (Kappa = 0.69), followed by Overjet (Kappa = 0.59) and MHB (Kappa = 0.46). Time to score 34 models per index (minutes): GOSLON (13.4) < Overjet (13.6) < 5YO (19.4) < EUROCRAN (24.8) < MHB (27.4).

CONCLUSION

As an outcome measure of UCLP models, only MHB and 5YO indices can be recommended for use at 5 years of age and GOSLON at 10 years of age.

Intraoral 3D Scanning or Dental Impressions for the Assessment of Dental Arch Relationships in Cleft Care: Which is Superior?

OBJECTIVE

This study was undertaken to evaluate intraoral 3D scans for assessing dental arch relationships and obtain patient/parent perceptions of impressions and intraoral 3D scanning.

MATERIALS & METHODS

Forty-three subjects with nonsyndromic unilateral cleft lip and palate (UCLP) had impressions taken for plaster models. These and the teeth were scanned using the R700 Orthodontic Study Model Scanner and Trios® Digital Impressions Scanner (3Shape A/S, Copenhagen, Denmark) to create indirect and direct digital models. All model formats were scored by three observers on two occasions using the GOSLON and modified Huddart Bodenham (MHB) indices. Participants and parents scored their perceptions of impressions and scanning from 1 (very good) to 5 (very bad). Intra- and interexaminer reliability were tested using GOSLON and MHB data (Cronbach's Alpha >0.9). Bland and Altman plots were created for MHB data, with each model medium (one-sample t tests, P < .05) and questionnaire data (Wilcoxon signed ranks P < .05) tested.

RESULTS

Intra- and interexaminer reliability (>0.9) were good for all formats with the direct digital models having the lowest interexaminer differences. Participants had higher ratings for scanning comfort (84.8%) than impressions (44.2%) (P < .05) and for scanning time (56.6%) than impressions (51.2%) (P > .05). None disliked scanning, but 16.3% disliked impressions. Data for parents and children positively correlated (P < .05).

CONCLUSIONS

Reliability of scoring dental arch relationships using intraoral 3D scans was superior to indirect digital and to plaster models; Subjects with UCLP preferred intra-oral 3D scanning to dental impressions, mirrored by parents/carers; This study supports the replacement of conventional impressions with intra-oral 3D scans in longitudinal evaluations of the outcomes of cleft care.

Rating dental arch relationships and palatal morphology with the EUROCRAN index on three different formats of dental casts in children with unilateral cleft lip and palate

Background

The EUROCRAN index has been used in inter-center studies to assess dental arch relationship (DAR) and palatal morphology (PM) in children with unilateral cleft lip and palate (UCLP). For this type of inter-center research, a scoring method that could be performed over the internet would be the most effective. Therefore, the aim of this study was to investigate the reliability of application of the EUROCRAN index on 3D digital models or photographs of plaster models instead of using plaster models.

Methods

The EUROCRAN reference models were presented in three formats: plaster models, 2D photographs of plaster models, and 3D digital models. Plaster models of children with UCLP (n = 45) were rated. Of each case, all three formats were rated by six calibrated observers in random order. The strength of agreement of the ratings was assessed with kappa statistics. Concordance among observers was evaluated with the intra-class correlation coefficient (ICC).

Results

The ICC showed a good inter-observer agreement for the DAR and poor inter-observer agreement for the PM. Intra-observer agreement for the DAR was moderate to very good, yet for the PM poor to moderate. Comparison between the three formats per observer for the DAR was good or very good and for the PM moderate to poor.

Conclusions

The overall results show that the EUROCRAN index is an acceptable and reliable scoring method for the DAR on plaster models, 2D photographs of plaster models, and 3D digital models. However, due to the small range of deviations in palatal morphology between the cases in our study, the PM component of the index was difficult to assess.

Clinical relevance

In clinical audits and inter-center studies, plaster models can be substituted by 2D photographs of plaster casts or 3D digital models when grading treatment outcome with the EUROCRAN index.

A Comparison of Three Viewing Media for Assessing Dental Arch Relationships in Patients With Unilateral Cleft Lip and Palate

OBJECTIVE

To determine the repeatability and reproducibility of using three different viewing media to assess the outcomes of the dental arch relationships of patients with unilateral cleft lip and palate (UCLP) using the GOSLON Yardstick.

DESIGN

The GOSLON Yardstick was used to rate the dental arch relationships of 29 patients with UCLP. Three experienced calibrated orthodontists rated the plaster study models, digital study models, and stereoscopic projected three-dimensional (3D) study models separately. There was a minimum of a 1-week interval between each rating session. All three rating sessions were repeated 1 month later. A linear weighted kappa statistic was performed to assess intra-rater repeatability and inter-rater reproducibility, as well as the comparison between different viewing media using Kendall's Coefficient of Concordance (Kendall's W) statistic.

RESULTS

Intra-rater repeatability was very good for all three viewing media (kappa = 0.83-0.92). Inter-rater reproducibility was good to very good across the three viewing media (kappa = 0.63-0.88). Agreements between plaster study models and digital study models or stereoscopic projected 3D study models were good to very good (kappa = 0.78-0.97 and kappa = 0.72-0.97, respectively), and a Kendall's W ranging from 0.86 to 0.92 (P < .001).

CONCLUSIONS

Stereoscopic projected 3D is an alternative method to assess the outcomes of dental arch relationships in patients with cleft lip and palate using the GOSLON Yardstick. It could also be used for viewing patient records, as it recovers the full 3D information captured at the time of the clinical examination.