A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 2. Craniofacial form and soft tissue profile

Clinical Outcomes of Bilateral Cleft Lip and Palate Repair with Nasoalveolar Molding and Gingivoperiosteoplasty to Facial Maturity

BACKGROUND

The long-term effects of nasoalveolar molding (NAM) on patients with bilateral cleft lip and palate (BCLP) are unknown. The authors report clinical outcomes of facially mature patients with complete BCLP who underwent NAM and gingivoperiosteoplasty (GPP).

METHODS

A single-institution retrospective study of nonsyndromic patients with complete BCLP who underwent NAM between 1991 and 2000 was performed. All study patients were followed to skeletal maturity, at which time a lateral cephalogram was obtained. The total number of cleft operations and cephalometric measures was compared with a previously published external cohort of patients with complete and incomplete BCLP in which a minority (16.7%) underwent presurgical orthopedics before cleft lip repair without GPP.

RESULTS

Twenty-four patients with BCLP comprised the study cohort. All patients underwent GPP, 13 (54.2%) underwent alveolar bone graft, and nine (37.5%) required speech surgery. The median number of operations per patient was five (interquartile range, two), compared with eight (interquartile range, three) in the external cohort ( P < 0.001). Average age at the time of lateral cephalogram was 18.64 years (1.92). There was no significant difference between our cohort and the external cohort with respect to sella-nasion-point A angle (SNA) [73 degrees (6 degrees) versus 75 degrees (11 degrees); P = 0.186] or sella-nasion-point B angle (SNA) [78 degrees (6 degrees) versus 74 degrees (9 degrees); P = 0.574]. Median ANB (SNA - SNB) was -3 degrees (5 degrees) compared with -1 degree (7 degrees; P = 0.024). Twenty patients (83.3%) underwent orthognathic surgery.

CONCLUSION

Patients with BCLP who underwent NAM and GPP had significantly fewer total cleft operations and mixed midface growth outcomes at facial maturity compared with patients who did not undergo this treatment protocol.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Effectiveness of pre-surgical orthopedics on patients with cleft lip and palate: A systematic review and meta-analysis

OBJECTIVE

Evaluate the effectiveness of pre-surgical orthopedics (PSO) in patients with cleft lip palate (CLP) in maxillary morphology (MM), facial growth and development (FGD), occlusal alterations (OA), parental satisfaction (PS), and side effects.

DESIGN

Systematic review and meta-analysis of randomized and controlled clinical trials. Searches was performed in CENTRAL, MEDLINE, and EMBASE.

RESULTS

From the eight studies included, three are randomized clinical trials, and five clinical trials are controlled. MM was evaluated by the intercanine width (Mean difference (MD) =1.44; CI95%= -0.30, 3.19; very low certainty), anteroposterior length (MD=1.32; CI95%= -0.59, 3.24; very low certainty) and intertuberocity width (MD=0.09; CI95%= -0.68, 0.49; certainty: very low). FGD was evaluated by SNA angle (MD: 1.29; P = 0.306; moderate certainty), SNB angle (MD: -0.79; P = 0.550; moderate certainty) and ANB angle (MD: 1; P = 0.362; moderate certainty). OA was evaluated by 5-years-old-index (MD= -0.09; P = 0.49; moderate certainty) and by Huddart score (MD=0.51; P = 0.736; moderate certainty). A valid questionnaire assessed PS only in one study (MD= -0.1; P = 0.199; moderate certainty). No studies reported side effects.

CONCLUSION

Due to the uncertainty of the effect of PSO on MM and the lack of clinically relevant effect on FGD, OA, or PS, it is not reasonable to include this intervention as a treatment until future studies clarify its effect.

Current Surgical Practice for Children Born with a Cleft lip and/or Palate in the United Kingdom

OBJECTIVE

This study describes primary surgical reconstructions performed for children born with a cleft lip and/or palate (CL ± P) in the United Kingdom (UK).

DESIGN

Data forms completed at the time of surgery included details on timing, technique, and adjuncts used during the operative period. Demographic data on participants were validated via parental questionnaires.

SETTING

Data were obtained from the Cleft Collective, a national longitudinal cohort study.

PATIENTS

Between 2015 and 2021, 1782 Cleft Collective surgical forms were included, relating to the primary reconstructions of 1514 individual children.

RESULTS

The median age at primary cheiloplasty was 4.3 months. Unilateral cleft lips (UCL) were reconstructed with an anatomical subunit approximation technique in 53%, whereas bilateral cleft lips (BCL) were reconstructed with a broader range of eponymous techniques. Clefts of the soft palate were reconstructed at a median age of 10.3 months with an intravelar veloplasty in 94% cases. Clefts of the hard palate were reconstructed with a vomer flap in 84% cases in a bimodal age distribution, relating to reconstruction carried out simultaneously with either lip or soft palate reconstruction. Antibiotics were used in 96% of cases, with an at-induction-only regimen used more commonly for cheiloplasties (P < .001) and a 5 to 7-day postoperative regime used more commonly for soft palatoplasties (P < .001). Perioperative steroids were used more commonly in palatoplasties than cheiloplasties (P < .001) but tranexamic acid use was equivalent (P = .73).

CONCLUSIONS

This study contributes to our understanding of current cleft surgical pathways in the UK and will provide a baseline for analysis of the effectiveness of utilized protocols.

Systematic Review of the Long-Term Effects of Presurgical Orthopedic Devices on Patient Outcomes

Objective:

To perform a systematic review of the literature to identify the long-term effects of presurgical orthopedic (PSO) device use on patient outcomes.

Design:

A comprehensive literature review of Embase and Ovid databases was performed to identify all English-language publications related to unilateral cleft lip and palate, presurgical devices, and patient outcomes. Studies were excluded if they did not report patient outcomes beyond 2 years of age, did not describe the use of a PSO device, were case reports (n < 10), or were purely descriptive studies.

Main Outcome Measures:

Reported patient outcomes following the use of PSO devices.

Results:

Following a review of all articles by 2 independent reviews, 30 articles were selected for inclusion. Overall, there was no reported consensus as to the long-term effects of PSO devices. Furthermore, this study identified that only 10% of published research controlled for confounding factors that could influence the reported results. Confounding factors that were identified included different operating surgeon, different surgical protocols, and different rates of revision surgeries.

Conclusions:

Overall, this systematic review identified 2 important conclusions. Firstly, there is no consensus in the literature about the long-term effects of PSO devices on long-term patient outcomes. Secondly, research in this domain is limited by confounding factors that influence the applicability of the reported results.

Reliability and Reproducibility of Landmark Identification in Unilateral Cleft Lip and Palate Patients: Digital Lateral Vis-A-Vis CBCT-Derived 3D Cephalograms

BACKGROUND

The aim of the retrospective observational study was to compare the precision of landmark identification and its reproducibility using cone beam computed tomography-derived 3D cephalograms and digital lateral cephalograms in unilateral cleft lip and palate patients.

METHODS

Cephalograms of thirty-one (31) North Indian children (18 boys and 13 girls) with a unilateral cleft lip and palate, who were recommended for orthodontic treatment, were selected. After a thorough analysis of peer-reviewed articles, 20 difficult-to-trace landmarks were selected, and their reliability and reproducibility were studied. These were subjected to landmark identification to evaluate interobserver variability; the coordinates for each point were traced separately by three different orthodontists (OB_A, OB_B, OB_C). Statistical analysis was performed using descriptive and inferential statistics with paired t-tests to compare the differences measured by the two methods. Real-scale data are presented in mean ± SD. A p-value less than 0.05 was considered as significant at a 95% confidence level.

RESULTS

When comparing, the plotting of points posterior nasal spine (PNS) (p < 0.05), anterior nasal spine (ANS) (p < 0.01), upper 1 root tip (p < 0.05), lower 1 root tip (p < 0.05), malare (p < 0.05), pyriforme (p < 0.05), porion (p < 0.01), and basion (p < 0.05) was statistically significant.

CONCLUSION

In patients with a cleft lip and palate, the interobserver identification of cephalometric landmarks was significantly more precise and reproducible with cone beam computed tomography -derived cephalograms vis-a-vis digital lateral cephalograms.

Scandcleft trial of primary surgery for unilateral cleft lip and palate: Craniofacial cephalometrics at 8 years

BACKGROUND

The Scandcleft trial is a randomized controlled trial that includes children with unilateral cleft lip and palate where registrations are standardized and therefore provides the opportunity to describe craniofacial characteristics in a very large sample of patients.

OBJECTIVES

The aim of this study was to describe craniofacial growth and morphology in a large study sample of 8-year-old children with unilateral cleft lip and palate (UCLP); before orthodontic treatment and before secondary alveolar bone grafting; and to compare the cephalometric values with age-matched non-cleft children from previous growth studies to identify the differences between untreated cleft- and non-cleft children.

MATERIALS

There are 429 eight-year-old UCLP patients in the Scandcleft study group. A total of 408 lateral cephalograms with a mean age of 8.1 years were analysed. Cephalometric analyses were performed digitally. The results from three previously published growth studies on non-cleft children were used for comparison.

RESULTS

Cephalometric analyses showed a large variation in craniofacial morphology among the UCLP group. In general, they present with significant maxillary retrusion and reduced intermaxillary relationships compared to the age-matched non-cleft children. In addition, the vertical jaw relationship was decreased, mainly due to decreased maxillary inclination. The upper and lower incisors were retroclined. It can be expected that these differences will increase in significance as the children age.

CONCLUSION

Results from this study provide proposed norms for the young UCLP before any orthodontic treatment and can be valuable for the clinician in future treatment planning.

TRIAL REGISTRATION

ISRCTN29932826.

Frontal and Axial Evaluation of Craniofacial Morphology in Repaired Unilateral Cleft Lip and Palate Patients Utilizing Cone Beam Computed Tomography; An Observational Study

The current study was conducted to assess the extent of maxillary arch collapse on the cleft vis-a-vis non-cleft sides in the same individual presenting withunilateral cleft lip and palate (UCLP), using cone-beam computed tomography (CBCT). Thirty-one children (eighteen boys andthirteen girls) with surgically repaired UCLP, who met the inclusion criteria, were selected. Following the acquisition of CBCT scans, fourteen bilateral landmarks were selected. The distance of the bilateral landmark was calculated from the midsagittal plane on the cleft and non-cleft sides for both frontal and axial views. Tracings were done;the data obtained was subjected to statistical analysis;and intra-observer variability was checked with intraclass correlation coefficient (ICC) and two-way ANOVA. Subsequently, the measurements were subjected to paired t-tests at the 95% level of significance with Bonferroni correction. A significant reduction of pyriforme and an alveolar crest above the maxillary 1st molar were discerned in frontal analysis on the cleft side. In the axial view, the zygomatic arch, malar, porion and alveolar crest at the molar region were non-significant, but the alveolar crest at the premolar region (p < 0.004)) was significantly decreased. In the frontal analysis, pyriforme and the alveolar crest above the maxillary 1st molar, and, in the axial view, premolar widths, showed significant reduction when comparing the cleft vis-a-vis non-cleft sides.

Validation of the Hubli Grading System for Assessing Unilateral and Bilateral Cleft Lip Outcomes

BACKGROUND

When determining whether a cleft lip repair outcome is acceptable, the severity of a patient's cleft at initial presentation must be considered. Currently, there is not a widely agreed upon scale for grading the pre-operative severity or post-operative surgical outcome for patients with unilateral and/or bilateral cleft lip. The aim of this study is to validate the Hubli grading system as a reliable and reproducible system for characterizing cleft lip repair outcomes.

METHODS

Craniofacial surgeon graders independently evaluated 2489 patients from 56 different countries undergoing both unilateral and bilateral cleft lip repair from April 2004 to December 2018. Preoperative severity and postoperative surgical results were assessed, and these grades were combined to determine surgical outcome acceptability based on initial cleft severity. Intrarater and interrater reliability were calculated as percentages of agreement.

RESULTS

Intrarater and interrater acceptability scores had an agreement of 94.50% and 87.04%, respectively. These results indicate that using the Hubli grading system, independent raters are able to reliably and reproducibly measure the acceptability of a cleft lip repair.

CONCLUSIONS

This study validates the use of the Hubli grading system to evaluate the acceptability of unilateral and bilateral cleft lip repairs. This is the largest study to date to evaluate cleft lip severity and repair outcomes, and the Hubli grading system is the only scale to determine the acceptability of surgical outcomes based on initial cleft severity. This system is designed to identify surgeons with sub-optimal outcomes in order to implement timely, individualized training on a global scale.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: maxillary growth at eight years of age

OBJECTIVES

To assess differences in craniofacial growth at 8 years of age according to the different protocols for primary cleft surgery in the Scandcleft project.

DESIGN AND SETTING

Prospective, randomized, controlled clinical trial (RCT) involving 10 centres, including non-syndromic Caucasians with unilateral cleft lip and palate (UCLP). In Trial 1, a common surgical method (1a) with soft palate closure at 3-4 months of age and hard palate closure at 12 months of age was tested against similar surgery but with hard palate repair at 36 months (delayed hard palate closure) (1b). In Trial 2, the common method (2a) was tested against simultaneous closure of both hard and soft palate at 1 year (2c). In Trial 3, the common method (3a) was tested against hard palate closure together with lip closure at 3 months of age and soft palate closure at 1 year of age (3d). Participants were randomly allocated by use of a dice. Operator blinding was not possible but all raters of all outcomes were blinded.

SUBJECTS AND METHODS

The total number of participating patients at 8 years of age was 429. Lateral cephalograms (n = 408) were analysed. The cephalometric angles SNA and ANB were chosen for assessing maxillary growth for this part of the presentation.

RESULTS

Within each trial (Trial 1a/1b, Trial 2a/2c, and Trial 3a/3d), there was no difference in cephalometric values between the common and the local arm. There were no statistically significant differences in the SNA and ANB angles between the common arm in Trial 1a (mean SNA 77.8, mean ANB 2.6) and Trial 2a (mean SNA 79.8, mean ANB 3.6) and no difference between Trial 1a and Trial 3a, but a statistical difference could be seen between Trial 2a and Trial 3a (mean SNA 76.9, mean ANB 1.7). However, the confidence interval was rather large. Intra- and inter-rater reliability were within acceptable range.

CONCLUSIONS

The timing and the surgical method is not of major importance as far as growth outcomes (SNA and ANB) in UCLP are concerned.

REGISTRATION

ISRCTN29932826.

PROTOCOL

The protocol was not published before trial commencement.

Influence of vomer flap on craniofacial growth in patients with cleft lip and palate: A systematic review

The aim of this review was to evaluate the impact of the vomer flap on craniofacial growth in patients with cleft lip and palate. The review was conducted according to the PRISMA checklist and is registered in the International Prospective Register of Systematic Reviews (PROSPERO - CRD42018095714). Two investigators performed the research using the PubMed/MEDLINE, Embase, and Web of Science databases for studies published until November 2018. The focused question was 'Does the vomer flap have a lesser impact on craniofacial growth in patients with cleft lip and palate?'. A total of 13 articles was selected for this review, comparing the vomer flap technique with other flap surgery techniques. The outcomes analyzed were: facial development (primary outcome); and the growth of the maxilla and mandible, occlusion, occurrence of fistula, and speech development (secondary outcomes). It was concluded that there is no difference in impact between vomer flap and the other flap surgery techniques on craniofacial development.

Protocols for Reporting Speech Outcomes following Palatoplasty or Velopharyngeal Surgery: A Literature Review

Background:

To determine best practices, surgeons who perform cleft palate surgery or surgery for velopharyngeal insufficiency need to be able to compare their outcomes in normalizing the velopharyngeal valve.

Methods:

We conducted a comprehensive review of articles that reported speech/resonance outcomes following palatoplasty or surgery for velopharyngeal insufficiency. We analyzed protocols that were used and how the results were reported. We found 170 articles, published between 1990 and 2014, that met our inclusion criteria.

Results:

Most studies (66%) had a sample size of <50 subjects, were retrospective (67%), were not blinded (83%), and did not report the use of reliability (68%). Most studies included 1 evaluator (27%) or 2 evaluators (30%). Only 80% of the articles specified that at least one speech pathologist was an evaluator. Most articles (56%) did not specify the speech samples used, and 65% used an informal test or did not specify the type of test used. Most studies used a perceptual rating scale for articulation (75%) and resonance (83%). Only 39% of the studies included an evaluation of velopharyngeal function. Finally, objective measures were used in only 28% of the studies (9% used aerodynamic measures and 19% used nasometry).

Conclusions:

Because these articles showed significant variability in how speech/resonance is evaluated and how the outcomes are reported, it is virtually impossible to compare results to determine best surgical procedures. Suggestions are given to standardize outcome measures to improve comparability of data.

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.

An Intercenter Comparison of Dental Arch Relationships and Craniofacial Form Including a Center Using Nasoalveolar Molding

Objective:

To compare dental arch relationship and craniofacial morphology of patients with CUCLP in pre-adolescence from five cleft centers including a center using NAM.

Design:

Retrospective cohort study.

Setting:

Five cleft centers in North America.

Patients:

One hundred eighty-two subjects with repaired CUCLP from the five cleft centers participated in the craniofacial form study. One hundred forty-eight subjects from four of the five centers participated in the dental arch relationship study.

Methods:

Digital dental models were assessed using the GOSLON Yardstick. Eighteen cephalometric measurements were performed. Measurement means, by center, were compared. Analysis of variance and Tukey-Kramer analysis were used to compare GOSLON scores and cephalometric measurements.

Results:

The center that performed neither PSOT (including NAM) nor primary bone grafting exhibited the most favorable mean GOSLON score. The same center also showed the highest mean SNA, ANB, and ANS-N-Pg angles. However, the mean ANB and ANS-N-Pg angles were not significantly different from those of the center using NAM. No statistically significant differences were seen for mandibular prominence, vertical dimensions, or dental inclinations. The center with NAM also showed a significantly smaller nasoform angle than two of the four other centers.

Conclusion:

The centers that used NAM and other forms of PSOT did not have better dental arch relationships or craniofacial morphology compared with the centers that performed only primary lip repair. However, this study was not designed to investigate the cause-and-effect relationship between specific outcomes and particular features of those protocols.

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.

Influence of Different Palatoplasties on the Facial Morphology of Early Mix Dentition Stage Children with Unilateral Cleft Lip and Palate

Objective

To compare the maxillofacial morphology in the early mixed dentition phase between two patient groups with unilateral cleft lip, alveolus, and palate who underwent different types of palatoplasty.

Design

Cross-sectional study.

Setting

An institutional study.

Patients and Interventions

Seventy-one patients with unilateral cleft lip and palate (UCLP) treated at Osaka University Dental Hospital, Japan, were divided into two groups: 33 patients were treated by early two-stage palatoplasty by the modified Furlow Technique (ETS), and 38 patients were treated by one-stage Wardill-Kilner push-back palatoplasty (PB). Intergroup comparisons were performed.

Main Outcome Measures

The dental, skeletal, and soft-tissue features were evaluated. For intergroup comparisons, Mann-Whitney U test was used for the statistical analyses.

Result

No significant differences existed between the ETS and PB groups regarding the skeletal features except for the mandibular ridge height. Meanwhile, the upper central incisor and upper lip of the ETS group showed a more anterior position than those in the PB group.

Conclusions

Early two-stage Furlow palatoplasty leads to more protruded upper lip, providing more anteriorly positioned upper incisors compared with PB, at least at the early mixed dentition stage.

A Multicenter Outcomes Assessment of Five-Year-Old Patients with Unilateral Cleft Lip and Palate

Objective

Compare 5-year-old dental arch relationships of patients from three centers with differing primary protocols.

Design

Retrospective study of treatment outcomes using blinded evaluation of dental study casts.

Setting

Three major cleft-craniofacial centers; one (center A) is a free-standing institution, and two (centers B and C) are university hospitals.

Patients

118 (A = 41; B = 33; C = 44) consecutively treated 5-year-old patients with complete, nonsyndromic unilateral cleft lip and palate.

Interventions

Centers A and C completed primary repair without presurgical orthopedics by 18 months (center A in three surgeries and center C in two surgeries). Center B used passive presurgical orthopedics with lip/soft palate repair at 6 months and gingivo-alveoloplasty/hard palate repair at 18 to 36 months.

Main Outcome Measure

Averaged ratings of dental casts using the 5-year yardstick were computed for each patient. The Wilcoxon two-sample test was used to compare means; a chi-square test was used to compare distributions.

Results

Intra- and interexaminer reliability tests showed excellent reliability (>.90). Mean scores were not significantly different. Distribution of scores differed significantly. Center A had the highest percentage of good scores and the lowest percentage of poor scores (72% versus 6.5%), followed by center B (63% versus 6.6%) and center C (59% versus 16.3%).

Conclusions

Centers A and B had comparable scores and completely different protocols in surgical technique, timing, sequencing, and nonuse/use of appliances. Center C's results were slightly lower than those of 1 and 3, but the center had the protocol with the least burden of treatment (only two surgeries, without use of appliances).

A Comparison of Craniofacial Form in Northern Irish Children with Unilateral Cleft Lip and Palate Treated with Different Primary Surgical Techniques

Objective

The quality of outcomes in patients with unilateral cleft lip and palate (UCLP) was compared between two senior plastic surgeons. One surgeon carried out a one-stage Wardill-Kilner palate repair. The other surgeon employed a vomer flap hard palate repair followed by a von Langenbeck soft palate closure (Oslo protocol).

Design

Retrospective analysis.

Patients

Thirty-four children (mean age 9.7 years) born with complete skeletal UCLP in Northern Ireland from 1983 to 1991 who received primary repair surgery from one of the two surgeons.

Main Outcome Measures

Cephalometric analysis was used to determine the craniofacial form and soft tissue profile. The quality of the dental arch relationships was independently assessed using the Goslon ranking system.

Results

Twenty-nine of the 34 subjects had good or satisfactory arch relationships. Comparison between the surgeons revealed that the Wardill-Kilner group had a greater proportion of Goslon grades of greater than 3, indicating poor arch relationships. However, this difference failed to reach statistical significance. There were no significant cephalometric differences between patients treated by the two surgeons.

Conclusions

Although the difference was not statistically significant, the highest proportion of patients likely to require orthognathic surgery was found in those treated using the Wardill-Kilner technique.

Complete Unilateral Cleft Lip and Palate: Validity of the Five-Year Index and the Goslon Yardstick in Predicting Long-Term Dental Arch Relationships

Objective:

To assess the validity of the 5-year index by subjecting study models at the age of 5 years to both the 5-year index and the Goslon yardstick, and then relating these results to the Goslon ratings at 10 years.

Design:

Retrospective study.

Setting:

Sahlgrenska University Hospital, Gothenburg, Sweden.

Patients:

Study models of 94 patients with unilateral cleft lip and palate (UCLP) were evaluated at the ages of 5 and 10 years. The dental arch relationships were judged and categorized by using the Goslon yardstick for the 10-year models and both the Goslon yardstick and the 5-year index for the 5-year models.

Results:

When used for 5- and 10-year models, the Goslon yardstick showed a kappa score of 0.539 (weighted kappa = 0.579) with a moderate strength of agreement. However, 5-year index scores at 5 years compared with the Goslon scores at 10 years showed a kappa score of only 0.043 (weighted kappa = 0.090), showing poor strength of agreement. Goslon scores at 10 years showed improvement in 14 cases when graded by the same Goslon yardstick at 5 years, whereas there was improvement in 23 cases when the 5-year models were graded by the 5-year index (actual improvement in scores in UCLP cases is highly unlikely).

Conclusions:

Although use of the Goslon yardstick at 5 years has demonstrated some inherent flaws in its use at that age, these drawbacks are fewer than those when the 5-year index is used at 5 years of age.

Analysis of Dental Arch Relationships in Swedish Unilateral Cleft Lip and Palate Subjects: 20-Year Longitudinal Consecutive Series Treated with Delayed Hard Palate Closure

Objective:

To evaluate the dental arch relationships for a consecutive series from Goteborg, Sweden, who had delayed hard palate closure.

Design:

Retrospective study.

Setting:

Sahlgrenska University Hospital, Goteborg, Sweden.

Patients:

The dental study models of 104 consecutive unilateral cleft lip and palate subjects. The study cohort was born between 1979 and 1994. Longitudinal records were available at ages 5 (n = 94), 10 (n = 97), 16 (n = 59), and 19 years (n = 46). Five assessors rated models according to the GOSLON Yardstick on two separate occasions each.

Interventions:

These patients had been operated upon according to the Goteborg protocol of delayed hard palate closure (at age 8 years).

Results:

85% of subjects were rated in groups 1 and 2 (excellent or very good outcome), 12% were rated in group 3 (satisfactory), and 3% were assigned to group 4 (poor). No patients presented in Group 5 (very poor). Weighted kappa statistics for double determination of Yardstick allocation for five assessors demonstrated values between .65 and .90 for interrater agreement (good/very good) and between .70 and .90 for intrarater agreement (very good).

Conclusions:

Delayed hard palate closure as practiced in Goteborg since 1979 has produced the best GOSLON Yardstick ratings in a consecutive series of patients ever recorded worldwide, since the Yardstick was first used in 1983. However, it is noteworthy that a new protocol has been introduced in Goteborg since 1994, in which hard palate closure is done at 3 years due to concerns regarding speech.

Mandibular Morphology in Complete Unilateral Cleft Lip and Palate

Objective

The purpose of this study was to evaluate and compare mandibular morphology and spatial position in children with complete unilateral cleft lip and palate (UCLP) treated at two different cleft centers (Hannover and Brussels) following different surgical treatment protocols.

Patients

A total of 62 Caucasian children (40 boys, 22 girls) with nonsyndromic complete unilateral cleft lip and palate (UCLP) were evaluated by means of conventional cephalometric analysis at approximately the age of 10 years. Data of both cleft groups were compared with a control, noncleft group (n = 40) matched according to age and sex.

Interventions

The Hannover children with cleft (n = 36) underwent lip repair at a mean age of 5.83 ± 1.16 months. The hard and soft palates were closed at a mean age of 29.08 ± 4.68 and 32.25 ± 4.29 months, respectively. The Brussels children with cleft (n = 26) were treated according to the Malek surgical protocol with soft palate repair at a mean age of 3.04 ± 0.20 months and simultaneous lip and hard palate repair at a mean age of 6.15 ± 0.68 months.

Results

Statistical analysis (analysis of variance with post hoc Tukey's test) showed a significant (p = .001) smaller mandibular ramus length (Co-Go) in the Brussels cleft group, compared with the control group. The Hannover-Brussels comparison data revealed that the S-N-B angle was significantly (p = .047) less in the Brussels cleft group.

Conclusions

The influence of surgical procedures in patients with UCLP might not be restricted to the maxilla but could influence mandibular spatial position to the cranial base. Because of these positional changes of the mandible, both cleft groups showed facial balance.

The Influence of Surgery and Orthopedic Treatment on Maxillofacial Growth and Maxillary Arch Development in Patients Treated for Orofacial Clefts

This paper describes maxillofacial growth and dental arch development in relation to different orthodontic and surgical interventions utilized in the management of orofacial clefts. It addresses presurgical orthopedic treatment in patients with unilateral cleft lip and palate, primary periosteoplasty, primary bone grafting, lip surgery, palatal surgery, pharyngeal flap surgery, maxillary protraction, and early secondary bone grafting. Difficulties associated with synthesizing previously published data and suggestions for approaching still unanswered questions in the next millennium are presented.

The Eurocleft Study: Intercenter Study of Treatment Outcome in Patients with Complete Cleft Lip and Palate. Part 3: Dental Arch Relationships

Objective

To compare dental arch relationships up to age 17 in individuals with complete unilateral cleft lip and palate (UCLP) treated at five European centers.

Design

Longitudinal cohort study, where results were previously reported at 9 years and follow-up measurements were obtained for 12 and 17 years.

Setting

Multidisciplinary cleft services in Northern Europe.

Subjects

127 consecutively treated individuals with repaired UCLP.

Main outcome measure

Panel rating of dental arch relationship.

Results

The results revealed that at 17 years of age three of the centers had better ratings in dental arch relationship (means scores: 1.7, 1.9, and 2.2, respectively) than the other two centers (3.3, 3.4) at statistically significant levels (p < .01 to p < .001).

Conclusion

The results confirm that systematic differences in dental arch relationships may occur between different cleft centers, but do not allow specific causal factors to be identified.

Assessment of Dental Arch Relationships in Japanese Patients with Unilateral Cleft Lip and Palate

Objective

Evaluation of the dental arch relationships of Japanese patients with unilateral cleft lip and palate (UCLP) from the orthodontic clinic of the University of Tokyo Hospital (UTH) compared with patients treated by the Oslo Cleft Team, Norway.

Design

Retrospective study and comparison with previous reports.

Materials

Dental models of 24 patients with UCLP in UTH taken before orthodontic treatment and before alveolar bone grafting were included. Surgeons in many hospitals performed primary surgeries. These models were matched for age and gender with 24 models from a consecutive series of patients treated by the Oslo Cleft Team as part of the Eurocran Good Practice Archive. A total of 48 models were evaluated.

Main Outcome Measure

Dental arch relationship was rated with the Goslon Yardstick. The strength of agreement of rating was assessed with weighted kappa statistics.

Results

Intra- and interexaminer agreements evaluated by weighted kappa statistics were high, indicating good reproducibility. Almost 60% of the patients in UTH were classified into poor or very poor categories, and the mean Goslon score was 3.50. These results show a contrast to those in Oslo and were the poorest in comparison with previous reports.

Conclusion

Dental arch relationships in patients with UCLP in UTH were poor. This seemed to be attributable to surgical procedures, but a factor of racial difference in the craniofacial morphology was also considered. Further intercenter research is required to clarify this point.

Early Surgical Outcomes in 5-Year-Old Patients with Repaired Unilateral Cleft Lip and Palate

Objective:

To assess the surgical outcome of 5-year-old subjects with repaired unilateral cleft lip and palate who had been operated on by a single surgeon.

Design:

Retrospective consecutive outcome study.

Setting:

The cleft lip and palate center at Frenchay Hospital, North Bristol NHS Trust, U.K.

Participants:

All patients born with unilateral cleft lip and palate between May 1992 and April 1998 were identified and their study models were located.

Main Outcome Measures:

The reasons for failing to obtain study models were recorded. The “test” study models were combined randomly with a “gold standard” set of study models to give a group of 53 for assessment purposes. These study models were assessed twice by two examiners independently using the 5-Year-Olds’ Index. The weighted kappa (κ) statistic and components of variance were used to establish the levels of agreement within and between examiners, as well as between the gold standard and the examiners.

Results:

Thirty sets of study models out of a possible 43 were located. The most common reason for not obtaining records was poor cooperation. More than 50% of study models were assessed as being good outcomes (Index groups 1 and 2), whereas fewer than 20% of the records were evaluated as being poor outcomes (Index groups 4 and 5). There was good inter- and intraexaminer agreement and agreement with the gold standard values.

Conclusion:

Study model collection in this age group can be difficult due to patient cooperation.

Orthodontic Treatment of the Patient with Complete Clefts of Lip, Alveolus, and Palate: Lessons of the past 60 Years

This review paper summarizes 60 years of progress in the orthodontic care of patients with complete clefts of the lip, alveolus, and palate. The progress and evolution of orthodontic treatment for patients with complete clefts has taken a slow and sometimes circuitous route to present-day standards. Nonetheless, in spite of this history of slow and inefficient scientific and clinical progress, review of the literature of the past 60 years does, in fact, reveal that progress has been made. This progress has not only been in the area of improved surgical and orthodontic techniques but also relative to the scientific weaknesses of past decades. The investigations of more recent years seem to be moving in a direction of better documentation, stricter methodologies, longer-term follow-up, larger sample sizes, etc. However, there remains much work to be done. Only by adopting a more critical approach will protocols be defined that can achieve optimal outcomes, while minimizing the burden of the orthodontic treatment through elimination of superfluous intervention.

A Standard Set of Outcome Measures for the Comprehensive Appraisal of Cleft Care

Care of the patient with cleft lip and/or palate remains complex. Prior attempts at aggregating data to study the effectiveness of specific interventions or overall treatment protocols have been hindered by a lack of data standards. There exists a critical need to better define the outcomes- particularly those that matter most to patients and their families-and to standardize the methods by which these outcomes will be measured. This report summarizes the recommendations of an international, multidisciplinary working group with regard to which outcomes a typical cleft team could track, how those outcomes could be measured and recorded, and what strategies may be employed to sustainably implement a system for prospective data collection. It is only by agreeing on a common, standard set of outcome measures for the comprehensive appraisal of cleft care that intercenter comparisons can become possible. This is important for quality-improvement endeavors, comparative effectiveness research, and value-based health-care reform.

Centre-level variation of treatment and outcome in 5-year-old children with non-syndromic unilateral cleft lip and palate: The Cleft Care UK study. Part 1: Methodology and results for dento-facial outcomes

OBJECTIVES

Outline methods used to describe centre-level variation in treatment and outcome in children in the Cleft Care UK (CCUK) study. Report centre-level variation in dento-facial outcomes.

SETTING AND SAMPLE POPULATION

Two hundred and sixty-eight five-year-old British children with non-syndromic unilateral cleft lip and palate (UCLP).

MATERIALS AND METHODS

Between January 2011 and December 2012, data were collected on a comprehensive range of outcomes. Child facial appearance and symmetry were assessed using photographic pictures. Dental arch relationships were assessed from standardized dental study models. Hierarchical statistical models were used to predict overall means and the variance partition coefficient (VPC)-a measure of amount of variation in treatment or outcome explained by the centre.

RESULTS

Data on dento-alveolar arch relationships and facial appearance were available on 197 and 252 children, respectively. The median age of the children was 5.5 years, and 68% were boys. Variation was described across 13 centres. There was no evidence of centre-level variation in good or poor dento-alveolar arch relationships with a VPC of 4% and 3%, respectively. Similarly, there was no evidence of centre-level variation in good or poor facial appearance with a VPC of 2% and 5%, respectively.

CONCLUSIONS

There was no evidence of centre-level variation for dento-facial outcomes although this study only had the power to detect large variation between sites.

Predictive validity of the GOSLON Yardstick index in patients with unilateral cleft lip and palate: A systematic review

Among the various indices developed for measuring the results of treatment in patients born with unilateral cleft lip and palate (UCLP), the GOSLON Yardstick index is the most widely used to assess the efficacy of treatment and treatment outcomes, which in UCLP cases are closely linked to jaw growth. The aim of this study was to conduct a systematic review to validate the predictability of growth using the GOSLON Yardstick in patients born with UCLP. A systematic literature review was conducted in four Internet databases: Medline, Cochrane Library, Scopus and Embase, complemented by a manual search and a further search in the databases of the leading journals that focus on this topic. An electronic search was also conducted among grey literature. The search identified a total of 131 articles. Duplicated articles were excluded and after reading titles and abstracts, any articles not related to the research objective were excluded, leaving a total of 21 texts. After reading the complete text, only three articles fulfilled the inclusion criteria. The results showed a predictive validity of between 42.2% and 64.7%, which points to a lack of evidence in the literature for the predictive validity of the GOSLON Yardstick index used in children born with UCLP.

Evaluation of mandibular hard and soft tissues in cleft patients

Purpose:

The aim of this study was to compare the mandibular hard and soft tissue measurements of unilateral and bilateral cleft lip and palate patients with non-cleft individuals.

Materials and Methods:

The study sample comprised of lateral cephalograms of 45 subjects. Sample included 15 non-cleft (NC), 15 unilateral cleft lip and palate (UCLP) and 15 bilateral cleft lip and palate (BCLP) cases whose age were between 15 to 17. 1 angular 13 linear measurements were carried out using Arnett and Gunson soft tissue cephalometric analysis and 4 angular measurements were calculated with Steiner Analysis.

Results:

Mandibular incisor inclinations relative to the occlusal plane (Md1-Md OP) were significantly greater and mandibular incisor projections (Md1-TVL) were significantly retrusive in cleft subjects (p<0.05). Projection values pertaining to lower lip anterior (LLA-TVL), soft tissue B point (B’-TVL), and soft tissue pogonion (Pog’-TVL) were significantly deficient as well in cleft patients (p<0.05). Sagittal position of the maxilla (SNA) (p<0.001) and intermaxillary relation of the jaws (ANB) were significantly deficient in UCLP subjects (p<0.05) and BCLP individuals (p<0.01). LLA-TVL and B’-TVL correlated with SNB in cleft patients (p<0.05).

Conclusion:

Decreased lower lip and chin projection values suggest that mandibular region of cleft patients should be taken into account in forming the treatment plan to improve the esthetic outcome of orthodontic and plastic surgery interventions.

Three-dimensional evaluation of surgical techniques in neonates with orofacial cleft

Background:

Individuals with cleft lip and palate have many anatomic and functional alterations compromising esthetics, hearing, speech, occlusion, and development/craniofacial growth. The rehabilitative treatment of these patients is very challenging and starts at birth aiming at the best treatment for all functional demands. This study aimed to evaluate the dimensional alterations of the dental arches of neonates with cleft lip and palate after two different primary surgical techniques.

Materials and Methods:

The sample comprised 114 digital models of children aged from 3 to 36 months, with unilateral complete cleft lip and palate divided into two groups. Two different phases were evaluated: precheiloplasty and 1 year after palatoplasty. The evaluation was performed through the digital models of each child obtained by scanning digitalization (3D Scanner). Dental arches measurements were accomplished through Appliance Designer software. The following measurements were assessed: dental arch area, anterior amplitude of the cleft, total length of dental arch, intercanine distance, and intertuberosity distance. t-test was applied to compare differences between groups.

Results:

No statistically significant differences were observed between groups at precheiloplasty phase. At 1 year after palatoplasty, the groups differed in the total length of dental arch (P = 0.002), with greater values for Group I.

Conclusion:

This study suggests that the results of the different surgical techniques may alter the growth and development of the dental arches of neonates with cleft lip and palate.

Dental Arch Relationship Outcomes in One- and Two-Stage Palatoplasty for Japanese Patients with Complete Unilateral Cleft Lip and Palate

Objective

To compare dental arch relationship outcomes following one- and two-stage palatal repair.

Design

Nonrandomized, clinical trial with concurrent control.

Setting

Hokkaido University Hospital.

Patients

Sixty-eight consecutively treated Japanese patients with complete unilateral cleft lip and palate.

Interventions

Thirty-one of the 68 patients underwent two-stage palatoplasty with delayed hard palate closure, and 37 patients underwent one-stage pushback palatoplasty.

Main Outcome Measures

Dental casts were taken at 4.9 to 6.3 (mean: 5.2) years of age in the two-stage group and at 4.0 to 6.3 (mean: 5.1) years of age in the one-stage group, and dental arch relationships were assessed using the 5-Year-Olds’ Index (5-Y) by four raters and the Huddart/Bodenham Index (HB) by two raters.

Results

Intrarater and interrater reliabilities evaluated using weighted kappa statistics were good or better for the 5-Y and HB ratings. The mean 5-Y score was 2.94 in the two-stage group and 3.13 in the one-stage group ( P value was not significant). However, there was a significant difference in distributions between the groups ( P < .05). The HB scores of molars were significantly greater in the two-stage group than in the one-stage group ( P < .05). The rank correlation coefficients between the 5-Y and total HB score (ρ = −0.840, P < .01) and between the 5-Y and the score of the incisors in the HB (ρ = −0.814, P < .01) were significantly increased.

Conclusions

These results suggest that the anteroposterior relationship was not significantly different between the groups, but the transversal relationship was better in the two-stage group than in the one-stage group.

The impact of cleft lip and palate repair on maxillofacial growth

Surgical correction is central to current team-approached cleft treatment. Cleft surgeons are always concerned about the impact of their surgical maneuver on the growth of the maxilla. Hypoplastic maxilla, concaved mid-face and deformed dental arch have constantly been reported after cleft treatments. It is very hard to completely circumvent these postoperative complications by current surgical protocols. In this paper, we discussed the factors that inhibit the maxillofacial growth on cleft patients. These factors included pre-surgical intervention, the timing of cleft palate and alveolae repair, surgical design and treatment protocol. Also, we made a review about the influence on the maxillary growth in un-operated cleft patients. On the basis of previous researches, we can conclude that most of scholars express identity of views in these aspects: early palatoplasty lead to maxilla growth inhibition in all dimensions; secondary alveolar bone graft had no influence on maxilla sagittal growth; cleft lip repair inhibited maxilla sagittal length in patients with cleft lip and palate; Veau's pushback palatoplasty and Langenbeck's palatoplasty with relaxing incisions were most detrimental to growth; Furlow palatoplasty showed little detrimental effect on maxilla growth; timing of hard palate closure, instead of the sequence of hard or soft palate repair, determined the postoperative growth. Still, scholars hold controversial viewpoints in some issues, for example, un-operated clefts have normal growth potential or not, pre-surgical intervention and pharyngoplasty inhibited maxillofacial growth or not.

Current status of presurgical infant orthopaedic treatment for cleft lip and palate patients: A critical review

Rehabilitation of cleft lip and palate (CLP) patients is a challenge for all the concerned members of the cleft team, and various treatment modalities have been attempted to obtain aesthetic results. Presurgical infant orthopaedics (PSIO) was introduced to reshape alveolar and nasal segments prior to surgical repair of cleft lip. However, literature reports lot of controversy regarding the use of PSIO in patients with CLP. Evaluation of long-term results of PSIO can provide scientific evidence on the efficacy and usefulness of PSIO in CLP patients. The aim was to assess the scientific evidence on the efficiency of PSIO appliances in patients with CLP and to critically analyse the current status of PSIO. A PubMed search was performed using the terms PSIO, presurgical nasoalveolar moulding and its long-term results and related articles were selected for the review. The documented studies report no beneficial effect of PSIO on maxillary arch dimensions, facial aesthetics and in the subsequent development of dentition and occlusion in CLP patients. Nasal moulding seems to be more beneficial and effective in unilateral cleft lip and palate patients with better long-term results.

Can Occlusal Evaluation of Children with Unilateral Cleft Lip and Palate Help Determine Future Maxillofacial Morphology?

Objective

To investigate the change in occlusal evaluations from the 5-year-olds' index to the Goslon Yardstick and to compare the relationship between the evaluations and maxillofacial growth in patients with complete unilateral cleft lip and palate (UCLP).

Design

A prospective longitudinal study.

Subjects

The sample consisted of 85 patients with complete UCLP who underwent surgery from 1969 to 1994 and were treated at the Kyushu University Hospital in Fukuoka, Japan. Subjects had two serial dental casts performed at the ages of 5 and 10 years. Furthermore, each patient had lateral cephalographs taken at the age of 5 years, 76 of 85 subjects had films taken at the age of 10 years, and 54 subjects also had lateral cephalograms taken after the age of 15 years.

Methods

Every dental cast was evaluated by the 5-year-olds' index and the Goslon Yardstick, respectively. The lateral cephalographs were traced and digitized, and angular dimensions were calculated. Outcomes were compared using Spearman's rank-order correlation analysis and the Kruskal-Wallis analysis.

Results and Conclusion

Dental arch relationships were evaluated and rated as 2.96 in the 5-year-olds' index and 2.85 in the Goslon Yardstick, respectively. Both groupings showed a significant relationship, and they showed no change in 36 out of 85 subjects (42.3%), significant improvement in 30 (35.3%), and deterioration in 19 (22.3%). Two occlusal groupings and maxillofacial morphology on the cephalographs indicated that the grouping reflected the anteroposterior position of the mandible. Moreover, both groupings showed some relation to previous maxillofacial growth, but they did not show any relationship with future growth. The Goslon Yardstick may not predict maxillofacial morphology in adulthood.

Occlusal disorders among patients with total clefts of lip, alveolar bone, and palate

Clefts are common birth defects. They are accompanied by various malformations, including disturbances in facial look as well as skeletal disorders that include malocclusions, most frequently crossbites and class III anomalies. The aim of the study was to present the commonest malocclusions in patients with total cleft of the lip, alveolar bone and palate (n = 154) and compare the results to the healthy on-cleft patients (n = 151). Normal occlusion, characteristic for I angle class, was observed in 50% of the control group and 30% of the examined. In the examined patients with clefts, most frequently crossbite and open bite on the cleft side was observed. In patients with clefts, only 2 out of 154 patients presented isolated dental anomalies. In healthy individuals the commonest occlusal disorder was distal occlusion and dental anomalies. The commonest malocclusions among patients with clefts are crossbites and class III malocclusions.

Vertical maxillary growth after two different surgical protocols in unilateral cleft lip and palate patients

Objective : The aim of the present study was to compare vertical maxillofacial growth in patients born with unilateral cleft lip and palate (UCLP) who were treated using two different surgical protocols. Design : A retrospective cohort study. Subjects : We studied 92 patients with complete UCLP (61 male and 31 female) treated at Sahlgrenska University Hospital in Gothenburg, Sweden: 46 consecutive patients born between 1965 and 1974 who underwent surgical treatment according to the Wardill-Kilner (W-K) protocol and 46 consecutive patients born between 1982 and 1989 who underwent surgical treatment according to the Gothenburg delayed hard palate closure (DHPC) protocol. Methods : We analyzed lateral cephalograms obtained at 10 years of age. Results : Patients treated according to the Gothenburg DHPC protocol had significantly greater anterior upper facial height, anterior maxillary height, overbite, and inclination of the maxilla than those treated with the W-K protocol. Both techniques led to similar posterior upper facial height. Conclusion : The Gothenburg DHPC protocol in patients with complete UCLP results in more normal anterior maxillary vertical growth and overbite and therefore increased maxillary inclination at 10 years of age.

Palate Dimensions in Six-Year-Old Children with Unilateral Cleft Lip and Palate: A Six-Center Study on Dental Casts

Objective

To compare palatal dimensions in 6-year-old children with unilateral cleft lip and palate (UCLP) treated by different protocols with those of noncleft children.

Design

Retrospective intercenter outcome study.

Patients

Upper dental casts from 129 children with repaired UCLP and 30 controls were analyzed by the trigonometric method.

Setting

Six European cleft centers.

Main outcome measures

Sagittal, transverse, and vertical dimensions of the palate were observed.

Statistics

Palate variables were analyzed with descriptive methods and nonparametric tests. Regarding several various characteristics measured on a relatively small number of subjects, hierarchical, k-means clustering, and principal component analyses were used.

Results

Mean values of the observed dimensions for five cleft groups differed significantly from the control (p < .05). The group with one-stage closure of the cleft differed significantly from all other cleft groups in most variables (p < .05). Principal component analysis of all 159 cases identified three clusters with specific morphologic characteristics of the palate. A similar number of treated children were classified into each cluster, while all children without clefts were classified in the same cluster. The percentage of treated children from a particular group that fit this cluster ranged from 0% to 70% and increased with age at palatal closure and number of primary surgical procedures.

Conclusion

At 6 years of age, children with stepwise repair and hard palate closure after the age of two more frequently result in palatal dimensions of noncleft control than children with earlier palatal closure and one-stage cleft repair.

Dental arch relationships in Turkish patients with complete unilateral cleft lip and palate born between 1976 and 1990: a comparison with eurocleft

OBJECTIVE

To compare the dental arch relationships of Turkish patients with complete unilateral cleft lip and palate (UCLP) with the results reported for participants in the Eurocleft study.

PATIENTS

Study models of 109 patients with complete UCLP from five university clinics in Turkey were evaluated (clinic A = 25 patients, clinic B = 23 patients, clinic C = 20 patients, clinic D = 21 patients, and clinic E = 20 patients). The mean age of the patient cohort was nine years old (range = 8-11 years old), and the cohort was born between 1976 and 1990.

METHODS

The examiners rated the three-dimensional (3D) models using the GOSLON Yardstick. The scores were compared with those from the Eurocleft centers: E1(B), E2(E), E3(A), E4(F), E5(C), and E6(D). Intra- and interexaminer agreements were evaluated using weighted kappa statistics.

RESULTS

The mean GOSLON scores for the Turkish clinics were as follows: clinic A = 3.16, clinic B = 3.13, clinic C = 3.25, clinic D = 3.67, and clinic E = 3.70. Scores for three of the Turkish clinics (A, B, and C) were significantly worse than the scores for the three best Eurocleft centers, E1(B), E2(E), and E3(A) (P < .001, P < .001, and P < .05, respectively). Scores for two of the Turkish clinics (D and E) were similar to those for Eurocleft center E6(D) but worse than the scores for the other Eurocleft centers (P < .01, P < .001, respectively).

CONCLUSIONS

This was the first study in which three-dimensional models were used to derive scores to compare with those of the Eurocleft centers. According to the results of analysis of 109 3D models, 50.4 % of the patients in Turkey were classified as GOSLON score 4 and 5. This may have been attributable to poor surgical procedures, low-volume surgeons, and the decentralized treatment approach in Turkey between 1985 and 2000. Further research is needed to assess the situation in Turkey in more recent years.

Congenital and postnatal factors inducing malocclusions in Japanese unilateral cleft lip and palate patients-determination using logistic regression analysis

Objective : To assess the congenital and postnatal factors that affect degree of malocclusion in patients with unilateral cleft lip and palate using multivariate statistical analysis. Design : Retrospective study. Patients : All information on 135 subjects with unilateral cleft lip and palate was obtained from an oral examination and radiograph at the initial examination at an orthodontic clinic and from surgical records. Plaster models were taken before orthodontic treatment. The ages of the subjects ranged from 5 to 8 years with a mean age of 6.9 years. All primary surgeries for the patients were performed at a university hospital. Main Outcome Measures : The GOSLON Yardstick was used to assess the dental arch relationships (degree of malocclusion) in patients. Family history of Class III, degree of cleft, and congenitally missing upper lateral incisor on the cleft side were chosen as congenital factors inducing malocclusion. Presurgical orthopedic treatment, cheiloplasty, and palatoplasty were chosen as postnatal factors. Associations between various factors and dental arch relationships were assessed using logistic regression analysis. Results : According to adjusted odds ratios, family history of Class III is associated with a significantly worse dental arch relationship. Palatoplasty using push-back alone correlated to a dental arch relationship that was significantly worse than palatoplasty using push-back with a buccal flap. Conclusions : Multivariate analysis shows evidence that a positive family history of Class III and palatoplasty using push-back alone are associated with worse malocclusion of unilateral cleft lip and palate patients.

Long-Term Effects of Presurgical Infant Orthopedics in Patients with Cleft Lip and Palate: A Systematic Review

Objective

This study aimed to assess the scientific evidence on the efficiency of presurgical infant orthopedic appliances in patients with cleft lip and palate to shed light on a specific, contemporary discussion of whether the appliances have long-term advantages with respect to treatment outcomes.

Design

A systematic review.

Method

Two literature surveys from the five electronic databases were performed with a 1-month interval. Randomized controlled trials and controlled clinical trials (controls had no presurgical infant orthopedics) that had follow-up periods of a minimum of 6 years were included in the study. The exceptions to the follow-up limit were studies related to feeding and parent satisfaction.

Results

Of the 319 articles retrieved in the literature surveys, 12 were qualified for the final analysis. The level of evidence of these articles ranged from 1b to 4. Eight randomized controlled trials and four controlled clinical trials were available on eight treatment outcomes. The longest follow-up period of the randomized controlled trials was 6 years. No randomized controlled trials were found on active presurgical infant orthopedic appliances and on nasoalveolar molding appliances.

Conclusions

Based on the results, presurgical infant orthopedic appliances have no long-term positive effects on seven of the eight studied treatment outcomes in patients with cleft lip and palate. More randomized controlled trials need to be done to have evidence regarding the effects of presurgical infant orthopedics in different surgical protocols. Also, the encouraging results about the effect of nasolaveolar molding appliances on nasal symmetry have to be supported by future randomized controlled trials.

Craniofacial morphology in complete unilateral cleft lip and palate patients consecutively treated with 1-stage repair of the cleft

OBJECTIVE

To retrospectively evaluate the craniofacial morphology of children with a complete unilateral cleft lip and palate treated with a 1-stage simultaneous cleft repair performed in the first year of life.

METHODS

Cephalograms and extraoral profile photographs of 61 consecutively treated patients (42 boys, 19 girls) who had been operated on at 9.2 (SD, 2.0) months by a single experienced surgeon were analyzed at 11.4 (SD, 1.5) years. The noncleft control group comprised 81 children (43 boys and 38 girls) of the same ethnicity at the age of 10.4 (SD, 0.5) years.

RESULTS

In children with cleft, the maxilla and mandible were retrusive; the palatal and mandibular planes were more open, and sagittal maxillomandibular relationship was less favorable in comparison to noncleft control subjects. Soft tissues in patients with cleft reflected retrusive morphology of hard tissues--subnasal and supramental regions were less convex, profile was flatter, and nasolabial angle was more acute relative to those of the control subjects.

CONCLUSIONS

Craniofacial morphology after 1-stage repair was deviated in comparison with noncleft control subjects. However, the degree of deviation was comparable with that found after treatment with alternative surgical protocols.

The Americleft study: an inter-center study of treatment outcomes for patients with unilateral cleft lip and palate part 3. Analysis of craniofacial form

OBJECTIVE

To compare craniofacial morphology for individuals with nonsyndromic complete unilateral cleft lip and palate between the ages of 6 and 12 years.

DESIGN

Retrospective cohort study.

SETTING

Four North American cleft palate centers.

SUBJECTS

A total of 148 subjects with repaired complete unilateral cleft lip and palate who were consecutively treated at the four centers.

METHODS

The 148 preorthodontic lateral cephalometric radiographs were scanned, scaled, digitized, and coded to blind the examiners to radiograph origin. On each radiograph, 18 (angular and ratio) cephalometric measurements were performed. Measurement means, by center, were compared using analysis of variance and Tukey-Kramer analysis.

RESULTS

Significant differences were found for sagittal maxillary prominence among the four centers. The most significant difference was seen between Center B (lowest SNA) and Center C (highest SNA). Similar differences were seen at the soft tissue level, with Center C showing a significantly larger ANB angle compared with Centers B and D. Center C was also shown to have statistically greater mean soft tissue convexity than Centers B, D, and E. The mean nasolabial angle in Center B was significantly more acute than in Centers C, D, and E. No statistically significant differences were seen for mandibular prominence, vertical dimensions, or dental inclinations.

CONCLUSION

Significant differences were seen among the centers for hard and soft tissue maxillary prominence, but not for mandibular prominence, vertical dimensions, or dental inclinations. A modest but statistically significant (p < .001) negative correlation was found between Goslon scores and ANB angle (r = -.607).

The Americleft study: an inter-center study of treatment outcomes for patients with unilateral cleft lip and palate part 1. Principles and study design

OBJECTIVE

The Americleft study is a North American initiative to undertake an intercenter outcome study for patients with repaired complete unilateral cleft lip and palate from five well-established North American cleft centers.

DESIGN

Retrospective cohort study.

SETTING

Five cleft palate centers in North America.

METHODS

This is the first paper in a series of five that outlines the overall goals of the study and sets the basis for the clinical outcome studies that are reported in the following four papers. The five centers' samples and treatment protocols as well as the methods used for each study are reported. The challenges encountered and possible mechanisms to resolve them and reduce methodological error with intercenter studies are also reviewed.

Two-stage palate repair with delayed hard palate closure is related to favorable maxillary growth in unilateral cleft lip and palate

BACKGROUND

Two-stage palate repair with delayed hard palate closure is generally advocated because it allows the best possible postoperative maxillary growth. Nevertheless, in the literature, it has been questioned whether maxillary growth is better following use of this protocol. The authors therefore aimed to investigate whether stage of palate repair, one-stage versus two-stage, had a significant effect on facial growth in patients with unilateral cleft lip and palate.

METHODS

Seventy-two patients with nonsyndromic complete unilateral cleft lip and palate operated on by two different protocols for palate repair, one-stage versus two-stage with delayed hard palate closure, and their 223 cephalometric radiographs were available in the retrospective longitudinal study. Clinical notes were reviewed to record treatment histories. Cephalometry was used to determine facial morphology and growth rate. Generalized estimating equations analysis was performed to assess the relationship between (1) facial morphology at age 20 and (2) facial growth rate, and the stage of palate repair.

RESULTS

Stage of palate repair had a significant effect on the length and protrusion of the maxilla and the anteroposterior jaw relation at age 20, but not on their growth rates.

CONCLUSIONS

The data suggest that in patients with unilateral cleft lip and palate, two-stage palate repair has a smaller adverse effect than one-stage palate repair on the growth of the maxilla. This stage effect is on the anteroposterior development of the maxilla and is attributable to the development being undisturbed before closure of the hard palate (i.e., hard palate repair timing specific).

Early one-stage repair of complete unilateral cleft lip and palate

BACKGROUND

The purpose of this prospective study was to evaluate craniofacial morphology in children with complete unilateral cleft lip and palate treated at the Brussels cleft center after a 1-stage complete closure at 3 months and compare the results with a series of children operated on at 3 and 6 months of age according to the Malek surgical protocol.

METHODS

A series of 72 consecutive patients who were operated on for nonsyndromic complete unilateral cleft lip and palate were included in this study at approximately the age of 10 years. Thirty-four were treated according to the Malek surgical treatment protocol: the soft palate was closed at a mean (SD) age of 3.04 (0.20) months, followed by simultaneous repair of the lip and hard palate at 6.15 (0.67) months. Thirty-eight underwent 1-stage all-in-one (AIO) closure of the lip and hard and soft palates at 2.98 (0.16) months. Craniofacial morphology was evaluated by means of a digital cephalometric analysis. Cephalometric data were compared with a noncleft control group (n = 40) matched according to age. The same 2 series of children were followed up until 15 years of age, and the results were again compared.

RESULTS

Statistical analysis (analysis of variance with post hoc Tukey test) showed in both groups who were operated on a decreased anteroposterior growth compared with the children without cleft at 10 years but the AIO group only was not different from the group without cleft. The maxillary (MxPI/SN) plane was significantly (P = 0.002) increased in the Malek cleft group compared with the AIO group with cleft. At 15 years of age, a difference was not observed anymore between the 2 groups for the anteroposterior growth or for the maxillary plane inclination.

CONCLUSIONS

One-stage AIO closure based on the Malek surgical principles provided good anteroposterior midfacial morphology and resulted in less opening of the maxillary plane to the anterior cranial base.

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

Objective:

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

Material:

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

Methods:

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

Results:

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

Conclusions:

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