Structural outcomes in the Cleft Care UK study. Part 2: dento-facial outcomes

Are NHS cleft services in England ready for delegation to integrated care systems?

Cleft care services in the UK have been nationally funded since centralisation 25 years ago and during this time have been able to demonstrate improved clinical outcomes. Integrated care systems have been introduced into legislature as part of the Health Care Act of 2022 and will be responsible for the paradigm shift of allocating funds on a regional basis for cleft care services in England from 2024. The proposed population-based funding formulas present an opportunity to improve current inequities in cleft care, including access to speech therapy and adult services. However, the regional footprint of integrated care systems does not align with that of the centralised cleft service system and represents a threat to the standardised patient-centred care that has taken two decades to build. Awareness needs to be raised so that cleft care providers can proactively adapt to this mandatory change to service funding to ensure that clinical standards are maintained and continue to improve.

Treatment Outcomes of Interdisciplinary Care on Speech and Health-Related Quality of Life Outcomes in Adults With Cleft Palate

PURPOSE

Individuals born with a cleft palate with or without a cleft lip (CP ± L) often experience functional, aesthetic, and psychosocial consequences well into adulthood. This study aimed to investigate outcomes of speech and health-related quality of life (HRQoL) in adults with a CP ± L who received interdisciplinary cleft care at the Ghent University Hospital using valid, reliable, and condition-specific instruments.

METHOD

Thirteen Belgian Dutch-speaking participants with a CP ± L with a mean age of 25.4 years (SD = 5.1, range: 20-33 years) and an age- and gender-matched control group of 13 participants without a CP ± L with a mean age of 25.2 years (SD = 4.8, range: 20-32 years) were included in this study. Speech characteristics were evaluated perceptually and instrumentally. HRQoL was assessed through standardized patient-reported outcome measures. Outcomes were compared with those of the control group and to normative data where available.

RESULTS

Participants with a CP ± L in this sample demonstrated significantly lower speech acceptability (p < .001) and higher rates of hypernasality (p = .015) and nasal turbulence (p = .005) than the control group. They showed significantly higher satisfaction with appearance of the cleft scar compared with norms of adults with a CP ± L (p = .047). No other differences in speech characteristics, sociodemographics, or HRQoL were found between participants with and without a CP ± L.

CONCLUSIONS

The reduced speech acceptability and the presence of resonance and nasal airflow disorders may indicate the need for standardized long-term outcome measurement and interdisciplinary follow-up for speech characteristics and velopharyngeal insufficiency in young and middle adulthood in future clinical practice. Additional research is necessary to further substantiate these findings and to determine predictors for these continuing complications in adults with a CP ± L.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24243901.

Knowledge assessment on cleft lip and palate among recently graduated dentists: a cross-sectional study

BACKGROUND

The complex presentation, associated co-morbidities and multi-disciplinary requirements dictate the requirement for in-depth knowledge in order to effectively manage patients with cleft lip and palate (CLP). We aimed to develop a validated questionnaire for cleft lip and palate knowledge assessment and to evaluate the knowledge of cleft lip and palate among a group of recently-graduated dentists.

MATERIALS AND METHODS

A multiple-site, cross-sectional questionnaire-based study was conducted. The study population included recently graduated dentists involved in a dental internship program. A bespoke questionnaire was developed and validated, with internal consistency assessed using Cronbach's alpha and factor analysis performed. A 47-item prototype was distilled into a 15-item questionnaire. This was distributed to the participants with a response rate of 67% obtained.

RESULTS

The overall proportion of correct responses among dental interns was moderate (73%). The best results were found in relation to CLP treatment including the effect of unfavorable surgical outcomes on speech (89.5%) and the impact of CLP on the occlusion (87.6%). The lowest rate of correct responses (26.7%) was identified in relation to the association between CLP and smoking.

CONCLUSION

A validated CLP questionnaire was developed, permitting evaluation of the knowledge of cleft lip and palate and its management among recently graduated dentists. There is limited appreciation among dental interns of the risk factors for CLP as well as post-surgical complications. Given that general dentists are often the gatekeepers for the management of patients with cleft lip and palate, it is important that the findings of this survey are used to inform the curriculum and teaching of cleft lip and palate.

An introduction to the UK care pathway for children born with a cleft of the lip and/or palate

Cleft lip and/or palate includes a spectrum of congenital disorders affecting union on the lip, alveolus, hard and/or soft palate. The management of children born with an orofacial cleft requires a complex process from a multidisciplinary team (MDT) to restore form and function. Since the Clinical Standards Advisory Group (CSAG) report in 1998, the UK has reformed and restructured cleft services to improve the outcomes for children born with a cleft.The spectrum of cleft conditions, the members of the MDT and a chronological description of the stages of cleft management from diagnosis to adulthood are described using a clinical example. This paper forms the introduction to a series of more detailed papers which span all major aspects of cleft management. The papers will cover the following topics: dental anomalies; associated medical conditions among children; orthodontic management of patients; speech assessment and intervention; role of the clinical psychologist; challenges for the paediatric dentist; genetics and orofacial clefts; surgery - primary and secondary; restorative dentistry; and global perspectives.

Long-term treatment outcomes from the perspective of a patient with unilateral cleft lip and palate

The management of patients with orofacial cleft (OFC) often extends from diagnosis or birth well into adulthood and requires many different specialists within multidisciplinary teams (MDT). The aims of treatment are to restore form and function relating to hearing, speech, occlusion and facial aesthetics. People with OFCs that include the lip, alveolus and palate (cleft lip and palate (CLP)) require several different staged and coordinated surgical and non-surgical interventions, and the treatment pathway is associated with a heavy burden of care. Due to the extensive nature of the interaction with these patients, MDT members have opportunities to provide enhanced patient-centred care and support. This case report provides an overview of the current knowledge of the aetiology of OFC and the management of these patients. It provides a unique perspective from one of the coauthors who has a unilateral CLP (UCLP) and reports on his treatment experiences and long-term treatment outcomes. By having a better understanding of the impact of UCLP and treatment provided, MDT members can not only provide improved clinical treatment but also offer improved patient experiences for those with craniofacial anomalies, in particular, an increased awareness of the psychosocial challenges, they endure throughout their treatment pathway and beyond.

Changes in the Transverse Dimension of the Maxillary Arch of 5-Year-Olds Born With UCLP Since the Introduction of Nationwide Guidance

Objective:

To determine whether the transverse dimensions of the maxillary arch of 5-year-old children with unilateral cleft lip and palate (UCLP) have changed following centralization of cleft services in the United Kingdom.

Design:

Retrospective cross-sectional study.

Setting:

Digital analysis of UCLP maxillary dental casts.

Participants:

All available maxillary dental casts from 5-year-old participants of the Clinical Standards Advisory Group (CSAG, N = 114) and Cleft Care UK (CCUK, N = 175) studies.

Interventions:

Quantitative measurements of the intercanine width (ICW), intermolar width (IMW), and the distance from the midline to the greater and lesser side canine (GC/LC) and greater side and lesser side second primary molar (GE/LE). Degree measurements of the greater and lesser arch form angles, arch length, anterior palatal depth (APD), and posterior palatal depth were also measured.

Main outcome:

Differences between the transverse dimensions of the maxillary arch for the CSAG and CCUK cohorts.

Results:

In 5 (ICW, IMW, LC, LE, and APD) of the 11 measurements, there was a statistically significant difference between the CSAG and CCUK cohorts. In all of these, the CCUK values were greater than CSAG.

Conclusions:

There have been small but positive improvements for the transverse maxillary dimensions since centralization of the UK cleft service.

Factors Associated With Psychological Adjustment in Adults With Cleft Lip and/or Palate: Findings From a National Survey in the United Kingdom

OBJECTIVES

Research has identified adults born with cleft lip and/or palate (CL/P) to be at risk of poorer psychological outcomes compared to the general population. This study investigated factors that may contribute to positive and negative adjustment in adults born with CL/P.

DESIGN

A survey was designed and distributed by the Cleft Lip and Palate Association in collaboration with the Centre for Appearance Research CAR at the University of the West of England (UWE). There were 207 eligible responses (95% completed online) received between July and October 2018. Dependent variables included the Body Esteem Scale for Adolescents and Adults, Harter's Self Perception Profile for Adults (Global Self-Worth, Social Competence, and Intimacy subscales), the Fear of Negative Appearance Evaluation Scale, and the Revised Adult Attachment Scale. Independent variables were the Revised Life Orientation Test, biodemographic data, and self-reported single-item questions.

RESULTS

Factors associated with positive adjustment included reports of a happy childhood, talking about CL/P with family, close friendships, comfort in public spaces, satisfaction with appearance, and a positive life orientation. Psychological distress was associated with a desire for further surgery to improve appearance and/or function.

CONCLUSIONS

Several factors were identified that may influence psychological adjustment in adults with CL/P. Throughout childhood, family-centered practice to support family cohesion and an open dialogue about CL/P is indicated, as is support for young people to develop social confidence. For adults returning to the cleft service, treatment options for appearance and/or functional concerns should be explored, with access to psychological support when indicated. Interventions to increase optimism, resilience, and self-acceptance may also be warranted throughout the life span.

Dental Arch Relationship Outcomes Following 2-Stage Palatoplasty for Japanese Patients With Complete Unilateral Cleft Lip and Palate: A 3-Center Study

OBJECTIVE

To compare dental arch relationship outcomes following 3 different 2-stage palatal repair protocols.

DESIGN

Retrospective, cross sectional.

SETTING

Three cleft palate centers (A, B, C) in Japan.

PATIENTS

Ninety (A: 39, B: 26, C: 25) consecutively treated Japanese patients with complete unilateral cleft lip and palate.

INTERVENTIONS

In A, the soft palate and the posterior half of the hard palate were repaired at a mean age of 1 year 7 months. In B, the soft palate and hard palate were closed separately at a mean age of 1 year 6 months and 5 years 8 months, respectively. In C, the soft palate and hard palate were closed at a mean age of 1 year and 1 year 5 months, respectively.

MAIN OUTCOME MEASURES

Dental arch relationships were assessed using the 5-Year-Olds' (5-Y) index by 5 raters and the Huddart/Bodenham (HB) index by 2 raters.

RESULTS

Intra- and inter-rater reliabilities showed substantial or almost perfect agreement for the 5-Y and HB ratings. No significant differences in mean values and distributions of 5-Y scores were found among the 3 centers. The mean HB index scores of molars on the minor segment were significantly smaller in C than those in A and B (P < .05).

CONCLUSIONS

There were no significant differences in dental arch relationships at 5 years among the times and techniques of hard palate closure. However, further analysis of the possible influence of infant cleft size as a covariable on a larger sample size is needed.

The Relationship Between Maxillary Growth and Speech in Children With a Unilateral Cleft Lip and Palate at 5 Years of Age

OBJECTIVE

This study sought to investigate the association between maxillary growth and speech outcomes for children with a repaired unilateral cleft lip and palate (UCLP) at 5 years of age.

PARTICIPANTS

In all, 521 children (180 females and 341 males) with a nonsyndromic complete UCLP, born between 2007 and 2012 in England, Wales, and Northern Ireland were included in this study.

OUTCOME MEASURES

Maxillary growth was analyzed using dental models scored by the 5-Year-Olds' index, and perceptual speech analyses were scored by the Cleft Audit Protocol for Speech - Augmented rating.

RESULTS

Forty-one percent of the children achieved good maxillary growth (scores 1 and 2 on 5-Year-Old' index). Fifty percent of the children achieved normal speech (achieving UK speech standard 1). Maxillary growth was not found to have an impact on speech outcome when described by the 3 UK National Cleft Lip and Palate Speech Audit Outcome Standards. Analysis according to individual speech parameters showed dentalizations to be less prevalent in children with good maxillary growth compared to fair and poor growth (P = .001). The remaining speech parameters within resonance, nasal airflow, and articulation categories were not significantly associated with maxillary growth.

CONCLUSION

The findings from this study suggest that children with a history of complete UCLP, who have poor maxillary growth, are not at a higher risk of having major speech errors compared to children with good or fair maxillary growth at 5 years of age.

Perceptual Speech Outcomes After Early Primary Palatal Repair in Ugandan Patients With Cleft Palate

OBJECTIVE

To provide speech outcomes of English-speaking Ugandan patients with a cleft palate with or without cleft lip (CP±L).

DESIGN

Prospective case-control study.

SETTING

Referral hospital for patients with cleft lip and palate in Uganda.

PARTICIPANTS

Twenty-four English-speaking Ugandan children with a CP±L (15 boys, 9 girls, mean 8.4 years) who received palatal closure prior to 6 months of age and an age- and gender-matched control group of Ugandan children without cleft palate.

INTERVENTIONS

Comparison of speech outcomes of the patient and control group.

MAIN OUTCOME MEASURES

Perceptual speech outcomes including articulation, resonance, speech understandability and acceptability, and velopharyngeal composite score (VPC-sum). Information regarding speech therapy, fistula rate, and secondary surgery.

RESULTS

Normal speech understandability was observed in 42% of the patients, and 38% were judged with normal speech acceptability. Only 16% showed compensatory articulation. Acceptable resonance was found in 71%, and 75% of the patients were judged perceptually to present with competent velopharyngeal function based on the VPC-sum. Additional speech intervention was recommended in 25% of the patients. Statistically significant differences for all these variables were still observed with the control children (P < .05).

CONCLUSIONS

Overall, acceptable speech outcomes were found after early primary palatal closure. Comparable or even better results were found in comparison with international benchmarks, especially regarding the presence of compensatory articulation. Whether this approach is transferable to Western countries is the subject for further research.

Treatment Experiences in Adults Born With Cleft Lip and/or Palate: A Whole of Life Survey in the United Kingdom

Objectives:

Adults with cleft lip and/or palate (CL/P) may report dissatisfaction with aesthetic and/or functional outcomes and express desire for further treatment. Although medical intervention can improve quality of life, surgical procedures require complex decision-making and can invoke psychological distress. The aim of this study was to gain a better understanding of ongoing treatment-related support needs by examining self-reported treatment experiences of a sample of adults born with CL/P.

Design:

An online, mixed-methods survey was designed by the Cleft Lip and Palate Association in collaboration with the Centre for Appearance Research at the University of the West of England. A total of 207 eligible responses were received. Qualitative data were analyzed using inductive content analysis, while quantitative data were analyzed using descriptive statistics.

Results:

Although participants were satisfied with surgical and dental/orthodontic outcomes overall, many reported ongoing difficulties. Some stated they would seek further treatment while others felt conflicted about risks and benefits. Some had refused treatment, citing treatment fatigue, anxiety, and/or concerns that treatment would be unsuccessful. More than 40% of participants were unaware of their entitlement to cleft-related treatment provided by the National Health Service, and many others had experienced difficulties accessing care.

Conclusions:

Although advances in health care may offer opportunities for adults to improve their quality of life, treatment decisions should be weighed with the support of a clinical psychologist where available. Guidance for young adults considering future treatment is also recommended. Finally, training and resources for local practitioners may improve general awareness of CL/P services and increase access to specialist care for adults with ongoing CL/P-related concerns.

Educational Attainment of Children Born with Unilateral Cleft Lip and Palate in the United Kingdom

Objective:

This study evaluated association between functional outcomes in children born with unilateral cleft lip and palate (UCLP) and educational attainment.

Design:

Cleft Care UK (CCUK) was a United Kingdom (UK) wide cross-sectional study.

Setting:

UK Cleft Teams (data collected from all UK sites providing centralized cleft services).

Patients, Participants:

Five-year olds born with nonsyndromic UCLP (n = 268).

Main Outcome Measure(s):

National tests for educational attainment Key Stage 1 (KS1) undertaken by children at age 7 were linked to CCUK data to describe differences in educational attainment. Associations between functional outcomes and KS1 results were evaluated using regression analysis. We adjusted for birth month, gender, and an area-based measure of socioeconomic status.

Results:

Data were available for 205 children with UCLP. These children scored lower than national average (NA) scores across all subject areas, with a 0.62 lower score observed in the Average Point Score (APS; P = .01). There was association between being in a lower category for a cleft related outcomes and poorer KS1 results, with a trend for poorer attainment with higher numbers of poor functional outcomes. Those with 3 or more poor outcomes had a −2.26 (−3.55 to −0.97) lower APS compared to those with 0 to 1 poor outcomes.

Conclusions:

Children born with UCLP have poorer educational attainment at age 7 across all subject areas though differences were modest. Children with poor functional outcomes at age 5 had worse educational outcomes age 7. Improvements in functional outcomes could enhance educational outcomes.

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

OBJECTIVE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Facilitators and Barriers to Implementing Standardized Outcome Measurement for Children With Cleft Lip and Palate

OBJECTIVE

Identify facilitators and barriers to implementing standardized outcome measurement in cleft care.

DESIGN

Cross-sectional, qualitative study.

SETTING/PARTICIPANTS

Participants included 24 providers and staff from a large, multidisciplinary cleft team in the southwest United States, 5 caregivers of children with cleft palate (with or without cleft lip) treated by this team, and 3 experts involved in implementing a cleft-specific standardized outcome measurement in the United Kingdom.

INTERVENTIONS

Semistructured, qualitative interviews were conducted exploring perceived facilitators and barriers to implementing standardized outcome measurement in cleft care. Interviews were audio-recorded, transcribed, and analyzed for content. The Consolidated Framework for Implementation Research was used to guide the interviews and analysis. The analysis focused on the characteristics of standardized outcome measurement that directly influence its adoption.

RESULTS

Participants identified both facilitators and barriers to implementing standardized outcome measurement. Facilitators included the strength and quality of evidence supporting improvements in cleft care delivery following implementation of standardized outcome measurement and the relative advantage of standardized outcome measurement over continuing the status quo. Barriers included the difficulty adapting standardized outcome measurement to meet local context and patient-specific needs and the complexity of implementing standardized outcome measurement.

CONCLUSIONS

Providers, staff, and caregivers involved in cleft care perceive multiple benefits from standardized outcome measurement, while also recognizing substantial barriers to its implementation. Results from this study can be used to guide development of an implementation strategy for standardized outcome measurement that builds upon perceived strengths of the intervention and reduces perceived barriers.

The Trend of Cleft Care at a Children's Referral Center in Thailand

OBJECTIVE

To investigate the trend in cleft care at a major children's referral center in Bangkok, Thailand.

STUDY DESIGN

Retrospective chart review.

PATIENTS AND METHODS

A review of 129 patients under 18 years of age who had underwent care by the senior author for cleft treatment between January 2015 and October 2017 was done. The impact of varying factors on patient care was analyzed. We compare our demographics and treatment timeline to that of previously published literature in more developed countries.

SETTING

Tertiary care medical center.

RESULTS

One hundred and two patient charts were reviewed with 53% male patients. Most patients had both cleft lip and cleft palate, 44%. Cleft lips most commonly were complete and occurred on the left side. In all, 77.4% of clefts were nonsyndromic. On average, primary cleft lip surgery was delayed being performed about 11 months of age. Sixteen percent of patients were treated with an obturator, while 11 patients had nasoalveolar molding use. Hearing screenings occurred on average at around 6 months of age. Abnormal tympanograms were evident in 32% of individuals. There was a significant difference in timing of surgery for patients who lived a distance greater than 30 kilometers from the hospital versus those from the Bangkok metropolis (P < .05).

CONCLUSION

Reviewing data from a high-volume referral center in Thailand reveals mild variance with regard to cleft care timing compared to published literature from the developed world. Distance traveled was found to impact timing of surgery.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate. Dental arch relationships in 8 year-olds

BACKGROUND AND TRIAL DESIGN

The Scandcleft intercentre study evaluates the outcomes of four surgical protocols for treatment of children with unilateral cleft lip and palate (UCLP). Originally 10 cleft centres in Denmark, Finland, Norway, Sweden, and the UK participated in a set of three randomized trials of primary surgery. Three groups of centres (Trials 1, 2, and 3) tested their traditional local surgical protocols (Arms B, C, and D) against a common protocol (Arm A).

OBJECTIVES

To evaluate dental arch relationships at age 8 years after four different protocols of primary surgery for UCLP. These results are secondary outcomes of the overall trial.

METHODS

Study models of 411 children (270 boys, 141 girls) with non-syndromic UCLP at a mean age of 8.1 (range 7.0-10.0) years were available. Dental arch relationships were analysed using the GOSLON Yardstick by a blinded panel of 11 orthodontists. To assess reliability, Kappa statistics were calculated. The trials were tested statistically with t-tests.

RESULTS

Comparisons within each trial showed no statistically significant differences in the mean 8-year index scores or their distributions between the common protocol and the local team protocol. The mean index scores were Trial 1: Arm A 3.03, Arm B 2.82, Trial 2: Arm A 2.78, Arm C 2.64, and Trial 3: Arm A 3.06, Arm D 3.08. Comparisons between the trials detected a significantly (P < 0.005) better mean index score Trial 2 Arm C than in Trial 3 Arm D. The intra- and inter-rater reliabilities were acceptable.

CONCLUSION

The results of these three trials do not provide evidence that one surgical protocol is better than the others.

TRIAL REGISTRATION

ISRCTN29932826.

Occlusion at 5 Years of Age Following Hard Palate Closure With Vestibular Flap

OBJECTIVE

This study aims to assess occlusal relationships and frequency of oronasal fistula at 5 years of age following 2 hard palate closure techniques and to compare results.

DESIGN

Retrospective longitudinal study.

SETTING

Institutional study.

PATIENTS

Study patients included 57 patients with nonsyndromic complete unilateral cleft lip and palate who were consecutively treated. All patients underwent our early 2-stage protocol for palatoplasty, which consisted of soft palate plasty at 1 year of age and hard palate closure at 1.5 years of age. Twenty-nine patients underwent hard palate closure using vestibular flap (VF group) technique (2009-2011) and 28 patients underwent conventional hard palate closure with local palatal flap (LPF group) technique (2006-2008).

MAIN OUTCOME MEASURES

Occlusal relationships were assessed with 5-year-olds' index, and frequency of oronasal fistula was investigated.

RESULTS

Average 5-year-olds' index scores for VF and LPF groups were 3.11 and 3.57, respectively (P < .001). Oronasal fistula occurred in approximately 7% of patients in the VF group and in 18% of patients in the LPF group.

CONCLUSION

Hard palate closure with VF technique may provide better occlusal relationships at 5 years of age than does conventional local closure with the LPF.

Deglutition in Patients With Hypernasality Associated With Unilateral Cleft Lip and Palate Evaluated With High-Resolution Manometry

Objective:

To evaluate pharyngeal pressure profiles during swallowing in patients with unilateral cleft lip and palate (UCLP) and identify compensation mechanisms.

Design:

Prospective experimental study.

Setting:

University Hospital and Medical School.

Participants:

Ten volunteers and 10 patients with nonsyndromic repaired UCLP with hypernasality (age: 19-27 years, 5 females and 5 males per group) were included.

Interventions:

All participants swallowed 2 and 10 mL of water and underwent high-resolution manometry (HRM).

Main Outcome Measures:

Pharyngeal and upper esophageal sphincter (UES) parameters were measured using HRM. Student t test was used for statistical intergroup comparisons. Additionally, the Sydney Swallowing Questionnaire (SSQ) was used as a subjective measure.

Results:

Patients exhibited reduced velopharyngeal closing pressure and velopharyngeal and tongue base (TB) region contraction times, compared to volunteers ( P < .05). The UES opening and closing functions did not change. The SSQ revealed nasal regurgitation in some patients.

Conclusions:

In patients with UCLP, velopharyngeal region alterations are caused by impaired muscle force and function. The reduced TB contraction time may be a compensation mechanism allowing bolus transportation without nasal regurgitation. However, deglutition is not completely altered since UES function remains normal. Future studies will need to reveal at which point a decrease in velopharyngeal closing pressure will result in velopharyngeal insufficiency.

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.

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

Objective:

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

Design:

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

Participants:

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

Main Outcome Measure:

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

Results:

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

Conclusion:

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

A retrospective intercenter comparison of two surgical protocols through the dental arch relationship of 5- to 6-year-old unilateral cleft patients

OBJECTIVES

The objectives of this retrospective equivalence trial were to assess the dental arch relationship of 5- to 6-year-old patients with unilateral cleft lip and palate (UCLP) treated in two specialized cleft centers with a different surgical protocol using the 5-Year-Olds' Index and the modified Huddart/Bodenham scoring system, and to determine the correlation between these two scoring indices.

MATERIALS AND METHODS

The dental arch relationship of seventy-three 5- to 6-year-old patients with complete UCLP was evaluated on plaster casts using the 5-Year-Olds' Index and the modified Huddart/Bodenham scoring system. The sagittal occlusion, overbite, and overjet were also recorded. Inter- and intra-examiner agreement was determined using Intraclass Correlation Coefficients.

RESULTS

A good to very good inter- and intra-examiner agreement was found. No significant mean difference in outcome based on the 5-Year-Olds' Index, the modified Huddart/Bodenham scoring system, overjet, or overbite was detected. For mean difference in sagittal occlusion, the hypothesis that both centers are clinically equivalent was confirmed. A strong negative correlation (r_s = - 0.832) between the 5-Year-Olds' Index and the modified Huddart/Bodenham scoring system was found.

CONCLUSIONS

The dental arch relationship of 5- to 6-year-old unilateral cleft patients treated in two Belgian cleft centers is clinically equivalent based on sagittal occlusion, despite substantial differences in their treatment protocol. Clinical equivalence for other parameters was not confirmed. There is a strong correlation between the 5-Year-Olds' Index and the modified Huddart/Bodenham scoring system.

CLINICAL RELEVANCE

A well-implemented treatment protocol for cleft patients is of the utmost importance, but case load and skill of the surgeon are also important factors for the quality of the results.

Outcome Measures in UCLP: The Modified 5-Year-Olds'-Index-Development and Reliability

OBJECTIVE

Can we reliably discriminate severity within the existing categories of the 5-Year-Olds' Index?

DESIGN

Retrospective method comparison and development study.

SETTING

School of Oral and Dental Science, University of Bristol.

METHODS

Dental study models of 5-year-olds with unilateral cleft lip and palate (UCLP) were collected from the archives of 2 national cleft surveys (n = 351). One hundred randomly selected models were ranked to construct the modified 5-Year-Olds' Index and also scored using a visual analogue scale (VAS). Reliability testing was performed on 51 study models. Visual analogue scale scores were used to aid statistical analysis and investigate the reliability of a VAS for outcome measurement. The modified 5-Year-Olds' Index was then applied to 198 study models of 5-year-olds with UCLP.

RESULTS

The modified 5-Year-Olds' Index showed excellent intra and interexaminer agreement (intraclass correlation > 0.94) and good discrimination of severity. When applied to the Cleft Care UK participants (n = 198), the modified 5-Year-Olds' Index showed good discrimination of severity within the better categories (groups 1-3) of the 5-Year-Olds' Index. Visual analogue Scale scores resulted in unacceptable variation between measurements.

CONCLUSIONS

The new modified 5-Year-Olds' Index is a reliable method of assessing outcomes at 5 years of age and showed improved discriminatory power between the "better" outcome categories than the original 5-Year-Olds' Index. A VAS was found to be unsuitable for assessing outcome at 5 years of age for children with UCLP.

Centralization of cleft care in the UK. Part 6: a tale of two studies

Objectives

We summarize and critique the methodology and outcomes from a substantial study which has investigated the impact of reconfigured cleft care in the United Kingdom (UK) 15 years after the UK government started to implement the centralization of cleft care in response to an earlier survey in 1998, the Clinical Standards Advisory Group (CSAG).

Setting and Sample Population

A UK multicentre cross-sectional study of 5-year-olds born with non-syndromic unilateral cleft lip and palate. Data were collected from children born in the UK with a unilateral cleft lip and palate between 1 April 2005 and 31 March 2007.

Materials and Methods

We discuss and contextualize the outcomes from speech recordings, hearing, photographs, models, oral health and psychosocial factors in the current study. We refer to the earlier survey and other relevant studies.

Results

We present arguments for centralization of cleft care in healthcare systems, and we evidence this with improvements seen over a period of 15 years in the UK. We also make recommendations on how future audit and research may configure.

Conclusions

Outcomes for children with a unilateral cleft lip and palate have improved after the introduction of a centralized multidisciplinary service, and other countries may benefit from this model. Predictors of early outcomes are still needed, and repeated cross-sectional studies, larger longitudinal studies and adequately powered trials are required to create a research-led evidence-based (centralized) service.

Centralization of Cleft Lip and Palate Services in the United Kingdom

Background:

Since the implementation of centralized services in the United Kingdom for those affected by cleft lip and/or palate (CL/P), several studies have investigated the impact of service rationalization on the delivery of care. While large-scale quantitative studies have demonstrated improvements in a range of patient outcomes, and smaller studies have reported on the benefits and challenges of centralization from the views of health professionals, little research has attempted to capture the patient perspective. Furthermore, few studies have investigated the views of adult “returners” who have undergone treatment both pre- and postcentralization.

Methods:

Qualitative data relevant to the subject of this article were extracted from 2 previous larger studies carried out between January 2013 and March 2014. A total of 16 adults born with CL/P contributed data to the current study. These data were subjected to inductive thematic analysis.

Results:

The findings suggest that centralization of CL/P services has considerably enhanced the patient experience. Specifically, the overall standard and coordination of care has improved, service delivery has become more patient centered, and access to professional psychological support and peer support has greatly improved patients’ capacity to cope with the associated emotional challenges.

Conclusions:

The data collected provide additional insight into the impact of centralization from the perspective of a largely unexplored patient population. In combination with other literature, these findings are also relevant to future efforts to centralize other specialist services around the world.

The Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 11. What next?

BACKGROUND AND AIMS

Longstanding uncertainty surrounds the selection of surgical protocols for unilateral cleft lip and palate (UCLP), and randomised trials have only occasionally been performed. The Scandcleft Project consists of three trials initiated in 1997. The results at age 5 have been published in the series of reports that precede this manuscript, which aims to distill some of the issues that future trialists may need to address.

METHOD

The shared experience of this group of trials is reviewed with reference to the current literature on trial management and, more specifically, trials of surgical technique and timing.

RESULTS

The main discussion points relate to the challenges associated with research bureaucracy, learning curve, individuality of skill, and ethics.

CONCLUSIONS

Compliance with current regulatory requirements for clinical trials and recruitment rates for cleft sub-types represent substantial challenges. Mastery of new surgical techniques prior to trials raises important ethical issues, although recent reports in the wider surgical literature suggest that learning may be hastened with the assistance of anonymised peer review ratings of intraoperative performance. The three Scandcleft Trials succeeded in meeting the planned recruitment targets, and completed follow-up with remarkably high retention rates (99.3%). The design of the study required the majority of participating surgeons to master a new technique and, although overall outcomes were comparable with those in the literature, the associated learning curve increased postoperative complications in two of the trials.

TRIAL REGISTRATION

ISRCTN29932826.

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

BACKGROUND AND AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

TRIAL REGISTRATION

ISRCTN29932826.

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.

Centre-level variation in behaviour and the predictors of behaviour in 5-year-old children with non-syndromic unilateral cleft lip: The Cleft Care UK study. Part 5

OBJECTIVES

The aims of this study were to describe child behavioural and psychosocial outcomes associated with appearance and speech in the Cleft Care UK (CCUK) study. We also wanted to explore centre-level variation in child outcomes and investigate individual predictors of such outcomes.

SETTING AND SAMPLE POPULATION

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

MATERIALS AND METHODS

Parents completed the Strengths and Difficulties questionnaire (SDQ) and reported their own perceptions of the child's self-confidence. Child facial appearance and symmetry were assessed using photographs, and intelligibility of speech was derived from audio-visual speech recordings. Centre-level variation in behavioural and psychosocial outcomes was examined using hierarchical models, and associations with clinical outcomes were examined using logit regression models.

RESULTS

Children with UCLP had a higher hyperactive difficulty score than the general population. For boys, the average score was 4.5 vs 4.1 (P=.03), and for girls, the average score was 3.8 vs 3.1 (P=.008). There was no evidence of centre-level variation for behaviour or parental perceptions of the child's self-confidence. There is no evidence of associations between self-confidence and SDQ scores and either facial appearance or behaviour.

CONCLUSIONS

Children born with UCLP have higher levels of behaviour problems than the general population.

The Primary Care Pediatrician and the Care of Children With Cleft Lip and/or Cleft Palate

Orofacial clefts, specifically cleft lip and/or cleft palate (CL/P), are among the most common congenital anomalies. CL/P vary in their location and severity and comprise 3 overarching groups: cleft lip (CL), cleft lip with cleft palate (CLP), and cleft palate alone (CP). CL/P may be associated with one of many syndromes that could further complicate a child's needs. Care of patients with CL/P spans prenatal diagnosis into adulthood. The appropriate timing and order of specific cleft-related care are important factors for optimizing outcomes; however, care should be individualized to meet the specific needs of each patient and family. Children with CL/P should receive their specialty cleft-related care from a multidisciplinary cleft or craniofacial team with sufficient patient and surgical volume to promote successful outcomes. The primary care pediatrician at the child's medical home has an essential role in making a timely diagnosis and referral; providing ongoing health care maintenance, anticipatory guidance, and acute care; and functioning as an advocate for the patient and a liaison between the family and the craniofacial/cleft team. This document provides background on CL/P and multidisciplinary team care, information about typical timing and order of cleft-related care, and recommendations for cleft/craniofacial teams and primary care pediatricians in the care of children with CL/P.

The Slav-cleft: A three-center study of the outcome of treatment of cleft lip and palate. Part 1: Craniofacial morphology

Results of a comparison of the outcomes of treatment of cleft lip and palate can be affected by growth characteristics of populations from which subjects with the clefts are derived. Moreover, conventional cephalometric techniques used in cleft studies for analysis of facial morphology provide only a partial description of shape and are confounded by biases regarding the reference structures. In this retrospective comparison, craniofacial morphology of preadolescent patients with unilateral cleft lip and palate treated in Warsaw (n = 35, age = 10.6 years, SD = 1.2), Prague (n = 38, age = 11.6 years, SD = 1.4), and Bratislava (n = 26, age = 10.5 years, SD = 1.6) were evaluated on cephalograms with the cephalometric method used in the Eurocleft study and geometric morphometrics. We found that patients treated in Warsaw showed slightly more favorable outcomes than in Prague and Bratislava. The differences were related primarily to the position of maxillary alveolar process, cranial base, mandibular angle, and soft tissues. Although no association between a component of treatment protocol and the outcome was found, it is possible that organizational factors such as participation of high-volume, experienced surgeons contributed to these results.