Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: comparison of dental arch relationships and dental indices at 5, 8, and 10 years

Background and trial design

The Scandcleft intercentre study evaluates the outcomes of four surgical protocols (common method Arm A, and methods B, C, and D) for treatment of children with unilateral cleft lip and palate (UCLP) in a set of three randomized trials of primary surgery (Trials 1, 2, and 3).

Objectives

To evaluate and compare dental arch relationships of 5-, 8-, and 10-year-old children with UCLP after four different protocols of primary surgery and to compare three dental indices. The results are secondary outcomes of the overall trial.

Methods

Study models taken at the ages of 5 (n = 418), 8 (n = 411), and 10 years (n = 410) were analysed by a blinded panel of orthodontists using the Eurocran index, the 5-year-olds’ (5YO) index, and the GOSLON Yardstick. Student’s t-test, Pearson’s correlation, chi-square test, and kappa statistics were used in statistical analyses.

Results

The reliability of the dental indices varied between moderate and very good, and those of the Eurocran palatal index varied between fair and very good. Significant correlations existed between the dental indices at all ages. No differences were found in the mean 5-, 8-, and 10-year index scores or their distributions within surgical trials. Comparisons between trials detected significantly better mean index scores in Trial 2 Arm C (at all ages) and in Trial 1 Arm B (at 5 and 10 years of age) than in Trial 3 Arm D. The mean Eurocran dental index scores of the total material at 5, 8, and 10 years of age were 2.50, 2.60, and 2.26, and those of the 5YO index and GOSLON Yardstick were 2.77, 2.90, and 2.54, respectively. At age 10 years, 75.8% of the patients had had orthodontic treatment.

Conclusions

The results of these three trials do not provide evidence that one surgical method is superior to the others. The reliabilities of the dental indices were acceptable, and significant correlations existed between the indices at all ages. The reliability of the Eurocran palatal index was questionable.

Trial registration

ISRCTN29932826.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: impact of maxillary dental agenesis on craniofacial growth and dental arch relationship in 8 year olds

BACKGROUND

It is suggested that dental agenesis affects maxillary protrusion and dental arch relationship in children with unilateral cleft lip and palate (UCLP). In addition, an association between the need for orthognathic surgery and dental agenesis is reported.

AIM

The aim was to study the impact of maxillary dental agenesis on craniofacial growth and dental arch relationship in 8-year-old children with UCLP.

SUBJECTS AND METHODS

The sample consisted of individuals with UCLP from Scandcleft randomized trials. The participants had available data from diagnosis of maxillary dental agenesis as well as cephalometric measurements (n = 399) and GOSLON assessment (n = 408) at 8 years of age.

RESULTS

A statistically significant difference was found for ANB between individuals with agenesis of two or more maxillary teeth (mean 1.52°) in comparison with those with no or only one missing maxillary tooth (mean 3.30° and 2.70°, respectively). Mean NSL/NL was lower among individuals with agenesis of two or more maxillary teeth (mean 9.90°), in comparison with individuals with no or one missing maxillary tooth (mean 11.46° and 11.45°, respectively). The number of individuals with GOSLON score 4-5 was 47.2% in the group with two or more missing maxillary teeth and 26.1% respectively 26.3% in the groups with no or one missing maxillary tooth. No statistically significant difference was found in the comparison between individuals with no agenesis or with agenesis solely of the cleft-side lateral.

CONCLUSION

Maxillary dental agenesis impacts on craniofacial growth as well as dental arch relationship and should be considered in orthodontic treatment planning.

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.

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.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: dental anomalies in 8-year olds

BACKGROUND

Children born with unilateral cleft lip and palate (UCLP) are reported to display several dental anomalies including agenesis, supernumeraries, as well as variations in dental size, shape, and path of eruption. The extensive sample of individuals with UCLP included in the Scandcleft randomized control trials offers the opportunity to study more rare conditions, which is seldom possible with limited samples.

OBJECTIVES

The aim was to study dental anomalies at 8 years of age in children born with UCLP included in the Scandcleft randomized control trials.

METHODS

Panoramic and intraoral radiographs from 425 individuals (279 males and 146 females) with a mean age of 8.1 years were assessed by four orthodontists regarding dental anomalies.

RESULTS

Agenesis was found in 52.5 per cent and supernumerary teeth in 16.9 per cent of the participants. The cleft lateral was missing in 43.8 per cent and was found peg shaped in 44.7 per cent. The distribution of ectopic eruption was 14.6 per cent, mainly affecting maxillary first molars, while transposition was found in 3.4 per cent of the individuals. In addition, infraocclusion of one or several primary molars was registered in 7.2 per cent of the participants.

CONCLUSION

We conclude that 8-year-old children born with UCLP display multiple dental anomalies. The Scandcleft sample allowed rarely studied conditions such as infraocclusion of primary molars and transposition to be studied in children born with UCLP.

TRIAL REGISTRATION

ISRCTN29932826.

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.

Scandcleft randomized trials of primary surgery for unilateral cleft lip and palate: occlusion in 8-year-olds according to the Modified Huddart and Bodenham index

BACKGROUND

The Scandcleft international multicenter study is a prospective clinical trial of the long-term outcome after four different surgical protocols for palatal closure in patients born with unilateral cleft lip and palate (UCLP). This paper is one of a series of follow-up studies in 8-year olds.

OBJECTIVES

To evaluate the dental occlusion of 8-year-old patients after four different protocols of primary surgery for UCLP.

TRIAL DESIGN

Ten cleft centres in five countries tested three different surgical procedures for primary palatal repair in three parallel trials (Arms B, C, and D) against a common procedure (Arm A).

METHODS

Initially 448 children born with non-syndromic UCLP were included in the project. At 8 years of age, 428 children remained in the study. Dental casts of 411 patients (270 boys, 141 girls), mean age 8.1 years (range 7.0-10.0) were taken. The casts were blindly assessed with the Modified Huddart and Bodenham (MHB) index by four orthodontists. The main outcome measures were anterior (+2 to -6) and posterior (0 to -8) mean scores. Comparisons were made with previous data in 5-year-olds.

RESULTS

The inter- and intra-examiner reliability was good to excellent (0.75-0.90; 0.73-0.97), respectively. The mean total scores varied from -7.09 (Trial 2C) to -10.13 (Trial 3D). The mean anterior scores varied from -1.75 (Trial 2C) to -3.18 (Trial 1A). The mean posterior cleft-side scores varied from -4.32 (Trial 1B) to -5.21 (Trial 3D) and the mean non-cleft-side scores varied from -0.88 (Trial 2C) to -2.40 (Trial 3A). No significant differences were found within the trials. A significant difference was found between Trials 2 and 3 (Arm C/D) for the total score (P = 0.004).

CONCLUSIONS

There was no evidence of clinically significant differences in occlusion between the two surgical methods in each trial or between the trials. All mean scores showed more negative values in 8-year-olds compared with previously reported values in 5-year-olds.

TRIAL REGISTRATION

ISRCTN29932826.

Do Infant Cleft Dimensions Have an Influence on Occlusal Relations? A Subgroup Analysis Within an RCT of Primary Surgery in Patients With Unilateral Cleft Lip and Palate

Aim:

To investigate whether infant cleft dimensions, in a surgical protocol with early or delayed hard palate closure, influence occlusion before orthodontics.

Design:

Subgroup analysis within a randomized trial of primary surgery (Scandcleft).

Setting:

Tertiary health care. One surgical centre.

Patients and Methods:

A total of 122 unilateral cleft lip and palate infants received primary cheilo-rhinoplasty and soft palate closure at age 4 months and were randomized for hard palate closure at age 12 versus 36 months. A novel 3D analysis of cleft size and morphology was performed on digitized presurgical models. Occlusion was scored on 8-year models using the modified Huddarth–Bodenham (MHB) Index and the Goslon Yardstick.

Main Outcome Measurements:

Differences in MHB and Goslon scores among the 2 surgical groups adjusted for cleft size.

Results:

The crude analysis showed no difference between the 2 surgical groups in Goslon scores but a better MHB ( P = .006) for the group who received delayed hard palate closure. When adjusting for the ratio between cleft surface and palatal surface (3D Infant Cleft Severity Ratio) and for posterior cleft dimensions at tuberosity level, the delayed hard palate closure group received 3.65 points better for MHB (confidence interval: 1.81; 5.48; P < .001) and showed a trend for reduced risk of receiving a Goslon of 4 or 5 ( P = .052). For posterior clefts larger than 9 mm, the Goslon score was better in the delayed hard palate closure group ( P = .033).

Conclusions:

Seen from an orthodontic perspective, when the soft palate is closed first, and the cleft is large, the timing of hard palate closure should be planned in relation to posterior cleft size.

Influence of Infant Cleft Dimensions on Velopharyngeal Function in 5-Year-Old Danish Children Born With Unilateral Cleft Lip and Palate

Aim:

To examine the association of cleft severity at infancy and velopharyngeal competence in preschool children with unilateral cleft lip and palate operated with early or delayed hard palate repair.

Design:

Subgroup analysis within a multicenter randomized controlled trial of primary surgery (Scandcleft).

Setting:

Tertiary health care. One surgical center.

Patients and Methods:

One hundred twenty-five infants received cheilo-rhinoplasty and soft palate repair at age 3 to 4 months and were randomized to hard palate closure at age 12 or 36 months. Cleft size and cleft morphology were measured 3 dimensionally on digital models, obtained by laser surface scanning of preoperative plaster models (mean age: 1.8 months).

Main outcome measurements:

Velopharyngeal competence (VPC) and hypernasality assessed from a naming test (VPC-Sum) and connected speech (VPC-Rate). In both scales, higher scores indicated a more severe velopharyngeal insufficiency.

Results:

No difference between surgical groups was shown. A low positive correlation was found between posterior cleft width and VPC-Rate (Spearman = .23; P = .025). The role of the covariate “cleft size at tuberosity level” was confirmed in an ordinal logistic regression model (odds ratio [OR] = 1.17; 95% confidence interval [CI]:1.01-1.35). A low negative correlation was shown between anteroposterior palatal length and VPC-Sum (Spearman = −.27; P = .004) and confirmed by the pooled scores VPC-Pooled (OR = 0.82; 95% CI: 0.69-0.98) and VPC-Dichotomic (OR = 0.82; 95% CI: 0.68-0.99).

Conclusions:

Posterior cleft dimensions can be a modest indicator for the prognosis of velopharyngeal function at age 5 years, when the soft palate is closed first, independently on the timing of hard palate repair. Antero-posterior palatal length seems to protect from velopharyngeal insufficiency and hypernasality. However, the association found was significant but low.

Palatal morphology in unilateral cleft lip and palate patients: Association with infant cleft dimensions and timing of hard palate repair

OBJECTIVES

To assess the impact of cleft severity and timing of hard palate repair on palatal dimensions in unilateral cleft lip and palate (UCLP) children.

SETTING AND SAMPLE POPULATION

Single-centre analysis within a multicenter RCT of primary surgery; 122 UCLP randomized to early hard palate closure (EHPC) at 12 months or delayed hard palate closure (DHPC) at 36 months; 28 frequency-matched controls.

METHODS

Linear measurements of palatal height, width and length were performed on 116 digital models of UCLP subjects (8.21 years, SD = 0.53) and 28 models of non-cleft individuals (8.44 years SD = 0.72). Cleft dimensions at infancy (mean 1.8 months) were considered. In a pilot study, shell-to-shell distances between the 3D cleft palate objects and a reference mesh were calculated and differences between the groups assessed. Morphological differences were visualized using colour mapping.

RESULTS

Compared to controls, UCLP subjects presented a higher palate at the level of the anterior scar (P = 0.002), but generally a lower palate in the middle region (P < 0.001). Comparing UCLP subgroups, the DHPC subjects showed a flatter palate posteriorly (P = 0.048) and the EHPC group exhibited more transversal constriction (P = 0.003 at M1 level). 3D analysis revealed a shallower palate in the DHPC group both in the middle (P = 0.002) and the posterior part (P = 0.008). Anterior cleft severity correlated negatively with palatal height (P = 0.01).

CONCLUSIONS

Unilateral cleft lip and palate palates differ from controls in width and height. DHPC may represent an advantage for the transversal dimension, but a disadvantage for palatal height. Infant cleft dimensions partially explain differences in palatal height.

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.

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.

Maxillary and Sella Turcica Morphology in NewbornsWith Cleft Lip and Palate

Objective

The first aim was to examine maxillary developmental fields by analyzing bone size parameters within the maxillary bone complex in newborns with unilateral cleft lip (UCL) and unilateral cleft lip and palate (UCLP). The second aim was to evaluate sella turcica morphology in unilateral cleft lip and unilateral cleft lip and palate.

Subjects and Methods

Axial and profile radiographs from 40 newborns (boy–girl, 1:1) in each group (20 unilateral cleft lip and 20 unilateral cleft lip and palate) were randomly selected among radiographs taken for optimizing treatment planning. Analysis of maxillary bone size was performed on axial radiographs and size parameters were measured. Furthermore, analysis of sella turcica morphology was performed on profile radiographs. The results were divided into groups with normal morphology and severe deviations in the morphology.

Results

The maxillary areas were significantly shorter and broader in unilateral cleft lip and palate than in unilateral cleft lip. A profound asymmetry in the maxillary areas was seen in unilateral cleft lip and palate, but not in unilateral cleft lip. In both cleft types, approximately half of the individuals had deviations in sella turcica morphology. The most severe deviations occurred in newborns with unilateral cleft lip and palate.

Conclusions

In newborns with unilateral cleft lip and palate, the maxillary areas are significantly shorter, broader, and more asymmetric than in newborns with unilateral cleft lip. The present study showed that bone structures are a suitable parameter for characterizing the craniofacial developmental fields. Additionally, a high incidence of deviations in sella turcica morphology might indicate that this area is affected in individuals with clefts.

A Scandcleft randomised trials of primary surgery for unilateral cleft lip and palate: 1. Planning and management

BACKGROUND AND AIMS

Longstanding uncertainty surrounds the selection of surgical protocols for the closure of unilateral cleft lip and palate, and randomised trials have only rarely been performed. This paper is an introduction to three randomised trials of primary surgery for children born with complete unilateral cleft lip and palate (UCLP). It presents the protocol developed for the trials in CONSORT format, and describes the management structure that was developed to achieve the long-term engagement and commitment required to complete the project.

METHOD

Ten established national or regional cleft centres participated. Lip and soft palate closure at 3-4 months, and hard palate closure at 12 months served as a common method in each trial. Trial 1 compared this with hard palate closure at 36 months. Trial 2 compared it with lip closure at 3-4 months and hard and soft palate closure at 12 months. Trial 3 compared it with lip and hard palate closure at 3-4 months and soft palate closure at 12 months. The primary outcomes were speech and dentofacial development, with a series of perioperative and longer-term secondary outcomes.

RESULTS

Recruitment of 448 infants took place over a 9-year period, with 99.8% subsequent retention at 5 years.

CONCLUSION

The series of reports that follow this introductory paper include comparisons at age 5 of surgical outcomes, speech outcomes, measures of dentofacial development and appearance, and parental satisfaction. The outcomes recorded and the numbers analysed for each outcome and time point are described in the series.

TRIAL REGISTRATION

ISRCTN29932826.

The Eurocleft Study: Intercenter Study of Treatment Outcome in Patients with Complete Cleft Lip and Palate. Part 5: Discussion and Conclusions

Objective

To review the lessons learned from a longitudinal intercenter comparison study.

Design

Longitudinal cohort study.

Setting

Multidisciplinary cleft services in Northern Europe.

Subjects

Individuals with repaired complete unilateral cleft lip and palate.

Main Outcomes Measures

The first four papers in this series report amount of treatment, cephalometric form, nasolabial appearance, dental arch relationship, patient/parent satisfaction. This paper considers the consistency of outcome at the five centers over time, and other relationships between outcomes.

Results

Some outcomes measured in childhood can be predictive over time. The amount of treatment does not correlate with the quality of clinical outcome.

Conclusions

Measurement of clinical outcome in childhood is an important and valid form of clinical audit. Intercenter studies are more informative than single center reports, and will have an important future role in cleft care.

Long-term outcome of secondary alveolar bone grafting in cleft lip and palate patients: a 10-year follow-up cohort study

The objective was to assess the long-term outcome of secondary alveolar bone grafting (SABG) in cleft lip and palate patients and to examine relationships between preoperative and postoperative factors and overall long-term bone graft success. The records of 97 patients with cleft lip and palate, who had secondary alveolar bone grafting of 123 alveolar clefts, were examined. Interalveolar bone height was assessed radiographically a minimum of 10 years after grafting using a 4-point scale (I-IV), where types I and II were considered a success. After an average follow-up of 16 years after SABG (range = 10.2-22.7 years), 101 of the 123 grafts (82%) were categorised as successes. Mean age in the success group was 12.1 years and 13.6 years in the failure group (p = 0.03). It was found that the success rate was significantly lower (p = 0.02) if SABG was performed after eruption of the tooth distal to the cleft. No significant differences were found with regard to the other parameters investigated. The timing of secondary alveolar bone grafting is critical with regard to the age of the patient and the stage of eruption of the tooth distal to the cleft.

The morphology of the sella turcica in velocardiofacial syndrome suggests involvement of a neural crest developmental field

We described the morphology of the sella turcica in individuals with velocardiofacial syndrome (VCFS), also known as chromosome 22q11.2 deletion syndrome, and compared the morphology with that of a control group of individuals from the Oslo University Craniofacial Growth Archive. The aim was to measure the cranial base angles in individuals with VCFS and, if possible, to discover the developmental field that may be involved in the condition. The study included 33 patients with VCFS from the Copenhagen Cleft Palate Center, Denmark. The genotype was confirmed by fluorescence in situ hybridization. The morphology of the sella turcica was described and measurements of the cranial base angles were performed on lateral cephalometric radiographs. The VCFS individuals had larger deviations in the morphology of the sella turcica compared to individuals from the Oslo University Craniofacial Growth archive. The deviations were mostly in the posterior part of the dorsum sellae. Individuals with VCFS had increased cranial base angles. The results of this study combined with the information in the literature on the main defects in VCFS (palatal abnormalities, cardiac anomalies, thymic hypoplasia or aplasia, hypothyroidism, and posterior brain abnormality), suggest involvement of a specific developmental field.

A cohort study of recurrence patterns among more than 54,000 relatives of oral cleft cases in Denmark: support for the multifactorial threshold model of inheritance

OBJECTIVES

To determine if the anatomical severity of oral clefting affects familial recurrence in a large population based sample. To provide reliable recurrence risk estimates for oral cleft for first, second, and third degree relatives.

DESIGN

Population based cohort study.

SETTING

Denmark.

PARTICIPANTS

6776 individuals affected with an oral cleft born from 1952 to 2005 and 54 229 relatives.

MAIN OUTCOME MEASURES

Recurrence risk estimates for oral cleft for first, second, and third degree relatives and stratification by severity, specificity, parent of origin effect, and family size for first degree relatives.

RESULTS

For cleft lip and palate probands we observed recurrence risks for first, second, and third degree relatives of respectively 3.5% (95% CI 3.1% to 4.0%), 0.8% (95% CI 0.6% to 1.0%), and 0.6% (95% CI 0.4% to 0.8%). Individuals affected by the most severe oral cleft had a significantly higher recurrence risk among both offspring and siblings, eg, the recurrence risk for siblings of a proband with isolated bilateral cleft lip with cleft palate was 4.6% (95% CI 3.2 to 6.1) versus 2.5% (95% CI 1.8 to 3.2) for a proband born with a unilateral defect.

CONCLUSIONS

Anatomical severity does have an effect on recurrence in first degree relatives and the type of cleft is predictive of the recurrence type. Highly reliable estimates of recurrence have been provided for first cousins in addition to more accurate estimates for first and second degree relatives. These results and the majority of prior data continue to support a multifactorial threshold model of inheritance.

Pierre Robin sequence may be caused by dysregulation of SOX9 and KCNJ2

BACKGROUND

The Pierre Robin sequence (PRS), consisting of cleft palate, micrognathia and glossoptosis, can be seen as part of the phenotype in other Mendelian syndromes--for instance, campomelic dysplasia (CD) which is caused by SOX9 mutations--but the aetiology of non-syndromic PRS has not yet been unravelled.

OBJECTIVE

To gain more insight into the aetiology of PRS by studying patients with PRS using genetic and cytogenetic methods.

METHODS

10 unrelated patients with PRS were investigated by chromosome analyses and bacterial artificial chromosome arrays. A balanced translocation was found in one patient, and the breakpoints were mapped with fluorescence in situ hybridisation and Southern blot analysis. All patients were screened for SOX9 and KCNJ2 mutations, and in five of the patients expression analysis of SOX9 and KCNJ2 was carried out by quantitative real-time PCR.

RESULTS

An abnormal balanced karyotype 46,XX, t(2;17)(q23.3;q24.3) was identified in one patient with PRS and the 17q breakpoint was mapped to 1.13 Mb upstream of the transcription factor SOX9 and 800 kb downstream of the gene KCNJ2. Furthermore, a significantly reduced SOX9 and KCNJ2 mRNA expression was observed in patients with PRS.

CONCLUSION

Our findings suggest that non-syndromic PRS may be caused by both SOX9 and KCNJ2 dysregulation.

The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 2: craniofacial form and nasolabial appearance

OBJECTIVE

To compare craniofacial morphology and nasolabial appearance up to age 17 in individuals with repaired complete unilateral cleft lip and palate (UCLP) treated at five European centers.

DESIGN

Longitudinal cohort study.

SETTING

Multidisciplinary cleft services in Northern Europe.

SUBJECTS

127 consecutively treated individuals with repaired complete UCLP.

MAIN OUTCOME MEASURES

Cephalometric variables, 14 angular and 2 ratio variables, and panel ratings of nasolabial appearance, 4 variables.

RESULTS

The results revealed that at ages 12 and 17, two centers had a flatter profile (gs-sn-pgs) and retrognathic maxilla (sss-ns-sms). Additionally, one of the two centers had increased lower face height. Ratings of nasolabial appearance showed more similarity between the centers.

CONCLUSION

The results confirm that systematic differences in craniofacial morphology and nasolabial appearance may occur between different cleft centers, but do not allow specific caused factors to be identified.

The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 1: introduction and treatment experience

OBJECTIVE

To calculate the amount of treatment and associated travel experienced by five groups of patients treated at different centers. (This data is related to outcomes and patient/parent satisfaction in subsequent papers in this series).

DESIGN

A 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 unilateral complete cleft lip and palate.

MAIN OUTCOME MEASURES

Numbers of surgeries and outpatient visits, number of visits, and treatment duration for early orthopedics and orthodontic treatment, associated travel time and difficulties.

RESULTS

The mean number of operations per center ranged from 3.5 to 6; length of orthodontic treatment from 3.3 to 8.5 years, and attendance from 49 to 94 visits; and for early orthopedics, 0 to 15 months of treatment, 0 to 17 visits, and 0 to 146 days in hospital.

CONCLUSION

Protocols for the management of complete unilateral cleft lip and palate can vary dramatically in the burden of treatment imposed.

The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 4: relationship among treatment outcome, patient/parent satisfaction, and the burden of care

OBJECTIVE

To assess patient/parent satisfaction with the treatment they had received from their respective teams, and to explore interrelationships between satisfaction, objectively rated outcome, and the burden of care.

DESIGN

This study reports cross-sectional data as part of the overall longitudinal cohort study reported in the other four papers of this series.

SETTING

Multidisciplinary cleft services in Northern Europe.

SUBJECTS

127 consecutively treated 17-year-olds with repaired complete unilateral cleft lip and palate and their parents.

MAIN OUTCOME MEASURE

Patient/parent satisfaction.

RESULTS

Generally, there was a high level of patient/parent satisfaction. There were no relationships among satisfaction, objectively rated outcomes, and the amount of care.

CONCLUSIONS

This study highlights various challenges involved in questionnaire surveys into patient/parent satisfaction, and underlines the need for collective efforts to improve our understanding of this issue.

Cross-sectional study of the length of the nasal bone in cleft lip and palate subjects

OBJECTIVE

The purpose of this study was to analyze the human nasal bone length in newborns and male adults with cleft lip (CL), cleft palate (CP), and unilateral cleft lip and palate (UCLP) and to compare the results to previous findings in prenatal material.

DESIGN

This study was a radiographic profile cephalometric cross-sectional analysis.

SUBJECTS AND METHODS

Profile radiographs from 60 newborns with a male-to-female ratio of 1:1 in each group (20 CL, 20 CP, and 20 UCLP) and 60 male adults (20 CL, 20 CP, and 20 UCLP) were randomly selected among radiographs, taken for optimizing the treatment planning. The nasal bone lengths (n-na) were measured with a digital caliper on the profile radiographs. To compare the nasal bone lengths in the different cleft groups, Student's t tests at a significant level at 5% were performed.

RESULTS

Nasal bone length was significantly shorter in male adult patients with CL compared with patients with CP. Furthermore, the nasal bone length was significantly shorter in newborns with CL (2 months) compared to newborns with UCLP (2 months). A borderline significance was seen in the comparison of patients with CL and UCLP in male adults. There was no significant difference in the nasal bone length between the patients with CP and UCLP, in either the newborns or the male adults.

CONCLUSIONS

Nasal bone length was significantly shorter in subjects with CL compared with subjects in whom the palate was clefted. The results show that the clefted lip in CL is associated with a subjacent skeletal deviation in the upper midface.

Occurrence of cleft lip and palate in the Faroe Islands and Greenland from 1950 to 1999

OBJECTIVE

To describe the occurrence of cleft lip with or without cleft palate (CL/P) and isolated cleft palate (CP) in the Faroe Islands and Greenland over a 50-year time period that has included substantial changes in lifestyle.

DESIGN

A prevalence study based on patient records obtained from the Institute of Speech and Hearing Disorders in Copenhagen, Denmark, at which the treatment of patients with CP and CL/P from Greenland, the Faroe Islands, and Denmark is coordinated.

PARTICIPANTS

All live-born children in the Faroe Islands, Greenland, and Denmark with CL/P or CP born in the period 1950 to 1999 (Faroe Islands and Greenland) and 1950 to 1987 (Denmark).

RESULTS AND CONCLUSION

The mean prevalence of CL/P in the Faroe Islands and Greenland during the period 1950 to 1999 was 1.0 and 0.6 per 1000 live births, respectively. This is significantly lower than the mean prevalence of 1.4 (p <.05 and p <.001) per 1000 live births found in Denmark. The mean prevalence of CP in the Faroe Islands and Greenland was 1.5 and 1.1 per 1000 live births, respectively, which is significantly higher than the Danish prevalence of 0.5 per 1000 live births (p <.001 in both tests). There was no clear time trend in the prevalence, indicating that genetic factors or timetable environmental factors play a dominating role in the etiology of CL/P and CP in the Faroe Islands and Greenland.

The Eurocleft project 1996-2000: overview

INTRODUCTION

The original Eurocleft project, a European intercentre comparison study, revealed dramatic differences in outcome, which were a powerful stimulus for improvement in the services of respective teams. The study developed a preliminary methodology to compare practices and the potential for wider European collaboration including opportunities for the promotion of clinical trials and intercentre comparison was recognized by the European Commission. Therefore, the project: 'Standards of Care for Cleft Lip and Palate in Europe: Eurocleft' ran between 1996 and 2000 and aimed to promote a broad uplift in the quality of care and research in the area of cleft lip and palate.

RESULTS

The results of the 1996-2000 project include: a register of services in Europe, with details of professionals and teams involved in cleft care, service organization, clinical protocols and special facilities for research; a set of common Policy Statements governing clinical practice for European cleft teams, Practice Guidelines describing minimum recommendations for care that all European children with clefts should be entitled to and recommendations for Documentation governing minimum records that cleft teams should maintain; encouraging initial efforts to compare outcomes (results) of care between centres. A survey showed a wide diversity in models of care and national policies as well as clinical practices in Europe. Of the 201 centres that registered with the network, the survey showed 194 different protocols being followed for only unilateral clefts.

CONCLUSION

Cleft services, treatment and research have undoubtedly suffered from haphazard development across Europe. Attainment of even minimum standards of care remains a major challenge in some communities and both the will to reform and a basic strategy to follow are overdue. It is hoped that the Eurocleft Consensus Recommendations reached during the present project will assist in improving the opportunities for tomorrow's patients. It is also hoped that the collaborative research now beginning under the European Commission's Framework V Programme will provide a focus for European researchers wishing to improve understanding, treatment and prevention of clefts of the lip, alveolus and palate in the years ahead.

Treatment outcome in cleft lip and palate: issues and perspectives

In the last 40 years, great progress has been made toward a better understanding of many aspects of the cleft lip and palate defect, but there is still a long way to go before there is agreement on the optimal treatment procedures. With regard to the primary operations, it can be stated, in a somewhat simplified form, that there are two main schools of thought in cleft treatment. One advocates early closure of the lip and palate, a procedure which imparts a high priority to early speech function. The other recommends delayed closure of the hard palate, thereby according a high priority to the growth of the maxilla. A number of intercenter and multicenter studies have been carried out recently in an effort to elucidate which procedures give the best result, both esthetically and functionally. The results are ambiguous, and this has led a number of researchers to suggest that the randomized clinical trial is the only way to resolve the ambiguity. The fact that it has proved difficult to identify the optimal procedures in the field of cleft lip and palate treatment need not only be due to a less than optimal research design; a contributory factor might also be the great variability in craniofacial morphology and in the response to treatment in patients who have exactly the same cleft lip and palate diagnosis. Intensive research has made it possible to state categorically that clefts occur due to many different factors in an interplay between genetics and environment. Therefore, it is not likely that a single gene can be responsible for clefting. Since scar tissue presents many problems-for instance, impairment of growth-the reduction or prevention of scar formation has long been a desirable goal. The discovery that a fetus can heal without scar formation has led to many animal experiments. The timing of the surgical intervention on fetuses is critical, since late-gestation fetuses heal with adult-like scarring. There are still many unsolved problems connected with fetal surgery, and at present prenatal surgery for repair of cleft lip and palate is not ethically defensible in humans. On the other hand, it appears that there are considerable possibilities for the reduction of human scarring after surgery with the introduction of various wound-healing medications.

Craniofacial morphology in patients with Kallmann's syndrome with and without cleft lip and palate

OBJECTIVE

Kallmann's syndrome is characterized by the association of hypogonadotropic hypogonadism and anosmia or hyposmia. The principal endocrine defect of hypogonadotropic hypogonadism is a failure to secrete luteinizing hormone-releasing hormone (LHRH), resulting in underdevelopment of the pituitary gonadotropes and an inability to synthesize and release luteinizing hormone and follicle-stimulating hormone. The purpose of the present investigation was to describe the dentition and the craniofacial morphology in patients diagnosed with Kallmann's syndrome.

DESIGN

The sample consisted of 11 patients, 2 of whom also had bilateral cleft lip and palate. Radiographic investigations, including cephalometry, were performed. Comparisons were made to normal individuals and to cleft lip individuals without Kallmann's syndrome.

RESULTS

Dentition: tooth agenesis occurred more frequently in patients with Kallmann's syndrome. Craniofacial morphology: Increased mandibular inclination and mandibular angulation were seen in Kallmann patients. When clefting also occurred, extreme retrognathism of both maxilla and mandible was seen, a deviation which seemingly worsened during growth. The anterior cranial base and the sphenoid bone showed an altered morphology in one of the patients with Kallman's syndrome.

CONCLUSIONS

An early diagnosis of Kallmann's syndrome is very important because the prognosis for endocrine treatment thereby improves, and therefore, it is recommended that the sense of smell be evaluated in patients with the craniofacial morphology described.

Cranial base in newborns with complete cleft lip and palate: radiographic study

In a 1993 study, Mølsted and colleagues found an increased width of the spheno-occipital synchondrosis in newborns with complete clefts of the lip, alveolus, and palate compared with newborns with incomplete clefts. As the spheno-occipital synchondrosis represents remnants of the early chondrocranium that later ossifies and incorporates in the cranial base, it is possible that an inborn alteration, such as a deviant growth of cartilage, or a delayed maturation in the early development of the cartilaginous cranial base, can affect not only the length and the width of the cranial base, but also the petrous portion of the temporal bone and the nasal septum, as these structures also have a cartilaginous origin. The purpose of the present study was to measure the cranial base width, including the width of the maxilla, and to measure the bilateral angulation of the petrous portion of the temporal bone and the sphenoid bone in 3-month-old children with complete clefts and in 3-month-old children with an incomplete cleft of the lip, and to compare the two groups. Fifty-two children with complete clefts (CLP) without associated malformations comprised the test group. Forty-eight children with a minor, incomplete cleft lip (CL) constituted the control group. The results of the comparison showed marked differences between the CLP and CL groups. In the CLP children, the cranial base width and the bilateral angulation of the sphenoid bone increased. An increased angulation was also seen between left and right sides of the pars petrosa. Furthermore, increased maxillary width was found.(ABSTRACT TRUNCATED AT 250 WORDS)

The prenatal development of the human nasal and vomeral bones

The purpose of the present study was to establish normal prenatal development standards for the nasal and vomeral bones, both formed by intramembranous ossification in the membrane covering the cartilaginous nasal capsule. The study is based upon a combination of macroscopic (devisceration and radiography) and microscopic (histology) analyses on 62 normal human fetuses from spontaneous and induced abortions, ranging in gestational age from 9 to 24 weeks, representing crown-rump lengths (CRL) from 33 to 225 mm. Special attention was paid to the onset of bone formation in relation to other maturity aspects and to the growth of the bones. The very first onset of ossification of the vomeral bone is observed as two bilateral ossification centers, prior to nasal bone ossification. Later, the two bilateral ossification centers fuse caudally below the cartilaginous nasal septum, thus changing into a U-shaped bone when observed in the coronal plane. By bony apposition caudally the U-shaped vomer gradually changes into a Y-shape. The nasal bone appears as a thin bony contour ventral to the cartilaginous nasal septum in the sagittal plane, and changes gradually during growth to a wedge-shaped bone. Knowledge of the early development of the internal nose (vomeral bone) and external nose (nasal bone) is significant in understanding mid-face congenital malformations.

A multicentre comparison of treatment regimens for unilateral cleft lip and palate using a multiple regression model

The European Cleft Lip and Palate Research Group consists of specialists in orthodontics from six centres for the treatment of cleft palate in northern Europe. The purpose of this part of the multicentre study was to investigate whether differences in outcomes could be explained by specific treatment regimens. Three regimens that were assumed to influence the outcome of treatment were selected: Presurgical orthopaedics, closure of the palate, and primary bone grafting. The sample comprised 151 children with complete unilateral cleft lip and palate from the six centres. The result of multiple regression analysis showed that within that sample it was not possible to reach definite conclusions as to which factors exerted the most favourable influence on facial growth, but primary bone grafting was associated with reduced maxillary inclination and presurgical orthopedics with increased mandibular inclination.

Spheno-occipital synchondrosis in three-month-old children with clefts of the lip and palate: a radiographic study

The literature has been focused on differences in craniofacial form and dimension in cleft lip and palate patients. No attention has been given to possible alterations in the spheno-occipital synchondrosis although the synchondrosis is regarded as an important maturity and growth center. The purpose of the present investigation was to examine if the spheno-occipital synchondrosis in children born with major complete clefts differs on lateral radiographs from that of children born with minor incomplete clefts. Fifty-seven three-month-old children with complete clefts of the lip, alveolus and palate and 42 three-month-old children with minor incomplete clefts of the lip were included in the study. The results of the comparison showed that children with complete major clefts had a broader spheno-occipital synchondrosis compared to children with a minor incomplete cleft of the lip, and that the distance from the superior part of the synchondrosis to the sella point was shorter in children with complete clefts. These findings could be related to a defect or a delay in maturity in the early development of the cartilaginous cranial base in children with major clefts.

A six-center international study of treatment outcome in patients with clefts of the lip and palate: evaluation of maxillary asymmetry

This investigation was carried out by the European Cleft Lip and Palate Research Group. The purpose of this part of the investigation was to compare and evaluate maxillary asymmetry in children born with complete unilateral cleft lip and palate treated at cleft palate centers with different surgical management. Posteroanterior radiographs from three of the six participating centers were included in the investigation. Statistically significant differences were found in the symmetry of the anterior part of the maxillary complex. Children with a primary bonegrafting procedure involved in their primary treatment procedure had a more symmetric dentoalveolar development. Children from centers with primary surgical procedures including a vomer plasty and no involvement of the alveolar process had a more asymmetric development with a tilted premaxilla and a deviating inclination of the central incisors.

The need for long-term multicenter treatment assessment of craniofacial developmental disorders including cleft lip and palate

There has been an increase of interest in recent years in comparing treatment outcome in patients with craniofacial anomalies, including cleft lip and palate. When a treatment result is to be evaluated, it is important that it is multifaceted, taking all aspects into account. A comparison between treatment outcome in six centers showed that those with simple procedures and few surgeons involved in the primary operations had as good treatment results as those with more complicated treatment procedures. The center that used presurgical orthopedics with extraoral strapping in its treatment program ranked low as did the center employing primary bone grafting as part of the treatment program when compared with the other centers.

A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 3. Dental arch relationships

One hundred and forty-nine dental casts of subjects with complete unilateral clefts of the lip and palate from six European cleft palate centers were assessed by means of the Goslon Yardstick. The Yardstick proved capable of discriminating between the quality of the dental arch relationships between the six centers. Two centers showed especially poor results. Three centers obtained satisfactory results although differing surgical techniques were used in these centers. One of the centers showing satisfactory dental arch relationships employed a more complex and expensive treatment program than the other two centers, which both used simpler centralized treatment regimens.

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

The craniofacial morphology and the soft tissue profile were evaluated in this part of the intercenter study of the European Cleft Lip and Palate Research Group. The sample was comprised of cephalometric x-rays of the full cohort of 151 cases from the six European cleft palate centers. The facial morphology in complete unilateral cleft lip and palate patients was evaluated by means of roentgen cephalometry. Approximately 25 consecutive cases from each of six European cleft palate centers were compared. Only one center showed notable and consistent differences from the others. A contributing factor for these differences may be an inconsistent treatment regimen with many surgeons involved. Analysis of the soft tissue profile between the centers showed more pronounced differences than analysis of the skeletal profile. The treatment outcome in centers with more complex or expensive programs was no better than those centers using simpler management approaches.

A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 1. Principles and study design

This article describes the design of an intercenter comparative study of treatment outcome in the treatment of children with a unilateral complete cleft of the lip and palate. The rationale and aims of this study are defined and treatment schemes of the participating centers are described. The findings are presented in a series of three papers (Parts 2, 3, and 4) dealing with the comparison of craniofacial form, dental arch relationships, and nasolabial appearance. In Part 5, conclusions and general recommendations regarding future research are discussed.

A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 4. Assessment of nasolabial appearance

One hundred and fifteen frontal and profile photographs of the nasolabial area of subjects with complete unilateral clefts of the lip and palate from six European centers were assessed. Four components of the nasolabial area were rated separately by a panel of judges using a five-point scale of attractiveness. The Tukey multiple comparison test showed significant differences between the centers. The relative position of the six centers in this study followed a similar pattern to their respective positions in the cephalometric and dental cast studies.