Closer to the Truth on National Fistula Prevalence After Unilateral Complete Cleft Lip and Palate Repair? The Cleft Care UK Study.

OBJECTIVES: To (1) determine the prevalence of nonperialveolar palatal fistula up to age 5 following repair of unilateral cleft lip and palate (UCLP) in the United Kingdom, (2) examine the association of palatoplasty techniques with fistula occurrence, and (3) describe the frequency of fistula repairs and their success. DESIGN: Cross-sectional study. SETTING: All 11 centralized regional cleft centers in the United Kingdom. PARTICIPANTS: Two hundred sixty-eight children born between 2005 and 2007 recruited by Cleft Care UK, a nationwide cross-sectional study of all 5-year-old children born with nonsyndromic UCLP. MAIN OUTCOME MEASURE: Nonperialveolar palatal fistula prevalence up to age 5. RESULTS: Fistulas were found in 72 children (31.3%, 95% confidence interval: 25.4%-37.7%) and had no significant association with palate repair sequences. Twenty-four fistulas were repaired by age 5, 12 of which had data showing 10 (83.3%) successful repairs. CONCLUSION: The prevalence of nonperialveolar fistulas following primary palatoplasty of UCLP in the United Kingdom was higher than previously reported. This information should be part of the preoperative discussion with families. Prospective collection of the presence of fistulas will be necessary before we can associate the occurrence of fistulas with a surgeon, institution, surgical technique, or protocol of care.

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.

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.

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

BACKGROUND: High-quality aesthetic outcomes are of paramount importance to children growing up after cleft lip and palate surgery. Establishing a validated and reliable assessment tool for cleft professionals and families will facilitate cleft units, surgeons, techniques, and protocols to be audited and compared with greater confidence. This study used exemplar images across a five-point aesthetic scale, identified in a pilot project, to score lips and noses as separate units and compared these human scores with computer-based SymNose symmetry scores. METHODS: Forty-five assessors (17 cleft surgeons nationally and 28 other cleft professionals from the UK South West Tri-centre units), scored 25 standardized photographs, uploaded randomly onto a Web-based platform, twice. Each photograph was shown in three forms: lip and nose together, and separately cropped images of nose only and lip only. The same images were analyzed using the SymNose software program. RESULTS: Scoring lips gave the best intrarater and interrater reliabilities. Nose scores were more variable. Lip scoring associated most closely with the whole-image score. SymNose ranking of the lip images related highly to the same ranking by humans (p = 0.001). The exemplar images maintained their established previous ranking. CONCLUSIONS: Images illustrating the aesthetic outcome grades are confirmed. The lip score is reliable and seems to dominate in the whole-image score. Noses are much harder to score reliably. It appears that SymNose can score lip images very effectively by symmetry. Further use of SymNose will be investigated, and families of children with cleft will trial the scoring system. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Fistula incidence after primary cleft palate repair: a systematic review of the literature.

BACKGROUND: The development of an oronasal fistula after primary cleft palate repair has a wide variation reported in the literature. The aim of this review is to identify the reported oronasal fistula incidence to provide a benchmark for surgical practice. METHODS: A systematic review was undertaken to investigate the incidence of fistula. Multiple meta-analyses were performed to pool proportions of reported fistulae, in each data set corresponding to the continent of origin of the study, type of cleft, and techniques of cleft palate repair used. RESULTS: A total of 9294 patients were included from 44 studies. The overall incidence of reported fistula was 8.6 percent (95 percent CI, 6.4 to 11.1 percent). There was no significant difference in the fistula incidence corresponding to the continent of origin of each study or the repair technique used. The incidence of fistula in cleft lip-cleft palate was 17.9 percent, which was significantly higher (p = 0.03) than in cases of cleft palate alone (5.4 percent). CONCLUSIONS: Palatal fistulae were more likely to occur in cases of combined cleft lip-cleft palate, compared with cleft palate alone. The authors would recommend the prospective examination and recording of all fistulae to a standardized classification scheme. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

The continuing multidisciplinary needs of adult patients with cleft lip and/or palate.

OBJECTIVE: Babies born with cleft lip and/or palate are followed-up throughout their growth in childhood. During adulthood, they may require further functional and/or aesthetic treatment. Adult multidisciplinary cleft clinics have been in place in the West Midlands, U.K. since June 2000. The aim of this study was to review the number and nature of problems these adult patients had and the types of treatment they required. DESIGN: All adult patients seen in 2004 were identified. Case notes were reviewed for patient epidemiology, problems at initial presentation, and interventions carried out until their last clinic visit in 2004. RESULTS: In 2004, there were 145 patients seen in the adult cleft clinic. Of those, 55 patients attended as part of their continuing care. Ninety were newly referred as adults to the cleft service. Patients ranged in age from 15 to 70 years and had, on average, three clinical problems each. One hundred and sixteen patients were listed for surgery of varying types, nine patients had nonsurgical speech-related intervention, 21 patients had restorative dental intervention, and 16 patients needed an extended clinical psychology assessment. CONCLUSION: For some patients who have had a cleft lip and/or palate, problems continue into adulthood or arise later in life. These problems are often multiple and treatment often requires the input of more than one specialist. The results of this audit support the need for coordinated multidisciplinary care for adults who have had a cleft lip and/or palate.