Publicly funded healthcare costs associated with orofacial clefts for children born in Alberta, Canada between 2002 and 2018.

BACKGROUND: Orofacial clefts (OFCs) include cleft palate (CP), cleft lip (CL), and cleft lip with cleft palate (CLP) and require multidisciplinary healthcare services. Alberta, Canada has a publicly funded, universal access healthcare system. This study determined publicly funded healthcare costs for children with an OFC and compared these costs to children without congenital anomalies. METHODS: This retrospective population-based cohort analysis used the Alberta Congenital Anomalies Surveillance System to identify children born between 2002 and 2018 with an isolated OFC. They were matched 1:1 to a reference cohort based on sex and year of birth. The study population included 1614 children, from birth to 17 years of age linked to administrative databases to estimate annual inpatient and outpatient costs. Average annual all-cause costs were compared using two-sample independent t tests. RESULTS: The mean total cleft-related costs per patient were highest for children with CLP ($74,138 CAD, standard deviation (SD) $43,447 CAD), followed by CP ($53,062 CAD, SD $74,366 CAD), and CL ($35,288 CAD, SD $49,720 CAD). The mean total all-cause costs per child were statistically significantly higher (p < .001) in children with an OFC ($56,305 CAD, SD $57,744 CAD) compared to children without a congenital anomaly ($18,600 CAD, SD $61,300 CAD). CONCLUSIONS: Despite public health strategies to mitigate risk factors, the trend for OFCs has remained stable in Alberta, Canada for over 20 years. The costs reported are useful to other jurisdictions for comparison, and to families, healthcare professionals, service planners, and policy makers.

Global, regional and national burden of orofacial clefts from 1990 to 2019: an analysis of the Global Burden of Disease Study 2019.

BACKGROUND: Orofacial clefts are the most common congenital malformation, but the global burden and trends of orofacial clefts have not been comprehensively analysed. The aim of this study was to assess the global incidence, deaths and disability-adjusted life years (DALYs) of orofacial clefts by countries, regions, sex and sociodemographic index (SDI) from 1990 to 2019. METHODS: The data on orofacial clefts were obtained from the Global Burden of Disease Study 2019. The incidence, deaths and DALYs were analysed by countries, regions, sex and SDI. Age-standardized rates and estimated annual percentage change (EAPC) were calculated to evaluate the burden and temporal trend of orofacial clefts. The association between EAPC and the human development index was assessed. RESULTS: Globally, the incidence, deaths and DALYs of orofacial clefts decreased from 1990 to 2019. The high SDI region showed the biggest downward trend in incidence rate from 1990 to 2019, along with the lowest age-standardized death rate and DALY rate. Some countries, such as Suriname and Zimbabwe, experienced increased death rate and DALY rate over time. The age-standardized death rate and DALY rate were negatively associated with the level of socioeconomic development. CONCLUSION: Global achievement is evident in the control of the burden of orofacial clefts. The future focus of prevention should be on low-income countries, such as South Asia and Africa, by increasing healthcare resources and improving quality.KEY MESSAGESThis is the most recent estimate of the global epidemiology of orofacial clefts, with some countries not previously assessed.The global burden of orofacial clefts showed downward trends from 1990 to 2019; however, some low-income countries are still suffering from increasing burdens.Effective measures should be taken to reduce the burden of orofacial clefts in the uncontrolled regions.

Maxillary arch dimensions, occlusion assessment and space conditions in patients with cleft palate in the period of deciduous dentition-A retrospective study.

PURPOSE: The aim of this study was to evaluate the maxillary arch dimensions, dentoalveolar relationships and spacing conditions in patients with cleft palate in comparison with the control group. METHODS: The subjects consisted of 31 children with cleft palate only (CP) aged 5.5 ± 0.51 (20 with a cleft of hard and soft palate (SHPC group) and 11 with a cleft of soft palate only (SPC group)). In the control group 30 subjects had a normal occlusion at age 5. Maxillary arch dimensions, dentoalveolar relationship according to the Huddard Bodenham index (HBI) and space conditions were compared with the control group. RESULTS: In all variables of maxillary arch dimensions except for total arch height the control group exhibited greater values. Most of the significant differences were on account of differences between the control and the SHPC group, with only three comparisons yielding significant results when comparing the two groups of children with clefts (SHPC vs SPC, IV-IV central: pDunnett T3= 0.0002, 95%CIDifference=-9.9-(-3.18); V-V distopalatal cusps: pDunnett T3= 0.0002, 95%CIDifference=-9.97-(-3.17); Total arch length: pDunnett T3= 0.0014, 95%CIDifference=1.74-7.85). The three groups differed significantly in anterior HBI only (HKruskal-Wallis=15.56, p = 0.0067). The spacing conditions in both jaws were also shown to be significantly dependent on the group of subjects studied (Upper jaw: χ2omnibus= 16.79, p = 0.0018; lower jaw: χ2omnibus= 13.75, p = 0.0102). CONCLUSIONS: The growth of the upper dental arch at the age of five is impeded in participants with CP in comparison to a control group. It is important to assess the effect of cleft subtypes on growth and development to get a better understanding.

Dental anomalies and their therapeutic implications: retrospective assessment of a frequent finding in patients with cleft lip and palate.

BACKGROUND: Orofacial clefts are characterized by a frequent occurrence of dental anomalies. Numerous studies demonstrate the high prevalence of dental aplasia, supernumerary teeth, and hypoplastic teeth in patients with cleft lip with/without cleft palate (CL/P), yet the therapeutic consequences are rarely discussed. This study explores prevalence, localization, and association between primary and secondary dentition in a large European collective and begins to evaluate the significance of dental anomalies in the therapeutic course of patients with CL/P. METHODS: The medical reports of 1070 patients with different entities of CL/P who presented to our clinic within a 15-year investigation period were evaluated retrospectively. Dental anomalies were classified into three different diagnostic groups: dental aplasia, supernumerary teeth and hypoplastic teeth. The statistical analyses included studies of the frequency and localization of dental anomalies in different cleft entities as well as of the association between primary and secondary dentition and the therapeutic consequences. RESULTS: Uni- or bilateral cleft lip and palate (CLP) (47.5%) occurred most frequently, followed by cleft palate only (CPO) (32.9%) and cleft lip with or without alveolus (CL ± A) (19.6%). Dental anomalies were found significantly more often on the side of the cleft. Aplastic permanent teeth were mostly found in patients with CLP (54.8%), while supernumerary permanent teeth occurred primarily in patients with CL ± A (21.7%). Patients with CPO presented dental aplasia but no patient with CPO showed supernumerary teeth. The occurrence of dental aplasia in the primary dentition significantly increases the probability of aplastic teeth in the permanent dentition. Dental anomalies, in particular dental aplasia, significantly increase patients' need for subsequent orthodontic therapy and orthognathic surgery. CONCLUSION: Dental aplasia and hypoplasia are common in patients with CL/P not only in the cleft area but in the whole dentition. In the event of dental aplasia in the primary dentition, the frequency of aplastic teeth in the permanent dentition is significantly higher. Additionally, the need for therapeutic interventions, especially concerning orthognathic surgery, seems to be significantly higher in patients with CL/P who are affected by dental anomalies. Clinicians should take this into account when creating long-term treatment plans.

Thai Universal Health Care Coverage scheme promotes the accessibility to cleft lip/palate treatment: the result of cleft care provision assessment using modified Geographic Information System.

BACKGROUND: This study assessed the cleft lip/palate (CL/P) healthcare provision using data from the Thailand National Health Security Office from fiscal years 2012-2016. METHODS: Four national databases of Thailand comprising 1) admitted patient visit, 2) non-admitted patient visit, 3) birth defects registry and 4) civil registration databases were analyzed. All duplicate records were removed by a matching process using national identity number and date of birth prior to data extraction. Modified Geographic Information System was also used to compare each provincial patients with CL/P of Thailand to the number of provincial live births with CL/P. RESULTS: The results showed that the number of live births with CL/P during this period was 7,775 cases (1,555 cases/fiscal year). While the number of cases with CL/P registered under the Universal Health Care Coverage with hospital stay was 6,715 (86.37%), 927 cases (11.92%) visited hospitals without a stay, and the remaining 133 cases (1.71%) never visited any hospital. Modified Geographic Information System result showed that the provincial CL/P healthcare was relatively well-balanced with the provincial live births with CL/P (r = 0.92, p < 0.05). Moreover, provinces with CL/P tertiary care centers attracted more patients from the surrounding provinces. CONCLUSION: This study showed that the percentage of patients with CL/P receiving hospital treatment was 98. The Thai Universal Health Care Coverage scheme has promoted the accessibility to CL/P treatment. In order to achieve the best possible comprehensive cleft care coverage, periodical assessment and improvement of the function and accuracy of the national database registry are recommended.

The Panorama of Cleft Lip and Palate Live Birth in Brazil: Follow-up of a 10-Year Period and Inequalities in the Health System.

OBJECTIVE: To provide the prevalence and an overview of cleft lip and palate (CL/P) in the period of 2008 to 2017, as well as the profile of care provided for this condition in Brazil. DESIGN: Cross-sectional study of epidemiological character. SETTING: Brazilian government website. PARTICIPANTS: National Live Birth and Hospital Information System. INTERVENTION: Organization of the end databases and performance-based statistical analysis. MAIN OUTCOME MEASURE(S): Analysis of the prevalence of CL/P in newborns, sociodemographic condition of the mothers, surgical procedures and hospitalizations, and specialized hospitals in Brazil within a 10-year period. RESULTS: The average prevalence of CL/P in Brazil was ∼52 children per 100 000 live births in the covered period, corresponding to 1 per 1924 newborns. The presence of cleft was associated with preterm birth, being underweight, and the male gender. The highest prevalence was found in the South region, while the lowest was found in the Northeast region, with increasing rates in the North region of Brazil. The states with the highest prevalence were not those with a great number of hospitalizations and surgical procedures for live births with CL/P. CONCLUSION: In the 10-year study period, the prevalence of CL/P was 0.52 newborns per 1000 live births, a result which differs among the states of Brazil. The need to reinforce the national monitoring of the prevalence and surgical procedures of cleft patients have also emphasized the need to improve public medical care for CL/P subjects.

Child Protective Services Referral in a Cleft Lip and/or Palate Population: Assessment of Prevalence, Indications, and Outcomes.

OBJECTIVE: To determine the prevalence of, reasons for, and outcomes related to Child Protective Services (CPS) referral in an isolated and syndromic cleft lip/palate population. DESIGN: Retrospective cohort study. SETTING: Tertiary Children's Hospital. PATIENTS: Any patient <18 years of age attending the multidisciplinary cleft team for care at our institution with a history of referral to CPS by the cleft team during the study period 2009 to 2014. MAIN OUTCOME MEASURES: The number of children with CPS referrals, reasons for CPS referrals, outcomes of CPS referrals, associated psychosocial risk factors potentially predictive of CPS referral; demographics and cleft-related surgical history was also reviewed for each patient. RESULTS: Of 1392 patients, 25 (1.8%) were identified with a history of referral to CPS. Average age at referral was 11 months; 76.0% of patients were <1 year of age. Most referrals (64.0%) were directly associated with issues related to cleft care. Identified psychosocial risk factors included financial strain, mental illness/cognitive disability, transportation issues, and inadequate social support. Nine families ultimately lost custody of their children temporarily (n = 5) or permanently (n = 4). CONCLUSIONS: Cleft team family referral to CPS involves long-term patient care challenges requiring maximal medical and social support. Families are most commonly referred for issues related to medical neglect, which can lead to failure to thrive, delays in care, and ultimate removal from the home. Identifying families with known psychosocial risk factors and providing increased support may potentially help avoid referrals to CPS.

Global Burden of Orofacial Clefts and the World Surgical Workforce.

BACKGROUND: Orofacial clefts are one of the most common congenital anomalies, but this disease burden is unevenly distributed worldwide. The authors hypothesize that this burden falls disproportionately on the countries with the smallest surgical workforce or lowest Socio-Demographic Index, rather than those with the highest prevalence of disease. METHODS: The authors estimated the prevalence and disease burden of orofacial clefting from 1990 to 2017 in 195 countries using the Global Burden of Disease methodology. Prevalence and disability-adjusted life-years were compared geographically, temporally, and against the size of the national surgical workforce, Socio-Demographic Index, and income status. Linear and logarithmic regressions were performed. RESULTS: In 2017, the prevalence of orofacial clefting was estimated to be 10.8 million people, representing a disease burden of 652,084 disability-adjusted life-years, with most of this disease burden experienced by low- and middle-income countries (94.1%). From 1990 to 2017, there was a decrease in disease burden (-70.2%) and prevalence (-4.9%). There was negative logarithmic association between surgical workforce size and disease burden, with a surgical workforce of greater than six providers per 100,000 population (3.6 disability-adjusted life-years versus 22.4 disability-adjusted life-years per 100,000 population; p < 0.0001). CONCLUSIONS: Burden of orofacial clefting has a strong negative association with the size of the surgical workforce, suggesting that strengthening the surgical workforce will help alleviate this burden. Epidemiologic data on countries and regions with inadequate surgical workforces and high disease burden should guide future research efforts and allocation of resources, and guide the treatment and educational goals of international charitable organizations.

The Geographic Availability of Certified Cleft Care in the United States: A National Geospatial Analysis of 1-Hour Access to Care.

PURPOSE: Children with cleft lip and/or palate (CLP) require longitudinal multidisciplinary care. Travel distance to comprehensive cleft centers may be a barrier for some families. This study evaluated the geospatial availability of certified cleft teams across the United States. MATERIALS AND METHODS: A geographic catchment area within a 1-hour travel radius of each American Cleft Palate-Craniofacial Association-certified cleft center was mapped using TravelTime distance matrix programming. The proportion of children located within each catchment area was calculated using county-level data from the National Kids Count Data Center, with aggregate estimates of patients with CLP based on state-level data from the Centers for Disease Control and Prevention. One-hour access was compared across regions and based on urbanization data collected from the US Census. RESULTS: There were 182 American Cleft Palate-Craniofacial Association-certified centers identified. As per study estimates, 28,331 (27.3%) children with CLP did not live within 1-hour travel distance to any center. One-hour access was highest in the Northeast (84.2% of children, P < .001) and lowest in the South (65.7%) and higher in states with the greatest urbanization in comparison with more rural states (85.1 vs 37.4%, P < .001). Similar patterns were seen for access to 2 or more cleft centers. The number of CLP children-per-center was highest in the West (775) and lowest in the Northeast (452). CONCLUSIONS: Travel distances of more than 1 hour may affect more than 25,000 (1 of 4) CLP children in the US, with significant variation across geographic regions. Future studies should seek to understand the impact of and provide strategies for overcoming geographic barriers.

Data analysis of recent cleft lip and palate surgery in Korea using the National Health Insurance Service (NHIS) database.

BACKGROUND: No national epidemiological investigations have been conducted on several aspects of cleft lip and palate surgery. METHODS: The study was performed using the data of 5727 people who underwent cleft lip and palate surgery during the 6-year period from 2013 to 2018 archived by the National Health Information Database (NHID) of the Health Insurance Review and Assessment Service. Disease and operation codes were utilized for the analysis. RESULTS: Most patients underwent surgery during the first 5 years of life. The number of operations per patient remained almost constant during the study period, but hospital costs per patient gradually increased. When hospital costs per patient were subdivided by institution type, they were found to have steadily increased on an annual basis at all types with the exception of hospital .Since 2016, average hospital stay per operation decreased slightly, but the number of outpatient visits tended to increase. CONCLUSIONS: Accessibility to tertiary hospitals has improved and patients increasingly choose to be treated at larger hospitals in metropolitan areas. Furthermore, these tendencies are expected to be maintained. Despite reductions in hospitalization stays, the cost of treatment, including operation costs, have increasing considerably. Changes in the insurance system are required to reduce financial burdens imposed on patients and on the National Health Insurance Service.

Ondansetron in pregnancy revisited: Assessment and pregnancy labelling by the European Medicines Agency (EMA) & Pharmacovigilance Risk Assessment Committee (PRAC).

Ondansetron is an effective antiemetic that is being widely used as a second-line treatment option for severe nausea and vomiting of pregnancy in accordance with clinical guidelines. The safety of ondansetron during pregnancy has-following publication of controversial and seemingly contradictory results-been subject to considerable academic turmoil, specifically with respect to the risk of congenital cardiac malformations and oral cleft. In July 2019, the European Medicines Agency (EMA) Pharmacovigilance Risk Assessment Committee (PRAC) released an updated, comprehensive assessment report on the use of ondansetron in the first trimester. The ensuing Summary of Product Characteristics (SmPC) was updated in November 2019 with important changes to section on "Fertility, pregnancy and lactation." The SmPC now states that ondansetron should not be used in the first trimester of pregnancy. ENTIS, The European Network of Teratology Information Services, believes that the implementation of this regulatory step-which has important clinical consequences-is insufficiently substantiated and is not serving the interest of pregnant women with severe nausea and vomiting. Herein, we discuss the underlying evidence and argue the case against the EMA decision.

Using Virtual Augmented Reality to Remotely Proctor Overseas Surgical Outreach: Building Long-Term International Capacity and Sustainability.

BACKGROUND: Cleft lip affects one in 700 children globally, and the prevalence far surpasses capacity to deliver cleft care in underresourced and endemic regions. A hands-on educational presence is needed to promote overseas surgical autonomy, build overseas capacity, and ensure a sustained clinical and educational infrastructure. The goal of this study was to build and assess an augmented reality educational platform that allows a remote yet virtual interactive presence to transfer cleft surgery knowledge/skills to overseas colleagues. METHODS: A prospective study assessing a 13-month overseas augmented reality-based cleft surgery curriculum was conducted. Three semiannual site visits engaged two Peruvian surgeons in evidence-based didactics, on-site cleft surgery, and familiarization with the augmented reality platform. During 10 remote augmented reality visits, a surgeon stationed in United States guided the same Peruvian surgeons through cleft surgery. Quarterly assessments of the Peruvian surgeons were performed using visual analogue scale questionnaires. RESULTS: Visual analogue scale scores by both the remote and overseas surgeons demonstrated significant, progressive improvement in all facets of cleft lip repair throughout the curriculum. Site visits preferentially built capacity for cleft diagnosis and preoperative counseling (p < 0.001), principles of repair (p < 0.001), repair technique (p < 0.02) and intraoperative decision-making (p < 0.001). Remote sessions preferentially developed understanding of cleft operative design/anthropometry (p < 0.04), cleft anatomy (p < 0.01), and operative efficiency (p < 0.001). At 30-month follow-up, no children with cleft lip required transfer to tertiary care centers. CONCLUSION: A curriculum that combines on-site training and augmented reality-based hands-on remote teaching can build sustained capacity of comprehensive cleft care in underresourced areas.

Development of a valid and reliable instrument for the assessment of quality of life in parents of children with clefts.

PURPOSE: Orofacial clefts are the most common congenital malformations that affect craniofacial structures. Studies show that they have a major influence on psychological development of the patient, and on their families. A review of the literature showed a lack of specific questionnaires for children and their parents. This study investigated the impact of orofacial clefts in children on the quality of life of their parents. In addition, the results of the treatment and the quality of work of the health team members involved in this process were evaluated. MATERIALS AND METHODS: For the purpose of this study, an original questionnaire was made to analyse the effect of orofacial clefts in children who had undergone surgery on the quality of life of 73 of their parents. The questionnaire consisted of 28 simple statements, which were evaluated with a 5-degree Likert scale (from 1-fully disagree to 5-fully agree), did not require any specific additional clarification, and were easy to complete. RESULTS: Analysis of areas of the questionnaire that applied to the parents, resulted in two subscales, parental social health and child social health, which had satisfactory Cronbach's coefficients (0.907 and 0.897, respectively). However, some issues had a relatively poor coefficient of internal consistency, which justified their expulsion from the final model of the parent questionnaire. CONCLUSION: The questionnaire developed for this study comprised two subscales concerned with the social health of parents/respondents and the social health of adolescents, as perceived by the parents. It was a valid and reliable instrument, and it showed satisfactory quality of life for parents of adolescents with clefts.

Incidence and management of cleft lip and palate in Pakistan.

OBJECTIVE: To compare the occurrence, distribution and management of clefts of lip and palate in local patients with the available data from India and China. METHODS: The retrospective study was conducted at the Interdisciplinary Research Centre in Biomedical Materials, COMSATS University Islamabad, Lahore Campus, Lahore, Pakistan, and comprised data related to a three-month period from January to March 2015 at two medical centres in Lahore. Data from Pakistani centres was analysed based on province, gender, age and clefts of lip and palate conditions and Spearman's correlation matrix. RESULTS: Of the 1574 cases, 1061(67.4%) were from Punjab, 361(23%) Khyber Pakhtunkhwa, 85(5%) Sindh and 67(4.2%) were from Azad Jammu and Kashmir. The incidence of clefts of lip and palate was higher in males than females. There was higher awareness of the need for timely management in new borns with clefts of lip and palate. Some patients seeking secondary treatment were also being surgically corrected. There is no national registry of children born with cleft defect, making it difficult to assess the full scale of the problem.. CONCLUSIONS: Based on available data, it is likely that there are many adults who have not been treated when younger..

The Effectiveness of an International Cleft Mission Model in Asia: An Update.

BACKGROUND: Cleft lip/palate is a congenital craniofacial anomaly affecting patients physically and psychosocially and has contributed to the global burden of surgical disease, especially in underprivileged areas. For 20 years, Noordhoff Craniofacial Foundation (NCF) and the Chang Gung Craniofacial Center (CGCFC) have carried out missions to these areas. Rather than implementing short-term missions that lack proper follow-up care, the team has provided an effective, long-term, and multidisciplinary approach for the treatment of patients with cleft lip/palate. In this study, we evaluate the sustainability and effectiveness of the cleft mission model implemented by NCF and CGCFC. METHODS: Data from the years 1998-2017 were retrieved from the NCF database. All local centers were evaluated by a 3-stage categorization, levels 1 to 3, based on 4 criteria: (1) capacity to carry out independent missions, (2) diversity of cleft-care professionals, (3) diversity of surgical service offered, and (4) collaboration with local hospitals. Support and training of personnel were provided based on deficiency in these criteria. Noordhoff Craniofacial Foundation made close collaborations and partnerships with several organizations that shared its mission for comprehensive cleft care in developing countries. RESULTS: In all, 19 partner cleft teams in 9 different countries were established. In coordination with these teams, NCF and CGCFC have treated 1846 patients across 78 mission trips. To date, 158 personnel from 19 different countries have been successfully trained to provide cleft care in local centers. Most partner cleft teams centers have progressively reached category level 3, including those in the Philippines, Cambodia, and Mongolia. CONCLUSIONS: In order to establish and maintain sustainable cleft care in developing regions, commitment and compassion toward those who lack essential resources are necessary. Noordhoff Craniofacial Foundation and CGCFC have achieved a successful and practicable model through seeding medical personnel in order to provide effective and sustainable cleft care to the regions in need.

Assessment of Neurologic Disorders and Rare Intracranial Anomalies Associated With Cleft Lip and Palate.

Accompanying neurologic disorders directly affect psychosocial development of cleft lip and/or cleft palate (CLP) patients and make it difficult for their family to look after them properly. The aim of this study was to investigate the diversity and the incidence of additional neurologic malformations in children with CLP and to evaluate their effects on cleft care. All patients who applied to our Cleft and Craniofacial Center between July 2014 and July 2017 were included in the study. Demographic and perioperative data such as gender, cleft type, syndromic status of the patient, associated neurologic anomalies, timing and duration of operation, hospitalization period, and follow-up period in the intensive care unit are all recorded. All patients received an interdisciplinary evaluation including pediatric neurology specialists in terms of mental and/or motor developmental delay, epilepsy, and other neurologic disorders. After detailed neurologic examination, 83 (3.8%) out of 2190 were reported as having a neurologic defect. The most leading neurologic disorder was found to be mental-motor retardation in 57 children followed by epileptiform disorders detected in 36 children. In 22 patients, rare intracranial pathologies were detected on magnetic resonance imaging. According to our results, having a neurologic pathology increases the need for intensive care unit stay by 5 times in these patients. There was statistically significant relationship between hospitalization period, age of cleft surgery, and neurologic pathologies in these patients. Neurologic disorders could complicate cleft care, cause delays in the planned surgery schedule, and increase perioperative and postoperative morbidity.

Primary Repair in Patients With Unilateral Complete Cleft of Lip and Primary Palate: Assessment of Outcomes.

OBJECTIVE: Asymmetry of median facial structures is a major concern for patients with unilateral cleft lip and palate, and the principal goal of its treatment is to restore symmetry. Unilateral complete cleft of lip and primary palate (UCCLPP) is an uncommon subgroup and rarely reported. Patients with UCCLPP have protruding and deviating premaxilla, rendering a primary repair difficult. This study evaluated consecutive patients with UCCLPP and presented their treatment outcome. METHODS: We assessed 36 patients with UCCLPP and collected clinical information. Surgical repair was performed at 3 months of age by using a modified rotation-advancement method and primary nasal reconstruction. A single surgeon performed all surgical procedures. A postoperative nasal stent was used for 6 months. Follow-up standardized photographs were collected. Landmarks were identified, and nose and lip dimensions measured. The ratios of the corresponding parameters (cleft vs noncleft side) were obtained for evaluating nose and lip symmetry. RESULTS: No surgical complication was noted in any patient. The overall lip and nose outcome after the primary repair were adequate, and all ratios were close to 1. The nostril width was slightly wider on the cleft side, but the alar width and height were acceptable. The lip heights were balanced between the 2 sides. Patients who received presurgical nasoalveolar molding did not show more favorable lip and nose dimensions, except for the medial philtral height. CONCLUSION: Even in the presence of protruding and deviating premaxilla, our patients with UCCLPP obtained adequate lip and nose outcome after undergoing primary lip repair and nasal reconstruction.

From the Editors.

An important theme emerging in health services policy is that an individual's health - or lack of - is often attributable to situations and circumstances far beyond his or her control. We now understand that low levels of education, unemployment, poverty and other socio-economic factors too often also equate with poor health and lower life expectancies. Policy makers seeking to address health inequities will need to look outside of the traditional boundaries of health services to arrive at solutions and strategies to address the issue.

Treatment of Nonsyndromic Cleft Lip and/or Palate in Brazil: Existing Consensus and Legislation, Scope of the Unified Health System, Inconsistencies and Future Perspectives.

Cleft lip and/or palate (CL/P) are the most prevalent craniofacial birth defects in humans, affecting around ten and a half million people across the world and over three hundred thousand in Brazil. Of that, about 70% of the cases occur as a nonsyndromic form, while the remaining 30% are syndromic. In turn, individuals with nonsyndromic CL/P (NSCL/P) often have anatomic deformities involving the lip, alveolar ridge and palate. In this case, the treatments generally require multiple surgeries and various other health interventions throughout childhood, adolescence and adulthood. Another relevant point is that various problems regarding the treatment of NSCL/P in Brazil through the Unified Health System (SUS) have been reported. There are also many inconsistencies in this scenario, including the territorial coverage of healthcare assistance from the craniofacial centres across the country. However, very little data can be found in the scientific literature about the current situation for the treatment of NSCL/P in Brazil. Thus, the present article discusses the existing consensus and legislation, the scope of the SUS, as well as inconsistencies and future perspectives related to the treatment of these craniofacial abnormalities at a national level.