Early Secondary Alveolar Bone Grafting and Facial Growth of Patients with Complete Unilateral Cleft Lip and Palate.

OBJECTIVE: To investigate the craniofacial growth outcomes of early secondary alveolar bone grafting(ABG) around 6 years of age. DESIGN: Retrospective cohort study. SETTING: 1 North-American and 5 Northern-European cleft centers. SUBJECTS: 33 subjects with CUCLP consecutively treated with secondary ABG around 6 years of age were compared to 105 subjects from 4 centers treated with late secondary ABG and 19 subjects from 1 center with primary ABG. METHODS: Preorthodontic standardized lateral cephalometric radiographs taken after 12 years of age were traced and analyzed according to the Eurocleft Study protocol. Fourteen angular and two proportional measurements were performed. Measurement means from the Study Center(SC) were compared to 5 Northern-European centers using analysis of variance and Welch's modified t-tests, and P < .05 was considered statistically significant. RESULTS: For the SC, the mean age ± SD at the time of bone graft was 5.85 ± 0.71 years and the mean age at the time of the lateral cephalogram was 13.4 ± 1.8 years. The sagittal maxillary prominence of the SC was favorably comparable to the 5 Northern-European centers. The mean SNA (78.1 ± 4.3) for the SC was significantly higher compared to 4 of the 5 Northern-European centers(all P < .05), and the mean ANB angle was comparable to 4 of the 5 centers. Similarly, the mean soft tissue ANB angle was not significantly different to the 5 centers. The soft tissue vertical proportions compared favorably to all 5 Northern-European centers(all P < .01). CONCLUSIONS: Craniofacial growth outcomes of early secondary ABG around 6 years compare favorably to the outcomes of late secondary ABG.

Facial Growth of Patients With Complete Unilateral Cleft Lip and Palate Treated With Alveolar Bone Grafting at 6 Years.

OBJECTIVE: To investigate the effect that alveolar bone grafting (ABG) around 6 years of age has on facial growth by assessing craniofacial growth outcomes. DESIGN: Retrospective cohort study. SETTING: North American cleft centers. PARTICIPANTS: A total of 33 children with complete unilateral cleft lip and palate who were consecutively treated with secondary ABG around 6 years of age were compared to 148 participants from 4 centers with late secondary ABG. METHODS: Preorthodontic standardized lateral cephalometric radiographs were analyzed and traced according to the Americleft Study protocol. Sixteen angular and 2 proportional measurements were performed. The outcomes of all ABG were assessed using the Standardized Way to Assess Graft scale. Measurement means from the study center (SC) were compared to 4 North American centers using analysis of variance and Welch modified t tests, and P < .05 was considered statistically significant. RESULTS: For the SC, the mean age (SD) at the time of bone graft was 5.85 (0.71) years and the mean age at the time of the lateral cephalogram was 13.4 (1.8) years. The sagittal maxillary prominence of the SC was comparable to the 4 other centers. The mean SNA (78.1 [4.3]) for the SC was significantly higher compared to one center that used primary bone grafting ( P = .03). The soft tissue mean ANB (3.52 [4.09]) for the SC was significantly lower compared to 3 of the centers. CONCLUSIONS: Early secondary ABG around 6 years of age did not result in reduced midface projection as assessed by SNA and thus did not compromise anterior maxillary growth.

Active Presurgical Infant Orthopedics for Unilateral Cleft Lip and Palate: Intercenter Outcome Comparison of Latham, Modified McNeil, and Nasoalveolar Molding.

OBJECTIVE: To compare dental arch relationship, craniofacial form, and nasolabial aesthetic outcomes among cleft centers using distinct methods of presurgical infant orthopedics (PSIO). DESIGN: Retrospective cohort study. SETTING: Four cleft centers in North America. PATIENTS: One hundred ninety-one children with repaired complete unilateral cleft lip and palate (CUCLP). MAIN OUTCOME MEASURES: Dental arch relationship was assessed using the GOSLON Yardstick. Craniofacial form was assessed by 12 cephalometric measurements. Nasolabial aesthetics were assessed using the Asher-McDade system. Assessments were performed between 6 and 12 years of age. RESULTS: The center that used no PSIO achieved the most favorable dental arch relationship and maxillomandibular relationship, with a median GOSLON score of 2.3 ( P < .01) and an ANB angle of 5.1° ( P < .05). The proportion of children assigned a GOSLON score of 4 or 5, predictive of the need for orthognathic surgery in adolescence, was 16% at the center that used no PSIO and no secondary surgery, compared to 76% at the centers that used the Latham appliance and early secondary lip and nose surgery ( P < .01). The center that used no PSIO and no secondary surgery achieved significantly less favorable nasolabial aesthetic outcomes than the centers using Latham appliance or nasoalveolar molding (NAM) ( P < .01). CONCLUSIONS: Effects of active PSIO are multifaceted and intertwined with use of revision surgery. In our study, centers using either the Latham appliance combined with early revision surgery or the NAM appliance without revision surgery achieved better nasolabial aesthetic outcomes but worse maxillary growth, compared to a center using no PSIO and secondary surgery.

The Americleft Project: Plaster Dental Casts Versus Digital Images for GOSLON Yardstick Ratings When Used in Intercenter Comparisons.

The purpose of this investigation was to determine reliability and validity of GOSLON Yardstick ratings using plaster casts versus photo galleries of digital images in actual intercenter comparisons. The dental arch relationships of 112 patients with complete unilateral cleft lip and palate from 3 North American cleft/craniofacial centers were rated in 2 separate studies. In the first, plaster casts were used. For a later intercenter comparison, the same dental casts were scanned, digital bases added, and two-dimensional photographic galleries (6 views) were created for each set of casts. Three raters experienced with the GOSLON Yardstick carried out 2 separate ratings of the plaster casts in the first study, then of the photographic gallery of scanned digital images of the same casts in the second study. Inter- and intrarater reliabilities were calculated using the Weighted Kappa statistic. Average scores for each patient were calculated and compared between methods with correlation statistics and a Bland-Altman plot. Kruskal-Wallis test was used to compare results between centers using both media. Reliability using both methods was very good and comparable between methods. Mean weighted Kappas were: inter-rater = 0.815 (plaster) versus 0.891 (photo); and intrarater = 0.866 (plaster) versus 0.891 (photo). There was a highly significant correlation (r = 0.920). Mean difference between centers was 0.033 of a GOSLON category. The level of significance of the differences found between centers with both methods was identical, confirming the interchangeability of both media presentations.

The Americleft Project: A Modification of Asher-McDade Method for Rating Nasolabial Esthetics in Patients With Unilateral Cleft Lip and Palate Using Q-sort.

The purpose of this study was to investigate ways to improve rater reliability and satisfaction in nasolabial esthetic evaluations of patients with complete unilateral cleft lip and palate (UCLP), by modifying the Asher-McDade method with use of Q-sort methodology. Blinded ratings of cropped photographs of one hundred forty-nine 5- to 7-year-old consecutively treated patients with complete UCLP from 4 different centers were used in a rating of frontal and profile nasolabial esthetic outcomes by 6 judges involved in the Americleft Project's intercenter outcome comparisons. Four judges rated in previous studies using the original Asher-McDade approach. For the Q-sort modification, rather than projection of images, each judge had cards with frontal and profile photographs of each patient and rated them on a scale of 1 to 5 for vermillion border, nasolabial frontal, and profile, using the Q-sort method with placement of cards into categories 1 to 5. Inter- and intrarater reliabilities were calculated using the Weighted Kappa (95% confidence interval). For 4 raters, the reliabilities were compared with those in previous studies. There was no significant improvement in inter-rater reliabilities using the new method. Intrarater reliability consistently improved. All raters preferred the Q-sort method with rating cards rather than a PowerPoint of photos, which improved internal consistency in rating compared to previous studies using the original Asher-McDade method. All raters preferred this method because of the ability to continuously compare photos and adjust relative ratings between patients.

The Americleft Project: Burden of Care from Secondary Surgery.

BACKGROUND: The burden of care for children with cleft lip and palate extends beyond primary repair. Children may undergo multiple secondary surgeries to improve appearance or speech. The purpose of this study was to compare the use of secondary surgery between cleft centers. METHODS: This retrospective cohort study included 130 children with complete unilateral cleft lip and palate treated consecutively at 4 cleft centers in North America. Data were collected on all lip, palate, and nasal surgeries. Nasolabial appearance was rated by a panel of judges using the Asher-McDade scale. Risk of secondary surgery was compared between centers using the log-rank test, and hazard ratios estimated with a Cox proportional hazards model. RESULTS: Median follow-up was 18 years (interquartile range, 15-19). There were significant differences among centers in the risks of secondary lip surgery (P < 0.001) and secondary rhinoplasty (P < 0.001). The cumulative risk of secondary lip surgery by 10 years of age ranged from 5% to 60% among centers. The cumulative risk of secondary rhinoplasty by 20 years of age ranged from 47% to 79% among centers. No significant differences in nasolabial appearance were found between children who underwent secondary lip or nasal surgery and children who underwent only primary surgery (P > 0.10). CONCLUSIONS: Although some cleft centers were significantly more likely to perform secondary surgery, the use of secondary surgery did not achieve significantly better nasolabial appearance than what was achieved by children who underwent only primary surgery.

Mesiodens--diagnosis and management of a common supernumerary tooth.

Mesiodentes are the most common supernumerary teeth, occurring in 0.15% to 1.9% of the population. Given this high frequency, the general dentist should be knowledgeable about the signs and symptoms of mesiodentes and appropriate treatment. The cause of mesiodentes is not fully understood, although proliferation of the dental lamina and genetic factors have been implicated. Mesiodentes can cause delayed or ectopic eruption of the permanent incisors, which can further alter occlusion and appearance. It is therefore important for the clinician to diagnose a mesiodens early in development to allow for optimal yet minimal treatment. Treatment options may include surgical extraction of the mesiodens. If the permanent teeth do not erupt in a reasonable period after the extraction, surgical exposure and orthodontic treatment may be required to ensure eruption and proper alignment of the teeth. In some instances, fixed orthodontic therapy is also required to create sufficient arch space before eruption and alignment of the incisor(s). Early diagnosis allows the most appropriate treatment, often reducing the extent of surgery, orthodontic treatment and possible complications. This paper outlines the causes and modes of presentation of mesiodentes, and presents guidelines for diagnosis and management of nonsyndromic mesiodentes.

Canine eruption in patients with complete cleft lip and palate.

OBJECTIVE: To describe erupting maxillary canine positions in patients with bone-grafted alveolar clefts. SAMPLE: The sample consisted of 101 cleft sites from patients with complete unilateral or bilateral cleft lip and palate who had early (< or =9 years) or late (>9 years) secondary alveolar bone grafts. METHODS: Canine position was assessed using panoramic radiographs taken before and after alveolar bone grafts. Vertical canine positions were assessed using the long axis of the maxillary permanent canine relative to a 90 degrees vertical reference line. Lateral canine positions were defined using the relationship between the canine tip and the midplane of the lateral incisor root. Anomalous lateral incisors were recorded. Statistical analysis included Student's t tests and chi-square tests. RESULTS: Patients with alveolar clefts had a 20-fold increased risk for canine impaction, based on erupting canine positions. Abnormal vertical canine positions decreased following early and late alveolar bone grafts (p < .05), whereas abnormal lateral canine positions increased following late alveolar bone grafts (p < .01). Of the cleft sites with altered canine positions, 61% also had a lateral incisor anomaly. Based on canine position, the non-cleft-side canine had the same risk for impaction as the cleft-side canine. CONCLUSIONS: Patients with alveolar clefts have a significantly higher risk for canine impaction compared with patients without clefts. Timing of alveolar bone grafts and lateral incisor anomalies influenced the risk for canine impaction. An alveolar bone graft should be planned in accordance with maxillofacial development, including the eruption of teeth adjacent to the cleft.

A population-based evaluation of antenatal diagnosis of orofacial clefts.

OBJECTIVES: To evaluate the changes in prevalence and antenatal detection of cleft lip with or without cleft palate and isolated cleft palate and to describe the association between anomalies and rates of antenatal diagnosis in Nova Scotia from 1992 to 2002. DESIGN: This population-based cohort study employed the Nova Scotia Atlee Perinatal Database, the Fetal Anomaly Database, and IWK Cleft Palate Database in Halifax, Nova Scotia, Canada. OUTCOME MEASURES: Cleft type, mode of diagnosis, and associated abnormalities of orofacial clefts for liveborn infants, stillbirths, and second trimester terminations of pregnancy between 1992 and 2002 were determined. RESULTS: There were 225 fetuses identified as having orofacial clefts. The overall prevalence of clefts was 2.1 in 1000 live births, and this prevalence did not change with time. The overall antenatal detection of cleft lip with or without cleft palate was 23%; however, there was improvement in detection of cleft lip with or without cleft palate from the years 1992 to 1996 (14%) to the years 1997 to 2002 (30%, p = .02). No isolated cleft palates were detected antenatally. Associated structural anomalies were seen in 34.2% of cases with orofacial clefts, and chromosomal abnormalities were associated with 9.8%. CONCLUSIONS: The prevalence of orofacial clefts in Nova Scotia has not changed from 1992 to 2002. The proportion of antenatally diagnosed cleft lip with or without cleft palate in Nova Scotia is consistent with rates reported in the literature and has increased from 1992 to 2002.