Margareta Larson

Dental abnormalities and ectopic eruption in patients with isolated cleft palate

The aim of this study was to evaluate the influence of cleft size and surgical treatment on the development of permanent teeth in patients with isolated cleft palate. The series comprised 109 children with isolated cleft palate, 70 girls and 39 boys, including 14 patients with Robin sequence. The patients were grouped according to the sagittal extent of the palatal cleft, measured on dental casts obtained before the primary palate surgery. Forty-six children were treated by one-stage palatoplasty, and 63 in two stages. The dentition was studied on orthopantomograms taken at 5, 8, 11, and 14 years of age. Congenitally missing permanent teeth (third molars excluded) were found in 33 subjects (30%). Children with large clefts had significantly more missing teeth than children with small clefts. The tooth most usually missing was the mandibular second premolar, followed by the maxillary lateral incisor, and the upper second premolar. The incidence of dental malformation was 23%, mostly mild forms. Ectopic eruption of the upper first permanent molars was seen in 23 (45%) of the subjects with large clefts, and in 18 (31%) of those with small clefts. The surgical method did not significantly affect the direction of the eruption. There is a correlation between cleft size and hypodontia, dental deformity, and ectopic eruption. Children with Robin sequence had almost the same incidence of hypodontia, malformed teeth, and ectopic eruption as children with large clefts. There was no correlation between surgical method and ectopic eruption of the maxillary first permanent molars.

Dental Occlusion After Veau-Wardill-Kilner Versus Minimal Incision Technique Repair of Isolated Clefts of the Hard and Soft Palate

OBJECTIVEnTo compare the Veau-Wardill-Kilner technique with a technique similar to the minimal incision technique described by Mendosa et al. on the basis of surgical complications and dentoalveolar status in the deciduous dentition.nnnDESIGNnRetrospective study of medical and dental records and casts.nnnPATIENTSnA consecutive series of 129 Caucasian children born with isolated cleft palate between 1980 and 1992.nnnMAIN OUTCOME MEASURESnFrom medical records, the variables of time for surgery, blood loss, complications in the immediate postoperative period, and frequency of fistulas were evaluated. On dental casts, the variables of sagittal, transversal, and vertical relations; structure of the palatal mucosa; and height of the palatal vault were studied.nnnRESULTSnTime for surgery was shorter in the extensive clefts repaired with a Veau-Wardill-Kilner technique. Blood loss was higher using the Veau-Wardill-Kilner technique. The width of the upper jaw was significantly narrower in the Veau-Wardill-Kilner group, compared with the minimal incision group. Scar tissue and pits of the palate were more frequently found in the Veau-Wardill-Kilner group.nnnCONCLUSIONSnThe minimal incision technique in this study has been shown to result in better development of the upper jaw with a better dental occlusion and palatal mucosa with significantly less scar tissue.

Classification, recording, and cleft palate surgery at the Uppsala Cleft Palate Centre.

This paper describes the classification system, method of recording, and surgical techniques used in Uppsala for children with isolated cleft palate. The classification is based on the system described by Kernahan and Stark and the more detailed system described by the American Cleft Palate Association. Separation of the hard palate into thirds, and into right and left sides, assures a detailed description of the cleft, and separates small morphological differences. The longitudinal registration system was introduced into the Uppsala Cleft Palate Centre in 1967. After the initial recording at the time of primary surgery, it is repeated at 5, 8, 11, 14, 17, and 20 years. By emphasising the therapeutic aspects of various stages of growth, it has been possible to limit the recording to once every third year. This has resulted in an important reduction in the dose of radiation without compromising the reliability of the results. Children born before 1975 had clefts of both the soft and hard palate closed at 18-24 months in a one-stage procedure. For children born in 1975 and later a two stage technique has been used, while clefts limited to the soft palate only have been closed entirely in the first operation. At first, the soft palate cleft was closed at 18 months of age and the hard palate at 4 to 5 years. The timing was changed in several steps to the present soft palate closure at 6 months and hard palate closure at 2 years of age.

Morphologic effect of preoperative maxillofacial orthopedics (T-traction) on the maxilla in unilateral cleft lip and palate patients.

Sixty-eight children born with complete unilateral cleft lip and palate were studied using dental casts taken at ages 0-0.1; 0.2-0.4; and 0.5-0.6 years of age. They were all treated with preoperative maxillofacial orthopedics using an external device (T-traction). The treatment was started after the first model was taken. Dental casts were analyzed regarding the morphology of the cleft region and the maxillary segments before and after treatment. The measurements were compared with measurements on dental casts of nontreated cleft children of similar age. The results suggest that a more normal anatomy of the cleft region occurs during the first 6 months of life whether preoperative maxillofacial orthopedics (T-traction) is used or not. However, this normalized growth seems to occur faster with the T-traction.

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

Abstract 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.

Morphology of isolated cleft palate in children, including robin sequence, treated with one or two-stage operations

A classification developed at the Uppsala Cleft Palate Centre was used to describe isolated cleft palate in children with and without Robin sequence. The study included 109 patients born between 1968 and 1983 with isolated cleft palate. In 46 patients the cleft was closed in a single operation and 63 were treated by a two-stage procedure. Of the 109 patients 70 (64%) were girls. In 19 patients (17%), the cleft was limited to the soft palate. Ninety of the patients had clefts of the hard palate and in 39 (43%) of these patients the clefts involved less than a third of the hard palate. Only four children (4%) had total clefts of both the hard and soft palate. The Robin sequence was diagnosed in 14 children (13%), and it was more common in boys with isolated cleft palate (7/39; 18%) than in girls (7/70; 10%). In those with Robin sequence the cleft was U-shaped anteriorly in nine (64%), with great variations in width. Generally, however, the clefts were wider than other clefts involving the hard palate. In all cases, closure of the soft palate was followed by a spontaneous reduction in the width of the remaining cleft in the hard palate. The greatest improvement was noted in subjects with the U-shaped clefts, in whom the position of the tongue probably had the greatest influence on the development of wide primary clefts. In 10 subjects with clefts of the soft palate only and 12 patients in whom the cleft included part of the hard palate (35%), only the first operation of the two-stage procedure was done because there was no residual cleft. In these subjects the original cleft had involved less than a third of the length of the hard palate.

The influence of the initial width of the cleft in patients with unilateral cleft lip and palate related to final treatment outcome in the maxilla at 17 years of age

The aim of this study was to assess whether the initial cleft width in patients born with complete unilateral cleft lip and palate (UCLP), is correlated to final treatment outcome regarding maxillary growth. This report is a retrospective longitudinal cohort study of 45 consecutive non-syndromic individuals with UCLP, 19 from the Stockholm Cleft Team, and 26 from the Oslo Cleft Team. The treatment protocols in the two teams differed. The initial transversal width in infants was measured at three levels on study casts. The width was correlated to variables obtained from lateral cephalograms at 17 years of age, from rating of dental arch relationship and to treatment variables obtained from the medical records: existence of Simonarts band, missing maxillary teeth, duration of orthopaedic/orthodontic treatment, and the need for orthognathic surgery. The initial width of the middle part of the cleft and final maxillary inclination (NSL/NL) showed a weak correlation (P < 0.05); the wider the cleft, the less the inclination. No further correlations were found between the initial width and final outcome measurements studied. In the Oslo group where Simonarts band was present, the anterior and middle widths of the cleft were significantly smaller (P < 0.001). Additionally, the existence of Simonarts band had a significant effect on final maxillary inclination (P < 0.05), i.e. the maxillary inclination increased. Treatment outcome seems mainly to depend on the treatment protocol performed rather than the severity of the cleft. The width of the middle part of cleft may be associated with the final maxillary inclination.

Length of the cleft in relation to the incidence of hypodontia of the second premolar and to inheritance of cleft lip and palate in children with isolated cleft palate

We studied severity of the isolated cleft palate expressed as the length of the cleft in relation to hypodontia in the second premolar regions and known inheritance of any type of cleft lip and palate. The material consisted of 47 children at 10 years of age born with non-syndromic isolated cleft palate of varying extent, who all had hypodontia of at least one second premolar, and had panoramic radiographs taken at 10 years of age. Information about length of cleft and inheritance of cleft lip and palate was collected from surgical files initiated at birth. The higher the number of missing second premolars, the more extended was the length of the cleft. More children had hypodontia of the second premolar in the mandible than in the maxilla. The family history had little influence on the length of the cleft.

Facial Growth at 5 and 10 Years After Veau-Wardill-Kilner Versus Minimal-Incision Technique Repair of Isolated Cleft Palate

Objective: To compare the Veau-Wardill-Kilner technique with the Minimal-Incision technique repair of isolated clefts of the hard and soft palate regarding facial growth at 5 and 10 years of age. Design: Retrospective study of lateral cephalograms. Setting: Hospital and university based. Patients: A consecutive series of 145 Caucasian nonsyndromic children born with isolated cleft palate between 1980 and 1996 were studied. Children with Pierre Robin sequence (PRS) were included in the study. The patients were divided into 4 groups: 2 groups regarding surgical technique and 2 groups regarding cleft length. Intervention: Veau-Wardill-Kilner or Minimal-Incision palatoplasty. Main Outcome Measures: Eleven skeletal and 1 soft tissue measurement were evaluated from lateral cephalograms taken at 5 and 10 years of age. Results: Only minor differences in cephalometric morphology were found between the Veau-Wardill-Kilner technique group and the Minimal-Incision technique group. Similar results were found independent of cleft length or the inclusion of PRS in the sample. Conclusion: The craniofacial cephalometric morphology at 5 and 10 years of age in patients with isolated cleft palate is similar between the Veau-Wardill-Kilner and the Minimal-Incision technique group.

Minimal incision palatoplasty with or without muscle reconstruction in patients with isolated cleft palate: a cast and medical records analysis

ObjectivesnTo compare the minimal incision (MI) technique with the minimal incision including muscle reconstruction (MMI) technique regarding surgical complications and dentoalveolar status at 5 years of age.nnnSubjects and methodnA consecutive series of 202 Caucasian non-syndromic children (apart from Pierre Robin Sequence) born with isolated cleft palate between 1987 and 2007 and treated with MI (n = 78) or MMI (n = 102) palatoplasty at a mean age of 12.7 (SD = 1.43) months in Stockholm. Twenty-two patients did not fulfill the inclusion criteria. The patients were divided into two subgroups: clefts within the soft palate only (small cleft, n = 50) and clefts within the hard and soft palate (big cleft, n = 130). Dental relations, structure of the palatal mucosa, and height of the palatal vault at 5 (mean age 5.3, range: 4.4-6.9) years of age were studied using plaster models. Time for surgery, blood loss, complications in the immediate postoperative period, frequency of fistulas, and additional pharyngeal flap surgery were evaluated. Students t-test, chi-square test and 95 per cent confidence intervals were calculated.nnnResultsnMMI compared to MI technique result in statistically significant increased operation time, less need for pharyngeal flap surgery, and to shallower palatal vault. Big clefts result in statistically significant increased operation time and need for pharyngeal flap surgery. Dental relations were the same in all groups.nnnLimitationsnRetrospective single centre study, limited sample size, more than one surgeon.nnnConclusionsnThe muscle reconstruction results in a reduced subsequent need for pharyngeal flap surgery, but to shallower palatal vault and demand for almost double operation time. The dental relations were the same in all groups.