Nikki Atack

A comparison of three methods of repairing the hard palate.

OBJECTIVE To compare growth, speech, and nasal symmetry outcomes of three methods of hard palate repair. PATIENTS Consecutive available records of children born with unilateral bony complete cleft lip and palate over the period 1972 to 1992. INTERVENTIONS Identical management of lip, nose, alveolus, and soft palate. Hard palate repair by Cuthbert Veau (CV) from 1972 to 1981, von Langenbeck (vL) from 1982 to 1989, or medial Langenbeck (ML) from 1989 to 1991. OUTCOME MEASURES For growth: GOSLON yardstick or 5-year model index. For speech: articulation test. Nasal anemometry. For nasal symmetry: Coghlan computer-based assessment. All these measures were developed during the period of data collection but not for this project. RESULTS There was a strong trend toward more favorable anteroposterior maxillary growth with the change from CV to vL to ML techniques. This fell short of statistical significance because of the small sample size. There was a significant reduction in cleft-related articulation faults (p =.01) considered to be related to improved arch form. In the absence of improved rates of velopharyngeal insufficiency or nasal symmetry, increased surgical experience was discounted as a significant contribution to improved growth and articulation outcomes. CONCLUSIONS Reduced periosteal undermining and residual exposed palatal shelf from CV to vL to ML improved incisor relationships and articulation.

Dentoalveolar relations in children born with a unilateral cleft lip and palate (UCLP) in Western Australia.

OBJECTIVE Our objective was to evaluate complete unilateral cleft lip and palate repair outcome in the Cleft Unit in Perth, Western Australia, by assessment of dentoalveolar relationships. DESIGN This is a retrospective study. SETTING Our subjects were individuals under the care of the cleft team in Perth, Western Australia. PARTICIPANTS All patients with unilateral cleft lip and palate and available 6-year casts who had been born since January 1, 1985, were identified from the cleft units database. The nature of the cleft was verified by examination of birth study models and photographs. A total of 54 such patients were identified. MAIN OUTCOME MEASURES Main outcome measures were identified through dental arch relationship grading of study models using the 5 Year Old Study Model Index. RESULTS Interexaminer and intraexaminer agreement kappa statistics revealed good to very good agreement using this index. The results indicate that the surgical outcome was graded as excellent, good, or fair for 77% of patients and poor or very poor for 23% of patients. CONCLUSIONS The results of the Western Australia study compare favorably to the overall U.K. outcome (the Clinical Standards Advisory Group study) but unfavorably to the results of some European centers, such as Oslo.

Which Way Forward? Fixed or Removable Lower Retainers

OBJECTIVE To determine whether lower lingual, canine to canine, bonded multistrand retainers prevent relapse of lower labial segment alignment following fixed appliance therapy and to compare this with lower Hawley-type removable retainers. MATERIALS AND METHODS Two groups of 29 patients were identified. Group 1 had bonded lower canine to canine multistrand retainers placed following debonding, whereas Group 2 had lower Hawley-type retainers (with acrylic labial to the incisors) fitted following debonding. Study models were taken of all patients at debonding (T(1)) and at least 1 year post debonding (T(2)). Changes in Littles index over the study period were recorded using a reflex microscope. RESULTS Statistically significant changes in Littles index occurred in the lower labial segment of both study groups (P = .001) over the observation period. There was no statistically significant difference in the amount of change in Littles index between the bonded and removable retainer groups (P = .13). Bonded retainers tended to be placed in older patients (P = .02). CONCLUSIONS Relapse can occur in the lower labial segment with both fixed and removable retainers. The amount of relapse seen with both types of retainer is not statistically significantly different.

A review of outcome measures used in cleft care

This article provides a summary of the main outcome measures currently available and in use within modern cleft care. The fact that there are such a diverse range, including surgical, orthodontic, dental, speech and patient satisfaction measures, is a reflection of the complex, multidisciplinary and longitudinal nature of the care provided. The use of such measures of outcome is essential in the auditing and drive for continued improvements in the standards of care for patients affected with cleft lip and palate.

Early surgical outcomes in 5-year-old patients with repaired unilateral cleft lip and palate.

Objective: To assess the surgical outcome of 5-year-old subjects with repaired unilateral cleft lip and palate who had been operated on by a single surgeon. Design: Retrospective consecutive outcome study. Setting: The cleft lip and palate center at Frenchay Hospital, North Bristol NHS Trust, U.K. Participants: All patients born with unilateral cleft lip and palate between May 1992 and April 1998 were identified and their study models were located. Main Outcome Measures: The reasons for failing to obtain study models were recorded. The “test” study models were combined randomly with a “gold standard” set of study models to give a group of 53 for assessment purposes. These study models were assessed twice by two examiners independently using the 5-Year-Olds’ Index. The weighted kappa (κ) statistic and components of variance were used to establish the levels of agreement within and between examiners, as well as between the gold standard and the examiners. Results: Thirty sets of study models out of a possible 43 were located. The most common reason for not obtaining records was poor cooperation. More than 50% of study models were assessed as being good outcomes (Index groups 1 and 2), whereas fewer than 20% of the records were evaluated as being poor outcomes (Index groups 4 and 5). There was good inter- and intraexaminer agreement and agreement with the gold standard values. Conclusion: Study model collection in this age group can be difficult due to patient cooperation.

Outcome Measures in UCLP: The Modified 5-Year-Olds’-Index—Development and Reliability

Objective: Can we reliably discriminate severity within the existing categories of the 5-Year-Olds’ Index? Design: Retrospective method comparison and development study. Setting: School of Oral and Dental Science, University of Bristol. Methods: Dental study models of 5-year-olds with unilateral cleft lip and palate (UCLP) were collected from the archives of 2 national cleft surveys (n = 351). One hundred randomly selected models were ranked to construct the modified 5-Year-Olds’ Index and also scored using a visual analogue scale (VAS). Reliability testing was performed on 51 study models. Visual analogue scale scores were used to aid statistical analysis and investigate the reliability of a VAS for outcome measurement. The modified 5-Year-Olds’ Index was then applied to 198 study models of 5-year-olds with UCLP. Results: The modified 5-Year-Olds’ Index showed excellent intra and interexaminer agreement (intraclass correlation > 0.94) and good discrimination of severity. When applied to the Cleft Care UK participants (n = 198), the modified 5-Year-Olds’ Index showed good discrimination of severity within the better categories (groups 1-3) of the 5-Year-Olds’ Index. Visual analogue Scale scores resulted in unacceptable variation between measurements. Conclusions: The new modified 5-Year-Olds’ Index is a reliable method of assessing outcomes at 5 years of age and showed improved discriminatory power between the “better” outcome categories than the original 5-Year-Olds’ Index. A VAS was found to be unsuitable for assessing outcome at 5 years of age for children with UCLP.