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Scientific Section |
1 Eastman Dental Institute for Oral Health Care Sciences, London, UK
2 Mount Vernon Hospital, Middlesex, UK
3 University Dental Hospital of Manchester, Manchester, UK
Correspondence: Maren J. Gaukroger, Eastman Dental Institute for Oral Health Care Sciences, University College London, 256 Gray's Inn Road, London WC1X 8LD, UK. E-mail: mjgaukroger{at}hotmail.com.
Abstract
Aim: To examine whether the treatment provided by the Mount Vernon Cleft Team produces craniofacial growth outcomes comparable with that of the Oslo Team.
Location: Mount Vernon Hospital, Middlesex, UK.
Design: A retrospective cephalometric investigation.
Subjects: Seventy-five Mount Vernon children and 150 Oslo children with complete unilateral or bilateral clefts of the lip and palate
Method: The subjects were matched for age, gender, and cleft type, and their radiographs were digitized. The radiographs from each site were grouped according to patient age (9–11 or 14–16) and cleft classification (bilateral/unilateral). Patients with associated craniofacial anomalies were excluded from the study.
Results: Of the four variables studied (SNA, SNPg, NGn, sNANsPG) significant differences in maxillary growth were noted for bilateral and unilateral cleft groups at 14–16 years of age. The soft tissue profile was significantly flatter in bilateral and unilateral Mount Vernon cases at 14–16 years. The craniofacial growth exhibited by the Mount Vernon patients demonstrated 3.9–5.1 degrees reduction in maxillary prominence with respect to the Oslo sample. The bilateral cases from Mount Vernon had greater anterior face heights at 14–16 years.
Conclusion: The treatment provided by the Mount Vernon Cleft team leads to a reduced maxillary prominence in children aged 14–16 years compared with the Oslo sample. This reduction is statistically significant in unilateral cleft lip and palate.
Key words: Cephalometry, inter-centre comparison, treatment outcome, unilateral and bilateral complete cleft lip and palate
Introduction
It has been documented that children with repaired complete clefts of the lip and palate suffer adverse maxillary growth.1
It appears that scarring produced by the primary surgical repair is a major aetiological factor.2 Whatever the mechanism growth impairment becomes progressively apparent as patients reach maturity.3 The Clinical Standards Advisory Group (CSAG), reported that compared with some centres in Europe, many aspects of cleft care in the UK are inadequate.4 The Report suggested that there should be a common database made available for comparative audit studies on all cleft patients. Difficulties arise in comparing growth from samples of cases described in the literature, treated by different methods, due to potential biases. Thus, randomized controlled trials are the ideal in terms of research for comparing specific clinical methods. However, for obtaining an impression of the outcome of the overall package of care, including surgical protocols and proficiency, retrospective inter-centre studies are considered to be acceptable, providing certain criteria are met.5 This study aims to compare the craniofacial growth of patients with unilateral and bilateral cleft lip and palate treated at Mount Vernon Hospital, Middlesex and Rikshospitalet, Oslo, Norway. It examines the hypothesis that craniofacial growth outcomes for children treated at the two centres are the same.
Materials and method
The study groups consisted of 150 patients with unilateral complete cleft lip and palate (UCLP), 50 from Mount Vernon and 100 from Oslo, and 75 patients with bilateral complete cleft lip and palate (BCLP), 25 from Mount Vernon and 50 from Oslo. Children with associated craniofacial anomalies were excluded from the study. Those with incomplete clefts and radiographs of poor quality were also excluded. The patients were divided into two groups aged 9–11 and 14–16 years. The Oslo and Mount Vernon Groups were matched for age, gender, and cleft type, and a description of the material is presented in Table 1. The resultant small numbers in the bilateral group decrease the power of the statistical comparisons. For this reason double matching was undertaken.
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The Mount Vernon protocol
Pre-surgical orthopaedics was not employed at Mount Vernon, but in babies with wider clefts a reduction in cleft width was encouraged using neonatal lip adhesion. This technique was introduced to the protocol in the late 1980s and has therefore been employed in some of the 10-year-old children studied. Patients with UCLP then had lip closure with the Millard approach and a vomer flap prior to 3 months of age.
Patients with BCLP also had lip adhesion where clefts were wide, followed by straight-line closure and vomer flap. The posterior palate was closed at 4–12 months using the Wardill–Kilner pushback. Alveolar bone grafting was undertaken prior to completion of root formation of the maxillary canines. At Mount Vernon too, secondary surgery was undertaken on an individual basis.
Oslo was chosen as the reference centre because it has a large database, which meant that double matching could be undertaken. This study design would increase the statistical power of the comparison.6 A total of 50 unilateral cleft children were analysed and comparisons made with 100 Oslo children. A group of 25 bilateral cleft children were analysed and compared with 50 Oslo views. The landmarks used were the following:
For linear measurements the distance measured was divided by the magnification factor for each unit to allow direct comparison. All cephalograms were digitized by one individual (MJG).
Forty radiographs were digitized a second time 2 weeks later to enable the cephalometric measurement error of the operator to be calculated (Table 2).
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Results.
Student t-tests were used to compare the two samples. The results as mean values, standard deviations, confidence intervals, and P-values are tabulated in Tables 3–6.
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Discussion
Clinical audit in cleft care should ideally include the inter-related outcomes of facial growth, nasolabial appearance, dental arch relationships, speech, hearing, and burden of care, and can be achieved in a number of ways:
17. To some extent this approach allows prospective planning for standardized record collection and blinded panel analysis to minimize analysis bias. 18 and as proposed in the establishment of a European reference archive.19 This study has analysed the practice of one cleft centre over a 20 year period under the care of one cleft team. The numbers reported are small despite the fact that the centre has been one of the busier cleft units in the UK, and has had an organized and committed team approach for many years. The collection of longitudinal data, however, requires extreme rigour and depends not only on the cleft team members, but also on other members of staff, such as dental technicians, secretaries, and others involved in the storage and filing of information within a hospital. These difficulties, together with patients and their families moving area during the long treatment period, makes record collection extremely difficult. The Oslo cohort was chosen as this represents a centre with an established database that has been used in a number of previous inter-centre comparisons.
The Mount Vernon cohort was assessed for facial growth at ten and fifteen years of age as this relates to the recommendations made by the Clinical Standards Advisory Group (CSAG) for milestone records.
As in the present study, the retrusive maxilla of UK patients compared with those of some other North European centres has been observed before.4,6,13,18,21,22 In this study the differences may be attributable to the earlier timing of surgery or to differences in surgical protocol, i.e. the use of the Wardill–Kilner pushback. The maxillary prominence of the 10-year-old Mount Vernon children compares well with the Bristol UCLP patients of the same age.18 It has also been suggested that there are differences in the craniofacial growth of Norwegian and British children.23
Conclusions
The results demonstrated in this study show that there are no significant differences in facial profile and A–P position of the maxilla or mandible as measured on lateral cephalograms for either unilateral or bilateral cleft lip and palate patients between the Mount Vernon sample and the Oslo sample at 10 years.
Patients at age 15 years with UCLP and BCLP treated at Mount Vernon had flatter facial profile, and reduced maxillary prominence compared with a matched group of patients treated by the Oslo team. This difference was significant in the unilateral cleft lip and palate patients (P < 0.0001).
Acknowledgments
The authors would like to thank Marie Pinkstone, Cleft Coordinator, for her assistance with data collection and the Restoration of Appearance and Function Trust (RAFT) for their support.
References
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19 Shaw WC, Semb G, Nelson P, Brattström V, Mølsted K, Prahl-Andersen B. The Eurocleft Project 1996–2000. Standards of care for cleft lip and palate in Europe. Amsterdam: IOS Press; 2000.
20 Bearn DR. Outcome assessment in unilateral cleft lip and palate. PhD Thesis, University of Manchester; 2000.
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22 Morris DO, Semb G, Roberts-Harry DP. A comparative study of facial growth in 10-year old children with unilateral cleft lip and palate (UCLP). The Sixth European Craniofacial Congress, Manchester; 1999 (abstract).
23 Trenouth MJ, Laitung G, Naftel AJ. Differences in cephalometric reference values between five centres: relevance to the Eurocleft Study. Br J Oral Maxillofac Surg 1999; 37: 19–24.[Medline]
Received May 3, 2001; accepted October 3, 2001
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