Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate...

Twenty-Year Follow-Up of 50 ConsecutivePatients Born with Unilateral Complete CleftLip and Palate Treated by the Oslo CleftTeam, NorwayGunvor Semb, Elisabeth Rønning, and Frank Åbyholm

Long-term follow-up of patients with complete clefts provides a more

certain indication of treatment outcome than short-term studies. Rela-

tively few published reports, however, describe outcomes at age 20 years

or beyond. This retrospective cohort study involved 50 patient (17 female,

33 male) born with complete unilateral cleft lip and palate who were

consecutively treated by the Oslo Cleft Team. The data were analyzed by

internal and external observers with the use of standardized procedures,

ie, for assessment of dental arch relationship, the late adolescent version

of the original Goslon Yardstick; for facial growth, standardized cepha-

lometry; and an extension of the Bergland scale for rating alveolar bone

grafting success. The kappa statistic was used to evaluate interrater

reliability. The burden of care in numbers of operations and duration of

orthodontic treatment was calculated. Results for dental arch relation-

ship were as follows: 40% had excellent, 32% good, 18% fair, and 10% had

poor outcome. The cephalometric measurements are comparable with

other published results. A completely normal interdental septum after

bone grafting was observed in 80%, a slightly reduced septum in 18%,

and a failed graft in 2%. Long-term follow-up suggests that the Oslo

treatment protocol for unilateral cleft lip and palate achieves a satisfac-

tory balance between the burden of care and dentofacial outcome. (Se-

min Orthod 2011;17:207-224.) © 2011 Elsevier Inc. All rights reserved.

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Senior Lecturer in Craniofacial Anomalies, Dental School, Uni-versity of Manchester and affiliated with the Oslo Cleft Team,Department of Plastic Surgery, Oslo University Hospital, and Bredt-vet Resource Center and Adjunct Professor at the Faculty of Odon-tology, University of Oslo, Norway; Head of Dental Unit, Depart-ment of Plastic Surgery, Oslo University Hospital, Norway;Professor, Department of Plastic Surgery, Oslo University Hospital,Norway.

This article is based on the work of the Oslo Cleft Team, OsloUniversity Hospital, Norway.

Address correspondence to Gunvor Semb, Dental School, Univer-sity of Manchester, Higher Cambridge Street, Manchester M15 6FH,United Kingdom. E-mail: [email protected]

© 2011 Elsevier Inc. All rights reserved.1073-8746/11/1703-0$30.00/0

5doi:10.1053/j.sodo.2011.02.005

Seminars in Orthodontics, Vol 17, No

Long-term follow-up to adulthood of a spe-cific treatment protocol is a desirable but

elatively uncommon occurrence in the cleftiterature because the following circumstances

ay not commonly coexist: adequate caseoad, commitment to research, consistencyver time of treatment methods, record collec-ion, team membership, and patient atten-ance.

Enemark et al1 appear to have reported therst major longitudinal long-term follow-up.he study by Enemark et al involved multidis-iplinary evaluation of 57 patients with unilat-ral cleft lip and palate (UCLP) at 21 years ofge and included skeletal and soft-tissue facialrowth (cephalometry), occlusion, speech,nd need for secondary surgery. Fifty-one of
7 patients had an acceptable occlusion.
2073 (September), 2011: pp 207-224

mailto:[email protected]

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208 Semb, Rønning, and Åbyholm

Cleft care in Norway has been centralized in 2multidisciplinary teams for more than 50 years,one in Oslo and the other in Bergen. Approxi-mately 70-80 new patients with clefts are referredto the Oslo Team annually. The Norwegian pop-ulation is fairly homogenous, and staff at theCleft Centre have tended to remain on staff fora long time. All treatment and travel is free forthe patient and one parent, and patient atten-dance has been very good. One principle sincethe 1960s has been that the Team’s specialistsshould do all key treatment. With long distancesto travel and a desire to minimize the burden ofcare for the patients and the family, treatmentwith no proven long-term benefit has not beenadopted, and treatment periods have been con-centrated to keep visits to a minimum. Since the1960s, standardized record keeping has alsobeen seen as very important so that outcomescan be monitored and protocols revised as nec-essary. All attempts are made to have the finalrecord collection for patients with completeclefts at 21 years of age. This article will focus onpatients born with UCLP.

The Surgical Protocol for UCLP

Apart from the introduction of alveolar bonegrafting, changes to primary surgery protocolshave been modest. Since 1968, in patients withUCLP, the lip was closed at 3 months of age byuse of the Millard procedure2 and at the sametime the hard palate was closed by a single layervomer flap. A modified von Langenbeck proce-dure3 was used to close the soft palate at 18months, then the timing was changed to 12months in 1993. Alveolar bone grafting usingcancellous bone from the iliac crest was intro-duced in 1977 and soon became a routine pro-cedure for all patients with alveolar clefts. Sec-ondary surgery (pharyngoplasty, sulcoplasty, lipand/or nose corrections) was performed ac-cording to individual needs.

The Orthodontic Protocol for UCLP

No presurgical orthopedics or treatment in thedeciduous dentition has ever been undertakenin Oslo because of the absence of evidence inpast decades or until the present time. Since the
introduction of alveolar bone grafting, orth-
odontic treatment has been provided in 2 dis-tinct stages:

Pregrafting Orthodontic Preparation (WhenNecessary)

Anterior cross-bites and severe rotations ofmaxillary incisors are corrected. This is mostlydone if the patients are very motivated to havetheir new front teeth aligned and sometimesto move a retroclined cleft side incisor out ofthe alveolar cleft region to improve surgicalaccess during bone grafting. Segmental dis-placement, if sufficiently severe, is correctedjust before bone grafting using a removablequad helix, which is kept in place for 3 monthspostoperatively.

Permanent dentition orthodontics is dis-tinctly different for patients with complete cleftscompared with noncleft patients for many rea-sons. Some degree of reduced maxillary growthpotential is the rule (Fig 1),4 and early determi-nation of the eventual need for maxillary osteot-omy is a challenge, requiring borderline cases tobe assessed carefully. There is a tendency for themaxillary arch midline to be displaced to thecleft side. The permanent lateral incisor is miss-ing in 45% of Norwegian patients with alveolarclefts,5 and many laterals that are present are

alformed or erupt ectopically and cannot beept with a good long-term prognosis. Othereeth are more frequently missing in patientsith clefts.6

The orthodontist will choose whether orth-odontic space closure is the best option orwhether the lateral incisor space should be pre-served for replacements of various kinds. In Osloorthodontic space closure has been favored overprosthodontic restorative space closure for rea-sons discussed in this article. Protraction head-gear/facemask is sometimes used to stabilize theincisor position while posterior teeth are movedmesially. However, we do not consider protrac-tion to achieve significant or lasting skeletalchange in the position of the maxilla. Facialesthetics takes precedence over “normal” toothpositioning, and slight proclination may help tosupport the upper lip.

Cleft side canine impaction occurs in 25%of 191 Norwegian patients with UCLP who
have had alveolar bone grafting.7 This “com-

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209Twenty-Year Follow-Up of UCLP

plication” calls for an extra oral surgery pro-cedure and an increase in the duration of theorthodontic treatment. The relapse tendencyin patients with complete clefts is greater whencompared with noncleft patients, and this isrelated to the scar tissues from the surgeries. Atight upper lip and scars in the alveolus and inthe palate will encourage the migration ofteeth into crossbite.8,9 The continued impair-ment of maxillary growth together with con-tinued mandibular growth in the late teens(especially for males)4,10 may be factors in theworsening of the occlusion seen in some pa-tients in the late teens or early twenties.

The purpose of the present paper is to pres-ent dentofacial outcomes at the mean age of 20years for a cohort of consecutively treated pa-tients with UCLP using study models, cephalo-grams and occlusal radiographs of the bone-grafted region. The occlusal changes fromdebonding to follow-up at about 5 years later isdescribed as is the total amount of surgical in-

Figure 1. Changes in maxillary prominence (s-n-ss [se257 patients with UCLP and a noncleft group (all de

terventions and orthodontic treatment. t

Participants

The inclusion criteria for participants withUCLP of this study were as follows:

● nonsyndromic clefting and no other malfor-mation;

● all surgery and treatment follow-up by theOslo Cleft Team;

● full records (cephalograms, study models andocclusal radiographs of the bone grafted cleftregion, and clinical case notes) available atapproximately 20 years of age; and

● complete bony cleft, although patients witha soft tissue band (Simonart’s band) wereincluded.

he sample consisted of the first 50 patientsorn from January 1, 1975, who met the inclu-ion criteria. It included 17 female and 33 maleatients born between January 1, 1975, and Oc-ober 1979. None of the patients in the samplead chosen to have orthognathic surgery by the

asion-subspinale] or SNA angle) from 5 to 18 years inons in Appendix).2

lla-n

ime of record collection, although surgery had

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60


been discussed with several of them. The detailsof the study sample are presented in Table 1.Thirty-three patients (66%) had a cleft on theleft side, with 17 (34%) on right side. Twentysubjects (40%) had a soft-tissue band across thecleft, either under the nostril or between thealveolar processes. The mean age and range ofrecords for the models and radiographs is alsofound in Table 1. The time from debondinguntil follow-up models was a mean of 4.9 years(range, 0.5-10.4 years) and the follow-up timeafter bone grafting was at a mean of 10.4 years(range, 3.5-12.9 years).

All patients had the same primary surgery: lipclosure (Millard’s technique) and simultaneoushard palate closure with a single layer vomer flapat a mean age of 3.2 months (range, 2.2-4.9months), posterior palate closure (modified vonLangenbeck technique) at 18.2 months (range,15.7-31.1 months) and alveolar bone grafting atmean age of 9.7 years (range, 8.8-12.6 years).The dental status of the patients, number ofmissing lateral incisors and missing teeth beyondthe cleft region is presented in Tables 2 and 3.

Table 1. Overview of the Sample: Sex, Cleft Side, SoGraft Radiographs

Patients

Cleft Side

Soft-Tissue BanLeft Right

n % n % n % Yes % No

Females 17 34 10 59 7 41 8 47 9Males 33 66 23 70 10 30 12 36 21Total 50 100 33 66 17 34 20 40 30

Table 2. Status of Cleft Side Lateral Incisor, Presentor Absent, and the Number of Lateral Incisors Keptfor Alignment

Status of Cleft SideLateral

Number of LateralsKept

n % n %

Missing 17 34 — —Present

On larger segment 7 14 5 71On smaller

segment15 30 4 26

On both segments 11 22 On largersegment, 8

73

On smaller 9
segment, 1
Methods

Assessing Dental Arch Relationship

The dental arch relationship was assessed with amodification of the Goslon Yardstick,11 whichranks dental study casts of subjects with UCLP inthe late mixed dentition/early permanent denti-tion into 5 categories: group 1 (excellent results);group 2 (good results); group 3 (fair results);group 4 (poor results); and group 5 (very poorresults). The Yardstick has been used in manystudies, including the Eurocleft comparative stud-ies of 9- and 12-year-old patients with UCLP.12,13

The Yardstick was adapted for the Eurocleft 17-year-old assessment,13 and this modification was

sed in the present study. Three judges (2 externalnd 1 internal) scored the models by using theollowing definitions: group 1 (excellent result):ood horizontal and vertical relations. One toothn the lateral segment in cross bite is accepted. Anxample of a study model in group 1 is seen in FigA (left; from the Eurocleft Study13). Group 2

(good result): positive overjet and overbite.Crossbite in one lateral segment is accepted.Group 3 (fair result): edge-to-edge anterior oc-clusion, inversion of one tooth in the frontalregion (including canine) is accepted, and uni-lateral or bilateral cross bite also is accepted.Group 4 (poor result): negative incisal overjetwith symmetric form of the upper arch, unilat-eral or bilateral cross bite is accepted. Group 5(very poor result): severe negative overjet with anarrow upper arch. An example of a studymodel in group 5 from the Eurocleft Study13 iseen in Figure 2B (right). The interrater reliabil-ty was assessed by the Kappa statistics.14

Cephalometry

Standard cephalometric analysis also was per-

sue Band, Age at Models, Cephalogram and Bone

Age at Model, yrAge at

Cephalogram, yrAge at Bone Graft

Radiograph, yr

Mean Range Mean Range Mean Range

19.9 17.7-22.8 20.0 18.2-22.8 20.0 18.2-22.820.1 17.4-22.1 20.1 17.4-22.3 20.5 17.4-22.320.0 17.4-22.8 20.1 17.4-22.8 20.3 17.4-22.8

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formed. All cephalograms were traced by one

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investigator (G.S.). Fourteen angular measure-ments were calculated.

Success of Alveolar Bone Grafting

The height of the interdental septum after alve-olar bone grafting in the mixed dentition wasevaluated by a panel of 4 judges (2 internal and2 external) who used the Bergland/Åbyholmscale (Fig 3).15,16 This is a 4-category scale: typeI, completely normal interdental septum; type II,the septum reaches 75% of normal septumheight; type III, the septum reaches less that75% of normal septum; and type IV, failure, nobony bridge across the cleft. In addition, a 3-cat-egory scale for scoring the naso-apical aspect ofthe bone graft was used (Fig 4).17 The defini-ions are score 1: no naso-apical defect; score 2:efect in apical area, but with sufficient boneresent to allow uprighting of teeth and closing

he gap; and score 3: defect in apical area withnsufficient bone to allow uprighting of teeth.

Amount of Surgical and OrthodonticTreatment

A survey of the written hospital records was un-dertaken to calculate the average number oftreatment episodes and days in hospital for sur-gery. Forty-five of the patients had had all orth-

Table 3. Overview of Patients (n � 18) With Missing

Missing Teeth in Upper Jaw

Cleft Side CentralIncisor, n

Cleft Side SecondPremolar, n

Noncleft Side SecondPremolar, n

1 3 7

Figure 2. Left: A representative case (lateral view) fro
A representative case (lateral view) from the 17-year Yard
odontic treatment at the Cleft Centre, and visitsand duration of orthodontic treatment could becalculated.

Results

Dental Arch Relationship

The 3 judges had very good inter-rater agree-ment. The Kappa values ranged from 0.845 to0.915. The interpretation of the Kappa score isfound in Table 4. As indicated in Figure 5, 40%were in the very good category of the dental archrelationship and no patients were in the verypoor category. The mean score for the samplewas 2.03.

Change in Occlusion from 16 to 20 Years ofAge

The change in scores from 16 to 20 years is alsoseen in Figure 5. Thirty-five patients (70%)scored the same at 16 and 20 years. In 15 pa-tients (30%), the score had worsened:

● Five patients slipped from score 1-2 becausemore than one premolar had assumed a lat-eral crossbite.

● Four patients changed from score 2 to score 3.For 3, the reason was continued mandibular

th Beyond the Cleft Region

Missing Teeth in Lower Jaw

Both Secondremolars, n

Three UpperPremolars, n

One SecondPremolar, n

Two SecondPremolars, n

3 1 2 3

e 17-year Yardstick group 1: excellent result.11 Right:

Tee

P

m th
stick group 5: very poor result.11

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growth resulting in a change from positiveoverjet/verbite into an edge to edge bite.

● Three patients had changed from score 3 toscore 4. The edge-to-edge bite had become ananterior crossbite.

● Two patients changed from 1 to 3; one be-cause the premolars, the first molar, and thecleft side canine (in the lateral incisor’s posi-tion) had all assumed a crossbite. The otherpatient’s continued mandibular growth hadresulted in edge-to-edge bite.

● One patient changed from 1 to 4 because ofmarked continued mandibular growth.

nterestingly, 2 patients without evidence of an-erior crossbite in the deciduous dentition hadeteriorated to category 4 by age 20 years.

Figure 3. The Bergland/Åbyholm13,14 scale for assesalveolar bone grafting: Type 1: interdental septumthree-quarters of normal height; Type 3: height less tcontinuous bony bridge across the cleft achieved.

Figure 4. A 3-category scale for scoring the nasolabiScore 2: defect in apical area, but with sufficient bon
apical area with insufficient bone present to allow uprigh
An example of a patient with a relatively sta-le occlusion (found in 70% of the sample)rom 12.4 to 22.8 years of age is illustrated inigure 6. Figure 6F was taken at 13.9 years, andigure 6H was taken at 22.8 years. This patient issed as an example of reasonable stability of thecclusion after orthodontic treatment. An exam-le of a patient with deterioration of occlusionrom debonding at 15.2 years (score 1) to 20.1ears of age(score 3) is illustrated in Figure 7.igure 7G was taken at 16.1 years and Figure 7It 20.1 years, and this is an example of relapse ofhe crossbite after orthodontic treatment. Theutcome was mostly attributable to relapse ofhe cleft side crossbite in addition to one frontooth also in crossbite. An example of a patient

the height of the interdental septum achieved afterght approximately normal; Type 2: height at leastthree-quarters of normal height; Type 4: failure. No

pect of the bone grafted region. Score 1: no defect.esent to allow uprighting of teeth. Score 3: defect in

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ting of teeth.

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with deterioration of occlusion from score 1 at17.5 years to score 3 at 21.3 years mostly attrib-utable to continued mandibular growth is illus-trated in Figure 8.

Facial Growth

The results of the cephalometric analysis areseen in Table 5. The mandibular prominencewas statistically significantly larger in male thanin female patients, as was soft-tissue maxillaryprominence.

Success of Alveolar Bone Grafting

Scores for the height of the interdental bone inthe bone grafted area are presented in Figure 9.

ighty percent had a completely normal septumscore 1), 18% had 75% of normal bone height,hereas one bone graft failed. This patient un-erwent repeat surgery and subsequently ob-

ained a score 1. Examples of the scores 1 and 2n patients in this study can be seen in Figure 10.he scores of the naso-apical aspect are as fol-

ows: 96% had no naso-apical defect, 2% (1 pa-ient) had a small defect, and 2% (1 patient)ith insufficient bone to allow uprighting of

eeth.

Burden of Care—Surgery

Tables 6 and 7 summarize the proportion ofpatients who received different surgeries, aver-age age of surgeries, and the distribution ofsurgeries across patients. The average number ofsurgeries per patient was 4.8 and the mean num-ber of days in hospital was 24.1 (Table 8).

Burden of Care—Orthodontic Treatment

Tables 8 and 9 show the number of patientseceiving orthodontic interventions, average du-ation, age at completion and number of visits

Table 4. Interpretation of Kappa Values14

Value of Kappa Strength of Agreement

�0.20 Poor0.21-0.40 Fair0.41-0.60 Moderate0.61-0.80 Good0.81-1.00 Very good

1.00 Perfect agreement

or orthodontic treatment and follow-up. Cor-

rection of rotated and/or retroclined incisors inanterior crossbite was performed in 74% of pa-tients in the present sample, usually commenc-ing at age 7-8 years. Transverse expansion beforebone grafting was done in 16% of this sample,usually starting 6-8 months before bone grafting(in unpublished data of a larger survey of 485patients with UCLP the number of incisal cor-rections was lower and the number of expan-sions was higher, 64% and 28%, respectively).

All patients in this sample had orthodontictreatment in the permanent dentition. This treat-ment was done by the Center’s orthodontistsin 45 of the 50 patients. The orthodontic treat-ment of the permanent dentition started at amean age of 12.7 years (range, 9.3-15.6 years)and lasted on average 2.4 years (Table 9). Allbut 3 patients had fixed appliances in botharches, except for 3 who did not want appli-ances in the lower jaw. The number of visitsfor treatment was on average 24.3 per patientand nontreatment reviews from 6 to 21 yearswere on average 11.9 (Table 8). In many ofthese follow-up visits, the patient was seen byseveral members of the Cleft Team.

In this sample 58% of the patients had surgi-cal exposure of the cleft side canine, which ismore than twice as high than the frequencyfound in the unpublished data of 485 patientswith UCLP where 27% of patients had surgicaluncovering of cleft side canine. The duration ofthe orthodontic treatment is usually longer

Figure 5. Modified Goslon Yardstick scores of dentalarch relationship at mean age of 16 years (cross-hatched columns) and at 20 years (plane columns).Score 1: excellent results. Score 2: good results. Score3: fair results. Score 4: poor results. Score 5: very poor
results.


when canines need traction to be aligned in thearch. In 3 patients the canine had assumed atransposition with the first premolar.

In 8 patients (18%), both lower first premo-

Figure 6. Example of a patient with fairly stable occlua left-sided complete cleft lip and palate with soft tisslip and hard palate closure at 3.4 months. (B, C) Aftex-ray of the alveolar cleft before bone grafting at 9.6 y1.5 years after debonding, age 13.9 years. Total duratioat 22.8 years. (J) Occlusal radiography of the cleft regiat 22.8 years.

lars were extracted because of moderate-to-se-

vere crowding and in another 8 (18%) patients alower incisor was extracted because of mildcrowding (6 patients) and because a better over-bite/overjet could be obtained (2 patients). In 2

after debonding (score 1). The patient was born withridge. (A) Occlusal view of the maxilla on the day ofption of permanent incisors, 6.1 years. (D) OcclusalMissing cleft side lateral incisor. (E, F, G) Occlusionorthodontic treatment was 2.2 years. (H, I) Occlusion.4 years after bone grafting. (K) Lateral cephalogram

sionue br eruears.n ofon 8

patients one lower premolar was extracted and


Figure 7. Example of a patient who had scored 1 (excellent result) at 16 years of age but who had experienceddeterioration of the occlusion at age 20.1 years resulting in score 3 (fair result). The patient was born with aleft-sided complete cleft lip and palate. (A) Occlusal view of the maxilla on the day of lip and hard palate closureat 2.9 months. (B, C) After eruption of permanent incisors, at 8.1 years. (D) Occlusal radiograph of the alveolarcleft before bone grafting at 10.2 years. (E) Occlusion at 11.9 years. Awaiting eruption of permanent teeth. (F,G, H) Occlusion 8 months after debonding at 16.1 years. Total duration of orthodontic treatment was 2.5 years.(I, J) Occlusion at 20.1 years. Crossbite of premolars and first molar on cleft side and of the cleft side canine (inthe laterals incisor’s place). (K) Occlusal radiograph of the cleft region 11.4 years after bone grafting. (L) Lateral
cephalogram at 20.1 years.


Figure 8. Example of a patient who had score 1 (excellent result) at 16 years of age but in whomdeterioration of the occlusion at age 21.3 years resulted in score 3 (fair result). The patient was born witha left-sided complete cleft lip and palate with a soft tissue bridge (collapsed maxillary arches at 3 months,but no bony bridge across the cleft was confirmed at surgery). (A) Occlusal view of the maxilla on theday of lip and hard palate closure at 3.6 months. (B) After eruption of permanent incisors, at 9.2 years.(C) Occlusal radiograph of the alveolar cleft before bone grafting at 10.3 years. Missing cleft side lateralincisor. (D) Occlusion at 14.5 years. The option of possible orthognathic surgery was discussed, butdeclined. Orthodontic treatment started non-extraction in lower arch. (E, F) Occlusion 2 months afterdebonding at 17.5 years. Total duration of orthodontic treatment 2.9 years. (G, H) Occlusion at 21.3 years.Anterior edge-to edge bite and slightly open bite. (I) Occlusal x-ray of the cleft region 11.1 years after bone
grafting. (J) Lateral cephalogram at 21.3 years.

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discarded and a second lower premolar wastransplanted to the upper premolar region.

Relapse Treatment

In 4 patients who lost their bonded retainer anddid not wear their soft acrylic retainer a smallgap opened in the cleft region or the teeth inthe cleft area rotated or moved in a palatal di-

Table 5. Cephalometric Variables, Means, and SD fo

Total Sample,n � 50

Mean Age 20.3 Years

Mean SD

Skeletal variabless-n-ss 76.0 3.5s-n-pg 79.3 4.0ss-n-sm �0.9 2.7n-ss-pg 183.0 16.9NSL/ML 31.9 6.7NL/ML 24.7 6.5

Dental variablesIls/NL 107.7 7.1Ili/ML 89.5 6.1Ils/Ili 134.1 20.3

Soft-tissue variabless-ns-sss 85.3 4.1s-ns-sms 82.3 3.7Sss-ns-sms 3.1 2.4ns-sn-pg 176.7 6.2gs-sn-pg 178.1 6.5

or definitions of cephalometric abbreviations, see the AppP � 0.05.P � 0.01.

Figure 9. Graph presenting the outcome of thescores for the interdental septum after alveolar bonegrafting.15,16 Type 1: interdental septum height ap-

roximately normal (80% of sample); Type 2: heightt least three-quarters of normal height (18% of sam-le); Type 3: height less than three-quarters of normaleight; Type 6: failure. No continuous bony bridge
cross the cleft achieved (2% of sample).
rection. The relapse was such that the patientschose to have another period of orthodontictreatment (mean duration, 0.9 years; range, 0.3-1.4 years).

Orthognathic Surgery

The possibility of orthognathic surgery was dis-cussed with 10 patients, at least 5 of whom theorthodontists believed would really benefit. Allpatients, however, declined the offer of thistreatment.

Discussion

Is the Sample Representative?

The 50 patients included were consecutive from1975 to 1979 and they are probably representa-tive of patients who received treatment over sev-eral decades. The age range in the present studywas from 17.4 to 22.8 years, with mean of 20.1 asthe cohort reported was partly a conveniencesample as much of the material was already ac-cumulated for Oslo’s Eurocleft consecutive se-ries that included records to a minimum age of17 years. Some further records exist in archivesof the Oslo team and it is planned to repeat thestudy with a larger sample where the minimum

Total Sample and Divided by Sex

Females,n � 17

Mean Age 19.9 Years

Males,n � 33

Mean Age 20.5 Years

Mean SD Mean SD

75.1 2.9 76.5 3.777.5 3.0 80.2 4.2*

�0.4 2.6 �1.4 2.8183.6 6.5 182.6 20.334.0 7.1 30.8 6.225.2 6.7 24.5 6.4

108.7 7.0 107.2 7.289.3 6.4 89.6 6.1

137.3 6.3 132.5 24.5

83.0 2.4 86.6 4.3†80.5 2.5 83.2 3.9*2.5 2.0 3.5 2.6

177.9 7.2 176.0 5.7180.0 7.0 177.2 6.2

.

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endix

age for final records are 20 years.

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T


Figure 10. Examples of the bone graft score achieved in this sample. (A) Before bone grafting at 9.6 years.B) Cleft site 8.7 years postgrafting. (C) Before bone grafting at 9.9 years. (D) Cleft site 11.2 yearsostgrafting. (E) Before bone grafting at 10.2 years. (F) Cleft site 11.4 years postgrafting. (G) Before bonerafting at 10.1 years. (H) Cleft site 10.3 years postgrafting. Note that 80% had a bone graft score I, ie,ormal interdental septum (B and D) and 18% had a bone graft score II, ie, 75% of normal septum height
F and H) and 2% (1 patient) had a failed bone graft.
able 6. Surgical Interventions in the Study Sample

Patients n � 50

Number % Mean Age, yr Age Range, yr

Cleft closureLip and hard palate closure 50 100 0.27 0.2-0.4Soft palate closure 50 100 1.5 1.3-2.6Alveolar bone grafting 50 100 9.7 8.8-12.6

Additional surgeryPharyngeal flap 14 28 7.7 6.3-9.4Lip revision 17 34 9.8 4.6-18.9Fistula closure 2 4 9.1 4.5-13.7Surplus mucosa 8 16 7.4 5.3-13.5Sulcoplasty 2 4 8.1 7.6-8.6Second lip revision 4 8 14.5 7.6-20.7Second fistula closure 1 2 15.2Lip/nose revision 18 36 16.2 13.0-21.3Second lip/nose revision 3 6 20.5 17.0-22.5Nose revision 18 36 15.9 6.1-19.1
Second nose revision 3 6 16.6 15.3-17.6

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This sample had slightly different facial formfrom results presented in the larger cephalomet-ric study of 131 patients (of 257) with UCLP whowere 18 years or more from the same center4

(Table 10). The present sample had a slightlymore prominent maxilla and mandible, but thedifference of the maxillomandibular angle be-tween the 2 samples was only 0.5 degrees.

The Influence of a Soft-Tissue Band

In this sample 40% of patients had a soft-tissueband across the cleft (but no bony union). Inthe earlier study of 257 patients with UCLP 31%had a soft-tissue band,18 so the number of soft-tissue bands in the present sample was slightlygreater than the average for the Oslo cleft pop-ulation. The Oslo Eurocleft sample of 30 con-secutive patients had the greatest frequency ofsoft-tissue bands among the 6 centers, suggest-ing that this may be a trait in the Norwegian cleftpopulation.

There are some grounds for supposing thatindividuals with UCLP and a soft-tissue bandwould be subject to less disturbed growth anddevelopment because preoperatively maxillaryand nasal distortion are generally less severebecause of the restraining influence of the softtissue band, tissue deficiency is potentially less,and surgery in turn, is arguably facilitated. Inthe cephalometric study the maxillomandibu-lar angle (ss-n-sm/ANB) was slightly more fa-vorable although the maxilla (s-n-ss/SNA) was

Table 7. Number of Surgeries Per Patient

Number ofSurgeries n %

3 8 164 15 305 12 246 9 187 5 108 1 2

Table 8. Visits to Cleft Centre for Surgery and DaysTreatment, and Number of Visits for Treatment and

No of Surgeries Days in HospitalOrthodon

Du

Mean Range Mean Range Mean

4.8 3-8 24.1 15-40 3.0 years 0.

not more prominent in those with soft-tissuebands compared with those without soft-tissuebands.18 However, in the present study therewas no statistically significant difference be-tween the groups with and without a soft-tissueband for any cephalometric variables or forthe dental arch relationship. It has also beenhypothesized that patients with soft-tissuebands would have fewer missing lateral inci-sors. In this sample patients without a soft-tissue band had missing lateral incisor in 33%of patients and those with a soft-tissue bandhad missing laterals in 35% of patients. How-ever, the sample in this study was rather smallfor subgroup comparisons.

Comparison with Other Centers

Cephalometric Comparisons

In Table 10 the cephalometric values from 5other cephalometric studies of young adults arelisted. Three of these presented results of pa-tients with UCLP at 20 or more years,1,10,19 and2 studies20,21 had cephalometric data from pa-ients at 18 years. The results from Oslo on aarger sample of UCLP4 (n � 131) are also listedn Table 10. The results of these studies appearomparable to the Oslo group.

Comparison of Dental Arch Relationship

ne large mixed-longitudinal study of UCLPreated in Gothenburg has been reported, inhich the authors used study casts of 47 19-ear-old patients.22 Because the original Gos-on yardstick was used for the Gothenburgatings, the data are not directly comparable,nd they were reported in graphic form. Esti-ating the values for the Gothenburg sample

owever suggest that the Oslo outcomes areetter at 16 and poorer at 20 years of age.

ospital and Duration of Total Orthodonticw-Up

reatmentn

Visits forOrthodonticTreatment

Visits forOrthodontic andTeam Follow-Up

Range Mean Range Mean Range

in HFollo

tic Tratio

7-5.6 years 24.3 10-47 11.9 2-28


Surgical Interventions

On average, there were 4.8 surgeries per patient(range, 3-8). The low frequency of fistulae clo-sure is probably explained by the fact that mostresidual fistulas in the Oslo patients are found inthe region of the alveolus, are asymptomatic andcan be closed during bone grafting.

The patients had stayed in hospital for anaverage of 24.1 days, but recent years have seenan increasing trend to shorter stays and many lipand even nose revisions are today done in theoutpatient clinic. However, geography dictatesthat many Norwegian patients have a long way totravel and for some surgeries with a potential forpostoperative difficulties (palate closure andpharyngeal flaps), the patients from distant ar-eas still stay a day or 2 longer than those who livecloser to Oslo.

Orthodontic Treatment

As a rule, orthodontic treatment of patients withcomplete clefts is carried out at the Cleft Centreor occasionally when appropriate, in close col-laboration with a selected local orthodontist. Alltreatment is done using fixed appliances.

Anterior Space Management

In this study sample 18 patients (36%) had alateral incisor that could be aligned and keptwith a good long-term prognosis. In the remain-ing 32 patients with missing lateral incisors thegap in the dental arch was closed orthodonti-cally in 29 patients. In 3 patients a resin-bondedbridge was used for space closure, ie, in onepatient in whom the central incisor was missing,

Table 9. Overview of Orthodontic Treatment, Type,

Pregrafting orthodonticsIncisor correctionDurationAge at completionTransverse expansionDurationAge at completion

Orthodontic treatment in permanent dentitionDurationAge at completionRelapse treatmentDurationAge at completion

in one in whom the cleft side canine showed

cervical root resorption and was lost 7 years afterbone grafting, and in one treated by a localorthodontists who had chosen prosthetic spaceclosure.

The optimal treatment for missing lateral in-cisors is a controversial issue and has been dis-cussed at length in the orthodontic literature.The major benefit, in the authors’ opinion, isthat at the end of the orthodontic treatment, theoverall dental treatment can be completed. Byrecontouring the canine to a more ideal lateralincisor shape and size orthodontic space closureprovides long-term results that are as good as, orsuperior to space opening for prosthetic replace-ment.23-25 Other investigators23-27 have shownthat the periodontal conditions are significantlybetter with orthodontic space closure than withprosthetic replacement, the temporomandibu-lar joint function is not impaired and patientsatisfaction is high.

Three patients had tooth transplantations:one had a small noncleft side second premolarthat was transplanted into the bone-grafted re-gion 6 months after grafting (Fig 11). The sec-ond patient was missing the cleft side lateralincisor and both upper second premolars. Alower second premolar was transplanted into thecleft side second premolar region. The thirdpatient with tooth transplantation was missingthe cleft side lateral incisor and second premo-lar and also both lower second premolars. Hisnoncleft side second premolar was transplantedto the cleft side second premolar region. Toothtransplantation is a good option in selected pa-tients who otherwise would have had to haveprosthetic space closure and the procedure is

Duration

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The survival rate at a mean follow-up of 26.4years (range, 17-41 years) posttransplantation of33 teeth in a Norwegian noncleft material was90%.28

Changes in Occlusion from 16 to 20 Years

The deterioration in occlusion after debondingas described in this paper has also been found inother studies.8,9,30 Ramstad and Jendal8 found areduction in upper dental arch width in 22 sub-jects with UCLP who had received a fixed bridgeacross the cleft to replace a missing lateral inci-sor and retain the previous orthodontic expan-sion. The follow-up time was 13.5 years. Marcus-son and Paulin9 recorded occlusal changes from19 to 25 years in 39 subjects with UCLP. Therewas a significant deterioration in the total occlu-sal score during the follow-up period and thiswas larger on the cleft side than the noncleftside.

A multidisciplinary follow-up of 20 patientswith UCLP with records at 10 and 20 years of agefound a significant shift in the Goslon Yardstickscore of dental arch relationship towards the lessfavorable end of the yardstick and the cephalo-metric measurements showed a more retrusivemaxilla at 20 years compared with the findings at10 years.30 These studies all highlight the neces-sity for long-term follow-up through to adult-hood as outcomes cannot be accurately reporteduntil maturity.

Other Outcomes

The present report is confined to dentofacialoutcomes; however, speech, hearing, nasolabialappearance, patient satisfaction, and psychoso-cial well-being are also essential aspects of theoutcome in adulthood. A subgroup of the pres-ent sample has been analyzed for speech at 12years, and nasolabial appearance and patientsatisfaction at age 17 years as part of the Euro-cleft material.31-33 Speech for the patients fromthe 6 Eurocleft centers was assessed by a panel ofjudges at 12 years of age.31 There were no statis-ically significant differences between the 6 cen-ers, but speech for the Oslo group was rankedigh. Nasolabial appearance was assessed by alinded panel of judges32 and no significant dif-

ferences were found between Oslo and the other4 centers. (At 9 and 12 years, there were 6 cen-
ters, but 1 center, Center C, did not participateT
a

For

lant


in the comparison at 17 years.) Oslo was rankedon a combined third place of 5 centers. In theEurocleft studies a patient questionnaire wasdone at the age of 17 years.33 There were nosignificant differences between centers in therating of satisfaction with overall care.

Conclusions

As noted, long-term follow-up of patients withcleft lip and palate is a major challenge forcleft teams. It took 25 years to accumulate thematerial for the present study. External com-parison is presently limited because the gen-eral lack of comparative material and the lackof consistency of analysis systems. One keyelement that should be included in futurestudies in addition to psycho-social well-beingis the need to document the burden of careimposed by different protocols upon childrenand their families. Differences in the complex-ity and costs of different protocols, such asrevealed by a survey of 201 European cleftservices,34 are surprisingly large. The relativesimplicity of the Oslo protocols, no presurgicalorthopedics, relatively few primary operations,and limited periods of orthodontics, appearsto have been compatible with acceptable long-term dentofacial treatment outcomes.

AcknowledgmentsThe authors are grateful to Mr Philip Eyres for statistical

Figure 11. Patient with a small second premolar froregion 6 months after surgery. (A) Before alveolar bsecond premolar from the noncleft side was trantransplantation. (C) Nine months after tooth transp

assistance and preparation of the manuscript and to Profes-

sor William C. Shaw and Dr Nicky Mandall, University ofManchester, United Kingdom, and Dr Susana Dominguez-Gonzalez, North-West Clinical Network for CLP, UK forscoring models and occlusal x-rays.

Appendix

Definition of Cephalometric Landmarks

s � sella. The center of sella tursica.n � nasion. The most anterior point on the

fronto-nasal suture.ss � subspinale (A-point). The deepest point

on the anterior contour of the upperalveolar arch.

sm � supramentale (B-point). The deepestpoint on the anterior contour of thelower alveolar process.

pg � pogonion. The most anterior point onthe mandibular symphysis.

ns � soft tissue nasion. The deepest point inthe fronto-nasal curvature.

sss � soft tissue subspinale (soft tissue Apoint). The point of greatest concavityin the midline of the upper lip.

sms � soft tissue supramentale (soft tissue B-point). The point of greatest concavityof the midline of the lower lip

sns � subnasale. The deepest point in the na-solabial curvature

pgs � soft tissue pogonion. The most promi-nent point of the chin

gs � soft tissue glabella. The most anterior

e noncleft side transplanted into the bone graftedgrafting. (B) Six months after bone grafting a smallnted into the bone graft, 3 months after tooth

ation. (D) At 11.8 years after tooth transplantation.

m thonespla

point on the soft tissue glabella

C


Cephalometric Reference Lines

NSL � Nasion-sella line, the line through na-sion and sella

ML � Mandibular line, the tangent to thelower border of the mandible throughgn

NL � Nasal line. The line through spina na-salis anterior (the apex of the anteriornasal spine) and pterygomaxillare (theintersection between the nasal floorand the posterior contour of the max-illa)

Ils � Axis of upper incisors, a line from inci-sion superius (the midpoint of the in-cisal edge of the most prominent uppercentral incisor) and apex superius (theapex of the root of the most prominentupper central incisor).

Ili � Axis of the lower incisors, a line fromincision inferius (the midpoint of theincisal edge of the most prominentlower central incisor) and the apex infe-rius (the apex of the root of the mostprominent lower central incisor).

ephalometric Variables

s-n-ss (SNA): maxillary prominence, angle be-tween s-n line at n and subspi-nale ss (A-point)

s-n-pg: mandibular prominence, angle be-tween s-n line at n and pogonion

ss-n-sm: anteroposterior relationship betweenthe maxilla and the mandible

n-ss-pg: the facial convexity angleNSL/ML: angulation between the nasion-

sella line and the mandibular lineNL/ML: angulation between the nasal and

mandibular linesIls/NL: upper incisor inclination to the nasal

lineIli/ML: lower incisors inclination to the man-

dibular lineIls/Ili: interincisal angless-ns-sss: soft tissue maxillary prominence

(soft-tissue SNA)ss-ns-sm: soft tissue mandibular prominence

(soft-tissue SNB)sss-ns-sms: soft tissue anteroposterior relation-

ship between the maxilla and man-dible (soft-tissue ANB)

ns-sns-pgs: soft-tissue facial convexity angle

gs-sns-pgs: soft-tissue facial convexity anglemeasured from glabella

References1. Enemark H, Bolund S, Jørgensen I: Evaluation of uni-

lateral cleft lip and palate treatment: Long term results.Cleft Palate J 27:354-361, 1990

2. Millard DR Jr: Cleft Craft I. Boston, Little Brown andCo., 1976

3. von Langenbeck B: Operation der angeborenen totalenSpaltung des harten Gaumens nach einer neue Meth-ode. Dtsch Klin 8:231, 1861

4. Semb G: A Study of facial growth in patients with unilat-eral cleft lip and palate treated by the Oslo CLP team.Cleft Palate Craniofac J 28:1-21, 1991

5. Bøhn A: Dental anomalies in harelip and cleft palate.Acta Odontol Scand 21:1-109, 1963

6. Ranta R: A review of tooth formation in children withcleft lip/palate. Am J Orthod 90:11-18, 1986

7. Semb G, Schwartz O: The impacted tooth in patientswith alveolar clefts, in Andreasen JO, Petersen JK, LaskinDM (eds): Textbook and Color Atlas of Tooth Impac-tion. Copenhagen, Munksgaard, 1997, pp 332-348

8. Ramstad T, Jendal T: A long-term study of transversestability of maxillary teeth in patients with unilateralcomplete cleft lip and palate. J Oral Rehabil 24:658-665,1997

9. Marcusson A, Paulin G: Changes in occlusion and max-illary dental arch dimensions in adults with treated uni-lateral complete cleft lip and palate: A follow-up study.Eur J Orthod 26:385-390, 2004

10. Paulin G, Thilander B: Dentofacial relations in youngadults with unilateral cleft lip and palate. A follow-upstudy. Scand J Plast Reconstr Hand Surg 25:63-72, 1991

11. Mars M, Plint DA, Houston WJB, et al: The GoslonYardstick: A new system of assessing dental arch relation-ships in children with unilateral clefts of the lip andpalate. Cleft Palate J 24:314-322, 1987

12. Mars M, Asher-McDade C, Brattström V, et al: A six-center international study of treatment outcome in pa-tients with clefts of the lip and palate: Part 3. Dental archrelationships. Cleft Palate Craniofac J 29:405-408, 1992

13. Mølsted K, Brattström V, Prahl-Andersen B, et al: TheEurocleft study: intercenter study of treatment outcomein patients with complete cleft lip and palate. Part 3:dental arch relationships. Cleft Palate Craniofac J 42:78-82, 2005

14. Landis JR, Koch GG: The measurement of observeragreement for categorical data. Biometrics 33:159-174,1977

15. Åbyholm F, Bergland O, Semb G: Secondary bone graft-ing of alveolar clefts. A surgical/orthodontic treatmentenabling a non-prosthodontic rehabilitation in cleft lipand palate patients. Scand J Plast Reconstr Surg 15:127-140, 1981

16. Bergland O, Semb G, Åbyholm F: Elimination of theresidual alveolar cleft by secondary bone grafting andsubsequent orthodontic treatment. Cleft Palate J 23:175-
205, 1986

1

1

2

2

2

2

2

2

2


17. Semb G, Arctander K, Ronning E, et al: Factors that influ-ence the outcome of alveolar bone grafting [abstract]. The7th European Craniofacial Congress, Bologna, Italy, 2003

8. Semb G, Shaw WC: Simonart’s band and facial growth inunilateral clefts of the lip and palate. Cleft Palate Cranio-fac J 28:40-46, 1991

9. Smahel Z, Betincová L, Mullerová Z, et al: Facial growthand development in unilateral complete cleft lip andpalate from palate surgery up to adulthood. J CraniofacGenet Dev Biol 13:57-71, 1993

0. Nollet PJPM, Katsaros C, Huyskens RWF, et al: Cephalo-metric evaluation of long-term craniofacial developmentin unilateral cleft lip and palate patients treated withdelayed hard palate closure. Int J Oral Maxillofac Surg37:123-130, 2008

1. Meazzini MC, Capasso E, Morabito A, et al: Comparisonof growth results in patients with unilateral cleft lip andpalate after early secondary gingivoalveoloplasty and sec-ondary bone grafting: 20 years follow up. Scand J PlastReconstr Surg Hand Surg 42:290-295, 2008

2. Lilja J, Mars M, Elander A, et al: Analysis of dental archrelationships in Swedish unilateral cleft lip and palatesubjects: 20-Year longitudinal consecutive series treatedwith delayed hard palate closure. Cleft Palate CraniofacJ 43:606-611, 2006

3. Rosa M, Zachrisson BU: Integrating esthetic dentistryand space closure in patients with missing maxillarylateral incisors. J Clin Orthod 35:221-234,

4. Tuverson DL: Close space to treat missing lateral inci-sors. Am J Orthod 125:17A, 2004

5. Zachrisson BU: Improving the esthetic outcome of ca-nine substitution for missing maxillary lateral incisors.World J Orthod 8:72-79, 2007

6. Nordquist GG, McNeill RW: Orthodontic vs. restorativetreatment of the congenitally absent lateral incisor—long term periodontal and occlusal evaluation. J Peri-
odontol 46:139-143, 1975
27. Robertsson S, Mohlin B: The congenitally missing upperlateral incisor. A retrospective study of orthodonticspace closure versus restorative treatment. Eur J Orthod22:697-710, 2000

28. Czochrowska EM, Stenvik A, Bjercke B, et al: Outcomeof tooth transplantation: Survival and success rates 17-41years posttreatment. Am J Orthod Dentofac Orthop 121:110-119, 2002

29. Czochrowska EM, Semb G, Stenvik A: Non-prosthodon-tic management of alveolar cleft with 2 incisors missingon the cleft side. A report of 5 cases. Am J OrthodDentofac Orthop 122:587-592, 2002

30. Hay N, Sommerlad BC: 20 Year Follow-Up of Patientswith Unilateral Complete Cleft Lip and Palate-MaxillaryGrowth [abstract 151]. American Cleft Palate-Craniofa-cial Association Conference, 2008, p 20

31. Grunwell P, Brøndsted K, Henningsson G, et al: Asix-centre international study of the outcome of treat-ment in patients with clefts of the lip and palate: Theresults of a cross-linguistic investigation of cleft palatespeech. Scand J Plast Reconstr Surg Hand Surg 34:219-229, 2000

32. Brattström V, Mølsted K, Prahl-Andersen B, et al: TheEurocleft study: Intercenter study of treatment outcomein patients with complete cleft lip and palate. Part 2:Craniofacial form and nasolabial appearance. Cleft Pal-ate Craniofac J 42:69-77, 2005

33. Semb G, Brattström V, Mølsted K, et al: The Eurocleftstudy: Intercenter study of treatment outcome in pa-tients with complete cleft lip and palate. Part 4: Rela-tionship among treatment outcome, patient/parent sat-isfaction, and the burden of care. Cleft Palate CraniofacJ 42:83-92, 2005

34. Shaw WC, Semb G, Nelson P, et al: The Eurocleft Project1996-2000: Overview. J Cranio-Maxillofac Surg 29:131-
140, 2001

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