A multidisciplinary long-term evaluation of patients born with unilateral cleft lip and palate treated with different surgical protocols

Abstract

Introduction and aims: The aim of this project was to evaluate the long-term outcome after the multidisciplinary treatment of young adults born with unilateral cleft lip and palate (UCLP) regarding speech and communicative ability dental arch relationships, craniofacial growth and periodontal status,. The examined patients were operated according to different surgical protocols and an additional aim was to evaluate if there were any differences in outcome between the different types of techniques used for the palatal repair.

Materials and methods: Between 40 and 87 patients born with UCLP from 1975-2004 were included in the four different studies included in this project. To evaluate dental arch relationships the Great Ormond Street, London, and Oslo (GOSLON) Yardstick was used to rate dental casts taken at 5 (n=87), 7 to 8 (n=27), 10 (n=81), 16 (n=61), and 19 (n=35) years of age. Results were compared between three different surgical techniques of one-stage palatal closure Veau-Wardill-Kilner (VWK), minimal incision technique (MIT) and MIT with muscle reconstruction (MITmr). The outcome was also compared with the mean GOSLON ratings of other cleft lip and palate (CLP) centers. To investigate speech outcome and self-reported speech and communicative ability, speech characteristics were blindly assessed by speech and language pathologists from audio recordings, and the use of a selfreport questionnaire concerning speech and communication (SOK). Two groups of 19-yearold patients were compared: one treated with a two-stage palatal repair protocol in Gothenburg (n=25) and one operated with one-stage palatoplasty according to the “minimal incision technique” (MIT) in Stockholm (n=17). The results were compared with normative data from individuals without cleft lip and palate. The relationship between patients’ and experts’ judgments was also studied. To evaluate facial growth after completed skeletal development, 68 lateral cephalograms taken of patients at 19 years of age operated with VWK (n=13), MIT (n=39) or MITmr (n=16) were assessed, and cephalometric values were compared between the groups. The results were compared with reference data of individuals born without a cleft and with previous reported outcomes from other CLP centers. To evaluate the possibility of predicting outcome at age 19 from cephalometric values at five years, the lateral cephalograms of 32 patients who had x-rays taken at both five and 19 years were assessed. To make a long-term periodontal evaluation of teeth in bone grafted alveolar clefts, 40 young adults operated according to MIT were assessed with a ”split-mouth design”. Every examined site on the cleft side was compared with the corresponding site on the contralateral side regarding periodontal probing depth, presence of gingival recessions, and presence or absence of gingival inflammation. Thirty-nine intraoral apical radiographs were assessed regarding bone height in the grafted area, with the Bergland index.

Results: The dental arch relationship was rated as excellent to satisfactory in 82% of all the patients assessed with the GOSLON Yardstick. The best result was found in the MIT group at ten years, and there was a statistically significant difference compared to the VWK group at 19 years. There were also significantly more patients who had received orthognathic surgery, to correct the maxillary hypoplasia and malocclusion, in the VWK group compared to the MIT group. The outcome, measured as a mean GOSLON score, was comparable with that from other CLP centers with excellent results on midfacial growth after different surgical protocols. The speech assessments revealed no group differences between the one-stage technique (MIT) of palatal repair (OS) and the two-stage protocol (TS). The occurrence of nasality symptoms was low in both groups. Surprisingly, perceived competent velopharyngeal function was only 60% and 65% respectively, even though pharyngeal flap surgery had been performed in 53% (OS) and 24% (TS) of patients. Both articulation proficiency and intelligibility were good. The patients’ opinion of their own speech and communicative ability agreed with norms and significantly associated with intelligibility, articulation, and correct s-sound. In the cephalometric analysis significant, but not major, differences were found between the three surgical protocols for several of the cephalometric variables (for example SNB, NSL/NL, NSL/ML och NL/ML) at 19 years of age. Most of the cephalometric variables assessed showed a strong positive relation between the value at five years and the value at 19 years. In the assessment of the periodontal status, there was no significant difference in probing depth between the teeth in the cleft and non-cleft sites and very few gingival recessions were found at 19 years of age. However, gingival inflammation was found to be significantly higher on the cleft side. The bone height in the cleft region was good with Bergland index I and II seen in 87% of the patients.

Conclusions: At 19 years of age, both dental arch relationships and cephalometric outcome were significantly better after MIT for palatal repair than after VWK. There were no differences between one- and two-stage palatoplasty regarding speech outcome but in both groups velopharyngeal function was rated significantly poorer compared to the norm. Nevertheless, patients were as satisfied with their speech and communicative ability as individuals born without a cleft. The periodontal status of teeth in the bone grafted region almost ten years after bone-grafting was in general good. However, patients born with UCLP had more gingival inflammation in the cleft zone. This implies that they should receive information about the need of prophylactic care in the future to prevent general health problems. Ultimately, the outcome after multidisciplinary treatment in individuals born with UCLP is generally good, but techniques of palatal repair with minimal incisions in the hard palate seem to produce better facial growth and occlusion than more invasive surgery. However, the burden of care in terms of speech improving surgery was higher with the onestage technique compared to the two-stage protocol.