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Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
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Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway

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  • 1. 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. ong-term follow-up to adulthood of a spe- L cific treatment protocol is a desirable but relatively uncommon occurrence in the cleft literature because the following circumstances may not commonly coexist: adequate case Senior Lecturer in Craniofacial Anomalies, Dental School, Uni- load, commitment to research, consistencyversity of Manchester and affiliated with the Oslo Cleft Team,Department of Plastic Surgery, Oslo University Hospital, and Bredt- over time of treatment methods, record collec-vet Resource Center and Adjunct Professor at the Faculty of Odon- tion, team membership, and patient atten-tology, University of Oslo, Norway; Head of Dental Unit, Depart- dance.ment of Plastic Surgery, Oslo University Hospital, Norway; Enemark et al1 appear to have reported theProfessor, Department of Plastic Surgery, Oslo University Hospital, first major longitudinal long-term follow-up.Norway. This article is based on the work of the Oslo Cleft Team, Oslo The study by Enemark et al involved multidis-University Hospital, Norway. ciplinary evaluation of 57 patients with unilat- Address correspondence to Gunvor Semb, Dental School, Univer- eral cleft lip and palate (UCLP) at 21 years ofsity of Manchester, Higher Cambridge Street, Manchester M15 6FH, age and included skeletal and soft-tissue facialUnited Kingdom. E-mail: gunvor.semb@manchester.ac.uk © 2011 Elsevier Inc. All rights reserved. growth (cephalometry), occlusion, speech, 1073-8746/11/1703-0$30.00/0 and need for secondary surgery. Fifty-one of doi:10.1053/j.sodo.2011.02.005 57 patients had an acceptable occlusion. Seminars in Orthodontics, Vol 17, No 3 (September), 2011: pp 207-224 207
  • 2. 208 Semb, Rønning, and Åbyholm Cleft care in Norway has been centralized in 2 odontic treatment has been provided in 2 dis-multidisciplinary teams for more than 50 years, tinct stages: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- Pregrafting Orthodontic Preparation (Whenulation is fairly homogenous, and staff at the Necessary)Cleft Centre have tended to remain on staff for Anterior cross-bites and severe rotations ofa long time. All treatment and travel is free for maxillary incisors are corrected. This is mostlythe patient and one parent, and patient atten- done if the patients are very motivated to havedance has been very good. One principle since their new front teeth aligned and sometimesthe 1960s has been that the Team’s specialists to move a retroclined cleft side incisor out ofshould do all key treatment. With long distancesto travel and a desire to minimize the burden of the alveolar cleft region to improve surgicalcare for the patients and the family, treatment access during bone grafting. Segmental dis-with no proven long-term benefit has not been placement, if sufficiently severe, is correctedadopted, and treatment periods have been con- just before bone grafting using a removablecentrated to keep visits to a minimum. Since the quad helix, which is kept in place for 3 months1960s, standardized record keeping has also postoperatively.been seen as very important so that outcomes Permanent dentition orthodontics is dis-can be monitored and protocols revised as nec- tinctly different for patients with complete cleftsessary. All attempts are made to have the final compared with noncleft patients for many rea-record collection for patients with complete sons. Some degree of reduced maxillary growthclefts at 21 years of age. This article will focus on potential is the rule (Fig 1),4 and early determi-patients born with UCLP. nation of the eventual need for maxillary osteot- omy is a challenge, requiring borderline cases to be assessed carefully. There is a tendency for theThe Surgical Protocol for UCLP maxillary arch midline to be displaced to the cleft side. The permanent lateral incisor is miss-Apart from the introduction of alveolar bone ing in 45% of Norwegian patients with alveolargrafting, changes to primary surgery protocols clefts,5 and many laterals that are present arehave been modest. Since 1968, in patients with malformed or erupt ectopically and cannot beUCLP, the lip was closed at 3 months of age by kept with a good long-term prognosis. Otheruse of the Millard procedure2 and at the same teeth are more frequently missing in patientstime the hard palate was closed by a single layer with clefts.6vomer flap. A modified von Langenbeck proce- The orthodontist will choose whether orth-dure3 was used to close the soft palate at 18 odontic space closure is the best option ormonths, then the timing was changed to 12 whether the lateral incisor space should be pre-months in 1993. Alveolar bone grafting using served for replacements of various kinds. In Oslocancellous bone from the iliac crest was intro- orthodontic space closure has been favored overduced in 1977 and soon became a routine pro- prosthodontic restorative space closure for rea-cedure for all patients with alveolar clefts. Sec- sons discussed in this article. Protraction head-ondary surgery (pharyngoplasty, sulcoplasty, lip gear/facemask is sometimes used to stabilize theand/or nose corrections) was performed ac- incisor position while posterior teeth are movedcording to individual needs. mesially. However, we do not consider protrac- tion to achieve significant or lasting skeletal change in the position of the maxilla. FacialThe Orthodontic Protocol for UCLP esthetics takes precedence over “normal” toothNo presurgical orthopedics or treatment in the positioning, and slight proclination may help todeciduous dentition has ever been undertaken support the upper lip.in Oslo because of the absence of evidence in Cleft side canine impaction occurs in 25%past decades or until the present time. Since the of 191 Norwegian patients with UCLP whointroduction of alveolar bone grafting, orth- have had alveolar bone grafting.7 This “com-
  • 3. Twenty-Year Follow-Up of UCLP 209Figure 1. Changes in maxillary prominence (s-n-ss [sella-nasion-subspinale] or SNA angle) from 5 to 18 years in257 patients with UCLP and a noncleft group (all definitions in Appendix).2plication” calls for an extra oral surgery pro- Participantscedure and an increase in the duration of the The inclusion criteria for participants withorthodontic treatment. The relapse tendency UCLP of this study were as follows:in patients with complete clefts is greater whencompared with noncleft patients, and this is ● nonsyndromic clefting and no other malfor-related to the scar tissues from the surgeries. A mation;tight upper lip and scars in the alveolus and in ● all surgery and treatment follow-up by thethe palate will encourage the migration of Oslo Cleft Team;teeth into crossbite.8,9 The continued impair- ● full records (cephalograms, study models andment of maxillary growth together with con- occlusal radiographs of the bone grafted clefttinued mandibular growth in the late teens region, and clinical case notes) available at(especially for males)4,10 may be factors in the approximately 20 years of age; andworsening of the occlusion seen in some pa- ● complete bony cleft, although patients withtients in the late teens or early twenties. a soft tissue band (Simonart’s band) were The purpose of the present paper is to pres- included.ent dentofacial outcomes at the mean age of 20years for a cohort of consecutively treated pa- The sample consisted of the first 50 patientstients with UCLP using study models, cephalo- born from January 1, 1975, who met the inclu-grams and occlusal radiographs of the bone- sion criteria. It included 17 female and 33 malegrafted region. The occlusal changes from patients born between January 1, 1975, and Oc-debonding to follow-up at about 5 years later is tober 1979. None of the patients in the sampledescribed as is the total amount of surgical in- had chosen to have orthognathic surgery by theterventions and orthodontic treatment. time of record collection, although surgery had
  • 4. 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. ong-term follow-up to adulthood of a spe- L cific treatment protocol is a desirable but relatively uncommon occurrence in the cleft literature because the following circumstances may not commonly coexist: adequate case Senior Lecturer in Craniofacial Anomalies, Dental School, Uni- load, commitment to research, consistencyversity of Manchester and affiliated with the Oslo Cleft Team,Department of Plastic Surgery, Oslo University Hospital, and Bredt- over time of treatment methods, record collec-vet Resource Center and Adjunct Professor at the Faculty of Odon- tion, team membership, and patient atten-tology, University of Oslo, Norway; Head of Dental Unit, Depart- dance.ment of Plastic Surgery, Oslo University Hospital, Norway; Enemark et al1 appear to have reported theProfessor, Department of Plastic Surgery, Oslo University Hospital, first major longitudinal long-term follow-up.Norway. This article is based on the work of the Oslo Cleft Team, Oslo The study by Enemark et al involved multidis-University Hospital, Norway. ciplinary evaluation of 57 patients with unilat- Address correspondence to Gunvor Semb, Dental School, Univer- eral cleft lip and palate (UCLP) at 21 years ofsity of Manchester, Higher Cambridge Street, Manchester M15 6FH, age and included skeletal and soft-tissue facialUnited Kingdom. E-mail: gunvor.semb@manchester.ac.uk © 2011 Elsevier Inc. All rights reserved. growth (cephalometry), occlusion, speech, 1073-8746/11/1703-0$30.00/0 and need for secondary surgery. Fifty-one of doi:10.1053/j.sodo.2011.02.005 57 patients had an acceptable occlusion. Seminars in Orthodontics, Vol 17, No 3 (September), 2011: pp 207-224 207

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