The Americleft Project: A Proposed Expanded Nasolabial Appearance Yardstick for 5- to 7-Year-Old Patients With Complete Unilateral Cleft Lip and Palate (CUCLP).

OBJECTIVE: To develop a yardstick of reference photographs for nasolabial appearance assessments of 5- to 7-year-old patients with complete unilateral cleft lip and palate (CUCLP). DESIGN: Blind retrospective analysis of clinical records and comparison to historical controls. PATIENTS: Subjects were two groups of 6- to 12-year-olds (n = 124 and n = 135) and one group of 5- to 7-year-olds (n = 149) with nonsyndromic CUCLP from three previous Americleft studies, including cohorts from seven different cleft/craniofacial centers. INTERVENTIONS: All patients received the infant management protocols of their respective centers. Eleven trained and calibrated judges (five participated in all three studies) did blind ratings of nasolabial appearance using the Asher-McDade method. MAIN OUTCOME MEASURES: Patients receiving the most consistent ratings between judges, selected first from the groups of 6- to 12-year-olds, were used to create a pilot yardstick for eventual use in the third study of 5- to 7-year-olds. For each of the Asher-McDade categories, 8 of the 5- to 7-year-old patients receiving the most consistent scores between raters were ranked by 10 judges for a final elimination to leave three per category. RESULTS: Using this method of successive changes in rating methods, a new reference yardstick for nasolabial appearance rating was established and linked to the original Asher-McDade method as well as the single examples in a previously published yardstick for patients with CUCLP. Pilot testing using the yardstick improved reliabilities. CONCLUSIONS: Use of an expanded nasolabial yardstick of reference photographs representative of the range of possibilities of each of the five Asher-McDade categories is now available to see if reliability of these ratings can be improved.

The Americleft Project: A Comparison of Short- and Longer-Term Secondary Alveolar Bone Graft Outcomes in Two Centers Using the Standardized Way to Assess Grafts Scale.

OBJECTIVE: To compare length of follow-up and cleft site dental management on bone graft ratings from two centers. DESIGN: Blind retrospective analysis of cleft site radiographs and chart reviews for determination of cleft-site lateral incisor management. PATIENTS: A total of 78 consecutively grafted patients with complete clefts from two major cleft/craniofacial centers (43 from Center 1 and 35 from Center 2). INTERVENTIONS: Secondary iliac crest alveolar bone grafting, at a mean age of 9 years 9 months (Center 1: 9 years 7 months; Center 2: 10 years 0 month). MAIN OUTCOME MEASURES: The Americleft Standardized Way to Assess Grafts scale from 0 (failed graft) to 6 (ideal) was used to rate graft outcome at two time points (T1, T2). Average T1 was 11 years 1 month of age, 1 year 3 months postgraft. Average T2 was 17 years 11 months of age, 8 years 0 months postgraft. Six trained and calibrated raters scored each radiograph twice. Reliability was calculated at T1 and T2 using weighted kappa. A paired Wilcoxon signed rank test (P < .05) tested T1 and T2 differences for each center. A Kruskal-Wallis test was used to determine the significance of differences between centers at T1 and T2. Correlation tested whether T1 ratings predicted T2. Linear regression determined possible factors that might contribute to graft rating changes over time. RESULTS: Reliability was good at T1 and T2 (interrater = .713 and .701, respectively; intrarater = .790 and .805, respectively). Center 1 scores were significantly better than those from Center 2 at both T1 (5.21 versus 3.29) and T2 (5.18 versus 3.44). There was no statistical difference between T1 and T2 scores for either center; although, there was a greater chance of bone graft score improving with completion of canine eruption and substitution for missing lateral incisors. CONCLUSIONS: Short-term ratings of graft outcomes identified significant differences between centers that persisted over time. Dental cleft-site management influenced final graft outcome.

Craniofacial correction of giant frontoethmoidal encephalomeningocele.

The surgical treatment of a very large anterior encephalocele in an infant is presented. Because of the large size of the encephalocele, a combined transfacial-transcranial approach was used for correction of the associated intracranial, cranioorbitonasal bone, and facial skin deformities.

Primary alveolar cleft bone grafting in unilateral cleft lip and palate: arch dimensions at age 8.

The purpose of this investigation is to determine whether primary alveolar cleft bone grafting in infants with unilateral cleft lip and palate (N = 17) leads to less favorable dental arch dimensions at age 8 when compared with other 8-year-old patients with unilateral cleft lip and palate who received no alveolar bone grafting procedures (N = 49). Dental casts were obtained for the primary grafted group, and arch lengths and widths were digitally recorded with a reflex microscope. These arch dimensions were then compared with the reported data for a nongrafted group and a noncleft group of 8-year-old children. The major findings were: 1) that the dental arches of both cleft groups generally demonstrated a significant diminution in length and width (P < 0.05) compared with the noncleft groups, and 2) that the patients who underwent primary alveolar cleft bone grafting showed no statistically significant difference for any arch dimension (P < 0.05) when compared with the nongrafted group lacking this additional surgical procedure.

Primary alveolar cleft bone grafting in unilateral cleft lip and palate: craniofacial form at age 8.

Counterpart analysis can be advantageous for the clinician interested in the underlying determinants of the craniofacial form for any given person. This analysis was performed for a group of patients who underwent primary alveolar cleft bone grafting (N = 18) and a group of patients who did not undergo grafting (N = 19) who were 8 years of age (+/- 6 months). The primary grafting group more frequently noted maxillary retrusion, but of a nonsignificant magnitude. Also, the primary grafting group had greater mean magnitudes of mandibular opening as a compensatory adjustment in some patients, but this could not be generalized to all patients who had underdone primary grafting. The mean magnitude of craniofacial vertical shortening was also greater for some patients who had undergone primary grafting, but it, too, did not exhibit a generalized pattern for all patients who had undergone primary alveolar cleft bone grafting procedures. This study emphasizes the great diversity of craniofacial skeletal adjustments made within each group of patients with unilateral cleft lip and palate and cautions the clinician against generalizations concerning a particular treatment protocol.

Direct current stimulation of the coronal suture in rabbits.

The purpose of this investigation was to determine whether a constant direct current stimulation applied at the coronal suture would alter sutural morphology and selected cephalometric parameters of the cranial vault and cranial base. In each of six rabbit litters (N = 36), animals were randomly assigned to control, sham, and experimental groups. At 21 days of age, the sham and experimental groups had thin titanium wire cathodes surgically positioned between the fascial layers of the scalp overlying the coronal suture. On this same day and on day 70, all animals had standardized lateral and dorsoventral cephalograms taken and also received lead acetate vital stain injections. The following results were demonstrated: (1) a significantly greater flexure in the cranial base angle (P < 0.01) for the experimental group at day 70; (2) no statistically significant differences for percentage changes (day 70/day 21) in cranial vault length or cranial vault width among the control, sham, and experimental groups (P < 0.05); (3) alterations in sutural morphology at day 70 for the experimental group, including lengthened collagenous fibers, abundant cartilage in the suture, and a twofold increase in the bony modeling of the ectocranial surface. This study concludes that, although the exact mechanisms of action for direct current stimulation remain unknown, this manipulation can indeed alter some parameters of the cranial skeleton and suture morphology.

A comparison of transverse and vertical pharyngeal flaps using electromyography and judgments of nasality.

Previous studies have reported less than adequate speech results for vertical types of pharyngeal flaps with some patients. However, no controlled judgments of nasality have been reported for transverse pharyngeal flaps, and no comparative studies have been done. In this investigation, 21 listeners evaluated nasality in two groups of seven cleft palate patients. One group had had vertical pharyngeal flaps, while the other group had had transverse pharyngeal flaps. The possible relationship of observable electromyographic activity to nasality was also studied. The results indicated that perceptual ratings of postoperative speech in the two groups did not differ significantly. Also, because similar muscle action potentials were observed in both types of pharyngeal flaps, it was concluded that this activity was not a contributing factor in the judgments of nasality.