Classification, recording, and cleft palate surgery at the Uppsala Cleft Palate Centre.

This paper describes the classification system, method of recording, and surgical techniques used in Uppsala for children with isolated cleft palate. The classification is based on the system described by Kernahan and Stark and the more detailed system described by the American Cleft Palate Association. Separation of the hard palate into thirds, and into right and left sides, assures a detailed description of the cleft, and separates small morphological differences. The longitudinal registration system was introduced into the Uppsala Cleft Palate Centre in 1967. After the initial recording at the time of primary surgery, it is repeated at 5, 8, 11, 14, 17, and 20 years. By emphasising the therapeutic aspects of various stages of growth, it has been possible to limit the recording to once every third year. This has resulted in an important reduction in the dose of radiation without compromising the reliability of the results. Children born before 1975 had clefts of both the soft and hard palate closed at 18-24 months in a one-stage procedure. For children born in 1975 and later a two stage technique has been used, while clefts limited to the soft palate only have been closed entirely in the first operation. At first, the soft palate cleft was closed at 18 months of age and the hard palate at 4 to 5 years. The timing was changed in several steps to the present soft palate closure at 6 months and hard palate closure at 2 years of age.

Morphology of isolated cleft palate in children, including Robin sequence, treated with one or two-stage operations.

A classification developed at the Uppsala Cleft Palate Centre was used to describe isolated cleft palate in children with and without Robin sequence. The study included 109 patients born between 1968 and 1983 with isolated cleft palate. In 46 patients the cleft was closed in a single operation and 63 were treated by a two-stage procedure. Of the 109 patients 70 (64%) were girls. In 19 patients (17%), the cleft was limited to the soft palate. Ninety of the patients had clefts of the hard palate and in 39 (43%) of these patients the clefts involved less than a third of the hard palate. Only four children (4%) had total clefts of both the hard and soft palate. The Robin sequence was diagnosed in 14 children (13%), and it was more common in boys with isolated cleft palate (7/39; 18%) than in girls (7/70; 10%). In those with Robin sequence the cleft was U-shaped anteriorly in nine (64%), with great variations in width. Generally, however, the clefts were wider than other clefts involving the hard palate. In all cases, closure of the soft palate was followed by a spontaneous reduction in the width of the remaining cleft in the hard palate. The greatest improvement was noted in subjects with the U-shaped clefts, in whom the position of the tongue probably had the greatest influence on the development of wide primary clefts. In 10 subjects with clefts of the soft palate only and 12 patients in whom the cleft included part of the hard palate (35%), only the first operation of the two-stage procedure was done because there was no residual cleft. In these subjects the original cleft had involved less than a third of the length of the hard palate.

Dental abnormalities and ectopic eruption in patients with isolated cleft palate.

The aim of this study was to evaluate the influence of cleft size and surgical treatment on the development of permanent teeth in patients with isolated cleft palate. The series comprised 109 children with isolated cleft palate, 70 girls and 39 boys, including 14 patients with Robin sequence. The patients were grouped according to the sagittal extent of the palatal cleft, measured on dental casts obtained before the primary palate surgery. Forty-six children were treated by one-stage palatoplasty, and 63 in two stages. The dentition was studied on orthopantomograms taken at 5, 8, 11, and 14 years of age. Congenitally missing permanent teeth (third molars excluded) were found in 33 subjects (30%). Children with large clefts had significantly more missing teeth than children with small clefts. The tooth most usually missing was the mandibular second premolar, followed by the maxillary lateral incisor, and the upper second premolar. The incidence of dental malformation was 23%, mostly mild forms. Ectopic eruption of the upper first permanent molars was seen in 23 (45%) of the subjects with large clefts, and in 18 (31%) of those with small clefts. The surgical method did not significantly affect the direction of the eruption. There is a correlation between cleft size and hypodontia, dental deformity, and ectopic eruption. Children with Robin sequence had almost the same incidence of hypodontia, malformed teeth, and ectopic eruption as children with large clefts. There was no correlation between surgical method and ectopic eruption of the maxillary first permanent molars.

The influence of tonsillar obstruction and tonsillectomy on facial growth and dental arch morphology.

Children, who were tonsillectomized because of sleep apnea were examined with respect to facial growth and dental arch morphology. Dental casts and lateral roentgencephalograms were analysed before surgery and two years after tonsillectomy. The findings were compared to data from children without tonsillary obstruction. A higher proportion of malocclusion than normal, especially open bite and crossbite, was noticed before surgery. Two years after surgery, 77% of the open bites were normalised and 50-65% of the buccal and anterior crossbites. The best results were seen in children operated before the age of 6.

Effects of adjuvants to local anaesthetics on their duration. I. Studies of dextrans of widely varying molecular weight and adrenaline in rat infraorbital nerve block.

Local anaesthetics of the amide type were studied in a modified rat infraorbital nerve block model, with which it was possible to determine varying degrees of sensory block. Of the agents investigated, 0.5% bupivacaine tended to give a longer duration of block than 2% prilocaine or 2% lidocaine, while 0.5% etidocaine had the shortest duration. The duration of prilocaine was prolonged by addition of adrenaline, 5 micrograms/ml, more than that of the other agents. Addition of dextrans of Mw 40-110 X 10(3) did not cause any prolongation of block induced by bupivacaine. When mixed with dextrans over a wide range of Mw (40-4900 X 10(3), prilocaine exhibited significant prolongations of its action by up to 200%. The extent of prolongation was dependent on the degree of block, the concentration of dextrans in the local anaesthetic solution, and the Mw of the dextran although in a less uniform way. An increase in the relative viscosity of the solutions might be a factor of importance for the prolonging effect of addition of dextran to local anaesthetics. Since a formulation providing analgesia of a long duration would be of clinical value, further studies on combinations of the comparatively low-toxicity agent prilocaine and macromolecular substances are of interest.

A longitudinal study of delayed periosteoplasty to the cleft alveolus.

The effects of delayed periosteoplasty were studied longitudinally from 5 to 17 years of age in 35 consecutive cases (24 boys and 11 girls) with clefts involving the maxillary alveolar process. The mean age at operation was 6.4 years. In patients younger than 7 years of age at the time of delayed periosteoplasty, good bone formation developed in 80%, compared with 47% after infant periosteoplasty. After delayed periosteoplasty the formation of new bone continued an average of 5 years postoperatively. The frequency of anterior crossbite was lower than that reported for other Scandinavian cleft lip and palate materials of the same age and type of cleft. Cephalometric analysis indicated that growth of the facial skeleton of the patients in the present material was well within the limits reported for the above-mentioned Scandinavian materials subjected neither to periosteoplasty nor to bone-grafting. The results indicate that delayed periosteoplasty might be a superior method in the reconstruction of the alveolar cleft in young individuals.

Experiences with infant and delayed periosteoplasty.

At the Cleft Palate Centre, Uppsala, Sweden, the periosteoplasty procedure had been used since 1964 to obtain bone continuity in the maxillary alveolar cleft area. This operation is performed either in infancy or as an early secondary (delayed) procedure. The amount of new bone formed in the alveolar cleft area was classified in 4 types according to Hellquist & Skoog 1976. The influence of the periosteoplasty on craniofacial growth and dental occlusion was studied longitudinally in different series of patients from the Uppsala region of Sweden, operated on with either infant or delayed periosteoplasty. As a result of delayed periosteoplasty, good bone formation in the alveolar cleft area was noted in 80% of the cases in patients younger than 7 years of age at the time of operation, compared with 47% after infant periosteoplasty. In the patients subjected to delayed periosteoplasty, the frequency of anterior crossbite was lower than that reported for other Scandinavian cleft lip and palate materials of the same age and type of cleft. Cephalometric analysis indicated that growth of the facial skeleton of the patients subjected to delayed periosteoplasty was well within the limits reported for other Scandinavian cleft lip and palate materials of the same age and type of cleft, subjected neither to periosteoplasty nor to primary bone-grafting.

The influence of cleft length and palatoplasty on the dental arch and the deciduous occlusion in cases of clefts of the secondary palate.

In patients with clefts of the secondary palate, the effect of surgical reconstruction was studied from the time of the palate repair, at the age of 18-24 months, to the age of 5 years. The material comprised 99 children (37 boys and 62 girls). The material was grouped according to the antero-posterior size of the cleft. The changes of the maxillary dimensions were studied on the casts by linear measurements. The occlusion was analysed by descriptive and numerical methods. In the deciduous dentition the smallest intercanine and intermolar dimensions were recorded in patients with large palatal clefts. A the age of 5, the frequency of anterior crossbite was 38% in patients with large palatal clefts, compared with 19--21% in patients with smaller clefts. In boys with cleft palates, the frequency of anterior crossbite was 13% higher than in girls, in spite of the fact that in the material the incidence of large palatal clefts was lower in boys than in girls. In cases of large clefts of the secondary palate, the incidence of anterior crossbite was 12.5 times higher than in a material of non-cleft patients of the same age.

The influence of primary periosteoplasty on maxillary growth and deciduous occlusion in cases of complete unilateral cleft lip and palate. A longitudinal study from infancy to the age of 5.

The influence of infant periosteoplasty upon the growth of the maxilla, its form and size, and the prevalence of malocclusion in the deciduous dentition was investigated. The material consisted of 66 patients with total unilateral clefts of the primary and secondary palate. Thirty-six had periosteoplasty performed in conjunction with cleft-lip and/or palate repair. Thirty patients were operated upon without periosteoplasty and served as controls. Repair of the lip had a notable effect upon the width of the alveolar cleft and palatal cleft, both in the periosteoplasty cases and in the controls, with no certain difference between the groups. Following lip repair, the anterior width of the alveolar arch was slightly reduced. After palatal repair a further reduction was noted in the deciduous dentition, both in the cases treated with periosteoplasty and in the controls, while the posterior width of the palate across the tuberosities increased during growth. In the deciduous dentition, no differences were found in intercanine and intermolar dimensions between the periosteoplasty cases and the controls. Thus, the new bone formed in the cleft area after periosteoplasty does not seem to withstand the contracting forces introduced by palate surgery. An increased length of the buccal alveolar arch on the cleft side, compared with that on the non-cleft side, was found at both the lip repair and the palate repair in the periosteoplasty cases, as well as in the controls. In the deciduous dentition, this difference was negligible. In the deciduous dentition an anterior position of the lateral maxillary segment proved more common in the periosteoplasty cases than in the controls. On the non-cleft side, there was an increased frequency of mesial occlusion and a corresponding decrease of neutral and distal occlusion in the periosteoplasty cases. No increased frequency of anterior crossbite was found even after repeated periosteoplasty, nor was the maxillary dental-arch length unfavourably influenced. Descriptive analysis of occlusion revealed an increase of buccal crossbite in the periosteoplasty cases of a select group of the widest clefts, treated by repeated periosteoplasty. These cases also had the highest total occlusal score according to the numerical classification, while the total occlusal score after one periosteoplasty in patients with less wider clefts was smaller than in the controls. In all patients who had undergone periosteoplasty new bone formed within the alveolar cleft. A good amount of new bone developed in about half the number of cases.(ABSTRACT TRUNCATED AT 400 WORDS)