Structural outcomes in the Cleft Care UK study. Part 2: dento-facial outcomes

A child born with a cleft lip and/or palate (CLP) will receive treatments from a range of specialties as the anomaly affects several anatomical areas. Correction of anatomical structures is a key determinant of facial appearance, dento-alveolar relations and function. Appearance and dento-alveolar relationships are thus important outcome measures in these children. A number of methods are available to evaluate appearance. These include photographs, videotapes, projected cine films, black and white drawings, identikit pictures (a composite picture made from individual elements) and computer generated pictures 1. Facial aesthetics can be determined by direct clinical assessment or indirect assessment using models or clinical photography 2. Much work has gone into developing measures for rating nasolabial aesthetics. Probably, the most widely adopted method is that described by Asher-McDade et al. 3. This method focuses on rating photographs of the child’s face and uses a five-point rating scale from very poor to very good. It can be used to assess nasal form, symmetry of the nose, shape of the vermillion border as well as upper lip and nasal profile. This outcome measure has been used in several large multicentre studies 4,5. Several systems have been described for measuring dento-alveolar relationships as an outcome measure for CLP. The first widely adopted dento-alveolar outcome measure was the Great Ormond Street, London and Oslo Yardstick, more commonly known as GOSLON 6. The reliability of the yardstick has been confirmed in several studies 7–9. Although GOSLON provides a useful outcome measure in the early permanent dentition, it cannot be used to assess anatomical outcome until a child is at least 10 years old. A child of this age with cleft lip and palate may have had orthodontic treatment or secondary alveolar bone grafting that, along with primary surgery, will influence the observed outcome. The 5-Year-Olds’ Index was therefore developed to provide an earlier measure of outcome that is strongly determined by primary surgery 10. Following CSAG, the 57 units which provided cleft care before have now been reduced to 11 centres or managed clinical networks 11. This has led to an increase in the number of children seen and treated in each cleft unit, and it is anticipated that this high-volume multidisciplinary service has driven up the quality of care and outcomes. The primary objective of this study was to compare two key anatomical outcomes for children born with UCLP (facial appearance and dento-alveolar relations) pre- and post-CSAG to assess potential changes in quality of care. The secondary objective was to assess agreement between and within assessors for both outcomes.