Semelhante a Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway
Semelhante a Twenty year follow-up of 50 consecutive patients born with unilateral complete cleft lip and palate treated by the oslo cleft team, norway (20)
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 referred
to the Oslo Team annually. The Norwegian pop- Pregrafting Orthodontic Preparation (When
ulation is fairly homogenous, and staff at the Necessary)
Cleft Centre have tended to remain on staff for
Anterior cross-bites and severe rotations of
a long time. All treatment and travel is free for
maxillary incisors are corrected. This is mostly
the patient and one parent, and patient atten-
done if the patients are very motivated to have
dance has been very good. One principle since
their new front teeth aligned and sometimes
the 1960s has been that the Team’s specialists
to move a retroclined cleft side incisor out of
should do all key treatment. With long distances
to travel and a desire to minimize the burden of the alveolar cleft region to improve surgical
care 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 corrected
adopted, and treatment periods have been con- just before bone grafting using a removable
centrated to keep visits to a minimum. Since the quad helix, which is kept in place for 3 months
1960s, 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 clefts
essary. 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 growth
clefts 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 the
The 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 alveolar
grafting, changes to primary surgery protocols clefts,5 and many laterals that are present are
have been modest. Since 1968, in patients with malformed or erupt ectopically and cannot be
UCLP, the lip was closed at 3 months of age by kept with a good long-term prognosis. Other
use of the Millard procedure2 and at the same teeth are more frequently missing in patients
time the hard palate was closed by a single layer with clefts.6
vomer 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 or
months, 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 Oslo
cancellous bone from the iliac crest was intro- orthodontic space closure has been favored over
duced 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 the
and/or nose corrections) was performed ac- incisor position while posterior teeth are moved
cording to individual needs. mesially. However, we do not consider protrac-
tion to achieve significant or lasting skeletal
change in the position of the maxilla. Facial
The Orthodontic Protocol for UCLP esthetics takes precedence over “normal” tooth
No presurgical orthopedics or treatment in the positioning, and slight proclination may help to
deciduous 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 who
introduction of alveolar bone grafting, orth- have had alveolar bone grafting.7 This “com-
3. Twenty-Year Follow-Up of UCLP 209
Figure 1. Changes in maxillary prominence (s-n-ss [sella-nasion-subspinale] or SNA angle) from 5 to 18 years in
257 patients with UCLP and a noncleft group (all definitions in Appendix).2
plication” calls for an extra oral surgery pro- Participants
cedure and an increase in the duration of the
The inclusion criteria for participants with
orthodontic treatment. The relapse tendency
UCLP of this study were as follows:
in patients with complete clefts is greater when
compared 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 the
the palate will encourage the migration of
Oslo Cleft Team;
teeth into crossbite.8,9 The continued impair-
● full records (cephalograms, study models and
ment of maxillary growth together with con-
occlusal radiographs of the bone grafted cleft
tinued 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; and
worsening of the occlusion seen in some pa-
● complete bony cleft, although patients with
tients 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 20
years for a cohort of consecutively treated pa- The sample consisted of the first 50 patients
tients 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 male
grafted 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 sample
described as is the total amount of surgical in- had chosen to have orthognathic surgery by the
terventions and orthodontic treatment. time of record collection, although surgery had
