Treatment outcome after two-stage palatal closure in unilateral cleft lip and palate: a comparison with Eurocleft.

OBJECTIVE: To evaluate dental arch relationships of patients with unilateral cleft lip and palate (UCLP) treated with a two-stage palatal closure and to compare them with the six centers from the Eurocleft study that used various treatment protocols. DESIGN: Repeated-measures study. SETTING: Cleft Palate Craniofacial Unit of Radboud University Nijmegen Medical Center, Nijmegen, the Netherlands. PATIENTS: Records of 9-year-old children with complete unilateral cleft lip and palate (n = 43) were included.Interventions: The dental arch relationships of these patients were assessed by applying the Goslon Yardstick and subsequently compared with the Goslon outcome of the six-center Eurocleft study. MEAN OUTCOME MEASURES: Statistics of intra- and interexaminer agreement. RESULTS: For the Nijmegen UCLP group, 9% of dental arch relationships had a Goslon score of 1, 52% had a score of 2, 30% has a score of 3, 9% had a score of 4, and none had a score of 5. The mean Nijmegen Goslon score showed no significant differences with Eurocleft centers A, B, and E, which achieved the best treatment results, but did significantly differ from Goslon outcomes of Eurocleft centers D (p < .001), C, and F (p < .01), which had relatively poor treatment outcome. CONCLUSIONS: Treatment outcome of the patients in the Nijmegen UCLP group treated with two-stage palatal closure was comparable with the results of the Eurocleft centers with the best outcome. Treatment protocol could not explain differences in the quality of treatment results.     

Palate height: another indicator of surgical outcome in unilateral cleft lip and palate?

OBJECTIVE: To determine whether palate height and maxillary arch depth are systematically related to the surgical center at which primary repair in unilateral cleft lip and palate (UCLP) was carried out. DESIGN: A retrospective comparison based on study casts of consecutive cases of UCLP obtained at age 9 years from six different centers. The observer who conducted measurements was blinded to the source of individual records. SETTING: The patients whose records were analyzed received all their surgical care in a national health service setting in six different northern European centers and regions. PATIENTS: Patients were consecutively treated Caucasian children with non-syndromic complete UCLP born in the period 1976 to 1979. MAIN OUTCOME MEASURES: The main outcome measures for the original study were craniofacial form, dental arch relationships, nasolabial appearance, and speech. This report focuses on measurements of anterior maxillary arch depth and palate height. Results: Anterior arch depth and anterior palate height showed some variation among the centers. There was a tendency for anterior arch depth and palate height to also be reduced at centers at which patients showed unfavorable dental arch relationships. CONCLUSIONS: Anterior arch depth and palate height might be considered in future studies of surgical outcome and in their possible relationship to problems of articulation.     

Dental arch relationships after two-flap palatoplasty in Taiwanese patients with unilateral cleft lip and palate

The authors evaluated the dental arch relationships of patients with unilateral cleft lip and palate treated with two-flap palatoplasty at the Chang Gung Craniofacial Center, Taipei, Taiwan, and compared them with the 6 centers from the Eurocleft study. Intraoral dental photographs of 60 consecutively treated Taiwanese patients with complete unilateral cleft lip and palate were used. The dental arch relationships were rated with the Goslon yardstick and compared with the Goslon outcome of the 6 center Eurocleft study. The strength of agreement of rating was assessed with quadratic-weighted kappa statistics. Inter- and intra-examiner agreements were high. 75% of patients were classified into poor or very poor categories, and the mean Goslon score was 3.92. These results showed no significant difference with Eurocleft center D, which had relatively poor treatment outcome. These data suggest that intraoral dental photographs provide a reliable method for rating dental arch relationships. Dental arch relationships in patients with unilateral cleft lip and palate at Chang Gung Craniofacial Center were unfavorable. This seemed to be attributable to the surgical procedures and racial differences in craniofacial morphology.     

A six-center international study of treatment outcome in patients with clefts of the lip and palate: Part 3. Dental arch relationships.

One hundred and forty-nine dental casts of subjects with complete unilateral clefts of the lip and palate from six European cleft palate centers were assessed by means of the Goslon Yardstick. The Yardstick proved capable of discriminating between the quality of the dental arch relationships between the six centers. Two centers showed especially poor results. Three centers obtained satisfactory results although differing surgical techniques were used in these centers. One of the centers showing satisfactory dental arch relationships employed a more complex and expensive treatment program than the other two centers, which both used simpler centralized treatment regimens.     

The Eurocleft study: intercenter study of treatment outcome in patients with complete cleft lip and palate. Part 3: dental arch relationships.

OBJECTIVE: To compare dental arch relationships up to age 17 in individuals with complete unilateral cleft lip and palate (UCLP) treated at five European centers. DESIGN: Longitudinal cohort study, where results were previously reported at 9 years and follow-up measurements were obtained for 12 and 17 years. SETTING: Multidisciplinary cleft services in Northern Europe. SUBJECTS: 127 consecutively treated individuals with repaired UCLP. MAIN OUTCOME MEASURE: Panel rating of dental arch relationship. RESULTS: The results revealed that at 17 years of age three of the centers had better ratings in dental arch relationship (means scores: 1.7, 1.9, and 2.2, respectively) than the other two centers (3.3, 3.4) at statistically significant levels ( p < .01 to p < .001). CONCLUSION: The results confirm that systematic differences in dental arch relationships may occur between different cleft centers, but do not allow specific causal factors to be identified.     

Photographs of study casts: an alternative medium for rating dental arch relationships in unilateral cleft lip and palate.

OBJECTIVE: To investigate the reliability of using photographs of study casts as an alternative to casts for rating dental arch relationships. DESIGN: Repeated-measures study. SETTING: Cleft Palate Center of the University Medical Center Nijmegen, Nijmegen, The Netherlands. PATIENTS: Records of children with complete unilateral cleft lip and palate (UCLP) (n = 49) at the age of 9 years were included. MEAN OUTCOME MEASURE(S): Statistics of intra- and interexaminer agreement. RESULTS: No significant differences were found between the rating of dental casts and photographs of dental casts, using the Goslon Yardstick. CONCLUSIONS: Photographs of dental casts provide a consistent, reproducible method for rating dental arch relationships in patients with UCLP at the age of 9 years and provide a reliable alternative to the application of the Goslon Yardstick on dental casts.     

单侧完全性唇腭裂上下牙弓关系评价研究

目的　评价单侧完全性唇腭裂（UCLP）患者上、下颌牙弓关系的协调性,并与亚洲和欧洲几大著名唇腭裂治疗中心的研究结果进行比较,为唇腭裂继发牙牙合畸形的诊断、矫治设计和序列治疗提供依据。方法　回顾性分析2013年3月至2014年3月于青岛大学附属医院口腔正畸科就诊的52例UCLP患者治疗前的记存模型,按照Goslon Yardstick 评价系统和Eurocleft三分类法进行牙弓协调性评价。与中国台湾长庚医院、日本东京大学医院及欧洲6所唇腭裂治疗中心（A～F）的同类研究结果相比较,并进行统计学分析。结果　本中心UCLP患者Goslon Yardstick平均等级为3.75 ± 0.93,Goslon Yardstick等级为4的患者最多,占36.5%,59.6%患者属于差及较差的等级。与台湾长庚医院、东京大学医院及欧洲唇腭裂D治疗中心的结果相接近（P＞0.05）,比其他5所欧洲唇腭裂治疗中心患者的牙弓协调性差（P＜0.05）。结论　UCLP患者上、下牙弓协调性差。青岛大学附属医院接受正畸治疗的UCLP患者,上下牙弓协调性与台湾长庚医院、东京大学医院、欧洲唇腭裂D治疗中心接近,比其他5所欧洲唇腭裂治疗中心牙弓协调性差。     

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??Objective    To evaluate the dental arch relationship of patients with unilateral complete cleft lip palate??UCLP??by comparing them with previous study and to provide theoretical basis on diagnosis??treatment plan design and team approach for patients with UCLP. Methods??Totally 52 UCLP patients treated in the Department of Orthodontics in the Affiliated Hospital of Qingdao University during March 2013 to March 2014 were selected. The dental models of UCLP patients were categorized using Great Ormond Street??London and Oslo Yardstick??Goslon Yardstick??index. Compare the results with the Goslon Yardstick scores of Chang Gung Craniofacial Center??Hospital of Tokyo University and 6 Eurocleft centers reported in previous studies and make statistical analysis. Results??Mean Goslon Yardstick score of UCLP treated in Affiliated Hospital of Qingdao University was 3.75±0.93??36.5% patients had a Goslon Score of 4??and 59.6% patients were classified into poor and very poor categories. The results of our center showed significant differences from those of Eurocleft centers A??B??C??E and F??P < 0.05????but did not differ significantly from those of Eurocleft center D??Chang Gung center or Hospital of Tokyo University??P > 0.05??. Conclusion??Dental arch relationship in patients with UCLP in the Affiliated Hospital of Qingdao University is poor??which is similar to that in Chang Gung Craniofacial Center??Hospital of Tokyo University and Eurocleft center D??but is poorer than the other fove Eurocleft centers.     

A comparison of craniofacial form in Northern Irish children with unilateral cleft lip and palate treated with different primary surgical techniques.

OBJECTIVE: The quality of outcomes in patients with unilateral cleft lip and palate (UCLP) was compared between two senior plastic surgeons. One surgeon carried out a one-stage Wardill-Kilner palate repair. The other surgeon employed a vomer flap hard palate repair followed by a von Langenbeck soft palate closure (Oslo protocol). DESIGN: Retrospective analysis. PATIENTS: Thirty-four children (mean age 9.7 years) born with complete skeletal UCLP in Northern Ireland from 1983 to 1991 who received primary repair surgery from one of the two surgeons. MAIN OUTCOME MEASURES: Cephalometric analysis was used to determine the craniofacial form and soft tissue profile. The quality of the dental arch relationships was independently assessed using the Goslon ranking system. RESULTS: Twenty-nine of the 34 subjects had good or satisfactory arch relationships. Comparison between the surgeons revealed that the Wardill-Kilner group had a greater proportion of Goslon grades of greater than 3, indicating poor arch relationships. However, this difference failed to reach statistical significance. There were no significant cephalometric differences between patients treated by the two surgeons. CONCLUSIONS: Although the difference was not statistically significant, the highest proportion of patients likely to require orthognathic surgery was found in those treated using the Wardill-Kilner technique.     

The Slavcleft: A three-center study of the outcome of treatment of cleft lip and palate. Part 2: Dental arch relationships

PurposeOur aim was to evaluate the dental arch relationship in a preadolescent Slavic population with unilateral cleft lip and palate (UCLP) by using the Goslon Yardstick.Materials and methodsPatients treated in Warsaw, Poland (n = 32), Prague, Czech Republic (n = 33) and Bratislava, Slovakia (n = 30) were included in this retrospective study. Each cleft center used a unique surgical protocol. Three raters scored blindly the dental arch relationship on plaster models. Intra- and inter-rater agreement were assessed with kappa statistics, and differences between the groups were evaluated with one-way analysis of variance. Intra-rater agreement was very good (k > 0.825), while inter-rater agreement was either good or very good (kappa >0.703).ResultsWe found that patients treated in Warsaw showed a more favorable dental arch relationship (Goslon score = 2.58, SD = 0.77) than patients treated in Prague (Goslon score = 3.21, SD = 1.04). Patients treated in Bratislava showed an intermediate Goslon score (3.07; SD = 0.99).ConclusionThis study showed that the dental arch relationships in patients treated in Warsaw with a one-stage repair were more favorable than in patients treated in Prague and Bratislava with a two-stage protocol and comparable to the best results obtained in the Eurocleft and Americleft studies.     

Assessment of dental arch relationships in Japanese patients with unilateral cleft lip and palate.

OBJECTIVE: Evaluation of the dental arch relationships of Japanese patients with unilateral cleft lip and palate (UCLP) from the orthodontic clinic of the University of Tokyo Hospital (UTH) compared with patients treated by the Oslo Cleft Team, Norway. DESIGN: Retrospective study and comparison with previous reports. MATERIALS: Dental models of 24 patients with UCLP in UTH taken before orthodontic treatment and before alveolar bone grafting were included. Surgeons in many hospitals performed primary surgeries. These models were matched for age and gender with 24 models from a consecutive series of patients treated by the Oslo Cleft Team as part of the Eurocran Good Practice Archive. A total of 48 models were evaluated. MAIN OUTCOME MEASURE: Dental arch relationship was rated with the Goslon Yardstick. The strength of agreement of rating was assessed with weighted kappa statistics. RESULTS: Intra- and interexaminer agreements evaluated by weighted kappa statistics were high, indicating good reproducibility. Almost 60% of the patients in UTH were classified into poor or very poor categories, and the mean Goslon score was 3.50. These results show a contrast to those in Oslo and were the poorest in comparison with previous reports. CONCLUSION: Dental arch relationships in patients with UCLP in UTH were poor. This seemed to be attributable to surgical procedures, but a factor of racial difference in the craniofacial morphology was also considered. Further intercenter research is required to clarify this point.     

Predictors of poor dental arch relationship in young children with unilateral cleft lip and palate

The aim of this cross-sectional outcome study using retrospective data capture of treatment histories was to examine the characteristics of young children with unilateral cleft lip and palate who had poor dental arch relationship (i.e., Goslon 5). The study sample comprised 120 children born with nonsyndromic complete unilateral cleft lip and palate between 1995 and 2003, and were aged between 5.0 and 7.0 years (mean age, 5.1 years) at the time of data collection. The dental arch relationship was assessed using the Goslon yardstick from intraoral dental photographs. An independent investigator recorded treatment histories from the clinical notes. The inter- and intraexaminer agreements evaluated by weighted kappa statistics were high. There was no association between dental arch relationship and the type of presurgical orthopedics or pharyngeal flap. Dental arch relationship was associated with the initial cleft size (odds ratio, OR = 1.3; 95% confidence interval, CI = 1.1-1.5, p < 0.01), surgeon grade for palate repair (OR = 5.0, 95% CI = 1.2-19.9, p < 0.05), and primary gingivoperiosteoplasty (OR = 2.8, 95% CI = 1.0-8.1, p = 0.05). These data suggest that intraoral dental photographs provide a reliable method for rating dental arch relationship. Wide initial cleft, high-volume surgeon, and primary gingivoperiosteoplasty are predictors of poor dental arch relationship outcome in young children with unilateral cleft lip and palate. These findings may improve treatment outcome by modifying the treatment protocol for patients with unilateral cleft lip and palate.     

The effects of palatoplasty and pre-surgical infant orthopedic treatment on occlusion in unilateral cleft lip and palate patients

PurposeThe aim of this study was to evaluate the effect of pre-surgical infant orthopedic treatment (Hotz plate) and type of palatoplasty on the dental arch relationship and the dental arch morphology of unilateral cleft lip and palate (UCLP) patients.Materials and methodsSeventy-four children with UCLP were divided into three groups. One group had undergone one-stage palatoplasty without Hotz plate (OSP w/o H), the second had undergone one-stage palatoplasty with Hotz plate (OSP w/H), and the third had undergone two-stage palatoplasty with Hotz plate (TSP w/H). We evaluated the dental models which were taken during initial examination at our orthodontic clinic, using the Goslon Yardstick, the 5-year-old index, and dental model analysis.ResultsRegarding both indices, there were no significant differences among the three groups. However, the dental arch width between maxillary deciduous canines in OSP w/H and TSP w/H was significantly greater than that of OSP w/o H. The dental arch width at the maxillary deciduous second molars in TSP w/H was significantly greater than in OSP w/H and OSP w/o H.ConclusionDental arch relationship in UCLP patients was not influenced by the type of palatoplasty and the use of pre-surgical infant orthopedic treatment. Our results suggest that pre-surgical infant orthopedic treatment results in the increase of anterior dental width, whereas two-stage palatoplasty is significantly effective for increasing posterior dental width in UCLP patients.     

Complete unilateral cleft lip and palate: validity of the five-year index and the Goslon yardstick in predicting long-term dental arch relationships.

OBJECTIVE: To assess the validity of the 5-year index by subjecting study models at the age of 5 years to both the 5-year index and the Goslon yardstick, and then relating these results to the Goslon ratings at 10 years. DESIGN: Retrospective study. SETTING: Sahlgrenska University Hospital, Gothenburg, Sweden. PATIENTS: Study models of 94 patients with unilateral cleft lip and palate (UCLP) were evaluated at the ages of 5 and 10 years. The dental arch relationships were judged and categorized by using the Goslon yardstick for the 10-year models and both the Goslon yardstick and the 5-year index for the 5-year models. RESULTS: When used for 5- and 10-year models, the Goslon yardstick showed a kappa score of 0.539 (weighted kappa = 0.579) with a moderate strength of agreement. However, 5-year index scores at 5 years compared with the Goslon scores at 10 years showed a kappa score of only 0.043 (weighted kappa = 0.090), showing poor strength of agreement. Goslon scores at 10 years showed improvement in 14 cases when graded by the same Goslon yardstick at 5 years, whereas there was improvement in 23 cases when the 5-year models were graded by the 5-year index (actual improvement in scores in UCLP cases is highly unlikely). CONCLUSIONS: Although use of the Goslon yardstick at 5 years has demonstrated some inherent flaws in its use at that age, these drawbacks are fewer than those when the 5-year index is used at 5 years of age.     

腭裂修复术对不同年龄患者上下颌牙弓关系影响的研究

目的 通过回顾性研究探讨接受腭裂修复术的年龄对患者上颌牙弓相对于下颌牙弓位置关系的影响. 方法 年龄>10岁、腭裂术后2年以上的单侧完全性唇腭裂患者103例,根据接受腭裂修复手术时的年龄分为3组,A组:≤3.0岁手术组(n=38)、B组:≤6.0岁手术组(n=36)和C组:>6.0岁手术组(n=29).用上下颌牙弓石膏模型,对其牙弓关系行Goslon Yardstick等级评价,并对不同手术年龄组间的Yardstick等级进行统计学检验. 结果 统计学检验显示Yardstick等级在A组与B组间差异无统计学意义(P>0.05),A组与C组间差异有统计学意义(P<0.05),B组与C组间差异无统计学意义(P>0.05). 结论 6.0岁以下行腭裂手术的两组患者的上颌牙弓相对于下颌牙弓的后缩程度无差异,6.0岁以上行腭裂手术患者的上颌牙弓相对后缩程度要明显小于3.0岁以下手术者,稍小于6.0岁以下手术者,上颌牙弓相对后缩程度随手术年龄的增大有减小的趋势.     

Retrospective evaluation of treatment outcome in Japanese children with complete unilateral cleft lip and palate. Part 1: Five-year-olds' index for dental arch relationships.

OBJECTIVE: To evaluate the dental arch relationships of Japanese children with complete unilateral cleft lip and palate (UCLP) and to examine the 5-year-olds' index for its validity. DESIGN: Retrospective study and comparison with previous reports. SUBJECTS: One hundred thirty-six children with complete UCLP who received primary cheiloplasty and palatoplasty in the Kyushu University Hospital from 1966 to 1999. MATERIALS: Dental models taken from children 53 to 67 months of age and their cephalograms. Methods: Study models were assessed using five scores; 1=excellent, 2=good, 3=fair, 4=poor, and 5=very poor, in accordance with the 5-year-olds' index and also evaluated using Huddart and Bodenham's numerical classification. Dental arch widths, three-dimensional maxillary dental arch form, and lateral cephalograms were traced and measured. The outcome by 5-year-olds' index was compared with Huddart and Bodenham's numerical classification, dental arch dimensions, and cephalometric measurements. RESULTS: Occlusal outcome evaluated by the 5-year-olds' index was rated 2.95, which was classified as fair. This index rating showed a significant relationship with numerical classification and dental arch length, but not with dental arch width. The index showed a relationship with mandibular form and position, but not with maxillary position. CONCLUSION: The occlusal outcome of the cases with UCLP was fair as evaluated using the 5-year-olds' index. The index evaluates the anteroposterior relationship of maxillary/mandibular dental arches but does not evaluate the collapse of maxillary segments.     

Dentoalveolar relations in children born with a unilateral cleft lip and palate (UCLP) in Western Australia.

OBJECTIVE: Our objective was to evaluate complete unilateral cleft lip and palate repair outcome in the Cleft Unit in Perth, Western Australia, by assessment of dentoalveolar relationships. DESIGN: This is a retrospective study. SETTING: Our subjects were individuals under the care of the cleft team in Perth, Western Australia. PARTICIPANTS: All patients with unilateral cleft lip and palate and available 6-year casts who had been born since January 1, 1985, were identified from the cleft unit's database. The nature of the cleft was verified by examination of birth study models and photographs. A total of 54 such patients were identified. MAIN OUTCOME MEASURES: Main outcome measures were identified through dental arch relationship grading of study models using the 5 Year Old Study Model Index. RESULTS: Interexaminer and intraexaminer agreement kappa statistics revealed good to very good agreement using this index. The results indicate that the surgical outcome was graded as excellent, good, or fair for 77% of patients and poor or very poor for 23% of patients. CONCLUSIONS: The results of the Western Australia study compare favorably to the overall U.K. outcome (the Clinical Standards Advisory Group study) but unfavorably to the results of some European centers, such as Oslo.     

The relationship between arch dimensions and the 5-year index in the primary dentition of patients with complete UCLP.

OBJECTIVE: To compare dental arch dimensions of children in the primary dentition with repaired unilateral clefts of the lip and palate (UCLP) to a noncleft group of a similar age and determine how the dimensions of the cleft arches relate to an index of treatment outcome. METHOD: Dental study casts of 44 5- to 6-year-olds with complete UCLP (22 boys and 22 girls) from a single center, whose primary surgery had been carried out by one surgeon, were matched for age, sex, and ethnicity with dental study casts from a longitudinal growth study. Analysis of variance was used to ascertain differences in arch dimensions between the two groups. The cleft group casts were then assessed with an established index of surgical outcome, the 5-year-old index. Spearman's rank correlation coefficient was used to see how the arch dimensions of the cleft group related to the categories of the index. RESULTS AND CONCLUSIONS: Maxillary arch dimensions were significantly smaller in the cleft group than in the noncleft group, irrespective of sex (p < .05). In the mandibular arch, there was no difference between the cleft and noncleft groups (p > .05). Maxillary arch dimensions of the cleft group correlated significantly with the 5-year-old index for arch length and intercanine width (p < .05) but not intermolar width (p = .842). This would suggest that the 5-year-old index is a suitable tool for assessing the outcome of treatment in the primary dentition for anteroposterior and anterior transverse arch dimensions.     

单侧完全性唇腭裂患者上下颌牙弓关系的评价

目的：用Goslon Yardstick评价系统来评价替牙列期和恒牙列期单侧完全性唇腭裂患者上、下颌牙弓协调性的差异,为继发牙畸形的诊断、矫治设计和序列治疗提供依据。方法：对40例患者取牙模型并根据牙列情况分为两组,替牙列期组（n=18）和恒牙列期组（n=22）。用石膏模型,对其牙弓关系行Goslon Yardstick等级评价,并对不同牙列期组间的Yardstick等级进行统计学检验。结果：替牙列期组中,22.2%患者上下颌牙弓协调性差,属于GoslonYardstick等级4和5;Goslon Yardstick均值为2.72。恒牙列期组中,40.9%患者上下颌牙弓协调性差,属于GoslonYardstick等级4和5;Goslon Yardstick均值为3.46。结论：单侧完全性唇腭裂患者恒牙列期比替牙列期上下颌牙弓协调性差,治疗难度更大。     

Cleft lip and palate care in the United Kingdom--the Clinical Standards Advisory Group (CSAG) Study. Part 2: dentofacial outcomes and patient satisfaction.

OBJECTIVE: To describe facial development and appearance, quality of bone grafts, oral health, and patient/parent satisfaction, with clinical outcome, for children in two age cohorts born with unilateral cleft lip and palate (UCLP) throughout the United Kingdom. DESIGN: Cross-sectional outcome study. SETTING: Fifty National Health Service cleft centers. PARTICIPANTS: Children born with complete UCLP between April 1, 1982, and March 31, 1984, (12-year-olds) and April 1, 1989, and March 31, 1991 (5-year-olds). Data were collected for 239 5-year-olds and 218 12-year-olds. The parents of these children were also interviewed to determine levels of satisfaction with care received. MAIN OUTCOME MEASURES: Skeletal pattern, dental arch relationship, success of alveolar bone grafting, facial appearance, oral health status, and patient/parent satisfaction. RESULTS: Nearly 40% of 5- and 12-year-olds had poor dental arch relations, and 70% of 12-year-olds had midface retrusion. Fifteen percent of 12-year-olds had not received an alveolar bone graft, and only 58% of bone grafts that had been undertaken were successful. Twenty percent of 12-year-olds and 40% of 5-year-olds had untreated dental caries. Less than one-third of subjects had a good facial appearance as judged by a panel of experts. Levels of patient and parent satisfaction were generally high. CONCLUSION: A rigorous evaluation of cleft care in the United Kingdom reveals disappointing outcomes.