Evaluation of dental arch relationship of patients with unilateral cleft lip and palate

Anjuman Preet Kaur Dua; Ajit Kumar Jaiswal; Kapil Dua

doi:10.4103/0976-4003.191723

ORIGINAL ARTICLE

Year : 2016 | Volume : 8 | Issue : 3 | Page : 135-138

Evaluation of dental arch relationship of patients with unilateral cleft lip and palate

Anjuman Preet Kaur Dua¹, Ajit Kumar Jaiswal², Kapil Dua³
¹ Department of Orthodontics, Baba Jaswant Singh Dental College and Research Institute, Ludhiana, Punjab, India
² Department of Orthodontics, Maharaja Ganga Singh Dental College, Sri Ganganagar, Rajasthan, India
³ Department of Conservative Dentistry, Christian Dental College, Ludhiana, Punjab, India

Date of Web Publication

7-Oct-2016

Correspondence Address:
Dr. Anjuman Preet Kaur Dua
78-C, BRS Nagar, Ludhiana - 141 012, Punjab
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0976-4003.191723

Abstract

Background: Several classifications have previously been described to assess dental arch relationships of cleft patients and therefore the surgical outcome. The most commonly used method for evaluation of surgical outcome is Goslon Yardstick. Another scoring system that can be used is the modified Huddart/Bodenham scoring system. Aim: The objective of this study was to evaluate the dental arch relationships of subjects with repaired unilateral and cleft lip and palate who come at an orthodontic center by means of Goslon and modified Huddart/Bodenham scoring system and to find a correlation between the two systems. Methodology: The study models of 16 patients (9 males, 7 females) with an average age of 14.2 years (range 11–23 years) were evaluated for arch constriction by four observers which included two orthodontists and two postgraduate students. Results: The analysis of dental arch relationship using Goslon Yardstick revealed that 63% of patients ranked between Goslon 3 and 5. The mean modified Huddart/Bodenham score was −16.13. Conclusion: The study revealed that modified Huddart/Bodenham scoring system provided better interobserver agreement than Goslon Yardstick by untrained observers. There was a good inverse correlation between two scoring systems.

Keywords: Goslon Yardstick, modified Huddart/Bodenham, unilateral cleft lip and palate

How to cite this article:
Dua AP, Jaiswal AK, Dua K. Evaluation of dental arch relationship of patients with unilateral cleft lip and palate. Indian J Dent Sci 2016;8:135-8

How to cite this URL:
Dua AP, Jaiswal AK, Dua K. Evaluation of dental arch relationship of patients with unilateral cleft lip and palate. Indian J Dent Sci [serial online] 2016 [cited 2023 May 28];8:135-8. Available from: http://www.ijds.in/text.asp?2016/8/3/135/191723

Introduction

Management of unilateral cleft lip and palate (UCLP) requires a multidisciplinary approach involving the primary surgical repair of the lip at around 3 months and the palate repair at any time between 6 and 14 months.^[1] Recent studies indicate that poorly performed primary surgery is likely to compromise facial growth, dental development,^[2] and speech.^[3] Poor surgical outcome tends to result in constriction or collapse of the maxilla,^[4] and therefore, success or failure can be related to the dental arch relationships and the frequency with which the crossbite occurs. Several classifications have previously been described to assess dental arch relationships and therefore the surgical outcome.^{[1],[5],[6],[7],[8],[9]} The most commonly used method for evaluation of surgical outcome is Goslon Yardstick. The use of the Goslon Yardstick however requires a degree of professional judgment with regard to the possibility of orthodontic correction which introduces an element of subjectivity. It also requires the use of reference models for comparison, and a calibration course is necessary for its competent use. Another scoring system that can be used is the modified Huddart/Bodenham scoring system. This is an objective method for evaluation of arch constriction and does not require any calibration course. In India, we have yet to standardize the treatment protocols and establish interdisciplinary centers;^[10] hence, there is a need for simple, objective, and less expensive method for evaluation of arch constriction for the purpose of intercenter studies. The objective of this study was to evaluate the dental arch relationships of patients with repaired unilateral and cleft lip and palate who come at an orthodontic center by means of Goslon and modified Huddart/Bodenham scoring system and to determine the intra- and inter-rater agreement between several raters for both the systems. The study also aims to determine the numerical range of modified Huddart/Bodenham score for each group of Goslon Yardstick and to find a correlation between them.

Methodology

The study models of 16 patients (9 males, 7 females) with an average age of 14.2 years (range 11–23 years) were evaluated for arch constriction by four observers which included two orthodontists and two postgraduate students. These patients had been surgically treated at different centers across the country. The models were evaluated twice at interval of 1 month by Goslon Yardstick and modified Huddart/Bodenham scoring system. Syndromic cases and patients with a history of major orthodontic treatment were excluded from the study. Profile photographs and lateral cephalograms were evaluated while using Goslon Yardstick. According to Goslon Yardstick, models were ranked from Group 1 to Group 5 depending on the requirement of orthodontic treatment and orthognathic procedures for achievement of normal arch relationships.^[8] Group 1 requires minimal orthodontic treatment, and Group 5 requires complex orthodontic treatment along with orthognathic surgery for achievement of normal arch relationship.

In modified Huddart/Bodenham scoring system, each maxillary tooth, except for the lateral incisors (which may be missing or in an abnormal position in cleft lip and palate patients), was scored (from −3 to +1) according to their buccolingual and anteroposterior relationship to the corresponding mandibular tooth.^[11] Before the age of 6 years, the first permanent molars were not scored even if erupted; therefore, the maximum range of scores was -24 to +8. After the age of 6 years, the first permanent molars were scored if present as such the maximum range of scores was -30 to +10.^[1]

To find out the correlation between the two scoring systems, different scores of Huddart system for each Goslon category were obtained by applying the class interval.

Statistical analysis

Goslon Yardstick: Mean percentage of patients in each group was calculated and the intra- and inter-examiner variability was calculated using Kruskal–Wallis test and Cohen's kappa statistics.

Modified Huddart/Bodenham system: Intra- and inter-examiner variability was calculated using one-way ANOVA and post hoc tests (Tukey honest significant difference [HSD] multicomparison test).

The correlation between Goslon Yardstick and modified Huddart/Bodenham system was evaluated using the Spearman rank correlation coefficient.

Results

Evaluation by Goslon Yardstick

Mean percentage of patients who fell in each Goslon category was evaluated. Thirty-seven percent of patients belonged to each Goslon 2 and Goslon 4 category, while 13% belong to both Goslon category 3 and Goslon 5 category [Figure 1].

Figure 1: Percentage of patients in different Goslon groups.

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Evaluation by Modified Huddart/Bodenham score

The average mean modified Huddart/Bodenham score was −3.43 for incisors, −3.3 for canines, −6.93 for premolars, and −1.85 for molars. The mean total score for the sample was −16.13.

Intra- and inter-rater reliability for Goslon

The P value for Goslon rating in Kruskal–Wallis test was 0.988. [Figure 2] shows mean kappa scores for the first and second ratings of each observer. The mean kappa scores for two ratings by each observer were in between moderate (0.551) to very good (0.826). [Figure 3] shows the mean kappa scores (strength of agreement) in between observers for two different ratings. The degree of strength of agreement in between observers was toward from moderate to substantial (in between 0.41 and 0.6) most of the time.

Figure 2: Intraobserver reliability for Goslon Yardstick.

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Figure 3: Interobserver reliability for Goslon.

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Intra- and inter-rater reliability for modified Huddart/Bodenham

One-way ANOVA test showed that P value was 0.996 which was more than 0.05, and hence, there was no significant difference between first and second ratings of each observer. On multicomparison by Tukey HSD statistics, P value was always >0.05 which showed that there was no significant difference in between observers at two different observations. However, the absolute value of P was 1 most of the time, which shows interrater agreement was very high and similar within different groups and subgroups [Figure 4].

Figure 4: Intra- and inter-observer reliability for modified Huddart/Bodenham system.

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Correlation of different Goslon category to modified Huddart/Bodenham scores

Spearman's correlation coefficient showed that there was a high inverse correlation between two systems.

Calculation of different Goslon category to modified Huddart/Bodenham scores

The range of modified Huddart/Bodenham scores is from −30 to +10. The range for each Goslon category can be obtained using class interval as follows:

Group 1: +3 to +10
Group 2: +2 to −5
Group 3: −6 to −13
Group 4: −14 to −21
Group 5: −22 to −30

Discussion

The CSAG report by Sandy et al. in 1998^[12] investigated surgical outcomes in patients with UCLP in the United Kingdom in terms of dental arch relationships, facial growth, esthetics oral health, speech, and patient satisfaction. The results from the investigation were disappointing, and recommendations were made for the centralization of cleft centers, improved record keeping, and organized training for staff and intercenter audit. If standards of care are to be improved in orofacial clefting, it is essential to have a means of evaluating surgical outcome in some way such as assessment of arch constriction. The result of this study also revealed that high proportion of patients had poor dental arch relationship. None of the patients could score Goslon 1 which indicates that there is need for orthodontic treatment in all patients. Only 37% of patients ranked in Goslon 2 (favorable group), and 63% of patients were placed in Goslon 3 through Goslon 5, toward the worst side of scale [Figure 5] while 50% of our patients belonged to unfavorable Groups 4 and 5. The study suggested that the treatment outcome of patients attending our orthodontic center was not satisfactory when compared with other centers which have centralized treatment regimen. Mars et al.^[2] in a six-center international study found that the patient treated at Great Ormond Street Hospital and Oslo center had good results with only 33% and 6% of patient in the unfavorable Groups 4 and 5. Unfavorable results were also reported by Hathorn et al. in 1996, where 55.5% of cases were unfavorable;^[13] Bhateja et al. reported 40% of cases as poor in a study in 2001.^[14] Sixty percent of cases had an unfavorable outcome in a study by Susami et al. in 2006.^[15] The results from these studies suggested that unfavorable outcomes could be attributed to noncentralized treatment approach and poor treatment regimen that included multiple surgeries and radical nasal correction at the time of lip repair. The mean total modified Huddart/Bodenham score for our sample was −16.13, which again indicated unfavorable dental arch relationships. These results reinforce the need for centralization of cleft lip and palate care with a definite treatment protocol.

Figure 5: Percentage of patients in favorable (A) and unfavorable (B) Goslon group.

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Intra- and inter-rater reliability

Altman ^[16] suggested that kappa value >0.8 indicates good agreement, >0.6 indicates substantial agreement, and >0.4 indicates moderate agreements. While kappa value >0.2 indicates fair agreement, <0.2 indicates poor agreement.

The lesser interobserver strength (most of the time <0.6) of agreement in comparison to intraobserver strength (most of the time >0.6) for Goslon Yardstick may be due to the nontraining of observers with calibration course, which is required for its competent use. On the other hand, modified Huddart/Bodenham system showed better strength of agreement since it is objective in nature and does not require any training (most of the time, P value was 1).

The conceptual difference between these two systems is that unlike the Huddart/Bodenham system, the Goslon scoring systems take into account the potential for orthodontic management to mask any interarch discrepancy, following surgery. An element of subjectivity based on experience is inherent in the Goslon scoring system, which in turn is likely to adversely affect the intra- and inter-rater reliability.^[1]

The advantages of modified Huddart/Bodenham system are its objectivity, versatility, sensitivity, no requirement for any special training, and its ability to be applied to any cleft subgroup at any age. It is a continuous scale of severity of arch constriction rather than a categorical scale and therefore provides a greater degree of sensitivity and the ability to differentiate the severity within the categories.

Hence, in a country like India where different treatment protocol are followed at different centers and relative unavailability of research grants for calibration courses, modified Huddart/Bodenham scoring system can be helpful in large-scale intercenter comparisons. This will also help in developing nationalized treatment protocols and research work.

Conclusion

The analysis of dental arch relationship using Goslon Yardstick revealed that 63% of patients ranked between Goslon 3 and 5. The mean modified Huddart/Bodenham score was −16.13
Modified Huddart/Bodenham scoring system provided better interobserver agreement than Goslon Yardstick by untrained observers
There was a good inverse correlation between two scoring systems, which confirms the reliability of modified Huddart/Bodenham scoring system.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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