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Evaluation of patient satisfaction after therapy of unilateral clefts of lip, alveolus and palate
Journal of Cranio-Maxillofacial Surgery (2006), 34, Suppl. S2, 31–33 © 2006 European Association for Cranio-Maxillofacial Surgery available online at http://www.sciencedirect.com
Evaluation of patient satisfaction after therapy of unilateral clefts of lip, alveolus and palate Petra LANDSBERGER 1 , Peter PROFF 1 , Sabine DIETZE 1 , Anja HOFFMANN 1 , Wolfram KADUK 2 , Fritz-Ulrich MEYER 2 , Florian MACK 3 1
Department of Orthodontics, Preventive and Pediatric Dentistry (Head: Prof. Dr. T. Gedrange), Ernst Moritz Arndt University of Greifswald, Germany 2 Department of Oral and Maxillofacial Plastic Surgery (Head: Prof. Dr. Dr. H.R. Metelmann), Ernst Moritz Arndt University of Greifswald, Germany 3 Department of Prosthetic Dentistry, Gerodontology and Biomaterials, (Head: Prof. Dr. R. Biffar), Ernst Moritz Arndt University of Greifswald, Germany
SUMMARY. Introduction: Cleft lip, alveolus and palate (CLAP) is a craniofacial abnormality and is one of the most frequent human developmental anomalies. Therapy of clefts does not only comprise surgical closure of the cleft, but rather aims at an aesthetically and functionally optimal result at adult age. Material and methods: Thirty-three cleft patients with total clefts of lip, alveolus and palate were enrolled in this study. Osseous bridging of the alveolar cleft (osteoplasty) was performed in all patients followed by different types of subsequent treatment. All patients answered a questionnaire to assess their satisfaction with the treatment result and their facial appearance. Patient satisfaction was correlated to the type of alveolar cleft repair. Results: The returned questionnaires revealed varying patient satisfaction with their appearance, occlusal conditions, and dental aesthetics depending on the type of dental treatment in the alveolar cleft area. Questionnaire analysis by gender revealed clear gender-dependent differences in self-rated satisfaction. Conclusion: Aesthetics gain increasing importance for self-perception. Therefore, patient satisfaction with her facial appearance should move even more into focus of therapy of clefts. © 2006 European Association for Cranio-Maxillofacial Surgery Keywords: cleft lip and palate, patient satisfaction, questionnaire
INTRODUCTION
ing severity arise depending on cleft size, treatment is conducted according to an individually tailored therapy concept in close co-operation of maxillofacial surgeons, phoniatrists and paedaudiologists, orthodontists, paediatricians, otorhinolaryngologists, dentists and, if necessary, medical geneticists as well as child psychologists. Osseous closure of the alveolar cleft is a special aspect of the treatment. Shaping a regular alveolar ridge in the cleft area and stabilization of the maxillary segments are aimed at by maxillofacial surgeons by means of osteoplasty. Moreover, the grafted bone supports the alae of the nose. Surgical management of the alveolar cleft is mostly performed as secondary osteoplasty, i.e. in the late mixed dentition, in order to permit eruption and alignment of the teeth near the cleft area. If orthodontic space closure is not possible, osteoplasty is postponed until the permanent dentition. By that time, an implant may be placed into the newly inserted bone or, alternatively, a bridge is incorporated. This study aimed to evaluate patient satisfaction following secondary osteoplasty and subsequent interdisciplinary therapy of unilateral clefts.
Cleft lip, alveolus and palate (CLAP) is classified as craniofacial dysplasia and is among the most frequent human developmental anomalies (Grimm, 1981). In Europe, their prevalence in newborns amounts to about 1 : 500 (Kozelj, 1996; Peterka et al., 2000). It is the result of disturbed facial development between the 36th and 58th day of intrauterine embryogenesis (Tammoscheit, 1986). Clefts of lip and alveolus is different from isolated cleft palate and a combination of both (cheilo-gnatho-palatochisis). While isolated cleft palates always appear along the body midline, the other types of cleft are either unilateral or bilateral. Regarding the aetiology, a multifactorial genetic system needs to be considered where additive polygeny and exogeny equally play a role (Schulze, 1986). Therapy of clefts consists not only in surgical closure of the cleft, but rather aims at an aesthetically and functionally optimal result at adult age. Treatment of patients with clefts, therefore, lasts from birth until growth is completed. Since functional disorders of vary31
32
Journal of Cranio-Maxillofacial Surgery
PATIENTS AND METHODS
Table 3 – Mean patient satisfaction depending on type of gap closure
Thirty-three cleft patients (18 males and 15 females) with total clefts of lip, alveolus and palate were enrolled in this study. Osteoplasty was performed by an oral and maxillofacial surgeon in all patients prior to participation in this study. Subsequently, orthodontic space closure was performed in most patients. Some patients were treated with a bridge or an implant, if gap closure was not feasible using orthodontic means. Prior to examination, a questionnaire was mailed to all patients. They were asked to complete it at home and bring it to their appointment. The questionnaire served to assess satisfaction of the cleft patients with the current treatment result and their facial appearance. It comprised a number of closed questions with response options (numeric marks) corresponding to a sevengrade Likert-type scale. Patient satisfaction was contrasted to the type of management and/or space closure. RESULTS A left-sided cleft was found in 22 (right-sided in 11) of the 33 cleft patients examined (Table 1). While most patients were between 10 and 25 years of age, 4 were older than 25 years at the time of examination (Table 2). In 20 of the 33 patients the lateral incisor in the cleft area was either missing or markedly hypoplastic so that the resulting gap needed closure. In 22 patients the space was closed orthodontically. In 6, the gap was closed with a bridge; in 2 an implant had been placed. At the time of the examination, three other patients wore a denture with one tooth and were scheduled for an implant. Analysis of the questionnaires revealed varying patient satisfaction with their facial appearance, occlusal conditions, and dental aesthetics depending on the type of gap closure (Table 3). Patients wearing a bridge (0) were least satisfied on average with their facial appearance, followed by the patients with orthodontic space closure (0.5). Most satisfied with their facial appearance were patients wearing a plate (1) or an implant (1). Table 1 – Gender-specific distribution of left- and right-sided clefts (CLAP)
Left-sided CLAP Right-sided CLAP
Male
Female
Total
13 5
9 6
22 11
Table 2 – Age groups Age
Number of patients
10–15 yrs 15–20 yrs 20–25 yrs 25–30 yrs >30 yrs
7 13 9 2 2
Orthodontic closure Bridge Implant Denture Facial appearancenn 0.5 Occlusal conditions 1.5 Dental aesthetics 1
0 2 2
1 2 2.5
1 0 0
Table 4 – Mean satisfaction with facial appearance depending on gender
Satisfaction with facial appearance
Male
Female
0.35
0.77
With respect to their occlusal conditions, cleft patients wearing a denture (0) were least satisfied followed by patients with orthodontic space closure (1.5). Treatment with a bridge (2) or an implant (2) was judged equally positive. Regarding dental aesthetics, a plate (0) was rated as least appealing, followed by orthodontic gap closure (1) and bridge construction (2). Implants (2,5) were judged as the most aesthetic type of treatment. Breakdown of questionnaire analysis by gender revealed clear gender-dependent differences in self-rated satisfaction with facial appearance (Table 4), occlusal conditions, and dental aesthetics. Generally, female patients were more satisfied than males. There was no significant difference between right- or left-sided clefts on facial appearance. DISCUSSION Management of cleft patients has nowadays been clearly improved owing to increasing knowledge of craniofacial growth and further development of surgical and orthodontic therapy (Reisberg, 2000; Shaw et al., 2001). Cleft treatment generally aims to achieve good aesthetic and functional long-term results (Jeffery and Boormann, 2001; Marcusson et al., 2002). Treatment success of patients with cleft lip, alveolus and palate does not lend itself easily to measurement, as judgement is based upon certain criteria which are not necessarily of equal importance to physician and patient. In a study by Sinko et al. (2005), for instance, the aesthetic outcome of cleft treatment was rated as significantly poorer by the patients than by the experts. Despite such discrepancies, numerous studies on life quality and patient satisfaction after therapy of cleft lip and palate have been conducted in recent years (Noar, 1991; Semb et al, 2005, and others) and have thus taken account of aspects reaching beyond the correction of functional disorders only. Normally, these studies employed questionnaires and used scales for measurement of personal attitudes like patient satisfaction. The scaling method introduced by the psychologist Rensis Likert in 1932 is very common and generally accepted for written questioning thanks to the limited time and effort required for data collection. It was applied also in this study thus enabling the patients to estimate treatment outcome from their point of view.
Evaluation of patient satisfaction after therapy of unilateral clefts of lip, alveolus and palate
Generally, female patients were more satisfied in this study with their facial appearance, dental aesthetics and occlusal conditions. Conversely, in the study of Sinko et al. (2005) particularly the female patients were dissatisfied with their aesthetic result. Similarly, in a study of Marcusson et al. (2002) the ratings by female cleft patients were clearly less favourable on a Likert-type scale that those by male patients. The findings of the two aforementioned studies correspond to the assumption that females are subject to greater pressure from social norms regarding their attractiveness and, therefore, more self-critical with respect to their physical appearance. It remains unclear, however, how to account for the more positive self-assessment of females in this study. Furthermore, the present study shows that the type of space closure in the dentition of cleft patients has an impact on satisfaction with facial appearance, occlusal conditions, and dental aesthetics. Generally, the highest satisfaction was obtained after implant treatment. Hence, gap closure using an implant may become the future therapy of choice for cleft patients in order to achieve the highest possible satisfaction from an aesthetic point of view. CONCLUSION Facial aesthetics gain increasing importance for selfperception, especially in persons between 18 and 30 years of age (Harris and Carr, 2001; Jacobson, 1984). Besides functional aspects, therefore, satisfaction with her facial appearance should move even more into the focus of cleft therapy. Enhanced consideration of aesthetic aspects might possibly lead to considerable improvement of the individual cleft patient’s selfesteem and social situation. Patient questioning is a valuable instrument making the subjective outcome of treatment susceptible to measurement by the team. In the long run it may permit further improvement of the therapy concept for the patient’s benefit. References Andrä A, Neumann HJ: Lippen-Kiefer-Gaumenspalten. Ätiologie, Morphologie, Klinik, Komplexe Rehabilitation. Leipzig: JA Barth, 1989 Grimm G: Lippen-Kiefer-Gaumenspalten. In: Schwenzer N, Grimm G. (Hrsg.): Spezielle Chirurgie. Zahn-Mund-Kieferheilkunde. Bd. 2, 2. Aufl. Stuttgart, New York, Thieme: 338–341, 1981
33
Harris DL, Carr AT: Prevalence of concern about physical appearance in the general population. Br J Plast Surg 54: 223–226, 2001 Jacobson A: Psychological aspects of dentofacial esthetics and orthognathic surgery. Angle Orthod 54: 18–35, 1984 Jeffery SL, Boormann JG: Patient satisfaction with cleft lip palate services in a regional centre. Br J Plast Surg 54: 189–191, 2001 Kozelj V: Epidemiology of orofacial clefts in Slovenia, 1973–1993: comparison of the incidence in six European countries. J Craniomaxillofac Surg 24(6): 378–382, 1996 Marcusson A, Paulin G, Östrup L: Facial appearance in adults who had cleft lip and palate treated in childhood. Scand J Plast Reconstr Surg Hand Surg 36: 16–23, 2002 Noar JH: Questionnaire survey of attitudes and concerns of patients with cleft lip and palate and their parents. Cleft Palate Cranifac J 28 (3): 279–284, 1991 Peterka M, Peterkova R, Tvrdek M, Kuderova J, Likovsky Z: Significant differences in the incidence of orofacial clefts in fifty-two Czech districts between 1983 and 1997. Acta Chir Plast 42: 124–129, 2000 Reisberg DJ: Dental and prosthodontic care for patients with cleft or craniofacial conditions. Cleft Palate Cranifac J 37 (2): 534–537, 2000 Schulze C: Über genetische Faktoren bei der Ätiologie von Lippen-Kiefer-Gaumen-Spalten. Journal of Orofacial Orthopedics/Fortschritte der Kieferorthopädie Bd. 47 (5): 346–355, 1986 Schwenzer N, Arold R: Lippen-Kiefer-Gaumenspalten. Deutsches Ärzteblatt 95(37): 46–51, 1998 Semb G, Brattström V, Molstedt K, Prahl-Andersen B, Zuurbier P, Rumsey N, Shaw W: The eurocleft study. Intercenter study of treatment outcome in patients with complete cleft lip palate. Part 4: Relationship among treatment outcome, patient/parent satisfaction, and burden of care. Cleft Palate Cranifac J 42 (1): 83–92, 2005 Shaw WC, Semb G, Nelson P, Brattstrom V, Molsted K, PrahlAndersen B, Gundlach K: The Eurocleft project 1996-2000: overview. J Craniomaxillofac Surg 29(3): 131–140, 2001 Sinko K, Jagsch R, Prechtl V, Watzinger F, Hollmann K, Baumann A: Evaluation of esthetic, functional, and quality-of-life outcome in adult cleft lip and palate patients. Cleft Palate Craniofac J 42 (4): 355–361, 2005 Tammoscheit UG: Entstehungsmechanismen von Lippen-Kiefer(Gaumen-) Spalten. Fortschr Kieferorthop 47 (5): 339–345, 1986 Dr. Petra LANDSBERGER Poliklinik für Kieferorthopädie, Präventive Zahnheilkunde und Kinderzahnheilkunde Zentrum für Zahn-, Mund- und Kieferheilkunde Ernst-Moritz-Arndt-Universität Greifswald Rotgerberstraße 8 17487 Greifswald, Germany Tel.: +0 (49) 3834/86-7110 Fax: +0 (49) 3834/86-7113 E-mail: kieferorthopä[email protected]
Evaluation of patient satisfaction after therapy of unilateral clefts of lip, alveolus and palate Petra LANDSBERGER 1 , Peter PROFF 1 , Sabine DIETZE 1 , Anja HOFFMANN 1 , Wolfram KADUK 2 , Fritz-Ulrich MEYER 2 , Florian MACK 3 1
Department of Orthodontics, Preventive and Pediatric Dentistry (Head: Prof. Dr. T. Gedrange), Ernst Moritz Arndt University of Greifswald, Germany 2 Department of Oral and Maxillofacial Plastic Surgery (Head: Prof. Dr. Dr. H.R. Metelmann), Ernst Moritz Arndt University of Greifswald, Germany 3 Department of Prosthetic Dentistry, Gerodontology and Biomaterials, (Head: Prof. Dr. R. Biffar), Ernst Moritz Arndt University of Greifswald, Germany
SUMMARY. Introduction: Cleft lip, alveolus and palate (CLAP) is a craniofacial abnormality and is one of the most frequent human developmental anomalies. Therapy of clefts does not only comprise surgical closure of the cleft, but rather aims at an aesthetically and functionally optimal result at adult age. Material and methods: Thirty-three cleft patients with total clefts of lip, alveolus and palate were enrolled in this study. Osseous bridging of the alveolar cleft (osteoplasty) was performed in all patients followed by different types of subsequent treatment. All patients answered a questionnaire to assess their satisfaction with the treatment result and their facial appearance. Patient satisfaction was correlated to the type of alveolar cleft repair. Results: The returned questionnaires revealed varying patient satisfaction with their appearance, occlusal conditions, and dental aesthetics depending on the type of dental treatment in the alveolar cleft area. Questionnaire analysis by gender revealed clear gender-dependent differences in self-rated satisfaction. Conclusion: Aesthetics gain increasing importance for self-perception. Therefore, patient satisfaction with her facial appearance should move even more into focus of therapy of clefts. © 2006 European Association for Cranio-Maxillofacial Surgery Keywords: cleft lip and palate, patient satisfaction, questionnaire
INTRODUCTION
ing severity arise depending on cleft size, treatment is conducted according to an individually tailored therapy concept in close co-operation of maxillofacial surgeons, phoniatrists and paedaudiologists, orthodontists, paediatricians, otorhinolaryngologists, dentists and, if necessary, medical geneticists as well as child psychologists. Osseous closure of the alveolar cleft is a special aspect of the treatment. Shaping a regular alveolar ridge in the cleft area and stabilization of the maxillary segments are aimed at by maxillofacial surgeons by means of osteoplasty. Moreover, the grafted bone supports the alae of the nose. Surgical management of the alveolar cleft is mostly performed as secondary osteoplasty, i.e. in the late mixed dentition, in order to permit eruption and alignment of the teeth near the cleft area. If orthodontic space closure is not possible, osteoplasty is postponed until the permanent dentition. By that time, an implant may be placed into the newly inserted bone or, alternatively, a bridge is incorporated. This study aimed to evaluate patient satisfaction following secondary osteoplasty and subsequent interdisciplinary therapy of unilateral clefts.
Cleft lip, alveolus and palate (CLAP) is classified as craniofacial dysplasia and is among the most frequent human developmental anomalies (Grimm, 1981). In Europe, their prevalence in newborns amounts to about 1 : 500 (Kozelj, 1996; Peterka et al., 2000). It is the result of disturbed facial development between the 36th and 58th day of intrauterine embryogenesis (Tammoscheit, 1986). Clefts of lip and alveolus is different from isolated cleft palate and a combination of both (cheilo-gnatho-palatochisis). While isolated cleft palates always appear along the body midline, the other types of cleft are either unilateral or bilateral. Regarding the aetiology, a multifactorial genetic system needs to be considered where additive polygeny and exogeny equally play a role (Schulze, 1986). Therapy of clefts consists not only in surgical closure of the cleft, but rather aims at an aesthetically and functionally optimal result at adult age. Treatment of patients with clefts, therefore, lasts from birth until growth is completed. Since functional disorders of vary31
32
Journal of Cranio-Maxillofacial Surgery
PATIENTS AND METHODS
Table 3 – Mean patient satisfaction depending on type of gap closure
Thirty-three cleft patients (18 males and 15 females) with total clefts of lip, alveolus and palate were enrolled in this study. Osteoplasty was performed by an oral and maxillofacial surgeon in all patients prior to participation in this study. Subsequently, orthodontic space closure was performed in most patients. Some patients were treated with a bridge or an implant, if gap closure was not feasible using orthodontic means. Prior to examination, a questionnaire was mailed to all patients. They were asked to complete it at home and bring it to their appointment. The questionnaire served to assess satisfaction of the cleft patients with the current treatment result and their facial appearance. It comprised a number of closed questions with response options (numeric marks) corresponding to a sevengrade Likert-type scale. Patient satisfaction was contrasted to the type of management and/or space closure. RESULTS A left-sided cleft was found in 22 (right-sided in 11) of the 33 cleft patients examined (Table 1). While most patients were between 10 and 25 years of age, 4 were older than 25 years at the time of examination (Table 2). In 20 of the 33 patients the lateral incisor in the cleft area was either missing or markedly hypoplastic so that the resulting gap needed closure. In 22 patients the space was closed orthodontically. In 6, the gap was closed with a bridge; in 2 an implant had been placed. At the time of the examination, three other patients wore a denture with one tooth and were scheduled for an implant. Analysis of the questionnaires revealed varying patient satisfaction with their facial appearance, occlusal conditions, and dental aesthetics depending on the type of gap closure (Table 3). Patients wearing a bridge (0) were least satisfied on average with their facial appearance, followed by the patients with orthodontic space closure (0.5). Most satisfied with their facial appearance were patients wearing a plate (1) or an implant (1). Table 1 – Gender-specific distribution of left- and right-sided clefts (CLAP)
Left-sided CLAP Right-sided CLAP
Male
Female
Total
13 5
9 6
22 11
Table 2 – Age groups Age
Number of patients
10–15 yrs 15–20 yrs 20–25 yrs 25–30 yrs >30 yrs
7 13 9 2 2
Orthodontic closure Bridge Implant Denture Facial appearancenn 0.5 Occlusal conditions 1.5 Dental aesthetics 1
0 2 2
1 2 2.5
1 0 0
Table 4 – Mean satisfaction with facial appearance depending on gender
Satisfaction with facial appearance
Male
Female
0.35
0.77
With respect to their occlusal conditions, cleft patients wearing a denture (0) were least satisfied followed by patients with orthodontic space closure (1.5). Treatment with a bridge (2) or an implant (2) was judged equally positive. Regarding dental aesthetics, a plate (0) was rated as least appealing, followed by orthodontic gap closure (1) and bridge construction (2). Implants (2,5) were judged as the most aesthetic type of treatment. Breakdown of questionnaire analysis by gender revealed clear gender-dependent differences in self-rated satisfaction with facial appearance (Table 4), occlusal conditions, and dental aesthetics. Generally, female patients were more satisfied than males. There was no significant difference between right- or left-sided clefts on facial appearance. DISCUSSION Management of cleft patients has nowadays been clearly improved owing to increasing knowledge of craniofacial growth and further development of surgical and orthodontic therapy (Reisberg, 2000; Shaw et al., 2001). Cleft treatment generally aims to achieve good aesthetic and functional long-term results (Jeffery and Boormann, 2001; Marcusson et al., 2002). Treatment success of patients with cleft lip, alveolus and palate does not lend itself easily to measurement, as judgement is based upon certain criteria which are not necessarily of equal importance to physician and patient. In a study by Sinko et al. (2005), for instance, the aesthetic outcome of cleft treatment was rated as significantly poorer by the patients than by the experts. Despite such discrepancies, numerous studies on life quality and patient satisfaction after therapy of cleft lip and palate have been conducted in recent years (Noar, 1991; Semb et al, 2005, and others) and have thus taken account of aspects reaching beyond the correction of functional disorders only. Normally, these studies employed questionnaires and used scales for measurement of personal attitudes like patient satisfaction. The scaling method introduced by the psychologist Rensis Likert in 1932 is very common and generally accepted for written questioning thanks to the limited time and effort required for data collection. It was applied also in this study thus enabling the patients to estimate treatment outcome from their point of view.
Evaluation of patient satisfaction after therapy of unilateral clefts of lip, alveolus and palate
Generally, female patients were more satisfied in this study with their facial appearance, dental aesthetics and occlusal conditions. Conversely, in the study of Sinko et al. (2005) particularly the female patients were dissatisfied with their aesthetic result. Similarly, in a study of Marcusson et al. (2002) the ratings by female cleft patients were clearly less favourable on a Likert-type scale that those by male patients. The findings of the two aforementioned studies correspond to the assumption that females are subject to greater pressure from social norms regarding their attractiveness and, therefore, more self-critical with respect to their physical appearance. It remains unclear, however, how to account for the more positive self-assessment of females in this study. Furthermore, the present study shows that the type of space closure in the dentition of cleft patients has an impact on satisfaction with facial appearance, occlusal conditions, and dental aesthetics. Generally, the highest satisfaction was obtained after implant treatment. Hence, gap closure using an implant may become the future therapy of choice for cleft patients in order to achieve the highest possible satisfaction from an aesthetic point of view. CONCLUSION Facial aesthetics gain increasing importance for selfperception, especially in persons between 18 and 30 years of age (Harris and Carr, 2001; Jacobson, 1984). Besides functional aspects, therefore, satisfaction with her facial appearance should move even more into the focus of cleft therapy. Enhanced consideration of aesthetic aspects might possibly lead to considerable improvement of the individual cleft patient’s selfesteem and social situation. Patient questioning is a valuable instrument making the subjective outcome of treatment susceptible to measurement by the team. In the long run it may permit further improvement of the therapy concept for the patient’s benefit. References Andrä A, Neumann HJ: Lippen-Kiefer-Gaumenspalten. Ätiologie, Morphologie, Klinik, Komplexe Rehabilitation. Leipzig: JA Barth, 1989 Grimm G: Lippen-Kiefer-Gaumenspalten. In: Schwenzer N, Grimm G. (Hrsg.): Spezielle Chirurgie. Zahn-Mund-Kieferheilkunde. Bd. 2, 2. Aufl. Stuttgart, New York, Thieme: 338–341, 1981
33
Harris DL, Carr AT: Prevalence of concern about physical appearance in the general population. Br J Plast Surg 54: 223–226, 2001 Jacobson A: Psychological aspects of dentofacial esthetics and orthognathic surgery. Angle Orthod 54: 18–35, 1984 Jeffery SL, Boormann JG: Patient satisfaction with cleft lip palate services in a regional centre. Br J Plast Surg 54: 189–191, 2001 Kozelj V: Epidemiology of orofacial clefts in Slovenia, 1973–1993: comparison of the incidence in six European countries. J Craniomaxillofac Surg 24(6): 378–382, 1996 Marcusson A, Paulin G, Östrup L: Facial appearance in adults who had cleft lip and palate treated in childhood. Scand J Plast Reconstr Surg Hand Surg 36: 16–23, 2002 Noar JH: Questionnaire survey of attitudes and concerns of patients with cleft lip and palate and their parents. Cleft Palate Cranifac J 28 (3): 279–284, 1991 Peterka M, Peterkova R, Tvrdek M, Kuderova J, Likovsky Z: Significant differences in the incidence of orofacial clefts in fifty-two Czech districts between 1983 and 1997. Acta Chir Plast 42: 124–129, 2000 Reisberg DJ: Dental and prosthodontic care for patients with cleft or craniofacial conditions. Cleft Palate Cranifac J 37 (2): 534–537, 2000 Schulze C: Über genetische Faktoren bei der Ätiologie von Lippen-Kiefer-Gaumen-Spalten. Journal of Orofacial Orthopedics/Fortschritte der Kieferorthopädie Bd. 47 (5): 346–355, 1986 Schwenzer N, Arold R: Lippen-Kiefer-Gaumenspalten. Deutsches Ärzteblatt 95(37): 46–51, 1998 Semb G, Brattström V, Molstedt K, Prahl-Andersen B, Zuurbier P, Rumsey N, Shaw W: The eurocleft study. Intercenter study of treatment outcome in patients with complete cleft lip palate. Part 4: Relationship among treatment outcome, patient/parent satisfaction, and burden of care. Cleft Palate Cranifac J 42 (1): 83–92, 2005 Shaw WC, Semb G, Nelson P, Brattstrom V, Molsted K, PrahlAndersen B, Gundlach K: The Eurocleft project 1996-2000: overview. J Craniomaxillofac Surg 29(3): 131–140, 2001 Sinko K, Jagsch R, Prechtl V, Watzinger F, Hollmann K, Baumann A: Evaluation of esthetic, functional, and quality-of-life outcome in adult cleft lip and palate patients. Cleft Palate Craniofac J 42 (4): 355–361, 2005 Tammoscheit UG: Entstehungsmechanismen von Lippen-Kiefer(Gaumen-) Spalten. Fortschr Kieferorthop 47 (5): 339–345, 1986 Dr. Petra LANDSBERGER Poliklinik für Kieferorthopädie, Präventive Zahnheilkunde und Kinderzahnheilkunde Zentrum für Zahn-, Mund- und Kieferheilkunde Ernst-Moritz-Arndt-Universität Greifswald Rotgerberstraße 8 17487 Greifswald, Germany Tel.: +0 (49) 3834/86-7110 Fax: +0 (49) 3834/86-7113 E-mail: kieferorthopä[email protected]