ARNOLD HUDDART MEDAL

The Arnold Huddart Medal was established in 1990 for the encouragement of original and promising research papers at the Annual Scientific Conference. The adjudication panel consists of one member from each of the Society's five main membership categories and is chaired by the Vice President of the Society.

Papers are judged on content, presentation and handling of the discussion following presentation of the paper. The paper should be of general interest and understandable to all disciplines of the Society. The prize is normally awarded to a presenter under the age of 40 years, at the time of presentation. The rules have been amended in recent times and priority is now given to sole authors over multi-authored papers. The decision of the adjudication panel is final.

 

List of Winners

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2016 A CLINCIAL AND MOLECULAR GENETIC STUDY OF ORAL-FACIAL-DIGITAL SYNDROMES. S Faily, R Perveen, Urquhart J, Clayton-Smith J

2015 INTRA-ORAL THREE DIMENSIONAL SCANNING FOR ASSESSMENT OF SURGICAL OUTCOME IN PATIENTS WITH UCLP. E Chalmers, G McIntyre, W Wang, T Gillgrass, C Martin, P Mossey

2014 Fistula incidence after primary cleft palate repair – a meta-analysis of 9,444 patients. Joseph Hardwicke, Bruce Richard

2013 Radical Muscle Dissection In Cleft Palate Repair – What About The Lesser Palatine Nerves? Jeremy Mortimer, Felicity Mehendale and Simon Parson.

2012 Two potential novel loci for orofacial clefting identified on Array CGH. Rita Ibitoye, Usha Kini, Joanna Roberts.

2011 The 5-year old index: Determining the optimal media for rating dental arch relationships in unilateral cleft lip and palate. Ourvinder Chawla, Scott Deacon, Nikki Atack, Anthony Ireland, Jonathan Sandy

2010 Surgical management of the spectrum of submucous cleft palate(SMCP): Speech outcome following anatomical muscle dissection.repair of the palate. Mr Ali M. Ghanem with O. Gilleard, D. Sell, M. Birch and B.C. Sommerlad.

2009 Effect of Buccinator Mucomuscular Flaps on Speech in Cleft Palate Patients. Ms Arwa Meki and members of the cleft team at Addenbrookes Hospital, Cambridge

2008 Pre and perioperative Dexamethasone improves postoperative recovery following cleft palate surgery. Matthew Potter, Specialist Registrar in Plastic Surgery, Radcliffe Hospital Oxford

2007 The effect of presurgical orthopaedics on archform in unilateral cleft lip and palate. N.Adali, and M.Mars, A. Petrie, J.Noar, B. Sommerlad

2006 Intra Operative Blood Loss – Anaesthetic Type and Adrenaline Concentration. Patrick Gillespie, Specialist Registrar in Plastic Surgery, Addenbrookes Hospital, Cambridge

2005 Dimensional Stereophotogrammetry. Mark Devlin, Cleft Surgery Fellow, South Thames Cleft Unit, Guy's Hospital.

2004 Effects of the Fgfr2 Crouzon-type Mutation on Palatal Shelf Development. Chad Perlyn, Dept of Human Anatomy & Genetics, University of Oxford

2003 Assessment of Early Dental and Facial Deformity in Repaired Unilateral Cleft Lip and Palate. Dr A Garrahy, Glasgow Dental Hospital

2002 Sequalae of Otitis Media with Effusion among Children with Cleft Lip and/or Cleft Palate. Patrick Sheahan MB AFRCSI, Specialist Registrar in Otolaryngology, Dublin, Ireland

2001 Can maxillary growth be predicted from 3-dimensional parameters of neonatal study models in patients with unilateral Cleft Lip and Palate? Ms Felicity V Mehendale, Cleft Fellow in Plastic Surgery at Great Ormond Street Hospital for Children, London and St Andrew's Centre for Plastic Surgery, Broomfield Hospital, Essex

2000 The Tendons of the Levator Veli Palatini. Ms Felicity V Mehendale, Cleft Fellow in Plastic Surgery at Great Ormond Street Hospital for Children, London and St Andrew's Centre for Plastic Surgery, Broomfield Hospital, Essex

1999 The Orthodontist's contribution to the management of Obstructive sleep Apnoea. Mr A Johal, Senior Registrar in Orthodontics at the Royal London Hospital

1998 Reorganisation of Cleft services - implications of non cleft anomalies. Ms Lucinda Huskisson, Senior Registrar in Paediatric Surgery at The Children's Hospital, Birmingham

1997 Craniofacial abnormalities in Nicosia, Cyprus, and the significance of parental consanguinity. Ms Sonia Vartoukian, Dental undergraduate at King's College Dental Institute, London

1996 A twenty year follow-up assessment of nasal symmetry in patients with unilateral complete Cleft Lip and Palate. Norma Timoney, Senior House Officer in the Department of Plastic & Reconstructive Surgery Royal Devon & Exeter Hospital

1995 Does the McComb primary cleft nose correction affect nasal growth? A longitudinal study. Mr Brian Coghlan, Senior Registrar in Plastic Surgery in the Yorkshire region.

1995 An audit of bilateral alveolar bone grafting at Great Ormond Street Hospital 1983-1993. Dr Yilin Jia, Honorary Registrar in Orthodontics at The Hospital for Sick Children, Great Ormond Street, London

1994 Management of 100 cases of pheneme specific nasality - a two centre audit. Mrs Liz Albery, Speech & Language Therapist at Frenchay Hospital, Bristol. Mrs Kim Harland, Speech & Language Therapist at St. Andrew's Hospital, Billericay.

1993 Growing up with a Cleft. Ms Eileen Bradbury, Clinical Counsellor in Plastic Surgery at Withington Hospital, Manchester and Lecturer at the University of Manchester

1992 The vascular basis of posterior pharyngeal flaps. Mr Nigel SG Mercer, Consultant Plastic Surgeon with Frenchay Healthcare Trust, Bristol

1991 The characteristics of pre-speech vocalisations in Cleft Palate children. Mrs Jane Russell, Principal Speech Therapist at Birmingham Children's Hospital. Prepared in conjunction with Professor Pamela Grunwell

1990 The relationship between Intracranial pressure and restricted skull volume in children with Craniosynostosis. Mr Gault, Senior Registrar in Plastic Surgery at The Hospital for Sick Children, Great Ormond Street, London. Prepared in conjunction with B. Jones, D Marchac and D Renier

 

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2015 Winner

Intra-oral three dimensional scanning for assessment of surgical outcome in patients with UCLP

Aim: To examine the reliability of intra-oral 3D scans as an alternative to study models for the assessment of dental arch relationships in 9-21 year olds with UCLP.

To evaluate patient and parent satisfaction with 3D intra-oral scanning compared with dental alginate impressions for study models.

Methods: 43 patients underwent intra-oral 3D scanning and impressions. Participants and parents scored their perception and time required for the 3D scan and impressions via a questionnaire. Three examiners scored both model formats using the MHB and GOSLON indices.

Results: All examiners achieved an intraexaminer reliability score greater than 0.98. The direct digital scans demonstrated superior interexaminer reliability to plaster models.

Conclusions: Reliability of GOSLON and MHB scoring using intra-oral 3D scans was superior to plaster models. Participants and their parents preferred the experience of the intra-oral 3D scan.
This study supports the replacement of conventional impressions with intra-oral 3D in longitudinal evaluations of the outcomes of cleft care.

 

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2014 Winner

Fistula incidence after primary cleft palate repair – a meta-analysis of 9,444 patients
J. Hardwicke & B. Richard

Aim: The development of an oronasal fistula after primary cleft palate repair has a wide variation reported in the literature. The aim of this review is to identify the reported oronasal fistula incidence to provide a benchmark for surgical practice.

Methods: A systematic review was undertaken to investigate the incidence of fistula. Multiple meta-analyses were performed to pool proportions of reported fistulae, in each dataset corresponding to the continent of origin of the study, type of cleft, and techniques of cleft palate repair employed.

Results: A total of 9,444 patients were included. The overall incidence of reported fistula was 8.5% (95% CI: 6.3 - 10.9). There was no significant difference in the fistula incidence corresponding to the continent of origin of each study, nor the repair technique employed. The incidence of fistula in cleft lip and palate was 17.9%, which was significantly higher (p = 0.03) than in cases of cleft palate alone (5.1%).

Conclusions: Palatal fistula were more likely to occur in cases of combined cleft lip and palate, compared to cleft palate alone. We would recommend the use of a well-practiced surgical repair technique and treatment schedule, and audit of outcomes against the reported fistula incidence of 6-11%.

 

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2013 Winner

Radical Muscle Dissection In Cleft Palate Repair – What About The Lesser Palatine Nerves?
J. Mortimer, F.V. Mehendale & S. Parson

Aim: The lesser palatine nerves (LPNs) are overlooked in radical muscle dissection techniques for cleft palate repair. As well as supplying sensation, taste and glandular secretion to the velum, reports suggest they carry facial nerve motor fibres to levator veli palatini (LVP). This study explores LPN anatomy with reference to a Sommerlad dissection.

Methods: LPNs and LVP were dissected under magnification in 3 cadavers. Sihler nerve staining was carried out for the first time in the velopharyngeal region. A literature review was also undertaken to identify trends in the reported inconsistencies of LVP innervation.

Results: LPN branches ran oral to the tensor aponeurosis, terminating within the glandular layer oral to the muscular velum. No LPN fibres entered LVP. The main LVP nerve emerged from the lateral pharyngeal wall. Evidence refuting LPN facial nerve motor contribution to LVP seems only found in non-primate studies.

Conclusions: Radical muscle dissection severs LPNs, which carry fibres of sensation, taste and glandular secretion to the velum. Primates may have evolved facial nerve motor relays between the facial speech muscles and LVP via LPNs that would also be lost. Post-cleft palate repair outcome studies of non-motor velar function should be undertaken, possibly informing modifications in technique and timing of surgery.

 

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2012 Winner

Two potential novel loci for orofacial clefting identified on Array CGH.

Orofacial clefting is relatively common, occurring up to 1 in 700 live births. The aetiology is postulated to be a combination of genetic and environmental factors.

Rita Ibitoye, Usha Kini, Joanna Roberts

 

Aim: To present two potential new genetic loci for orofacial clefting.

Methods: A family presenting with a syndromic cleft palate in the child and another family with non-syndromic bilateral cleft lip and palate (BCLP) across 3 generations were investigated using Agilent Array comparative genomic hybridisation (Array CGH).

Results:We identified a de novo 4.3Mb deletion on chromosome 5q23 in the patient with syndromic cleft palate. Five other patients with cleft palate and 5q23 microdeletion were identified using a national database (DECIPHER). A potential critical locus for cleft palate has been narrowed.

A 350 kb chromosome 17p13.3 microduplication was identified in the family with non-syndromic BCLP, segregating with four affected family members. There is one other patient described with a similar duplication and BCLP.

We discuss the potential candidate genes for orofacial clefting in these regions.

Conclusions:We have identified two potential new loci for orofacial clefting using array CGH. This relatively new technique is now easily accessible through the NHS cytogenetics laboratories. Further work is needed to refine the causative candidate genes. Prenatal testing will now be available for these families.

 

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2011 Winner

The 5-year olds' Index: Determining the optimal media for rating dental arch relationships in unilateral cleft lip and palate

O Chawla, S A Deacon, N E Atack, A J Ireland, J R Sandy

Department of Child Dental Health, Bristol Dental Hospital, Lower Maudlin Street, Bristol, BS1 2LY

Aim: To determine the optimal format for presenting the 5-year olds’ Index reference models, for the assessment of dental arch relationships in unilateral cleft lip and palate (UCLP).

Design: The 5-year olds’ Index reference models were presented in four different formats; plaster models, coloured acrylic models and two digital formats which included three dimensional digital models (3D) and black & white photographs. For each format, scoring was undertaken one week apart and used to rate 45 models of patients with UCLP. To determine intra-examiner agreement, the same examiners repeated the scoring three weeks later under similar conditions. The level of inter-examiner agreement was calculated using the plaster reference models as the “gold” standard to which the other formats were then compared.

Participants: Seven examiners, comprising experienced and inexperienced examiners

Results: Kappa statistics revealed the level of intra-examiner agreement for all the formats of the 5-year olds’ Index were good to very good between examiners.   Compared to the “gold”, kappa values for acrylic models ranged from 0.68 to 0.87, kappa values for the digital photographs ranged from 0.68 to 0.90 and finally, for the 3D digital models ranged from 0.67 to 0.91.

Conclusions: At present, 3D digital models are not in widespread use but this study clearly demonstrated that 3D models of the 5-year olds’ Index could prove to be a promising alternative to physical models of the 5-year olds’ Index.

 

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2010 Winner

Surgical Management of the Spectrum of Submucous Cleft Palate (SMCP): Speech Outcome Following Anatomical Muscle Dissection Repair of the Palate.

Mr Ali M Ghanem(1): Honorary Registrar in Plastic Surgery; Mr Onur Gilleard (2): Core Surgical Trainee; Dr Debbie Sell (1) : Head of Speech and Language Therapy Department; Dr Malcolm Birch (2): Head of Medical Physics Department; Mr Brian C Sommerlad (1): Consultant Plastic and Cleft Surgeon.

(1) North Thames Cleft Service (GOStA), Great Ormond Street Hospital for Children NHS Trust, London, UK.
(2) Department of Clinical Physics. Bart’s and the London NHS Trust, London, UK.

Aim: to evaluate the role of velar surgery in the management of SMCP.

Results: 93 patients were included with 81 having rateable speech records. 30 patients had other malformations (syndrome group). Anatomical muscle dissection palate repair significantly improved intelligibility, hypernasality, nasal emission and passive CTCs scores. Successful achievement of normal post-op hypernasality was possible in 77% of cases (70% in the syndrome group). On videofluoroscopy velar repair significantly increased functional palate length, palate lift and closure ratio. The surgical repair also significantly decreased the velopharyngeal gap size at attempt closure. No significant changes were observed in velopharyngeal gap size at rest or velar extensibility. Pre-op hypernasality, passive CTCs high scores as well as large pre-operative gap size were predictive of less satisfactory post-operative speech outcome. There was no post operative complication. Secondary pharyngoplasty was necessary in 20% of cases.

Conclusion: Anatomical muscle dissection repair of the palate is safe and effective first line treatment option of hypernasality in patients with SMCP.

 

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2009 Winner

Effect of buccinator mucomuscular flaps on speech in cleft palate patients

Aim - To investigate the efficacy of unilateral and bilateral buccinator mucomuscular flaps in secondary surgery for speech in patients with cleft palate.

Method - 49 patients were assessed pre- and post- operatively on a range of speech parameters using GOSSPASS assessments.

Results

The complex relationship between these speech characteristics and cleft-type consonant production was also considered.

Conclusion - Use of buccinator flaps in secondary surgery results in a considerable improvement in several speech characteristics. The techniques and rationale for use of buccinator flaps will be outlined and a preliminary algorithm for the use of these flaps is presented. The speech characteristics most frequently affected by surgery were identified; this study provides an opportunity to consider the possibility of weighting specific characteristics in reporting speech outcomes.

 

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2008 Winner

Pre and Perioperative Dexamethasone Improves Postoperative Recovery Following Cleft Palate Surgery

Aims - To investigate the hypothesis that peri and postoperative steroid use in cleft palate surgery does not influence recovery.

Design - Perioperative and postoperative Dexamethasone was administered to paediatric patients (n=100) undergoing routine posterior palate surgery by a single surgeon. Patients were evaluated post operatively against an aged and case matched control group for a change in:

  • Heart rate
  • Respiratory rate
  • Temperature    
  • Analgesia
  • Pain score
  • Respiratory effort
  • Sedation
  • Time to feed
  • Nausea

Data sets were compared using one way analysis of variance tests.

Participants ranged from 3 months to 16 years, were of equal sex distribution and underwent surgery between 2003-2007.

Results - Less pain (P= 0.003, Dunn’s), a lower sedation score (P= 0.026, Dunn’s) and less nausea and vomiting (P= 0.012, Dunn’s) was found in the active group. This effect was lost at 24 hours. Respiratory rate was less at day 3 in the steroid group (P=0.042, Dunn’s). Other observed changes were statistically insignificant.

Conclusion - This study has demonstrated beneficial effects of preoperative steroid use and its postoperative continuation in cleft palate surgery. Whilst this small single operator study has given promising and significant results it gives the evidence base foundation and structure for a future, larger multicentre randomised controlled trial. 

 

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2007 Winner

The effect of presurgical orthopaedics on archform in unilateral cleft lip and palate

Objectives of Investigation - To identify archform dimensional change in unilateral clip lip and palate infants treated with pre-surgical orthopaedics compared with those not receiving PSO, up to age 6 months.

Subjects and Methods - The study included 75 study model sets of patients with complete UCLP patients (PSO=14, non PSO=61), treated by one surgeon and orthodontist. Each set comprised of study models taken close to birth, before lip repair / vomer flap (3 months), before palate repair (6 months). Suction-retained active PSO was used.

Thirteen landmarks were measured three-dimensionally using Reflex Microscope and COMP3D software. Sixteen variables were computed to describe the archform in transverse, anteroposterior, vertical dimensions, and arch circumference. The groups were comparable at birth in all variables.

Intraoperator repeatability tests and Repeated Measures Hierarchical ANOVA (significance level p,0.01) were performed.

Results - Repeatability tests showed good measurement precision. There were no statistically significant mean changes in any archform variable between the groups. The power of the study was 93%.

Conclusions - PSO treatment produced no effect on archform. Lip repair had a greater impact on archform than PSO.

Potential Applications of the Study - The use of PSO has now been discontinued in the cleft unit. Psychosocial benefits should also be studied.

 

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2006 Winner

Intra Operative Blood Loss - Anaesthetic Type and Adrenaline Concentration. An Audit.

A prospective study of intraoperative blood loss for all Cleft procedures was undertaken from January 2003 to May 2005 for 2 surgeons and their respective anaesthetists. Local anesthetic infiltration with chirocaine (0.25% or 0.5%) was performed in all cases with the concentration of adrenaline being determined by the anaesthetic type - a maximum strength of 1/200,000 being used in Gaseous Anaesthesia (GA) whereas the stronger 1/100,000 was allowed when a Total Intravenous Anaesthetic technique (TIVA) was used. In all cases a minimum wait of 7 minutes from injection to incision was enforced. We wanted to determine if this made a difference to blood loss.

235 useable datasets were analysed and results fell into the following grid.

The results suggest a trend towards almost double the bleeding volume when the weaker concentration of adrenaline is used. This seems independent of surgeon or surgical procedure undertaken.

The study continues to enable detailed statistical analysis with larger numbers.

 

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2005 Winner

Dimensional Stereophotogrammetry. A method of assessing facial symmetry as a surgical outcome in the surgical management of residual nasal deformity using block bone grafting. The results of a prospective trial.

Aim - To assess 3 Dimensional (3D) facial symmetry in repaired UCLP patients with residual nasal deformity before and after bone grafting to the deficient alar base on the cleft side

Method - A method of 3-dimensional (3D), quantitative assessment of facial symmetry in patients with treated UCLP deformity is described. The outcome of bone grafting using a cortico-cancellous block of iliac crest to reconstruct the support for the deformed, volume-deficient alar base is assessed using 3D stereophotogrammetry is assessed with specific reference to facial symmetry scoring. Sixteen patients are included in the study. The facial symmetry score using landmark data is assessed pre- and post-operatively.

Results - The reconstruction results in statistically significant improvement in facial symmetry postoperatively as assessed by this method.

 

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2004 Winner

Effects of the Fgfr2 Crouzon-type Mutation on Palatal Shelf Development

Introduction: The purpose of this project is to investigate the mechanisms through which the Crouzon mutation causes palatal abnormality. The project exploits a mouse model that has the Crouzon-type mutations Fgfr2Cys342Tyr.

Methods: Approaches used were: (1) comparative morphology; (2) cell proliferation analysis; (3) in situ hybridisation. Histological techniques were used for evaluating palatal sections. Cell proliferation analysis was performed using 5'Bromodeoxyuridine (BrdU). Nuclei that took up BrdU (indicating that they were synthesising DNA) were detected using an anti-BrdU antibody technique. Changes in gene expression are being analyzed by in situ hybridization, using molecular probes for markers of bone differentiation and FGFR signalling.

Results: Results from embryonic day (E)13.5-15.5 show significant morphologic differences in palatal development in wild-type mice as compared with heterozygote and homozygote mutants. There appears to be a pattern of development delay by one embryonic day in the heterozygotes and two days in the homozygotes as evidenced by orientation of palatal shelves and degree of shelf fusion. Result of cell proliferation studies for the embryonic day 12.5 (the time at which palatal shelf outgrowth begins) show a significantly higher number of proliferating cells in the homozygote and heterozygote shelves as compared to the wild-types. The effects of this are seen in a decrease in hyaluronic acid in the mutant shelves on the following day. This may lead to decreased osmosis within the extracellular matrix and diminished shelf elevation. Gene expression studies, using in-situ hybridizatio, show abnormal expression of FGFR1 and FGFR2 in the palatal shelves, which correlates to the above findings.

Conclusion: The Fgfr2Cys342Tyr mutation leads to developmental delay of palatal shelf elevation and fusion. FGFR2 remains expressed in the mutant shelves, possibly delaying the switch from cell proliferation to cell differentiation. As such, the necessary factors for palatal development are not present at the appropriate embryonic stage. Further work will be performed to examine this in more detail.

 

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2003 Winner

Assessment of Early Dental and Facial Deformity in Repaired Unilateral Cleft Lip and Palate

Objective - To assess the relationship between deformity of soft tissue facial morphology and of the dental arches in children with repaired UCLP. Deformity is defined as deviation from normal.

Methods - 16 healthy Caucasian children aged 3 years with repaired UCLP and 78 matched control children were recruited. A set of images of each child's face at rest was recorded within 6 weeks of his or her third birthday using computerised stereophotogrammetry and dental impressions were recorded. Analysis of facial and dental interlandmark distances was performed. The correlation between two features of the dental arch and one feature of soft tissue facial morphology with greatest deviation from normal was analysed.

Results - The correlation coefficient for nasal base width and maxillary arch cleft-affected quadrant length was 0.4 (p value 0.14) in children with repaired UCLP. The correlation coefficient for nasal base and maxillary arch intercanine widths was 0.28 (p value 0.32).

Conclusion - The cleft-related deformities of soft tissue morphology and bone based dental arches are not directly related to each other.Suggested application - Further radiation-free exploration of facial, appearance and dental arch development in combination.

 

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2002 Winner

Sequalae of Otitis Media with Effusion among Children with Cleft Lip and/or Cleft Palate

The purpose of this paper is to investigate the long-term outcome of treatment of otitis media with effusion (OME) among children with cleft lip and/ or palate. OME is a common finding among children with cleft palate, and concerns have been expressed regarding the possible long-term effects of the associated hearing loss on speech and language development. However, although treatment of OME by tympanostomy tube insertion can reverse the hearing loss in the short-term, in the long-term, this improvement in hearing is not maintained.

The study comprised of a retrospective review of 104 children with clefts treated for OME at our institution. Mean duration of follow-up was 6.9 years, and mean age at latest follow-up was 9.6 years. The incidence of chronic otitis media was 19%, and the incidence of cholesteatoma was 1.9%. An abnormal tympanic membrane appearance was highly significantly correlated with reduced hearing (p=0.000). Surprisingly, ears which had undergone a greater number of previous ventilation tube insertions had a significantly higher incidence both of abnormal tympanic membrane appearance (p=0.0071 for left ears and p=0.0003 for right ears) and of reduced hearing at long-term follow-up (p=0.0546 for left ears and p=0.0014 for right ears).

The findings of our study would suggest that the excessive use of tympanostomy tubes in children with OME and cleft palate may be associated with a higher incidence of long-term tympanic membrane abnormalities and hearing loss. We would suggest that a conservative approach to OME in children with cleft palate is appropriate and is more likely to lead to the best long-term outcome.

This article was accepted for publication by Clinical Otolaryngology and Allied Sciences (Blackwell Science)

 

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2001 Winner

Can Maxillary Growth be Predicted from 3-Dimensional (3D) Parameters of Neonatal Study Models in Patients with Unilateral Cleft Lip and Palate (UCLP)?

Aim - Post-surgical scarring has been implicated in poor maxillary growth in patients with UCLP. However, the effect, (if any) of poor inherent growth potential is difficult to determine. Studies based on 2-dimensional measurements have not shown a correlation between cleft dimensions and maxillary growth. However, 3-dimensional parameters may be more representative of the characteristics of the cleft maxilla and may correlate with outcome.

Methods - 30 non-syndromic UCLP patients operated on by a single surgeon and with assessable neonatal and 5-year study models were included. All patients had pre-surgical orthopaedics, a lip repair at 3 months and a palate repair at 6 months.

Neonatal models were allocated random numbers before CT scanning in a Siemens scanner. 3D reconstructions were generated, identified only by their random numbers and measured using 3D measuring software (© Robin Richards, UCL). Greater and lesser segment surface areas (alveolus and palatal shelf) were measured.

5-year models were graded using the 5-year index (Atack); arch dimensions were also measured. Statistical analysis was carried out using SPSS v10.0.5.

Results - 5-year index scores were as follows- groups 1&2, 19 patients, group 3, 7 patients, groups 4&5, 4 patients. Correlation between dimensions of the neonatal models and maxillary growth at 5 years will be discussed.

 

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2000 Winner

The Tendons of the Levator Veli Palatini

The insertions of the muscle fibres of the levator veli palatini (LVP) into the tensor aponeurosis (TA), the oral and nasal heads of palatopharyngeus and the contra lateral LVP have been described. However, a tendinous insertion of the LVP has not been described.

The palates of fresh adult cadavers (without cleft lip or palate) were dissected under the operating microscope (3-25 x magnification). Anatomical findings were confirmed on histology. The anterolateral fibres of the LVP were found to end in a number of fine tendons which lie nasal to the oral head of palatopharyngeus, fan out through a localised collection of adipose tissue and insert into the posterior edge of the TA. The tendons are 0.3-0.8mm wide and run individually or in groups of two or more tendons. Incision of the fascial sheath of the LVP shows that discrete muscle bellies (with their own blood supply) give rise to these tendons. Traction on these anterolateral muscle fibres of the LVP selectively stretches the TA, whereas traction on the posterior muscle fibres causes elevation of the velum to form the levator knee. These actions will be demonstrated, and their potential functional significance with regard to velar extensibility and lift will be discussed.

 

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1999 Winner

Work later published as -

An Investigation into the Changes in Airway Dimension and the Efficacy of Mandibular Advancement Appliances in Subjects with Obstructive Sleep Apnoea.

Johal A, Battagel JM, Brit J of Orthodontics Vol 26 1999 205-210

 

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1998 Winner

The conclusion to the study was that patients with clefts have a large number of associated anomalies. Centres treating cleft patients should be equipped to assess, prioritise and treat all anomalies in cleft patients. She produced evidence to support screening for cardiac, ophthalmic and renal anomalies.

 

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1997 Winner

Craniofacial abnormalities in Nicosia, Cyprus, and the significance of parental consanguinity

This study investigated the prevalence of craniofacial dysmorphology in Cyprus compared to the UK. Parental consanguinity as an aetiological factor was considered.

Three-year data-bases of craniofacial abnormalities were formulated for the matched sites of Southern (Greek) Cyprus and Buckinghamshire, UK.

Consanguinity is known to increase the risk of autosomal recessive, chromosomal and polygenic conditions (study group). Those with dominantly inherited disorders formed the control group.

There was a greater proportion of dysmorphology in every group in Cyprus. A highly significant difference was found between Cyprus and Buckinghamshire in the proportion of "non-clefting" craniofacial abnormalities in the study group (p < 0.001). The majority (86%) of "non-clefting" cases seen in Buckinghamshire were dominantly inherited (control group), whereas the greatest proportion (62%) seen in Cyprus belonged to the study group.

Many factors influence the inheritance of recessive e conditions. However, an increased level of consanguinity in Cyprus may attest the higher prevalence of some craniofacial disorders.

 

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1996 Winner

A 20 year audit of nose-tip symmetry in patients with unilateral cleft lip and palate
Source: British Journal of Plastic Surgery. 54(4):294-8, 2001 Jun

Abstract: The purpose of this study was to audit the process and outcome in terms of nasal-tip symmetry of the first 20 patients with unilateral complete cleft lip and palate treated by the Pigott alar leapfrog primary nasal correction in the early 1970s and followed for 20 years. Symmetry was assessed using the Coghlan computer-based analysis of frontal and basal views to determine the stability of the correction. The Abyholm technique of alveolar bone grafting was performed in 12 of the 20 patients. Various other secondary procedures have been performed on the nose tip and septum to improve the airway or appearance. Photographs were taken within one year of ages 5, 10, 15 and 20 years, and the lower border of the nose, the alar domes and the nostrils were assessed. To assess the overall change from 5 years to 20 years, both views were available for 17 patients. No significant change was found in the lower border or nostril symmetry, but significant deterioration at the P< 0.01 level was found on the basal view. We assessed the 10, 15 and 20 year views of all 12 patients who had undergone alveolar bone grafting to determine early and late changes. No significant benefit was found from alveolar bone grafting or minor secondary procedures for appearance. Consequently, our criteria for undertaking minor adjustments to improve appearance have become more stringent. We consider that objective reporting of appearance should become essential in peer-reviewed journals. Copyright 2001 The British Association of Plastic Surgeons.

 

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1995 Joint Winner

The paper looked at a longitudinal series of how McCombs cases treated only with a primary nose repair and then followed up 18 years with no further intervention. Measurements were made of nasal symmetry at the ages of 5, 10 and 18 looking for the overall results, as well as the affects of growth. The results supported the McComb nose correction, a technique that achieves good nasal symmetry of unilateral cleft lip which does not appear to affect the growth of the nose over the 18 year study.

Work published as: McComb HK, Coghlan BA Primary repair of the unilateral cleft lip nose: completion of a longitudinal study. Cleft Palate Craniofac J. 1996 Jan;33(1):23-30; discussion 30-1 Department of Plastic and Maxillofacial Surgery, Princess Margaret Hospital for Children, Perth, Western Australia.

Abstract of the paper: The first 10 consecutive unilateral cleft subjects operated on in 1975 by a technique of primary cleft nose correction, developed by the author (HKM), were reviewed at ages 10 and 18. No further nasal surgery had been performed on these cases. The anteroposterior and inferior facial appearances of each of the cases have been published for evaluation. A computer-based method of measuring nasal asymmetry was used to objectively analyze the results and compare them with normal and cleft control faces that were age matched. The results support the observation that nasal growth of the cleft side of the nose is unaffected by early primary nasal surgery and that the vertical shortening of the nose by the alar lift technique is preserved into adult life. Residual nostril asymmetry from septal deviation persists into adulthood.

 

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1994 Winner

Phoneme specific nasal emission occurs as nasal fricatives replace oral fricatives or affricates when there is normal velo-pharyngeal function for other sounds. This pattern of velopharyngeal function is sometimes misdiagnosed and in consequence may be managed surgically or with inappropriate management techniques.

This paper reports a review of 100 individuals using active nasal fricatives and presenting with phoneme specific nasal emission.

The most significant retrospective finding is the presence of middle ear hearing loss in 95% of patients. The type, frequency, timing and success of speech and language therapy techniques used with these patients are reported and recommendations for management given.

 

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1993 Winner

Growing up with a Cleft

This paper examines the psychosocial impact of growing up with a cleft, and the intereaction between parental adjustment and the child's psychological well-being.

As part of a wider study, 13 families of older children with clefts were assessed using detailed interviews and standard psychological measures. The assessment focused on parental adjustment, and on the childrens' self esteem, social experience and behaviour.

It was found that although none of the children were psychologically disturbed, the experience of a cleft was difficult for them. They were less socially competent and more defensive than their peers, and suffered more anxiety, although they were less likely to exhibit difficult behaviour. There was a significant relationship between parental adjustment and the children's problems. Those whose parents were poorly adjusted experienced more difficulties.

Psychological intervention will be described, and an early screening measure to assist in the identification of poorly adjusted parents will be presented.

 

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1992 Winner

Work published in the following articles:

The vascular anatomy of the pharynx, NSG Mercer and P MacCarthy in Proceedings of the Craniofacial Society of Great Britain in the British Journal of Plastic Surgery 43. 2. 358 (1989)
 

The Arterial Basis of Pharyngeal Flaps, NSG Mercer and P MacCarthy in Plastic and Reconstructive Surgery 96. 1026-1037 (1995)
 

The Arterial Supply of the Palate: Implications for Closure of Cleft Palates, NSG Mercer and P MacCarthy. Plastic and Reconstructive Surgery 96. 1038-1044 (1995)


The work formed the basis of Mr Mercer's Masters degree (ChM (Bristol) 1993)

 

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1991 Winner

The Characteristics of Pre-speech Vocalisations in Cleft Palate Children

This paper reports some results of a longitudinal investigation into the babbling and speech development of cleft palate children. Audio recordings were made of the vocalisations of eight cleft palate children prior to the operation to repair the palate, six to eight weeks post-operatively and six months later. The data were analysed according to the frequency of use of the active articulators and the frequency of occurrence of manner of articulation categories.

The results, demonstrate the delayed and deviant nature of the pre-speech vocalisations of cleft palate children prior to palate repair. Following palate repair certain common changes can be detected in the majority of the children. The third recording suggests that there are different rates in the resolution of delayed and deviant development. the implications of this study are that it may be possible to detect at an early age children who might subsequently have major pronunciation problems.

 

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1990 Winner

This work was published as Intracranial Pressure and Intracranial Volume in Children with Craniosynostosis by Gault DT, Renier D, Marchac D, Jones BM in Plastic and Reconstructive Surgery September 1992 Vol 90 (3) 377 - 381

A summary of Mr Gault's presentation follows. This study looks at the relationship between intra-cranial pressure and intra-cranial volume in children with cranio-synostosis. When one of the coronal sutures fuses early, there is little growth of the vault on that side. This is thought to deny the growing brain room to develop normally. The skull affects the underlying brain and many of these children have raised intra-cranial pressure. The rise in pressure is slow in onset and clinical symptoms, such as headaches, are often absent. Normal intra-cranial pressure increases with age and it is likely that the young child's brain is especially sensitive to intra-cranial hypertension. The life threatening rises in intra-cranial pressure seen after head injury is not seen in these children.

At present the only satisfactory way to measure intra-cranial pressure is to place a sensor within the skull. This requires a general anaesthetic. If reduced intra-cranial volume is causing the rise in intra-cranial pressure then perhaps volume measurement alone would pick out the children with intra-cranial hypertension and thus save them an additional, albeit minor, operation to insert the pressure sensor. This was a study of 66 children with craniosynostosis presenting to the Hospitals for Sick Children in Paris and London. There were 48 boys and 18 girls. Their ages ranged from 6 months to 14 years with a mean age of 29 months. Intra-cranial pressure was recorded using the epidural sensor in 61 children. 3 patients had their pressure measured with a Camino Subdural bolt and in 2 cases lumbar puncture was used.

In each case an overnight record was obtained. As intra-cranial volume varies as the child grows, the data has been examined in terms of Standard Deviation Scores (also known as the Z score). The Z score measures the tendency of any particular value to drift from normal, where V is the volume; V(a) is the volume of a normal child of the same age and sex & SD(a) is the standard deviation of a group of normal children of the same age and sex. Those children with raised pressure had a mean Z score of -1.568 they had a significant reduction in volume when compared to the group with normal pressure. The reduction in volume of the borderline group was not statistically significant.

The key question is, does reduced volume pick out the children with raised pressure? When the children with the greatest reduction in volume were examined, however, less than 50% had a raised pressure. Our hypothesis that volume measurement alone would highlight the children at risk with raised pressure was clearly not supported.

Hydrocephalus occurs in about 4% of children with craniosynostosis and is particularly common in those with Crouzons, Aperts and Clover Leaf deformities. This study has shown that when the intra-cranial pressure is elevated there is a significant reduction in intra-cranial volume. A reduced intra-cranial volume however does not reliably indicate whether the intra-cranial pressure is elevated or not. There is, unfortunately, no short cut to direct intra-cranial pressure measurement in these children.

 

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