Cleft lip and palate (CLP) is the most common congenital malformation, occurring at a rate of 1/700 live births globally.1 For complete reconstruction, patients born with CLP undergo a series of surgeries and associated treatments during childhood. The typical surgical algorithm begins in infancy with cleft lip repair around 10 weeks of age followed by cleft palate repair at 10 months of age. After the eruption of the permanent maxillary first molars around 6 years of age, alveolar bone grafting is performed to unite the maxillary arches 2. At skeletal maturity, the final jaw surgery and septorhinoplasty are performed as the final surgeries of cleft care.
The relatively standardized treatment algorithm for CLP allows for a unique opportunity to evaluate the impact of variations in care, such as reoperation or complications, in the long term psychosocial outcomes of children. Previously, we reported age-related differences in psychosocial functioning in children born with craniofacial anomalies using the Pediatric Patient-Reported Outcomes Measures Information System (PROMIS).3 In a prospectively collected, multi-institutional cross-sectional study, we noted that children with craniofacial anomalies between the ages of 8-10 years reported higher anxiety, depression, and lower peer relationships compared older cohorts, suggesting that the 8-10 year age range represents a critical time period for psychosocial dysfunction. As this is a frequent time period for children with CLP to have surgery, a logical subsequent question is whether surgery, or repeat surgery, at this time period would result in long term psychosocial consequences.
In particular, one of the most common reasons for increased surgeries in CLP children is repeat alveolar bone grafting. Alveolar bone grafts repair the gum ridge, allowing proper tooth development. Regrafting occurs frequently in these children with variabilities in rates depending on the severity of the clefts, resorption of the graft, time period between grafting and tooth eruption or orthodontic manipulation, and the types of grafting offered to the children.2 In this work, we evaluate the psychosocial impact of surgical burden during childhood on teenage patients born with cleft lip and palate by number of surgeries as well as using repeat alveolar bone grafts as a common unanticipated variation in the surgical algorithm.
To assess whether alveolar bone regrafting rates have an effect on the psychosocial outcomes of children undergoing repeat surgeries for CLP based on Pediatric PROMIS assessments.
We conducted a prospective, cross-sectional study examining pediatric psychosocial outcomesin children with cleft lip and palate treated at the UCLA Craniofacial Clinic (n=110). Demographics, numbers of surgeries, and types of surgeries were collected from clinic and operative notes. Using theNIH Pediatric Patient-Reported Outcomes Measurement Information System (PROMIS) short forms for Anxiety, Depressive Symptoms, Peer Relationships,andAnger, children and their parents were approached during clinic appointments or contacted by phone for psychosocial evaluations. All evaluations for children were performed with both child assent and parent consent.Statistical analyses were performed using independent sample t-tests using SPSS Version 24 (Chicago, Illinois) with a p-value <0.05 considered significant.
Among the 110 children examined in this study, 47.3% were female and 52.7% were male. 73.6% of the cohort did not have alveolar bone regrafts, while 26.4% did have regrafts at the time of assessment. The mean total number of surgeries was 5.25 (SD=2.66), with most of the surgeries (mean=3.17, SD=1.88) occurring between 0-7 years of age.
There is an increase in pediatric anxiety in children with regrafts compared to those without regrafts. A significant increase in anxiety correlated with increased surgical burden that was seen in patients with 3-4 total surgeries compared to patients with 5-8 total surgeries.
In children between 14-17 years of age, an increase in the number of surgeries at 8-10 years of age is correlated with an increase in anxiety. CLP children between 14-17 years of age (n=40) had a regraft rate of 77.5%. 50.0% of CLP children between 14-17 years of age had 0 surgeries when they were between 8-10 years of age, while 50.0% had at least one surgery in that age interval. 75% of children between 14-17 years of age had at least 3 surgeries when they were between 0-7 years of age, 62.% had at least one surgery when they were between 11-13 years of age, and 27.5% had at least one surgery between 14-17 years of age.
There is a significant relationship between surgical burden and psychosocial functioning. We found that an increase in pediatric anxiety is correlated with alveolar bone regrafting and an increase in the total number of surgeries. Higher regrafting rates could possibly cause decreased satisfaction with aesthetic outcomes, which may explain the increase in pediatric anxiety. The scars may hinder their social acceptance and thus contribute to their psychosocial functioning. It is also possible that this increase in anxiety can be attributed to an increase in severity of the alveolar cleft, which would likely increase the number of regrafts necessary to correct the anomaly.
We also found that increasing the number of surgeries done at 8-10 years of age is associated with an increase in anxiety in children between 14-17 years of age. Other than patients 18 years of age and older, children between 14-17 years of age had the lowest mean total number of surgeries (mean=0.32, SD=0.73). Since 77.5% of children between 14-17 years of age did not have a regraft between 8-10 years of age, it is possible that regrafting plays the most significant role in increased anxiety. Increasing the number of surgeries done at 8-10 years of age may be associated with an increase in regraft rates, which would be consistent with our previous conclusion.
1. Searle, Aidan, Patricia Neville, and Andrea Waylen. "Psychological growth and well-being in individuals born with cleft: An application of self-determination theory." Psychology & health 32.4 (2017): 459-482.
2. Weissler, E. Hope, et al. "Alveolar bone grafting and cleft lip and palate: a review." Plastic and reconstructive surgery 138.6 (2016): 1287-1295.
3. Volpicelli, Elizabeth J., et al. "Age-Related Differences in Psychosocial Function of Children with Craniofacial Anomalies." Plastic and reconstructive surgery 140.4 (2017): 776-784.