Recommendations for Minimum Records for Cleft Audit

Adopted by the Craniofacial Society of Great Britain and Ireland on 14th April 2005

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Table 1 - CFS Audit Group Recommendations for Complete Clefts (UCLP & BCLP)

Timing	Models & Photos	Lat Ceph	Speech	Audiology/ Tympanology/ Otoscopy	Satisfaction (p=parents c=children)	Psychology (p=parents c=children)	Dental Health	General growth/ feeding
Birth - 6 weeks					p	p		ht / wt / head circ at birth
Before primary surgery	upper model only
12 months					p (after primary surgery)			ht / wt / head circ at birth
18 months						p
5 - 5.11 years					p	p & c	DMFS enamel defects
10 years	(pre-ABG)*				(post-grafting) p & c	p & c
12 years							DMFS enamel defects
15 years						p & c
18+ years or end of treatment					p & c	p & c

* records taken between the ages of 9 - 11 years, in preparation for orthodontic treatment / bone grafting, may also be used for audit

Table 2 - CFS Audit Group Recommendations for Isolated Cleft Palate

Timing	Models & Photos	Lat Ceph	Speech	Audiology/ Tympanology/ Otoscopy	Satisfaction (p=parents c=children)	Psychology (p=parents c=children)	Dental Health	General growth/ feeding
Birth - 6 weeks					p	p		ht / wt / head circ at birth
Before primary surgery	upper model only
12 months					p (after primary surgery)			ht / wt / head circ at birth
18 months						p
5 - 5.11 years					p	p & c	DMFS enamel defects
10 years	(pre-ABG)*				(post-grafting) p & c	p & c
12 years							DMFS / DDE
15 years					p & c	p & c
18+ years or end of treatment						p & c

* records taken between the ages of 9 - 11 years, in preparation for orthodontic treatment, may also be used for audit

Table 3 - CFS Audit Group Recommendations for Isolated Cleft Lip +/- cleft of the Alveolus

Timing	Models	Photos	Satisfaction (p=parents c=children)	Psychology (p=parents c=children)	Dental Health	General growth/ feeding
Birth - 6 weeks			p	p		ht / wt / head circ at birth
Before primary surgery	upper model only
12 months			p (after primary surgery)			ht / wt / head circ at birth
18 months				p
5 - 5.11 years	†		p	p & c	DMFS enamel defects
10 years	(pre-ABG)*	†	* (post-grafting) p & c	p & c
12 years					DMFS / DDE
15 years				p & c
18+ years or end of treatment			p & c	p & c

* records taken between the ages of 9 - 11 years, in preparation for orthodontic treatment / bone grafting, may also be used for audit

† for cases involving the alveolus only 

Table 4 - Alveolar bone grafting records

	Intra oral radiograph (occlusal centred through cleft)	Photos	Models	Patient satisfaction
Pre-orthodontic preparation
6 months post graft
When canine on cleft side has erupted			*

* end of orthodontic treatment models

Table 5 - Orthognathic surgery record

	Lateral ceph	Models & photos	Speech	Patient satisfaction
Pre-orthodontic preparation
Just before operation	(for surgical planning)	(for surgical planning)
One year post operation

Table 6 - Orthodontic treatment records

	Models	Lateral ceph	Photos
Pre-orthodontic treatment		(only if clinically necessary)
Post-orthodontic treatment		(only if clinically necessary)	*

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