Anthropometrics versus Experts' Subjective Analysis of Cleft Severity and PSIO Outcomes in Unilateral Clefts: A New Grading System.

BACKGROUND

The severity of unilateral cleft lip significantly influences surgical outcomes, yet no standardized system exists to classify cleft severity or assess the impact of presurgical infant orthopedics (PSIO). This study proposes an objective classification system, integrating anthropometric measurements with expert evaluations.

METHODS

Deidentified pre-PSIO and post-PSIO photographs of 50 infants with unilateral cleft lip from the Smile Train Express database were analyzed. Three anthropometric parameters-nostril width ratio (NWR), columellar angle (CA), and subnasale lateral displacement (SN)-were measured. An expert panel of orthodontists and surgeons independently rated cleft severity and PSIO outcomes, in a structured 3-stage process. Severity thresholds were established through consensus, and interrater agreement was analyzed using weighted kappa.

RESULTS

Consensus-derived thresholds categorized NWR, CA, and SN into 4 severity levels. Interrater agreement for cleft severity improved across stages, reaching nearly perfect levels in stage 3 (pre-PSIO weighted kappa, 0.91; post-PSIO weighted kappa, 0.93). Although pre-PSIO agreement was similar between surgeons and orthodontists, post-PSIO assessments showed greater variability. PSIO had a disproportionate effect on nasal morphology (CA) compared with maxillary segments (NWR and SN), with severe NWR and SN frequently coexisting with mild CA. The proposed classification system demonstrated substantial reliability, aligning at least 2 parameters within the same severity subclassification.

CONCLUSIONS

This study introduces a standardized classification system for cleft severity and PSIO outcomes, demonstrating strong interrater reliability. By integrating anthropometric data with expert assessments, it provides a reproducible framework for clinical and research applications. Further refinements, including intraoral measurements and 3-dimensional imaging, may enhance its precision and applicability.