European Journal of Orthodontics 35 (2013) 772782

doi:10.1093/ejo/cjt009
Advance Access publication 15 March 2013

The Author 2013. Published by Oxford University Press on behalf of the European Orthodontic Society.
All rights reserved. For permissions, please email: journals.permissions@oup.com

SystematicReview
Indices to assess malocclusions in patients with cleft lip and palate
MostafaAltalibi, HumamSaltaji, RyanEdwards, Paul W.Major and CarlosFlores-Mir
School of Dentistry, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
Corespondence to: Mostafa Altalibi, Orthodontic Graduate Program, University of Alberta, 5528 Edmonton Clinic
Health Academy, Edmonton, Alberta, Canada, T6G 1C9. E-mail: mostafa.altalibi@gmail.com

Introduction
Cleft lip and/or palate (CLP) is the most common congenital malformation in the head and neck and represents
a group of heterogeneous disorders that affect between one
and seven out of 1000 newborns (Vanderas, 1987). These
disorders can affect the face and the oral cavity. Moreover,
patients with this condition may exhibit an array of functional and aesthetic co-malformations, in addition to those
malformations specific to the CLP by definition, ranging
from a mid-face deficiency and a constricted maxillary
dental arch to congenitally missing and malformed teeth
(Vargervik, 1981; Mossey et al., 2009). The sum of these
malformations gives rise to a malocclusion that can be
extremely difficult to treat at times; thus, treatment is largely
through a multidisciplinary approach (Evans, 2004).
This comprehensive treatment plan can prove to be a
large burden on the public health sector, and since CLP
manifests as a spectrum of severities (Gorlin etal., 2001), it
was deemed by the government-funding agencies that there

needs to be a system to judge the severity of the malocclusions. Certain indices, having already been used for
other purposes, were applied to attempt to give an objective
measure of the severity of the malocclusion in CLP patients
(Parker, 1998; Hong etal., 2001).
Many indices are now available, each with different
criteria and uses, and although it has been quite some time
since the introduction of these indices, there is no consensus
as to which index should be used for CLP populations
(Parker, 1998; Hong et al., 2001). Furthermore, because
each index arose due to specific related circumstances,
not all the indices should be used for patients with CLP.
This ambiguity makes the task of choosing an appropriate
index to report CLP malocclusions daunting, be it to assess
the severity of malocclusions for research, governmentfunding purposes, or prognosis of surgical and orthodontic
treatment in patients with CLP. According to the World
Health Organization (WHO), the ideal index should excel
in the following criteria: reliability, validity and acceptance

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Background: Several indices are now available to assess the severity of the malocclusion in cleft lip
and/or palate (CLP) patients; and although it has been quite some time since the introduction of these
indices, there is no consensus as to which index should be used for CLP populations.
Objective:To systematically review the available literature on the indices used to assess the occlusal
schemes in dental models of CLP patients, with respect to the most commonly used index and the index
that most fulfils the World Health Organization (WHO) criteria.
Search methods:Ten electronic databases, grey literature, and reference list searches were conducted.
Selection criteria:The inclusion criteria consisted of studies that aimed to assess a particular malocclusion index on study models of patients with CLP.
Data collection and analysis: Full articles were retrieved from abstracts/titles that appeared to have
met the inclusion -exclusion criteria which were subsequently reviewed using more detailed criteria for a
final selection decision. The Quality Assessment of Diagnostic Accuracy Studies tool was used to appraise
the methodological quality of the finally included studies. Due to the heterogeneity of the data, only a
qualitative analysis was performed.
Results:A total of 13 studies met the inclusion -exclusion criteria. These studies revealed seven utilized indices, namely the GOSLON Yardstick, Five-Year-Old, Bauru-Bilateral Cleft Lip and Palate Yardstick,
Huddart -Bodenham, Modified Huddart -Bodenham, EUROCRAN Yardstick, and GOAL Yardstick. The
GOSLON Yardstick was the most commonly used index, and the Modified Huddart -Bodenham performed
the best according to the WHO criteria.
Conclusions: Current evidence suggests that the Modified Huddart -Bodenham Index equalled or outperformed the rest of the indices on all the WHO criteria and that the GOSLON Yardstick was the most
commonly used index, possibly due to a longer time in use. Therefore, the Modified Huddart -Bodenham
could be considered as the standard to measure outcomes of patients with CLP.

773

CLEFT LIP AND PALATE INDICES

by the profession; require minimal judgment; lend itself

to statistical analysis; and be administratively simple
(Summers, 1971). This index assessment criteria list was
chosen because it seemed to be the most all-encompassing
type of the attributes important for anindex.
To date, there have been no studies reviewing the available indices used for patients with CLP in a systematic way.
Therefore, the overall aim of this report is to systematically
review the available literature on the indices used to assess the
pre-orthodontic occlusal schemes in dental models of patients
with CLP. Consideration will be given to the most commonly
used index and the index that fulfils most of the aforementioned six WHO criteria. The results of this systematic review
will guide researchers and clinicians alike in choosing an
appropriate index to report the malocclusions of cleft patients.
Materials and methods
Reporting of this systematic review was performed in
accordance with the PRISMA statement for reporting systematic reviews of health sciences (Liberati etal., 2009).

A comprehensive review of the literature was conducted on

18 July 2012 using the electronic databases: PubMed (1966
to July 2012); MEDLINE (19482012, week 28); EMBASE
(1974 to 18 July 2012); Scopus (19602012, week 28); ISI
Web of Science (1899 to 18 July 2012); all EBM (EvidenceBased Medicine) Reviews, Cochrane DSR, ACP Journal
Club, DARE, CCTR, CMR, HTA, and NHSEED; Global
Health (1910 to June 2012); PASCAL (19842012, week
28); and HealthSTAR (1966 to June 2012). The search strategy was devised with the help of a health science librarian
specializing in the field of dental research. The used key
words varied slightly to be tailored to the databases but generally involved cleft, malocclusion, index, dental models, reproducibility, observer variation, and sensitivity
and specificity. For a more detailed account including the
way the terms were combined refer to online Supplementary
Table1 (Appendix). Of the relevant selected articles, hand
searches were subsequently performed on the bibliography
lists, and in cases of ambiguity, the authors of the articles
were contacted. An additional search was conducted using
the indices found in the relevant articles as keywords in order
to obtain a quantitative measure of the number of studies that
use the index. No restrictions were applied regarding publication year or language. When additional information was
needed, efforts were made to contact the authors.
Study selection
Query1. The studies included in this systematic review
were selected in a two-phase process and fulfilled the following criteria:

Phase 1 (titles and abstracts): 1. Oral cleft studies,

2. human studies, 3. occlusal analysis using an index,

Query2. In order to identify the most commonly used

index, all identified indices were tracked through the
Google Scholar database. The Google Scholar engine
was used because it includes the peer-reviewed journals
of Europe and Americas largest scholarly publishers,
scholarly books and other non-peer-reviewed journals
and allows you to sift through the full texts of all the
articles in search of a particular word. This second query
had the following inclusion criteria: the specific index
was used in the study, analyzed in the study, or reviewed
in thestudy.
Selection of articles that met the inclusion/exclusion
criteria was done by two researchers independently, and
there was a discussion following each phase and search. All
contested articles were unanimously agreed upon before
proceeding to the next step. If an abstract was deemed
ambiguous in phase 1, it was included for phase 2 selection,
and if an article was ambiguous in phase 2, then the authors
were contacted for clarification.
Data items and collection
From the relevant articles in query 1, we extracted data
on the reliability, and/or validity, and/or acceptance by the
profession, and/or requirement for judgment, and/or statistical analysis, and/or the administrative simplicity in all
of the indices used to evaluate the malocclusions in dental
models of patients with cleft lip and/or palate. In query 2,
we only extracted the name of the index or indices used in
the article, in order to quantify the prevalence of the given
index.
Risk of bias in individual studies
The Quality Assessment of Diagnostic Accuracy Studies
(QUADAS) tool (Whiting etal., 2003) was used to appraise
the methodological quality of the relevant studies (Table1).
This tool represents a validated quality assessment tool for
diagnostic studies (Cook et al., 2007). Two researchers
independently appraised the methodologic quality of each
study and contested scores were discussed until unanimous
agreement was achieved.
Data synthesis and bias across studies
A meta-analysis was planned if the quality and quantity of
the information retrieved warranted a meaningful statistical
combination.

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Data sources and searches

4.measurements done on dental casts, and 5.assessment

of the index, the aim of the study. Case reports and case
series were excluded.
Phase 2 (complete articlesin addition to the criterion
from phase I): Assess the reliability, validity, acceptance by the profession, requirement for judgment,
statistical analysis or administrative simplicity of the
index.

774
Table1 QUADAS (Whiting etal., 2003) criteria for evaluating
diagnostic accuracy studies.
I. Study design (7 )

Maximum number of s=14.

Results

Study characteristics
Among the included studies were eight cross-sectional
studies (Huddart and Bodenham, 1972; Mars etal., 1987;
Hathorn et al., 1996; Gray and Mossey, 2005; Tothill and
Mossey, 2007; Manosudprasit et al., 2011; Patel, 2011;
Dobbyn etal., 2012) and five longitudinal studies, (Mossey
etal., 2003, Atack etal., 1997b, Atack etal., 1997a, Bartzela
etal., 2011, Mars etal., 2006), and all of them were retrospective (Table2).
Synthesis of results
The selected articles revealed seven indices: the GOSLON
Yardstick (Mars etal., 1987; Hathorn etal., 1996; Mars etal.,
2006; Manosudprasit etal., 2011), the Five-Year-Old Index
(Atack etal., 1997a; Atack etal., 1997b; Mars etal., 2006),
the Bauru-Bilateral Cleft Lip and Palate (BCLP) Yardstick
(Bartzela etal., 2011), the HuddartBodenham (HB) Index
(Huddart and Bodenham, 1972; Bartzela et al., 2011), the
Modified HuddartBodenham (MHB) Index (Mossey etal.,
2003; Gray and Mossey, 2005; Tothill and Mossey, 2007;
Manosudprasit etal., 2011; Patel, 2011; Dobbyn etal., 2012),
the EUROCRAN Yardstick (Patel, 2011), and the GOAL
Yardstick (Friede etal., 1991). Summaries of the articles are
presented in Table2. Furthermore, the prevalence and a brief
description of these indices are presented in Tables 3 and 4.
Within the included studies, zero assessed the reliability of the GOAL Yardstick, one assessed the EUROCRAN
Yardstick (Patel, 2011), one assessed the BCLP Yardstick
(Bartzela et al., 2011), two assessed the reliability of the
Five-Year-Old Index (Atack et al., 1997a; Atack et al.,
1997b), two assessed the reliability of the HB Index

Study selection
The devised search strategy yielded 832 articles from
the 10 electronic databases, which are listed in detail
in online Supplementary Table 1 (Appendix). Of these
articles, 20 met the criteria of phase 1 selection (Mars
et al., 1987; Tobiasen et al., 1991; Mars et al., 1992;
Morris et al., 1994; Hathorn et al., 1996; Atack et al.,
1997a; Atack etal., 1997b; Parker, 1999; DiBiase etal.,
2002; Johnson and Sandy, 2003; Gray and Mossey, 2005;
Nollet et al., 2005; Mars et al., 2006; Deacon et al.,
2007; Suzuki etal., 2007; Tothill and Mossey, 2007; Liao
et al., 2010; Bartzela et al., 2011; Patel, 2011; Dobbyn
et al., 2012), and of the 20 atricles, 10 met the phase
2 selection criteria (Mars et al., 1987; Hathorn et al.,
1996; Atack etal., 1997a; Atack etal., 1997b; Gray and
Mossey, 2005; Mars et al., 2006; Tothill and Mossey,
2007; Bartzela et al., 2011; Patel, 2011; Dobbyn et al.,
2012) with an additional three added through the reference search (Huddart and Bodenham, 1972, Mossey
etal., 2003; Manosudprasit etal., 2011), yielding a total
of 13 articles. Accounts of the literature search results
are presented in Figure1.

Figure1 Flow diagram of the literature search according to the PRISMA

statement.

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A.Was the spectrum of patients representative of the patients who will

receive the test in practice? ()
B.Were selection criteria clearly described? ()
C.Is the reference standard likely to correctly classify the target
condition? ()
D.Is the time period between reference standard and index test short
enough to be reasonably sure that the target condition did not change
between the two tests? ()
E.Did the whole sample or a random selection of the sample receive
verification using a reference standard of diagnosis? ()
F.Did patients receive the same reference standard regardless of the
index test result? ()
G.Was the reference standard independent of the index test (i.e. the
index test did not form part of the reference standard)? ()
II. Study measurements (5 )
H.Was the execution of the index test described in sufficient detail to
permit replication of the test? ()
I.Was the execution of the reference standard described in sufficient
detail to permit its replication? ()
J.Were the index test results interpreted without knowledge of the
results of the reference standard? ()
K.Were the reference standard results interpreted without knowledge of
the results of the index test? ()
L.Were the same clinical data available when test results were
interpreted as would be available when the test is used in practice? ()
III. Statistical analysis (2 )
M.Were uninterpretable/intermediate test results reported? ()
N.Were withdrawals from the study explained? ()

M. ALTALIBI ET AL.

Index evaluated

Five-Year-Old Index

Five-Year-Old Index

HB + Bauru-BCLP
Yardstick

MHB

MHB

GOSLON Yardstick

Articles

Atack etal. (1997b)

Atack etal. (1997a)

Bartzela etal. (2011)

Dobbyn etal. (2012)

Gray and Mossey (2005)

Hathorn etal. (1996)

32 subjects at 10 y

50 subjects at 5 y
and 50 subjects
at 10 y

184 subjects at 5 y
and 96 subjects at
10 y

27 subjects at 5 and
10 y (different sample
than above)
43 subjects at 6,9
and 12 y

54 subjects at (56)
and (1618 y)

Sample size

Reliability

Reliability

Reliability

Reliability and
validity

Reliability and
validity

Reliability and
validity

Criteria evaluated

IAER: 0.890.95***
IEER: 0.880.95***

5y
IAER: 0.8710.912*
IEER: 0.8530.887*
10 y
IAER: 0.7830.897*
IEER: 0.7460.865*
MHB and the GOSLON Yardstick/
Five-Year-Old Index have a high
degree of correlation

Not all of the (56 y) in groups 4 and 5 were

predicted to need surgery at (1618 y)
Needs calibration
Reliable but not useful for prediction
Only useful for UCLP
Reliable index
None of the subjects received any orthodontic
treatment or secondary bone grafting
BCLP is a categorical scale
Predictive values for the HB scores of the incisors
were highly significant, borderline significant for
the total score and not significant for the lateral
segments
BCLP has a simpler analysis because it gives one
score per age
BCLP needs professional judgment and calibration
HB assesses many teeth minimizing random error

IAER: 0.730.96* (good-very good)**

IEER: 0.490.73* (moderate-good)**
PV: (56 y): 1318% were in group 4 and 5
(predicted need for surgery) (1618 y): 9%
needed surgery
IAER: 0.60.8* (good)**
IEER: 0.40.8* (fair-good)**
PV: 7093%
BCLP Yardstick
IAER: 0.5060.627* (moderate-good)**
IEER: 0.4270.581* (moderate)**
HB:
IAER: 0.920.97***
IEER: 0.880.96***
PV: the scores from the BCLP Yardstick |
were able to predict the outcome at 12 y
with an explained variance of 41.3%****,
while the HB score had 44.4%****
Adding the incisors and lateral measurement
of the HB system to the BCLP Yardstick
increases the explained variance to 67%****
5y
IAER: 0.9710.978*****
IEER: 0.982*****
10 y
IAER: 0.9930.994****
IEER: 0.996*****
MHB correlates well with the GOSLON
Yardstick and the Five-Year-Old Index
and has much more sensitivity

GOSLON and Five-Year-Old Index is subjective

MHB is more objective and simpler and avoids the
need for calibration
MHB is more versatile because it can be applied to
all cleft subtypes at any age.
MHB uses a 40-point quasi-continuous scale
MHB does not take into account the underlying
antero-posterior skeletal discrepancy, incisor inclination and is based on cross-bites, some of which is
only dental
There is a high degree of correlation between the
GOSLON indices and the MHB
GOSLON and Five-Year-Old Index are subjective
and requires calibration
MHB has a larger range of scores making it more
sensitive
MHB is an ordinal scale, and since it is objective,
it lends itself to a digital-recorded, computer-based
approach
MHB is objective, relatively simple, and versatile
The GOSLON Yardstick and the Five-Year-Old
Index are currently regarded as the best measures
for assessing surgical outcome. They also allow
non-parametric statistical tests (which more easily
interpreted) rather than contingency table testing
Consecutive patients

Comments

Results

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Table2 Summaries of the selected articles.

CLEFT LIP AND PALATE INDICES

775

GOSLON and
Five-Year-Old Index

MHB and
EUROCRAN

MHB

Mars etal. (2006)

Patel (2011)

Tothill and Mossey (2007)

Reliability and
simplicity

Reliability and
Validity

Reliability

Reliability

Criteria evaluated

19 subjects with
Reliability
BCLP + 55 subjects
with isolated cleft palate
at 5 and 10 y

30 subjects at 5 y

94 subjects at 5
and 10 y

55 subjects at 12 y

GOSLON

Mars etal. (1987)

Sample size
60 subject at 810 y

Index evaluated

Manosudprasit etal. (2011) MHB and GOSLON

Yardstick

Articles

Using the GOSLON Yardstick to assess the models

is quicker
The MHB provides more site specific information
of the deficiency in the arch

MHB
IAER: 0.98*****
Inter-examiner reliability:
0.950.97*****
GOSLON
IAER: 0.95* (very good)**
IEER: 0.86* (very good)**
IAER: 0.890.95***
IEER: 0.840.95***
GOSLON
IAER: 1.00* (very good)**
IEER: 0.800.89* (very good)**
PV
Five-Year-Old Index at 5 y vs
GOSLON at 10 y: 0.090* (poor)**
GOSLON at 5 y vs at 10 y: 0.579*
(moderate)**
Reliability
MHB
IAER: 0.850.94*****
IEER: 0.740.94*****
EUROCRAN
IAER: 0.150.60******
IEER: 0.300.95***
Simplicity
Time needed to learn the index:
(no statistical difference P<0.05)
MHB: 49 and 39min
EUROCRAN: 97 + 50min
Time needed to score the models:
(statistical difference P<0.05)
MHB: 270 and 216min
EUROCRAN: 182 and 126min
Friendliness (Likert scale)
MHB: Average of 2.2 and 2.1
EUROCRAN: 3.4 and 2.6
BCLP
At 5 y
IAER: 0.310.78* (fair-good)**
IEER: 0.570.74* (moderate-good)**
At 10 y
IAER: 0.580.70* (moderate-good)**
IEER: 0.480.69* (moderate-good)**
ICP
At 5 y
IAER: 0.800.84* (very good)**
IEER: 0.640.81* (good-very good)**
At 10 y:
IAER: 0.770.86* (good-very good**
IEER: 0.660.74* (good)**
MHB is reliable in all types of oral clefts

The EUROCRAN Yardstick is an ordered, categorical scale

MHB showed no statistical difference between
calibrated and non-calibrated examiners
MHB is more reliable, simple and straightforward
to apply
The EUROCRAN is quicker to score the models

The broadness of the categories in the GOSLON

Yardstick contributes to its reliability
The validity of the Five-Year-Old Index is worse
than the GOSLON Yardsticks validity at 5 y,
when using the GOLSON score at 10 y as the gold
standard
In 5 y, the GOSLON group 3 should be modified to
a 2, and group 4 should become 3

Comments

Results

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Table2Continued

776
M. ALTALIBI ET AL.

777
IAER, Intra-examiner reliability; IEER, Inter-examiner reliability; PV, predictive validity; UCLP, unilateral cleft lip and/or palate; BCLP, bilateral cleft lip and/or palate; HB, HuddartBodenham; MHB,
Modified HuddartBodenham.
*Weighted kappa () values.
**As described by Altman (1991).
***Spearman correlation coefficient.
****Regression model.
*****Intra-classcorrelation coefficient.
******Unweighted kappa () values.

Mossey etal. (2003)

MHB

10 subjects aged 10 y andReliability and

10 subjects aged 5 y
validity

IAER: 0.7390.952*
IEER: 0.8320.921*
PV: comparing the score of the MHB
with the Five-Year Index and GOSLON
showed statistically significant correlation
in the results 0.830.92***(P<0.01)

Similar reliability to categorical scales

MHB is easier to perform statistics on and gives
more information
Unlike the MHB, GOSLON and Five-Year Index
take into account the potential for orthodontic
camouflage of skeletal discrepancies, and dental
malocclusions with no skeletal components
Disadvantages of GOSLON is its subjectivity
Advantage of MHB: objectivity, relative simplicity,
versatility, sensitivity
IAER: average of 81.8%
IEER: average of 79.7%
Reliability
34 subjects at 5 y
HB
Huddart and Bodenham
(1972)

Criteria evaluated
Sample size
Index evaluated
Articles

Table2Continued

Table3 Quantification of the prevalence of each index

(Query2).
Index

Year developed Search results

Prevalence

Bauru-Bilateral Cleft
Lip And Palate Yardstick
(Ozawa etal., 2011)
EUROCRAN Yardstick
(Fudalej etal., 2011,
Patel, 2011)
Five-Year-Old Index
(Atack etal., 1997b)
GOAL Yardstick (Friede
etal., 1991)
GOSLON Yardstick
(Mars etal., 1987)
HuddartBodenham
(Huddart and
Bodenham, 1972)
Modified Huddart/
Bodenham (Mossey
etal., 2003, Patel, 2011)

2011

2011

1997

53

43

1991

1987

286

273

1972

27

2003

24

24

(Huddart and Bodenham, 1972; Bartzela etal., 2011), four

assessed the GOSLON Yardstick (Mars etal., 1987; Hathorn
etal., 1996; Mars etal., 2006; Manosudprasit etal., 2011),
and six assessed the MHB Index nine times (Mossey etal.,
2003; Gray and Mossey, 2005; Tothill and Mossey, 2007;
Manosudprasit et al., 2011; Patel, 2011; Dobbyn et al.,
2012), although some studies assessed the MHB more than
once in the same study using a different sample.
Moreover, the validity was assessed zero time for the
EUROCRAN Yardstick and GOAL Yardstick; one time
for the BCLP Yardstick (Bartzela et al., 2011), HB index
(Bartzela etal., 2011), and the MHB (Mossey etal., 2003);
three times for the Five-Year-Old Index (Atack etal., 1997a;
Atack etal., 1997b; Mars etal., 2006); and two times for
the GOSLON Yardstick (Mossey etal., 2003; Mars etal.,
2006). Finally, the simplicity of the EUROCRAN index and
MHB Index was assessed in one of the studies (Patel, 2011).
Due to the heterogeneity of the data and statistics in the
included studies, no meta-analysis of the data could be
performed.
Risk ofbias
The QUADAS methodologic assessment tool portrayed a
variance of 67.9 to 92.9% of the total scores in the chosen
articles. These findings are summarized in Table5 and represent moderate-to-high methodologic assessment scores.
Discussion
A review of the available literature of the indices used to
assess the pre-orthodontic occlusal schemes in dental models of patients with CLP was done. The most commonly
used index and the index that most fulfilled the WHO criteria were investigated.

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Results

Comments

CLEFT LIP AND PALATE INDICES

Ordinal

Ordinal

Ordinal

Ordinal

Ordinal

Continuous

Bauru-Bilateral Cleft Lip And Palate

Yardstick (Ozawa etal., 2011)

EUROCRAN Yardstick (Fudalej etal.,

2011, Patel, 2011)

Five-Year-Old Index (Atack etal.,

1997b, Patel, 2011)

GOAL Yardstick (Friede etal., 1991)

GOSLON Yardstick (Mars etal., 1987)

HuddartBodenham (Huddart and

Bodenham, 1972)
Modified Huddart/Bodenham
(Mossey etal., 2003, Patel, 2011)
Continuous

Scoring scale

Index

Unilateral cleft lip and palate; deciduous

dentition
All cleft types; all age groups (above 3
years old)

Unilateral cleft lip and palate; late mixed

dentition

Unilateral cleft lip and palate; late mixed

dentition

Unilateral cleft lip and palate; deciduous

dentition

Unilateral cleft lip and palate; late mixed

dentition

Bilateral cleft lip and palate; deciduous,

mixed and permanent dentition

Target population

An adaptation of the GOSLON Yardstick for bilateral cleft lip and palate rates the dentition
on a scale of 15 (bestworst prognosis, respectively), divided into 6-, 9- and 12-year-old
yardsticks
The 6- and 9-year-old yardsticks evaluate
the apical base relationships
the incisor relationships
the presence of a cross-bite (except for the permanent and deciduous lateral incisors,
deciduous canines and edge to edge buccal segments)
the arch form
The 12-year-old yardstick evaluates
the apical base relationship
the incisor relationships
The 12-year-old yardstick adds 1 point for a moderate-to-severe anterior open bite
A modification of the GOSLON Yardstick to remove the extremes and incorporate the
palatal morphology rates two components separately:
Dental arch relationship:
ranked from 1 to 4 (best to worst prognosis, respectively)
Palatal morphology:
ranked from 1 to 3 (best to worst prognosis, respectively)
An adaptation of the GOSLON Yardstick for deciduous dentition rates the dentition on a
scale of 15 (bestworst prognosis, respectively) based on
overjet and overbite
incisor inclinations
presence of cross-bites
maxillary arch shape and palatal vault
A modification of the GOSLON Yardstick rates the dentition on a scale of 15 (bestworst
prognosis, respectively) based on
presence of cross-bites
the apical base relationships
Rates the dentition on a scale of 15 (bestworst prognosis, respectively) based on
overjet and overbite
incisor inclinations
the apical base relationships
Rates the dentition on a scale of +2 to 18 (bestworst prognosis respectively) based on
presence and severity of cross-bites in the anterior segment and the two buccal segments
Rates the dentition on a scale of +10 to 30 (bestworst prognosis respectively) based on
presence and severity of cross-bites in the anterior segment and the two buccal segments

Use

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Table4 Description of indices.

778
M. ALTALIBI ET AL.

779

CLEFT LIP AND PALATE INDICES

Table5 QUADAS (Whiting etal., 2003) tool for selected articles.

Article

Atack etal. (1997b)

Atack etal. (1997a)
Bartzela etal. (2011)
Dobbyn etal. (2012)
Gray and Mossey (2005)
Hathorn etal. (1996)
Manosudprasit etal. (2011)
Mars etal. (1987)
Mars etal. (2006)
Patel (2011)
Tothill and Mossey (2007)
Huddart and Bodenham (1972)
Mossey etal. (2003)

Study design

Measurements

Statistical
analysis

x
x

Total

9.5
9.5
12.5
10.5
12
9.5
11.5
11
13
13
9.5
11
10.5

Total %

67.9
67.9
89.3
75
85.7
67.9
82.1
78.6
92.9
92.9
67.9
78.6
75

AN, methodologic criteria in Table1: () Fulfilled satisfactorily the methodologic criteria (1 check point); () unclear or fulfilled partially the
methodologic criteria (0.5 check point); and (x) did not fulfil the methodologic criteria (0 check point).

The GOSLON Yardstick had more than three times the

prevalence of the rest of the indices combined. This represents a considerable amount of research that uses the
GOSLON and speaks to its popularity. Although, being
the most commonly used index does not necessarily suggest that it is the best index, there could be many political
and convenience factors that would bring about a similar
result. Also of note is that the GOSLON Yardstick that was
introduced in 1987 (Mars etal., 1987) has been available
for use much longer than the rest of the indices. The MHB
was revealed as an index in 2003 (Mossey etal., 2003), and
prior to that, the HB was only for assessment of deciduous
dentition (Huddart and Bodenham, 1972). Furthermore,
much of the new research has modified the GOSLON
Yardstick in order to counteract some of its limitations.
For instance, the EUROCRAN Yardstick eliminated one of
the scores of the GOSLON, and made it out of a scale of
4, because the 5-point scale was seen to have redundancy
between two of the score categories. It also added a scoring system for palatal morphology (Fudalej etal., 2011).
Nevertheless, the GOSLON Yardsticks great prevalence
does give an indication to the perceived importance of the
index in comparing the results of a sample of cleft malocclusions to other studies, but its high prevalence should be
viewed with caution.
Reliability
Both the intra-examiner and inter-examiner reliability of
the Five-Year-Old Index, HB Index, BCLP Yardstick, MHB
Index, and GOSLON Yardstick were seen to be acceptable.

The variability in the reliability scores within different studies of the same index may be due to the variance in the sample sizes among the studies, as well as the level of training
of the examiners. The EUROCRAN Yardstick had a very
irregular reliability score (Fudalej etal., 2011; Patel, 2011),
while the GOAL Yardsticks reliability was not tested in any
of the chosen studies.
In addition, with regards to using a 40-point scale, such
as the MHBs, as opposed to a 5-point scale, such as the
GOSLONs, it is much more difficult to achieve a good reliability score. This should be taken into account when evaluating the reliability of the MHB and the HB.
Validity
Within the field of CLP, true validation of an index is difficult because it would require a cohort of patients with
CLP with only the primary surgeries and who did not
receive any orthodontic treatment or restorative treatment
until adulthood. Without this cohort, validation tests will
inevitably be biased. Furthermore, there is no gold standard for prognosis in assessing the severity of malocclusions within cleft patients. Therefore, all the studies thus
far rely on face validity, which relies on what the investigator deems important and is more subjective (Atack
etal., 1997a).
The GOSLON Yardstick, HB, MHB, and BCLP showed
acceptable validity. While the studies evaluating the FiveYear-Old Index did not show a good ability to predict outcome, the EUROCRAN and GOAL Yardsticks did not have
any studies within those selected in this systematic review
that examined predictive validity.

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Prevalence

780
Judgment required

Ease of statistical analysis

The HB and MHB are both continuous scales, which make
them statistically more powerful and lend themselves to parametric statistical analysis more readily. The rest of the indices
are ordinal scales, which are statistically more challenging to
use. Also the HB scales have the ability to localize the areas
within the mouth of problematic occlusion, while the rest of
the indices are unable to do so. This allows you to statistically
assess different parts of the mouth separately or as a whole.
Simplicity
The MHB and HB can both be used in any cleft type at
any age, making their usage easy in many different types of
study samples. These indices also required minimal judgment and were given good scores with regards to its user
friendliness, which also adds to its simplicity (Patel, 2011).
But the disadvantage of using this index is the time it takes
to score each set of models. Because it follows a cumulative 40-point scale of many different teeth within the same
mouth, the MHB index requires longer time to assess the
malocclusion compared to the global 5-point scales, such as
the GOSLON Yardstick.
Acceptance by the profession
Historically, the GOSLON Yardstick has been proven to
be the most popular choice for assessing cleft deformities because it has the highest prevalence, but from 1987
to 2003 (Mars et al., 1987; Mossey et al., 2003), it was
the only validated index that assessed malocclusion in

unilateral cleft lip and palate patients at 10 years of age.

Today, given that the GOSLON Yardstick only specializes
in assessing unilateral clefts of the lip and palate in patients
aged approximately 10years old, and due to its other limitations and the many newer indices developed since the
GOSLON Yardsticks inception to overcome these limitations, it cannot be considered the most accepted by the
profession. Moreover, the current scientific literature suggests that there is no clear consensus, with the GOSLON
Yardstick still being used in many new publications (Dogan
et al., 2012; Love et al., 2012; Ren et al., 2012) and the
MHB being declared a new, better alternative by others
(Dobbyn etal., 2012). According to this review, the MHB
seems to be the index that is most accepted for use in all of
the cleft deformities, based on the amount and quality of
studies that use it and assessit.
The reviewers experienced difficulty in finding all the
CLP indices that measure dental models since there is
no readily available database. Therefore, the reviewers
attempted to track down all the available indices through
selected searches and databases. Although studies of all languages were included in the searches, there is an inevitable
bias towards the English language articles, as the English
search engines may not have extensive databases in all the
languages. Some indices were excluded from this review
because they were extremely outdated (Pruzansky and
Aduss, 1964; Matthews et al., 1970) and would not have
added anything to the review, while one index was included,
the GOAL Yardstick, despite none of its studies having met
the inclusion criteria.
Another limitation to this review is that there was no clear
definition of what constitutes an index. For example some
studies looked at whether overjetalone can act as a prognostic variable for the need of future surgeries in CLP patients
(Morris etal., 1994). These studies were excluded because,
although the overjet measurements were seen as variables
that affect prognosis, they did not seem like an index as
understood by the authors.
In addition, although the methodologic assessment
revealed moderate-to-high quality within all the studies, the
methodologic assessment tool used, the QUADAS, assesses
the methodologic quality of diagnostic tests not prognostic
tests. Since the articles in this review aim at determining
prognosis, and with no better methodologic assessment tool
available, it represents a limitation to be considered.
Promising research is finding correlations between the
various indices in order to be able to readily convert between
them (Bartzela et al., 2011; Manosudprasit et al., 2011;
Dobbyn etal., 2012), but the current correlations could be
strengthened and more research is yet needed. This ability to
convert the data will allow research done with one index to be
compared with other studies measured using another index,
and it is especially important because it will allow previous
CLP research done using the GOSLON Yardstick to be compared with this research results of the MHB. Moreover, more

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The HB and MHB are the only indices that do not require
calibration and show similar rates of reliability among
trained and non-trained individuals. That is because the
point scale that the HB indices use rely on dental measurements solely, thus making it simple, objective, and eliminates the need for calibration. The disadvantage of such
a system is that it does not assess the skeletal component
of the malocclusion, not differentiating dental cross-bites
from skeletal discrepancies leading to cross-bites. Also,
it cannot differentiate between a generalized mild malocclusion and a localized severe malocclusion and cannot
assess the vertical discrepancies of the malocclusions.
Conversely, the GOSLON Yardstick uses clinical measurements, evaluates the ease of treating a particular malocclusion, and takes that into account in its score (Mossey
et al., 2003), but that requires a calculated judgment by
the evaluator, which adds to its subjectivity and need
for calibration. However, despite the fundamental difference between the MHB and the GOLSON Yardstick, the
results have been shown to be highly correlated (Gray and
Mossey, 2005).

M. ALTALIBI ET AL.

CLEFT LIP AND PALATE INDICES

781

research is needed to modify the current indices in order to

better fulfil the WHO criteria for an ideal index.

Gorlin R J, Cohen M M, Hennekam R C M 2001 Orofacial clefting

syndromes. In: Bobrow M, Harper PS, Scriver C (eds.). Syndromes
of the Head and Neck. Oxford University Press, New York, pp.
850860

Conclusion

Gray D, Mossey P A 2005 Evaluation of a modified Huddart/Bodenham

scoring system for assessment of maxillary arch constriction in unilateral cleft lip and palate subjects. European Journal of Orthodontics 27:
507511

1. The GOSLON Yardstick is much more prevalent than

any of the other indices, possibly due to a longer time in
use.
2. The MHB equalled or outperformed the rest of the indices in all of the WHO criteria for an ideal index.
It is the authors recommendations that the MHB Index be
used to assess the malocclusions of all clefts of the lip and/
or palate of all ages and to standardize the measurement
of outcomes in cleft lip and palate patients malocclusions
in order to facilitate international inter-centre studies and
allow for the optimization of cleft treatment protocols.
Supplementary material

Hathorn I, Roberts-Harry D, Mars M 1996 The Goslon yardstick applied

to a consecutive series of patients with unilateral clefts of the lip and
palate. Cleft Palate-Craniofacial Journal 33: 494496
Hong S, Freer T J, Wood E B 2001 An evaluation of the changes in
malocclusion index scores over a 25-year period. Australian Dental
Journal 46: 183185
Huddart A G, Bodenham R S 1972 The evaluation of arch form and
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194209
Johnson N, Sandy J 2003 An aesthetic index for evaluation of cleft repair.
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Liao Y F, Prasad N K, Chiu Y T, Yun C, Chen P K 2010 Cleft size at the
time of palate repair in complete unilateral cleft lip and palate as an indicator of maxillary growth. International Journal of Oral & Maxillofacial
Surgery 39: 956961
Liberati A et al. 2009 The PRISMA statement for reporting systematic
reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. Journal of Clinical Epidemiology 62:
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