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Letters to the Editor

May we add our kudos to the recently published four-part article concerning the Eurocleft intercenter study. The scope of the work is impressive. Much has been learned already from this fine work, and needed information will continue to be forthcoming. Having thus stated the obvious, may we point out what we feel is a glaring and misleading statement in Part 3: Dental Arch Relationships (pp. 78–82). The statement is somewhat incomplete and therefore prejudicial. Even more damning is what it does not say. We refer to page 81, in the next to last paragraph, which states that this was the only center where primary bone grafts were part of the early protocol and that they subsequently found that 50% of the patients eventually needed orthognathic surgery. It is then stated, ‘‘The finding that primary bone grafting is associated with poor growth of the maxilla is in agreement with earlier studies (Friede and Johanson, 1974, 1982; Ross, 1987; Brattström et al., 1991).’’ Indeed, the statement is true, but what it does not state (thus confirming prior prejudicial attitudes in reference to primary bone grafts) and what the authors could have added or merely stated elsewhere, is the phrase ‘‘as executed in the technique and protocol in the center in this study.’’ One should never lose sight of the fact that when these procedures were initially utilized (and this study was started), grafts often were placed at the time of lip closure, separately, or even at the time of palate closure. Often they were placed over large bony voids accompanied by extensive undermining. There were no common denominators other than that they were all done within approximately the first year of life; one northern European center undermined extensively and raised large double transpalatal flaps. Without this knowledge, one readily can understand the present-day lack of objectivity in assessing the long-term veracity of early bone grafts. As presented in this current publication, the information merely perpetuates previously held misconceptions and closes down an open mind. In contrast, we have been part of a well-defined protocol, initiated in the 1960s, that included type and timing of primary osteoplasty. The primary graft is basically a small, autogenous subperiosteal onlay rib graft placed across the maxillary alveolus, with minimal undermining, after the segments have been aligned in close approximation. Long-term studies have consistently shown no growth attenuation and a 35-year retrospective study of 82 complete cleft lip and palate cases (mean age, 17.5 years; Rosenstein, et al., 2003) showed an incidence of orthognathic surgery to be 18.29%! Indeed, one should keep in mind the old adage of the baby and the bath water.