362 BRITISH JOURNAL OF PLASTIC SURGERY

Bone grafting in the cleft maxilla

K. W. L. VIG and R. J. FONESCA

School of Dentistry, University of Michigan, Ann Arbor, USA

Alveolar bone grafting in patients with cleft lip and/or palate is a well-established method of treatment. Autologous bone grafting, although widely accepted, has the associated morbidity of a second operative site from which the donor bone is harvested. An alternative is the use of allogeneic bone, which has been the preferred method of alveolar bone grafting since 1985 at the University of Michigan Medical Center, Ann Arbor, USA.

The orthodontic implications and management of post-surgical movement of teeth into the grafted area were evaluated in 24 patients who had unilateral complete clefts of the lip and palate. The age of the patients ranged from 9-16 years, with a mean age at the time of surgery of 12.3 years, Radiographic and clinical data were available preoperatively, postoperatively and at long-term follow-up which ranged from 20-47 months. All patients had allogeneic bone chips grafted into the cleft and, pre-surgically, 21 patients had an associ- ated oronasal fistula.

The results from this retrospective study indi- cated that 10 of the patients in which the permanent canine was unerupted showed spontaneous move- ment into the grafted area with eruption of the canine. Those patients in whom the canine was already partially or fully erupted at the time of

alveolar cleft grafting had the canine moved into the graft with orthodontic appliances. Of the 24 patients evaluated, 19 had pre-surgical orthodontic treatment which invariably included palatal expan- sion, and 23 had orthodontic treatment post- surgically. The presence of dehiscence and bone spicules from the surgical site occurred in 18 patients although none became infected.

The oronasal fistula was closed at the time of surgery and remained closed except in two patients. Radiographic evaluation to determine bony bridg- ing of the cleft site was achieved in 21 of the cases.

The preliminary findings from this study indicate that all the criteria for success were not fully satisfied. The absence of morbidity from a second surgical site with allogeneic bone grafting may become the preferred treatment in the future. However, clinicians should be cautious in recom- mending this treatment until long-term results are available. Alternative treatment methods of graft- ing the cleft maxilla, with autogenous or allogeneic bone, poses a decision analytical problem with respect to utility. Ideally, a case-control study should be designed to determine relative efficacy and to provide probability estimates of the various treatment outcomes with each option.

Factors influencing the ability of families to cope with a craniofacially deformed child

E. WALTERS

Park Hospital for Children, Oxford

In an attempt to understand what factors may influence the development of self-esteem in children born with craniofacial deformity, the parents’ coping ability of 22 families with children under 5 years presenting for craniofacial surgery was rated clinically following a preoperative semi-structured interview. The families were then divided into coping and non-coping groups. Detailed informa-

tion was gathered regarding demographic features, factors relating to chronic illness, factors specific to craniofacial disorder, potentially compounding stresses, parents’ attitute to surgery and satisfaction with services.

There were 11 families in both the coping and non-coping groups. Comparing them showed no significant differences regarding the child’s age,

ABSTRACTS 363

ordinal position, social class, severity of condition, pregnancy complications, family history of congeni- tal defects, availability of social supports, problems with siblings, negative social experiences, presence of developmental delay or additional physical problems. The non-coping families had more affected boys (7) than girls (4), with more girls (8) than boys (3) in the coping group.

Poor handling of the initial diagnosis, with unnecessary periods of uncertainty and being given incorrect or inadequate information, was reported by nine of the non-coping families but by none of

those coping well. The non-coping parents also reported more problems with acceptance by grand- parents and acquaintances, more dissatisfaction with services and more negative attitudes to craniofacial surgery.

Handling of the original diagnosis may affect the ability of parents to accept the deformed child’s condition and deal constructively with the many problems they encounter. Help at this time may have long-standing benefits for both the parents and their child.

The “tadpole flap”-its role in the closure of palatal fistulae

J. D. WATSON

Department of Plastic and Reconstructive Surgery, Frenchay Hospital, Bristol

Published in the British Journal of Plastic Surgery (1988), 41,485.