Figure 1 - available via license: Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International
Content may be subject to copyright.
Source publication
Objective: Palatal fistula is a significant complication following cleft palate repair. The guidelines of management of the palatal fistula is dependent on the type of cleft, site of fistula, condition of surrounding tissue and associated problem. We studied the management and outcome of 194 cleft palate fistula in our institute. Design: We present...
Context in source publication
Context 1
... Alveolar extension palatoplasty (AEP) flaps were extremely useful [ Figure 1a] for fistula in postalveolar region. The AEP flaps could be raised cautiously even in the presence of the previous scars between mucoperiosteum flaps and its extension into alveolus [ Figure 1b]. However, an interval of 6 months or more between the palate repair and the fistula repair by AEP flaps is necessary. ...
Similar publications
Background: Cleft lip and cleft palate are the most common congenital developmental deformities found worldwide. Children with oral clefts have a range of functional and esthetic complications. Hence, the successful management of children born with oral clefts requires coordinated care provided by several specialties. Knowledge of oral health-relat...
Cleft lip and palate (CLP) deformity is reported in the literature as having a varied incidence.1 As per report of the International Perinatal Data Base of Typical Oral Clefts (IPDTOC) working group, the overall prevalence of cleft lip with or without cleft palate was 9.92 per 10,000. The prevalence of cleft lip was 3.28 per 10,000, and that of cle...
Aim:
The aim of the study was the identification of predictors of psychology and beliefs among parents of children affected by cleft lip and cleft palate.
Methods:
The study included a sample of 157 parents of children having cleft lips and cleft palates. Parents were given a questionnaire related to their beliefs and reasons behind deformity....
The majority (85%) of nonsyndromic cleft lip with or without cleft palate (nsCL/P) cases occur sporadically, suggesting a role for de novo mutations (DNMs) in the etiology of nsCL/P. To identify high impact protein-altering DNMs that contribute to the risk of nsCL/P, we conducted whole-genome sequencing (WGS) analyses in 130 African case-parent tri...
Rev Soc Bras Cir Craniomaxilofac 2008; 11(2): 55-61
Introduction: The palatoplasty is the treatment of choice for the correction of the cleft palate. The search for the technique that provides better results is a major concern. It is clear that the best analysis for the efficiency of a palatoplasty technique is the speech itself. However, others f...
Citations
... Primary cleft palate width was not studied in this work. The most frequent fistula location was the hard palate (Pittsburgh IV and V), followed by the soft and hard palate junction (Pittsburgh III), consistent with other studies (13,14) (Figs. 2-4). ...
Introduction:
Palate fistula is the most frequent complication following palatoplasty. The objectives of this study were: to describe the most widely used repair techniques; to study results and recurrence rate; to analyze potentially predictive recurrence variables; and to assess whether a specific technique is superior according to fistula size and location.
Materials and methods:
Retrospective study of patients undergoing palate fistula repair in 7 healthcare facilities from 2008 to 2018. All facilities had at least 20 new cases of cleft lift and palate annually (range: 20-80), with a fistula incidence of 14% (range: 1.5-20%). Minimum follow-up was 1 year. 8 variables were collected for statistical analysis purposes.
Results:
234 fistula patients underwent surgery. Most fistulas occurred in complete bilateral cleft lift and palate (Veau type IV). The most frequent location was the hard palate (Pittsburgh types IV and V (63.2%)), and fistulas were mostly large (42.1%) and medium (39.5%). The most frequent repair technique was re-palatoplasty (34.2%). Recurrence rate was 22%. The multivariate analysis demonstrated more recurrences in re-palatoplasty repaired type III fistulas in patients over 3 years old.
Conclusion:
A tendency towards using flap repair in large hard palate fistulas, re-palatoplasty in medium hard palate and soft and hard palate junction fistulas, and local flaps or re-palatoplasty in small fistulas at any location was observed. However, it could not be statistically demonstrated whether a specific repair technique was superior in different clinical situations.
... We prefer to close the nasal layer using 2-layered reconstructions. Flap division has been done by various authors varying from 10 to 21 days (9,17). In our series, we chose to do flap division after a period of 3-week. ...
... However, no objective blindness or double-blind evaluation has been published, and the work by Li et al, 7 Nadon et al, 9 Baykul et al, 13 Nadal et al, 12 Sándor et al, 20 and Carlini et al 14 did not present a priori calculation of the sample size, while Murthy 17 did not do it properly. However, Scott et al, 4 Nadon et al, 9 Lopes-Cedrún et al, 17 Cho-Lee et al, 15 Walia, 19 and Sándor et al 20 did not define in their methodology a protocol for collecting the data to be extracted. In addition, Paris et al, 16 Cho-Lee et al, 15 and Miller et al 21 presented, in comparison to the other studies, a shorter follow-up time of the evaluation of the main outcome and of possible adverse events, which represents a risk for the judgment of a false positive in the success of the treatment analyzed by them. ...
Background:
The oronasal fistula in cleft patients is one of the complications that can be found after primary surgeries due to a failure of healing of the surgical repair that causes the communication between the oral and nasal cavities. A number of procedures can be implemented to correct the fistula and it is not clear if a particular technique is the best to be recommended.
Objective:
This study aims to systematically analyze the scientific evidence regarding the treatment of oronasal fistulas located in the lingual-alveolar and labial-alveolar regions in patients with cleft lip and palate who have undergone primary surgeries.
Material and methods:
A bibliographic search of articles published until September 2018 without restricted year and language of publication, in PubMed (Medline), Scopus, Cochrane, Web of science, and BVS databases. The MeSHterms "Fistula," "Oral Fistula," and "Cleft Lip" were used, which were related to each other and with other keywords related to the subject of the review through the "OR" and "AND" operators. The quality of the publications was evaluated according to the guidelines of the Methodological Index for Nonrandomized Studies.
Results:
After applying the eligibility criteria, a total of 18 articles were selected for the extraction of data and qualitative analysis.
Conclusion:
All publications analyzed in this review reported the fistula treatment at the same surgical time as the bone graft, independently of the donor area, the type of cleft treated and the patient's age at operation. There was no consensus among the studies on the best treatment type for oronasal fistulas located in the alveolar region, and further comparative studies between the existing techniques will be necessary to address this question.
... Detachment, flap necrosis secondary to pressure by a hematoma, and airway obstruction are other serious complications of tongue flaps [11,12]. The rates of detachment, which is the most common complication, vary between 4 and 20% [1,[13][14][15]. In our study, flap detachment occurred in nine of 34 (26%) patients. ...
Large palatal fistulas after cleft palate surgery are difficult to treat using local mucoperiosteal flaps alone, particularly if multiple attempts to close the fistulas have resulted in tissue scarring. In this study, we present our 15-year surgical experience with tongue flaps for large palatal fistulas. A total of 34 patients who underwent tongue flap surgery at our institution between January 2000 and January 2015 were retrospectively analyzed. An anteriorly-based dorsal tongue flap was used for the treatment of anteriorly localized large palatal fistulas in all patients. Data including demographic characteristics of the patients, previous surgeries, localization of the fistula, time between the first and second surgery, and complications were recorded. Factors affecting the surgical success were evaluated. Of the patients, 21 were males and 13 were females with a mean age of 11.7 ± 6.9 (range: 4 to 29) years. Detachment of the tongue flap was observed in nine patients after surgery. Seven of the patients with detachment were male aged ≤6 years (p < 0.05). Resuturing the flap back to the defect did not significantly affect the results. Our study results suggest that proper patient selection and attentive and rigorous surgical technique have a critical importance in the tongue flap repair and tongue flap is not recommended for patients who are under seven years of age.
... Difficulty in dissecting anterior palate (especially nasal layer) and inability in achieving watertight closure are prime causative factors of fistula in this area. Murthy [21] also found incisive foramen as the most common site. The review of literature [22] showed that another common site of fistula formation was junction of hard and soft palates, which was the second common site in this study. ...
... Tongue flap was also done in two cases. Murthy [21] reported a similar pattern of the type of surgeries. On follow-up of 6 months, we found recurrent fistula in four of the operated cases of anterior fistulae (Veau Types III and IV). ...
Objective:
The purpose of this study was to retrospectively review the incidence, profile, and the management of palatal fistula occurring in patients operated for cleft palate in our institute.
Materials and methods:
A retrospective analysis was performed on all cleft palatal fistula patients who presented during the period from August 2007 to October 2017, to classify their site, age of presentation, surgery performed, and outcome. A record of the type of cleft palate and previous palatoplasty was also obtained. The outcome in terms of incidence and fistula formation depending on Veau's classification was analyzed.
Results:
Twenty-two patients reported with palatal fistula during this period. The incidence of fistula formation of our institute was 9.6%. Incisive foramen (13/22) was the most common site of fistula formation. Among various techniques used, local and buccal flaps were found to be useful in a maximum number of cases (14/22). The rate of fistula recurrence was 18.2% (4/22). On retrospective analysis of our institutional data, it was found that the incidence of cleft palate fistula was significantly higher in clefts with Veau Types III and IV (13/18) as compared to Veau Types I and II (5/18).
Conclusion:
This study shows that the fistula rate of our institution was 9.6%. Complete clefts (unilateral or bilateral) involving both primary and secondary palates predispose more to fistula formation.
... Various surgical techniques have been suggested for the closure of palatal defects which include secondary healing, palatal flaps, tongue flaps, turnover flaps of adjacent mucoperiosteum, and pedicled flap from the buccal fat pad (BFP). [1][2][3][4][5][6][7][8][9] The use of BFP as a pedicled flap (PBFPF) as a graft for intraoral defects is a common procedure since its first publication by Egyedi in 1977, [10] and the outcomes from the use of this flap for closure of intraoral defects have been encouraging. The success of the PBFPF has been attributed to its rich vascular supply, less donor site morbidity, almost constant weight for all individuals, ease to harvest, and the fast epithelialization during 3-6 weeks. ...
Introduction
The integrity of the palatal mucosa can be lost due to congenital, pathological, and iatrogenic conditions. Various surgical techniques have been suggested for the closure of palatal defects. The aim of the current study is to present the free buccal fat pad graft as a novel technique to repair the soft-tissue defects at the palate.
Patients and Methods
During a 2-year period, the free fat tissue graft harvested from the buccal fat pad (BFP) (FBFG) and used to reconstruct five soft-tissue defects of the palate in five patients (2 women, 3 men; mean age, 34 years; range, 22–58 years). In two patients, the palatal defect size was 2–3 cm and resulted from the resection of pleomorphic adenoma. In two other patients, the defect was due to odontogenic lesion, and in the last patient, the etiology was an iatrogenic dehiscence during maxillary segmentation surgery. Patients were examined every 2 weeks in the first 3 months and thereafter every 3 months.
Results
Five patients were treated with FBFG to reconstruct palatal defects and were followed up for 6–24 months. The healing process of the BFP and the recipient sites were uneventful, with minimal morbidity. At 3 months after the surgery, there was complete epithelialization of the graft at the recipient sites.
Conclusions
Harvesting of FBFG is a simple procedure with minor complications; manipulation and handling the graft are easy. The use of FBFG in reconstruction of small and medium palatal defects is encouraging with excellent clinical outcomes.
... Reconstruction of large palatal fistulas in cleft patients is often extremely challenging. [1] Because of adjacent mucosal atrophy and insufficient volume, closure of large fistulas is too difficult. [2] Tongue flaps are appropriate techniques in such situations. ...
Background:
Large palatal fistula in cleft patients is a difficult situation, especially with previous multiple surgeries, which have led to severe scars in the palatal mucosa. Tongue flaps are useful aids in such situations.
Materials and methods:
Seven cleft patients who were reconstructed by posteriorly based lateral tongue flap between 2005 and 2012 were studied. Variables such as flap-ability to close the fistula, remaining tongue shape at least 1 year after operation, and speech improvement (patients' self-assessment) were evaluated.
Results:
Age range of the patients was 14‒45 years. The male-to-female ratio was 2/7. Posteriorly based lateral tongue flap effectively closed the large fistula in 6/7 of patients. The largest dimensions of fistula closed by this flap was 5 cm × 1.5 cm. Follow-up of 2‒7 years showed that the tongue never returned to the original size and remained asymmetrical. In addition, the nasal speech did not improve dramatically after the closure of large palatal/alveolar fistulas in this age group.
Conclusion:
Posteriorly based lateral tongue flap is an effective method to solve the problem of large palatal fistulas in adult cleft patients. The most useful indication for this flap is a large longitudinal palatal fistula, extending to the alveolar process. Asymmetrical tongue shape after surgery is the rule and speech improvement depends on patient's age and location of fistula.
... A nterior palatal fistula or oronasal fistula is the most common complication of cleft palate repair, the incidence ranging from 4% to 35%. [1][2][3] Palatal fistulae can be classified according to their size as small (<2 mm in diameter), medium (2-5 mm) and large (>5 mm). [4] The common symptoms include hypernasality of speech due to nasal escape of air and leakage of fluid and food into the nasal cavity leading to poor oral hygiene and foul smell. ...
... Tongue flap has been a work horse for difficult palatal fistulae with shortage of tissue. [3] The use of the lingual flap for repair of hard palate fistulae was first reported by Guerrero-Santos and Altamirano. [6] The rich vascular supply from the lingual artery and its four branches and the extensive anastomotic network with the contralateral side contributes to the versatility of the tongue flap. ...
... Success rate of the tongue flap has been reported varying from 85% to 95.5%. [3,[11][12][13][14] Success depends upon proper flap elevation, tension free nasal layer closure, edge to edge approximation of the flap with palatal tissues and not too tight closure of the donor area near the base of the flap. While raising the flap one should not take more than 5-7 mm. ...
Introduction:
Despite the improved techniques of repair of cleft palate, fistula occurrence is still a possibility either due to an error in the surgical technique or due to the poor tissue quality of the patient. Though commonly the fistula closure is established by use of local flaps but at times the site and the size of the fistula make use of local flaps for its repair a remote possibility. The use of tongue flaps because of the central position in the floor of the mouth, mobility and the diversity of positioning the flaps make it a method of choice for closure of anterior palatal fistulae than any other tissues. The aim of this study was to analyse the utility of tongue flap in anterior palatal fistula repair.
Materials and Methods:
We had 41 patients admitted to our hospital during the period 2006-2012 for repair of palatal fistula and were enrolled into the study. In the entire 41 cases, fistula was placed anteriorly. The size of the fistulae varied from 2 cm × 1.5 cm to 5.5 cm × 3 cm. The flaps were divided after 3-week and final inset of the flap was done.
Observation and Result:
None of the patients developed flap necrosis, in one case there was the dehiscence of the flap, which was reinset and in one patient there was bleeding. None of our patients developed functional deformity of the tongue. Speech was improved in 75% cases.
Conclusion:
Leaving apart its only drawback of two-staged procedure and transient patient discomfort, tongue flap remains the flap of choice for managing very difficult and challenging anterior palatal fistulae.
... Some researchers consider the palatal fistula only when it is located in the secondary palate (Emory et al., 1997;Parwaz et al., 2009;Landheer et al., 2010), called true fistulas (Phua and Calain;2008), including fistulas of the anterior palate, hard palate, transition between hard and soft palate, and soft palate (Amaratunga, 1988;Emory et al., 1997;Diah et al., 2007;Andersson et al., 2008;Parwaz et al., 2009;Landheer et al., 2010). However, others also include fistulas in the primary palate (Åbyholm et al., 1979;Cohen et al., 1991;Phua and Chalain, 2008;Murthy, 2011), classified as pre-alveolar, post-alveolar, or anterior fistula (Phua and Chalain, 2008;Murthy, 2011). ...
... Some researchers consider the palatal fistula only when it is located in the secondary palate (Emory et al., 1997;Parwaz et al., 2009;Landheer et al., 2010), called true fistulas (Phua and Calain;2008), including fistulas of the anterior palate, hard palate, transition between hard and soft palate, and soft palate (Amaratunga, 1988;Emory et al., 1997;Diah et al., 2007;Andersson et al., 2008;Parwaz et al., 2009;Landheer et al., 2010). However, others also include fistulas in the primary palate (Åbyholm et al., 1979;Cohen et al., 1991;Phua and Chalain, 2008;Murthy, 2011), classified as pre-alveolar, post-alveolar, or anterior fistula (Phua and Chalain, 2008;Murthy, 2011). ...
Objective:
To evaluate the prevalence of fistulas after palate repair and analyze their location and association with possible causal factors.
Design:
Retrospective analysis of patient records and evaluation of preoperative initial photographs.
Setting:
Tertiary craniofacial center.
Participants:
Five hundred eighty-nine individuals with complete unilateral cleft lip and palate that underwent palate repair at the age of 12 to 36 months by the von Langenbeck technique, in a single stage, by the plastic surgery team of the hospital, from January 2003 to July 2007.
Interventions:
The cleft width was visually classified by a single examiner as narrow, regular, or wide. The following regions of the palate were considered for the location: anterior, medium, transition (between hard and soft palate), and soft palate.
Main outcome measures:
Descriptive statistics and analysis of association between the occurrence of fistula and the different parameters were evaluated.
Results:
Palatal fistulas were observed in 27% of the sample, with a greater proportion at the anterior region (37.11%). The chi-square statistical test revealed statistically significant association (P ≤ .05) between the fistulas and initial cleft width (P = .0003), intraoperative problems (P = .0037), and postoperative problems (P = .00002).
Conclusions:
The prevalence of palatal fistula was similar to mean values reported in the literature. Analysis of causal factors showed a positive association between palatal fistulas with wide and regular initial cleft width and intraoperative and postoperative problems. The anterior region presented the greatest occurrence of fistulas.
An oronasal fistula (ONF) is an abnormal structure between the oral and nasal cavities, which is a common complication of cleft palate repair due to the failure of wound healing. When some patients with ONF are unsuitable for secondary surgical repair, the obturator treatment becomes a potential method. The objectives of the obturator treatment should be summarized as filling the ONF comfortably and cosmetically restoring the dentition with partial function. The anatomy of patients with cleft palate is complex, which may lead to a more complex structure of the ONF. Thus, the manufacturing process of the obturator for these patients is more difficult. For performing the design and fabrication process rapidly and precisely, digital techniques can help, but limitations still exist. In this review, literature searches were conducted through Medline via PubMed, Wiley Online Library, Science Direct, and Web of Science, and 122 articles were selected. The purpose of this review was to introduce the development of the obturator for treating patients with ONF after cleft palate repair, from the initial achievement of the obstruction of the ONF to later problems such as fixation, velopharyngeal insufficiency, and infection, as well as the application of digital technologies in obturator manufacturing.
