Descriptive study of management of palatal fistula in one hundred and ninety-four cleft individuals

Reconstruction of persistent oronasal communication using an anteriorly based tongue flap following failed cleft palate repair-Report of two cases

The tongue flap is a suitable alternative to local mucoperiosteal flaps in closure of wide, persistent oronasal communications, surrounded by scarred and fibrotic tissue as a result of previously attempted palatoplasty. Herein, we report two cases with large recurrent oronasal communication closed using the anteriorly based dorsal tongue flap.

Cleft Palate Fistula: A Review

Background

The development of postoperative oronasal fistulae (ONF) is a complication that plagues all cleft surgeons to varying degrees. There is extensive literature discussing the incidence, functional impact, and treatment of ONF. The goal of this article is to provide an extensive review of the literature discussing the incidence, causative factors, functional impact, classification systems, and treatment of ONF.

Methods

A literature review was performed using PubMed using the Medical Subject Heading terms "cleft palate" AND "fistula" OR "palatal fistula" OR "oronasal fistula". After review, a total of 356 articles were deemed relevant for this study.

Results

Information regarding ONF care, prevention, and management in patients with cleft palate was collected from the articles included in this review. Treatment of ONF remains a challenging problem as there is not a consensus in the available literature on the best palatoplasty techniques for their prevention and treatment. A myriad of reconstructive options and adjunctive therapies exist, and their use is guided by the size and location of the fistula.

Conclusions

Fistula treatment should be tailored to the specific needs of the patient, and consideration must be given to not only the ONF itself but also the patient's stage of growth and development. Large-scale, multicenter studies are needed in which ONF are described using standardized nomenclature, and improved outcomes reporting is necessary to better define an algorithm for a truly holistic approach to palate surgery and reduce the incidence of palatal fistula.

Obturator Manufacturing for Oronasal Fistula after Cleft Palate Repair: A Review from Handicraft to the Application of Digital Techniques

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.

The Application of Buccal Fat Pad to Cover Lateral Palatal Defect Causes Early Mucolization

Introduction

Cleft lip and cleft palate are among the most common birth defects. These deformities lead to profound psychosocial and functional effects on cleft palate patients. Several surgical techniques have been described for the repair of the cleft. The defects lateral to mucoperiosteal flaps closure are sometimes covered with sterile gauze soaked with soft paraffin or tincture of benzoin or are left open for mucolization by means of secondary intention. The buccal fat pad (BFP) is used as a pedicled graft to cover the exposed bone of the lateral palatal defect, and it is associated with proposed benefits of early healing and fewer effects on transverse growth of the maxilla.

Materials and methods

This was a prospective study involving 42 cleft palate patients who underwent cleft palate repair; 21 patients received BFP as an additional step to cover lateral palatal defect while the rest of the patients (n=21) underwent conventional surgical cleft palate repair and the defect was covered with Surgicel (Ethicon, Inc., Bridgewater, NJ). Postoperative follow-up was conducted at first, second, and third weeks postoperatively to assess the time required for mucolization.

Results

Our cohort of 42 patients included an equal number of complete and incomplete cleft palate patients. Follow-up at the first postoperative week showed an equal number (n=21, 100%) patients with incomplete mucolization on both groups, while at the second postoperative follow-up, only one (4.8%) of the patients who underwent conventional cleft palate repair had complete mucolization while 20 (95.2%) among the patients who underwent BFP had complete mucolization. At the third-week postoperative follow-up, three (14.3%) patients from the conventional group had complete mucolization, while 18 (85.7%) had incomplete mucolization. Only two patients (4.8%) developed recipient area complications, and they were managed conservatively.

Conclusion

BFP is a good source of vascularized tissue to cover the hard palate bones after primary cleft repair. It is easy to harvest as a local tissue with a low learning curve. The epithelialization rate is faster than conventional methods with minimal complication rates.

Evaluation of Prognostic Factors for Palatal Fistulae after Cleft Lip and Palate Surgery in a North-Western Romanian Population over a 10-Year Period

Cleft lip and palate is the most frequent birth anomaly, with increasing reported rates of complications, such as palate fistulae. Current studies concerning the occurrence rate of cleft lip and palate (CLP) report 2 to 10 cases in 10,000 births. The purpose of this study was to investigate the existence of factors that could predict the occurrence of fistulae after cleft lip and palate surgery. A retrospective study was performed by collecting and analyzing data from all patients who were operated for cleft lip and/or palate in the Maxillo-Facial Department of the Emergency Clinical County Hospital of Cluj-Napoca, Romania, between 2010 and 2020. We investigated the existing evidence for possible links between the number of fistulae observed after the primary palatoplasty and the age at which the primary palatoplasty was performed, the sex of the patient, the type of cleft, the timing of the surgical corrections, and the presence of comorbidities. A total of 137 cases were included for analysis. A significant link between the number of fistulae and the type of cleft was found (with fistulae occurring more frequently after the surgical correction of CLP—p < 0.001). No evidence was found for the existence of significant links between the number of fistulae and the patient’s sex, the timing of surgery, or the presence of comorbidities. This study concluded that the incidence of palatal fistulae appears to be influenced by the type of cleft (CLP), but not by the sex of the patient, the timing of surgery, or the presence of comorbidities.

Management of Oronasal Fistulas in Patients With Cleft Lip and Palate

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.

Patients With a History of Oronasal Fistula Repair Exhibit Lower Oral Health Measured With Patient-Centric Outcomes Measures

INTRODUCTION

Oronasal fistulae following palatoplasty may affect patients' quality of life by impacting their ability to eat, speak, and maintain oral hygiene. We aimed to quantify the impact of previous oronasal fistula repair on patients' quality of life using patient-reported outcome psychometric tools.

METHODS

A cross-sectional study of 8- to 9-year-old patients with cleft palate and/or lip was completed. Patients who had a cleft team clinic between September 2018 and August 2019 were recruited. Participants were divided into 2 groups (no fistula, prior fistula repair). Differences in the individual CLEFT-Q and Child Oral Health Impact Profile-Short Form 19 (COHIP-SF 19) Oral Health scores between the 2 groups were evaluated using a multivariate analysis controlling for Veau classification and syndromic diagnosis.

RESULTS

Sixty patients with a history of cleft palate were included. Forty-two (70%) patients had an associated cleft lip. Thirty-two (53.3%) patients had no history of fistula and 28 (46.7%) patients had undergone a fistula repair. CLEFT-Q Dental, Jaw, and Speech Function were all higher in patients without a history of a fistula repair; however, none of these differences were statistically significant. The COHIP-SF 19 Oral Health score demonstrated a significantly lower score in the fistula group, indicating poorer oral health (P = .05).

CONCLUSIONS

One would expect that successful repair of a fistula would result in improved function and patient satisfaction, but the consistent trend toward lower CLEFT-Q scores and significantly increased COHIP-SF 19 Oral Health scores in our study group suggests that residual effects linger and that the morbidity of a fistula may not be completely treated with a secondary correction.

A Toolbox of Surgical Techniques for Palatal Fistula Repair

OBJECTIVE

To provide an inventory of oronasal fistula repair techniques alongside expert commentary on which techniques are appropriate for each fistula type.

DESIGN

A 4-stage approach was used to develop a consensus on surgical techniques available for fistula repair: (1) in-person discussion of oronasal fistula cases among cleft surgeons, (2) development of a schema for fistula management using transcripts of the in-person case discussion, (3) evaluation of the preliminary schema via a web-based survey of additional cleft surgeons, and (4) revision of the management schema using survey responses.

PARTICIPANTS

Six cleft surgeons participated in the in-person case discussion. Eleven additional surgeons participated in the web-based survey. Participants had diverse training experiences, having completed residency and fellowship at 20 different hospitals.

RESULTS

A schema for fistula management was developed, organized by fistula location. The schema catalogues all viable approaches for each location. For fistulae involving the soft palate, the schema stresses the importance of evaluating for velopharyngeal insufficiency (VPI) and incorporating VPI management into fistula repair. For fistulae involving the hard palate, the schema separately enumerates the techniques available for nasal lining repair and for oral lining repair in each region. The schema also catalogues the diversity of approaches to lingual- and labioalveolar fistula, including variation in timing, orthodontic preparation, and simultaneous alveolar bone grafting.

CONCLUSIONS

This study employed consensus methods to create a comprehensive inventory of available fistula repair techniques and to identify preferential techniques among a diverse group of surgeons.

Synchronous correction in secondary cleft deformities: a prospective cohort study

BACKGROUND

Patients with cleft lip and palate deformities undergo multiple surgical procedures from infancy till adolescence. We hypothesized that combining these surgical procedures might offer a better quality of life without compromising on surgical outcomes.

METHODS

A prospective cohort study was conducted at our center including all adult patients who reported to us for the correction of secondary cleft deformities. All patients with secondary deformities associated with cleft lip palate and alveolus were enrolled in the study. Patients with medical issues who are not fit for general anesthesia, Bilateral Cleft deformities, and patients with gross skeletal deformity warranting surgical correction by Le fort I distraction were excluded from the study. All the patients who were included in the study underwent simultaneous lip revision, rhinoplasty and cleft alveolar bone grafting. The outcome lip nose profile was assessed using standardized patient photographs with Ascher Mcdade Scale and Aesthetic outcome index by 2 blinded maxillofacial surgeons and the bone grafting was assessed using Berglands grading system.

RESULTS

Twenty-eight patients were enrolled in the study, 10 patients were excluded based on the exclusion criteria. Thus 18 patients planned for synchronous correction of unilateral secondary cleft deformities were included in the study The Ascher Mcdade Score improved from 15 (13-16), to 4 (4-5) in the post op. All the patients were totally satisfied with the surgical outcome. The aesthetic index showed excellent outcomes in all the lip-nose procedures, except for one case which showed a good outcome. The Bergland Scale showed normal bone height in all cases of alveolar bone grafting, except for one case, which showed less than 3/4^th fill of bone. No complications were associated with any of the procedures.

CONCLUSIONS

Simultaneous correction of multiple secondary cleft lip deformities should be considered when feasible, to improve the psychological benefit and reduce financial burden on these patients. However, careful planning and execution of the techniques is essential to avoid complications associated with vascular compromise.

The tongue flap for large palatal fistulas, a success or a failure? Our 15-year experience

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.

A statistical analysis of incidence, etiology, and management of palatal fistula

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.

Difficulty Index-Based Management of Palatal Fistula After Primary Cleft Palate Repair: An Institutional Experience

PURPOSE

In the present study, we have highlighted the occurrence of different palatal fistulas and evaluated the difficulty level in planning the treatment, thereby enabling the prediction of the prognosis preoperatively.

MATERIALS AND METHODS

The present retrospective study included 62 nonsyndromic cases with primary surgery and palatal fistula repair performed in our unit. Data were collected on the fistula incidence, site, and size, cleft type, fistula closure method. All these were categorized, analyzed, and scored according to the difficulty index reported by Richardson et al. The data were statistically analyzed using χ² analysis and Fisher's exact test.

RESULTS

The incidence of palatal fistula was 4.58%, with the transverse type (74%) the predominant type. The difficulty index was grade 1 and 2 for 33 (53.2%) and 29 (46.8%) patients, respectively. The recurrence rate was 35.4%, with 6.4 and 28.9% observed in the grade 1 and grade 2 groups, respectively (P = .019). The surgical techniques included tongue flap, redo palatoplasty, rotation flap, and a combination of rotation with a buccal fat pad. The incidence of recurrence was dependent on the type of surgical management and the difficulty index score (P = .047).

CONCLUSIONS

Palatal fistula closure is a technically difficult procedure with a high recurrence rate. Thus, the difficulty level index for closure must be evaluated to predict the outcomes of the procedure before surgery. Also, further studies are required to introduce a standardized classification system of fistula complexity to address the difficulty in their management.

Post-Septoplasty Palatal Fistula in A Patient with Normal Palate: Case Report

Nasal septoplasty is a common procedure performed in plastic surgery and otorhinolaryngology. Many complications after septoplasty have been reported. Palatal perforation is one of the rarest complications with only a few cases reported in the literature. The reported cases had misdiagnosed submucousal cleft palate or high arched palate, but a patient with palatal perforation after septoplasty is presented here which have had neither evidence of submucousal cleft palate nor high arched palate.

Tongue flap as salvage procedure for recurrent and large palatal fistula after cleft palate repair

BACKGROUND

Recurrent palatal fistula is a common complication of cleft palate repair. The main causes are poor surgical technique or vascular accidents and infection. Local flaps are not adequate for larger and recurrent fistula. The aim of this study is to analyze the utility of tongue flap in recurrent and large palatal fistula repair.

MATERIALS AND METHODS

From January 2008 to July 2016, 18 patients with recurrent palatal fistula were included in the study. All the patients had undergone repair of cleft palate and fistula previously. Tongue flap repair of the recurrent palatal fistula was performed in all 18 patients. The flaps were divided after 3 weeks and final inset was done. Flap viability, fistula closure, residual tongue function, esthetics, and speech impediment were assessed.

RESULTS

In all the patients, fistula could be closed primarily by tongue flap. None of the patients developed flap necrosis while flap dehiscence and bleeding were observed in one patient each. No functional deformity of the tongue and donor-site morbidity was seen. Speech was improved in 80% cases.

CONCLUSION

The central position, mobility, excellent vascularity, and versatility of tongue flap make particularly suitable choice for the repair of large fistula in palates scarred by previous surgery. It is very well tolerated by children. We, therefore, recommend tongue flap for large and recurrent palatal fistula in children.

Oronasal fistula post-septoplasty

Nasal septal surgery is one of the most common otolaryngology procedures performed, with rare occurrences of major postoperative complications. Oronasal fistula is a rare complication of septal surgery, with only few cases being reported in the literature. It is commonly caused by a congenital cleft palate, cleft palate surgery, traumatic injuries, infections, or neoplasms; however, it does not usually occur post-septal surgery. Here, we report the case of a 55-year-old male who presented with a symptomatic oronasal fistula post-septoplasty. Unlike other reported cases, there were no features of underlying palatal pathologies, and no previous history of other nasal or oral procedures. We described a multilayer surgical closure technique that was utilized in this case, with no recurrence seen during a 6-month follow-up period. Additionally, we reviewed the other 3 reported cases of this complication, and discussed the possible etiology in this case.

The use of buccal fat pad free graft in closure of soft-tissue defects and dehiscence in the hard palate

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.

Versatility of Tongue Flaps for Closure of Palatal Defects- Case Report

Palatal defects following congenital anomalies, traumatic injuries, benign and malignant pathologies frequently require resection and reconstruction. Reconstruction of these defects is challenging and complex due to the amount of tissue left for primary closure after excision, compromised vasculature as on repaired cleft palate and limited pedicled flaps around the lesion. Tongue flap though doesn't fulfil all the ideal requirements of a flap, however because of its flexibility, good blood supply and position it can be considered as the best among other flaps for reconstruction of oral and palatal defects. In this article we describe two different cases in which tongue flap was used to reconstruct palatal defects, one an oroantral communication secondary to a tumour excision and the other an oro-nasal fistula secondary to cleft palate repair.

Premaxillary palatal flap (PPF) as an aid to create nasal floor in anterior palatal fistula closure of cleft patients. Technical note

Fistula behind premaxilla in cleft patients is the second most common in frequency and the most difficult location for closure. High risk of failure is reported after corrective surgeries in this region. Two layer closures are important in this topic. Reflection of palatal premaxillary mucosa provides a new source for nasal lining that is introduced in this article as a technical note and is explained with four cases. While the premaxillary palatal flap is a promising alternative for closure of these types of clefts, more studies are necessary before it can be universally recommended.

Posteriorly based lateral tongue flap for reconstruction of large palatal-alveolar fistulas in cleft patients

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.

Role of tongue flap in palatal fistula repair: A series of 41 cases

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.

Prevalence, Cause, and Location of Palatal Fistula in Operated Complete Unilateral Cleft Lip and Palate: Retrospective Study

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.

Incidence of oronasal fistula formation after nasoalveolar molding and primary cleft repair

The incidence of postoperative complications in cleft care is low. In this 19-year retrospective analysis of cleft lip and palate patients treated with preoperative nasoalveolar molding, we examine the incidence of postoperative oronasal fistulae. The charts of 178 patients who underwent preoperative nasoalveolar molding by the same orthodontist/prosthodontist team and primary cleft lip/palate repair by the same surgeon over a 19-year period were reviewed. Millard, Mohler, Cutting, or Mulliken-type techniques were used for cleft lip repairs. Oxford-, Bardach-, or von Langenbeck-type techniques were used for cleft palate repairs. One nasolabial fistula occurred after primary cleft lip repair (0.56% incidence) and was repaired surgically. Four palatal fistulae (3 at the junction between soft and hard palate and 1 at the right anterior palate near the incisive foramen) occurred, but 3 healed spontaneously. Only 1 palatal fistula (0.71%) required surgical repair. All 5 fistulae occurred within the first 8 years of the study period, with 4 (80%) of 5 occurring within the first 3 years. Although fistula rate may be related to surgeon experience and the evolution of presurgical techniques, nasoalveolar molding in conjunction with nasal floor closure contributes to a low incidence of oronasal fistulae.