A 14-year-old African female was referred to the Nairobi hospital,
Kenya, seeking treatment for secondary defects of bilateral cleft lip
and palate together with oro-nasal fistulae. The chief complaint was
misalignment of anterior teeth, creating an unsatisfactory aesthetic
appearance for the patient. In addition, the patient reported difficulty
in feeding due to oro-nasal regurgitation, especially while consuming
fluids. The patient had unsuccessfully undergone previous cheiloplasty
and several attempts at cleft palate repair prior to referral.
Extra-oral examination revealed a whistling deformity characterized by
an unsightly central vermillion notching and residual scars on the upper
lip consistent with past surgical procedures. Upon intra-oral and dental
cast analysis, it was verified that the patient had a collapse of the
maxilla characterized by a class III skeletal relationship, anterior
crossbite, bilateral posterior crossbite as well as palato-nasal and
labio-nasal fistulae. Additionally, the maxillary lateral incisors (12
and 22), maxillary canine (13) and maxillary 2ndpremolar (25) were clinically absent (Figure 1).
Through the panoramic radiograph, absence of 12 was confirmed while 13,
18, 22, 28, 38 and 48 were all impacted. A computed tomography (CT) scan
revealed a bilateral discontinuity of the maxillary alveolar ridge
resulting in a floating anterior maxillary segment with attachment
solely to the nasal septum. In addition, a total of three round/oval
oro-nasal fistulae were visualized (Figure 2).
The patient was managed with a multidisciplinary approach in three
well-defined phases. The first phase consisted of pre-surgical
orthodontic treatment and involved use of a hyrax rapid maxillary
expander. The screw was turned one quarter of a turn once a day for a
total of 5 weeks. At the end of expansion, the device was kept in place
for another 5 months, after which, upper and lower orthodontic fixed
appliances were bonded. The lower 1st premolars were
extracted in an attempt to balance the occlusion. The final step in the
first phase of treatment involved right maxillary ABG to reconstruct the
cleft of the alveolus. Surgical exposure and consequent orthodontic
traction was then employed to align the 13 into occlusion (figure
3).
The second phase of treatment entailed left maxillary ABG and closure of
the oro-nasal fistulae. It was noted that the wisdom teeth were impacted
(see figure 2) and upon recommendation from the orthodontist,
they were removed. Hence proper planning of the surgery was imperative
which comprised of surgical odontectomies (disimpactions) of 18, 28, 38
and 48 followed by harvesting of the particulate cortico-cancellous bone
from the maxillary tuberosity, distal to 18 and 28 and from the
retromolar area distal to 38 and 48. The volume of bone harvested in
this case was 15 cc in total. After the bone was obtained, a buccal flap
was raised to expose the cleft region, followed by disimpaction of the
unfavorably positioned 22 present within the cleft. Nasal floor soft
tissue repair was then performed followed by packing of the particulate
bone into the cleft (figure 4). Due to the heavy scarring
resulting from multiple unsuccessful palatal surgeries performed
previously, a poor soft tissue profile (deficiency) was noted around the
oro-nasal fistulae (figure 3(b)). This prevented adequate local
soft tissue closure necessitating the use of an anteriorly based, left
dorsal tongue flap. The flap was designed and elevated with a 5 mm
thickness and adequate pedicle length that was enough to allow suturing
to the palate without any tension. Post-operatively, the patient was fed
via nasogastric tube for 5 days after which the oral feeding resumed
albeit, on a pureed (blenderized) diet. Three weeks later, the flap was
divided and the rest returned to the donor site (figure 5).Postoperative pain was managed using a combination of paracetamol and
diclofenac. Antibiotic cover consisted of Augmentin 1.2g, IV for 3 days
and then 1g peroral twice a day for 4 days. Clinical evaluation after
discharge was undertaken at 2 weeks, 1, 3 and 6 months duration. In
order to assess graft survival and dental arch stability, intraoral
periapical (IOPA) and a digital orthopantomogram (OPG) were taken after
6 months (figure 6).
The third phase of treatment comprised of post-surgical orthodontics in
order to close spaces and coordinate the occlusion. Overall, the
orthodontic treatment took 47 months to complete.