Nasoalveolar molding (NAM) is an established form of presurgical infant orthopedics (PSIO). However, evidence on its medium- and long-term effects remains limited due to the few long-term studies. This study analyzes the medium-term impact of NAM, with a particular focus on the need for secondary or corrective surgeries following NAM or non-NAM treatment protocols. A retrospective cohort study was conducted of patients with cleft lip and palate (CLP) and cleft lip and alveolus (CLA) who received primary cheiloplasty between January 2012 and December 2021. All secondary or corrective surgeries following the same treatment protocol from PSIO through the end of 2024 were documented, including lip corrections, nostril corrections, oronasal fistula closure, and velopharyngoplasty. A univariable regression analysis was performed to assess the association between NAM therapy and the occurrence and number of secondary procedures. A total of 140 patient records were analyzed, comprising 53 females and 87 males. Of these, 104 patients were diagnosed with CLP and 36 with CLA. NAM treatment was administered to 97 patients (69%). The most common secondary procedures were lip correction (42%) and closure of oronasal fistula (19%), followed by nostril correction (12%) and velopharyngoplasty (6%). However, no significant associations were found between NAM treatment and necessity, frequency, or kind of secondary surgical interventions. This study provides initial insights into the medium-term effects of NAM therapy and its effect on early secondary surgeries. Although NAM was predominantly applied in more severe CLP and CLA cases, there was no increased need for secondary or corrective surgeries compared with the control group.

Evaluation and volumetric analysis of various grafting materials for alveolar cleft repair.

Rhinofacial pythiosis with basilar empyema in a lamb.

Cleft lip and palate affect 6000 to 8000 children annually in the United States. Alveolar bone grafting (ABG) restores maxillary continuity, facilitates tooth eruption, and closes oronasal fistulae, yet donor-site pain often exceeds graft-site pain. Although multimodal, opioid-sparing analgesia is increasingly used, optimal perioperative pain management remains undefined. This review evaluates current evidence on analgesic strategies for pediatric ABG. A literature review of PubMed, ScienceDirect, and Google Scholar (2010-2025) identified studies addressing perioperative pain management in pediatric ABG. Two independent reviewers screened studies and extracted data on study design, analgesic interventions, and pain-related outcomes. Of 407 records identified, 14 studies met the inclusion criteria. Study designs included retrospective cohorts (57%), systematic reviews (14%), randomized prospective studies (14%), randomized controlled trials (7%), and quasi-experimental studies (7%). Pediatric cohorts ranged from 3 to 18 years. Over 90% used local or regional analgesia. Continuous bupivacaine or ropivacaine infusions (43%) produced the lowest pain scores, the longest analgesic duration (8-12h), and 60% to 80% reductions in opioid use. Liposomal bupivacaine, regional nerve blocks, and ERAS pathways consistently outperformed single-dose infiltration. Continuous infusions and ERAS protocols reduced length of stay from 0.5 to 1.0 days, enabled up to 80% same-day discharge, and lowered costs by ∼40% to 45%. Adverse events were infrequent and self-limited. Multimodal analgesic strategies-particularly regional anesthesia and continuous local anesthetic delivery-effectively improve pain control, reduce opioid use, and enhance perioperative outcomes in pediatric ABG. However, heterogeneity in pain assessment and limited comparative data underscore the need for standardized outcomes and targeted subgroup analyses.

Oro-nasal fistulas may result from congenital defects, trauma, infections, neoplasms, or chronic cocaine use, affecting speech, swallowing, and quality of life. The tongue flap stands out for its rich vascularization and low donor-site morbidity. A 36-year-old female presented with nasal speech and liquid regurgitation through the nose. She had a history of chronic cocaine use for 7 years, discontinued 2 years prior. Clinical and radiographic examination revealed a 2.0 cm oro-nasal fistula in the hard palate. Reconstruction was performed under general anesthesia using an anteriorly based pedicled tongue flap, secured to the recipient bed with 3-0 Vicryl sutures. Maxillomandibular fixation was maintained for 21 days, and the flap was divided after 3 weeks. The anteriorly based tongue flap proved to be a reliable and effective technique for closing large cocaine-induced oro-nasal fistulas, offering excellent functional and aesthetic outcomes.

Maxillary segmentation in Le Fort I osteotomy: a meta‑analysis of complications compared with one‑piece surgery.

This case series describes the prosthodontic treatment of five patients who were treated with surgical resection, with or without flap reconstruction, and had remaining oronasal fistulas following their maxillary neoplasms. All five patients obtained spontaneous closure of their partial maxillectomy defects following the use of a maxillary protective removable dental prosthesis that did not engage the fistula.

Rate of fistula repair following palatoplasty in patients with cleft lip and palate: A systematic review of the literature.

Introduction: Gnatoschizis (alveolar cleft), is a developmental defect of the maxillary alveolar bone, occurring in up to 75% of patients with cleft lip and palate. This condition may impair mastication and cause persistent oronasal fistulas if it is left untreated. Gnatoplasty with bone grafting is a reliable procedure to restore alveolar continuity and oral function. This report describes the management of bilateral gnatoschizis with bilateral gnatoplasty and bone graft reconstruction. Case Report: A 25-year-old female presented with nasal fluid leakage during meals. Two small openings were foung in the upper labial mucosa, forming oronasal communications. OPG and 3D CT scan confirmed anterior maxillary defects directly communicating with the nasal cavity. The patient treated by bilateral gnatoplasty under general anesthesia. Closure of nasal and oral mucosa were performed to seal the fistulas. Bone grafting followed without membrane coverage using AmGraft® (freeze-dried dentin matrix, allograft) and Bonefill Ortho® (bovine hydroxyapatite, xenograft). Postoperative CBCT demonstrated well-positioned grafts completely filling the defects and patient reported no nasal leakage and regained normal mastication. Discussion: This case highlights the effectiveness of gnatoplasty with bone grafting performed without membranes. This approach simplifies the procedure while still achieving both anatomical repair and functional rehabilitation. Conclusion: Bilateral gnatoplasty with bone graft reconstruction is effective for closing oronasal communication and restoring oral function, without using membranes, making this approach practical for patients with residual cleft defects.

Oronasal fistula formation, associated with maxillary canine teeth, is a frequent sequela to untreated periodontal disease, and extraction has traditionally been regarded as the primary treatment. A 10-year-old spayed female miniature Dachshund was presented with an oronasal fistula involving the left maxillary canine tooth. After initial non-surgical management with minimally invasive non-surgical technique (MINST) failed to resolve the periodontal pocket and fistula, microscope-assisted periodontal regenerative therapy combined with an Er:YAG laser was performed. The treatment achieved complete closure of the fistula together with reduction of the periodontal pocket. Cone beam computed tomography at 8 months post-surgery confirmed new bone formation. This case demonstrates that the integration of microsurgical visualization and Er:YAG laser therapy can enable preservation of maxillary canine teeth with oronasal fistula, providing a minimally invasive alternative to extraction.

AimThe aim of this systematic review and meta-analysis was to compare the outcomes of secondary alveolar bone grafting (SABG) performed before and after 12 years of age in patients with nonsyndromic cleft alveolus.MethodAll relevant studies from database untill September 2024 were identified through all relevant databases. Randomized Controlled Trials (RCTs), Controlled Clinical Trials (CCTs), prospective, and retrospective studies were included.PopulationPatients with cleft alveolus who underwent SABG using iliac crest bone graft.InterventionEarly SABG performed below 12 years.ComparisonSABG performed on or after 12 years of age.Primary outcomeBone fill assessed through radiographic imaging techniques. Secondary outcomes included skeletal relationship, canine eruption, Asher-Mcdade index, Goslon yardstick index, presence of oronasal fistula, and revision surgeries. All articles were screened for the title, abstract, and full text by 2 reviewers independently and in duplicate. Risk of bias was assessed for RCT using Cochrane's risk of bias tool and the CCT was assessed using the ROBINS-I tool.ResultsOf the 3545 records identified, 9 studies met the inclusion criteria for qualitative and quantitative synthesis. Eight of the 9 included studies were rated as having moderate to serious risk of bias, and one judged as critical risk of bias. There is very low-quality evidence in favor of secondary grafting performed below 12 years of age compared to secondary grafting performed on or after 12 years.ConclusionFuture high-quality RCTs with standardized protocols are necessary to determine the most effective timing for SABG in cleft care.

Impact of Quad-Helix Expansion and Bone Grafting on Speech in Children With Unilateral Cleft Lip and Palate.

Purpose This retrospective descriptive study aimed to evaluate the clinical outcomes, complication rates, and flap survival of the nasolabial flap used for reconstruction of various orofacial soft-tissue defects, with particular attention to the flap design(tunneled island flap vspedicled flap) and the impact of facial artery ligation. Patients and methods A total of 20 cases at the Department of Oral and Maxillofacial Surgery, National Defense Medical College Hospital, between 2017 and 2025, in which the nasolabial flap was used to reconstruct soft-tissue defects, resulting from oral cancer, jaw osteonecrosis, soft-tissue defects due to trauma, and oronasal fistula, were retrospectively reviewed after obtaining ethical approval from the ethics committee. Results A total of 17 cases involved intraoral reconstruction using a tunneled island flap. Meanwhile, the pedicled flap was used in three cases for lip reconstruction. In all cases, the flap survived, and satisfactory functional and esthetic outcomes were achieved. In three cases, flap resection was required after reconstruction, and only one (5%) patient developed partial flap dehiscence. Two (10%) patients exhibited distal flap necrosis, both of which involved random-pattern and tunneled island flaps in patients who had their facial artery ligated, but the flap's viability was ultimately good. All cases of orofacial reconstruction using the nasolabial flap during the study period were included. Conclusions Based on our study, the nasolabial flap is a reliable reconstructive method for orofacial defects. However, we believe that cautious attention to blood supply is needed in cases involving tunneled island flaps where the facial artery is ligated.

Introduction and aimsVelopharyngeal insufficiency (VPI) is a common functional complication in patients with cleft palate, often resulting in impaired speech, social difficulty, and psychosocial distress. This study aims to assess VPI–related quality of life (VPI-QOL) in cleft palate patients after primary palatoplasty, and to identify clinical and functional predictors, particularly speech outcomes and postoperative complications, that significantly affect the perceived QOL.MethodsThis cross-sectional study involved 170 cleft palate patients assessed using the validated Chinese version of the VPI Effects on Life Outcomes (VELO) instrument. Both parent-proxy and youth self-reports were collected. Patients were stratified by QOL status into adequate and inadequate QOL groups. Demographic, surgical, and anatomical variables, along with professional speech evaluations, were analysed. Statistical comparisons used Chi-square and Mann–Whitney U tests, with multivariate logistic regression to identify independent predictors of poor QOL.ResultsAmong 170 patients, 107 (62.9%) had adequate and 63 (37.1%) had inadequate QOL. Inadequate QOL was associated with older age at surgery (mean 5.19 vs 1.98 years; P < .001) and at evaluation (P < .01). Oronasal fistula (ONF) occurred in 14.7%, and VPI in 30%. Delayed palatoplasty, presence of ONF, and poor speech intelligibility were significantly linked to lower VELO scores. ONF (odds ratio = 8.531, P < .001) and speech intelligibility deficits (odds ratio = 8.854, P < .001) were independent predictors of poor QOL. Patients with VPI reported significantly lower scores across all VELO domains. Youth and parental responses were generally consistent, with parents noting more pronounced emotional and social effects.ConclusionSpeech deficits and postoperative complications, particularly ONF and reduced intelligibility, are major determinants of VPI-related QOL. Timely surgery, prevention of ONF, and targeted speech intervention are essential for optimizing both functional and psychosocial outcomes.Clinical relevanceSpeech intelligibility and ONF strongly influence VPI-QOL; early surgery, ONF management, speech therapy, and VELO use improve outcomes and guide multidisciplinary cleft care.

Oronasal fistula (ONF) repair remains a significant challenge in patients with cleft lip and palate, particularly when local palatal tissue is insufficient. Regional flaps, including the buccal myomucosal flap (BMMF) and the facial artery musculomucosal (FAMM) flap, offer reliable reconstructive options. This study reviews the surgical anatomy, design, and clinical outcomes of these buccinator-based flaps in ONF repair. This retrospective case series included 13 patients who underwent ONF repair using a BMMF or a FAMM flap between 2017 and 2024. Patient demographics, fistula characteristics, surgical details, postoperative care, and outcomes were collected and analyzed. Six patients underwent BMMF reconstruction, while 7 received FAMM flaps. Successful fistula closure was achieved in 66.7% of patients in the BMMF group, with flap dehiscence occurring in 2 cases, both associated with digital manipulation. The FAMM flap cohort had a 100% fistula closure rate but exhibited a high incidence (86%) of postoperative scar contracture, with 4 patients requiring contracture release. Based on this experience, the authors propose an algorithm for flap selection in ONF repair. Posteriorly based BMMFs are well suited for fistulas at the junction of the hard and soft palate (Type III) and the posterior third of the hard palate (Type IV). Superiorly based FAMM flaps are preferred for anterior ONFs, particularly those extending into the alveolus. The central hard palate remains a reconstructive challenge, with FAMM flaps offering better reach, though they require staged inset and debulking. Both BMMF and FAMM flaps provide vascularized tissue for ONF closure with minimal donor site morbidity. Strategic flap selection based on fistula location optimizes outcomes while mitigating complications.

Super-Passive Alveolar Correcting Equipment (SPACE): a novel presurgical cleft device with 5-year outcomes following one-stage repair.

VATER syndrome is a non-random association of birth defects affecting multiple organ systems, with orofacial clefts uncommonly reported. This study presents a unique case of a patient with VATER syndrome with a bilateral cleft lip and palate who underwent the rare surgical removal of the premaxilla during cleft lip repair, resulting in a large maxillary defect and oronasal fistula. This report highlights the successful use of non-vascularized bone graft in this setting, with 13-month follow-up demonstrating bone consolidation and fistula closure. The case adds to the evidence supporting non-vascularized bone graft for extensive maxillary defects, even with oronasal fistula.

Background: Cleft palate is a pervasive congenital craniofacial anomaly characterized by the failure of palatal shelf fusion, resulting in a persistent communication between the oral and nasal cavities. While developed healthcare systems mandate repair between 9 and 12 months, delayed presentation in adolescence remains a distinct clinical entity in developing regions. These cases are surgically complex due to maxillary skeletal maturity, tissue fibrosis, and wider cleft gaps compared to infant cases. The primary surgical objective is to seal the defect and restore the velopharyngeal sphincter to prevent hypernasality. This study evaluates the efficacy and physiological advantages of the Furlow double opposing Z-plasty technique in a high-risk delayed primary repair scenario. Case presentation: We report the management of a 14-year-old male presenting with an uncorrected non-syndromic incomplete cleft palate. Preoperative assessment revealed severe hypernasality and audible nasal air emission. Clinical examination confirmed a Veau Type I defect confined to the soft palate with a bifid uvula. Primary palatoplasty was executed using the Furlow technique. The procedure successfully recruited lateral tissue for palatal lengthening and achieved transverse muscle reorientation without the need for lateral relaxing incisions. Conclusion: The intervention resulted in complete anatomical closure with no evidence of wound dehiscence, hemorrhage, or oronasal fistula formation. The Furlow technique proved to be a feasible and safe modality for Veau Type I defects in adolescents, effectively addressing the vertical pharyngeal gap and restoring the sphincter mechanism's anatomy.

Purpose: Post-operative restrictions such as arm restraints (AR) and suction-less feeding are commonly used to decrease rates of oronasal fistulas after cleft surgery; however the utility of these restrictions remains unclear. We hypothesize that the use of arm restraints and suction-less feeding methods do not impact the rate of oronasal fistula development following palatoplasty. Methods: A retrospective case-control study identified clinical data for 105 primary palatoplasty patients from the multidisciplinary craniofacial clinics of 2 university hospitals from 2009 to 2020. Forty-nine patients underwent bottle feeds and did not have arm restraints (Limited Restrictions group, LR); 56 patients underwent suction-less feeding methods and used arm restraints (Highly Restricted group, HR). Primary outcomes included the rate of reoperations, post-operative length of stay (LOS), and the rate of oronasal fistula (ONF) development were compared. Results: The post-operative LOS for the LR and HR groups was 1.88 ± 0.81 days and 2.05 ± 1.33 days, respectively ( P = .42). The rate of post-operative ONF development was 5/49 (10.2%) and 4/56 (7.1%) for the LR and HR cohorts, respectively ( P = .73). There was no significant difference in the rate of reoperation between the LR and HR groups (LR: 5/49 [10.2%] vs HR: 2/56 [3.6%]; P = .24). The rate of oronasal fistula development did not vary by veau type or syndromic status. Conclusions: Our preliminary data suggest that restrictions do not impact the rate of oronasal fistula development in patients undergoing primary palatoplasty. Our findings also indicate that postoperative restrictions do not impact the rate of reoperation or LOS. In light of this, we recommend that practitioners reconsider the utility of highly restrictive post-operative protocols.

ObjectiveTo investigate whether the use of buccal fat pad flap during cleft palate repair reduces the risk of post-operative palatal fistula formation.DesignRetrospective analysis of cleft palate repairs undertaken by a single surgeon over the period 2013-2025.SettingTertiary care institution in London.PatientsTwo hundred and seventy-seven patients (146 female, 131 male) who underwent cleft palate repair between 2013 and 2025 were included in the study. One hundred and seventy-three patients had an isolated cleft palate, 78 patients had a unilateral cleft lip and palate, and 26 patients had a bilateral cleft lip and palate. The range of cleft width treated was 3-22 mm. The standard surgical technique employed a Sommerlad style intravelar veloplasty with von Langenbeck releases where necessary.InterventionsThe utilization of pedicled buccal fat pad flap in primary cleft palate repairs.Main Outcome Measure(s)Development of post-operative palatal fistula.ResultsAmong 277 patients, 21 (7.6%) patients developed a post-operative fistula, most commonly in Zone IV (52%). The fistula rate was 3.7% with buccal fat pad flap use compared with 8.5% without (P = 0.39). Bayesian logistic regression showed a two-thirds reduction in the odds of fistula formation (odds ratio [OR] = 0.33; 95% credible interval [CrI]: 0.15-0.74), suggesting a high probability of a protective effect.ConclusionsThis study demonstrates that the use of buccal fat pad flaps in primary cleft palate repair is an effective adjunct associated with a reduced incidence of post-operative oronasal fistula.