CASE PRESENTATION
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.