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Palatal fistula Dr. Hayder H. Hindawi Plastic & reconstructive surgeon
Al-Yarmook teaching hospital
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Definition * Fistula is an abnormal communication between oral and nasal cavities lined by epithelial cells. * Heeling by first intention is the goal of the plastic surgeon. * Surgical failure is considered when fistula occurs anywhere along the site of repair.
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Incidence After complete unilat. Cleft 7.7%.
After complete bilat. Cleft % After incomplete cleft % After late closure %
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Classification Etiology … ( congenital ) ( post traumatic )
( post inflammatory ) ( post surgical )
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Classification 2. Size … ( Ohsumi-N classification ) :
Type I … < 2 mm. Type II … 2 – 5 mm. Type III … > 5 mm.
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Classification 3. Site … ( Converse classification ) :
- Anterior ( Alveolar ). - Posterior ( Post-alveolar ).
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Causes 1. Local factors : - Tension. - Hematoma. - Infection.
2. General factors : - Systemic disease. - Steroids. - Resp. T. I.
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Complications Fluid and food escape. Speech defects.
Teeth mal-positioning and irregularities. Nasal airway obstruction.
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Assessment History & Cl. Examination. Objective assess.
Imaging … ( lateral cephalometry ) ( video fluroscopy ) - Nasoscopy … ( rigid ) ( flexible ).
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Timing of closure Labio-nasal : - - Small … 2ndry lip surgery
or alveolar bone graft. - Large ... < school age. Palatal : - - Small … ( spontaneous )( delayed ). - Large … closed early.
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Methods of closure * Non-surgical … ( prosthesis )
( palatal appliance ) ( Silver Nitrate cauterization ) * Surgical …
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Methods of closure * Surgical : 1. Local tissue repair.
2. Regional tissue repair. 3. Distal tissue repair. 4. Free tissue transfer.
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Surgical repair Labio-nasal … - Rotation f. - Advancement f. Palatal …
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Surgical repair Palatal … a – Soft palatal f. b – Longitudinal f.
c – Transverse f. d – Lateral defect f. e – Round f. f – Slit-like f. g – Large fistula in the anterior aspect of the hard palate.
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a – Soft palatal f.
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b – Longitudinal f.
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c – Transverse f.
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Closure of round fistula by lateral rotational or transpositional flap
e – Round f. Closure of round fistula by lateral rotational or transpositional flap
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Closure of round fistula by ‘’ Rintata ‘’ method
e – Round f. Closure of round fistula by ‘’ Rintata ‘’ method
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‘’ Reid ‘’ method in closing a slit-like fistula
f – Slit-like f. ‘’ Reid ‘’ method in closing a slit-like fistula
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‘’ Gabka ‘’ method in closing a slit-like fistuls
f – Slit-like f. ‘’ Gabka ‘’ method in closing a slit-like fistuls
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g – Large fistula in the anterior aspect of the hard palate.
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Regional tissue transfer
1. Tongue : a/ Free composite graft. b/ Tongue flap.
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Regional tissue transfer
2. Cheek. 3. Lip ( buccal flap ). 4. Nasal septum. 5. Pharynx.
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Distal tissue repair 1. Naso-labial flap. 2. Forehead flap.
3. Neck flap. 4. Arm flap. 5. Little finger flap.
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Free tissue transfer Free radial forearm flap.
Free facial forearm flap.
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Surgical closure of Oro-nasal fistula by ‘’ tissue interposition ‘’
Autogenous bone graft. Cartilage graft ( Choncal )( Ohsumi & Onizuka ). Ossio-integrated implant. Closure using ( Dermal – Fat graft ).
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Dermal – Fat graft
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Dermal – Fat graft
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Dermal – Fat graft
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C1,a
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C1,b C1,c
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C1,d C1,e
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C1,f
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C2,a
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C2,b
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C2,c
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C3,a
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C3,b Cartilage graft
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Cartilage graft
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C3,c
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C4,a
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C4,b
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C4,c
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C4,d
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C5,a C5,b
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C5,c
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Conclusion 1. THE CONCHAL GRAFT PRECLUDES THE NEED
FOR EXTENSIVE LOCAL SURGERY. 2. MAY ACT AS SUBSTITUE FOR NASAL LINING FLAPS. 3. ACTS AS A THIRD LAYER. 4. FILL THE DEAD SPACE. 5. PREVENTS THE COMUNICATION BETWEEN TWO SUTURE LINES.
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