Closure of an unusually large palatal fistula in a cleft patient by bony transport and corticotomy-assisted expansion.

The management of cleft lip and palate can vary among patients because the size of a cleft defect and its anatomy vary. Although treatments involving orthodontics and surgery have been developed that can help a large number of children with cleft lip and palate, there are always unusual clefts that defy conventional treatments. In such cases, with each gain made during treatment, there also is the possibility of introducing an additional complication. The secondary bone graft performed during the mixed dentition stage of dental development is an example of treatment gains that are balanced against additional complications. Ordinarily, the maxillary segments are expanded to attain a normal archform before the alveolar bone graft. If there is an anterior palatal fistula present before orthodontic expansion, the size of the fistula concomitantly increases as the expanders widen the anterior maxillary segments. There are, however, extreme cases that present with a combination of collapsed maxillary segment, large anterior palatal fistula, and large alveolar clefts. In such cases, orthodontic expansion could make both the alveolar clefts and anterior palatal fistula unmanageable. In the expanded position, there would be insufficient soft tissue to close the fistula or cover the alveolar bone graft. Consequently, dental prosthetics is often needed to cover the palatal fistula to support speech and eating. In this report, we present the case of an 11-year-old girl who had a 20-mm anterior palatal fistula before orthodontic expansion. In the opinion of our surgeons, the fistula was too large to close before the segments were expanded and would prove more difficult to treat after expansion. To make the palatal fistula and cleft sites manageable, the treatment sequence and procedures were modified. Rather than expand the maxillary segments, the segments were compressed to make the cleft space narrower so that the surgeons could graft the alveolar cleft. To provide more bone support and donor soft tissue for a palatal flap, the palatal tooth and surrounding bone were distracted across the anterior palatal opening. A sequence of minor procedures allowed the cleft sites to be grafted, the unusually large palatal fistula to be closed, the lateral segments to be expanded, and the dental alignment to be improved.