Use of regenerative tissue matrix as an oral layer for the closure of recalcitrant anterior palatal fistulae: a pilot study.

OBJECTIVES: To evaluate the effectiveness of regenerative tissue matrix (Alloderm) as an oral layer for difficult anterior palatal fistula closure. MATERIALS AND METHODS: The authors have tested the feasibility of a novel surgical technique of adding a regenerative tissue matrix (Alloderm) as an oral layer for closure of recalcitrant large anterior palatal fistulae and report the outcome of the first 12 patients in this pilot study. Patients with recurrent large fistula who otherwise would require either a local pedicled flap, free flap, or an obturator were treated with this technique and followed up for at least 6 months to monitor the progress of healing. RESULTS: Of the 12 patients, 8 patients (66.7%) had complete closure of the fistula, and 2 patients (16.7%) showed reduction in size of the fistula to the extent that symptoms were eliminated, for an overall success rate of 83.3% (10/12 patients). Premature graft loss and recurrence of the fistula were noted in 2 patients (16.7%). CONCLUSION: Alloderm provided an adequate barrier allowing healing to occur unimpeded and allowed closure of the palatal fistula. In our experience, this new technique using regenerative tissue matrix as an adjunct to the oral layer in large anterior palatal fistula has an advantage compared to other more invasive complex procedures and has been shown to provide satisfactory results.

Palatal fistulae: a comprehensive classification and difficulty index.

INTRODUCTION: Palatal fistula formation is a known complication of palatoplasty. Numerous classifications have been proposed that help in identifying the location of fistula and systematically arrange data for record keeping. They do not assess the difficulty level of the fistula. Management of fistulae can be very tricky and a definitive success cannot be guaranteed even in the best of hands. Hence we devised a classification system and a difficulty index to help evaluate the difficulty level and plan the treatment accordingly to predict the prognosis prior to surgery. MATERIALS AND METHODS: We reviewed 610 cases of palatal fistula operated at our center with a minimum follow-up of 6 months from May 2003 to May 2010. They were classified according to our classification. Difficulty index was also assessed. The data was tabulated and analysed. RESULTS: Longitudinal fistulae showed a recurrence rate of 7.87 % whereas transverse fistulae showed a recurrence rate of 19.66 %. Total recurrence rate was 11.31 %. Unilateral clefts with fistulae showed a recurrence of 6.55 % whereas bilateral clefts with fistulae showed a recurrence of 14.17 %. A total of 220 Grade 1 and 390 Grade 2 fistulae were managed. Out of these, 7 (3.18 %) Grade 1 and 62 (15.90 %) Grade 2 fistulae recurred. 90 % of failed fistulae showed decrease in the size of the fistula. CONCLUSION: Classification and evaluation of difficulty of palatal fistula is essential to plan the surgical treatment so as to give better results. Bidimensional fistulae in the anterior hard palate are associated with higher recurrence rate. Also, fistulae in bilateral clefts are more difficult to close than those in unilateral clefts. Classification of fistulae according to the difficulty index helps in pre-operative judgment of the outcome.

Anterior maxillary distraction using a tooth-borne device for hypoplastic cleft maxillas-a pilot study.

PURPOSE: The management of maxillary retrusion in a patient with cleft lip and palate is performed using Le Fort I advancement or distraction osteogenesis using an external or an internal device. Distraction mostly involves movement of the entire maxilla at the Le Fort I level and is characterized by a higher relapse rate and a hampering of speech. Hence, distraction of the anterior maxilla was performed using a tooth-borne palatal distractor similar to the one proposed by Gunaseelan et al (J Oral Maxillofac Surg 65:1044, 2007). However, the technique was modified by placing the distractor preoperatively before performing the osteotomy cut. The main advantage of this modification is that more control over the vector can be achieved and chances of cement failure caused by contamination and an inability to achieve isolation is drastically decreased. This study investigated the efficacy and stability of anterior maxillary distraction in the management of cleft maxillary retrognathia and any resulting complications. MATERIALS AND METHODS: Fourteen patients older than 12 years with cleft maxillary retrognathia were included in the study irrespective of gender, type of cleft lip and palate, and the amount of advancement needed. The patients were evaluated using Orthopantomogram and lateral cephalograms preoperatively and at 3 months postoperatively (ie, before appliance removal) and at 6 months postoperatively. The distractor was fabricated extraorally on a cast and cemented into the patient's mouth the day before surgery. The initial deficiency, amount of advancement achieved, and relapses at 6 months, if any, were studied. The data were tabulated and analyzed. RESULTS: Only 1 of the 14 patients showed a relapse, of 2 mm, because this patient was lost to follow-up and thus delayed tooth replacement. CONCLUSIONS: Anterior maxillary distraction with a tooth-borne device is a feasible modality for the management of cleft maxillary retrognathia, with stable results.

Rural centre based management of the carotid body tumour.

A 40 year old male patient reported to our rural based hospital with a complaint of discomfort associated with a swelling on the left side of the neck since 8 years. A provisional diagnosis of a carotid body tumour was made based on clinical examination and ultrasound examination. Higher investigations could not be performed due to unavailability at the rural setup and referral to a specialty centre was not possible due to financial constraints of the patient. Even with advances in diagnostic and surgical techniques, surgery still presents a major threat of injury to the cranial nerves. Nevertheless, it remains the preferred method of treatment for these tumours. Our case shows that such masses can be removed successfully and that, with care, the cranial nerves and the carotid arteries can be preserved at the rural hospital.