Management of chronic exogenous rhinolith with gingivonasal fistula: A case report.

Recurrent rhinorrhoea that occurs chronically, needs to consider the possibility of a fistula in the nasal cavity, which has the potential to form a rhinolith. We report the case of a 39-year-old man with complaints of recurrent rhinorrhoea since four years ago, accompanied by thick secretions, symptoms of post-nasal drips, and olfactory disturbances. The patient had a history of removing the left upper molar (molar I), which causes a fistula in the tooth extraction site, making it more likely for food and drink to enter the left nasal cavity. Anterior rhinoscopy examination revealed a white mass in the left inferior meatus and a purulent odour discharge. In addition, there were gingival defects of the first molar teeth, multi-sinusitis, and nasal septum deviation. Rinolith extraction was performed using functional endoscopic sinus surgery, submucosal resection, and repair of gingivo-nasal defects with rotational flaps. Follow-up for one week showed that the flap was in place and there were no complications.

Use of a haired angularis oris axial pattern flap in a dog to correct a large oronasal fistula secondary to resection of a hard palate multilobular osteochondrosarcoma.

A 6-year-old neutered male mixed-breed dog underwent curative-intent surgical resection of a hard palatal multilobular osteochondrosarcoma and closure of the defect using bilateral buccal mucosal flaps. However, failure of the flaps resulted in a massive hard palatal defect that was subsequently repaired using a haired skin angularis oris axial pattern flap. This report describes the clinical outcome using this surgical approach and novel complications encountered. Key clinical message: The haired skin angularis oris axial pattern flap appears to be a suitable and robust option for reconstruction of large palatal defects.

Utilisation d'un lambeau cutanée poilus avec rotation axiale au niveau de l'artère angularis oris chez un chien pour corriger une fistule oronasale volumineuse secondaire à la résection d'un ostéochondrosarcome multilobulaire du palais dur. Un chien croisé mâle castré de 6 ans a subi une résection chirurgicale à visée curative d'un ostéochondrosarcome multilobulaire du palais dur et une fermeture de l'anomalie par des lambeaux de la muqueuse buccale. Cependant, la défaillance des lambeaux a entraîné un défaut important du palais dur qui a ensuite été réparé à l'aide d'un lambeau de peau avec poils avec rotation axiale au niveau de l'artère angularis oris. Ce rapport décrit les résultats cliniques de cette approche chirurgicale et les nouvelles complications rencontrées.Message clinique clé :L'utilisation d'un lambeau de peau avec poils avec rotation axiale au niveau de l'artère angularis oris semble être une option appropriée et robuste pour la reconstruction des défauts importants du palais.(Traduit par Dr Serge Messier).

Longitudinal Speech and Fistula Outcomes Following Primary Cleft Palate Repair at a Single Institution.

INTRODUCTION: Fistula formation and velopharyngeal insufficiency (VPI) are complications of cleft palate repair that often require surgical correction. The goal of the present study was to examine a single institution's experience with cleft palate repair with respect to fistula formation and need for surgery to correct velopharyngeal dysfunction. METHODS: Institutional review board approval was obtained. Patient demographics and operative details over a 10-year period were collected. Primary outcomes measured were development of fistula and need for surgery to correct VPI. Chi-square tests and independent t tests were utilized to determine significance (0.05). RESULTS: Following exclusion of patients without enough information for analysis, 242 patients were included in the study. Fistulas were reported in 21.5% of patients, and surgery to correct velopharyngeal dysfunction was needed in 10.7% of patients. Two-stage palate repair was associated with need for surgery to correct VPI (P = 0.014). Furlow palatoplasty was associated with decreased rate of fistula formation (P = 0.002) and decreased need for surgery to correct VPI (P = 0.014). CONCLUSION: This study reiterates much of the literature regarding differing cleft palate repair techniques. A 2-stage palate repair is often touted as having less growth restriction, but the present study suggests this may yield an increased need for surgery to correct VPI. Prior studies of Furlow palatoplasty have demonstrated an association with higher rates of fistula formation. The present study demonstrated a decreased rate of fistula formation with the Furlow technique, which may be due to the use of the Children's Hospital of Philadelphia modification. This study suggests clinically superior outcomes of the Furlow palatoplasty over other techniques.

Comparison of modified Furlow palatoplasty using small double-opposing Z-plasty and conventional Furlow palatoplasty: A long-term outcome study.

BACKGROUND: The aim of palatoplasty is to create a functional palate to achieve normal speech, while minimizing post-operative complications. This study aimed to compare the long-term outcomes of modified Furlow palatoplasty using small double-opposing Z-plasty (small-DOZ) and conventional Furlow palatoplasty (conventional-DOZ) performed in a single center. METHODS: A retrospective review of consecutive patients who underwent Furlow palatoplasty between May 2007 and March 2014 was executed. Non-syndromic patients subjected to palatoplasty prior to 24 months of age and followed-up until at least 9 years of age were included. RESULTS: A total of 196 small-DOZ and 280 conventional-DOZ palatoplasty patients were included in this study. Overall, 14 patients (2.9%) developed oronasal fistula, and 40 patients (8.4%) received velopharyngeal insufficiency (VPI) surgery. In comparisons, oronasal fistula rate was significantly higher in conventional-DOZ (0.5% vs. 4.6%, p = 0.01), and the VPI prevalence was not significantly different (9.2% vs. 7.9%, p = 0.62). Patients who developed fistula had a significantly higher likelihood of developing VPI than patients without oronasal fistula (50.0% vs. 7.1%, respectively; p < 0.01), with an odds ratio of 13.0. CONCLUSION: Both modalities of palatoplasty yielded commendable velopharyngeal function in the long-term follow-up. The small-DOZ with reduced tension lowered the risk of oronasal fistula.

Dehiscence and Fistula Formation Following Anterior Palatal Reconstruction With Vomer Flap.

BACKGROUND AND PURPOSE: Anterior palatal reconstruction using vomer flaps has been described during primary cleft lip repair. In this procedure, the mucoperiosteal tissue of the vomer is elevated to reconstruct the nasal mucosa overlying the cleft of the hard palate. Here the authors, evaluate the efficacy of a technique in which a superiorly based vomer flap is sutured to the lateral nasal mucosa. The authors assess vomer flap dehiscence rates and compare the likelihood of fistula development in this cohort to patients who underwent palatoplasty without vomer flap reconstruction. METHODS: A retrospective chart review was conducted of all palatoplasties performed by the senior author at an academic institution during a 7-year period. Medical records were reviewed for demographic variables, operative characteristics, and postoperative complications up to 1 year following surgery. Logistic regression analysis was conducted to assess the effects of vomer flap reconstruction on fistula formation, adjusting for age and sex. RESULTS: Fifty-eight (N=58) patients met the inclusion criteria. Of these, 38 patients (control group) underwent cleft palate reconstruction without previous vomer flap placement. The remaining 20 patients underwent cleft lip repair with vomer flap reconstruction before palatoplasty (vomer flap group). When bilateral cases were counted independently, 25 total vomer flap reconstructions were performed. Seventeen of these 25 vomer flap reconstructions (68%) were completely dehisced by the time of cleft palate repair. In the vomer flap group, 3 of the 20 patients (15%) developed fistulas in the anterior hard palate following the subsequent palatoplasty procedure. In the control group, only 1 of the 38 patients (2.6%) developed a fistula in the anterior hard palate. There was no significant association between cohorts and the development of anterior hard palate fistulas [odds ratio=10.88, 95% confidence interval (0.99-297.77) P =0.07], although analysis was limited by low statistical power due to the small sample size. CONCLUSIONS: In our patient population, anterior palatal reconstruction using a superiorly based vomer flap technique was associated with complete dehiscence in 68% of cases. Fistula formation in the anterior hard palate was also proportionately higher following initial vomer flap reconstruction (15% versus 2.6%). These results prompted the senior author to adjust his surgical technique to 1 in which the vomer flap overlaps the oral mucosa. While follow-up from these adjusted vomer flap reconstruction cases remains ongoing, early evidence suggests a reduced requirement for surgical revision following implementation of the modified technique.

Two-flap technique with interpositional dermofat graft for anterior oronasal fistula closure in patients with cleft: A case series.

BACKGROUND: Oronasal fistula at the anterior hard palate is one of the common sequelae after cleft surgery, and the leakage negatively affects the patient's quality of life. Although several surgical techniques have been proposed for reconstruction, it remains challenging because of the scarred regional tissue with a high rate of fistula recurrence. In this study, we present the anterior oronasal fistula repair using a two-flap technique with an interpositional dermofat graft (DFG). METHODS: A retrospective review of anterior oronasal fistula repair performed by the senior author between April 2018 and August 2022 at the Craniofacial Center was conducted. Patients who underwent a fistula repair using the technique were further identified and investigated. RESULTS: Thirty-four operations were performed using the technique, and 31 fistulas were completely closed, with a success rate of 91.2%. The fistula symptom improved but persisted postoperatively in 3 patients, of whom 2 patients underwent a second fistula repair using the same procedure, resulting in successful closure. Fistula recurrence was significantly correlated with fistula size (p = 0.04). The DFG was simultaneously utilized for nasal dorsum and/or vermillion reconstruction in 28 cases. CONCLUSION: The two-flap technique enabled tension-free approximation, and the interpositional DFG facilitated watertight closure of the fistula, resulting in a high success rate of anterior oronasal fistula repair. The fistula closure could be combined with other revisional procedures for cleft-related deformities, where the DFG was simultaneously utilized.

Surgical treatment for cleft palate in dogs yields excellent outcomes despite high rates of oronasal fistula formation: a narrative review.

Cleft palate is the most common congenital orofacial defect in dogs. Although this topic has been extensively studied in experimental dogs, current literature on clinical patients is limited to case reports and small case series studies with many individual opinions based on experience. This narrative review summarizes the literature of the last 10 years with application to clinical practice, focusing on the preparation of the patient until surgery, options for surgical management, and perioperative complications. Surgical treatment must be performed to obtain separation between the nasal/nasopharyngeal and oral/oropharyngeal passages. This will allow the dog to have independent function and reduce clinical signs associated with food, water, and other foreign material entering the respiratory tract. Surgical treatment has good to excellent outcomes when the procedure is carefully planned and appropriately executed despite the high rates of postoperative oronasal fistula reported.

Intravelar veloplasty in submucous cleft palate without lateral relaxing incision or nasal mucosal incision.

BACKGROUND: Surgical treatment is recommended for patients with symptomatic submucous cleft palate once velopharyngeal insufficiency has been proven. This study describes the procedure and clinical outcomes of minimally invasive intravelar veloplasty. METHODS: From August 2013 to March 2017, seven patients (median age, 36 months; range, 16-60 months, 5 females and 2 males) with submucous cleft palate underwent intravelar veloplasty. Neither a nasal mucosal incision nor a lateral relaxing incision was applied. Follow-up was performed at least twice: once at three weeks postoperatively and again between two and three years postoperatively (average, 31 months; range, 26-35 months). Speech was assessed by speech-language pathologists when the patients were at least 3 years old. RESULTS: There were no cases of oronasal fistula or noticeable disturbance of facial development. All seven patients showed no or mild hypernasality and air emission and competent or at least borderline competent velopharyngeal function. CONCLUSION: Intravelar veloplasty could serve as another option for managing submucous cleft palate with velopharyngeal insufficiency, resulting in satisfactory improvement in velopharyngeal function. Because neither a lateral nor a nasal incision was used, the burden of facial growth and risk of oronasal fistula can be minimized.

Endoscope-Assisted Multilayered Repair in Oronasal Fistula.

Oronasal fistula following cleft palate repair is a considerable complication with a recurrence rate of 33% to 37% and remains a challenging problem for surgeons. Furthermore, many patients have undergone several operations and experienced scar problems and other forms of morbidity. Therefore, we report a multilayered technique for oronasal fistula closure using an endoscopic nasal inferior turbinate composite graft with a palatal advance flap. This will increase the success rate after closure of small-sized oronasal fistula surgery without complications or recurrence (IRB: 2020-1671-0001).

Sternohyoideus-sternothyroideus muscle flap to reconstruct oronasal fistulas due to maxillary cancer in four dogs.

OBJECTIVE: To describe the repair of oronasal fistulas in dogs treated for maxillary cancer, with a novel sternohyoideus-sternothyroideus muscle flap, and to report the outcome. ANIMALS: Client-owned dogs (n = 4) with oronasal fistulas related to cancer. STUDY DESIGN: Short case series. METHODS: Maxillary defects were caused by tissue destruction by the tumor and tumor response to radiation therapy in two cases and a complication of caudal maxillectomy in two cases, one of which had neoadjuvant radiation therapy. All tumors were >4 cm at the level of the maxilla. Flaps were harvested by transecting the ipsilateral sternothyroideus and sternohyoideus muscles from their origin at the manubrium and costal cartilage. The muscles were rotated around the base of the cranial thyroid artery and tunneled subcutaneously in the neck and through an incision in the caudodorsal aspect of the oral cavity. The muscle flap was sutured to the edges of the oronasal fistula. RESULTS: The flap reached as far rostral as the level of the first premolar without tension. All dogs had clinical signs that improved postoperatively. All dogs had partial dehiscence of the flap. CONCLUSION: This flap was associated with a high rate of complications; however, all flaps were used in challenging cases. Clinical signs related to oronasal fistula were improved in all dogs in this case series.

Nasal Septal Flaps for Repair of Large or Recurrent Palatal Fistula: Report of Technique and 4-Year Experience.

SUMMARY: Large or multiply recurrent oronasal fistulas following cleft palate repair present a challenging problem. Nasal septal mucoperichondrial flaps have been widely used for repair of skull base defects; however, their use in the repair of oronasal cleft palate fistulas has not previously been described. In this pilot study, the authors describe anterior palatal fistula repair using a nasal septal flap and review their experience with this technique over 4 years. Fourteen patients with anterior palatal fistulas not amenable to repair using local palatal flaps were included for analysis. The mean size of the fistula was 12 mm in maximum dimension. Flap healing with complete or near-complete closure of fistula was achieved in 13 patients (93%). Five of these patients had a small, slit-like residual fistula that was asymptomatic. Nasal septal flaps are a new technique for repair of large or recurrent palatal fistulas. The procedure is well-tolerated with minimal side effects, high success rate, and low incidence of recurrence. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Sommerlad-Furlow Modified Palatoplasty Technique: Postoperative Complications and Implicating Factors.

OBJECTIVE: To explore the incidence of postoperative complications and investigate the impact of preselected factors on functional and quality of life outcomes following the Sommerlad-Furlow modified palatoplasty technique. STUDY DESIGN: Retrospective cohort. METHODS: A total of 429 patients with cleft palate, who received Sommerlad-Furlow modified technique between 2011-2017 were enrolled. The postoperative complications including oronasal fistula (ONF), velopharyngeal insufficiency (VPI), and inadequate quality of life (QOL) were collected. Data of preselected factors including gender, age at palatoplasty, cleft type, cleft width, palatal width, pharyngeal cavity depth, and operation duration were also collected. RESULTS: Among 429 patients, 40.1% were males whereas 59.9% were females. The mean age at palatoplasty was 1.23 ± 0.69 (0.42-4) years, and the average cleft width was 10.15 ± 2.95 (4-27) mm. The cleft types had recorded rates of about 6.8%, 69.5%, 17.7%, and 6.1% of Veau I, II, III, and IV, respectively. The overall incidence rates of ONF, VPI, and inadequate QOL were 2.3%, 19.4%, and 31.3%, respectively. In both the univariate and multivariate analyses, the cleft type was significantly implicated in ONF formation (p = 0.023 and 0.032, respectively) whereas the velopharyngeal function was impacted by the palatoplasty age (p Ë‚ 0.001). The receiver operating characteristic curve indicated that age of palatoplasty ≥1.3 years (area under the curve = 0.611, p = 0.002) was the cutoff value for predicting the incidence of VPI. CONCLUSIONS: The Sommerlad-Furlow modified technique appears to have appropriate postoperative outcomes, even in the wide cleft palate. The older age at palatoplasty has a major impact on the overall postoperative outcomes. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:822-829, 2023.

The use of acellular dermal matrix in palatoplasty to decrease the rate of postoperative oronasal fistula.

Different cleft palate repair techniques have been described to achieve optimum results and minimise complications. Postoperative fistulae are one of the most challenging complications after palate repair. In this clinical study, we reviewed the records of patients who underwent palatoplasty using acellular dermal matrix (ADM) as an addition to facilitate difficult cleft palate and palatal fistula closure. It was a retrospective, comparative, single-centre study, in which records of patients who underwent cleft palate surgeries between 2015 and 2018 were reviewed. Patients who underwent cleft palate or palatal fistula repair with and without ADM were included. Fischer's exact test was used to compare the two groups (primary cleft palate repair with and without ADM) in relation to the rate of fistula occurrence postoperatively. Charts of a total of 31 patients were reviewed. ADM was used in 13 patients; 8(61.5%) were primary repairs and 5(38.5%) were fistula repairs. Eighteen patients were repaired without ADM, of whom 16(88.9%) were primary cleft palate repairs and 2(11.1%) were fistula repairs. The statistical analysis showed no significant difference in fistula formation rate or recurrence in both the groups. ADM is a simple, safe, and helpful tool for augmenting cleft palate repair, mainly in relatively wide and high-tension cleft palate repairs. In our study, a trend showing decreased complications with ADM was observed. Therefore, we recommend a multi-centre study with a larger sample to assess the significance of ADM in cleft palate and palatal fistulae repair.

Buccal Fat Pad: Adjunctive Procedure for Lateral Defect Coverage following Primary Palatoplasty.

BACKGROUND: The buccal fat flap is an encapsulated mass originating from a specific fat tissue that is easily accessed and richly vascularized. The aim of this study was to report the effect of using the buccal fat flap on the oronasal fistula rate in primary palatoplasty. METHODS: A case-controlled study of 94 patients who underwent primary cleft palate repair. Patients were divided into two groups: (1) two-flap palatoplasty with buccal fat flap for coverage of lateral hard palate defect and (2) conventional two-flap palatoplasty. The incidence of oronasal fistula and postoperative complications were compared between groups. Multivariate analysis was performed to determine the risk factors of oronasal fistula development. RESULT: Forty-seven patients in each group demonstrated the same baseline characteristics. The buccal fat group showed a significant lower postoperative oronasal fistula rate (2.13 percent versus 21.28 percent, p = 0.008) and smaller fistula size (2 mm versus 4 mm, p = 0.049). A cleft width wider than 11.5 mm increased the odds ratio of fistula formation by 8.44-fold (p = 0.047), and the use of buccal fat protected against postoperative palatal fistula formation (OR, 0.08, p = 0.019). CONCLUSION: The use of buccal fat flaps for lateral hard palatal defect coverage in primary palatoplasty can reduce the rate of postoperative palatal fistula, especially in cases of wide palatal cleft. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Surgical Repair of Acquired Oronasal Fistulas Secondary to Periodontal Disease in Dogs Using a Flexible Bone Membrane: A Case Series.

Oronasal fistulas are sequelae to periodontal disease in dogs. Previous case series have described the use of auricular cartilage as a type of membrane to help with surgical repair of oronasal fistulas. This case series explores the use of a commercially available flexible bone membrane in the surgical repair of ten acquired oronasal fistulas in dogs. The use of the flexible bone membrane did not necessarily improve the surgical outcomes in these cases; however, larger controlled trials are necessary to further evaluate its use.

The Palatal Fistula Closure Using Buccal Fat Graft After Palatoplasty for Cleft Palate: Two Case Reports.

Fistula recurrence is high after secondary follow-up operation to close the fistula after primary palatal surgery. Therefore, preventing fistula recurrence is important. Here, we describe the technique of closing palatal fistula after palatal surgery with a buccal fat graft in 2 cases. We elevate the mucosal flap around the palatal fistula, suture the nasal mucosa, transplant the buccal fat between the nasal and oral mucosa for the palatal fistula after palatal surgery, and suture the oral mucosa. Palatal fistula did not recur after surgery. This method is simple and useful for suturable fistula and does not require a local flap.

Orocutaneous Fistula After Oral Cavity Resection and Reconstruction: Systematic Review and Meta-Analysis.

OBJECTIVE: Orocutaneous fistula (OCF) after reconstruction for oral cavity resection can lead to prolonged hospitalization and adjuvant treatment delay. Few studies have examined factors leading to OCF after oral cavity resection. Primary objective: evaluate overall incidence and factors associated with OCF after oral cavity reconstruction. DATA SOURCES: Scopus 1960-database was searched for terms: "orocutaneous fistula," "oro cutaneous fistula," "oral cutaneous fistula," "orocervical fistula," "oral cavity salivary fistula." REVIEW METHODS: English language studies with >5 patients undergoing reconstruction after oral cavity cancer resection were included. About 1057 records initially screened; 214 full texts assessed; 78 full-texts included. PRISMA guidelines were followed, and MINORS criteria used to assess risk of bias. Data were pooled using random-effects model. Primary outcome was OCF incidence. Meta-analysis to determine the effect of preoperative radiation on OCF conducted on 12 eligible studies. Pre-collection hypothesis was that prior radiation therapy is associated with increased OCF incidence. Post-collection analyses: free versus pedicled flaps; mandible-sparing versus segmental mandibulectomy. RESULTS: Seventy-eight studies were included in meta-analysis of overall OCF incidence. Pooled effect size showed overall incidence of OCF to be 7.71% (95% CI, 6.28%-9.13%) among 5400 patients. Meta-analysis of preoperative radiation therapy on OCF showed a pooled odds ratio of 1.68 (95% CI, 0.93-3.06). OCF incidence was similar between patients undergoing free versus pedicled reconstruction, or segmental mandibulectomy versus mandible-sparing resection. CONCLUSION: Orocutaneous fistula after oral cavity resection has significant incidence and clinical impact. Risk of OCF persists despite advances in reconstructive options; there is a trend toward higher risk after prior radiation.

Five-year prospective fistula audit in a single center. TIG training negates consultant learning curve, but surgeons should beware the mid-range palatal defect.

The aim of primary palatoplasty is to achieve optimum speech with minimal morbidity. Symptomatic fistulae are well-recognised complications of palatoplasty and may require additional surgical intervention, increasing the burden of care. Our aims were to better understand fistula experience in our unit and compare fistula rates between an established consultant and a newly appointed training interface group (TIG) trained consultant. Post-operative fistulae were prospectively and independently recorded by Cleft Clinical Nurse Specialists as part of routine 6-week post-operative reviews. Cleft type and intra-operative hard-soft palate junction (HSPJ) width were prospectively recorded by operating surgeons. Data were collated and analysed using Microsoft Excel. Between 1 January 2014 and 31 December 2018, 250 primary palatoplasties were performed. The overall fistula rate was 8% (0% SMCP, ICP 7%, UCLP 8%, BCLP 22%). Fistulae clustered in clefts with a mid-range HSPJ width of 12-16 mm. Numerically, fistula rates remained similar over time despite increased unit activity (doubling of primary surgeries in 2017 and 2018). There was no significant difference in fistulae rates between surgeons (P > 0.05). Overall fistulae rate compared favourably with published data. TIG fellowships were designed in the context of cleft surgery to address issues relating to steep operative learning curves. These data demonstrate that results from a newly appointed TIG-trained surgeon are comparable to that of an established TIG-trained surgeon. Data also suggest surgeons should be aware of the risk of fistulae in the mid-range palatal defect and in HSPJ widths of 12-16 mm.

Nasal oral fistula revealing Langerhans´ cell histiocytosis in adult patient: case report.

Langerhans cell histiocytosis (LCH) is a rare systemic disease caused by proliferation of mature histiocytes; its association to histiocyto fibroma is rarely reported. It rarely affects adults. We report a case of systemic LCH, in an adult patient with osteolytic lesion causing a fistula between the left nasal cavity and hard palate, involving the bone, lung, lymph node and associated to multiple histiocyto fibroma. The patient was operating for a fistula, and he was treated by chemotherapy and corticosteroids. Langerhans´ cell histiocytosis is a rare case, especially in adult patient. The diagnosis was based on histological and immunohistochemical analyses. This patient was treated by steroids and chemotherapy.

Prevention and management of oronasal fistulas.

PURPOSE OF REVIEW: The aim of this article is to present the current opinion on the prevention and management of oronasal fistulas in cleft palate patients. RECENT FINDINGS: Though cleft palate repair has seen numerous modifications and improvements, oronasal fistulas remain one of the most common complications of palatoplasty. There are various techniques available for preventing and managing this complication. SUMMARY: Oronasal fistulas can be minimized by employing proper principles for palatoplasty. Once a fistula occurs, the repair technique should be appropriate for the fistula type. Oronasal fistula classifications, various repair techniques, tissue adjuncts, and biomaterials used in both the primary palate repair and oronasal fistula repair are discussed in this review.