Q: I am a 24 year old male who was born with a right cleft lip and palate and have been through five surgeries so far in my life. Besides my inital cleft lip and palate repairs, I underwent iliac crest bone grafting at age 11 and a Lefort 1 osteotomy combined with alveolar cleft bone grafting again at age 21. I have a fixed bridge across the alveolar cleft site. My current complaint is that I feels my upper jaw is collapsing again causing poor fitting of the bridge and thus pain. A CT shows a very small, but present, bridge of bone across the alveolar cleft. Also, the Lefort 1 plates appear in good position. I have no visible fistula but I can force air into my nose from the upper buccal sulcus. What, if anything would you recommend to try and solve my current orofacial problems? Thank you sincerely for your help.
A: It sounds to me like you still have a small oro-nasal fistula through the original alveolar cleft site with inadequate bone stock. I would look at repeating your alveolar cleft site grafting using a combination of some marrow and a cortical onlay graft screwed into place across the cleft site. It is very common to have resudal alveolar fistulae even though the site has been grafted more than once. If you can force air through it then there is a fistula. Plus if you have been grafted twice and it was done well, you should have more than just a small bridge of bone across the alveolus. I would wager you have a fistula going behind that bridge of alveolar bone. While alveolar cleft grafting seems simple, it actually is technically difficult and results can be less than ideal in many cases.