Good evening everyone. My name is Charlotte and thank you for joining us for tonight's webinar Surgical Options, the treatment of palatal defects presented by Doctor Anna Neemec. So a bit about our speaker today.
Anna graduated as a doctor of veterinary medicine from the University of Lbiana, Slovenia in 2004. She continued with a PhD programme in the biomedicine at the University of Lana, focusing on research in the systemic effects of periodontal diseases while working as a veterinarian at the small animal clinic of the Veterinary Faculty, University of Lana. She was awarded her PhD in 2009 and completed her three year residency training in dentistry and oral surgery at the University of California Davis, USA in July 2012.
Anna passed her board examination and became a diplomat of American Veterinary Dental College in 2013 and has also been accepted to the European Veterinary Dental College. Anna was working as a veterinary specialist in a private veterinary hospital in, Slovenia in 2018, before she returned to the small animal clinic of the veterinary faculty in Libiana as an assistant professor and also launched a private consultancy company. Anonymic.
C in 2019. Anna is a member of many veterinary dental boards and an invited lecturer at universities. Anna has received several awards, is an editor in journals, an author of research and professional papers, and a keen speaker and teacher.
Her main research interest is oral biology, and in particular, host response to oral bacteria and tumour biology. But her biggest passion remains the teaching of veterinary dentistry. So we're in good hands today to talk about palatal defects.
I wish to let you all know that tonight's session will be recorded and available on playback, and you will receive a certificate for tonight's attendance also. Please use the Q&A box for any questions you may have for Anna throughout the presentation and at the end of today's session, we'll see if we can answer any of these questions you may have. If we run out of time with the questions submitted, we'll email out any responses to you in the next few days.
So with no further ado, I'd now like to hand over to Anna to start this evening's session. Thank you, Anna. Thank you, Charlotte, and good evening anyone.
Welcome to this webinar on pilot and defects. So, we will talk today about defects that are either, either congenital, so this would be called palatal cleft. So we will first look into a bit of the palatogenesis, so the development of palate to better understand how these defects develop.
And then we will also talk about acquired defects which are, in other words called oro nasal fistulas, which are much more common because here we will mostly encounter defects such as oro nasal fistula or nasal fistulas from periodontal disease. Let's first look at congenital defects, so palatal clefts. When we talk about palatogenesis, which is a formation of the palate and upper lip, this actually happens sometime between 25th and 44th day of development in dogs.
And palate itself consists of primary palate and secondary palate. Primary palate, by definition is the upper lip and incisive bone, roster to pallatin fissures, and secondary palate is hard palate caudal to the palatin fissures and soft palate codle to it. So if we first look at the development of the primary palate, this forms by fusion of paired medial nasal processes and the nasal processes fuse with maxillary processes which are lateral to it to form the upper lip, alveolar process, and primary palate.
So all the all the structures caudal to the palatin fissures. Alveolar process forms by fusion of bilateral maxil incisive suture lines and then is followed by closure of the rostral nose and lip. The secondary palate, develops a bit later, and it starts with the, the development of so-called lateral palatin processes of palatal shelves, which are basically the palain processes of the maxilla.
These processes, it's very interesting. They initially grow in a ventromedial direction around the tank. So, first, what has to happen here is the tank literally has to drop down towards the floor of the oral cavity.
In order for the palatal shelves to elevate to the horizontal position, that happens in dogs around day 36 of their embryologic development. And then another very interesting, phenomena happens, namely, these two processes are all around covered by epithelium. So this epithelium has to actually dissolve, that is so-called peridermal peeling.
And this is, yeah, the dissolution of the medial epithelial seam, which happens sometime between day 37 and 44 of embryologic development in dogs. And after that happens, actually, the two pallatin shelves can completely fuse, fuse together and become covered by the epithelium on both sides. This process is guided by different intrinsic and extrinsic factors such as tongue movement, we already mentioned that, and also muscular contractions, for example.
And the fusion of the palatin shelves it begins in mid palate and then moves rotally and caudally to, to the whole palate. Secondary palette then fuses rostrually with the primary palette, and as we mentioned, the incisive papilla is is where we believe is the their fusion side. So if any of these sutures or structures fails to fuse, then we talk about orofacial clefts or what we are discussing today in particular are palatal clefts.
In general, if we talk about orofacial clefts, they affect about 3% of pappices for one of more recent studies. And of these defects, cleft lip, is, it happens in about 1/3 of cases, a bit less, one quarter of cases. Cleft palate is the most common affecting almost 2/3 of dogs, and cleft lip and palate is the rarest, which affects about 15% of these animals.
This, incidence of orofacial clefts, rise between the breeds, but, it has been shown in several studies that brachycephalic breeds are mostly affected and, an additional study found out that also massive and carrier breeds may be predisposed to orofacial casts. What is also interesting if we follow the line of, of dogs, we, we observe what was observed is that offspring of phenotypically cleft parents actually has clefts in almost half of, half of the cases. But the severity of the cleft in, in the offspring does not really relate with what we see in the parents.
Although No, following the, the line of dogs definitely shows towards, some genetic component to the, to the, to the problem. The precise aetiology of development of orofacial clefts is still unknown. Luckily, we can say luckily, genetic evidence is emerging and some of the candidate genes are being discovered.
Which can be very important also for breeding purposes for testing of the dogs. Other, factors can also contribute to, development of orofacial clefts in puppies, such as intrauterine exposure to medications and toxins, in other words, to teratogens. Poor nutrition, possibly trauma and mechanical forces during embryologic development, and there were some, suggestions that even geographic region in some aspect may have, may have an impact, but it may actually be related to all other factors.
So if we now have a deeper look into the classification of specific defects, and then we will later address one by one how we can repair them. Cleft lip we said is the second most common effect in about one quarter of dogs that are affected by orofacial clefts. And as we said, it involves the primary palates, so basically the leap.
And the alveolus, and it is the sequel of the failure of the nasal processes to fuse with the maxillary process. So, therefore, it typically occurs between the 2nd and 3rd incisor too. It can be unilateral, and if it's unilateral, then it has been shown that the left side is more commonly affected or it can also be bilateral.
It can also vary in depth, and in this top here, we can clearly see that the lip is barely affected. But then we can see an an extensive defect in the alveolus which is actually leading to formation of an oral nasal fistula or basically it's, yeah, it's a, it's a cleft, so it's a oronnasal communication. Why is this important?
Because if we only have a, a cleft in the lip, and there is no oronnasal communication. This can be considered just aesthetic defect and not really contributing to the poorer quality of life of the animal. But as soon as we have an oral nasal communication, then this has to be repaired because obviously such dogs are predisposed to nasal disease, chronic nasal, chronic nasal disease to foreign bodies and to all the sequel of this, these problems.
Cleft palate, we said is the most common defect affecting about 2/3 of the animals that suffer from orofacial clefts. And again, it can involve structures of the hard palates, as we can see in this top here, and or also soft palate. Maybe associated with a cleft lip or it may be an isolated defect.
Then there are several defects that are way rarer and also not that easy to explain what, what really went wrong during the facial development. And one of such described in dogs is the midline cleft of the primary palates. We can see it here, the cleft in the alveolus between the first incisor teeth of maxilla, and also the bifeed nose.
As we said, this is a very, very rare defect and in some breeds this almost cleft nose can actually be something that is more, more common and it's not even a, a problem. Then other rare congenital palatal defects include soft palate hyperplasia which can again be uni unilateral or bilateral. And then the rest is mostly known in humans, such as velar asymmetry, that's not something that we will see in animals, or at least it's not yet described.
Also, what we, what we need to, to learn from human part and we are gaining more and more evidence about that is that, these palatal defects may be part of, another syndrome. On the other hand, they can also coexist with other craniofacial anomalies. There, there is one study confirming that, we will look at it later, and also can coexist with extracranial anomalies that has also been described in different species of animals.
In other words, we have to think about other defects that, dogs that present with cleft lip and or cleft palate may actually suffer from. So an extended examination, is important in these animals. On the other hand, we will talk today also how to repair acquired palatal defects.
And as I mentioned at the very beginning, the most common acquired, palatal defect is or nasal fistula as a sequel of periodontal disease. This will most commonly affect canine teeth and especially, let's say in Dasund, it's very typical on the palatal aspect of the maxillary canine teeth. But it can actually happen at any tooth on the maxilla.
That's why periodontal probing, especially in small breeds of dogs, is very, very important. And as we will talk later, or nasal fistula from periodontal disease is actually our clinical diagnosis rather than our imaging diagnosis as opposed to palatal clefts. The other common or not that common, but it, another, possible, reason for or nasal fistula is also malocclusion.
This dog, we can see that, this dog was not really suffering from periodontitis. The the dentition actually looks pretty healthy periodontally. But then again, we have the maoclusion with lingual vertate mandibular canine 0, and also some mandibular relative mandibular bragnatia.
And we can see that this dog is actually, that this dog was brach there is brahynatic because we can actually see impingement on the hard palate from incisors here. And here I'm actually exploring the er. Or a nasal fistula at the palatal aspect of the maxillary canine tooth, which was caused by years of chronic or years of malocclusion in this poor animal.
Again, it is very, very important to evaluate occlusion in all our patients, when we do general physical examinations, when they come in for, for whatever reason. As I mentioned before, and as we will return to later as well, or a nasal fistula is our clinical diagnosis, and it's very simple diagnosis. What we need is actually a periodontal probe.
And this periodontal probe is actually a blunt ended instrument which is graded. Usually, it has grades of 3 millimetres or 2 millimetres, depends on the probe. And you can see that I'm using here a 12 millimetre periodontal probe, and it actually sinks all the way in.
And if this happens, that's an oral nasal fistula. What we commonly see when we probe an or nasal fistula is also a bleeding from the ipsilateral nostril, and that is our diagnosis of an oronnasal fistula, which can actually be, as we said, from periodontitis or from malocclusion. Or a nasal fistula can also be, yes, a sequel of previous, .
Not properly managed extraction of the teeth associated with oral nasal fistula. So these dogs had pre-existing oral nasal fistula, and during the extraction, these, areas were probably not, well managed in terms of surgical approach, and we will talk about how to do this later. And then this chronic or nasal fistula will, will, will keep, being there.
And again, sometimes it's very easy to just see them already on an awake clinical examination of the oral cavity, as we see on the dog on the left. This was visible to the naked eye. On the other hand, this dog on the right was suffering from a chronic unilateral nasal discharge.
And even if the tooth was missing, definitely the first thing what we would do is probe the areas around the teeth and also the areas of missing teeth. And we can see here that again, my 12 millimetre probe sinks in where the maxillary can I used to be. And actually penetrates into the nasal cavity.
So again, a simple diagnosis of, oral nasal fistula. Again, in such cases, we may definitely continue with our workup of, nasal discharge, including CT and, and rhinoscopy. But once we detect clinically or nasal fistula, that is our most likely reason for nasal discharge.
In this case, we see an oral nasal fistula, which was a sequel of previous electrocution trauma in a puppy that survived the event. And we can see several abnormalities including uneruption including tea that did not properly erupt. Also, some malocclusion is present due to abnormal development of the jaw that was affected.
And also this palatal defect that that includes, almost half of the soft and hard tissues of the palate. Or a nasal fistula can also be a sequel of a failed attempt to repair palatal defects, and we will talk about this later. And oro nasal fistula can also be a sequel of improperly managed palatal separation injuries in cats.
As we can see in this cat, these are commonly observed in cats with a high-rise syndrome, in cats that fall from heights, and usually they fell. The muzzle on the floor, and then literally their maxilla separate. And usually these cats will also present with sepificial separation, as well as TMJ fractures.
Again, we will discuss how to properly, diagnose and manage these cases a bit later. Yeah. So we are now coming to the diagnostic procedure.
So we mentioned that we have 22 different approaches. One is our clinical evaluation of the defect, and the other is our, imaging evaluation of the defect. And in some cases, as I mentioned before, our nasal fistula.
From periodontiti is definitely first line is our clinical evaluation. While in palattal defects that we will shortly see, it is of utmost importance that we actually perform advanced imaging to properly evaluate the, the, the defect and any associated defects. But first things first.
So what we do first is always our general physical examination. These animals will usually, sneeze if we are dealing with a palatal defects in young animals. These animals will usually have difficulties drinking, nursing, milk and water will come out through the nose.
They will also usually, not develop really properly, and so they will exhibit poor growth. And, most of these animals will have respiratory infections. Majority of them, will have rhinitis, but we need to have in mind that all of these animals, the bigger the defect, the more likely and especially soft palatetal defect, the more likely, aspiration pneumonia can develop.
Then the next step is our oral exam. As we said, the first thing, if we can do in an awake patient, we can, we should do it. If the animal allows it, lift the lip, check the mouth, and see what is happening, in the oral cavity.
Sometimes some big defects, definitely, we will be able to, to already see them, clinically, not so much when we talk about the defects of the soft tissues or the soft palate. And also it's very difficult to diagnose or nasal fistula from periodontitis also clinically because they are usually very small, very narrow, and associated with the, with the periodontal tissues of the teeth, obviously. We would also work these patients out in terms of complete, blood work, CBCM7 biochemistry, which are usually normal.
And in, In animals or in dogs where palatal defects are large, especially when we are talking about developmental defects or clefts, we would highly recommend to do chest X-rays, and depending on the clinical signs and also radiographic evaluation of the, of the lungs, we may even consider doing trache wash and nasal, especially fungal culture. Then we would clinically explore the defect. And again, we would normally use a periodontal probe for that regardless what defect we are exploring.
But as we mentioned, now already, periodontitis or, last periodontitis resulting in an oral nasal fistula is our simple clinical diagnosis using periodontal probe that sinks into the oral into the nasal cavity just next to the tooth. And usually, we will observe, as we said, ipsilateral nasal bleeding. Dental radiographs are a must, when we talk about evaluation of teeth and periodontal tissues.
So if we are dealing with periodontitis, and acquired or nasal fistula from this particular problem, then usually or then normally, dental radiographs are enough. We don't really need to go to advanced imaging. But we definitely want to support our clinical finding with dental radiographs.
The reason for this is to mostly look for any associated dental anomaly. We can actually see here on this can92 that we have to extract that there is Some, inflammatory root resorption, which may make our extraction potentially more difficult. This tooth may potentially fracture, so we need to open, we need to open a bigger flap and maybe remove more bone and go on with a careful extraction.
So, in, in particular, when we talk about or nasal fistula from peridontitis, clinical evaluation is, is our gold standard, but we have to support our clinical findings with dental radiographs. When we talk about bigger defects and especially when we talk about clefts, so developmental defects, then radiographs are usually not helpful. We can see that there are abnormalities in these two, in these two dogs, but it doesn't really describe the defect in a way that we would be able to plan our surgical treatment accordingly or appropriately.
So when we are dealing with bigger defects and especially with clefts of the palate, computed tomography of the head is definitely the gold standard of of diagnosis. The reasons are several. First of all, what is, what we described in the paper now 9 years ago, is actually that only with a computer tomography, we can, we can, Evaluate the defect in detail.
And we showed that what we see, so soft tissue defect, is always smaller than the underlying bone defect. And this is extremely important when it comes to planning the flaps to, surgically correct the defect, because We have to have the flap supported by bone. Other than that, we will just expose and create another or nasal fistula.
So evaluation of the size of the bony defect is just as important or even more important than an evaluation of the soft tissue defect. Also, Ah, let me look at this case. So that was an interesting case that, that supports what, what I was just describing.
This dog has a relatively narrow, yeah, palatal cleft, the cleft of the heart palate, from the incisive papilla all the way back to the, to the end of the heart palate. And this defect is the widest at the area of first premolar teeth, but it, it, it is relatively narrow. If we look, or basically, if we look at the canice, it's even narrower.
If we look at the CT image, we can see that the defect is actually in the bone, is actually the largest where The defect in the, in the soft tissues is relatively small. And it's, yeah, it's expected because the, the, the bony defect actually here kind of fused with palatine fissures, and that's why we have such a large bony defect. But then again, it's very important to correct, to plan, flaps or our incisions.
In a correct manner just in the area of canine P1 and P2. We don't want to cut too close to the edge of the soft tissue defect because we will expose the void space below. So that's why it is so important to have a CT planning when we are, surgically correcting palatal defects, palatal clefts.
Another important reason why we suggest the CT in animals with developmental clefts is what is it lies in the, in the fact that I mentioned before that these animals usually have other, cranial anomalies associated with their cleft. And it, it, it's Kind of expected because the whole head develops together with the face. And what we commonly see in dogs with palatal clefts, is abnormalities in the ebola.
It's abnormal abnormalities in the incisive bone in the number of teeth. And we sometimes also see other defects, that are associated with especially ventricles development in the brain. The, the sequel of these findings may not necessarily be detrimental to, to our surgical planning, but it's definitely definitely something that we, we need to know in terms of potential prognosis, in terms of explaining all the possible future complications to the client.
And the same applies for trauma cases. As I mentioned before, cats, that sustain head trauma and especially cats with high-rise syndrome, they will commonly have a palatal separation, and together with palatal separation, it's very common to see also synthvial separation and it is kind of understandable or kind of expected. That if a cat falls on its nose, the jaws actually are pushed back, and that results in commonly in fractures of the TMJ as we see in this cat.
So this cat suffered from palatal separation. We see that there are several other minor fractures, and usually there are plenty of them. But what we also always want to evaluate is the TMJs in these animals.
And that's why CT is the way to go. We just don't want to just do dental radiographs. Sku radiographs are actually of very, very little value, and we are not even discussing them in this lecture, and we are clinically not really employing skull radiographs in these cases.
But we are mostly talking about dental radiographs, if we talk about pure dental periodontal disease or we, consider doing advanced imaging and in these terms, we talk about CT. And yes, TMJ again, TMJ involvement may not necessarily change our, or, or, or what we see on the CT may not necessarily change our treatment approach, but it's definitely something that we want to know and we want to discuss with the client, because especially these intra-articular fractures may be associated with a later development of ankylosis in these animals. So once we performed the thorough diagnostic, thorough diagnostic workup, we have to decide how to treat these patients.
And several treatment approaches exist. We will look again, at this separately for clefts and then for acquired or nasal fistula. We also, created a step by step, guide on how to, evaluate and how to treat certain, congenital clefts, and I will again talk about this, shortly.
A few general principles to, to treatment first. If at all possible, we should delay treatment of palatal clefts until 3 to 4 months of age. And even later if possible, and especially if the defects are large, where we may need to extract the teeth to gain more tissues for the repair, we definitely need to wait until eruption of the permanent teeth.
. Normally, we would, yeah, we would wait for at least the animal to be, to, for the dog or, or a cat to be at least 5 to 6 months old, and then continue with the palatal repair of the palatal cleft. In some animals, obviously, it's very difficult to feed them and it's very difficult to raise them, so, for so long time. And recently also a temporary palatal prosthesis made of thermoplastic silicon was described in Puppies and that's what, that was actually, A removable device, that was moulded to the, to the, shape of the defect and was literally pushed in the palate of these puppies, just when they were, bottle fed, bottle-fed.
And, in those, it was just a few, I think 3 or 4 cases in this series. And, but in, in, in the author's experience, that really helped with, raising these animals to the desired age for repair. Then the second principle is that with the first repair, the chances of success are the greatest.
So that is why it is so important to plan these treatments appropriately. Because once the treatment fails, or the surgical repair fails, we are dealing with unhealthy, poorly vascularized cicatriized tissues that are even harder to, to, to heal and also harder to obtain good flaps. So, we should plan the first, repair well, and, and we should aim at success with the first procedure.
That is why it is so important to really understand the anatomy of the defects that we are dealing with, and that is why in larger defects and especially in palatal clefts, advanced imaging, as we discussed previously, is so, so, so important. We also have to be well prepared for these surgeries, especially when we talk, even when we talk about, oral nasal fistula repair from peritonitis, those bleed, quite significantly as well. And usually we are dealing with, small dogs, so blood loss is a very, very important factor to, to count in for.
And we have to have some, so this is one of our palatal repair procedures, that is how much blood this dog lost. And we have to have, some sort of monitoring of the blood loss in place, and, definitely also, blood, products available if we need to, perform transfusion. How would we repair the defects?
Let's let's have a, a bit of a look now. So cleft lip and dental alveolar repair really depends on the pre-existing anomaly, as we said, if it involves the deep, we have to consider. Either, if we are repairing the leap or not, and if, and what technique we shall, use for the leap as well.
But as we said, lip repair is not that critical because, it usually does not really interfere with the quality of the life of the patient. So what we have to always, plan and take care of is the, the a repair of the cleft of the alveoles. And then again, it really depends on what, what, shape, defect we have to begin with.
Usually, we have to extract some teeth to gain more space, more tissues, and then be creative with how we will use our soft tissue flap to actually repair the defect with, and recreate the oral, oral floor. Sometimes we have to, depends again, depends how the defect is. Sometimes we first have to recreate the nasal floor and then oral floor, but in this particular case, we can see that with a, with a bit of a flap, random, random mucosal flap, full thickness flap, we recreated, repair this, alveolar defect.
For the hard palate repair, there's several techniques, and in majority of the narrow defects as in the dock that we, we, looked before. We may use the we may use Folanggenberg technique, but then again, we really have to understand, the underlying bony defect so that we, place our releasing incisions to the, von Langenberg technique, appropriately, so that we do not cut into, soft tissues where there is no underlying bone. When we repair with von Lange volangeman technique, that means that we would first, Cut the .
Oral epithelium from nasal epithelium, at the cleft area. Yeah. And then we will make two releasing incisions, just about 2 millimetres palatal to the maxillary ity.
We do that bilaterally. And we do not obviously cut roster. So we would just do two releasing incisions all the way from, depends on how long the defect is, from the last molar, all the way to the, let's say 3rd incisor or a 2nd incisor too, and the same maybe on the other side.
And then we would lift two sliding flaps that we would, that would meet in the middle where we would suture, and we would leave the releasing incision sites to heal by second intention, and that usually heals within 2 to 3 weeks. . As you can see on this photo here, we are using stay sutures to manipulate flaps in order to keep the vascularization as as interrupted as possible.
When we suture the defect, we are usually using, the vertical or horizontal matric sutures, especially if the palate is very thick, which usually is especially in, I mean, in most of the animals, but especially in graycephalic breeds, and then the, the, the palate with the grain ruga tends to invert. So that's why we would nowadays recommend doing vertical horizontal metric sutures to actually invert the edges of the wound. This is, the same, animal with, with the final repair, we can see our suture line in the middle and to releasing incision that are gapping more where we have a larger defect, obviously, and that's why it is so important, as I mentioned already before, to make sure that we have underlying bone below our releasing incision.
Another option in this area of the pallatin fissures, if there is a huge defect. Another option in this area is to do a split thickness plat, meaning full thickness would mean that, yeah, we literally lift the whole palates with the whole underlying glucosa and periosteum off the palatin, . Processes, and then really due to sliding flaps, split thickness in would mean that we would, literally separate the flap, in the, submucosal layer.
That definitely makes the flap, less vascularized, with less, less underlying support, . But it may be another option to do if we are lacking tissues in the area of Palatin fissures. But then again, we may need to think about different repairs if we suspect that we will lack, soft, that we will lack, we will lack tissue or we will lack bone below this defect.
So this is the same the same animal. I'm sorry for the fingers on the picture. It was taken by the client.
That's how we usually do nowadays our WeChas. If everything goes well, clients would just send me in the, the images and we would just do the, the teleconsult with them. So this is 10 days post, post-surgery, and we can literally see that the wound has healed, the sutures are still present, and we can see that the majority of the releasing incision sites has already granulated in and mostly also, already is epithelized.
So the healing process is, is rapid in, especially in young animals and especially with appropriate surgical techniques. So, as we, as we said, before, be very careful with tissues, know the anatomy, use the sutures, and in this particular flaps, it's so very important to also, keep the vascularization from the major pallatin arteries which are emerging at the level of the maxillary 4th premolar somewhere halfway between the tooth and the midline of the palate. That is Why we will always create our releasing incision, about 2 millimetres away from the teeth for two reasons.
We want to avoid the, major pallatin, artery. And we also, at the same time, want to keep some, gingiva. We don't want to remove gingivine and, and some of the surrounding soft tissues in order, not to cause, traumatic gingiva recession.
So we have to keep some, some gingivine soft tissue around the teeth. As I mentioned before, nowadays that was also recommended by Doctor Poletti recently, vertical mattres sutures are, preferable for inverting the edges and therefore, will enable faster healing, less likely the histance because there will be no epithelial, within the suture line. And then we can on top of Excuse me.
On top of vertical matric sutures, we can also place a few simple interactive sutures to better align the edges of our, of our wound. OK. Another option, how to correct the the larger defects of the hard palate, is the single layer overlapping flap technique.
In this particular repair, we would again have to understand the defect, and then we would use one side of the, soft tissues of the heart palate to actually lift it up from the underlying bone and hinged it over to cover the defect and leave the other side intact. So what we would create here is as we can see is is an incision from the edge of the cleft towards the teeth. Again, Go in parallel about 2 millimetres away from the teeth and again continue with our incision towards the cleft towards the cleft.
On the other side, we would do the same thing as, excuse me, the same thing as we would do in prolonged techniques. So we would separate the oral and nasal mucosa just at the cleft. Then we would raise a full thickness flap.
Again, using our stay sutures and again, preserve the Palatin arteries. So again, make sure that, that we would, we would, identify or we would, yeah, recognise where the major Palatin arteries come out. Obviously, we would have to ligate the palatin artery at the Rostral aspect.
And then we would hinge this flap and suture it below the elevated flap on the other side. Sometimes we may need to do if there is, no, if there is tension on the suture line, because tension on the suture line will result in failure of the, of, of the treatment. We may need to do a releasing incision similar to for Langenbeck at the other side in order to move the non-hinged flap towards the midla.
And again, we would leave this bare bone for healing by second intention and again, this is what the client sent me two weeks later. We can see that everything has completely granulated in the, the, the, the, the, the cleft is is corrected and the the denuded bone is now being covered by by by granulation tissue that still has to reepithelialize. If, we are dealing with, several previous, with huge flap, with huge clefts or with a previous attempt at the repair that failed, we may need to look into other options to gain more tissue.
So we have an example here of a, of a defect that was Attempted to be repaired 5 times before. And now we are dealing with very unhealthy scar tissues. We see that this palate is definitely not normal.
This is not amenable to healing. Also, what we see is that the defect in the bone becomes very irregular when we try to correct it several times. So we really have to understand how the, the anatomy and the nature of, of the cleft.
For the defect now, this is now the or nasal fistula. It was a cleft, but now it's an over nasal fistula. So now we have to think, where can we get more tissues?
And the easiest way is to remove the teeth. Let everything heal and then we have all these buck of mucosa as healthy tissue that we can use for repair. In the meantime, we can use such an temporary operator in our defect, and we would wait at least 4 to 6 weeks before.
The extraction sites here. We, we plan extraction depends on the flaps that we want to have later on for the repair. And as we can see here now at the second stage of the procedure, we have plenty of buckle mucosa available for repair and we will use here Double layer technique.
So, we would use the palette on this, the tissues from the palate on the right side, which is in poor quality actually, to actually hinge it over to be a bottom actually or the to recreate nasal floor. And then we will use a large pedicle flap from the left side to cover the whole defect that, that is then created. So let's look at this.
Our, our right side soft tissue is is used as a hinge flap that is sutured to the bone. And then, and here we can see that and on the other side, we can see this huge, pedicle flap that is relying on our infraorbital artery, that is used to cover the majority of the, previous defect. And then we can create a third pedicle flap from the back of mucosa on the other side to actually complete our repair.
Sometimes the defects are really, really large, and we may think of, palatal curators, something that is known in human, dentist or human maxillofacial, surgery, but this should really be considered the salvage procedures. In humans, these obcurators obviously, can be taken off, cleaned daily, and then replaced. In dogs, that is definitely not that easy, but they have to be removed and cleaned because they become, you know, yeah, full of debris and dirt and, become a source of infection and also extremely bad breath.
So these animals then have to be an anaesthetized several times in order to actually take the, the, the operator off, clean it, clean it, put it back attached to the teeth again. So this may only be considered really as a salvage procedure in order to gain some more time for the clients to you know, to, to, to understand that these defects, are really not something that we can repair, and something that we may need to, consider euthanasia at some point. For the soft palates, we can use double or three layer oppositional technique.
A soft palate is usually very pliable, and usually there is not that much tension as we have when we are dealing with the hard palate. And we can see here. That what we created in this particular case is just the separation of the nasal and oral mucosa, at the edge of the cleft and then we are suturing here and just bring it together, and then we are just suturing here nasal mucosa, then or nasal aspect, then we can also suture a middle layer if it's the very thick palate and if it's a more thinner palate, we would just do another layer on the oral side.
So this is our nasal site and then this is completed with suture oral site. If there is any tension on the suture line, we may consider doing half thickness, releasing the incision at the, at the, level of the palate of the, . Of the fossa.
OK. Oral nasal fistula. We will mostly talk here about, as we said, or nasal fistula from periodontitis.
And the first that I will show is actually one that, that, remained of the previous extraction of the tooth that has or nasal fistula. So what we have to do here is actually debride the edges and you can see here that we cut literally the whole epithelium from the oral to the nasal side, with a scalpel blade. So we really have to debride it free of epithelium, make it free of epithelium.
And then usually the first, the first attempted repair which is usually successful with a large enough and good flap, is our large pedicle mucosal buckle, b mucosal flap. And again, we would suture it in the, in the most Let's say palatal area, we will suture it with vertical matrix sutures and the rest can be, the releasing incisions can be sutured in a simple interrupted manner. So again, this is this dog 2 weeks after the procedure, we see here some probably reaction to the suture material, but other than that, the, the, the, the wound has healed, and the oral nasophy the oral nasal fistula has been repaired.
In this particular case, we see that we, we are repairing the oral nasal fistula at the time of tooth extraction, which is normally done. We usually would include these two things in one procedure. We wouldn't just extract the tooth and then let it heal and then repair the oron nasal fistula as we saw in previous case.
That was, that is not our goal. Our goal is always, if we see an oro nasal fistula associated with a maxillary tooth, extract the tooth, debride the area properly. And then suture it with a, with a large, full thickness buckle pedicle flap, without any tension on the flap.
And it is really of extreme importance to very well the bright not only the edges of the fistula, but also to literally clean the whole, the whole defect. We should literally see in the nose and, and, normally. We will find here a lot of debris, dirt, and sometimes even foreign bodies.
So we really have to inspect well, the whole area, flush, flush, flush with a lot of sterile ringer lactate, and then again, suture the flap without tension back in, back in place. Palatal separation repair, as we said, it's normally or usually not the only defect that these animals have after trauma, but let's focus just on how we will repair the palatal separation. We would use a technique that is actually based on von Langenban technique.
So we would literally physically squeeze the two maxilla together to narrow the defect. And sometimes it is possible, it is possible just to deprive the edges, either with a scalpel or with scissors. I would normally actually use the big round diamondb on a high-speed handpiece with water spray to depri the edges and sometimes sometimes it's possible just to suture this perprimum.
So no, no, releasing incisions at the at the lateral aspects of the palate. But if there is any tension when we try to suture the defect, the, the soft tissues together at the defect side, we then have to approach it with a von Langenbeck technique, basically, with 21 or two releasing incision depends on how, how much tension there is, . Just close to the teeth and then again, preserve the major palatin artery in these flaps.
Two lateral sliding flaps, store the midline, suture at the midline, and then let's heal the, releasing incision slides by second intention. And this is the catheter too we recheck and we see basically complete healing and just a few sutures that are remaining, there. Another possibility is that there is no full, palatal separation, but it may be separation just in the incisive area, so where the incisive bones separate.
And still, we will have here a neuron nasal fistula, and that is very easy again to diagnose. We see that the teeth are separated, the first incisors teeth are separated and with the periodontal prop we fall in the nose. Again, in these cats, we highly recommend to do a CT because because other co-existing traumatic lesions are present.
And in these cats, again, we would literally squeeze the maxilla together. And then put a wire in a figure of 8 around the canine teeth, or knotted on one side and cover this with a temporary composite. So that would be an wire reinforced intraoral splint that will keep the bones together for the for the time being of healing.
It is very important to check the occlusion, because the, intra splint may interfere with occlusion and it must not. So if there is any interference, we have to correct that. So we have to extubate these cats during the procedure, check the occlusion.
If occlusion is fine, we may complete the procedure. If occlusion is not fine, we have to adjust the intraoral splint. And then have in mind that there are several other techniques that I'm not even touching in these lectures, even bigger flaps, bigger repairs, using, all sorts of approaches, that are available, not that commonly used, but are available, and, .
We may, we need to be aware of those. And again, if that is something that is beyond our skills, definitely there are colleagues, surgeons, oral surgeons, that are skilled with these procedures, and we shall seek their help and their opinion. So what we would normally do as a postoperative care in these patients, definitely analgesia, lots of analgesia, which will include non-steroidals and usually also opioids.
Antibiotics are not always necessary or usually not necessary unless there is some severe rhinitis associated with it. But with most of the periodontitis cases or those phonelagenbeck technique that we, we saw, or even the hinged flap, those are clean contaminated procedures and we don't really need antibiotics. The same applies for topical antiseptics.
We are moving away from using topical antiseptics. So really the most important thing is analgesia. And also, it's very important to educate the clients for, for how to take care of the animals in, in, in terms of appropriate diet and toys.
In other words, these animals should be fed liquid or soft diet for about 2 weeks, and usually we recommend no toys and no chewing for at least 6 weeks when we are talking about large palatal repairs. When we are dealing with oral nasal fistula from periodontitis, we would say normally, 2 to 3 weeks of no chewing. Prognosis, as we said, the best is, the best is always with the first repair.
And it's mostly excellent. If we look at the prognosis, what litre, literature says about repair of surgical clefts, it will sound that function. Success was achieved in majority, so 85% of dogs.
The histance was the most common complication and it was most commonly associated with poor surgical technique, which, which means mostly that there was tension on the suture line, or that manipulation of the tissues were, were not good. And also, an unsuccessful outcome was also found in dogs that were very small, smaller than 1 kg, and in those dogs that were older than 8 months. So in other words, we would, as we said, try to address cleft, repair of the palatal clefts, or congenital defects in somewhere between 5 to 6 months.
Sometimes if small or a nasal fistula remain after repair of the cleft, this may not always cause problems and we may consider not doing anything. But if the animal has a, a, a persistent or a nasal fistula after a repair of the cleft and it's clinical, then definitely we have to go in and repair it again. If defects are large, if technique was poor, if there was any coexisting disease and especially fungal infection in the nose, then a success rate is, is pretty poor.
When it comes to prognosis of acquired defects, it's mostly excellent again. And this study was looking at, at, A repair of hard palate defects, but not periodontal. So any other or nasal fistula apart those related to periodontitis, and they found out that it was mostly successful actually.
So persistent oral nasal communication was found only in one quarter of the cases. And usually it was associated with presence of neoplasia. So they were looking at cases that failed after huge flaps after, let's say neoplasia removal.
So presence of neoplasia was one of the main reasons why these procedures failed. Also, the area of the flap and the distance that, the, the tip of the flap travel was associated with higher risk of failure. And when we are looking at cats that were treated for palatal separation, basically all of them, were found to heal completely with an appropriate surgical technique.
And this is one of the cases that, that describes just the opposite of what I was, what I was describing in this lecture. So this dog was, several, the treatment of this dog was several times attempted without any planning in terms of advanced imaging. And at some point, they were also using some, non-resolvable mesh in order to help the tissues to grow into.
But obviously, we are dealing here with, here with infected tissues. I mean, with, with, or not infected, but, with the presence of bacteria, because here it's oral cavity, nasal cavity, and usually this this meshes will not really do any good and will be, considered by the body as the By the body as foreign bodies. And when we at this point evaluated the dog, there was literally no tissue of the heart palate that we could use for repair.
And we also, when we are evaluating the heart palate defect, it was very abnormal with several, other defects in the bone, not necessarily associated with the primary defect. And such defects, which may be amenable to relatively Easy repair if we would address them correctly at the first go, now became a very, very complicated cases. And with this, I would like to, to thank you, and I would reiterate how important it is to, well, well, well estimate, well know how the defect in the palate looks, use advanced imaging, especially when we talk about the clefts of the palate, and really plan the surgical repair well because with the first attempt, we have the best chances of success.
Thank you. Thank you, Anna, for presenting tonight's webinar. I especially love seeing the before and after photos.
Remember, everyone to check out Anna's, website, which is shown on the screen. Thank you again, Anna, for such an informative session. We hope you all enjoyed tonight's webinar, and thank you all for joining us.
We hope to see you again. Good night.