Dr Omar Ragab
Double Graft for the Management of Palatal Cleft with Severe Vertical and Horizontal Soft Tissue Deficiency:
A 17- year old female patient presented for implant placement in upper anterior region. Diagnosis revealed a unilateral cleft lip and palate. The surrounding soft tissues, at the edentulous site, showed marked vertical and horizontal deficiency. The patient reported seepage of nasal fluids into the oral fluids along with a bad taste. The patient has a history of failed block graft that was harvested from the iliac crest under general anesthesia to repair and augment hard tissue deficiency without considering the soft tissue deficiency. This failure added to the already existed large soft and hard tissue defect. CBCT showed incomplete unilateral palatal cleft with a small oro-nasal communication palatal to the missing lateral incisor area.
A staged approach for soft and hard tissue augmentation has been selected to manage the case. The first stage was to graft the soft tissue and the second was planned for hard tissue grafting. A temporary acrylic removable palatal stent was constructed for the patient to wear during the early healing period.
A crestal incision was carried out using a no. 15C scalpel. Two split-thickness pouches were created labial and palatal to the incision, including the palatal cleft area. These pouches were created to receive the de-epithelialized wings of the free gingival graft. Double graft, one as a pedicle, harvested from the palate close to the defect, and the other as a partially de-epithelized free graft, harvested from the other side of the palate, at the same session, to correct the soft tissue defect in one step. Both grafts were sutured overlying each other as a double graft. The pedicle graft was sutured at the base of labial flap, whereas the partially de-epithelialized free graft was adapted to the recipient site, which included labial and palatal pouches, overlying the pedicle. After 6 months, clinical outcome exhibited favorable results in the form of ample gain in both volume and quality of the soft tissue, restoration of the level of the muco-gingival junction, and closure of the palatal cleft. The patient reported cessation of seepage of the nasal fluids into the mouth indicating successful palatal cleft closure with soft tissue.
Schematic drawings have been carried out to describe the technique
