Anterior palatal fistulas after palatoplasty: clinical and morphological analysis and an etiology-based classification

Relevance. Anterior palatal fistulas are among the most common complications of primary palatoplasty in patients with cleft lip and palate (CLP) and isolated cleft palate (ICP), with reported rates ranging from 5% to 60%. These fistulas result in persistent functional impairment, including hypernasality, nasal regurgitation, and swallowing and breathing difficulties. They may also complicate orthodontic treatment and often require secondary reconstructive surgery. This study aimed to analyze the etiologic and pathogenic factors underlying the development of anterior palatal fistulas and to propose a clinical classification based on a comprehensive assessment of anatomical, surgical, and biomechanical factors.

Materials and methods. The study included 38 patients aged 6 to 18 years with anterior palatal fistulas after palatoplasty: 20 with unilateral CLP, 13 with bilateral CLP, and 5 with ICP. Clinical and radiographic examinations were performed. Anatomical factors related to cleft morphology, surgical factors, biomechanical factors associated with maxillary growth and orthodontic treatment, and postoperative risk factors were assessed.

Results. The development of anterior palatal fistulas was associated with a complex interplay of contributing factors. Cleft anatomy was the key predictor of fistula characteristics, including location, size, and timing of onset. Among the 38 patients, 18 (52.6%) had unilateral complete CLP at birth. In patients with ICP (n = 5), anterior palatal fistulas developed in all cases (100%) as a result of attempts to lengthen a congenitally short soft palate. Growth-related maxillary biomechanics was the leading cause of late-onset fistulas, and in 50% of cases the fistula developed within 3 months after surgery. A working classification was developed, identifying four types of anterior palatal fistula: combined alveolar-palatal, median, incisive foramen, and multiple.

Conclusion. Anterior palatal fistulas develop through a complex interaction of anatomical vulnerability of the anterior palate, technical shortcomings during palatoplasty, maxillary growth biomechanics, and orthodontic forces. Prevention of postoperative anterior palatal fistulas depends on careful planning of staged cleft repair with due regard for cleft type and severity, close follow-up during periods of craniofacial growth, and a multidisciplinary approach involving both the maxillofacial surgeon and the orthodontist.

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