Orofacial clefts are the most common congenital malformation in dogs (1.3% to 2.8%; malocclusion not included) with a high rate of mortality within the first month of life due to complications from aspiration pneumonia or not meeting the nutritional requirements.1,2 Of all orofacial clefts, cleft palate (CP) is the most common (59% to 72%), and cleft lip and palate (CLP) is the least common (12% to 15%).3,4 The American Veterinary Dental College classifies CP as a congenital defect of the midline of the hard and soft palate. Other congenital orofacial clefts are cleft lip (CL; longitudinal defect of the upper lip with or without alveolar cleft and defect in the most rostral part of the hard palate) or CLP (defect in the lip, alveolar bone, and hard and soft palate).5 A soft palate cleft is a defect in the midline of the soft palate, or it is situated unilaterally due to a lack of fusion of the soft palate with the pharyngeal wall.6–9 Soft palate hypoplasia is a congenital decrease in the length of the soft palate. Both bilateral soft palate cleft and soft palate hypoplasia usually manifest as a rudimentary uvula-like soft tissue structure in the midline that is laterally flanked by short clefts.7
From a practical standpoint, a full description of the cleft is necessary to plan surgical repair. Nomenclature systems describing the regions affected in dogs (such as the LAHSHAL or numeric systems) do not account for the width and shape of the defect and availability and quality of surrounding tissues, which is crucial information for surgical planning.4,7,10 Complete or incomplete defects (whether or not the full length of the structure is affected) can also be differentiated. In humans, microform (presence of a defect in the oral mucosa but not in the underlying bone or musculature) and submucosal defects (oral mucosa is intact, but there is a defect in the bone or musculature) have important clinical implications in children (speech development).4,7,11 It is likely that these cleft variations are also present in dogs, but they may not be recognized or treated in the absence of clinical signs.
Brachycephalic dogs and breeds belonging to the Mastiff/genetic cluster (eg, Boston Terrier, English and French Bulldog, Labrador Retriever, Yorkshire Terrier, Bullmastiff, Golden Retriever) have a higher risk of developing orofacial clefts.3 As the etiology of the cleft seems to be multifactorial with environmental and genetic factors involved in its manifestation, the clefts may present in any type of dog despite it genetically having a low risk.
While the number of articles published in dentistry and oral surgery have increased in the last 10 years, papers11–13 related to CP management in dogs remain within the categories of low evidence–based studies (case reports, expert opinions, and case series). The present paper aims to review the clinical approach to patients with CP and its management based on previous literature. We added our current approach to surgical management to guide the decision-making process for the reader. A detailed description of the etiology and embryologic development of orofacial clefts is beyond the scope of this review, and the reader is referred to recent literature on that topic.13–20
Management of the Puppy from Birth to Surgery
Cleft lip, CP, and CLP can be easily recognized at birth. The relative size of the cleft (size of the cleft in relation to the full width of the palate) changes as the puppy ages. A study21 conducted in a group of Old Spanish Pointer Dogs showed that the cleft becomes larger during the first 5 weeks of age. Between 5 and 12 weeks of age, the defect becomes proportionally smaller due to growth of the medial part of the palatine shelves (palatine processes) of the maxillae. Then, up to week 20, the cleft becomes larger again because the growth of the palate cannot keep up with the overall growth of the head, and after that time (> 5 months), the growth of the head slows down, and the cleft remains stable.21 Clefts of the soft palate may only be visible with the patient under sedation or anesthesia.6,8 Abnormal development of the soft palate should be considered in young patients with a history of aspiration pneumonia or nasal discharge.
Common clinical signs in affected puppies are foamy nasal discharge during feedings, lack of thriving, difficulty breathing, and increased respiratory effort if the puppy develops aspiration pneumonia. Puppies will likely die if they are not removed from the mother and have assisted feedings. Clinical signs vary and may change during the growth of the puppy. Cleft lip only may not show clinical signs. However, accumulation of food and debris within the cleft may cause inflammation of the surrounding soft tissues and foul odor, in particular when foreign bodies accumulate in the nasal cavity. Cleft palate and CLP usually are more of a concern due to the risk of coughing, gagging, dislodgment, and aspiration of food and fluids inside the nose. Due to the inquisitive and playful behavior of the puppy, it is not unusual to find foreign material in the nasal cavity.8,20,22 In addition to an orofacial cleft, patients may have a syndromic form with the presence of other congenital malformations that could be life threatening.1,2,15,23
The goal is to syringe feed the puppies during the first weeks of life until they can be weaned off of the formula and transitioned to hard kibble or other textured food. Nasoesophageal or orogastric feeding tubes are the most common methods used until they can eat solid foods. Fabrication of a custom-made temporary palatal prosthesis to be placed in the mouth during feedings has been described.24,25 One method seems to be most applicable in clinical practice,24 where the prosthesis is custom made with thermoplastic mouthguards that can be purchased in pharmacies. The mouthguard is softened in warm water, and a piece is cut to mold and adapt to the shape of the palate of the puppy. It can be reshaped as many times as needed to obtain the perfect match for the palate.24 Once the prosthesis is finalized, it is placed in the mouth of the puppy during feedings. A new prosthesis is made every 2 weeks to fit the growth of the puppy. Then, the puppy is transitioned from a liquid formula to a relatively large kibble by 3 to 4 weeks of age, when the deciduous teeth are present in the mouth. Clients have successfully fed food incorporated in gelatin cubes that can be cut to sizes larger than the width of the defect. Other adaptations are feeding in an elevated position of the head and use of rabbit water bottles. Rarely, the patient will need an esophagostomy tube pre- or postoperatively.
Preparation for Surgery and Timing
Surgical repair is performed to avoid the dislodgment of food into the nasal cavity/nasopharynx and prevent (as much as possible) chronic rhinitis and aspiration pneumonia. Cleft lip repair may not be necessary unless there is an alveolar cleft that reaches into the rostral most aspect of the hard palate (between incisor teeth and incisive papilla).8,15 Restoration of the floor of the nasal vestibule and closure of the defect of the alveolar and palatal cleft may be sufficient.
Surgery has been reported in puppies as young as 8 to 10 weeks of age, but palate defect repair before that may be related to more complications due to the small size of the patient, friability of delicate tissue, relative wider cleft at that age, growth restriction after elevation of mucoperiosteal flaps and bone exposure, and anesthetic considerations in pediatric patients.26,27 The recommended age for surgery is 4 months or older, but other factors such as overall health status of the patient, size/width of the cleft in relation to the palate, soft tissue available to close the defect, presence of deciduous and permanent teeth in the surgery site, areas of tension and ability to close the defect without tension, and vascularity of the tissues and flaps also influence the exact timing of palate defect repair.7,8,11,15 If the defect is too large to be repaired with the standard techniques and larger flaps are needed, surgery may be delayed until all the permanent teeth have erupted (7 to 8 months of age).7,8,15,22
A CBC count and serum chemistry screen and thoracic radiographs should be performed to determine overall anesthetic fitness and rule out preoperative aspiration pneumonia. In addition to CP, other maxillofacial malformations could be present.7,8 Dental radiography and CT will provide information about the presence of dental and skeletal malocclusion, size and location of the palate defect (soft tissue defect and bony defect), insufficient development of the nasal cavity (turbinates, vomer), hypoplasia of the tympanic bullae, and middle ear pathology.15,23,28,29 Contrast imaging with conventional CT can also add valuable information about infection/inflammation of the respiratory tract or the presence of an oronasal fistula (ONF) after previous CP surgery.23
A visual and palpatory evaluation of the palate defect and adjacent tissues is most critical to decide which surgical technique for repair should be employed.8,11 The soft tissue defect is always smaller than the bony defect.23 Due to the incomplete formation of the palatine fissures, the area with the proportionally widest defect in relation to the entire palate width is commonly localized at the level of the canine and premolar teeth.21 Unfortunately, this also tends to be the area with more tension (caudal to the incisive papilla) and potentially reduced vascularity (edge of the flaps). Dental occlusion and possible postoperative trauma of the flaps by opposing teeth should be considered, especially in the area of the canine and incisor teeth. Strategic extraction or crown reduction with vital pulp therapy of canine teeth may be necessary to avoid trauma and wound dehiscence during the healing period.
Surgical Management
The patient is positioned in dorsal recumbency, although some authors prefer positioning in sternal recumbency for surgery of the lip (CL).7,15,30 Before starting the procedure, copious rinsing of the nasal/nasopharyngeal and oral/oropharyngeal passages with lactated Ringer solution and 0.05% chlorhexidine is performed to remove mucoid discharge, food, and other foreign material. A pharyngeal pack is placed in the back of the mouth to avoid carriage of fluid into the trachea despite having an endotracheal tube with an inflated cuff in place.8 Bilateral maxillary nerve blocks are used during the procedure and can be repeated before recovery from anesthesia.31,32 The use of liposomal bupivacaine may reduce postoperative analgesic requirements.33 However, depending on the severity of the cleft and techniques used for repair, nerve blocks may not be fully sufficient for analgesia of soft palate surgery.31 Antiemetics such as metoclopramide, maropitant, and ondansetron and gastric protectants are usually added perioperatively.34–37 Blood transfusion may be necessary intra- or postoperatively.7,8
Many of the clefts affecting the hard and soft palate can be repaired with standard techniques. The Von Langenbeck technique (VLB; also called bilateral bipedicle flaps or medially positioned flaps), bilateral pedicle flaps (BPF), or an overlapping flap tucked under an envelope flap is routinely used to close the hard palate defect. BPF is traditionally indicated for narrow defects, and the overlapping flap is indicated for wider defects. However, there are no objective guidelines of what is narrow or wide, and ultimately, their use depends on the surgeon's preference and decision on whether the defect can be covered with any of these flaps (Figure 1).7,8,11,22
Decisional algorithm for repair of orofacial clefts based on the authors' opinion. AdvF = Advancement flap. BPF = Bilateral pedicle flaps. CL = Cleft lip. CLP = Cleft lip and palate. CP = Cleft palate. HP = Hard palate. OVF = Overlapping flap. SP = Soft palate. TranspF = Transposition flap. VLB = Von Langenbeck technique (bilateral bipedicle flaps). XSS = Tooth extractions.
Citation: Journal of the American Veterinary Medical Association 261, S2; 10.2460/javma.23.06.0330
For the Von Langenbeck technique, lateral full-thickness mucoperiosteal incisions are created 1 to 2 mm palatal to the dental arch. These lateral incisions may extend rostrally up to the level of the third incisor teeth and caudally up to the most caudal aspect of the hard palate, without extending into the soft palate mucosa. Incisions are also made at the defect edges from the incisive papilla up to the caudal aspect of the soft palate defect (usually at the level of the caudal pole of the palatine tonsils). In very narrow defects, they may be made about 2 mm away from the defect edges so that the palatal mucosa can be elevated and hinged to be sutured in the midline creating a first layer. Mucoperiosteal flaps between the defect and lateral incisions are then elevated from the bone without damaging the major palatine arteries. Critical points are the exit of the major palatine artery at the major palatine foramen (approximate level of the fourth premolar tooth) and the incomplete palatine fissures (approximate level of the canine tooth). Because the bony defect is wider between the canine teeth, partial thickness incisions should be made with utmost care in this area to avoid accidental penetration into the nasal cavity.20,38 Accessory palatine arteries emerge caudal to the major palatine foramen, which, if possible, should also be preserved. If tension is noted in the most rostral area, the lateral incisions and incisions at the defect edges can be connected to create BPFs. Removal of the incisive papilla may be necessary to achieve better apposition of the flaps. A 2-layer closure is made, when possible, by suturing the nasal and oral mucosa or by suturing the connective tissue of the mucoperiosteum in 1 layer (horizontal mattress) and the oral mucosa in another layer (simple interrupted). One suture layer (vertical mattress or simple interrupted) and only 1 oral mucosa layer (with no nasal mucosa layer) have also been reported with a good outcome (Figure 2).11,22
Cleft hard and soft palate in a 4-month-old English Cocker Spaniel repaired with the Von Langenbeck technique (bilateral bipedical flaps). A—The planned incisions were marked with a surgical marker pen. B—The nasal layer is partially closed with simple interrupted 4-0 poliglecaprone 25 sutures in the area of the greatest width of the defect after minimal hinging of palatal mucoperiosteum. The incisive papilla is retracted rostrally with stay sutures to facilitate closure of this first layer. C—The 2 bipedicle flaps were elevated, medially positioned, and sutured over the first layer. The lateral aspect of the flaps was loosely sutured to the gingiva for better stabilization. The soft palate cleft was closed with medially positioned flaps. D—The new caudal edge of the soft palate should be located at the level of the caudal pole of the palatine tonsils.
Citation: Journal of the American Veterinary Medical Association 261, S2; 10.2460/javma.23.06.0330
The overlapping flap technique has been historically indicated for wider defects and with the intention of larger connective tissue surfaces coming in contact with each other and creating a suture line that is supported by bone.6–8,20 An envelope flap is created on one side of the defect, elevating the mucoperiosteum to create an approximately 5- to 10-mm pocket between the bone and the mucoperiosteum. On the other side, an incision is made about 1 to 2 mm away from the dental arch and connected to the defect edge with 2 perpendicular incisions at the rostral and caudal aspect of the hard palate defect (caudal extent may be modified depending on the width of the defect and mucosa available). The mucoperiosteum is elevated toward the defect, ensuring that the major palatine artery and the nasal mucosa at the defect edge are not injured. Once elevated, the overlapped flap is tucked under the envelope flap. Because the defects may be parallel, oval, divergent, or pyriform,4 the incisions should be carefully designed to avoid an excessively wide flap caudally. Attention must be paid to the rostral incision to obtain a good overlap in the incisive papilla area. Insufficient overlapping with minimal connective tissue contact and injury to the mucosa at the defect edges or the nasal mucosa in the incompletely developed palatine fissure region will likely cause a permanent defect. The flaps are apposed with 4-0 horizontal mattress sutures and alternating simple interrupted 5-0 sutures at the edge of the envelope flap. Visualization of the arteries is important to avoid their incorporation into the suture line. It takes about 3 to 4 weeks for denuded bone and exposed connective soft tissue (including the major palatine artery) of the overlapped flap to be covered by granulation tissue and epithelium. This technique will not work if the defect were as wide as the tissue available for flap creation.11 A combination of the overlapping flap with an envelope flap (after a lateral releasing incision) or a pedicle flap on the other side that is moved further medially may provide full coverage of the defect (Figure 3).8
Cleft hard and soft palate in a 4.5-month-old Great Dane repaired with an overlapping flap technique. A—The planned incisions were marked with a surgical marker pen (overlapping flap on the left side, envelope flap on the right side). B—The overlapping flap was elevated, preserving the major palatine artery (which exits the major palatine foramen at the level of the deciduous maxillary fourth premolar tooth and continues rostrally at the underside of the flap). An accessory palatine artery is visible caudal to the major palatine artery. Stay sutures were used to manipulate the flap. C—The envelope flap was converted into a pedicle rotation flap in its rostral half to obtain better coverage caudal to the incisive papilla and at the level of the incompletely developed palatine fissures. D—The soft palate was closed in 3 layers (nasopharyngeal, muscular, oropharyngeal); image shows nasopharyngeal mucosa sutures. E—Final view of the repaired cleft palate. The overlapping flap is tucked underneath the pedicle flap with horizontal mattress sutures. Tincture of myrrh and benzoin was applied as wound protectant. F—Final closure of the soft palate cleft.
Citation: Journal of the American Veterinary Medical Association 261, S2; 10.2460/javma.23.06.0330
For large defects that cannot be repaired with standard techniques (and small modifications as described above), more complex procedures have been described. Selective extraction of teeth in 1 or both maxillary quadrants may be performed during the first anesthetic session about 6 to 8 weeks before definitive palate defect repair. Then, 1 or 2 buccal-based advancement flaps (composed of buccal mucosa, alveolar mucosa, gingiva, and palatal mucoperiosteum) alone or in combination with 1 or 2 underlying overlapping flaps of palatal mucoperiosteum can be made (Figure 4).6,39 Harvesting buccal-based advancement flaps will change the conformation of the upper lip and cheek, reducing the depth of the oral vestibule. Occlusal trauma from mandibular teeth to the flaps can be managed by means of extraction, odontoplasty without pulp exposure, or crown reduction with endodontic treatment. The musculocutaneous superior labial axial pattern flap includes mucosa of the upper lip and the orbicularis oris muscle.40 The pedicle remains attached to the caudal mucosa of the oral cavity and has the length of the upper lip. Once elevated, the flap is transposed over bilaterally overlapped flaps. Extraction of the maxillary molar teeth may be necessary to avoid self-trauma during mastication.40
Cleft hard and soft palate in a 1-year-old boxer repaired with bilateral overlapping flaps covered by labial/buccal advancement flaps. A—Extraction of the right and left maxillary canine, premolar, and molar teeth was performed 2 months before palate repair; note the very wide hard palate defect. B—Bilateral overlapping (hinge) flaps composed of palatal mucoperiosteum and some gingiva/alveolar mucosa were sutured in the midline to create the nasal layer. C and D—Bilateral labial/buccal advancement flaps were elevated (C; also visible is the completion of closure of the soft palate cleft) and sutured together in the midline (D).
Citation: Journal of the American Veterinary Medical Association 261, S2; 10.2460/javma.23.06.0330
The use of barrier membranes (autogenous auricular cartilage graft and allogenic fascia lata) has recently been described to cover very wide congenital hard palate defects and ONF after CP repair. This can be done in 1 anesthetic session without prior tooth extraction and decreases the risk of having residual defects in the incisive papilla area. The membranes are placed over the entire width of the hard palate and can be as long as needed to cover the defect. They are secured to the gingiva without tension before being covered by the flaps. The BPF can be used over the membranes.41
In a CP model using 6-week-old experimental puppies, the growth of bone after subperiosteal injection of hyaluronic gel containing a low dose of rhBMP-2 (0.25 mg/mL) along the defect edges was evaluated. It was demonstrated that the cleft narrowed enough to allow a relatively simple surgical closure at 10 weeks of age without the need for creating flaps. However, the application of this technique in clinical patients seems unlikely at this time.27
Clefts of the hard and soft palate should ideally be closed during the same anesthetic session. Soft palate defects may be present without a defect in the hard palate. Most soft palate defects are in the midline. Unilateral defects (due to failure of fusion of the soft palate with the pharyngeal wall) are less frequent. Special attention should be paid to the transition area between the hard and soft palate and the new caudal edge of the soft palate.7,8,11 The transition between the hard and soft palate is recognized as an area of increased tension and could be the location of a residual ONF following CP repair.22
The new caudal edge of the soft palate should be planned carefully to avoid creation of a soft palate that is too short or too long. It should be situated at the level of the caudal pole of the palatine tonsils and ideally just touch the tip of the epiglottis without extending further caudally (Figures 2 and 3).6–8 The elasticity of the soft palate mucosa facilitates closure of the defect edges with no tension. An incision along both sides of the cleft and blunt dissection to separate oropharyngeal from nasopharyngeal mucosa usually is enough to allow closure in 3 layers (nasopharyngeal, muscular, and oropharyngeal). Some authors advocate for lateral releasing incisions in the pharyngeal walls.11,22 Closure starts from caudal to rostral. Suturing the right and left levator veli palatini muscles in a slightly overlapped position is more resistant to direct pressure in the wound than apposing these muscles edge to edge.42 Another technique reported is overlapping mucosal single-pedicle flaps.43
A unilateral cleft of the soft palate can be repaired by incising the edge of the cleft and continuing the incision in the pharyngeal wall dorsal to the palatine tonsil. The new layers (nasopharyngeal, muscular, and oropharyngeal) are apposed with a simple interrupted suture pattern. The authors of the present review prefer to use mucosa of the tonsillar fold to reconstruct the soft palate. Thus, tonsillectomy is performed first with an elliptical incision in the mucosa, blunt dissection, removal of the palatine tonsil, and ligature of the tonsillar pedicle. An incision is then made in the pharyngeal wall from the tonsillectomy wound in a rostral direction and extended into the lateral and caudal soft palate edge. Closure is performed in at least 2 layers. A similar surgical technique following bilateral tonsillectomy can be used for the creation of a new soft palate in dogs with soft palate hypoplasia.8,9,20
The clinical presentation of patients with CL is very variable. The cleft may affect the lip going into the ipsilateral nostril. It can be more or less wide. There may also be an alveolar cleft (fissure in the alveolar bone) with or without a defect of the rostral most hard palate or the cleft continues midline along the entire hard and soft palate. When the alveolar bone is affected, the cleft occurs between the second and third incisor teeth, with deciduous and/or permanent incisor teeth erupting within the cleft.4 A midline CL may occasionally also be associated with a bifid nose.30 Wide CL defects cause exposure of the incisor teeth, gingiva, and labial mucosa. If mucosal desiccation occurs, patients may benefit from lip repair. Different surgical techniques extrapolated from the human literature (Z-plasty) have been described in textbooks, but their successful use has rarely been reported in client-owned dogs.26 Direct apposition of the edges of the cleft with the advancement of the oral mucosa is more commonly described.14,15,44
If the palate defect is narrow, incisions along the defect edges, extending palatal to the incisor, canine and first premolar teeth, mucoperiosteal elevation, and suturing in 2 layers (nasal and oral mucosa; a third connective tissue layer may be difficult to achieve) may sometimes be sufficient. The incisions can be extended into the alveolar cleft to use gingiva, alveolar, labial, and nasal mucosa to close the remaining defect. Extraction of deciduous and permanent incisor teeth is usually necessary because they often are situated in or may erupt into the cleft. Incisivectomy may be a reasonable option for large bilateral CL to close the resulting wound.15 A combination of the techniques described above is used to repair CLP (Figure 5).
A through C—Unilateral cleft lip and palate in a 4-month-old dog. A—Lip defect, alveolar cleft between the deciduous left second and third incisor teeth, and hard and soft palate cleft. B—The alveolar cleft and midline palate defect were repaired during the same anesthetic session. The deciduous and permanent left third incisor and canine teeth were extracted to close the alveolar cleft and rostral most hard palate with advancement flaps. Incisions were made in hard palate mucoperiosteum 1 to 2 mm away from the dental arch and at the defect edges to elevate medially positioned flaps; only the right bipedicle flap remained attached to the rostral gingiva. C—Final closure of the alveolar cleft and midline hard and soft palate defect. D through F—Bilateral cleft lip and palate in a 4.5-month-old dog. D—Labial mucosal flaps were made to facilitate extraction of the deciduous and permanent right and left third incisor and canine teeth. E—A fascia lata membrane was shaped to fit the width of the hard palate and placed onto the rudimentary palatine shelves of the maxillae; note the elevated bilateral pedicle flaps composed of palatal mucoperiosteum. F—The alveolar clefts were closed with labial advancement flaps. The pedicle flaps were sutured in 2 layers (connective tissue and oral mucosa). The membrane, visible at the releasing incisions, was sutured to the gingiva. Closure of the soft palate cleft occurred as in Figures 2 and 3.
Citation: Journal of the American Veterinary Medical Association 261, S2; 10.2460/javma.23.06.0330
Postoperative care
Oral activity should be restricted and only soft food fed for 3 to 4 weeks postoperatively. Analgesics and anti-inflammatory drugs are given for about 1 week. The puppy must not chew or grab toys or hard objects during the healing period, as wound dehiscence, perforation of the flaps, or injury to an exposed vessel may occur. Broad-spectrum antibiotics have routinely been recommended perioperatively or at discharge after palate surgery, but the authors of the present review do not routinely prescribe postoperative antibiotics in CP patients.15,22,38 A temporary prosthesis over the repaired palate to protect the suture line has been reported, but this may not be needed for successful healing to occur.45
Complications
The most frequent complication of CP surgery is ONF formation at the level of the incisive papilla or the transition of the hard and soft palate. The rate of ONF may reach 50% to 100% after the initial CP repair.11,22 Management of these residual defects may be difficult due to scar tissue formation, reduced vascularity, and limited tissue availability.7,8,11 Multiple surgeries may be needed to achieve complete closure of defects. Risk factors for developing ONF in dogs are previous surgical attempts and CP repair after 8 months of age. In addition, small-size dogs (< 1 kg) have a higher risk of an unsuccessful functional outcome (presence of ONF and clinical signs secondary to the ONF).22 The use of an auricular cartilage graft or a fascia lata membrane may decrease the incidence of rostral ONF when utilized at the initial CP repair.41
Pinpoint or very small ONF may not need to be closed if they do not cause clinical signs (sneezing after drinking/eating, chronic nasal discharge), but surgical repair of an ONF is often needed to resolve clinical signs when present. Location of the ONF may have an impact on the development of clinical signs. An ONF immediately caudal to the incisive papilla may not show as many clinical signs as one in the soft palate or at the transition between hard and soft palate where the tongue can press food and water into the nasal cavity during swallowing.7,8,11,22
Angularis oris axial pattern flaps, large buccal-based advancement flaps, and use of auricular cartilage grafts and fascia lata membranes partially or completely covered by flaps are some of the options available for repair.6,7,39,41,46 Procedures performed in areas that have been surgically manipulated previously do not always go as planned, and multiple surgical attempts may be necessary to achieve complete closure. In 1 study,22 33% of dogs had more than 1 surgery performed to repair the ONF. Palatal obturators may be used for defects located in the hard palate if surgery is no longer a viable treatment option.47
Infection is rare in maxillofacial surgery, but it may occur secondarily to a persistent palatal defect with chronic contamination of the nasal cavity.47,48 If there is an infection of the respiratory tract before surgery, it should be treated and controlled with broad-spectrum antibiotics before the palate defect repair is performed. Culture and sensitivity testing is recommended if the infection persists or does not respond to an initial course of an antibiotic or if there is a concern for resistant bacteria or possible fungal infection.
Conclusion
Management of puppies with orofacial clefts not only focuses on the closure of the defect but also on diet management and treatment of other possible maxillofacial abnormalities. Despite having a relatively high rate of ONF formation, surgical treatment usually has good to excellent outcomes if the procedures are planned carefully and executed appropriately. The authors' algorithm (Figure 1) provides a guide for the treatment of the various congenital orofacial defects in dogs.
Acknowledgments
None reported.
Disclosures
The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.
Funding
The authors have nothing to disclose.
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