Case Study: Fern
Complications Associated with Facial Malformation
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Figure 1: Initial presentation demonstrating right-sided cleft lip.
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Summary: We would like to introduce you to Fern—a Pitbull puppy who was rescued by the Philly Bully Team and first presented to Veterinary Dentistry Specialists® when she was five months old to evaluate her facial malformation. Her caretakers reported difficulty eating, nasal discharge after each meal, and chronic sneezing. Initial orofacial evaluation found a cleft-like palatal defect extending from the right nostril through the soft palate, exposing the nasal cavity and nasopharynx. Fern had age-appropriate mixed dentition and malocclusion with the right maxilla displaced forward in relation to its left counterpart, but not causing obvious occlusal interference.
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Figure 2a: Right-sides nasal cleft.
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Figure 2b: Complete primary and secondary palatal cleft palate and soft palate cleft.
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A cone-beam CT scan of the head was completed to evaluate the nasal passage for patency before considering surgical correction. The CBCT imaging confirmed our clinical finding of cleft defect in both hard and soft palates creating extensive communication between the nasal cavity and the oral cavity. The cleft extended through the right lip to the corresponding nostril. Additionally, complete stenosis of the right ventral nasal meatus as well as marked bilateral mucosal edema was noted.
Figure CT: Transverse section CBCT at level of teeth 106/507 – 206/607 demonstrating complete stenosis of the right ventral nasal meatus and mucosal edema.
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Diagnosis: Complete primary and secondary cleft palate including cleft lip and cleft soft palate.
Because of her continuous discomfort while eating, chronic nasal inflammation, risk of complications related to aspiration pneumonia, and the required extensive and continuous care, finding a permanent home for Fern would have been challenging. Therefore, surgical correction was recommended.
Surgical procedure: The objective of the surgical procedure was to restore oropharyngeal function for improved food prehension and airway protection, as well as improved esthetic appearance.
While under general anesthesia teeth in the immediate proximity to the defect, including the retained permanent canine tooth, were extracted to allow better soft tissue apposition. Nasal mucosa overlying the nasal septum was incised along the midline. Both edges of the cleft palate were incised and sutured to the nasal septum tissue on the respective sides to separate the oral cavity from the right and left nasal passages. A right-sided unilateral bipedicle flap technique was performed with a palatal incision at the right maxillary arcade. The flap was displaced to the left to cover the septal incision and to provide a second layer of closure. The major palatine artery was preserved to provide blood supply to the flap. The exposed right maxillary bone was left to heal by second intention. The palatal surgery sites were sutured and closed in a simple interrupted fashion using 5-0 Monocryl.
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The soft palate reconstruction was prepared by extending the incisions along the cleft edges to the level of the rostral aspect of the palatine tonsils. The soft palate was then repaired using two-layer apposition using 5-0 Monocryl. The cleft lip and nares were reconstructed in three layers using 4-0 and 5-0 Monocryl in a simple interrupted fashion.
Figure 3: Repaired primary and secondary palate utilizing right-sided bipedicle flap using resorbable sutures in a simple interrupted pattern.
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Figure 4a: Cleft lip and vestibulum reconstruction.
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Figure 4b: Right nasal cleft reconstruction.
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Recovery from anesthesia was quick, smooth, and uncomplicated and Fern ate a small meal without notable discomfort approximately one hour after recovery. She was sent home with a short course of oral non-steroidal anti-inflammatory medication (Carprofen 4.4 mg/kg a day).
Rimadyl 25 mg: Give 1/2 tablet by mouth every 12 hours for 5 days.
At the healing recheck two weeks after surgery, Fern was comfortable and active. Her reconstructed palate has completely healed. A small area of dehiscence was noted at the right nostril. No signs of increased respiratory effort, nasal or oral discharge, or infection were recorded. Fern was able to eat comfortably.
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Figure 5: A 2-week healing recheck shows unremarkable healing of surgery sites and normal granulation tissue at exposed maxillary bone.
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Figure 6: Fern is enjoying her new loving family!
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Because of the great functional improvement, the complete healing of the soft and hard palatal cleft, and the successfully reconstructed rostral vestibulum, further restrictions were no longer necessary, and the patient was gradually returned to her normal habits, including interaction with toys and food of various consistencies.
At the time of writing, Fern is living her life comfortably with her happy new parents ten months after surgery.
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LUNCH IS ON US!
ENJOY AN ADVANCED VETERINARY DENTISTRY
& ORAL SURGERY LUNCH & LEARN
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We offer a wealth of topics – or let us know what you’d like to learn about for a customized presentation. You bring your team, we’ll bring the food – and the expertise.
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Events are available virtually, at the VDS Mt. Laurel, NJ practice, or in person (within 30 miles of Mt. Laurel.) |
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OUTPATIENT VETERINARY CARDIOLOGY SERVICES AVAILABLE IN MT. LAUREL, NJ |
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In support of our promise to provide the safest and most advanced dentistry and oral surgery for dogs and cats, veterinary cardiologist Dr. Megan King provides comprehensive cardiology services in our Mt. Laurel, NJ, location. Outpatient cardiology appointments are available Tuesday-Thursday. Patients do not need to be seeing dentistry or oral surgery to be cared for by Dr. King.
Additionally, dentistry or oral surgery patients with cardiac concerns can receive a cardiology evaluation on the day of their procedure to assess heart health [if necessary] before general anesthesia. Along with our cardiologist’s assessment, one of our board-certified veterinary anesthesiologists will design and monitor an anesthetic protocol tailored to each patient’s needs, leading to safer procedures and better outcomes.
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AAHA-Accredited Referral Practice
2061 Briggs Rd, Suite 403 | Mt. Laurel, NJ 08054
Additional Locations: Chadds Ford, PA and Katy, TX
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