LatarBelakang:Sumbingbibirdan/ataulangit-langitadalahkelainankongenitalkraniofasialyang palingseringterjadi.Denganangkaprevalensi1setiap700kelahiran.Pasiendengansumbingbibirdan/ataulangit-langitpadaumumnyamemilikihigieneoralyangburukdanangkaprevalensikariesyang tinggi.Halinidapat terjadikarenakontrolplakyangsulitdicapaipadapasiendengankelainanpadagigi danadanyadefekpadabibirsertapalatum.Fistelpalatumadalahkomplikasiyangdapatterjadisetelah operasisumbinglangit-langit.Penelitianinibertujuanuntukmenemukankorelasiantarafstelpalatum dan karies dentis.PasiendanMetode:Subjekpenelitianadalahpasiendenganpalatoschiziskomplitunilateraldirumah sakitCiptoMangunkusumo,rumahsakitAdamMalik,padaperiodeJuli2012hinggaMaret2013.Pada semuakasusdilakukanoperasimodifedtwofappalatoplastydandilakukanfollow-updalamwaktu3-4 minggu untuk mengetahui ada tidaknya fstel.Hasil:Tigapuluhdelapanpasiendenganpalatoschizis komplitunilateraldiikutsertakandalampenelitian ini.Limabelas pasien(39.5%)adalahlaki-lakidan23pasien(60.5%)adalahperempuan.Enam(40%) dari limabelas pasienyangdidiagnosakaries dentis, mengalami fstel padasaat pemeriksaanfollow-up setelah operasi. Tidak ada pasien (0%) dengan fstel dari 21 pasien (58.3%) tanpa karies dentis.Kesimpulan:Kariesdentisadalahsalahsatufaktorpredisposisifstelpalatumpadapasienyang menjalani operasi palatoplasty. Kata Kunci: Palatal fstula, dental caries, cleft palateBackground:Cleftlip and/orpalate(CL&/P)isthemostcommoncongenitalcraniofacialabnormality, affectingapproximately1inevery700newborns.Patientswithcleft lip and/orpalate(CL&/P)generally displaypoororalhygiene and ahigherprevalenceof caries. This maybedueto thediffcultyin achieving adequateplaquecontrolassociated withdentalanomalies and defectsfromthelips and/orpalate.Palatal fstulaisasignifcantcomplicationfollowingcleftpalaterepair.Itistheaimofthisresearchtofnd correlation between palatal fstula and dental caries.PatientandMethod:PatientswithunilateralcompletecleftpalatesadmittedtotheCipto Mangunkusumohospital,AdamMalikhospitalwithintheperiod July2012tillMarch2013wereincluded inthisstudy.Allcasesunderwentmodifedtwofappalatoplastyleavinglateralperiosteumtechnique andfollow-up were done in two weeksto see if there are any palatal fstula.Result:Thirty eight patients with unilateralcleft palatewereenrolled inthe study.Fifteen(39.5%) ofthem areboysand 23(60.5%)aregirls. Fifteenofthepatients(41.7%) haddentalcaries,withsixpatients (40%) had palatalfstulainthefollow up afterpalatoplasty,whiletherewasnone(0%) ofthe21(58.3%) patients that were found negative for dental caries developed a fstula.Conclusion:Dentalcariesisoneoftheimportantpredisposingfactorsofpalatalfstulainpatientswho undergo palatoplasty.Keywords: Palatal fstula, dental caries, cleft palateDefry Utama, Frank Buchari, Gentur SudjatmikoJakarta, Indonesialeftlipand/orpalate(CL&/P)isthe mostcommoncongenitalcraniofacial abnormality,affectingapproximately1 inevery700newbornsintheUSA.1Patients withcleftlip(CL),cleftpalate(CP),orboth (CL&P)generallyrequireextensivetreatment byaninterdisciplinaryteamofmedicaland dentalspecialiststorectifytheircosmetic, speech,hearing,psychosocial,anddento-The Incidence of Palatal Fistula Postpalatoplasty in Children with Dental Caries: A Multi Centre Study!"#$%&'#!%#(Disclosure:Theauthorshavenofnancial interest todeclare in relation to the contentof this article.www.JPRJournal.com78!From the Division of Plastic Reconstructive and Aesthetic Surgery, Department of Surgery, Faculty of Medicine Universitas Indonesia, Cipto Mangunkusumo Hospital, Jakarta, Indonesia.Presented in the 17th IAPS Scientifc Meeting, Bandung, West Java, Indonesia.Received: 20 May 2013, Revised: 10 June 2013, Accepted: 15 June 2013. (Jur.Plast.Rekons. 2013;2:78-83)orthopedicproblems.Itisessentialto maintain excellentoralhealthandpreventdentaldecay, unfortunately,themajorityofstudieshave shownthatpatientswithCL/Pexhibitpoor oralhygieneandahighercariesprevalence.2 Thismaybeduetothediffcultyinachieving adequateplaquecontrol associatedwithdental anomaliesanddefectsfromthelipsand/or palate.3Dentalcariesisanoraldiseasethat leadstotoothcavities.Cavitiesresultfromthe lossofmineralsfromthetooth,causedbythe acidsproducedbybacteria.Researchsuggests thatdentalcariesisatransmissibleinfectious diseasethatcanbeprevented,andthatthe presenceofcavitiesisonlythemostnoticeable signofthedisease.Thebacteriathatcause dentalcariesandcavitiesaccumulatearound andbetweentheteeth,formingwhatiscalled dentalplaque.4Frequentingestionofsweets andlow salivafow also favor thedevelopment ofcavitiesinthepresenceofdentalplaque. Cavitiesmaysometimesresultinthetooth beingsensitive.Dentalcariesresultsfrom dentalplaque(bacteria)beingpresentinand aroundteethforextendedperiodsoftime. Someconditionsincreasethechancesfor cavitiestodevelop,suchasthefrequentintake ofsweets,adrymouth,andpoororal hygiene. Cavitiescanbeprevented,butoncepresent theyneedtobeflledtostoptheirprogression andtorestorethetoothtoitsnormalcontour and function.5 Patientswithoralcleftshavebeen reportedinseveralstudiestohavepooreroral hygiene when compared withnoncleft patients.6Thehigherincidencesofsupernumeraryteeth andthelimiteddentalarchspaceattributedto theunderdevelopedmaxillamayleadto malalignmentofteethintheCL&/Ppatients. Crowdingcausesrestrictedaccessforthe toothbrushandthenaturalcleansingofthe teethbythetongueandsaliva.7Therefore,the oral hygiene in these patients is compromised.Oralcleftchildrenfromfamilieswith lowsocioeconomicusuallyshowpoororal hygieneanddietaryhabits.Parentsinhigher social classesare more likely to comply with the nutritionrecommendations.10Parentsalso tendedtooverindulgetheirchildrentooffer somesatisfactionbecauseoftheirchildrens medicalconditions.Thismeansthattheymay providetheirchildrenwithinappropriatediets thatareconducivetocariesdestruction.7 Therefore,limitedparental understanding ofan appropriatedietaryhabitandadequateoral hygieneofthesechildrenwithCL&/Phasthe potentialtocontributetothehighercaries prevalence.11Themostimportantoutcomesafter palatoplastyaremeasuredintermsofspeech, feeding,maxillarygrowth,andhearing. Nevertheless,morethanhalfofpostoperative causesfstulas.12Fistulaformationisnot unc ommonc ompl i c at i onofpr i mar y palatoplasty.Theactualreportedincidenceof thiscomplicationvarieswidely,rangingfrom 0%to68%inpublishedreports.13 asurgical correctionandmorethantwo-thirdsof secondaryrepairsrequirereoperationto achievesuccessful closure.14 Itisclearthatthe preventionoffstulasisalsoanimportant aspectinthetreatmentofthecleftpalate. Palatalfstulasareoftensymptomatic, dependingonthesizeandlocationofthe fstula.Symptomsincludehypernasalityof phonationduetoaudiblenasalairescape duringspeech,leakageoffuidsintothenasal cavity,andlodgingoffoodwithriskof infection.14Althoughpostpalatoplastyfstulas mayoccuranywherealongthesiteofthe originalcleft(s),theyaremorecommononthe hardpalateandatthe junctionofthehardand softpalate.15Multipleaetiologieshavebeen proposedfortheformationoffstulafollowing cleftpalaterepair:tissuebreakdowndueto tensionatthesiteofwoundclosure16 ,tension aftermaxillaryorthodontics,infection17, hypoxemia18andrarely,hematomaformation. However,itappearsthatnecrosisofthe mucoperiostealfap,usedforcleftclosure,is themostcommoncauseofsimplefstula formation,especially whenthe greaterpalatine arterieshavebeeninjured.19 Otherreports emphasizetheimportanceofthesizeandtype of original defect, whether unilateral or bilateral cleftswerepresent19,20,thetechniqueusedto closethecleft,patientsex18,andassociated anomalies.Dependingontheextentof functionalimpairment,apalatalfstulamay 79Jurnal Plastik Rekonstruksi - April - June 2013havepsychological,social,anddevelopmental consequences and should be repaired.20Itisthegoalofthisstudyto reviewthe fstula rate in correlate with dental caries.METHODThestudyisconductedincohortstudy. Thestudytakesplace atCiptoMangunkusumo GeneralNational HospitalJakartaandat Adam MalikGeneralHospitalMedanstartedonJune 2012untilJune2013.Outpatientswith unilateral complete cleftpalates,foundpositive fordentalcariesareincludedingroupAand outpatientswithunilateralcompletecleft palates,foundnegativefordentalcariesare includedingroupB.Inclusioncriteriafor subjectsareasfollows:patientswithunilateral completecleftpalate,rangingfrom1to5years old, andwilling to join the research.Subjectsare excludedfromthestudyifthepatientsare syndromic,unwillingtojointheresearchand failed to follow up.Sourceofdataisprimarydata.Data obtaineddirectlyfromresearchsubjects includingname,age,address,telephone numberanddiagnosis.Thepatientsthen evaluatedafterthesurgery.Patientsaskedto controlonthethirdday,frstweekandsecond weekafterthesurgery,andthesurgeon examinestheoccurrenceofthepalatalfstula. Patientsoralhygieneandoralintakealso recorded.Clinicalphotographyofthecleft palateandsurroundingintraoral,including teethandgingivapriortosurgery,immediate aftersurgery,thirdday,oneweekandtwo weeks after surgery are recorded. Thestudydesi gni stwo-group-prospectivestudy,comparingtheincidenceof palatalfstulainchildrenfoundpositivefor dentalcarieswithchildrenfoundnegativefor dentalcaries. The samples wereanalysedusing independentTtestandsignifcant ifthe p value isless than 0.05.The total cost ofsurgery will be analysed with x2 test. Hypothesistestinginthisstudyisdoneusing SPSS20.0totestthesignifcantdifference between the two groups.RESULTThirty-eight patientswith unilateral cleft palatewereincludedinthisstudy.Fifteen (39.5%)ofthemareboysand23(60.5%)are girls(Figure1).Themeanageofthesample was21.8monthsold,orabout1yearsand9 monthsoldwitharangeof1to 5years(Figure 2).Fifteenofthepatients(41.7%)haddental caries, withsix patients(40%) hadpalatal fstula inthefollowupafterpalatoplasty,whilethere wasnone(0%)ofthe21(58.3%)patientsthat werefoundnegativefordentalcaries developed a fstula (Table 1).Table1showsthatpatientswithdental carieshadtheriskofcomplicationafter palatoplastythatistheoccurrenceofpalatal fstulaincreaseabout3.33timesthanpatients who did not have dentalcaries prior to surgery. WeusetheFishersexacttestwithpvalue= 0.003 (Table 2).RR (Relative Risk Ratio) = 6/ (6+0)= 3,33 9/(9+21)DISCUSSIONAlthoughthe causesofpalatalfstulaas oneofthecomplicationafterpalatoplastyare vary,20thisstudyshowsthatdentalcariescleft childrenaremorepronetohavingpalatal fstulaasacomplicationafterpalatoplasty. Previousstudy byKirchbergetal.andChapple etal.concludedthatpatientswithcleftitself hadahigher dentalcariesriskcomparedtothe noncleft one.2-3It meansthat patients with cleft growriskofdentalcariesthatlaterwillgrow theriskofpalatalfstulacomplicationsafter palatoplasty.Itisimportantthatthesurgeon, the paediatrician orthe general practitioner that hadthefrsthandlingtoacleftpatient,to educatetheparentsorotherfamilymembers thatitisalsoimportantforpatientstohavean optimaloralhealth,otherthanmanagementof thediseaseanddietaryadministration. Howeverinthisstudywestillhaventgotan optimalresultssincesamplenumberaretoo smallandthe age range1 to 5yearsoldare too wideapart.Itwillbeidealifthesamplecould have been in the same range ofageto lessenthe dietary differences postoperatively. 80Volume 2 - Number 2 - The Incidence of Palatal Fistula Postpalatoplasty81!"#$%& (. Cender ulsLrlbuuon!"#$%& ). Age ulsLrlbuuonAge (months)GenderJurnal Plastik Rekonstruksi - April - June 201382Palatal Fistula PositivePalatal Fistula NegativeTotalDental Karies PositiveCount6 9 15 Dental Karies PositiveExpected Count 2.5 12.5 15.0Dental Karies NegativeCount0 21 21 Dental Karies NegativeExpected Count 3.5 17.5 21.0Total TotalCount6 30 36Total TotalExpected Count 6.0 30.0 36.0*+,-& (. Cross Labulauon of denLal carles and sLula aer palaLoplasLyValue Df Asymp. Sig.(2-sided)Exact Sig.(2-sided)Exact Sig.(1-sided) Pearson Chi-Square 10.080a1 .001Continuity Correctionb7.4061 .007Likelihood Ratio12.250 1 .000Fisher's Exact Test.003 .003Linear-by-Linear Association9.800 1 .002N of Valid Cases36*+,-& ). Chl-Square LesLCONCLUSIONCari esi soneoft hei mport ant predisposingfactorsinthepredispositionof palatalfstulainpatientswhoundergo palatoplasty.Subjectswithcleftlipandpalate aresusceptibletodentalcaries.Ontheother hand,neglecting early treatment ofdental caries maysubsequentlyleadtoahigherriskofthe incidenceofpalatalfstulaafterpalatoplasty. The author strongly advisedthe needto give an adequateinformationandeducationoncleft patientsparentsorguardiansabouthow important to maintain a good oral health.REFERENCES1. MitchellJC,WoodRJ.Managementofcleftlipand palateinprimarycare.JPediatrHealthCare. 2000;14:139.2. KirchbergA,TreideA,HemprichA.Investigationof cariesprevalenceinchildrenwithcleftlip,alveolus, and palate. 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