Citation: Vale, F.; Pereira, F.; Saraiva, J.; Carrilho, E.; Prata Ribeiro, M.; Marques, F.; Travassos, R.; Nunes, C.; Paula, A.B.; Francisco, I. Reconstruction of Oronasal Fistula with Tongue Flap: A Cleft Palate Report. Bioengineering 2022, 9, 455. https://doi.org/10.3390/ bioengineering9090455 Academic Editors: Madhur Upadhyay and Chengfei Zhang Received: 30 June 2022 Accepted: 5 September 2022 Published: 8 September 2022 Publisher’s Note: MDPI stays neutral with regard to jurisdictional claims in published maps and institutional affil- iations. Copyright: © 2022 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https:// creativecommons.org/licenses/by/ 4.0/). bioengineering Article Reconstruction of Oronasal Fistula with Tongue Flap: A Cleft Palate Report Francisco Vale 1,2 , Flávia Pereira 1 , José Saraiva 3 , Eunice Carrilho 2,3,4,5 , Madalena Prata Ribeiro 1 , Filipa Marques 1 , Raquel Travassos 1 , Catarina Nunes 1 , Anabela Baptista Paula 1,2,3,4,5 and Inês Francisco 1,2, * 1 Faculty of Medicine, Institute of Orthodontics, University of Coimbra, 3004-531 Coimbra, Portugal 2 Faculty of Medicine, Area of Environment Genetics and Oncobiology (CIMAGO), Coimbra Institute for Clinical and Biomedical Research (iCBR), University of Coimbra, 3004-531 Coimbra, Portugal 3 Faculty of Medicine, Institute of Integrated Clinical Practice, University of Coimbra, 3004-531 Coimbra, Portugal 4 Centre for Innovative Biomedicine and Biotechnology (CIBB), University of Coimbra, 3004-531 Coimbra, Portugal 5 Clinical Academic Center of Coimbra (CACC), 3004-531 Coimbra, Portugal * Correspondence: ines70.francisco@gmail.com Abstract: Oronasal fistula can persist after conventional secondary alveolar bone graft surgery, which may lead to functional issues, such as regurgitation of fluids from the oral to the nasal cavity. This manuscript describes a clinical case of a patient with a bilateral cleft lip and palate that underwent tongue graft surgery for closure of an oronasal fistula after three failed local mucosa flap surgeries. The multidisciplinary treatment was comprised of orthodontic treatment, mucosa and alveolar grafts for palate closure and aesthetic rehabilitation of the anterior maxillary teeth. Smile aesthetics were noticeably improved, enhancing the patient’s self-perception and confidence. Keywords: aesthetics; dental restoration; cleft palate; bone transplantation; oronasal fistula; orthodontics 1. Introduction One of the most common congenital craniofacial deformities is cleft lip and palate (CLP), which affect 1 in 700 live births. The etiology of patients with CLP is multifactorial and still in study, but several genetic and environmental factors are already recognized as nefarious, such as viral infections, medication (e.g., anticonvulsants), drug use, smoking, and alcohol consumption during pregnancy. In early pregnancy, some nutritional deficits, such as folate deficiency, can also increase the risk of having a child with CLP [1]. Around the ages of 8 to 9, patients with CLP should undergo a secondary alveolar bone graft surgery before the eruption of canines or lateral maxillary incisors. This intervention will create bone support for the canine teeth, which may improve bone density maintenance in the grafted region. The bone graft will also provide enhanced support to the alar bases which in turn promotes nasal and lip symmetry, closure of the oronasal fistula, and cleft maxillary segment stabilization [2]. If, for any reason, this procedure fails, an oronasal fistula may persist due to a soft and hard tissue defect. The fistula will result in oronasal communication, which in turn can lead to abnormal speech, malocclusion, regurgitation of fluids from the oral to nasal cavities, deafness, severe facial deformity, and psychological impediments [3–5]. The local flap procedure, whilst important, may alone not be the most suitable tech- nique to attempt full fistula closure. Subsequent mucoperiosteum scarring will create tension on the local flaps, which can lead to necrosis and palate cleft dehiscence [6,7]. Clini- cal characteristics such as the presence of large defects, local scar tissue due to previous repair attempts with local mucosa flap, difficult access, and location can contribute to the Bioengineering 2022, 9, 455. https://doi.org/10.3390/bioengineering9090455 https://www.mdpi.com/journal/bioengineering