Anterior Hard Palate Research Articles

Role of Oral Mucosa in the Detection of Different Sizes of Objects in a Group of Young Adults

To assess the ability of the oral mucosa (tongue, palate, and buccal mucosa) to detect objects of different sizes, the accuracy of solid object size perception was measured in 14 healthy subjects. Five different sizes of steel spheres were used as objects for oral perception. First, the subjects were instructed to assess the size of the sphere, using the tip of the tongue, anterior hard palate, and one cheek without any visual or tactile information about the size of the testing sphere, and match the perceived size with a visual reference set of spheres placed in front of them (control experiment). The same procedure was repeated after local anesthesia (LA) of the tongue (T), tongue and palate (TP), and tongue palate and cheek (TPC), respectively. Two-point discrimination was tested on the tongue before and after LA to check its effect. Results showed a significant difference between two-point discrimination tests carried out with and without LA (paired t-test, p<0.05). One way repeated measures of ANOVA showed a significant (p<0.05) underestimation of the smallest sphere size in all groups except the control, and overestimation of a large sphere size with LA of the buccal mucosa. It was concluded that perception of the smallest sphere size could be affected by LA of the tongue alone, LA of both the tongue and palate, and LA of the tongue, palate, and cheek. Perception of the large sphere size (7.1 mm) was not affected by LA of the tongue alone or LA of both the tongue and palate. However, perception of this large sphere size (7.1 mm) was affected in the TPC experiment, in which cheek sensations were also lost.

Regional regulation of palatal growth and patterning along the anterior-posterior axis in mice.

Cleft palate is a congenital disorder arising from a failure in the multistep process of palate development. In its mildest form the cleft affects only the posterior soft palate. In more severe cases the cleft includes the soft (posterior) and hard (anterior) palate. In mice a number of genes show differential expression along the anterior-posterior axis of the palate. Mesenchymal heterogeneity is established early, as evident from Bmp4-mediated induction of Msx1 and cell proliferation exclusively in the anterior and Fgf8-specific induction of Pax9 in the posterior palate alone. In addition, the anterior palatal epithelium has the unique ability to induce Shox2 expression in the anterior mesenchyme in vivo and the posterior mesenchyme in vitro. Therefore, the induction and competence potentials of the epithelium and mesenchyme in the anterior are clearly distinct from those in the posterior. Defective growth in the anterior palate of Msx1-/- and Fgf10-/- mice leads to a complete cleft palate and supports the anterior-to-posterior direction of palatal closure. By contrast, the Shox2-/- mice exhibit incomplete clefts in the anterior presumptive hard palate with an intact posterior palate. This phenotype cannot be explained by the prevailing model of palatal closure. The ability of the posterior palate to fuse independent of the anterior palate in Shox2-/- mice underscores the intrinsic differences along the anterior-posterior axis of the palate. We must hitherto consider the heterogeneity of gene expression and function in the palate to understand better the aetiology and pathogenesis of non-syndromic cleft palate and the mechanics of normal palatogenesis.

Factors Influencing the Discomfort of Intraoral Needle Penetration

This study with 24 volunteers compared the discomfort produced by needle penetration in different parts of the palatal mucosa. In addition, comparing a fresh needle to one that was used for a previous penetration in the same patient, we assessed the influence of the status of the needle on insertion discomfort during buccal mucosal penetration. The results showed that needle penetration in the anterior hard palate was more uncomfortable than in the posterior palate. Although men could not differentiate between fresh and used needles for a second buccal mucosal penetration, women reported a significant increase in discomfort with used needles.

Newly Recognized Oral Manifestations of Schimmelpenning Syndrome

Schimmelpenning syndrome (SS) is an unusual disease that is characterized by mucocutaneous, central nervous system, ocular, and skeletal abnormalities. Nevus sebaceus, usually with broad involvement of the scalp and face, represents the classic skin finding associated with SS. We report a 6-year-old female with SS who presented with a variety of oral lesions, including a number of intraosseous jaw findings that have not been previously described in patients with the syndrome. These findings include bilateral central giant cell granulomas (CGCG)—one lesion involving the left maxilla, which perforated into the soft tissues, and a second distinct lesion involving the right anterior hard palate. Both CGCGs were diagnosed at the patient's initial presentation. Although there have been 2 published reports of CGCG identified in patients with the syndrome, in both cases the occurrence of the lesion was thought to represent a coincidental finding. We argue that CGCG represents a true clinical manifestation of SS. One year later, the patient presented again, this time with bilateral maxillary expansion. Microscopic review of the surgical specimens revealed bilateral benign fibro-osseous lesions, both complicated with foci of CGCG, typical appearing complex odontomas, and multiple malformed teeth containing melanin. A hybrid adenomatoid odontogenic tumor-odontoma involving the anterior mandible was also removed at that time. The findings of pigmented teeth and a hybrid odontogenic neoplasm are novel and have not been previously reported in patients with SS. Although the genetic defect associated with SS has not been characterized, it is intriguing to speculate that a common gene may be important in the pathogenesis of tooth development, maxillofacial benign fibro-osseous disease, and CGCG.

A Case of Atypical Croup

Case Presentation A previously healthy eight‐month‐old girl was admitted to the pediatric intensive care unit at Stollery Children′s Hospital (Edmonton, Alberta) following a waxing and waning course of respiratory distress. She had initially presented 11 days earlier to the emergency room with stridor and a brassy cough, and laryngotracheobronchitis was diagnosed. Treatment with racemic adrenaline and one dose of oral dexamethasone was effective and she was discharged after overnight observation. Nasopharyngeal aspirate was negative by direct fluorescent antibody and by viral culture for influenza A and B, parainfluenza and respiratory syncytial virus. Over the next three days, the child had increasing stridor and was admitted and again treated with racemic adrenaline and a four‐day course of oral dexamethasone. She was subsequently discharged. White lesions were noted on the tongue and were treated with topical nystatin. Four days later, the child presented to the emergency room with recurrence of stridor and fever and new onset of drooling. She had a respiratory rate of 44 breaths/min, heart rate of 170 beats/min, blood pressure of 90/58 mmHg, oxygen saturation of 98% and temperature of 39.6°C. She was in moderate respiratory distress, with marked stridor. Examination of the oropharynx revealed ulcerative lesions on the anterior tongue, hard and soft palate, and posterior pharynx. Laboratory studies revealed a white blood cell count of 18.1x109/L (74% neutrophils, 23% lymphocytes and 3% monocytes). Other hematological values were normal. A laryngobronchoscopy was performed and revealed that the mucosa of the laryngopharynx was studded with discrete white lesions on a background of mucosal inflammation with severe reduction of airway calibre requiring intubation (Figure 1). The subglottis and the tracheobronchial tree were severely inflamed but had no discrete lesions.

Surgical ciliated cyst after maxillary orthognathic surgery: Report of a case

J Oral Maxillofac Surg 61:138-141, 2003

Analysis of residual saliva and minor salivary gland secretions in patients with dry mouth

The importance of oral mucosal wetness in the condition of dry mouth and the role of salivary proteins in proper oral function are acknowledged. A negative correlation between mucosal wetness and the protein concentration of residual saliva has been reported in normosalivators. Here, to examine the suggestion that a reduction in residual salivary volume leads to a concomitant elevation of its protein concentration, the amount of residual saliva and minor salivary gland secretions, and their protein concentrations, were measured in hyposalivators and normosalivator controls. A Periotron 8000 ® micro-moisture meter was used to measure the thickness of the mucosal film at six selected mucosal surfaces and the minor salivary gland secretion rate at two mucosal surfaces. The unstimulated whole salivary flow rate was measured by the spitting method. The total protein concentration of all salivary samples was measured by bicinchoninic acid assay. The hyposalivators had significantly lower amounts of residual saliva and minor salivary gland secretions than the normosalivators at all selected mucosal sites except the soft palate. In both groups, the site with the thinnest coat of residual saliva was the anterior hard palate and the wettest site was the anterior dorsal mucosa of the tongue. The protein concentration of residual saliva was significantly higher in hyposalivators than normosalivators. In the minor salivary gland secretions there was no significant difference in protein concentration between the normo- and hyposalivators. When the hyposalivators were divided into two subgroups according to their severity of dryness, the reduction of residual salivary volume and the elevation of protein concentration were more apparent in the group with the more severe dry mouth. Collectively, these results indicate that oral mucosal wetness is associated with the flow rate of unstimulated whole saliva. The function of the minor salivary glands was less affected and relatively well preserved in patients with dry mouth. The increased protein concentration of residual saliva in the hyposalivators appeared to be the result of decreased salivary volume.

Malposition of the ProSeal Laryngeal Mask

To the Editor: We read with interest the report by Brimacombe and colleagues on the malposition of the ProSeal™ laryngeal mask airway (PLMA) (1) involving the posterior folding over of the tip of the mask. The PLMA is a new laryngeal mask device with an additional drainage tube that has its distal opening at the tip of the mask (2). The report describes gastric insufflation during the use of the PLMA for an elective laparoscopic cholecystectomy. This was associated with obstruction to the passage of a gastric tube down the drainage tube of the mask and fiberoptic inspection revealed the distal mask to be folded underneath the proximal mask. We have experienced three cases where the passage of a gastric tube down the drainage tube of the PLMA was obstructed. In these placements, tidal volumes >10 mL/kg were achievable with no leakage of gas up the drainage tube. The airway seal pressure was found to be 34 cm H2O in one instance and >40 cm H2O in two others. Fiberoptic visualization and subsequent removal of the masks strongly suggested folding over of the tips of the masks that had occurred during insertion. In Brimacombe’s case the PLMA was inserted with the finger; in two of our three cases, the mask insertion was performed using the introducer. We suspected the malposition to be associated with the introducer approaching the mouth at an acute angle to the posterior oropharynx instead of the recommended technique of Fastrach™ insertion involving flattening the tip of the mask against the anterior hard palate and inserting the mask in a rotational movement (2,3). We agree that this possibility of malposition occurs, resulting in obstruction to the passage of a gastric tube. This malposition may also occur with either finger or introducer insertion and be associated with an above-average airway seal pressure. N. R. Evans, MBChB, DA S. V. Gardner, FCA (SA) M. F. M. James, FRCA, FCA(SA), PhD

Analysis of residual saliva and minor salivary gland secretions

Residual saliva and minor salivary gland secretions are important for the maintenance of oral mucosal wetness. Salivary proteins and glycoproteins are the major components of the oral mucosal film, which functions as a moisture retainer and a protective barrier. Here, the correlations between the amounts of residual saliva and minor salivary gland secretions and their protein concentrations were investigated in 30 normal healthy individuals. The thickness of the mucosal film was measured at six mucosal surfaces and minor salivary gland secretion rate was measured at two mucosal surfaces. The thickness of residual saliva was determined by placing filter-paper strips against the mucosa at each site for 5 s and then measuring the volume electronically with a Periotron 8000 ® micro-moisture meter. The unstimulated rate of minor salivary gland secretion was measured for 30 s by the same method. Unstimulated whole salivary flow rate was measured with the spitting method. The total protein concentration of all salivary samples was measured by bicinchoninic acid assay. Before the experiment, the intra-/inter-examiner reliability of the method using the Periotron and the filter-paper strips was investigated. With a range of 0.4256–0.8846, the intraclass correlation coefficient, measured within and between examiners, was indicative of good reliability. The oral mucosal site with the thinnest coat of residual saliva was the anterior hard palate. Mucosal wetness on the hard palate and buccal mucosa showed significant positive correlations with the unstimulated whole salivary flow rate and significant negative correlations with the total protein concentration of residual saliva. Mucosal wetness on the upper and lower labial mucosa also showed significant negative correlations with the total protein concentration of residual saliva. Mucosal wetness on the soft palate was correlated with the minor salivary gland secretion rate ( r=0.477, P<0.01). Among the minor salivary glands, the secretion rate of soft palate glands in females showed a significant correlation with the unstimulated whole salivary flow rate ( r=0.563, P<0.05) and a significant negative correlation with its total protein concentration ( r=−0.525, P<0.05). These data suggested that oral mucosal wetness and minor salivary gland secretions could be influenced by various factors differently according to mucosal sites.

The development of normal feeding and swallowing: Showa University study of the feeding function

Since the 1980s the Department of Hygiene and Oral Health at the Showa University School of Dentistry has focused its research efforts on the development of feeding function and disorders. In addition, we have treated dysphagic children and dysphagic elderly using our feeding training program approach. The developmental course of the feeding function includes the following steps: 1) Suckle feeding and pre-feeding period; 2) Acquiring the ability to swallow with lips closed; 3) Acquiring the ability to take food with lips closed; 4) Acquiring the ability to push mashed food with the tongue and anterior hard palate; 5) Acquiring the ability to perform mastication; 6) Beginning self-feeding; 7) Beginning finger feeding; 8) Beginning using table ware

Melanotic neuroectodermal tumor of infancy (MNTI) of the hard palate: presentation and management

Objective: To discuss the presentation and management of melanotic neuroectodermal tumor of infancy (MNTI) of the hard palate. Method: Case presentation and literature review. Case: A 6-month-old girl presented with a slow growing, non-tender anterior oral hard palate mass. Radiologic imaging revealed a well-circumscribed cystic lesion containing teeth. After excision, histopathologic and electron microscopic evaluation revealed MNTI. No recurrence was seen at 12-month follow-up. Conclusions: This case and a review of the literature reveal MNTI to be a rare, benign hard palate tumor, which may present as a smooth, firm, painless, slow-growing anterior palatal lesion. Imaging reveals a well-circumscribed cystic lesion. Complete excision should be curative. Management requires attention to the potential need for palatal reconstruction, orthodontic care and correction of secondary nasal deformities.

Palatal distraction in a canine cleft palate model.

The purpose of this study was to determine whether the canine hard palate can be lengthened by distraction osteogenesis in a cleft palate model using a mostly submucosal distractor. Five mongrel dogs were used. After raising mucoperiosteal flaps, a midline strip of bone was removed from the hard palate of each dog to simulate the bony defect seen in a cleft palate. A transverse osteotomy was then made to separate the posterior segment of the hard palate from the anterior segment. Posterior osteotomies were also made laterally parallel to the teeth so that the 2 posterior segments (one on either side of the bony cleft) were mobile. An intraoral distractor that was mostly submucosal was attached to the anterior hard palate and both segments of the mobilized posterior hard palate. Radiopaque bone markers were placed, and x-rays were obtained. After a 10-day latency period, the distractor was expanded 0.675 mm per day until it had been lengthened 10.125 mm. Distractors were left in place for an additional 8 weeks. After distractor removal, animals were observed for an additional 8 weeks before euthanization. Follow-up x-rays and histologic examinations were performed. New bone formation was found at the site of distraction in all dogs at the time of death. This new bone was seen on the follow-up x-rays and on histologic examination of the hard palates using both hematoxylin and eosin staining and Masson's trichrome stain. Distraction osteogenesis using a mostly submucosal device is an effective technique for lengthening the hard palate in a canine cleft palate model. The technique may eventually provide an alternative treatment for velopharyngeal incompetence in humans that is more precise and involves less morbidity than existing treatments.

New Buccinator Myomucosal Island Flap: Anatomic Study and Clinical Application

The authors studied the vascular anatomy of the buccinator muscle by dissecting fresh cadavers. The anatomy of the buccal branches of the facial artery consistently confirmed the existence of a posterior buccal branch, a few inferior buccal branches, and anterior buccal branches to the posterior, inferior, and anterior portions of the buccinator. The buccal artery and posterior buccal branch anastomose to each other and ramify over the muscle. Several veins originate from the lateral aspect of the muscle, converge into the buccal venous plexus, and drain into the facial vein (from two to four tributaries) or into the pterygoid plexus and the internal maxillary vein (from the buccal vein). These vessels and nerves enter the posterior half of the buccinator posterolaterally. The facial artery and vein are located at variable distances from each other around the oral commissure and the nasal base. Two patterns of buccinator musculomucosal island flaps supplied by these buccal arterial branches are proposed in this article. The buccal musculomucosal neurovascular island flap (posteriorly based), supplied by the buccal artery, its posterior buccal branch, and the long buccal nerve, can be passed through a tunnel under the pterygomandibular ligament for closure of mucosal defects in the palate, pharyngeal sites, the alveolus, and the floor of the mouth. The buccal musculomucosal reversed-flow arterial island flap (superiorly based), supplied by the distal portion of the facial artery through the anterior buccal branches, can be used to close mucosal defects in the anterior hard palate, alveolus, maxillary antrum, nasal floor and septum, lip, and orbit. The authors have used the flaps in 12 patients. There has been no flap necrosis, and results have been satisfactory, both aesthetically and functionally.

Intraocular and Intraorbital Compartment Pressure Changes following Orbital Bone Grafting: A Clinical and Laboratory Study

Visual loss is an uncommon but catastrophic complication after intraorbital bone grafting for the reconstruction of acute traumatic defects or long-standing enophthalmos. Increased intraocular or intraorbital compartment pressure may be pathogenic in this setting. A two-part study was designed to test the null hypothesis that intraocular and intraorbital compartment pressure values remain constant despite orbital volume reduction with graft material. Laboratory study: Intraocular and intraorbital compartment pressures were measured during sequential orbital volume reduction in New Zealand White rabbits that had been randomized to one of three groups: intact orbits (n = 10), acute orbital wall defects (n = 8), and chronic (3 months) orbital wall defects (n = 11). Intraocular pressure was significantly (p<0.05) elevated in all three groups of orbits undergoing orbital volume reduction compared with control, nonoperated orbits. Intraorbital compartment pressure values did not change significantly from control levels throughout the grafting sequence. Although no significant differences existed between groups in the maximum levels of intraocular pressure attained, the chronic group demonstrated a greater rate of rise and slower rate of decline. Clinical study: Using applanation tonometry, intraocular pressure was measured before and serially after orbital floor exploration and intraorbital placement of split calvarial bone grafts in 19 patients who presented with orbital-zygomatic complex fractures that required surgery. A separate group of 16 patients with orbital-zygomatic complex fractures that required exploration of the orbital floor but not bone grafting was used for comparison. A significant (p<0.05) elevation of intraocular pressure was observed immediately after bone grafting compared with nongrafted orbits, but values returned to normal within 30 minutes and remained stable through the third postoperative day. There were no cases of visual impairment in any patients in either group as the result of surgical treatment. These data indicate that orbital volume reduction with graft material results in significant, temporary elevation of intraocular pressure. No significant elevations of intraorbital compartment pressure were detected in the rabbit orbits. Data from this study may have direct relevance in defining guidelines for "tolerable" changes in orbital tissue and globe pressures after surgery.

The Goslon yardstick applied to a consecutive series of patients with unilateral clefts of the lip and palate.

First described in 1987, the Goslon yardstick has been used since as a reliable and reproducible means of measuring dental arch relationships and, therefore, the quality of facial growth. The dental study models of a group of 32 consecutively treated patients with unilateral clefts of lip and palate, from the Frenchay Hospital, Bristol, U.K., were analyzed using the Goslon yardstick. More than 50% of the sample were in the unfavorable Goslon groups IV and V. Because of these results, we at Frenchay Hospital now base our related surgical procedures on the early vomerine closure of the anterior hard palate without nasal or alveolar repair at 3 months, followed by primary hard and soft palate closure at 6 months.

Unusual leiomyomatous hamartoma of the hard palate: A case report

Harmartomas of the head and neck are common lesions, often taking the form of melanocytic nevi or vascular malformations such as hemangiomas and lymphangiomas. Hamartomas composed of other tissue types are much rarer and within the oral cavity are usually located on the tongue near the foramen cecum or on the anterior hard palate near the incisive papilla. Although most occur as isolated phenomena, a small number may be associated with other local developmental defects or with a syndrome complex. A normal 5-year-old girl had a 1 cm soft sessile swelling in the vault of the hard palate on the left side. Histopathologic examination showed bundles of smooth muscle embedded in fibrovascular stroma and accompanied by abundant mature fat and a small amount of salivary tissue. The features were regarded as those of a leiomyomatous hamartoma and could be distinguished from a smooth-muscle tumor, teratoma, and benign mesenchymoma by virtue of the clinical and histopathologic features. No recurrence has been seen after excision.

Sensory and pain thresholds to orofacial argon laser stimulation in patients with chronic burning mouth syndrome.

Psychophysical assessments of orofacial sensory function were performed in order to investigate neurophysiological aspects of the burning mouth syndrome (BMS). Sensory and pain thresholds to brief argon laser stimulation were determined on six test regions, which included the tip of tongue, the lower lip mucosa and skin, the buccal mucosa, the anterior hard palate, and the dorsum of the hand. The experimental examination was performed at the Pain Clinic Unit at the Royal Dental College. Twenty-three elderly denture-wearing patients diagnosed as suffering from BMS were studied, and a control group included 23 age-, sex-, and denture-matched subjects. The obtained thresholds were compared between groups. Sensory thresholds were significantly higher and ratios between pain and sensory thresholds significantly lower in patients with BMS on all the tested regions. Pain thresholds were significantly elevated on the lower lip skin, the anterior hard palate, and the hand in patients with BMS. At sensory threshold level, a faint pinprick perception was often reported by patients with BMS contrary to a perception of warmth described by control subjects. The intraregional variations in sensory and pain thresholds on the hard palate, the lower lip mucosa, and on the skin were similar in both groups, but differences occurred in sensory thresholds on the tongue in patients with BMS. The presence of abnormal prepain perceptions and disturbances in the perception of nonnociceptive and nociceptive thermal stimuli applied on both pain-affected and normal regions suggest a perceptual deficit unrelated to specific pathophysiological mechanisms in BMS. However, it appears that a psychological explanation of BMS should be used cautiously, as the present results suggest alterations in sensory function.

Improved Primary Surgical and Dental Treatment of Clefts

The improved combination of surgical and dental teamwork in the primary treatment of clefts presented here is consistent with principles. In fact, this is a staged design for correction of classic clefts of the lip and palate that, based on biological principles, facilitates the continuance of the failed embryonic "migrations" toward a normal end point. Positioning of the alveolar segments, dissection of mucoperiosteum out of the cleft, and union of mucoperiosteum across the alveolar and anterior hard palate cleft make it possible to create a periosteal tunnel across the bony gap and set up a condition conducive to bone formation and eventual tooth eruption in the cleft area. Lip closure by adhesion reduces the tension of the primary lip closure and allows gentle molding until solidification of the arch occurs. Thus a complete cleft has been rendered an incomplete cleft. With a balanced, stabilized maxillary platform, the definitive lip and nose corrections can be carried to completion early (by 2 to 4 years of age). These planned actions bypass a persistent cleft, fistulas, raw areas, malposition of alveolar segments, and probably the necessity for later bone grafting. The only question not totally answered is the effect of this approach on final growth. Although most reports seem to indicate that growth has and will proceed within normal limits, another 10 years of careful follow-up is indicated and, in fact, is in progress.

One-Stage Closure of the Entire Primary Palate

Timing of the closure of the anterior palate and alveolus is a subject of debate. Late repair of this defect is complicated by high fistula formation and subjects the patient to the problems of palate fistula for extended periods of time. We have utilized a single procedure performed when the child is 3 months of age that completely closes the anterior hard palate and alveolus along with the cleft lip. Our series consisted of 61 consecutive patients with unilateral clefts of the primary and secondary palate. Mucosal turnover flaps from the vomer along with lateral nasal mucosal flaps provide the nasal lining. A buccal sulcus flap with a Veau flap completes the oral repair. Ninety-five percent (58 of 61) of the patients had complete and stable closure of their anterior palate and alveolus after 1 year. The incidence of fistula formation in our series (3 of 61) is much lower than that reported with the utilization of other protocols. Excellent exposure of the anterior palate and alveolar defect during lip repair, early restoration of anatomic relationships, establishment of a good nostril floor and sill, and very low fistula formation are among the benefits of this procedure. The increase in operative time is considered minimal in light of aforementioned advantages.

Use of a buccal musculomucosal flap to close palatal fistulae after cleft palate repair

Forty-two patients aged 4 to 13 (mean 7 years) had palatal fistulae closed with a buccal musculomucosal flap. The pedicle was divided approximately 2 weeks after the initial operation. Complete closure at the first attempt was obtained in 69% of the cases though, when the fistulae were large and extended to the anterior hard palate, the results were not as good (36%). Almost no detrimental after-effects occurred at the donor site. The buccal musculomucosal flap was found to be a useful alternative to a tongue flap.