Anterior Hard Palate Research Articles

Re-Irradiation of Recurrent Buccal Mucosa Cancer Utilizing Customized Intraoral Mold-Based HDR Brachytherapy

Feasibility of re-irradiation in recurrent buccal mucosa squamous cell carcinoma after definitive external beam radiation therapy utilizing customized intraoral mold HDR brachytherapy, An 82-year-old male with a 3-year history of right buccal mucosal lesions, diagnosed as moderate dysplasia with inability to rule out invasion, was referred to radiation oncology as he was not a surgical candidate. Examination demonstrated extensive erythematous lesions involving the right oral commissure, gingivobuccal sulcus, right anterior tonsillar pillar, and soft and hard palate. He received 70 Gy in 35 fractions with a complete treatment response; however, 6 months later, he presented with stomatalgia and oral mucosa bleeding. Physical examination revealed new ulcerations of the right lower vermillion lip and exophytic plaque-like lesions along the posterior right maxillary alveolar ridge extending to the gingivobuccal sulcus and along the buccal mucosa and hard and soft palate. Biopsy of the tumor demonstrated hyperplastic squamous epithelium with mild to moderate dysplasia. Initially, the patient declined surgical treatment but returned as the tumors became more symptomatic. Subsequently, decision was made to treat with intraoral HDR brachytherapy as this was a previously irradiated field. Impressions were made and a customized mold was embedded with UV exposed low-Z shielding, which allowed for kV CT treatment planning. Eight 6-French catheters were inserted into the mold and a CT scan was obtained to determine the mold composition and needle placement. Modifications were made and a fitting test was conducted to assess reproducibility and comfort. A neck brace was constructed to secure the mold placement. Two CT simulations were obtained: one with contrast to delineate the extent of the tumor, and the other without contrast but with addition of radiopaque markers inside catheters to digitally reconstruct the source path. Rigid registration fused the two CT scans and the clinical target volume (CTV) and mandible were delineated. We prescribed 30 Gy in 10 fractions using the following criteria: CTV target, V90% ≥90% (28.6 Gy2/2) and mandible, D0.1cc < 28.6 Gy2/2 was a hard constraint. HDR plan produced a CTV V90%= 90.7%, V200% = 2.4 cc. Mandible D0.1cc received 25.9 Gy2/2. Prior to fraction 6 of 10, the plan was modified to address medial soft palate contours as a result of tumor shrinkage. Adaptive planning on new image data sets used the same criteria as the original plan. Soft palate D0.1cc was reduced by 9%. Patient completed treatment without complications or interruptions. Four months after treatment, he had no evidence of disease recurrence. This report demonstrates the design and use of non-invasive intraoral mold brachytherapy as a promising treatment modality for complex tumor recurrences within the oral cavity.

FGF8 Signaling Alters the Osteogenic Cell Fate in the Hard Palate

Fibroblast growth factor (FGF) signaling has been implicated in the regulation of osteogenesis in both intramembranous and endochondral ossifications. In the developing palate, the anterior bony palate forms by direct differentiation of cranial neural crest (CNC)–derived mesenchymal cells, but the signals that regulate the osteogenic cell fate in the developing palate remain unclear. In the present study, we investigated the potential role of FGF signaling in osteogenic fate determination of the palatal mesenchymal cells. We showed that locally activated FGF8 signaling in the anterior palate using a Shox2Cre knock-in allele and an R26RFgf8 allele leads to a unique palatal defect: a complete loss of the palatine process of the maxilla as well as formation of ectopic cartilaginous tissues in the anterior palate. This aberrant developmental process was accompanied by a significantly elevated level of cell proliferation, which contributes to an abnormally thickened palatal tissue, where the palatine process of the maxilla would normally form, and by a complete inhibition of Osterix expression, which accounts for the lack of bone formation. The coexpression of Runx2 initially with Sox9 and subsequently with Col II in the ectopic cartilaginous tissues indicates a conversion of osteogenic fate to a chondrogenic one. Consistent with the unique palatal phenotype, RNA-Sequencing analysis revealed that the augmented FGF8 signaling downregulated genes involved in ossification, biomineral tissue development, and bone mineralization but upregulated genes involved in cell proliferation, cartilage development, and cell fate commitment, which was further supported by quantitative real-time reverse transcription polymerase chain reaction validation of selected genes. Our results demonstrate that FGF8 signaling functions as a negative regulator of osteogenic fate and is sufficient to convert a subset of CNC cell-derived mesenchymal cells into cartilage in the anterior hard palate, which will have implications in future directed differentiation of CNC-derived precursor cells for clinical application.

NASOPALATINE DUCT CYST TREATMENT: REPORT OF TWO CASES

A 62-year-old male patient showed a purplish swelling in the anterior hard palate midline, measuring 1.5 cm, with pain and 40 days of evolution. CT showed a hypodense unilocular area in the incisive foramen region. A 25-year-old male patient presented a swelling in the central hard palate, with pain and 3 weeks of evolution. Radiography showed a unilocular radiolucent area with 2 cm in the anterior maxilla. In both cases, the related teeth responded to the vitality tests, the diagnosis hypothesis of nasopalatine duct cyst was proposed and needle aspiration reveals a translucent liquid. The treatment of both was surgical excision with full palatal flap and curettage. Histopathologic examination showed, in both cases, cystic capsule of fibrous connective tissue, with neurovascular bundle, lined by stratified squamous and cuboidal epithelium, establishing the diagnosis of nasopalatine duct cyst. Both patients were followed-up for 18 months with no signs of recurrence.

A retrospective study comparing the loss of anchorage following the extraction of maxillary first or second premolars during orthodontic treatment with fixed appliances in adolescent patients.

This retrospective study assessed the difference in anchorage loss using 3D superimposition of study models between cases treated with extraction of maxillary first premolars and maxillary second premolars carried out in orthodontic specialist practice. Sixty subjects who have undergone extractions of either maxillary first or second premolars as part of their orthodontic treatment were selected. Eligibility criteria included patients with a Class I, mild Class II or III malocclusions, mild-to-moderate crowding with no anchorage reinforcement. Pre- and post-treatment maxillary dental study cases were scanned using a surface laser scanner to produced 3D digital images which were superimposed using areas of stability on the anterior hard palate. Anchorage loss was measured by the mesial movement of the maxillary first permanent molar. The mean mesial movement for the maxillary first molars, when adjusted for confounding factors was 4.7 mm (SD 1.6) in the maxillary first premolar extraction group and 4.6 mm (SD 1.6) in the maxillary second premolar extraction group. There is no difference in anchorage loss when comparing the extraction of the maxillary first premolars to the extraction maxillary second premolars.

A Hypothesis and Pilot Study of Age-Related Sensory Innervation of the Hard Palate: Sensory Disorder After Nasopalatine Nerve Division.

BackgroundThe nasopalatine nerve may be injured during extraction of teeth embedded in the anterior hard palate. The neural recovery process and its impact on sensation in the anterior hard palatal region are controversial. In our clinical practice, we noticed a distinct recovery process in children compared with adolescents or adults after surgery. We hypothesized that the sensory innervations of the anterior palate might shift during later childhood and pre-adolescence, which is due to the development of the nasopalatine nerve along with the maxillary growth and permanent teeth eruption.Material/MethodForty patients (20 females and 20 males, mean age 11.8±2.2) with impacted supernumerary teeth in anterior palatine area were included into our study, and were divided into 3 groups according to their age. A 24-week follow-up was conducted and the sensation in the anterior hard palate region was examined at every check point. All the data were collected and analyzed by Kaplan-Meier analysis.ResultsFourteen children did not complain of any numbness immediately after anesthetization, and other children with sensory disorders had shorter healing periods compared to adolescent/adult patients.ConclusionsThe results indicated that the dominant nerve of the anterior hard palate region was dramatically changed from the greater palatine nerve to the nasopalatine nerve, which is important in deciding when to operate and in selection of anesthesia method.

Does altered mandibular position and dental occlusion influence upper cervical movement: A cross–sectional study in asymptomatic people

ObjectiveGross mandibular position and masticatory muscle activity have been shown to influence cervical muscles electromyographic activity. The purpose of this study was to investigate the influence of three different mandible positions including conscious occlusion, tongue tip against the anterior hard palate (Palate tongue position) and natural resting position (Rest), on sagittal plane cervical spine range of motion (ROM) as well as the flexion-rotation test (FRT) in asymptomatic subjects. Materials and methodsAn experienced single blinded examiner evaluated ROM using an Iphone in 22 subjects (7 females; mean age of 29.91years, SD 5.44). ResultsIntra-rater reliability for range recorded was good for the FRT with ICC (intraclass correlation) 0.95 (95% CI: 0.88–0.98) and good for sagittal plane cervical ROM with ICC 0.90 (95% CI: 0.77–0.96). A repeated measures ANOVA determined that mean ROM recorded during the FRT differed significantly between assessment points (F(1.99, 41.83) = 19.88, P < 0.001). Bonferroni Post hoc tests revealed that both conscious Occlusion and Palate tongue position elicited a significant large reduction in ROM recorded during the FRT from baseline (p < 0.01). Despite this, one activation strategy did not influence ROM more than the other. An additional repeated measures ANOVA determined that mean sagittal cervical ROM did not significantly vary between assessment points (F(2, 42) = 8.18, P = 0.08). ConclusionThis current study provided further evidence for the influence of the temporomandibular region on upper cervical ROM. Results suggest that clinicians should focus on the natural mandible rest position when evaluating upper cervical mobility.

Lymphohemangioma on Hard Palate: Case Report

Lymphangioma is a benign congenital malformation of the lymphatic tissue that occurs predominantly in children and clinically presents as a soft painless swelling, compressible of oral mucosa. Usually affects male individuals and the most common intraoral location is the tongue. Surgical excision is the treatment of choice and the prognosis is good. It is describes a case of lymphangioma in a non-caucasian 82 years old female. Intra-oral examination revealed the presence of reddish papules, with 0.5 cm in diameter, painless, flaccid consistency and smooth surface in the anterior hard palate. Excisional biopsy was performed and the histopathologic diagnosis was lymphangioma. After seven months follow-up, the patient has no recurrence of the lesion.

Closure of an open bite using the ‘Mousetrap’ appliance: a 3-year follow-up

AbstractRecently, skeletal anchorage devices have been used as anchorage units for upper molar intrusion as a way of correcting an anterior open bite malocclusion. To avoid the surgical procedures associated with the placement of miniplates in the zygomatic area, mini-implants may be inserted palatally or buccally in the alveolar process. However, consideration must be given to the potential risks of root damage and a higher failure rate associated with the placement of temporary anchorage devices (TADs) in the interradicular area. The anterior hard palate provides a safer and more stable alternative for TAD placement. The current paper describes the biomechanical principles and the clinical procedures of ‘Mousetrap’ mechanics using mini-implants in the anterior palate for upper molar intrusion. The stomatognathic response of maxillary molar intrusion is an autorotation of the mandible and so the sagittal implications for each patient must be considered. The presented patient demonstrates successful correction and stability of the treatment result at a three-year review.

Individual scoring and mapping of hard and soft tissues of the anterior hard palate for orthodontic miniscrew insertion.

The aim of the present study was to introduce a scoring system to select optimal sites to insert a miniscrew in a hard palate. The present study consisted of 37 adult patients (21 females and 16 males) aged between 20 and 50years, with a mean age of 34.81 (±9.52)years. Hard and soft tissues of the anterior hard palate were assessed using cone-beam computed tomography. The scoring system was as follows: mucosal thickness: 0-2mm (2 points), 2-4mm (1 point), and 4-6mm (0 points); total bone vertical height: ≥5mm (1 point) and <5mm (0 points); and palatal cortical thickness: ≥1mm (1 point) and <1mm (0 points). Significant variability was found between the individuals. Total vertical bone height decreased posteriorly and laterally. Mucosal thickness decreased posteriorly, but increased laterally. Palatal cortical thicknesses were higher than the nasal cortical thicknesses. The most balanced sites (highest point) were the midpalatal suture, followed by paramedian points located 3mm lateral to the midline and 4mm posterior to the incisive canal. Considering that both hard and soft tissue parameters are crucial to obtain the best possible success rates, careful investigation is recommended prior to clinical decisions being made.

Glial heterotopia of the oral cavity

Abstract We report an unusual case of a glial heterotopia arising from the oral cavity of an African neonate. The patient presented with an external pedunculated oral mass which was connected to the anterior hard palate by a firm, rubbery stalk of mucosal tissue. While the mass appeared painless, it interfered with the infant's feeding and was disturbing to the parents. After a computed tomography scan excluded an intracranial connection, the mass was excised at its base and sent for biopsy. Histopathology examination confirmed glial heterotopia. Glial heterotopias should be included in the differential diagnosis of congenital masses in the oral region.

Three dimensional anatomical exploration of the anterior hard palate at the level of the third ruga for the placement of mini-implants--a cone-beam CT study.

The aim of this retrospective investigation was to measure vertical bone thickness on the hard palate, determine areas with adequate bone for the insertion of orthodontic mini-implants (MIs), and provide clinical guidelines for identification of those areas. Pre-treatment records of 1007 patients were reviewed by a single examiner. A total of 125 records fulfilled the inclusion criteria and were further investigated. Bone measurements were performed on cone-beam computed tomography scans, at a 90° angle to the bone surface, on 28 predetermined and standardized points on the hard palate. Bone thickness at various areas was associated to clinically identifiable areas on the hard palate by means of pre-treatment plaster models. Bone thickness ranged between 1.51 and 13.86 mm (total thickness) and 0.33 and 1.65 mm (cortical bone thickness), respectively. Bone thickness was highest in the anterior palate and decreased significantly towards more posterior areas. Plaster model analysis revealed that bone thickness was highest at the level of the third palatal ruga. The areas on the anterior palate with adequate bone thickness for successful insertion of orthodontic MI correspond to the region of the third palatal ruga. These results provide stable and clinically identifiable landmarks for the insertion of palatal MIs.

Optimized orthodontic palatal miniscrew implant insertion angulation: a finite element analysis.

There is a controversial body of evidence regarding optimal insertion angulation of an orthodontic miniscrew as a mean of skeletal anchorage. A bracket head-type 8-mm-long miniscrew (60-degree symmetrical trapezoid thread, 0.1-mm thread fillet, 0.2-mm thread height, with 0.5-mm thread pitch) was designed and monocortically inserted at 30, 45, 55, 70, 90, 110, 125, 135, and 150 degrees of inclination to the surface of bone. A bilayer cortical (1.6 mm) and cancellous (8.5 mm) bone model was constructed, adopted from a 22-year-old male patient's cone beam computed tomography (CBCT) image of his anterior hard palate area. A horizontal force of 2 N was applied parallel to the bone surface. Bone material was simulated as normal and osteoporotic bone. The maximum equivalent von Mises stress and microstrain values were separately calculated for the miniscrew, cortical bone, and cancellous bone. Deflections of the whole bone and miniscrew were also reported. A significant lower stress was found in the cancellous bone compared to the cortical bone. Osteoporotic bone displayed higher strain values. Overall, 30-degree models exhibited the lowest von Mises stress and strain values for the cortical layer and miniscrew in both normal and osteoporotic models. Meanwhile, 90-degree models displayed the lowest strain values in the osteoporotic and normal cancellous bones. Minimum bone and miniscrew deflection values were related to the model of 30-degree insertion angulation. These results showed that, within the limitations of the study, the 30-degree angulation of miniscrew insertion toward the direction of applied force could lower the cortical bone stress and strain.

Effect of tongue position on masseter and temporalis electromyographic activity during swallowing and maximal voluntary clenching: a cross-sectional study.

The purpose of this study was to measure and compare the tonic electromyographic (EMG) activity of the temporalis and masseter muscles following placement of the tongue either on the palate or in the floor of the mouth during swallowing and maximal voluntary clenching (MVC). Thirty healthy dental students with natural dentition and bilateral molar support, between the ages of 18 and 22, with no prior history of oro-facial injury, or current or past pain in the jaw, mouth or tongue participated in the study. Tonic masseter and temporalis EMG activities were recorded using surface electrodes. Subjects were instructed to passively place the tongue either on the anterior hard palate or in the floor of the mouth during swallowing and MVC. At each tongue position, the resulting EMG was recorded. During swallowing, no significant difference in EMG activity was found either for the masseter (P-value = 0.1592) or the temporalis (P-value = 0.0546) muscles, regardless of the tongue position. During MVC, there was a statistically significant difference for both the masseter (P-value = 0.0016) and the temporalis (P-value = 0.0277) muscles with lower levels recorded with the tongue in the floor of the mouth. This study found that in normal, pain-free subjects, placing the tongue in the floor of the mouth significantly reduces masticatory muscle activity during MVC. Thus, it may be considered as a possible therapeutic option to decrease masticatory muscle activity; however, further research is needed in patients with oro-facial pain.

Extensive nasopalatine cyst with nasal involvement

Nasopalatine duct cyst also known as nasopalatine cyst is a developmental, epithelial, non-neoplastic cyst that is considered to be the most common non-odontogenic cyst in the maxillofacial region. It is unique in that it develops in only a single location – the midline anterior maxilla. Nasopalatine cysts are usually asymptomatic and are often discovered incidentally during routine radiological examination. In this article the authors present a case of a nasopalatine cyst found in a 45-year-old male. The patient was referred, reporting a pressure over the anterior maxilla. There were no other symptoms and no recent history of pain. Clinical examination revealed a palatal expansion on the anterior hard palate. The lesion was surgically removed under general anaesthesia and diagnosis of a nasopalatine cyst was confirmed after histopathologic examination. The patient showed no clinical or radiographic signs of recurrence one year after surgical excision.

CBCT imaging of extensive nasopalatine duct cyst :Case report

The nasopalatine duct cyst (incisive canal cyst) (NPDC) is the most common non-odontogenic cyst in the oral cacity, occuring approximately 1% of the population. It is an uncommon condition that generally occurs in the maxillofacial bones. This lesion may be clinically silent for years without any symptoms. On examination, painless swelling, which was tender and fluctuant, was confirmed in the midline of his anterior hard palate. The overlying mucosa appeared normal in color. We performed CBCT to better identify lesion.This case demonstrates the typical clinical and radiographical features of a NPDC. CBCT can provide high-resolution images, short scanning time, and reduced radiation dose. CBCT therefore provides the opportunity for multiplanar imaging and three-dimensional (3D) information.

Pyogenic granuloma - report of three cases in rare sites

Pyogenic granuloma is a benign, localized mass of exuberant granulation tissue produced in response to various stimuli. It is inflammatory hyperplasia of oral cavity commonly seen on gingival area and rarely on other parts of oral cavity such as lips, tongue, palate and buccal mucosa. It is seen predominantly in 2nd to 3rd decade of life in young females. Clinically manifesting as small red erythematous exophytic lesion, it must be biopsied to rule out other serious conditions. This article aims to present three cases of extra gingival pyogenic granulomas occurring in rare sites such as buccal mucosa, anterior hard palate and alveolar mucosa of completely edentulous ridge in maxilla. Pyogenic granuloma on buccal mucosa and anterior hard palate were seen in female patients with age of 40 years and 34 years respectively and pyogenic granuloma on alveolar mucosa of edentulous ridge in maxilla was noted in 70 years old male patient. Surgical excision was performed for all the lesion and follow up of one year did not show any recurrence. Please add little description of patient + treatment + followup results. DOI: http://dx.doi.org/10.3329/bjms.v12i4.16667 Bangladesh Journal of Medical Science Vol. 12 No. 04 October ’13 Page 445-448

The effect of tongue position and resulting vertical dimension on masticatory muscle activity. A cross-sectional study

The purpose of this study was to: (a) compare the tonic electromyographic (EMG) activity of the temporalis and masseter muscles between two tongue positions, (b) compare the vertical dimension (VD) resulting from each tongue position and (c) determine the influence of the VD on the tonic EMG activity for each tongue position. Thirty-three healthy dental students with natural dentition and bilateral molar support, between the ages of 18 and 22 years, with no prior history of oro-facial injury, or current or past pain in the jaw, mouth, or tongue participated in the study. Tonic masseteric and temporalis EMG activities were recorded using surface electrodes. Subjects were instructed to passively place the tongue either on the anterior hard palate or in the floor of the mouth. At each tongue position, the resulting EMG and VD were recorded. No significant difference in EMG activity was found for either the masseter (P-value = 0·5376) or temporalis muscle (P-value = 0·7410), between the two tongue positions. However, there was a significant difference in the VD resulting from the two different tongue positions, being greater with the tongue placed in the floor of the mouth. There was no statistically significant correlation between VD and EMG activity for both tongue positions. In spite of the lack of difference in the effect of both tongue positions on the masseteric and temporalis EMG activity, an increment of the VD was registered for the floor of mouth-tongue position. However, VD was not correlated with EMG activity for both tongue positions.

Palatal fistulae: a comprehensive classification and difficulty index.

Palatal fistula formation is a known complication of palatoplasty. Numerous classifications have been proposed that help in identifying the location of fistula and systematically arrange data for record keeping. They do not assess the difficulty level of the fistula. Management of fistulae can be very tricky and a definitive success cannot be guaranteed even in the best of hands. Hence we devised a classification system and a difficulty index to help evaluate the difficulty level and plan the treatment accordingly to predict the prognosis prior to surgery. We reviewed 610 cases of palatal fistula operated at our center with a minimum follow-up of 6months from May 2003 to May 2010. They were classified according to our classification. Difficulty index was also assessed. The data was tabulated and analysed. Longitudinal fistulae showed a recurrence rate of 7.87% whereas transverse fistulae showed a recurrence rate of 19.66%. Total recurrence rate was 11.31%. Unilateral clefts with fistulae showed a recurrence of 6.55% whereas bilateral clefts with fistulae showed a recurrence of 14.17%. A total of 220 Grade 1 and 390 Grade 2 fistulae were managed. Out of these, 7 (3.18%) Grade 1 and 62 (15.90%) Grade 2 fistulae recurred. 90 % of failed fistulae showed decrease in the size of the fistula. Classification and evaluation of difficulty of palatal fistula is essential to plan the surgical treatment so as to give better results. Bidimensional fistulae in the anterior hard palate are associated with higher recurrence rate. Also, fistulae in bilateral clefts are more difficult to close than those in unilateral clefts. Classification of fistulae according to the difficulty index helps in pre-operative judgment of the outcome.

Repair of Anterior Cleft Palate Fistulae with Cancellous Bone Graft

Cleft palate fistulas of the anterior hard palate following previous repair are a challenging surgical problem. In addition to nasal regurgitation and potential adverse effects on speech, these fistulas may necessitate obturation with a removable dental prosthesis and can mitigate a fixed prosthodontic dental reconstruction. The authors present a method of repair using cancellous bone graft and only native palatal mucosa. The authors carried out a retrospective review of 27 consecutive patients who underwent anterior palate fistula repair performed by a single surgeon over an 8-year period. The authors performed 29 fistula closure procedures using cancellous bone on 27 consecutive patients. Twenty-three (85 percent) of the initial 27 palatal fistula repairs in this study resulted in complete closure of the fistula. Two of the four patients who had incomplete closure went on to have a second operation using exactly the same technique, and complete closure was achieved. The remaining two patients in whom only partial closure was achieved were asymptomatic and no further treatment was necessary. All patients had an improvement in fistula symptoms after surgery. All patients who were using removable dentures/obturators were restored with fixed dental restorations supported by osseointegrated implants or fixed conventional bridges. This relatively simple method achieves reliable closure of most anterior hard palate fistulas and can be repeated if necessary. This technique removes the necessity of obturation of the defect with a removable prosthesis and in some cases facilitates the placement of dental implants.

Molecular signaling along the anterior–posterior axis of early palate development

Cleft palate is a common congenital birth defect in humans. In mammals, the palatal tissue can be distinguished into anterior bony hard palate and posterior muscular soft palate that have specialized functions in occlusion, speech or swallowing. Regulation of palate development appears to be the result of distinct signaling and genetic networks in the anterior and posterior regions of the palate. Development and maintenance of expression of these region-specific genes is crucial for normal palate development. Numerous transcription factors and signaling pathways are now recognized as either anterior- (e.g., Msx1, Bmp4, Bmp2, Shh, Spry2, Fgf10, Fgf7, and Shox2) or posterior-specific (e.g., Meox2, Tbx22, and Barx1). Localized expression and function clearly highlight the importance of regional patterning and differentiation within the palate at the molecular level. Here, we review how these molecular pathways and networks regulate the anterior–posterior patterning and development of secondary palate. We hypothesize that the anterior palate acts as a signaling center in setting up development of the secondary palate.