The document summarizes the development of the palate and its anomalies. It begins by describing how the face develops from structures around the stomodeum, including the frontonasal process and first pharyngeal arches. It then explains palate development in detail, from the primitive palate formed by the frontonasal process to the definitive palate formed by fusion of the palatine shelves. It classifies palate anomalies and describes cleft lip and cleft palate. It concludes by outlining treatment for cleft palate including surgical management and use of palatal obturators.

1. DEVELOPMENT OF
PALATE AND ITS ANOMALIES
PRESENTED BY
N.NARMATHA
I YEAR PG
DEPARTMENT OF ORAL MEDICINE
AND RADIOLOGY
PRESENTATION NO :1

3. INTRODUCTION
DEVELOPMENT OF FACE
• After the formation of the head fold ,the developing brain and the
pericardium form two prominent bulges on the ventral aspect of the
embryo.
• These bulgings are separated by the stomodeum.
• The floor of the stomodeum is formed by the buccopharyngeal
membrane,which separates it from the foregut.

4. FRONTONASAL PROCESS: Mesoderm covering the
developing forebrain proliferates and forms a downward
projection that overlaps the upper part of the
stomodeum.This downward projection is called the
frontonasal process.
Face is derived from the following structures that lie
around the stomodeum.
 The frontonasal process and
 The first pharyngeal (or mandibular) arch of each side.

5. • At this stage each mandibular arch forms the lateral wall of the
stomodeum.This arch gives off a bud from its dorsal end .This bud
is called as the maxillary process.
• It grows ventro-medially cranial to the main part of the arch which
is now called the mandibular process.

6.  The ectoderm overlying the frontonasal process soon shows
the bilateral localised thickenings that are situated a little
above the stomodeum. These are called the nasal placodes.
 The formation of these placodes is induced by the underlying
forebrain.

7.  The placodes soon sink below the surface to form nasal pits.
 The edges of each pit are raised above the surface.

8.  The medial raised edge is called the medial nasal process and the
lateral edge is called the lateral nasal process.
Medial nasal
process
Lateral
nasal
process

9. Prominence Structure formed
Frontonasal Forehead,bridge of the nose,medial and lateral nasal
prominences
Maxillary Cheeks,lateral portion of upper lip
Medial nasal Philtrum of upper lip,crest and tip of nose
Lateral nasal Ala of nose
Mandibular Lower lip
Structures contributing to the formation of face.

10. INTERMAXILLARY SEGMENT:
As a result of medial growth of the maxillary prominences, the two
medial nasal prominences merge not only at the surface but also at a
deeper level.The structures formed by the two merged prominences is
the intermaxillary segment.

11. It is composed of
1.Labial component –philtrum of the upper lip
2.An upper jaw component-which carries the four incisor teeth
3.Palatal component-triangular primary palate.
By 5th week the primordia for lip and palate are present.

12. PRIMITIVE PALATE:
The medial and lateral nasal prominences fuse and form a partition
between pit and stomodeum.
It is derived from the frontonasal process.

13. PRIMARY PALATE:
During seventh week, the medial nasal,frontonasal and maxillary
process fuse to form the primary palate which becomes the
• Medial portion of the upper lip
• Alveolus
• Anterior part of hard palate up to the incisive foramen.

14. From each maxillary process, a plate like shelf grows medially,called
the palatal process.The three components from which the palate will be
formed are
• the two palatal process
• the primitive palate
DEFINITIVE PALATE:
The definitive palate is formed by the fusion of these three parts -
• Each palatal process fuses with the posterior margin of the primitive
palate.

15. Lateral
palatine
process
Maxillary
process Primary palate
Nasal septum

16. Incisive foramen
Primary palate
Soft palate
Hard palate
Secondary palate
Secondary palate

17. • The medial edges of the palatal process fuse with the free lower
edge of the nasal septum,thus separating the two nasal cavities
from each other and from the mouth.
• These outgrowths , the palatine shelves appear in the sixth week
of development and are directed obliquely downward on each
side of the tongue.
• The two palatal processes fuse with each other in the midline.
Their fusion begins anteriorly and proceeds backwards.

18. In the seventh week ,however the palatine shelves ascend to attain a
horizontal position above the tongue and fuse,forming the secondary
palate.
Anteriorly ,the shelves fuse with the triangular primary palate, and the
incisive foramen is the midline landmark between the primary and
secondary palate.
At the same time as the palatine shelves fuse, the nasal septum grows
down and joins with the cephalic aspect of the newly formed palate.

19. HARD PALATE:
At a lateral stage, the mesoderm in the palate undergoes
intramembranous ossification to form the hard palate.
SOFT PALATE: Ossification does not extend into
the most portion which remains as the soft palate.
PREMAXILLA:
The part of the palate derived from the frontonasal process
forms the premaxilla which carries the incisor teeth.
Palatal fusion-completed by 11 th to 12 th week.
PREMAXILLA

21. Soft palate
(palatal throat form)
Hard palate
SHAPES OF PALATE

22. ANOMALIES:
Cleft lip and cleft palate:
Cleft lip and cleft palate are common defects that result in abnormal
facial appearance and defective speech .
The term cleft lip and palate is commonly used to represent two types
of malformations.
• Cleft lip with or without cleft palate(CL/CP)
• Cleft palate.
These are common congenital malformations.

24. INCIDENCE :
• Common in caucasians
• Higher frequency in asian population
• Lowest frequency in africans(1in 2500)
• In 75% of cases it is unilateral ,commonly occurs on the left side(60%)
• In 50% of cases it is combined cleft lip and palate.(Common in boys)
• In 15 to 25% of cases ,it is cleft lip alone.
• In 25 to 45% of cases it is cleft palate alone. (More common in girls.)
• Cleft of the lips-1 in 500;Cleft palate -1 in 2500 live births.

25. ETIOLOGY:
 Heriditary (most important single factor)
 Environmental factors
 Bhatia –single mutant gene,producing large effects,or by a number
of gene(polygenic inheritance)
 Bixler –hereditary, most probably polygenic (determined by several
different genes acting together),Monogenic or syndromic

26.  Strean and peer- physiologic, emotional or traumatic stress.
 Fraser and warburton –neither stress nor lack of prenatal nutritional
supplement

27. Other factors suggested as possible cause:
• A defective vascular supply to the area involved.
• A mechanical disturbance in which the size of the tongue may
prevent the union of parts.
• circulating substances ,such as alcohol and certain drugs
(anticonvulsants) and toxins
• Infections(rubella)
• Lack of inherent developmental force
• Radiation.

28. Lateral cleft lip,cleft upper jaw and cleft between primary and
secondary palates.
Due to a partial or complete lack of fusion of the maxillary
prominence with the medial nasal prominences on one or both sides.

29. Cleft (secondary palate) and cleft uvula.
-Due to lack of fusion of the palatine shelves,
-failure of the shelves to elevate ,
-inhibition of the fusion process itself,
-failure of the tongue to drop from between
the shelves(micrognathia)

30. CLASSIFICATION: unilateral
1.Cleft lip alone bilateral
median
2.Cleft of primary palate
Complete - means absence of premaxilla.
Incomplete - means rudimentary pre-maxilla.
1.unilateral
2.bilateral
3.median

31. 3.Cleft of secondary palate:
a. complete-nasal septum and vomer separated from palatine
process.
b. incomplete.
c. submucous
- cleft with soft palate involvement
- cleft without soft palate involvement.
4.Cleft of both primary and secondary palate.
5.Cleft lip and cleft palate together.

32. Davis and ritchie classification :
Group –I: clefts anterior to the alveolus
-unilateral
-median
-bilateral(cl)
Group –II: post alveolar clefts (cp alone,soft palate alone ,soft palate
and hard palate, submucous cleft)

33. Veau classification:
Group –I (A) : defects of the soft palate only .
Group -II (B) : defects involving hard palate and soft palate.
Group –III(c) : defects involving the soft palate to alveolus ,usually
involving the lip.
Group –IV(d): complete bilateral clefts.

34. Kernahan and stark symbolic:
>areas 1 and 4 : lip
>areas 2 and 5: alveolus.
>areas 3 and 6: palate between the alveolus and the incisive
foramen.
>areas 7and 8 : hard palate.
>areas 9 : soft palate.

35. International confederation of plastic and reconstructive surgery
classification:
Group 1 : cleft of the lip/alveolus
Group 2 : cleft of the secondary palate.
Hard palate
Soft palate
Both
Group 3:any combination of clefts involving primary palate and
secondary palate.

36. CLINICAL FEATURES:
Clefts can be classified into non syndromic forms( no other physical or
developmental anomalies) and syndromic form(additional birth
defects,chromosomal anomalies,teratogens,uncategorized syndromes)
Cleft lip: The line of cleft always start on the lateral part of the upper
lip and continues through the philtrum to the alveolus between the
lateral incisor and the canine tooth.

37. Cleft of primary palate-
• Clefting anterior to the incisive foramen.
Cleft lip variations-
• Notch on the left/right side of the lip.
• Bilateral cleft lip and alveolus that separates the philtrum of the
upper lip and premaxilla from the rest of the maxillary arch.
Cleft lip with cleft palate-
• When cleft lip continues from the incisive foramen further
through the palatal suture in the midline of the palate.

38. Incomplete cleft occurs in unilateral and bilateral cleft palate.
Complete cleft palate- constitute cleft of the
hard palate,soft palate and cleft uvula.
Cleft of secondary palate- clefting posterior to incisive foramen.
Defect is often associated with other congenital abnormalities of
cardiac,gastrointestinal ,neurological system.
 Pierrie-robin syndrome
 Shprintzen’s syndrome
 Klippel-feil syndrome

39.  Sicklers syndrome
 Downs syndrome
 Aperts syndrome
 Treacher collin syndrome
PROBLEMS IN CLEFT DISORDERS:
 Difficulty in sucking and swallowing.more common in cleft palate.
 Speech is defective especially in cleft palate,mainly to phonate
B,D,K,P,T,G.
 Altered dentition or supernumerary teeth
 Recurrent upper respiratory tract infection.

40.  Respiratory obstruction
 Chronic otitis media, middle ear problems.
 Cosmetic problems
 Hypoplasia of maxilla.
TREATMENT FOR CLEFT PALATE
Millard criteria for surgery
10 kg weight
10 months of age(10-18 months)
10 gram% haemoglobin.

41. SIGNIFICANCE OF MILLARD CRITERIA:
 General anaesthesia is usually necessary for surgery and is safe
when the infant satisfies the millard’s criteria.
Age criteria:
 Usually repaired in 10-18 months.
 Repair before age 1is generally thought to produce the least visible
scar.
• Early repair causes retarded maxillary growth-probably due to trauma
to growth center and periosteum of the maxilla during surgery.

42. • Late repair causes speech defect.
• If repair was performed one year after surgery the child would be
more susceptible to underweight.
• Recommended to repair before one year of age to achieve better
nutritional status,better speech ability,and reduce the incidence of
middle ear infection,reduced patient’s anxiety,accelarated
acheivement of normal feeding process.

43. Hemoglobin criteria:
Related to low capability of the infant myocardium to respond to
reduction in tissue oxygen delivery-susceptible to ischemia.

44. SURGICAL MANAGEMENT:
• Abnormal insertion of tensor palate is released and mucoperiosteal
flaps are raised in the palate which is severed together.
• With orthodontic help teeth extraction and alignment of dentition is
done.
• Post operative speech therapy.

45. • Wardil kibner push back operation-by raising mucoperiosteal flaps
based on greater palatine vessels.
• Palatoplasty.
Secondary management for speech, hearing and dental problems.
PALATAL OBTURATOR:
It is a prosthesis that totally occludes an opening such as in cleft palate,
oronasal fistula.

46. INDICATIONS:
• Individuals with ceft palate
• Individuals who have had tumors removed
• Traumatic injuries to the palate.
SIGNIFICANCE:
• To close defects of the hard palate/soft palate that may affect
speech production,or
• Cause nasal regurgitation during feeding.
• Used to compensate for hypernasality.

47. PARTS :
Acrylic plate
Retention clasps of orthodontic wire
TYPES OF PALATAL OBTURATORS:
Interim palatal obturator
Defenitive obturator.

48. References:
• Langman’s medical embryology
• Orban’s oral histology and embryology
• Shafer,s textbook of oral pathology
• SRB manual of surgery.

49. Thank you