Bmpr1a signaling plays critical roles in palatal shelf growth and palatal bone formation

Cleft palate, including submucous cleft palate, is among the most common birth defects in humans. While overt cleft palate results from defects in growth or fusion of the developing palatal shelves, submucous cleft palate is characterized by defects in palatal bones. In this report, we show that the Bmpr1a gene, encoding a type I receptor for bone morphogenetic proteins (Bmp), is preferentially expressed in the primary palate and anterior secondary palate during palatal outgrowth. Following palatal fusion, Bmpr1a mRNA expression was upregulated in the condensed mesenchyme progenitors of palatal bone. Tissue-specific inactivation of Bmpr1a in the developing palatal mesenchyme in mice caused reduced cell proliferation in the primary and anterior secondary palate, resulting in partial cleft of the anterior palate at birth. Expression of Msx1 and Fgf10 was downregulated in the anterior palate mesenchyme and expression of Shh was downregulated in the anterior palatal epithelium in the Bmpr1a conditional mutant embryos, indicating that Bmp signaling regulates mesenchymal-epithelial interactions during palatal outgrowth. In addition, formation of the palatal processes of the maxilla was blocked while formation of the palatal processes of the palatine was significantly delayed, resulting in submucous cleft of the hard palate in the mutant mice. Our data indicate that Bmp signaling plays critical roles in the regulation of palatal mesenchyme condensation and osteoblast differentiation during palatal bone formation.     

Human palatal growth evaluated on medieval crania using nerve canal openings as references

The purpose of this investigation was to measure postnatal lengthening and widening of the hard palate by use of nerve canal openings as references. The relationship of the dentition to the greater palatine foramina was also investigated. Thirty-nine medieval dry skulls were examined, 22 from children and 17 from adults. All crania were photographed at a 1:1 scale. The dimensions of the maxilla and the location of the dentition were determined from the photographs. The study showed that palatal growth in length in the sagittal plane takes place anterior to the greater palatine foramen. The growth increment in the area between the incisive foramen and the transverse palatine suture is more pronounced than the growth increment in the area between the transverse palatine suture and the greater palatine foramen. The distance from the greater palatine foramina to the posterior margin of the palate did not increase significantly with age. The growth in width seems to continue into adult life. The first permanent molars and the surrounding bone are moved forwards in relation to the greater palatine foramina during growth. The space for the developing maxillary premolars and molars therefore has to be obtained by growth in the transverse palatine suture. © 1996 Wiley-Liss, Inc.     

Orthopedic intrusion of premaxilla with distraction devices before alveolar bone grafting in patients with bilateral cleft lip and palate

Surgical repositioning of the downward displaced premaxilla in bilateral cleft lip and palate patients remains a controversial and perplexing issue because of its detrimental effects on the growth of the premaxilla. The purpose of this prospective clinical study was to introduce and evaluate the treatment results of an innovative technique for nonsurgically intruding the downward displaced premaxilla. Eight consecutive cases of bilateral cleft lip and palate at the age of mixed dentition were included for the correction of their premaxillary deformities. A pair of intraoral tooth-borne distraction devices was used for the orthopedic intrusion. Serial lateral and posteroanterior cephalometric radiographs were taken periodically for evaluating the growth of the premaxilla 1 year before the intrusion, changes during the intrusion, and growth/relapse up to 1 year after the intrusion. There was no overgrowth of the premaxilla or overeruption of the maxillary incisors during the 1-year observing period before the orthopedic intrusion. The treatment results revealed that the downward displaced premaxillae were all corrected within 1 month. Cephalometrically, 46 percent of the correction resulted from a true orthopedic intrusion and another 54 percent from a dentoalveolar effect in which the maxillary incisors were intruded and the premaxillary dentoalveolus was shortened. The cephalometric evaluations also implied that what occurred during the orthopedic intrusion was mostly the sutural contraction osteogenesis/osteolysis in the vomeropremaxillary suture combined with slightly mechanical upward displacement of the vomeronasal septum complex and nasal bones. The orthopedic intrusion of the premaxilla with distraction devices is an effective nonsurgical method for correcting the downward displaced premaxilla before alveolar bone grafting in patients with bilateral cleft lip and palate, and the results remained stable after 1 year.     

Palatal growth in baboons (Papio cynocephalus anubis)

In this study the structure and development of the palate as observed in a cross-sectional collection of olive baboons (Papio cynocephalus anubis) skulls are described and analyzed using craniometric techniques. Considered are structural functional relationships among different parts of the palate, and between the palate and other parts of the craniofacial skeleton. Several inferences are drawn and speculated upon. These inferences are as follows: odontogenesis affects premaxillary growth the most during late fetal and early postnatal development; maxillary length is significantly affected by development and eruption of the maxillary dentition, whereas maxillary breadth is less affected by dental development. Growth of the palatine bones and nasopharyngeal airway is correlated with dentomasticatory changes; the developmental and functional significance of these correlations is unclear. Further inferences are that growth rates for each palatal component differ for each sex even though lengths of the components relative to total palatal dimensions show no sexual dimorphism. Also, it is determined that maxillary length remains constant, premaxillary length reduces and palatine length increases relative to total palatal length with growth.     

Cleft palate repair by double opposing Z-plasty

In an attempt to improve speech results following palate repair while allowing adequate maxillary growth, a palatoplasty using two opposing Z-plasties of the soft palate, one of the oral and one of the nasal layers, has been used in 22 infants. Eight patients had unilateral cleft lip and palate, eight had bilateral cleft lip and palate, and six had cleft palate. The Z-plasties facilitate effective dissection and redirection of the palatal muscles to produce an overlapping muscle sling and lengthen the velum without using tissue from the hard palate, which permits hard palate closure without pushback or lateral relaxing incisions. Of the 20 children old enough for speech evaluation, 18 have no velopharyngeal insufficiency. Two have very mild velopharyngeal insufficiency. None has required a pharyngeal flap.     

Morphological observations in normal primary palate and cleft lip embryos in the Kyoto collection

Normal developmental events during human primary palate formation and alterations associated with cleft lip remain poorly defined. The purpose of this study was to analyze serially sectioned human embryos to identify morphological changes during normal palatal closure and alterations associated with failure of palatal formation. Normal and cleft embryos from the histological collection at the Congenital Anomaly Research Center at the University of Kyoto were studied and photographed for detailed evaluation. Seven serially sectioned cleft lip embryos of stages shortly after primary palate formation (Streeter-O'Rahilly stages 19, 20, and 22) with unilateral or bilateral clefts with varying degrees of clefting were studied. In the normal Kyoto embryos, initial nasal fin (epithelial seam) formation was observed between the medial nasal process and the lateral nasal and maxillary processes at stage 17. During stages 18 and 19, the nasal fin epithelium was replaced by an enlarging mesenchymal bridge, as the maxillary processes united with the medial nasal processes to form the primary palate. The most prominent features observed in the cleft embryos were a reduced thickness of mesenchymal bridging between the medial nasal and maxillary processes, with an excessive amount of epithelium at the junctions between these processes. With ingrowth of the maxillary processes, greater cell dispersion and apparent extracellular matrix accumulation were observed in the medial nasal region. During closure of the primary palate, terminal branches of the maxillary nerve crossed the mesenchymal bridge to the medial nasal region. The partial clefts had reduced maxillary ingrowth and smaller union areas with the medial nasal process. Detailed studies of experimental animal models are required to identify regional growth required for contact between the facial prominences, to clarify the mechanisms of mesenchymal ingrowth and epithelial displacement during palatal formation, and to identify local and/or general factors causing alterations that lead to primary palatal clefting.     

Palate development after fetal tongue removal in cortisone-treated mice

Morphological studies of cortisone-induced cleft palate have shown retardation in the rotation of palatine shelves from a sagittal to a transverse plane. Cortisone also reduces fetal muscular movements, which may explain why displacement of the tongue from between the palatine shelves is delayed. Previous work with extrauterine development of control fetuses demonstrated that fetal membranes and tongue were major obstacles to shelf rotation. Thus, removal of these obstacles might permit rotation and fusion of palatine shelves in cortisone-treated fetuses. In the present experiment, fetuses from cortisone-treated strain CD-1 mice were released from uterus and membranes and allowed to develop for eight hours in a fluid medium with the umbilical cord left intact. Compared to 4% fusion in utero, there was palatal fusion in 20% of fetuses released from membranes. When the fetal tongue was removed during extrauterine development, the frequency of fusions increased to 61%. Fusion appeared normal by the criteria applicable through light microscopy. Thus, cortisone induces cleft palate primarily through interference with shelf rotation. The palatine shelves of treated fetuses retain their ability to fuse when they can come in contact during the normal time for palate closure.     

Developmental deficiencies of the upper facial skeleton due to partial elimination of mesencephalic neural crest cells in the chick embryo

With the aim to test the hypothesis that cells derived from the mesencephalic portion of the neural crest, are involved in the process of differentiation of various upper facial bones, in 41 chick embryos of the 6-somite stage (approx. 26 hours of incubation) the anterior and middle thirds of this part of the neural crest were partially eliminated by micro-laser irradiation, either unilaterally or bilaterally. Of the 14 embryos sacrificed at the age of 12 days, a number of 6 proved to have developed harelip and/or cleft palate conditions. In these embryos, in addition a reduction or absence of the maxillary, palatal, jugale and quadrato-jugale was observed. On the contrary, other facial bones as well as the first and second branchial arch cartilages proved to have developed normally. From these results the conclusion may be drawn that (a sufficient number of) cells from the anterior and middle thirds of the mesencephalic neural crest are indispensable for a normal differentiation of the maxillary, palatal, jugale and quadrato-jugale.     

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.     

Prenatal repair of experimentally induced clefts in the secondary palate of the rat

A refined technique of amniotic sac puncturing at day 16.2 (i.e., 16 + 2/10 days) of gestation was employed in order to produce a series of total clefts and rare forms of partial clefts in Sprague-Dawley rat fetuses. From a total of 410 fetuses of a precise, individually determined age, 95 upper jaws were examined in the scanning electron microscope and, in part, in serial Epon sections. All fetal heads were examined macroscopically. Total clefts were found in 48.9% of a total of 184 viable rat fetuses examined at day 17.8 of smear age and in 21.8% of a total of 211 fetuses examined at day 19.3. Partial clefts were observed in 14.1% and 18.5% of fetuses at days 17.8 and 19.3 of smear age, respectively. At day 19.3, 16.1% of the viable fetuses showed a very inconspicuous, small abnormality (with residual clefting and incomplete fusion with the nasal septum) in the region of the palatine foraminae. Morphological observations suggested that under conditions of detained palatal closure (1) fusion of the soft palatal shelves commences independently from and prior to fusion of the hard palate, (2) delayed palatal shelf fusion proceeding in the anterior direction may occur with or without remaining sickle-shaped clefts in the anterior hard palate, and (3) in fetuses with small sickle-shaped clefts, fusion of the palatal shelves with the nasal septum does not occur. The present data imply that an almost total prenatal repair and delayed closure of the secondary palate may occur in rats that, at day 16.2 of multiple analysis age, most certainly had a total palatal cleft resulting from tongue resistance.     

Regeneration in surgically produced cleft palate in rabbits. A microscopical study

In order to study the effects of surgical procedures on the regeneration process in cleft palate, an artificial cleft was made in 4-weeks old female New Zealand rabbits. The 47 animals were divided into 5 groups: group 1: controls, group 2: cleft made in the bony palate, using a dental burr (phi 3 mm), group 3: cleft as in group 2, oral mucosa stitched, group 4: cleft made without perforating the nasal mucosa; oral mucosa stitched ("Veau"), group 5: cleft made as in group 4; before stitching the oral mucosa pieces of autologous rib bone were introduced into the cleft ("Schuchardt"). At the ages of 4, 5, 6, 8, 12, 18 and 24 weeks, one or two animals per group were sacrificed. The palatal region was microscopically studied using 10 mu paraffin sections stained according to Herovici. It was found that it is difficult to make a reproducible cleft on the histological level. A large interindividual variation in local damage due to the surgical procedure was observed; this might contribute to the variation in growth results of the facial skeleton reported in literature. Signs of excessive bone resorption were found. The presence of bone in places where sutural tissue should be present, observed in some growing animals, will contribute to reduction of palatal width, medial collapse of the palate and asymmetry of the facial skeleton. There appeared to be no striking differences between the three methods of repair, used in group 3, 4 and 5 respectively.     

Developmental anomalies induced by all-trans retinoic acid in fetal mice: I. Macroscopic findings

The administration of a single dose of all-trans retinoic acid on day 8 of gestation to pregnant mice, ICR strain, led to malformed fetuses in all of the litters. All-trans retinoic acid (RA) was dissolved in olive oil and given in doses of 60 or 40 mg/kg of body weight. The control mice were given vehicle alone. Examination on day 18 of gestation of the fetuses exposed to 60 mg/kg showed various malformations, such as exencephaly, exophthalmus, micrognathia, agnathia, cleft palate, cleft lower lip, spina bifida, atresia ani, tail anomalies, agenesis of the kidneys, or hydronephrosis. In the fetuses exposed to 40 mg/kg, isolated cleft palate was much more common than in those exposed to 60 mg/kg. Double-stained preparations of bone and cartilage showed cranio-facial anomalies and axial skeletal anomalies: a- or hypogenesis of palatine or maxillary bones, tympanic ring, squamosal temporal bone or otic ossicles in cartilage, and fusion of basioccipital to basisphenoid and maxilla, zygomatic and mandibular bones; a- or hypogenesis of caudal vertebrae and supernumerary thoracic and lumbar vertebrae. These results indicate that anomalies comparable to those seen in the infants of mothers treated with isotretinoin, 13-cis retinoic acid, during pregnancy can also be induced in mice and suggest that the site affected by RA may be neural crest cells, including those in the cephalic and caudal regions, and cells committed to somitic mesoderm in the trunk region.     

Modified technique of presurgical infant maxillary orthopedics for complete bilateral cleft lip and palate

This article introduces technical modifications to the conventional presurgical infant maxillary orthopedics device for newborns with complete bilateral cleft lip and palate, providing procedural simplicity and efficiency as well as therapeutic efficacy. The modifications incorporate a wax block-out on the stone model prior to device fabrication in a manner that the need for periodic acrylic addition and removal is not required, and thus eliminates the risk of natural maxillary growth restriction during infant maxillary orthopedics treatment. The premaxilla is completely excluded from the acrylic palatal plate and is repositioned primarily by the bilateral labial tape alone. In addition, nasal stent wires are installed on the same day of the palatal plate delivery to establish a tripod-like retention mechanism for the intraoral device to be able to replace the conventional mechanical lock-type retention methods. Applying these modifications, infant maxillary orthopedics treatment objectives for bilateral cleft lip and palate can be successfully achieved within 8 weeks of treatment, and the definitive primary cleft lip repair can be performed within 3-4 months of infant maxillary orthopedics treatment at our Center.     

Induction of cleft palate in mice by inhibitors of prostaglandin synthesis

The present study investigates the effects of several nonsteroidal anti-inflammatory drugs on mouse palatal fusion in vivo and in vitro. Five different nonsteroidal anti-inflammatory agents were injected into pregnant mice of the AKR-strain on day 13.5 of gestation. Paired palatal processes from 13.5- and 14.5-day-old mouse embryos were organ-cultured for 72 hours in control and anti-inflammatory drug-containing media. Each experimental group of animals and explants received one of the following drugs: naproxen, sulindac, indomethacin, diclofenac, and mefenamic acid. Drug treatment induced different frequencies of cleft palate in the offspring. The most teratogenic drug was sulindac, and indomethacin was almost ineffective. In vitro each drug prevented fusion of the palatine processes in treated explants, and the degree of inhibition was dependent on the stage of development at the time of explanation. In both the in vivo and in vitro experiments, the drugs prevented medial epithelial cell breakdown that normally occurs in the medial secondary palatal epithelium. The results obtained in the present study suggest that prostaglandins may play an important role in normal differentiation of the developing palatine region.     

Palatogenesis: morphogenetic and molecular mechanisms of secondary palate development

Mammalian palatogenesis is a highly regulated morphogenetic process during which the embryonic primary and secondary palatal shelves develop as outgrowths from the medial nasal and maxillary prominences, respectively, remodel and fuse to form the intact roof of the oral cavity. The complexity of control of palatogenesis is reflected by the common occurrence of cleft palate in humans. Although the embryology of the palate has long been studied, the past decade has brought substantial new knowledge of the genetic control of secondary palate development. Here, we review major advances in the understanding of the morphogenetic and molecular mechanisms controlling palatal shelf growth, elevation, adhesion and fusion, and palatal bone formation.     

Palatal dimensions in 45,X-females

Seventy-two females with 45,X-chromosome complement were examined for palatal dimensions, and the results of the measurements were compared to those of first-degree normal female relatives of the study subjects and population control females. Hard stone casts were prepared for measuring widths and lengths of the maxillary alveolar arch and palatal height between or at the level of the permanent canines, first and second premolars, and first molars with a palatometer and sharp-pointed vernier calipers (0.5 mm). According to the analyses of covariance (history of orthodontic treatment and loss of permanent teeth as cofactors and age as covariate), the differences in palatal dimensions between the groups were statistically significant or highly significant for all dimensions except for palatal height in the posterior segments. The group of the 45,X-females had the highest mean value for palatal height at the level of the canines and systematically the lowest mean values for palatal width in all segments, while no clear difference could be found in the length of the alveolar arch between the 45,X-females and the relatives, the population control group showing the lowest value in the posterior segments. The findings of this study indicate that the narrowed palate rather than the high palate is a frequent but not definite feature in 45,X-females. This may reflect the effect of sex-chromosomes on width but not other dimensions of the palate, resulting in deficiency of transversal growth of the palate possibly through decreased growth of the palatal shelves or through disturbances in the growth of the nasal septum, sutural growth, or--to which the exostosis on the palatal alveolar plates would refer--disturbances in apposition-resorption growth changes of the maxilla.     

Studies on orthocephalization. 8. Behaviour of the visceral part of the rat head in the period between 7 and 60 days after gestation

The present paper considers the significance of interosseous flexions of the palatal complex in the process of orthocephalization of the rat skull between 7 and 60 d after birth. The study is based on a sample of 25 female rats who have been X-rayed at 7, 14, 30, and 60 d with subsequent analysis of the photographs obtained. During this period the constituents of the bony palate, i.e. the palatine bone, the palatal process of maxilla and the palatal part of premaxilla grow steadily but with decreasing rate of increase with age. The premaxilla grows the most, while the palatal bone grows the least. The angle between the cranial base and the palatal plane decreases, i.e. the rat skull becomes more orthocranial with age. At the same time, the palate becomes more orthopalatal, primarily by an increase in the angle between the palatine bone and maxilla. As the angle between the cranial base and the palatine bone after 14 d increases, i.e. rotates in the opposite direction of the palatal plane, it may be concluded that the process of orthocephalization in this period is caused by the deflexion of the angle between the palatine bone and maxilla, while it before 14 d is caused by a combination of an interosseous deflexion in the palate and an upwards rotation of the palatine bone relative to the cranial base.     

Fate-mapping of the epithelial seam during palatal fusion rules out epithelial-mesenchymal transformation

During palatogenesis, fusion of the palatine shelves is a crucial event, the failure of which results in the birth defect, cleft palate. The fate of the midline epithelial seam (MES), which develops transiently upon contact of the two palatine shelves, is still strongly debated. Three major mechanisms underlying the regression of the MES upon palatal fusion have been proposed: (1) apoptosis has been evidenced by morphological and molecular criteria; (2) epithelial-mesenchymal transformation has been suggested based on ultrastructural and lipophilic dye cell labeling observations; and (3) migration of MES cells toward the oral and nasal areas has been proposed following lipophilic dye cell labeling. To verify whether epithelial-mesenchymal transformation of MES cells takes place during murine palatal fusion, we used the Cre/lox system to genetically mark Sonic hedgehog- and Keratin-14-expressing palatal epithelial cells and to identify their fate in vivo. Our analyses provide conclusive evidence that rules out the occurrence of epithelial-mesenchymal transformation of MES cells.     

Selection of appropriate artificial frontal teeth size using dimensions of hard palate

Eighty dentate students participated as a study group and another 74 as a control group. The aim was to determine a possibility to reconstruct maxillary frontal teeth dimensions by use of certain hard palate dimensions. The height (IH) and the incisal (IW), contact point (CtW) and cervical width (CW) of maxillary central incisors (MCI), hamular width (HW) and the distance between the incisive papilla and the palatine foveas (IP-FP) were measured on the maxillary casts. CtW of maxillary lateral incisors and canines were measured too. In the study group the ratios were computed: HW/IW (5.71), HW/CtW (5.69), HW/CW (5.51) and IP-FP/IH (4.76). These ratios were multiplied by incisor's dimensions (obtained from the control group) to calculate the hard palate dimensions. No significant differences were obtained between the calculated and the measured (study group) hard palate dimensions. Furthermore, there was no significant difference between the HW and the Sum of contact-point widths of all maxillary frontal teeth (p > 0.05) in the both groups. The results revealed: 1. MCI width and height might be calculated by dividing dimensions of a patient's hard palate and appropriate ratio; 2. hamular width dimension can be used as a selection guide for the sum of contact-point widths of six maxillary frontal teeth.     

Management and timing of cleft palate fistula repair

This study reviewed 199 cleft palate repairs resulting in 22 percent fistula formation. Of these, 49 percent were judged to be symptomatic. Of 44 fistulas, 21 required treatment, of which 14 had conventional type surgical closure with an overall success rate of 35 percent. Good surgical technique and good surgical judgment were felt to be important factors both in preventing postoperative fistula and in the success of their repair. Conventional methods of surgical repair of hard palate fistulas were seen to result in a very poor success rate. Orthodontic movement of maxillary segments was seen to contribute to late postoperative fistula formation. Therefore, orthodontic movement should be completed before undertaking surgical repair of anterior palatal fistulas. Finally, the success rate of anterior fistula repair has been dramatically improved by the addition of free periosteal grafts and cancellous bone grafts.