Cleft Lip: Congenital Anomalies

Lip Congenital Anomalies

• Cleft lip, or harelip, is a congenital condition with a split or opening in the upper lip
• The tissue that forms the lip does not fully join during fetal development causes cleft lip
• The severity of a cleft lip ranges from a small notch to complete separation that extends into the nose
• Cleft lip can occur unilaterally (one side) or bilaterally (both sides)
• A cleft lip can be associated with a cleft palate, an opening in the roof of the mouth
• Aetiology is genetic susceptibility, consanguinity, and prenatal exposure to alcohol, anticonvulsants, x-rays, or viral infections like German measles in the first 3 months of pregnancy
• Pathology includes failure of fusion between the frontonasal process and lateral maxillary processes during face development
• Clefts can be complete, reaching the nostril floor, or incomplete
• Cleft lip can occur isolated or associated with cleft palate or alveolus
• Cleft lip generally will not affect suckling, but it may be associated with abnormal teeth growth
• Cleft lip is associated with other congenital anomalies in 35% of cases
• The only treatment is surgery, ideally performed at 3-6 months of age
• Surgical principles involve paring of the edges and repairing the defect via suturing of the lip's three layers (skin, muscle, mucous membrane)

Cleft Palate

• Cleft palate is a congenital condition marked by an opening or split in the roof of the mouth (palate)
• Tissues forming the palate fail to fully join during fetal development
• The cleft can affect the hard palate, soft palate, or both
• Etiology is the same as for cleft lip
• Pathology includes arrest of fusion between two palatal processes with the premaxilla
• Cleft palate is classified into soft palate only, soft and hard palate complete, complete cleft palate plus one or both sides of premaxilla

Clinical Pictures of Cleft Lip and Palate

• Impairment of normal suckling occurs due to inability to create negative intra-oral pressure
• Aspiration pneumonia can result from food refluxing into the nose
• Hearing loss: inadequate emptying of the middle ear from abnormal levator palate insertion prevents proper Eustachian tube aeration and causes recurrent otitis media
• Speech defects stem from inadequate velopharyngeal mechanism or hearing loss
• Facial growth distortion and interference with normal teeth alignment can occur
• Surgery timing is best at 12-18 months
• Preoperative management focuses on feeding in an upright position using specialized bottles or spoons and chest infection prevention/treatment
• Objectives of surgery: closure of oro-nasal communication and achieving a competent velopharyngeal sphincter
• Principles of surgery: Trimming edges, suturing in three layers in the middle line (nasal mucosa, muscle & oral mucosa), lateral relaxation incisions, and fracture of the pterygoid hamulus to relax the tensor palati

Post-Op Cleft Lip and Palate

• Post operative treatment includes speech therapy and orthodontic treatment

Lip Cancer

• Etiology includes prolonged exposure to ultraviolet rays of the sun and chronic smoking
• Histologically, lip cancer is commonly a well-differentiated squamous cell carcinoma
• Grossly, the lower lip is more affected, starting as a treatment-resistant nodule or erosion that evolves into a typical ulcer
• Advanced signs include raised everted edges and an indurated base and margin
• Lip cancer may spread to submental nodes from the central lower lip and to submandibular nodes from the lateral parts
• Later, upper deep cervical nodes are involved
• Primary treatment involves surgical excision of the lesion with a safety margin or radiotherapy
• Radiation is effective for squamous cell carcinoma
• For lymph node metastases, suprahyoid or complete block dissection may be performed

Maxillofacial Injuries

• Frequent causes include road traffic accidents, fights, and contact sports
• Prioritizing patient treatment involves ensuring a patent airway, effective breathing, and hemorrhage control
• Skin injuries are treated with minimal debridement, suturing, and local flaps or skin grafts for defects
• Eyelid injuries require careful suturing to prevent ptosis if the levator is cut, and the tarsus must be repaired
• Parotid duct injuries necessitate end-to-end anastomosis over a small silastic catheter
• Gland and skin injuries are sutured with a small drain to manage salivary leakage, which usually resolves in 3 weeks
• Lip injuries are sutured in 3 layers with respect to anatomical landmarks
• Full-thickness ear tears are sutured with cutaneous perichondrial sutures
• Untreated hematomas can lead to cauliflower ear
• Nasal nostril tears should be sutured in two layers
• Unresolved septal hematomas can cause septal cartilage resorption and saddle nose deformity

Bites & Mandible Fractures

• Animal and human bites are heavily contaminated and require prompt excision, antibiotics, and rabies vaccination for animal bites
• Wounds are left open
• Common mandible fracture sites include the body, symphysis, angle, ramus, condyles, coronoid, and alveolar process
• Fractures of the body usually occur near the mental foramen because of the bone's curvature and deep canine socket
• In bilateral cases, digastric and geniohyoid muscle pull causes airway impairment
• Minimally Displaced fractures of the angle result from splinting by the masseter and pterygoid muscles
• Mandible fractures are generally compound into the mouth because the tightly attached mucoperiosteum
• Symptoms of mandibular fractures: Pain, especially on mouth opening, blood-stained saliva, impaired speech and swallowing, and anesthesia of the lower lip
• Signs include swelling, hematoma in the mouth floor, local tenderness, crepitus, and irregular teeth alignment
• Diagnosis is acheived by plain X-ray, panoramic view, and CT scan
• First Aid treatment: Jaw support with a four-tailed bandage, pain relievers, antibiotics, and mouth hygiene is important for preventing infection
• Reduction and fixation, is done under anaesthesia, with arch bars, inter-dental wiring or plates and screws

Maxilla Fractures & TMJ

• Maxilla fractures cause pain, excess salivation, malocclusion, epistaxis, diplopia, swelling, and crepitation
• Diagnosis involves X-ray or CT scan
• Le Fort classified maxillary fractures into three types: Le Fort I, Le Fort II, and Le Fort III
• Le Fort I features a transverse fracture above the level of the teeth
• Le Fort II involves a pyramidal fracture that traverses the base of the nose, the posterior wall of the maxillary antrum, and the orbit
• Le Fort III, there is craniofacial disjunction, i.e., separation of the facial bones from their cranial attachment
• Temporomandibular joint dislocation stems from direct blows, yawning, or wide mouth opening under anesthesia, commonly affecting middle-aged females bilaterally
• Clinical features: pain and dysarthria with the mouth held open with fixed jaws, and chin deviation in unilateral cases.
• Reduction treatment is done under anesthesia and involves downward traction on the molars with a padded thumb and upward rotation of the body with the outside fingers

Cysts of the Mouth Floor

• Mucous cysts of salivary glands are retention or extravasation cysts, up to 1.5cm, with slightly pink or blue discoloration
• Treatment: Excision
• Ranula is a retention cyst from the sublingual salivary glands
• A thin fibrous capsule with macrophage lining forms the wall, containing gelatinous material
• Plunging ranula forms where there’s extension to the neck over the mylohyoid, may rupture and refill
• Translucent, bluish, painless swelling occurs alongside prominent blood vessels and stretched mandibular duct occurs
• Treatment: Partial excision of the roof, edges sutured to mouth floor lining (marsupialization) to incorporate ranula floor
• Sublingual dermoid cysts are sequestration dermoid cysts occurring in the midline, appearing in the floor of the mouth (supramylohyoid) or neck (inframylohyoid) after puberty
• These cysts are lined by squamous epithelium, contains sebaceous material and has a thick and nontranslucent wall
• Supramylohyoid, small cysts, excised through mouth floor, inframylohyoid, large cysts, excision through submandibular incision

Tongue Anomalies

• Tongue Tie is due to a short fibrous lingual frenulum, which causes impairment of tongue movements & possibly speech defects
• It is treated by Division of the frenulum below the under surface of the tongue
• Congenital fissured tongue presents with fissures that usually run transversely from a median groove, unlike those of syphilis, which are longitudinal
• Macroglossia, is persistent painless tongue enlargement stems from congenital causes (cavernous hemangioma, congenital AV fistula, lymphangioma, or neurofibromatosis) or acquired causes (cretinism, acromegaly or amyloidosis)

Injuries & Symptoms of the Tongue

• Tongue trauma occurs in blunt trauma, road accidents, and may be associated with jaw fractures
• Bleeding can be arrested by compressing the tongue and/or suturing lacerations
• A tracheostomy is needed if respiratory issues exist
• Chronic superficial glossitis: chronic irritation causes the disease, which affects the anterior 2/3 of tongue occurs with middle age, symptoms/causes include smoking and sepsis
• Epithelium overgrowth causes leukoplakia and in advanced disease, will show ulcers
• Inflammation of the tongue is precancerous, treatment requires surgery or mouth wash
• Dental ulcers from dental irritation are on the margin of the tongue and usually small
• Dyspeptic/Aphthous ulcers of the tongue are sides of tongue and covered with white scabs
• Dyspeptic/Aphthous ulcers has an unknown cause, small, covered with white scabs, require gentian violet paint and an antiseptic mouthwash, alkaline lotion & anesthetic gel
• Neoplastic ulcers indicate squamous cell carcinoma

Tongue Cancer Etiology & Pathology

• Occurs more often in older, tobacco users, geographical linked with India
• Dental ulcers and bad oral hygiene linked as the cause, leukoplakia, syphilis and Erythroplakia contribute
• It occurs at the lateral margin and is rarely affected at the tip, and is mostly Squamous cell carcinoma
• Site: Lateral margin of the anterior 2/3 (50%) and posterior 1/3 (20%), dorsal/ventral tongue surface rare
• Gross pathology includes: Malignant ulcer, raised plaque, submucosal module or deep indurated fissure
• Direct spread: To the floor of the mouth, mandible. The posterior spread to the tonsils & larynx a.Tip: Spread from the tip of the tongue to the submental LNs then to both submandibular and cervical nodes on both sides b.Anterior 2/3: Tumors of the lateral 1/3 disseminates to the ipsilateral submandibular then to the upper deep cervical lymph nodes. Those near the midline disseminate bilaterally c.Posterior 1/3: Spread occurs directly to the upper deep cervical LNs

More on tongue Cancer

• Microscopic features: Squamous cell carcinoma (less differentiated than that of the lip) more the anterior, adenocarcinoma rare Clinical Indications:
• Blood spread is rare and has indurated base and elevated edges Early cases: Ulcer with indurated base, deep indurated fissure, papillae with white keratin
• Late presentations: Pain, dysphagia, excess salivation, metastatic selling Complications: Inhalation, necrotic tissue, tissue cancer, cachexia and bleeding can occur Investigations: Biopsy from lesion, FNAC and CT
• Radiotherapy helpful especially if Post T1
• Surgical Treatment effective with small lesions (Post radiation)
• Palliative care for patient relief using analgesics and chemotherapy

Issues with Teeth, Gums, Bone & Glands

• Alveolar abscess, results from necrotic pulp spread and points at the canine or maxillary antrum Treatment: Antibiotics and Extraction
• Acute affects the lower jaw from staphococcus spread with trismus and discharge
• Treatable using antibiotics and mouthwash
• Chronic affects lower jaws from arterial supply following acute abscesses, necrosis or radiation, with slow healing which requires surgical opening
• Pathology: Infection starts in the medulla and spreads to the subperiosteal space and requires CT scan
• Sialadenitis: bacterial infection of salivary glands
• Most often Staphylococcus aureus (and others), risk with dehydration and poor oral hygiene
• Leads to mumps or HIV, fungal in rare cases or in immunosuppressed patients
• Presents through: Retrograde bacterial entry through salivary ducts Viral tropism for glandular tissue (predisposing factors: dehydration, systemic illnesses, gland hypofunction
• Diagnosed from symptoms found from exams and cultures
• Treatment achieved through surgery, anti-biotics, supportive care (Hydration,sialogogues) and drainage

Salivary Gland Pathologies

• Sialolithiasis relates to the formation of calcified structures with salivary stones and ducts for which patients develop mineral
• Those patients with low hydration, poor oral hygiene, infections or scares can develop mineral on and in stone
• Submandibular gland (10-15%) for parotid gland Signs: pain, swelling glands with dry mouth and palpable lump Tests: Ultrasound to assess size, secretion, biopsy Treatment: Hydration and surgery

Salivary Gland Tumours

Distributions: Benign tumour often in parotid -70 percent) with bad ones as sub, small (10percent More often occurs at middle age with women more likely and comes from epithelial 2Types: Benign and Malignant

• Tumours come from a variety of tissues like epithelial with slow growing
• High survival rate with smokers or with low malignant traits Risk Factors: Genetic, Environment (and viral) Presentation: Tumours or pain at different points, function failure of facial nerves Testing: Ultrasound, imaging Treatment: Paratoidectomy, Nerve control and Chemo

Jaw Inflammations

Symptoms: Pain, swelling of structures, open or closed mouth and chewing Odontogenic Causes (tooth formation) Radicular Cyst: Forms at the root of a non-vital tooth due to chronic infection. Dentigerous Cyst: Associated with an unerupted or impacted tooth, commonly in the molar or canine region. Odontogenic Keratocyst (OKC): Aggressive cyst that can recur and expand into surrounding bone. Odontogenic Tumors: Ameloblastoma: A slow-growing but locally aggressive tumor, often presenting as painless jaw expansion. Non-Odontogenic Causes (other conditions) Benign and non infections Fibrous Dysplasia, Lesions, tissue destruction Trauma and Inflammatory Causes Bone remodelling, Infections Temporomandibular Joint Disorders (TMJ): Can cause joint-associated swelling and limited jaw movement. More factors include genetic related Management is excision antibiotics to fix these problems

Tumours to the Jaw

• Amlestocic carmiona of th jaw for nonodontogenci More causes Malicaciy Infections Traumal Symptoms rapid pain, numbness, bleeding Imaging test needed Multimodal approached needed Fix using surgery, radiation, chemo and grafting