DEVELOPMENTAL ANOMALIES OF ORAL CAVITY

CLEFT LIP/PALATE

ORAL TORI
Torus palatinus

Nodular or lobular bony growth in the midline of the

hard palate
Surgical removal if for maxillary denture construction
Midline bony growth in the palate.
Commonly seen in adults
Harmless

Torus mandibularis
Bony growths on the lingual aspect of mandible in the
region of the premolars

subdivided into PARTIAL AND COMPLETE CLEFT LIP

They could occur in isolation (cleft lip only) or they could go together as cleft lip and palate.
Complete cleft lip and palate
if it goes beyond the area of nostril, involving the nasal cavity
Incomplete cleft lip and palate
if it doesnt involve nasal cavity or it didnt go beyond incisive foramen and only involves secondary palate

Prognathism Forward displacement

of lower jaw. Underdevelopment of
maxilla or overdevelopment of
mandible or class 3 occlusion

Cleft lip could be unilateral or bilateral

More commonly occurs in the left but it could also occur in the right

Macroglossia In Down Syndrome

Cleft lip and palate is usually genetic

If one of the parents has this, their child would have a 70-80% chance of having it as well.
There IS FAILURE OF FUSION OF THE NASOMAXILLARY CREST AND BUCCOPHARYNGEAL CREST during the embryonic
period
When do we correct cleft LIP? We use the rule of 10s for cleft lip.

If indicated, do surgery

Congenital malformation that is usually gets noticed

when the child is already a teenager or during adulthood
when they get fitted for dentures.
We just drill or burn these to flatten out the area.
A common problem is that it is prone to trauma when
they eat because the MUCOSA IS THINNED OUT.
Just reassure patient. No surgical corrections are done
because these are bony overgrowths. Patient may only
have problems with their dentures, with the denture
edge causing trauma.

These bony overgrowths can be seen in mandible as well

(at medial, lateral or vestibular side of mandible). But
most commonly seen at the palate. Upon palpation, you
feel something hard, just reassure the patient that it is an
oral torus. However, sometimes, you can also have
tumors that are cystic so you have to rule out salivary
gland tumors. But if it really is Bony, then that is torus

OTHERS
Micrognathia Underdeveloment of
lower jaw. Class 2 occlusion

10 weeks old
10 g/dL Hemoglobin
10 pounds

WBC not more than 10,000 (in somebooks, but not a major consideration)
For, surgical correction of cleft PALATE, it is done before 2 years old, before onset of speech.
Cleft palate can be:

incomplete cleft of the primary palate (rare).

bilateral cleft of primary palate
complete (bilateral or unilateral) cleft involving both primary and secondary palate
Incomplete cleft of secondary palate

If only soft palate is involved, and not the hard palate

Sometimes patients with cleft lip and palate could also have bifid uvula (submucosal cleft)
Patients with bifid uvula will also have speech abnormalities such as nasal thwang
Patients with cleft palate will also have middle ear infections because of the muscles involved in the palate - the tensor vela
palatini and levator vela palatini. So you need to assess hearing
May involve only the vermilion border of the upper lip or may extend to involve the nostril and the hard and soft palates
50% of all maxillofacial clefts: Combination of cleft lip and cleft palate comprises
25% of all maxillofacial clefts: Isolated cleft lip or cleft palate is only

Micrognathia, prognathism and

malocclusion are
abnormalitites within
mandible.
Ankyloglossia
- Tongue-tie. With ankyloglossia
(Tongue tied), you have very thick
mucosa within lingual frenulum. So if
you ask the patient to stick his tongue
out, it will form a heart shape. But it
depends on severity of ankyloglossia.
This will give the child problems with
speech, or what we call "pitla". This
should be corrected before 7 years
old, so that the speech problems could
be corrected as well. If beyond 7 years
old, the brain is already mature, so
whatever the child has learned before
7 years old, ara na gid na ya.

Cleft lip, with or without

cleft palate

o 1 per 1000 births

o Increasing incidence
o High incidence in
Orientals,
blacks

low

Isolated cleft lip

o Unilateral or bilateral
o If unilateral, L>R
o If with cleft palate, usually

in

BILATERAL
Cleft lip-cleft palate is
more common in MALES

Isolated cleft palate

o 30% have associated
congenital anomalies
o More common in
females, Orientals

Cleft uvula

o Incomplete form of cleft

palate

o 1 per 80 whites, high

among American Indians

Otitis media is almost universal in infants under 2 yrs with unrepaired clefts
Angular as compared to linear incisions are preferred. In bilateral clefts, lip closure is accomplished in two stages
Bridge flap technique (von Langenbeck)
Pedicle flap technique (Veau)
o Lengthening of soft palate is accomplished using the push-back procedure
Velopharyngeal closure
o is important for speech and deglutition and blowing, if not achieved, foods and liquids may be directed into the
nasopharynx during deglutition. Evaluation of velopharyngeal closure is through speech itself

o
Associated developmental anomalies:
o Facial clefts
o Acrocephalosyndactyly (Apert Syndrome)
turribrachycephaly associated with syndactryly of the hands and feet
o Craniofacial Dysostosis (Crouzon syndrome)
underdevelopment or flattening of the middle of the face associated with relative mandibular prognathism and a
beaklike nose. Maxillary teeth are crowded, arch is V- shaped. Exophthalmos is a constant feature. It is Autosomal
dominant.

Mandibulofacial Dysostosis (Treacher Collins Syndrome)

autosomal dominant. Characterized by anomalies of the eye, abnormalities of the external and middle ears and hypoplasia
of the mandible and malar bones

CYSTS OF JAW/ORAL CAVITY

ODONTOGENIC CYST

A cyst is a cavity lined with epithelium. It is odontogenic if it comes from dental lamina, primary involving the teeth.
DENTIGEROUS CYST

o associated with unerupted tooth

o Surrounds the crown of an unerupted
tooth of either the regular (95%) or
the supernumerary dentition.
o Arises through alteration of the
reduced enamel epithelium after the
crown has been completely formed.
o Usually solitary. Suspect Nevoid Basal
Cell Carcinoma Syndrome if multiple.
Usually involves the ff teeth:
Mandibular third molar

ERUPTION CYST

GINGIVAL AND PALATAL CYST OF

NEWBORN

o Uncommon type of dentigerous

o White to yellowish white and

cyst associated with erupting

deciduous or rarely permanent
teeth.
o Accumulation of tissue fluid or
blood in a dilated follicular space
about the crown of an erupting
tooth.

with inclusion cysts.

o Become superficial and usually
rupture in the first few weeks of
life.
o Degeneration of dental lamina
remnants.

Maxillary canine
Maxillary third molar
Second mandibular
premolar

RADICULAR CYST

NEOVID BASAL CELL CARCINOMA

SYNDROME

o Most common oral cyst

o Inflammatory in origin
o Apical granuloma (mass of

o Multiple keratocysts with

inflammatory tissue) contains

epithelial rests of Malassez which
coalesce and become cystic
o Often symptomless
o Involves dental caries
o We request dental x-rays (panoramic)
to visualize cysts involving the roots
of teeth
o Treatment is surgical
o Removal of carious tooth if it is a
radicular cyst

multiple cutaneous nevoid basal

cell carcinomas and numerous
skeletal and other anomalies
o Autosomal dominant

NON-ODONTOGENIC CYST

noted along the incisive canal or embryonal fissure

INCISIVE CANAL CYST

Closed, epithelium-lined intrabony sac

Called cyst of the palatine papilla if

below the incisive foramen

th
th
Usually present in 4 to 6
decade of life

Painless unless infected

Often manifest with enlargement
of the palate

NASOALVEOLAR CYST

Klestadts cyst
Probably arising from epithelial rests located at the junction
of the globular, lateral nasal, and maxillary processes

Situated in the attachment of the ala of the naris

Not located within bone
May cause enough facial swelling to obliterate the
nasolabial fold on the involved side

Attached to the nasal mucosa

Clearly demonstrated with the use of an radiopaque dye

DERMOID AND EPIDERMOID CYST

Developmental cyst lined by epidermis and cutaneous

appendages

Incorporation of ectoderm at the time of closure of

embryonic fissures during the third to fourth week in
utero
Commonly arise in the floor of the mouth
Commonly originate above the mylohyoid muscle
May cause elevation and displacement of the tongue

RETENTION CYST

Rupture of a duct of a minor salivary gland

Occurs most often on the mucosal surface of the
lower lip

Cyst of Blandin-Nuhn ventral surface of the tip

of the tongue

Ranula involves the sublingual salivary gland

MOST COMMON
Usually brought about by trauma, kung ma kagat
sang patient. There is blockage of minor salivary
gland, leading to extravasation of fluid outside
the salivary gland, then there will be formation of
cyst

Treatment is excision

LICHEN PLANUS
Thickened white patch which can occur
anywhere in the oral mucosa
Premalignant lesions
Can appear in the buccal mucosa if the
patient is a smoker
Always perform biopsy if you see this in
your patient
Appear on buccal mucosa, tongue,
gingiva, and lips
May precede appearance of
cutaneous lesions by several years
Wickhams Striae fine
lacework of white reticular
hyperkeratotic papules
On tongue, begins in posterior area
and spread anteriorly
Asymptomatic, metallic taste

DISORDERS OF THE ORAL MUCOSA

APHTHOUS ULCER
PYOGENIC GRANULOMA
Common condition

Tumor of pregnancy
Small, round, or ovoid lesions with a circumscribed

Benign, rapidly growing vascular mass

margin, erythematous halos and yellow or gray
noted in the oral cavity
floors.

Usually seen in the interdental papillae,

Recurrent
most likely odontogenic
Can occur solitary or multiple lesions

Occurs in 5% of pregnant women

If recurrent and solitary but in different places, it can

Would usually complain of bleeding

be inflammatory; has multifactorial causes

Treatment is antibiotics and surgical

if it occurs in the same place and doesnt disappear,
removal
rule out malignancy by doing biopsy

Recurrent Aphthous Stomatitis

Unknown etiology but maybe Pleomorphic
transitional L for of alpha-hemolytic strep.
Definitely not viral
Recurrent, maybe autoimmune
Ulcer is covered by grayish white fibrinous
exudate and surrounded by a bright red halo
Lasts for one to two weeks and heals without
scarring
Xylocaine and Tetracycline may offer relief
Causes
Bacterial

Acute necrotizing ulcerative

gingivostomatitis

Streptococcal
Oral tuberculosis
Gonococcal
Stomatitis

Syphilis
Fungal

Oral Candidiasis
Histoplasmosis
Viral Infections

Herpes simplex
Recurrent herpes simplex

ERYTHEMA MULTIFORME
Acute, recurrent, self-limited
eruption of the skin and
mucus membranes
Probably a hypersensitivity reaction
Mucus membranes and joints
may be involved in severe cases
Steven Johnson Syndrome (toxic,
acute, febrile course)
Precipitating factors: viral
disorders especially herpes
simplex and mycoplasma, drugs
especially sulfonamides

CANDIDIASIS
Neonatal monilial stomatitis
th
th
present on the 5 to 6
postpartum day
Therapeutic use of
antibiotics increased the
incidence of candida
infections
Superficial monilial stomatitis
inflamed white mouth
Denture stomatitis
swelling, sensitivity, and
pain of the oral mucus
membrane at points of
denture contact
Treat with: Improved oral
hygiene, nutrition
(especially iron), Nystatin

 Varicella zoster virus

Autoimmune: SLE, Behcet's, Reiters
Allergy Steven Johnsons syndrome
Trauma
For treatment usually gives a concoction of
antibacterial, anti-inflammatory (steroids like Celesta
mine), antifungal (NY statin) dissolved in 1 glass of
water and ask the patient to gargle. Its more of a
topical application. This is given to dry out the lesions.
Shotgun treatment since there is no single etiologic
agent; doc treats with a combination of antifungal,
antibacterial and anti-inflammatory (steroids) through
a mouthwash

Minor ulcer if less than 10 mm

Major ulcer if more than 10 mm

ORAL TUMORS
Benign tumors that can behave like malignant tumors

ODONTOGENIC TUMOR
(AMELOBLASTOMA)
On x-ray, you will find multiple cystic masses (bubble soap appearance)
1% of the tumors and cysts of the jaw
Epithelial lining of a dentigerous cyst, remnants of the dental lamina of the enamel organ, basal layer of the
oral mucous membrane
This is a slow growing tumor. When it is enlarged it thins out the bone and disfigures the face.
Can be solitary or multiple loculated masses which explains the soap bubble appearance.
The patient will not consult with you because of pain because it is painless, but will consult because of
disfigurement or until such time that he/she already has difficulty of breathing.
Treatment is surgical.
Surgical reconstruction is impossible in large tumors and very expensive (plates). So they resort to using
antivac(???) or a floating mandible. There will be problems in swallowing
Most commonly occurs in 20-49 yrs old, ave 39
Arise in mandible in 90%, molar ramus area in 70%
Canine and antral areas are susceptible in the maxilla
Surgical resection or hemisection is treatment of choice. Insensitive to radiation

BONE DISORDER AFFECTING JAW

(FIBROUS DYSPLASIA)
Monostotic (single bone involvement) is the most common type
Polyostotic associated with McCune-Albright syndrome
Usually involves the femur, tibia, fibula and pelvic bones
Radiation should not be employed because it predisposes to malignant development
Begin in childhood and usually burn out in adolescence
Maxilla more frequently involved than the mandible
Radiographically, jaw lesion is dense, resembling ground glass with poor demarcation from normal bone

ACUTE TONSILLITIS
Inflammatory reaction of the tonsils which can be secondary to
a bacterial/ viral infection
Etiologic agents

B-hemolytic streptococcus (most common)

Fever

Bilateral hypertrophied tonsils

Staphylococcus
Pulmonitis diplococcus
Hemophilus influenzae
Adenoviruses
Rhinoviruses

Herpes simplex
Symptoms
General body malaise

DISEASES OF OROPHARYNX
PERITONSILLAR CELLULITIS AND ABSCESS
Recurrent tonsillitis involving the adjacent areas
seen in older children with history of tonsillar infection, not seen
in children of younger ages
Always presents with odynophagia, dysphagia and speech
abnormalities (sweet, este hot potato voice)

Etiology

Infections of the tonsil proceed to diffuse cellulitis that could

lead to peritonsillar abscess

May occur rapid or late

Unilateral and more common in older children and young

adults

Symptoms: marked dysphagia, pain referred to the ear in the

involved site, increased salivation, fever, drooling

Odynophagia
Dysphagia
Otalgia - referred pain

Sign
(+/-) pus - pus in exudative tonsillitis

Symptoms

Swelling interferes with articulation and speech is difficult

Inspection is difficult due inability to open mouth

Tonsil may appear normal as it is pushed medially and swelling

develops lateral to tonsil

Palpation distinguishes an abscess from cellulitis

(+) tender lymph nodes

You can differentiate this from pharyngitis with the
congestion of pharynx without tonsillar enlargement or
tender lymph nodes. Same treatment as pharyngitis.

Most common cause is beta hemolytic strep group A

There is general inflammation and swelling of the tonsil tissue with an
accumulation of leukocytes, dead epithelial cells and pathologic
bacteria
Treated with bed rest, adequate fluid intake and a light diet
Three glassfuls of gargling warm solutions every two hours
o Isotonic saline solution and sodium perborate powder
o Penicillin is drug of choice

Pathophysiology

Suppurative infiltration occurs most often in supratonsillar fossa

Causes edema of soft palate and displacement of uvula across

midline (inflammatory processes push the uvula to the
contralateral side)

Swelling extends to adjacent soft tissues, causing painful

swallowing
Bacteriology

Throat cultures are ineffective

Culture of the actual abscess is ideal through aspiration

More common bacteria Streptoccocus pyogenes; less common

Staph. aureus
Treatment

Surgical incision and drainage or needle aspiration technique

ACUTE PHARYNGITIS

Strep, pneumococci and influenza bacillus as causes

Hyperemia first then edema and increased secretion
Vesicles suggest herpes
Dryness or scratchiness of the throat
Headache
Fever
Pharyngeal wall is reddened and may have a dry, glazed
appearance and a coating of mucoid secretion
Treat with antibiotics and warm irrigation

When pus is collected peritonsillar abcess

o diagnostic, we release the pressure lessening the
pain and easing the swelling

When no pus is collected peritonsillar cellulitis

o if cellulitis, use three point needle aspiration, use
a large bore needle (gauge 18) and aspirate at
the junction between the soft palate and tonsillar
area, when we do this
Antibiotics and warm saline irrigation
Always advise admission, for aggressive treatment

Peritonsillar cellulitis and abscess (Quinsy)

Infection of tonsil proceed to a diffuse cellulitis of the tonsillar area
extending onto the soft palate

Manifestations of peritonsillar abscess: fever, sore throat, trismus

(muscle spasm making it difficult to open the jaw), adenopathy

Abscess requires drainage

When no pus is found, usually you are dealing with cellulitis rather
than a frank abscess

For repeated peritonsillar abscess or repeated pharyngitis, do

tonsillectomy

DEEP NECK SPACE INFECTION

Etiology

1.
2.
3.
4.
5.
6.
7.
8.
9.

Dental infection
Tonsillar and peritonsillar infection
Trauma of upper aerodigestive tract - iatrogenic on esophagoscopy on removal of foreign bodies
Retropharyngeal lymphadenitis
Potts disease
Sialadenitis
Bezolds abscess
Infection of congenital cyst and fistula
Intravenous drug abuse

PARAPHARYNGEAL SPACE INFECTION

Most common cause: Peritonsillar infection

may present as such, except that there is trismus
There is swelling at the lateral area of the buccal mucosa
Patients usually have history of recurrent tonsillitis
There is unilateral enlargement of the tonsils
Patients come to your clinic with a hot potato voice
These patients need to be admitted and started on IV antibiotics because they are at risk for airway obstruction
Typical finding
Trismus - limitation in opening of the mouth, less than two finger wide, if more than two fingers it is different
Angle mandible swelling
Medial displacement of lateral pharyngeal wall
Can present as upper airway obstruction so advise patient for admission to start antibiotics and assess for airway patency (tracheostomy for emergency cases)

Treatment
Evaluate and maintain airway & fluid hydration
Parenteral antibiotic high dose 24-48 hrs.
If not improve, consider surgical drainage - prophylactic tracheostomy
Pharyngomaxillary (Parapharyngeal) Space Infection
Marked trismus
Neck becomes swollen near the angle of the mandible
Complications include Septic thrombophlebitis, hemorrhage from erosion of the internal carotid artery
SUBMANDIBULAR SPACE INFECTION

Most common cause: Dental caries

Anterior teeth and first molar: infection enter sublingual space
Second and third molar: infection enter submaxillary space
If it involves the swelling of the whole submandibular space, it can be bilateral leading to Ludwigs angina

LUDWIGS ANGINA

Clinical features
Start unilateral and progress bilaterally
Induration of submandibular region and floor of mouth (severe cellulitis)
Tongue thrust posteriorly and superiorly (cause airway obstruction; do standby tracheostomy because you cannot do intraoral intubation)
Drooling, odynophagia, trismus, fever
No purulence(due to no time to develop) - more of cellulitis; very rigid if palpated like wood
Usually with history of tooth extraction
Treatment
Early stage (unilateral, mild swelling and edema)
IV antibiotic, extraction of infected tooth
Advance stage (bilateral swelling, dysphagia with drooling)
Early airway intervention
Surgical drainage (submandibular incision and IV
antibiotics)

Cellulitis or phlegmonous inflammation of the superior compartment of the suprahyoid space

Forces the tongue upward and posteriorly causing airway obstruction

Usually a result of infection of dental origin

RETROPHARYNGEAL SPACE INFECTION

Only lymph nodes are located in this area

Most common case is Kochs infection
Patients would usually come to you with dysphagia, odynophagia and drooling
and when you check the throat, the tonsils are not enlarged and there will be
trismus

Clinical features

In children

Request for soft tissue lateral x-ray of

the neck,
at level of C2 and C7

In adult

Fever, sore throat, odynophagia, neck tenderness, dyspnea

Lateral neck film

MASTICATOR SPACE INFECTION

PARTOID SPACE INFECTION

Irritability, neck rigidity, fever, drooling, muffled cry, airway

compromise, stridor (rapid onset)

C2 > 7 mm both children and adult

Detection of mediastinitis

C7 > 14 mm in children, 22 mm in adult

Chest film

Most common cause: Dental caries

Clinical features
Extreme trismus with minimum facial swelling
Masseteric space (lateral compartment):
Edema at ramus of mandible
Ptrygomandibular space (medial compartment):
Edema at retromolar trigone
request for CT scan of the neck, can be mistaken for tetanus
Most common cause: Bacterial retrograde from oral cavity
Clinical features:
High fever, weakness, marked swelling and tenderness of parotid gland,
fluctuation, pus at Stensens duct
Treatment : antibiotics and airway management
Parotitis
Acute suppurative parotitis sudden onset of pain and swelling of
the parotid region usually cause by coagulase negative S. aureus.
Immediate treatment with IV antibiotics is necessary

Most common cause:

In children

Retropharyngeal lymphadenitis, infections (Potts disease)

In adults

Regional trauma and endoscopic procedure

Treatment

Admit patient Complication can be mediastinitis

IV antibiotics

Airway

Irrigation and Drainage

Retropharyngeal abscess

Primarily in infants or children less than 2

Unexplained fever following an upper respiratory infection

Loss of appetite, change in speech, difficulty swallowing

Drain abscess, protect airway

Masticator abscess
In close proximity to the pharyngomaxillary space
Involves the internal pterygoid muscle, masseter and ramus of
the mandible
Treated initially and vigorously with appropriate antibiotics

Complications

Internal jugular vein thrombosis

Cavernous sinus thrombosis
Neurologic deficit
Osteomyelitis of the mandible
Osteomyelitis of the spine
Mediastinitis
Pulmonary edema
Pericarditis
Aspiration
SepsiS