CLEFT-PALATE AND CLEFT-LIP By W
i l l ia m
L. S h e a r e r , M .D ., D .D .S., O m aha, Nebr.
S H A L L not relate in detail the an atomy o f the palate, cleft and nor mal, but I shall try to point out the deviations observed in the cleft. T h e face is in progress of development in the human embryo from about the third week. From the front o f the cephalic mass, five tubercles bud, of which the middle one passes vertically downward. T h e middle tubercle is dou ble, and in it the intermaxillary bones, which contain the incisor teeth, are de veloped. From this fact, it is termed the “ incisive tubercle.” T h e rudimentary m axillary bones, which are widely separated, are devel oped at each side o f the incisive tubercle, but are not united with it. T h e fourth and fifth tubercles are separated in front and subsequently are united in the median line to form the mandible. A t the same time, the palate begins to be formed, by the approach toward the median line o f the two horizontal plates, developing from the m axillary processes on each side. I f the palatal processes of the m axilla unite in the median line and blend also with the incisive bones, and the vomer grows downward to meet the palatal processes in their line of union, the upper lip and jaw will be normal. If, however, the m axillary and the inter m axillary processes fail to unite, cleftlip and cleft-palate in one o f their many forms will be the result. I wish to point out the cause o f the deformity in question and to describe a practice as advised by the late Trum an
R ead before the Section on O ral Surgery, Exodontia and Anesthesia at the Eighty-First Annual Session of the American Dental Asso ciation, Milwaukee, Wis., July 19, 1939.
Jour. A.D .A., Vol. 27, April 1940
W. Brophy, after many years of experi ence in his hands, and also, later, by me, by which the defect can be overcome at a time of life when it can be corrected most successfully and easily. A great deal has been written on the causes of cleft-palate, much o f which has been largely theoretical. When we re view the literature, we find a great simi larity o f views among m any writers. Im perfect nutrition during the early months o f gestation is given as one of the causes. Heredity and prenatal impressions are given as other causes. T he condition o f the mouth of a child who has a congenital cleft-palate is de scribed th u s: “ W ant o f coaptation, re sulting from defective formation in the palatine plates o f the m axillary and pal ate bones, is the cause of congenital de ficiencies of the parts in question.” A g a in : “ T h e palate plates are arrested in their growth and permanent fissure o f the palate is the result. T h e principal effects from an absence of a portion of the palatine organs are an impairment o f the functions of mastication, degluti tion and speech.” T h e definition gener ally given for cleft-palate is: “ A con genital deform ity characterized b y a fissure or fissures o f the palate, due to arrested development.” In the foregoing quotations, we find the general opinion that congenital cleftpalate is the result o f incomplete de velopment o f the tissue necessary for its complete formation. T h e opinions thus expressed have been based, no doubt, on observations of the open space between the oral and nasal cavities. I agree with Dr. Brophy that the de formity is not the result o f “ defective
T h e Journal 0} the Am erican D en ta l Association
formation in the palatine plates,” “ con lower jaw on the palatal arch and which genital deficiencies of the parts in ques results in separation o f the bones. tion,” “ arrested growth o f the palate” H aving operated on more than 2,000 or “ absence of a portion of the palatine cleft-palate patients, about 600 o f whom tissue.” Children who have congenital were babies under 6 months o f age, I cleft-palate have, with rare exceptions, have found that the upper jaw , as com the normal amount of tissue in the palate, pared with the lower, is just as much although it is not united in the median broader than it should be as the distance line : it is a cleft. between the borders o f the fissure. When Congenital cleft-palate has a predispos we bring the borders o f the fissure into ing and an exciting cause. T h e predis contact, we have brought the upper jaw posing cause is heredity. T he exciting back to its normal breadth and to its cause is mechanical, the application of normal relation with the lower jaw. force in embryo. I have little faith in There are few exceptions to this state the theory that prenatal impressions ment, which was made by D r. Brophy cause failure o f union of the bones in many years ago, and with which I agree. question. In the greater number of cases In young infants who have cleftin which this cause has been given, it has palate, I have always found that slight been found that the mental shock oc forcing of the chin upward will cause curred subsequently to the time when, pressure of the lower jaw against the if the physiologic processes were not in segments of the upper jaw , springing the terfered with, union o f the bones would cleft bones apart. be complete. It is apparent that a m en Writers who have given a great deal have tal impression could not separate a su o f thought to the subject, who ture. Prenatal impressions m ay possibly dwelt at great length on its etiology and be a factor in failure o f union, but we who have proposed the more generous have no authentic evidence to that e f use o f phosphatic food for the mother during the period o f gestation have fect. I believe, however, that defective nu been unconscious o f the fact that the trition or general debility o f the mother bones are not, as a rule, defective in during the early months of gestation from structure or incomplete in development. any cause m ay delay union o f the palatal There is only failure o f union. plates. Nature does not fail to develop I have had five or six cases, however, the necessary bone and soft parts to form in which there apparently was a lack of a normal palate, but it does fail to bring tissue, but the condition has been so rare the parts into apposition and unite them. in m y practice as to be almost negligible. T h e bones having failed to unite prior Pediatric care is of great importance to the fifth month o f intrauterine life, in these cases. These children should be the mandible, as soon as the muscles of placed in the hands o f a well-trained mastication become active, brings pres pediatrician immediately. E very one of sure on the palato-alveolar inclined these cases is primarily a pediatric prob planes o f the ununited superior m axillary lem, and the m ortality rate can certainly bones, and, acting as a wedge, forces be greatly reduced if they are cared for them apart and widens the breach. by a competent pediatrician before and M oreover, the pressure o f the tongue and during surgical treatment. M an y times, the flexed position o f the head, with the before different societies, I have made symphysis o f the mandible resting on this plea, and today I make the plea the sternum, m ay contribute to some ex stronger than ever. tent to the force which is exerted by the M edical Arts Building.