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Functions of an oral cavity depend mostly on an opportunity to create the closed free space. For this purpose it is necessary that the anatomic structure and a functional condition of lips and the sky were normal. Otherwise there are defects of the speech, and also difficulty when chewing and swallowing liquid.
CREVICES OF THE LIP AND SKY
Frequency and prevalence. Crevices of a lip (labium leporium) and the sky occur at 1 of 600 — 1250 newborns. Genetic factors play a large role in emergence of a crevice of a lip (separately or in combination with rasshchelipy the sky), than in emergence only of a sky crevice. The lip crevice in combination with a crevice of the sky or without it occurs approximately at 1 of 1000 newborns, and is more often at boys whereas only the sky crevice — approximately at 1 of 2500 newborns and is more often at girls. The specified defects quite often are combined with other congenital anomalies and mental disturbances (is more often at a crevice only than the sky). This fact partially has a talk a hearing disorder at a crevice of the sky and considerable prevalence of this pathology among children with chromosomal anomalies. Data on risk of inheritance of crevices of a lip and the sky are provided in chapter 6.
Researches on animals showed that not only genetic factors, but also the damaging impacts on a fruit in a critical period of an organogenesis can be the cause of this pathology. The combined anomalies of a structure pablyudatsya especially often in the bodies coming from the 1st branchiate arch.
Clinical manifestations. A lip crevice варьируется^ from small cutting on a red border before the full discrepancy of fabrics taking a nose. Defect can be unilateral (more often at the left) or bilateral; usually the alveolar arch is involved in process. The deformed, accessory teeth or an adeptiya are observed.
Discrepancy of wings of a nose at a labium leporium is often combined with changes of a nasal partition and lengthening of a share, causing a protrusion of a front surface of the split alveolar shoot (fig. 12-2).
The crevice of the sky can arise separately or in combination with a labium leporium. The isolated crevice passes across the average line; at the same time it can involve only a uvula or take also soft and bone tissues of the sky up to a doreztsovy opening. At a combination to a labium leporium defect, beginning on lips, takes a soft and hard palate from one or two parties and the pas one or both nasal cavities (a unilateral or bilateral crevice of the sky) extends.
Treatment. The measures which are carried out from the moment of the birth are aimed at providing normal food, the prevention of aspiration and an infection. Concerning most of newborns these measures are reduced to feeding of the child in vertical position and to use of elastic pacifiers with a little expanded opening. In certain cases the child needs to be fed by means of a dropper or a gastric tube. The special nipples or plastic obturators closing a sky crevice usually are not required, but sometimes they can be useful.
Fig. 12-2. A double crevice of a lip and the upper sky at the child of 2 months. Growth between crevices is visible.
Surgical correction of a crevice of a lip is carried out, as a rule, at the age of 1 — 2 month on condition of a normal increase of body weight and lack of local or widespread infectious process. The Z-shaped plastics is most often applied (such form of a seam allows to minimize deformation of a lip at retraction of cicatricial fabric). At once after operation impose the tire of Logan (a wire arch which is pasted to cheeks) with the purpose to reduce tension in the field of a seam. If necessary the repeated cheiloplasty is carried out in 4 — 5-year age. In most cases cosmetic operations for defects of a nose postpone until achievement of teenage age. Results of operation depend on the size of defect, existence of consecutive infection and skill of the surgeon.
As sky crevices considerably differ in a form, the sizes and extent of deformation, resolve an issue of time of carrying out surgical correction in each case individually. Consider such criteria as crevice width, full value of segments of a palatal bone, a structure of surrounding educations (for example, stomatopharynx width), a functional condition of the neuromuscular device of a soft palate and walls of a throat. The purpose of surgical intervention — to connect the split segments, to achieve good diction and to avoid injury of the growing upper jaw. The optimum age for operation in the sky varies from 6 months to 5 flyings, at the same time consider the favorable changes connected with growth of a palatal bone. If surgical correction is carried out at 3-year age, then before operation it is possible to use the special obturator. He is fixed to back upper teeth in such a way that at reduction of muscles of a throat it comes in contact with surrounding fabrics, closing nasopharyngeal space and helping thereby the child to speak distinctly. Almost always the crevice takes an alveolar arch that influences development of teeth. Instead of the absent teeth it is necessary to establish prostheses; besides, there can be a need to improve the wrong situation of teeth.
Before - and postoperative maintaining patients. Even the suspicion on an infection is contraindication to operation. At a normality of food of the child and a water salt metabolism it is possible to allow feeding in 6 h after operation (section 5.31). In the early postoperative period special leaving is necessary. Careful aspiration of contents of a nasopharynx reduces probability of such frequent complications as an atelectasis and pneumonia. The main task in the postoperative period — ensuring purity in the field of a seam and the prevention of its tension. For this child it is necessary to feed through a dropper and to fix hands by means of elbow cuffs. The liquid or semi-fluid food is given during 3 weeks, using a spoon or a probe. It is necessary to watch that the child did not thrust into a mouth of a hand and foreign objects.
Complications. Often recurrent average otitis and a hearing loss meet. The expressed destruction of teeth demanding special treatment is quite often observed. At the shift of a maxillary tooth arch or the wrong position of teeth usually resort to orthodontic methods of correction.
Defects of the speech can remain even after recovery of anatomic integrity of the sky. The nasal shade when pronouncing many sounds is characteristic of such speech. Defects of diction before operation (and sometimes and after it) are caused by nonsynchronous action of muscles of the sky and a throat. A soft palate, and also lateral and back walls of a throat form the gate which separates a nasopharynx from a stomatopharynx at the time of swallowing and pronouncing certain sounds. If this gate functions badly, in a mouth it is impossible to create pressure necessary for an articulation of such "explosive" sounds as p, t, d, x, and hissing with, sh, h; words with these sounds are pronounced muffledly. After operation or installation of the speech obturator the help of the logopedist can be required.
The full program of rehabilitation of the child with a crevice of a lip or the sky can last many years. Various specialists have to participate in it: pediatricians, surgeons, otorhinolaryngologists, prosthetists, orthodontists, logopedists, psychologists, psychiatrists and social service providers. Ideally the family doctor has to carry out all work on consultation of parents and coordination of efforts of various specialists.
The alalias characteristic of the child with a sky crevice, can be caused by other bone and neuromuscular disturbances. Inability to form a dense muscular partition between a stomatopharynx and a nasopharynx during the swallowing or the speech is the cornerstone of them. Such pathology can be caused both by changes of a structure of the sky and a throat, and defect of the muscles which are attached to them. The adenoidectomy can cause an alalia in earlier normally speaking child if it has not recognizable submucosal crevice of the sky. It is supposed that adenoides, eminating in upper part of a throat, carry out static function — contacting to the lifted soft palate, they promote creation of a dense partition. After removal of adenoides it becomes impossible. If the neuromuscular device possesses a sufficient reserve, then the palatopharyngeal movements are compensated and defect of the speech disappears though often some signs of palatopharyngeal insufficiency remain. In other cases slow involution of adenoides provides gradual compensation of function of muscles of the sky and a throat. These can explain lack of explicit defects of the speech at some children with the submucosal crevice of the sky or other pathology contributing to palatopharyngeal insufficiency. The adenoidectomy should not be carried out if there is a submucosal crevice of the sky or potential palatopharyngeal insufficiency.
Clinical manifestations. Complaints at palatopharyngeal insufficiency same, as at a sky crevice though objective signs are various. Explosive and some "slot-hole" concordants (p, d, t, x, in, f, c) sound with a nasal shade; the strengthened movement of nostrils is noted during the speech; the child cannot whistle, rinse a throat, blow out the candle, inflate a ball; release of liquid through a nose at water drink with the hung head is possible, cases of average otitis and a hearing loss are frequent. At research of an oral cavity it is possible to find a crevice of the sky or rather short sky and a wide stomatopharynx; the movements of muscles of a soft palate and a throat at phonation or an emetic reflex are absent, are asymmetric or expressed in the minimum degree. Besides, at survey it is possible to diagnose a submucosal crevice of the sky. The last is confirmed by bifurcation of a uvula, existence of a transparent membrane on the average stone pine of a soft palate (that testifies intermittence of muscle fibers) palpatorno determined by a hollow by the rear edge of a hard palate instead of a nasal crest, a V-shaped form of a soft palate, and also shift it forward at phonation or gagging.
Palatopharyngeal insufficiency can be revealed by means of a X-ray analysis. When shooting the head of the patient has to be strictly in a lateral position. The first picture is done at rest, and the second when the patient says a long sound of "u-u-u". Normal the soft palate contacts to a back wall of a throat while at palatopharyngeal insufficiency such contact is absent.
Treatment. In some cases make a retroposition of the sky or a fariigoplastika with use of a rag from a back wall of a throat. With success use also special speech obturators.
Fangs have generally conical shape. Their durability and stability depend on communication with an alveolar bone and on a condition of a periodontium which fibers connect fangs to a bone. Except for normal change of teeth, their loss or loss happen owing to an injury or systemic lesion. At the differential diagnosis of not physiological dedentition it is necessary to remember a scurvy, osteomyelitis of jaws, juvenile periodontitis, a dentine dysplasia, a leukosis, an acrodynia, deficit of vitamin D, vitamin-B-refractory rickets, a hypophosphatasia, Papiyon's syndrome — Lefebvre (a palmar and bottom hyperkeratosis, disturbance of structure of an alveolar bone) and a reticuloendotheliosis.
Insufficient hygiene of an oral cavity can create conditions for emergence of more severe defeats of a periodontium. The inflammation of gingival edge is capable to lead to irreversible changes of capillary vessels. It arises owing to accumulation of microorganisms in gingival pockets and the damaging effect of microbic toxins. If the epithelial barrier is damaged, then more expressed ipfektion chastichpo destroy a periodontium or an alveolar bone. The measures directed to prevention of formation of plaques allow to reduce defeat of a periodontium considerably.
Periapical infection (alveolar abscess). Deep caries or an injury break blood supply of tooth owing to what it becomes impractical; this process can proceed without serious consequences. Such tooth gets gray coloring, is loosened, there is a sensitivity when chewing. Local hypostasis and reddening of a mucous membrane are usually connected with an infection around a root of lifeless tooth which can lead to formation of the fistulas seen on alveoluses at the level of tops of roots. The periapical infection of milk teeth can lead to defeat of rudiments of second teeth. Inflammatory exudate happens the reason of decalcification of enamel of rudiments of second teeth. At infection normal process of a resorption of roots of milk teeth is broken that adversely affects a prorezyvaniye of constants.
The uncured persistent periapical infection of lifeless tooth can become a background for development of acute infectious process. Control of a dental health has to become part of usual pediatric research. It is necessary to sanify also channels of milk teeth; it is especially important at a retention of second teeth. If necessary to extract the affected tooth it is necessary to liquidate previously acute symptoms to warn bacteremia and penetration of an infection into surrounding fabrics.
Retinirovanny teeth. Retention of teeth is quite often observed at children. Already cut through second tooth takes the place which other second tooth has to occupy in the available limited space of an alveolus. This phenomenon is usually observed in the field of upper canines and the third a niya "shkh painters. Retinirovanny tooth holds the wrong position in a jaw because its prorezyvaniye is disturbed by earlier cut through tooth. Retinirovanny tooth is cut through ektopicheskv or resolves. The specified process often is followed by pains. If there are no contraindications, all retinirovanny teeth need to be extracted. In that case when such teeth are not extracted, their development should be controlled periodically by means of a X-ray analysis to avoid complications.
Dermoidiy cysts. The Retinirovanny teeth which were late in an alveolar bone for a long time are a source of development of dermoid cysts. Most often the third lower painters and upper canines are involved in this process. On roentgenograms the crown of not cut through tooth is surrounded with accurately delimited zone. The dermoid cyst can displace tooth with which it is connected, for example to bottom edge of a mandible or to a nasal cavity bottom. At this defeat it is necessary to carry out enucleation or a curettage as the cysts proceeding from an enamel epithelium can turn into ameloblastomas. If immediate extraction is fraught with development of complications, it is possible to be limited to marsupialization *.
* Podshivaniye of edges of a wall of the opened cyst to edges of an operational wound with the subsequent healing by filling of a cavity with granulations. — Primech. lane.