What causes a deviated palate?

Causes of Deviated Palate

A deviated palate is primarily caused by congenital abnormalities, with cleft palate being the most common etiology, though trauma, tumors, and syndromic conditions can also lead to palatal deviation.

Congenital Causes

Cleft Palate

• Cleft palate is one of the most common congenital malformations affecting the palate, with an incidence varying from 1.3 to 25.3 per 10,000 live births 1
• Occurs due to incomplete fusion of the lateral palatine processes, the median nasal septum, and the median palatine process during embryonic development 2
• Can present as:
  • Complete cleft palate
  • Submucous cleft palate (often diagnosed late)
  • Isolated cleft palate (CPO)

Genetic Factors

• Approximately 50% of cleft palate cases occur as part of known genetic syndromes 1
• Several molecular pathways are involved in proper palate closure, including BMP, TGF-β, and SHH signaling pathways 1
• Risk for siblings and higher concordance in monozygotic twins suggest genetic etiopathogenesis 3

Syndromic Associations

• CHARGE syndrome: Coloboma, Heart defects, Atresia of choanae, Retardation, Genito-urinary abnormalities, and Ear anomalies 4
• Pierre-Robin syndrome: characterized by micrognathia, glossoptosis, and upper airway obstruction, with over 75% of patients also having palatoschisis 5
• Mandibulofacial dysostosis: includes Treacher Collins and Nager syndromes 5
• 22q11.2 deletion syndrome 5

Developmental Abnormalities

Choanal Atresia

• One of the most frequently observed congenital abnormalities of the nose (1 in 7,000-8,000 live births) 4
• Results when a widened vomer fuses with the narrow posterior nasal airway to form an atretic plate 4
• Can be purely bony (30%) or mixed bony and membranous (70%) 4
• Can affect palatal development and function

Facial Asymmetries

• Six categories of facial asymmetries can affect palatal development 4:
  1. Left-right difference in facial width
  2. Left-right difference of orbital level
  3. Rotation displacement of upper jaw/piriform aperture
  4. Isolated lateral placement of piriform aperture
  5. Non-horizontal alar base
  6. More pronounced facial asymmetry with midface slanting

Acquired Causes

Trauma

• Trauma during early childhood can lead to deviated palate development 4
• Can result in dilaceration (sharp curvature) of dental roots, which may affect palatal structure 4

Tumors

• Congenital teratomas originating from the nasal septum can interfere with fusion of palatal shelves 2
• Both benign and malignant tumors can cause deviation of palatal structures 4

Environmental Factors

• Maternal tobacco smoke exposure is strongly associated with cleft palate 1
• Maternal glucocorticoid exposure may increase risk 1
• Insufficient folic acid intake during pregnancy has been suggested to increase risk for cleft palate 3
• Advanced paternal age has been associated with increased risk 3

Clinical Presentation and Diagnosis

Signs and Symptoms

• Feeding difficulties, especially in infants 3
• Aerophagia requiring more frequent burping and slower feeding 3
• Speech articulation difficulties due to inability to generate intraoral breath pressure 3
• Hearing disorders due to chronic otitis media with effusion from eustachian tube dysfunction 3
• In submucous cleft palate: reduced palatal contraction (69.8%), lack of posterior nasal spine (55.7%), and bifid uvula (51.9%) 6

Diagnostic Approach

• Clinical examination of the oral cavity
• Radiographic examination (level I investigations like orthopantomography and intraoral radiography) for suspected dental morphology anomalies 4
• High-resolution CT scan to analyze individual anatomical topography 4

Management Considerations

• Multidisciplinary team approach including pediatric plastic surgeons, otolaryngologists, dentists, orthodontists, speech pathologists, and other specialists 5
• Surgical correction based on specific type of palatal deviation
• Early intervention for cleft palate, typically performed around 1 year of age 5
• Regular otologic monitoring throughout childhood due to higher incidence of middle ear disease 5
• Speech and language assessments beginning at 6-18 months 5

Understanding the specific cause of palatal deviation is crucial for appropriate management and to minimize long-term functional impairments in speech, hearing, and feeding.