Msx1 deficiency interacts with hypoxia and induces a morphogenetic regulation during mouse lip development

Nonsyndromic clefts of the lip and palate are common birth defects resulting from gene-gene and gene-environment interactions. Mutations in human MSX1 have been linked to orofacial clefting and we show here that Msx1 deficiency causes a growth defect of the medial nasal process (Mnp) in mouse embryos. Although this defect alone does not disrupt lip formation, Msx1-deficient embryos develop a cleft lip when the mother is transiently exposed to reduced oxygen levels or to phenytoin, a drug known to cause embryonic hypoxia. In the absence of interacting environmental factors, the Mnp growth defect caused by Msx1 deficiency is modified by a Pax9-dependent 'morphogenetic regulation', which modulates Mnp shape, rescues lip formation and involves a localized abrogation of Bmp4-mediated repression of Pax9 Analyses of GWAS data revealed a genome-wide significant association of a Gene Ontology morphogenesis term (including assigned roles for MSX1, MSX2, PAX9, BMP4 and GREM1) specifically for nonsyndromic cleft lip with cleft palate. Our data indicate that MSX1 mutations could increase the risk for cleft lip formation by interacting with an impaired morphogenetic regulation that adjusts Mnp shape, or through interactions that inhibit Mnp growth.

Face morphogenesis is promoted by Pbx-dependent EMT via regulation of Snail1 during frontonasal prominence fusion

Human cleft lip with or without cleft palate (CL/P) is a common craniofacial abnormality caused by impaired fusion of the facial prominences. We have previously reported that, in the mouse embryo, epithelial apoptosis mediates fusion at the seam where the prominences coalesce. Here, we show that apoptosis alone is not sufficient to remove the epithelial layers. We observed morphological changes in the seam epithelia, intermingling of cells of epithelial descent into the mesenchyme and molecular signatures of epithelial-mesenchymal transition (EMT). Utilizing mouse lines with cephalic epithelium-specific Pbx loss exhibiting CL/P, we demonstrate that these cellular behaviors are Pbx dependent, as is the transcriptional regulation of the EMT driver Snail1. Furthermore, in the embryo, the majority of epithelial cells expressing high levels of Snail1 do not undergo apoptosis. Pbx1 loss- and gain-of-function in a tractable epithelial culture system revealed that Pbx1 is both necessary and sufficient for EMT induction. This study establishes that Pbx-dependent EMT programs mediate murine upper lip/primary palate morphogenesis and fusion via regulation of Snail1. Of note, the EMT signatures observed in the embryo are mirrored in the epithelial culture system.

Genetic heterogeneity in Van der Woude syndrome: identification of NOL4 and IRF6 haplotype from the noncoding region as candidates in two families

Van der Woude syndrome (VWS) shows an autosomal dominant pattern of inheritance with two known candidate genes, IRF6 and GRHL3. In this study, by employing genome-wide linkage analyses on two VWS affected families, we report the cosegregation of an intronic rare variant in NOL4 in one family, and a haplotype consisting of three variants in the noncoding region of IRF6 (introns 1, 8 and 3'UTR) in the other family. Using mouse, as well as human embryos as a model, we demonstrate the expression of NOL4 in the lip and palate primordia during their development. Luciferase, as well as miRNA-transfection assays show decline in the expression of mutant NOL4 construct due to the creation of a binding site for hsa-miR-4796-5p. In family 2, the noncoding region IRF6 haplotype turns out to be the candidate possibly by diminishing its IRF6 expression to half of its normal activity. Thus, here we report a new candidate gene (NOL4) and a haplotype of IRF6 forVWS, and highlight the genetic heterogeneity of this disorder in the Indian population.

Nasolabial dimensions of the facial profile at 20 to 37 weeks' gestation on 2- and 3-dimensional sonography in normal Korean fetuses

OBJECTIVES

The purpose of this study was to evaluate normal nasolabial dimensions using the images of facial profiles in normal Korean fetuses.

METHODS

We conducted a cross-sectional study of 355 normal fetuses at 14 to 39 weeks' gestation. After the exclusion of inadequate images and inadequate numbers of fetuses at 14 to 19 and 37 to 39 weeks' gestation, the sonographic facial profiles from 222 fetuses at 20 to 37 weeks' gestation were evaluated. Five parameters, nose length, nose protrusion, pronasal-subnasal distance, distance between the upper philtrum and mouth, and distance between the tip of the nose and mouth, were measured and are presented according to gestational age. Data were analyzed by intraclass correlation coefficients and regression analysis.

RESULTS

There were significant linear correlations between gestational age and nose length (R = 0.390; P < .001), pronasal-subnasal distance (R = 0.415; P < .001), and distance between the upper philtrum and mouth (R = 0.315; P < .001). There were significant quadratic relationships between gestational age and nose protrusion (R(2) = 0.213; P < .001) and distance between the tip of the nose and mouth (R(2) = 0.173; P < .001).

CONCLUSIONS

We provide preliminary normative nasolabial dimensions of facial profiles at 20 to 37 weeks' gestation in normal Korean fetuses. These data may be of help not only in the understanding of normal nasolabial growth in utero but also in the diagnosis of abnormal facial dimensions.

Lateral fast muscle fibers originate from the posterior lip of the teleost dermomyotome

The predominant source of myogenic cells in vertebrates is the dermomyotome (DM). In teleost fish, recent research has provided a useful but limited picture of how myogenic precursors originate from the DM and how they develop into muscle fibers. Here, we combine detailed morphological analysis with examination of molecular markers in trout to describe the cellular mechanisms by which the lateral fast muscle growth zone is created during second phase myogenesis. Results suggest that this occurs by lateral-to-medial immigration of myogenic cells de-epithelializing from the posterior DM lip. These cells then appear to stop proliferation and migrate anteriorly to finally differentiate into muscle fibres. This seems to be a continuation of the rotational cell movement that creates the teleost DM during early somite development. These findings suggest an evolutionary conserved role of the posterior DM lip in amniotes and fish.

Laser burn wound healing in naso-labial region of fetal and neonatal mice

OBJECTIVE

To investigate the characteristics of wound healing in the mouse naso-labial region in both the fetal and neonatal stages, histological and immunohistochemical analyses were performed using a newly established laser burn wound healing system.

MATERIALS AND METHODS

Fetal mice at embryonic day 14 (E 14) were wounded as a model of fetal wound healing. To compare it, neonatal mice at day 5 after birth (d 5) were adopted as a model of neonatal wound healing. The healing process was examined by van Gieson staining and immunohistochemistry for fibronectin and tenascin.

RESULTS

Relatively large damage remained after wound healing even in fetal mice. In both types of wound healing, rapid regeneration of muscle tissues were observed. Fibronectin and tenascin immunostaining was detected not only in wound healing region, but also in the endomysium of regenerating muscle tissues. Especially, tenascin showed a restricted expression pattern.

CONCLUSIONS

Rapid regeneration of muscle tissues in the naso-labial region in both the fetal and neonatal mice seemed to leave relatively large damage even in the fetal wound healing. Contracted force exerted by muscle tissues may be a reason for this phenomenon. Fibronectin and tenascin were closely related to the wound healing process including muscle regeneration in this region.

Developmental expression analysis of the mouse and chick orthologues of IRF6: the gene mutated in Van der Woude syndrome

Development of the lip and palate involves a complex series of events that are frequently disturbed resulting in the congenital anomalies cleft lip and cleft palate. Van der Woude syndrome (VWS) is an autosomal dominant disorder that is characterised by cleft lip, cleft palate, lower lip pits, and hypodontia. VWS arises as the result of mutations in the gene encoding interferon regulatory factor 6 (IRF6). To provide insights into the role of IRF6 during embryogenesis, we have analysed the expression of this molecule during mouse and chick facial development. Irf6 was expressed in the ectoderm covering the facial processes during their fusion to form the upper lip and primary palate in both mouse and chick. However, while Irf6 was expressed in the medial edge epithelia of the developing secondary palate of the mouse, which fuses as in man, Irf6 was not expressed in the medial edge epithelia of the naturally cleft chick secondary palate. Similarly, Irf6 was found to be down-regulated in the medial edge epithelia of transforming growth factor beta3-null mice, which also exhibit cleft palate. Together, these results support a role for IRF6 during the fusion events that occur during development of the lip and palate.

Development of the upper lip: morphogenetic and molecular mechanisms

The vertebrate upper lip forms from initially freely projecting maxillary, medial nasal, and lateral nasal prominences at the rostral and lateral boundaries of the primitive oral cavity. These facial prominences arise during early embryogenesis from ventrally migrating neural crest cells in combination with the head ectoderm and mesoderm and undergo directed growth and expansion around the nasal pits to actively fuse with each other. Initial fusion is between lateral and medial nasal processes and is followed by fusion between maxillary and medial nasal processes. Fusion between these prominences involves active epithelial filopodial and adhering interactions as well as programmed cell death. Slight defects in growth and patterning of the facial mesenchyme or epithelial fusion result in cleft lip with or without cleft palate, the most common and disfiguring craniofacial birth defect. Recent studies of craniofacial development in animal models have identified components of several major signaling pathways, including Bmp, Fgf, Shh, and Wnt signaling, that are critical for proper midfacial morphogenesis and/or lip fusion. There is also accumulating evidence that these signaling pathways cross-regulate genetically as well as crosstalk intracellularly to control cell proliferation and tissue patterning. This review will summarize the current understanding of the basic morphogenetic processes and molecular mechanisms underlying upper lip development and discuss the complex interactions of the various signaling pathways and challenges for understanding cleft lip pathogenesis.

Epithelial-mesenchymal transformation during craniofacial development

Epithelial to mesenchymal phenotype transition is a common phenomenon during embryonic development, wound healing, and tumor metastasis. This transition involves cellular changes in cytoskeleton architecture and protein expression. Specifically, this highly regulated biological event plays several important roles during craniofacial development. This review focuses on the regulation of epithelial-mesenchymal transformation (EMT) during neural crest cell migration, and fusion of the secondary palate and the upper lip.

Regulation of ectodermal Wnt6 expression by the neural tube is transduced by dermomyotomal Wnt11: a mechanism of dermomyotomal lip sustainment

Ectodermal Wnt6 plays an important role during development of the somites and the lateral plate mesoderm. In the course of development, Wnt6expression shows a dynamic pattern. At the level of the segmental plate and the epithelial somites, Wnt6 is expressed in the entire ectoderm overlying the neural tube, the paraxial mesoderm and the lateral plate mesoderm. With somite maturation, expression becomes restricted to the lateral ectoderm covering the ventrolateral lip of the dermomyotome and the lateral plate mesoderm. To study the regulation of Wnt6 expression, we have interfered with neighboring signaling pathways. We show that Wnt1 and Wnt3a signaling from the neural tube inhibit Wnt6 expression in the medial surface ectoderm via dermomyotomal Wnt11. We demonstrate that Wnt11 is an epithelialization factor acting on the medial dermomyotome, and present a model suggesting Wnt11 and Wnt6 as factors maintaining the epithelial nature of the dorsomedial and ventrolateral lips of the dermomyotome, respectively,during dermomyotomal growth.

Differential effects of N-cadherin-mediated adhesion on the development of myotomal waves

Myotomal fibers form by a first wave of pioneer myoblasts from the medial epithelial somite, and by a second wave from all four lips of the dermomyotome. Then, a third wave of mitotic progenitors colonizes the myotome,initially stemming from the extreme lips and, later, from the central dermomyotome sheet. In vitro studies have suggested that N-cadherin plays a role in myogenesis, but its role in vivo remains poorly understood. We find that during the growth phase of the dermomyotome sheet, when the orientation of mitotic spindles is parallel to the mediolateral extent of the epithelium,N-cadherin protein is inherited by both daughter cells. Prior to dermomyotome dissociation into dermis and muscle progenitors, when mitoses become perpendicularly oriented, N-cadherin remains associated only with the apical cell located in apposition to the myotome, generating molecular asymmetry between basal and apical progeny. Local gene missexpression confirms that N-cadherin-mediated adhesion is sufficient to promote myotome colonization,whereas its absence drives cells towards the subectodermal domain, hence coupling the asymmetric distribution of N-cadherin to a shift in mitotic orientation and to fate segregation. Site-directed electroporation to additional, discrete somite regions, further reveals that N-cadherin-mediated adhesion is necessary for maintaining the epithelial configuration of all dermomyotome domains while promoting the onset of Myod transcription and the translocation into the myotome of myofibers and/or of Pax-positive progenitors. By contrast, N-cadherin has no effect on migration or differentiation of the first wave of myotomal pioneers. Altogether, we show for the first time that the asymmetric localization of N-cadherin during mitosis indirectly influences fate segregation by differentially driving the allocation of progenitors to muscle versus dermal primordia, that the adhesive domain of N-cadherin maintains the integrity of the dermomyotome epithelium,which is necessary for myogenic specification, and that different molecular mechanisms underlie the establishment of pioneer and later myotomal waves.

Expression and regulation of the LIM homeodomain gene L3/Lhx8 suggests a role in upper lip development of the chick embryo

LIM-homeodomain (Lhx) genes constitute a gene family that plays critical roles in the control of pattern formation and cell type specification. We have identified a chicken L3/Lhx8 gene, which was widely expressed in the craniofacial region. Whole-mount in situ hybridization showed that L3/Lhx8 mRNA was expressed from stage 15--31 HH in overlapping domains of the maxillary process. Frozen sections revealed these signals in the mesenchyme underneath the epithelium. To determine whether the expression of L3/Lhx8 in the maxillary primordia required signals from the overlying oral epithelium, maxillary processes of stage 23 HH chick embryos were transplanted into the limb bud, in which the mesenchyme was grown in the presence or absence of oral epithelium. The maxillary mesenchyme with epithelium showed significant levels of L3/Lhx8 gene expression. In contrast, no expression of L3/Lhx8 was detected in the epithelium-free mesenchyme. To further explore signaling molecule(s) responsible for Lhx induction, a bead, soaked in either Fgf-8b or TGF-beta3, was implanted into an epithelium-free mesenchymal graft. Both TGF-beta3 and Fgf-8b beads induced expressions of L3/Lhx8 in epithelium-free mesenchymal grafts. Our data suggest that the L3/Lhx8 gene contributes to epithelial mesenchymal interaction in facial morphogenesis and that Fgf-8b and TGF-beta3 were, at least in part, responsible for the Lhx expression in the maxillary process.

Embryology and epidemiology of cleft lip and palate

Craniofacial anomalies, in particular cleft lip and palate, are major human birth defects with a worldwide frequency of 1 in 700 and substantial clinical impact. This article reviews the embryology of the face, lip, and palate to enhance the understanding of the pathogenesis of these lesions, with particular attention to the period of susceptibility during gestation, complexity, and the factors that may influence their development. It includes an overview of the prevalence and environmental and genetic causes of cleft lip-with or without cleft palate- and cleft palate.

Expression ofWnt9b and activation of canonical Wnt signaling during midfacial morphogenesis in mice

Cleft lip with or without cleft palate (CLP) is the most common craniofacial birth defect in humans. Recently, mutations in the WNT3 and Wnt9b genes, encoding two members of the Wnt family of signaling molecules, were found associated with CLP in human and mice, respectively. To investigate whether Wnt3 and Wnt9b directly regulate facial development, we analyzed their developmental expression patterns and found that both Wnt3 and Wnt9b are expressed in the facial ectoderm at critical stages of midfacial morphogenesis during mouse embryogenesis. Whereas Wnt3 mRNA is mainly expressed in the maxillary and medial nasal ectoderm, Wnt9b mRNA is expressed in maxillary, medial nasal, and lateral nasal ectoderm. During lip fusion, Wnt9b, but not Wnt3, is expressed in the epithelial seam between the fusing medial and lateral nasal processes. Furthermore, we found that expression of TOPGAL, a transgenic reporter of activation of canonical Wnt signaling pathway, is specifically activated in the distal regions of the medial nasal, lateral nasal, and maxillary processes prior to lip fusion. During lip fusion, the epithelial seam between the medial and lateral nasal processes as well as the facial mesenchyme directly beneath the fusing epithelia strongly expresses TOPGAL. These data, together with the CLP lip phenotype in WNT3-/- humans and Wnt9b-/- mutant mice, indicate that Wnt3 and Wnt9b signal through the canonical Wnt signaling pathway to regulate midfacial development and lip fusion.

Tissue-plastinated vs. celloidin-embedded large serial sections in video, analog and digital photographic on-screen reproduction: a preliminary step to exact virtual 3D modelling, exemplified in the normal midface and cleft-lip and palate

This study analyses tissue-plastinated vs. celloidin-embedded large serial sections, their inherent artefacts and aptitude with common video, analog or digital photographic on-screen reproduction. Subsequent virtual 3D microanatomical reconstruction will increase our knowledge of normal and pathological microanatomy for cleft-lip-palate (clp) reconstructive surgery. Of 18 fetal (six clp, 12 control) specimens, six randomized specimens (two clp) were BiodurE12-plastinated, sawn, burnished 90 microm thick transversely (five) or frontally (one), stained with azureII/methylene blue, and counterstained with basic-fuchsin (TP-AMF). Twelve remaining specimens (four clp) were celloidin-embedded, microtome-sectioned 75 microm thick transversely (ten) or frontally (two), and stained with haematoxylin-eosin (CE-HE). Computed-planimetry gauged artefacts, structure differentiation was compared with light microscopy on video, analog and digital photography. Total artefact was 0.9% (TP-AMF) and 2.1% (CE-HE); TP-AMF showed higher colour contrast, gamut and luminance, and CE-HE more red contrast, saturation and hue (P < 0.4). All (100%) structures of interest were light microscopically discerned, 83% on video, 76% on analog photography and 98% in digital photography. Computed image analysis assessed the greatest colour contrast, gamut, luminance and saturation on video; the most detailed, colour-balanced and sharpest images were obtained with digital photography (P < 0.02). TP-AMF retained spatial oversight, covered the entire area of interest and should be combined in different specimens with CE-HE which enables more refined muscle fibre reproduction. Digital photography is preferred for on-screen analysis.

Distinct functions for Bmp signaling in lip and palate fusion in mice

Previous work suggested that cleft lip with or without cleft palate (CL/P)is genetically distinct from isolated cleft secondary palate (CP). Mutations in the Bmp target gene Msx1 in families with both forms of orofacial clefting has implicated Bmp signaling in both pathways. To dissect the function of Bmp signaling in orofacial clefting, we conditionally inactivated the type 1 Bmp receptor Bmpr1a in the facial primordia, using the Nestin cre transgenic line. Nestin cre; Bmpr1amutants had completely penetrant, bilateral CL/P with arrested tooth formation. The cleft secondary palate of Nestin cre; Bmpr1amutant embryos was associated with diminished cell proliferation in maxillary process mesenchyme and defective anterior posterior patterning. By contrast,we observed elevated apoptosis in the fusing region of the Nestin cre; Bmpr1a mutant medial nasal process. Moreover, conditional inactivation of the Bmp4 gene using the Nestin cretransgenic line resulted in isolated cleft lip. Our data uncover a Bmp4-Bmpr1a genetic pathway that functions in lip fusion, and reveal that Bmp signaling has distinct roles in lip and palate fusion.

Nomograms for the Sonographic Measurement of the Fetal Philtrum and Chin

OBJECTIVE

To generate nomograms for the sonographic measurement of the fetal philtrum and chin during pregnancy.

DESIGN

A prospective, cross-sectional study in normal singleton pregnancies.

SUBJECTS

One hundred and fifty-three fetuses between 13 and 42 weeks of gestation were studied.

METHODS

The philtrum was measured from the base of the columella to the upper lip. The chin was measured from the tip of the lower lip to the skin under the lower tip of the mandible. Predictive models were evaluated to generate graphic description of the 5th, 50th and 95th centiles for the fetal philtrum and chin.

RESULTS

Fetal philtrum length increased with gestational age. The regression equation for the philtrum length (y) according to gestational age in weeks (x) is best predicted by the S-curve (Gompertz) model, as described by the following equation: y = exp(a + b/x), where a = 2.778577, and b = -23.476723 (R(2) = 85.3%, p < 0.0001). The fetal chin length increased with gestational age. The regression equation for the mean chin length (y) according to gestational age in weeks (x) is best predicted by the S-curve model as described in the following equation. y = exp(a + b/x), where a = 3.7922, b = -28.043, (R(2) = 89.0%, p < 0.0001).

CONCLUSIONS

The nomograms generated in this study for the fetal philtrum and chin during pregnancy can be used in confirming subjective impression of facial dysmorphism.

Microvascularization of the mucocutaneous junctions of the head in fetuses and neonates

The mucocutaneous junctions of the head (oral, nasal and palpebral) are transitional zones between the integuments and the mucosa. Their microvascularization is studied in the heads of fetuses and neonates by injection of agarized China ink into the vascular system. These zones are situated deep with respect to the free edge of the oral or nasal cavity or relative to the free margin of the eyelid. They present cutaneous-type microvascularization with a papillary network and reticular networks. Long capillary loops connected to the deep reticular network are their main feature. In the lips and eyelids, the morphology of the networks and their relationship with the orbicular muscles are suggestive of a functional structure.

Development of the upper lip

OBJECTIVES

To affirm and reanalyze George L. Streeter's "merging theory" of upper-lip development in primates by observing progressive embryologic stages in facial development using scanning electron microscopy (SEM) and to further understand upper-lip development.

DESIGN

The study was conducted at the California Regional Primate Research Center, Davis. Twenty primate embryos (Macaca fascicularis) and 2 fetuses were examined with SEM. The development of the frontonasal prominence, maxillary prominence, medial nasal prominence, and lateral nasal prominence were sequentially observed. The contribution of these prominences to the formation of the upper lip and nose were carefully analyzed.

RESULTS

The maxillary prominence and medial nasal prominence form the upper lip, whereas the lateral nasal, medial nasal, and maxillary prominences form the nose. There is fusion of the maxillary prominence with the medial nasal prominence. This fusion has not been previously described. This has resulted in a modification of the current theory of upper-lip development into one we refer to as the "dynamic fusion theory."

CONCLUSIONS

The dynamic fusion theory explains the merging process of the mesenchymal and ecotodermal layers of the facial prominences that contribute to the upper-lip formation. The dynamic fusion theory of facial prominence movement details the interaction between epithelial layers: both epithelial layers must fuse properly to avoid cleft-lip deformities.

Organogenesis particularly relevant to fetal surgery

In utero surgical intervention is an exciting frontier in medicine. Fetal surgeons strive to treat congenital anomalies definitively while organogenesis is still occurring. Many of these anomalies pose such a threat to the viability of the affected fetus that waiting until after the child is born to treat them is frequently not satisfying and too often unsuccessful. We review the embryology of selected systems that have associated aberrancies of development for which fetal surgery is particularly applicable. The surgeon can more effectively launch an assault against congenital anomalies when armed with a solid appreciation of normal development. Recognizing the critical period for the development of a system allows him or her to formulate the optimal time and mode of intervention.

[Anatomy of the labial region]

The phylogenetic and embryologic basis, as well as compared anatomy allow for a greater grasp of the multiform organization, as of the complex functions for the cosmetic appearance of the facial expression, which, as it grows older, will not touch to the magical beauty of the first smile, as it always was.

Heterotopic shift of epithelial-mesenchymal interactions in vertebrate jaw evolution

Genes involved in late specification of the mandibular arch, the source of the vertebrate jaw, are expressed with similar patterns in the oral regions of chick and lamprey embryos. However, morphological comparisons indicate that apparently orthologous homeobox genes were expressed in different subdivisions of the ectomesenchyme in the two species. Therefore, the homology and gene expression of the oral region are uncoupled during the transition from agnathan to gnathostome; we conclude that a heterotopic shift of tissue interaction was involved in the evolution of the jaw.

Embryogeny of human labial glands: a structural, ultrastructural and cytochemical study

A histochemical study of labial glands was performed to compare the different stages of differentiation with those of lingual glands previously studied. Labial glands of 8 to 32 week old human fetuses were analyzed with Hematoxylin/eosine, PAS, Cason, Alcian blue, Toluidine blue, methenamine/silver, TEM and Ruthenium red techniques. At 8-10 weeks various differentiation phases of cell cords originated in the epithelium of the labial mucosa were observed. Acinar buds had PAS positive, alcianophilic and metachromatic material in the lumen of 14 week labial glands. The excretory ducts featured similar characteristics. At 24 weeks groups of mucous and seromucous acini were identified and the mucosubstances increased in the 32 week old fetuses. These results show that the labial glands are histophysiologically differentiated at an earlier stage of development (14 weeks) as compared to lingual glands (20 weeks). However, mucosubstance production would begin during the early phases of embryogenesis for both labial and lingual glands.

[Is there new knowledge on embryology and functional anatomy of human mimetic muscles and the upper lip? A contribution to point selection, skin incision and muscle reconstruction in primary lip-nose reconstruction of uni- and bilateral lip-jaw-palatal clefts]

BACKGROUND

The great variety of primary cheiloplastic procedures in CLP patients shows that there is disagreement regarding the embryological development of this part of the face, the point selection, skin incision philosophy, and the macroscopic and microscopic functional anatomy of the human muscles of facial expression. We suppose from findings in Asian and African populations that the real embryological development of the upper lip differs from current textbook descriptions. Our own anatomical and embryological investigations serve as a basis for a critical discussion of different techniques of muscle reconstruction, point selection, and skin incision and for a description of an embryologically, functionally, and anatomically oriented operation technique for different entities of CLP.

METHODS

The findings of this study result from investigations of the embryonal and early fetal development from the 26th to the 112th i.u. day in REM pictures of the Anatomical Institute of the University of Göttingen (n = 8) and serial histological investigations of the Carnegie and Hooker-Humphrey Collections at the Armed Forces Institute of Pathology, Washington, D.C. (n = 40). Furthermore, we carried out microsurgical dissections of the muscles of facial expression, the osseous and cartilaginous parts of the nose, and the midfacial sutures in two adult heads without congenital disorders and one newborn head with a primary unilateral complete cleft of the lip and alveolus.

RESULTS AND DISCUSSION

The formation of the lower third of the upper lip is the result of contact of the maxillary bulges in the midline below the prolabium. According to this finding, the point selections and skin incisions have to be modified in the midline region in different types of uni- and bilateral CLP. Our technique of primary dissection, reorientation, and suturing of the muscles of facial expression is presented. The muscle reconstruction has to be performed independently from the skin preparation.

A new approach to classify cleft lip and palate

OBJECTIVE

To propose a new method, which allows for a complete description of primary and secondary cleft palates, incorporating elements that are related to the palate, lip, and nose that will also reflect the complexity of this problem.

METHOD

To describe the type of cleft, two embryonic structures were considered: (1) the primary palate, formed by the prolabium, premaxilla, and columella and (2) the secondary palate, which begins at the incisive foramen and is formed by a horizontal portion of the maxilla, the horizontal portion of the palatine bones, and the soft palate. Anatomical characteristics to be considered were defined, and a new method is proposed to more fully describe any cleft.

RESULTS

A description of five cases was made using the method proposed in this work and compared with other published methods for the classification and description of clefts.

CONCLUSIONS

A mathematical expression was developed to characterize clefts of the primary palate, including the magnitude of palatal segment separation and the added complexity of bilateral clefts, yielding a numerical score that reflects overall complexity of the cleft. Clefts of the secondary palate are also considered in a separate score. Using this method, it is possible to incorporate elements that are not considered in other approaches and to describe all possible clefts that may exist.

Degeneration and regeneration of the lip mucosal epithelium after cryo treatment in mice

The process of degeneration and regeneration of the lip mucosal epithelium after cryo treatment was observed by transmission electron microscopy. The epithelial cells were degenerated by the formation of ice crystals and subsequently detached from the basement membrane, forming a blister cavity. The separation occurred between the epithelial cells and the lamina densa, leaving a small amount of cell debris on the lamina densa. The surviving cells at the periphery of the blister cavity, especially the cells in the basal half of the epithelium, provided the regeneration cells. They migrated over the cell debris, attached to the lamina densa and gradually phagocytozed it. Finally, they formed hemidesmosomes with the old lamina densa. The connections between the epithelial cells by desmosomes were so tight that desmosomes were preserved even between dead cells and between dead and living cells. Regenerating cells were moving in a multilayered form, remaining connected to each other by the dosmosomes. They were seen to divide by mitosis and thereby increase the number of the cell layer, whilst maintaining their connections with the neighbouring cells.

Epithelial-mesenchymal transformation is the mechanism for fusion of the craniofacial primordia involved in morphogenesis of the chicken lip

We have previously demonstrated that epithelial-mesenchymal transformation (EMT) brings about TGF beta 3-induced confluence of craniofacial primordia that derive from the maxillary processes and give rise to the avian palate. The upper lip of the chick embryo forms by confluence of primordia also derived from the maxillary processes, but in this case, they fuse with the intermaxillary segment of the nasofrontal process. Here, we ask whether the bilateral epithelial seams formed when these primordia contact each other in vivo are removed by apoptosis (as formerly was believed to occur in developing palate) or by EMT. We found that, as is the case in the palate, the periderm of the two-layered embryonic epithelium begins to slough shortly before these primordia fuse, bringing the basal epithelial cells into close contact. We show by TUNEL staining and confirm by TEM that apoptosis occurs only in periderm. TEM reveals that basal epithelial cells contacting each other to form the midline seam produce numerous desmosomes with each other. Then, basement membrane begins to disappear, numerous filopodia extend from the basal surfaces of epithelial cells, the space between them enlarges, and the seam breaks apart, leaving mesenchymal cells in its wake. Transformation of the carboxyfluorescein (CCFSE)-labeled epithelial seam is demonstrated in vivo by detection of CCFSE bodies in mesenchymal cells that replace it. This demonstration of EMT in avian lip development lays important groundwork for understanding the causes of human cleft lip and analyzing the mechanism of action of growth factors, such as SHH and BMPs, that have been shown (J. A. Helms et al., 1997, Dev. Biol. 187, 25-35) to be involved in avian lip confluence.

Functional matrix cleft repair: a common strategy for unilateral and bilateral clefts

At first glance, the morphologies of unilateral and bilateral clefts appear quite distinct. So much so, that many authors describe them as separate entities altogether. This has given rise to disparate surgical strategies. This paper presents a unifying theory of pathogenesis and treatment.

Development of the lip and palate in staged human embryos and early fetuses

Cleft lip and palate are the most common congenital malformations in humans. Using 43 staged human embryos and early fetuses ranging from the 4th to 12th week of development, we investigated the development of the lip and palate in order to provide the basic developmental concepts required for managing these anomalies. The lower lip appeared as bilateral mandibular arches at Carnegie stage 11, and these were completely merged at stage 15. The components of the upper lip, medial nasal prominence and maxillary process, appeared at stage 16, and completely merged at stage 20. The median palatine process appeared at stage 16, and the lateral palatine process, at stage 17. The palatine processes and the nasal septum started to fuse abruptly at stage 23, and from external observation seemed to be fused at the 9th week. However, complete fusion did not take place until the 12th week of development. The tongue was prominent at stage 16, showed differentiation of the muscular tissue at stage 21, and was located superior to the lateral palatine process before stage 23. These results may be used in understanding the different mechanisms present in the formation of various congenital anomalies in this region.

The spectrum of minimal clefting: process-oriented cleft management in the presence of an intact alveolus

The minimal cleft lip provides a model for study of the clefting process. Nasolabial embryogenesis can be best understood using the concept of embryonic fields in which midline structures (columella, philtrum, premaxilla, septum, vomer, and ethmoids) develop with paired, fused A fields. Anatomic features of the minimal cleft lip suggest that the actual clefting site is located at the interface between the A and B fields within the lateral piriform wall. Study of the progression of clefting, using this model, places the timing of the clefting event to Carnegie stage 14. The degree to which this initial event affects subsequent fusion of the lateral and medial nasal processes (D and C fields) determines the final morphology of the cleft. Using this model, a rational basis is presented for the surgical management of minimal clefting in its varying manifestations.

The Twirler mouse, a model for the study of cleft lip and palate

Twirler (Tw) is a semidominant mutation in the mouse affecting the embryonic development of the midfacial region. Most heterozygous Tw mice, +/-, become obese at adulthood with a concomitant decrease in fertility. Homozygous mice have clefts of the midfacial region and a disrupted nasal cavity. Midfacial clefts included clefts of the palate combined with either unilateral or bilateral clefts of the lip. The clefts of the lip were either complete or incomplete. The palatal shelves in Tw/Tw were very much reduced. Apart from these defects, homozygous Tw looked normal, and were born alive, although they reportedly die within 24 h after birth. It is proposed that the Twirler model can be used to improve understanding of the genetic mechanisms involved in the normal development of the midfacial region.

Fetal mustache in early pregnancy

OBJECTIVE

The aim of this study was to determine the incidence in an unselected population of a rod-like structure on the fetal upper lip (called a 'mustache') which we had previously observed as an incidental finding. A secondary aim was to determine whether this was associated with any abnormalities or abnormal outcomes.

DESIGN

Prospective non-randomized study.

SUBJECTS

Three thousand consecutive fetuses from an unselected population were scanned by one sonologist.

METHOD

Transvaginal ultrasound examinations were performed at 14-16 weeks' gestation. Repeat sonographic examinations were performed at 20-22 weeks' gestation in cases where a mustache was detected, and these neonates were examined by a pediatrician after delivery.

RESULTS

Seven of 3000 fetuses had a mustache-like structure on the upper lip. The 'mustache' disappeared later in gestation. No anomaly of the upper lip was detected after birth in these fetuses.

CONCLUSION

A mustache-like structure on the fetal upper lip in early pregnancy probably represents a normal variant of lip development. It is likely to represent a delay in the normal process of lip fusion during embryonic life.

Median cleft of the lower lip associated with lip pits and cleft of the lip and palate

OBJECTIVE

In this case report, we present an unusual combination of three congenital malformations: median cleft of the lower lip, lip pits, and unilateral cleft of the lip and palate without familial occurrence.

CONCLUSIONS

From an etiological point of view, this combination of malformations could have happened during the late embryogenic period. Why this combination is uncommon is not known.

Cystic hygroma as an early first-trimester ultrasound marker for recurrent Fryns' syndrome

We present a case of a fetus who at a 12-week ultrasound examination was shown to have a large cystic hygroma. Fryns' syndrome was suspected because the mother's previous pregnancy had been affected by the condition. Pathological examination confirmed the diagnosis at this early stage of gestation. In families with increased risk for Fryns' syndrome, first-trimester ultrasound screening should be offered to exclude cystic hygroma as an ultrasound marker for this most often lethal malformation.

Three-dimensional reconstruction of the human fetal philtrum

The anatomy of the philtrum is incompletely understood because it is difficult to analyze three-dimensionally. Previous anatomic studies suggested that the philtral ridges are formed by the dermal insertion of the orbicularis oris muscle and musculis nasalis decussating across the midline, with the philtral dimple an area of few muscular insertions. This theory is inconsistent with the usual finding of a normal-appearing philtrum contralateral to the cleft in patients with unilateral cleft lip. Using a microcomputer and three-dimensional software, we have created a three-dimensional model of the philtrum from digitized images of sequential transverse histological sections from a third-trimester fetus. Our studies demonstrate that the philtral ridges are formed by thickened dermis and dermal appendages. The labial levators are the predominant muscles associated with the philtrum throughout its length; their fibers insert into the dermis lateral to the philtral ridges. Crossing muscle fibers of the orbicularis oris pars marginalis only appear below the vermilion-cutaneous junction, caudal to the philtral ridges.

Comparative analysis of AP-2 alpha and AP-2 beta gene expression during murine embryogenesis

Transcription factor AP-2 has been identified as playing important roles during embryonic development of the neural tube, neural crest derivatives, skin, and urogenital tissues. Recently, we isolated a second AP-2 transcription factor, AP-2 beta, which is 76% homologous to the previously known AP-2 alpha gene, and showed that both genes are coexpressed in murine embryos at day 13.5 and 15.5 post coitum (pc). In the current study, we used specific cRNA probes to study comparatively AP-2 alpha and AP-2 beta expression by in situ hybridization of murine embryonic tissue sections. Our results reveal that expression of both genes starts at day 8 pc in the lateral head mesenchyme and extraembryonic trophoblast. The expression pattern was identical until day 10 pc but diverged significantly during later stages of development. From day 11 forward, specific expression patterns of AP-2 alpha and AP-2 beta mRNA were observed. Specific AP-2 beta signals were detected in the midbrain, sympathetic ganglia, adrenal medulla, and cornea. Specific AP-2 alpha signals were present in the limb buds, dorsal root ganglia, tooth germs, and Moll's and Meibom's glands. In contrast, expression of both genes occurred in skin, facial mesenchyme, spinal cord, cerebellum, and renal tubular epithelia. Our results indicate that both genes are expressed with different temporal and spatial patterns during embryonic development.

A peculiar malformation of the upper lip: report of six cases

Six cases of a peculiar type of upper lip malformation have been observed by the author during the last 40 years. The malformations in this case series were remarkably similar, suggesting a single teratologic entity not been reported before. The six patients included 1-, 11-, 4-, and 6-month-old males, a 20 year-old male, and an 11-year-old female. Each was characterized by a crooked folded philtrum, a flat thin vermilion region of the upper lip, and high-positioned ala(e), that was unilateral or bilateral. The upper median incisors were separated occasionally by the thick lip frenulum without marked distortion of the nasomaxillary framework. The author speculates that these cases exhibited some disturbed penetration of the lateral nasal eminence (process) to the median part of the nasolabial region in their early embryologic development.

Absence of the lateral philtral ridges: a clue to the structural basis of the philtrum

This study compares philtral development in the normal fetus with philtral development in specimens lacking normal philtral landmarks. Distinct differences in the structure of the upper lip were discovered between the two groups using a histological comparison. A new mechanism for the structural basis of the philtrum is proposed on the basis of these differences.

Median cleft of the lower lip and mandible: case reports, a new embryologic hypothesis, and subdivision

Median clefts of the lower lip and mandible are rare. In the literature so far, about 62 cases have been described. In addition, three more patients are presented here. These cases show a broad variation in the severity of this deformity, ranging from a simple notch in the vermillion to a complete cleft of the lip involving the tongue, the chin, the mandible, the supporting structures of the median of the neck, and the manubrium sterni. Several hypotheses concerning the pathogenesis of median clefts of the lip and mandible have been proposed. Most authors consider it to be a failure of fusion of the first pair of branchial arches or failure of mesodermal penetration into the midline. From our embryologic point of view, however, instead of paired branchial arches, only one first branchial arch develops during the early embryonic period (< or = 17 mm crown-rump length). Within this first branchial arch, two mandibular processes grow out, separated by a groove in the median. These mandibular processes do not fuse but merge during the late embryonic period (> or = 17 mm to < or = 60 mm crown-rump length). In the same developmental period, there is formation of the lip and the alveolar process and the anlage and outgrowth of one membrane bone center in each mandibular process, resulting in the formation of the mandible with its symphysis. As a consequence of the preceding, we propose the following subdivision of the median clefts of the lip and/or mandible: Hypoplasia of the mandibular processes during the early embryonic period will lead to the severest cleft of the mandible extending into the neck. During the late embryonic period, the less severe median clefts will develop. Disturbances of the outgrowth of bone centers of the mandible, resulting in nonformation of its symphysis, cause clefting of the mandible with involvement of all related soft tissues. Defects in the merging process produce just a notch of the vermilion or a higher cleft of the lower lip with or without involvement of the alveolar process of the mandible. In conclusion, the variety of the clefts in the median of the lower lip and/or mandible as well as the low rate of incidence can be explained by the embryologic hypothesis proposed here.

Volume imaging: three-dimensional appreciation of the fetal head and face

Quasi-three-dimensional volume imaging provides an inexpensive means of evaluating the usefulness of three-dimensional imaging. The technique works most efficiently with water-skin interfaces and therefore we investigated its application in obstetrical ultrasonography. Three-dimensional perspectives of the normal and abnormal fetal head and face were spectacular and at times provided more information than the two-dimensional images. The ability of an inexperienced observer to interpret the three-dimensional image more easily may have a role in training sonographers and counseling parents whose fetuses have structural defects. Volume imaging has certain limitations and can only be used as a complementary technique.

Evaluation of normal and abnormal lips in fetuses: comparison between three- and two-dimensional sonography

OBJECTIVE

The purpose of this study was to determine if three-dimensional (3D) sonography could improve prenatal evaluation of fetal lips in comparison with conventional two-dimensional (2D) sonography.

MATERIALS AND METHODS

Sixty-one high-risk pregnant women and 10 low-risk pregnant women were examined with conventional 2D sonography followed by 3D sonography with a volume transducer. The ability to visualize cleft lips and normal lips was compared between the two techniques.

RESULTS

Of the 71 fetuses studied, faces were seen in 68 and not seen in three by either 2D or 3D sonography. Abnormal lips were seen in five fetuses on both 2D and 3D sonograms. Of the remaining fetuses, 3D sonography was able to confirm the presence of a normal lip in 92% (58/63) compared with 76% (48/63) with 2D sonography. In the subgroup of fetuses less than 24 weeks' estimated gestational age, 3D sonography confirmed a normal lip in 93% (38/41) of fetuses as compared with 68% (28/41) for 2D sonography. There was no difference between 3D and 2D in the subgroup of fetuses older than 24 weeks. One false-positive finding of cleft lip was observed at 36 weeks' gestational age with the rendered surface display on 3D sonography, whereas the 3D planar views of the same volume showed the lips to be normal.

CONCLUSION

3D sonography was able to confirm the presence of normal lips more frequently than did 2D sonography in fetuses less than 24 weeks' gestational age. Abnormal lips were seen on both 2D and 3D sonograms; however, 3D images of cleft lip were easier to understand for both the family and clinical colleagues.

Programmed cell death and cell transformation in craniofacial development

Fusion of branchial arch derivatives is an essential component in the development of craniofacial structures. Bilaterally symmetric branchial arch processes fuse in the midline to form the mandible, lips, and palate. The mechanism for fusion requires several different morphologic and molecular events prior to the completion of the mesenchymal continuity between opposing tissue processes. The ectodermal covering of the branchial arches is one of the cell types that has an important role during craniofacial development. The surface epithelia provide the initial adherence between the processes; however, this population of cells is ultimately absent from the fusion zone. The medial edge epithelium of the secondary palatal shelves is one example of such an epithelium that must disappear from the fusion zone of the secondary palate during development in order to complete palatal fusion. The mechanisms for removal of the epithelial cells from the fusion zone could include either programmed cell death, epithelial-mesenchymal transformation, or migration to adjacent epithelia. All three of these fates have been hypothesized as a mechanism for the removal of the palatal medial edge epithelia. The processes of programmed cell death, epithelial-mesenchymal transformation, and epithelial migration are reviewed with respect to both palatal fusion and results reported in other model systems.

Fetal face visualization using three-dimensional ultrasonography

Evaluation of the fetal face is an essential part of the sonographic examination for high risk pregnancies. Even under optimal conditions, the complex curvature of the face makes it difficult to obtain adequate images with two-dimensional ultrasonography, and many cross-sectional images are required to obtain a complete impression. The purpose of this paper is to show preliminary work in assessing the utility of three-dimensional ultrasonographic visualization of the fetal face. Fetal facial features were evaluated with three-dimensional sonography by scanning with a volume transducer and compared to conventional two-dimensional ultrasonographic images in 27 fetuses (gestational ages 10 to 39 weeks). Surface rendered three-dimensional sonographic images of the fetal face were obtained in 24 of 27 fetuses. In four cases the upper lip was clearly imaged on three-dimensional ultrasonography when it could not be seen on two dimensional ultrasonography. Information requiring multiple planes with two-dimensional ultrasonography could be demonstrated on a single image from three-dimensional ultrasonography. Images of abnormal faces were seen with both two- and three-dimensional ultrasonography in two cases of cleft lip and one case of holoprosencephaly. Volume data acquisition required approximately 10 sec and reconstruction required approximately 5 sec with instantaneous review of planes through the volume data set. Surface rendering required 2 to 10 min depending on the angular viewing range. Three-dimensional ultrasonography has the potential to provide improved visualization of the fetal face compared with conventional two-dimensional sonographic imaging.

Histochemical study of lectin binding in the human fetal minor salivary glands

The emerging synthesis of glycoconjugates containing specific oligosaccharides in developing human fetal labial and lingual salivary glands has been investigated by lectin histochemistry. An avidin-biotin technique was used to study the binding of lectins from Ulex europeus I (UEA-I), Dolichos biflorus (DBA), Glycine maximus (SBA), Helix pomatia (HPA), Arachis hypogaea (PNA) and Triticum vulgare (WGA) to specific sugars on sections of tissue from labial glands, glands of Blandin and Nuhn, glands of von Ebner and the dorsoposterior lingual salivary glands. Incipient synthesis of glycoconjugates in early glands and their presence in the cells and ducts of the later glands was shown. The study also showed a time-related increase in both staining intensity and binding sites of serous acinar cells from all glands and for all lectins used. For mucous cells, peak intensity of staining was reached by the middle phase of development. During later gland development this intensity was maintained in dorsoposterior lingual glands but tended to decline in labial glands. The various lectins showed different degrees of binding but UEA-I lectin generally bound the L-fucose sugar group in all salivary glands at all gestational ages. The results showed that lectins appear to bind to the oligosaccharides on epithelial cell surfaces of fetal salivary glands at all stages of development. The degree of change depends upon the stage of differentiation and maturation of the glands.

[Experimental considerations of the mechanism of lip and palate fusion]

Although harelip, cleft palate, or both, are by far the most common major facial malformations, the mechanisms underlying their embryogenesis are only now beginning to be understood; this is due to the complexity of primary and secondary palate development and the fact that appropriate methods for study have only recently been developed. The authors present a review of the most significant data regarding the etiology of hare lip and cleft palate, both in their physiopathogenic aspects and in their clinical morphology. The peculiarity of these malformations is outlined, supported by literature data and personal experimental experience.

Embryonic rationale for the primary correction of classical congenital clefts of the lip and palate

Primary correction of congenital clefts of the lip and palate should be designed to carry the interrupted embryonic process to normal completion. This is best accomplished by maxillary alignment with presurgical orthodontics, stabilisation of the maxillary alignment, obliteration of the alveolar cleft and construction of the nasal floor with periosteoplasty. This allows early construction of the lip by rotation and advancement and correction of the nose with columella lengthening, alar cartilage positioning and alar base cinching. This can be accomplished before school age.

Stereological and immunohistochemical study of development of human fetal labial salivary glands and their S-100 protein reactivity

Stereological and certain histochemical aspects of fetal growth and development of human labial salivary glands are reported. Stereological analysis showed a highly significant progressive increase in proportional gland volume occupied by acini from 27% at 20 weeks to 56% at 38 weeks (P < 0.0001), and a comparable having of the relative gland volume occupied by connective tissue in the same period (P < 0.0001). Linear regression fitted the data well (r2 = 0.59 and 0.47 respectively, n = 46). The change in relative volume occupied by ducts or by vascular tissue was small and did not reach significance. S-100 protein reactivity was demonstrated in the cytoplasm of cells of the labial gland primordia from their origin. As gland differentiation progressed, the S-100 reactivity became localized in basophil acinar cells and in proximal (intercalated and intralobular), but not in distal, duct cells. A gradual increase in intensity of S-100 protein activity at these sites during salivary gland development was observed. Morphological maturity seems to be complete before 29 weeks but myoepithelial cells could not be identified with certainty.