Embryology & Pharyngeal Arches

Hey everyone, Ryan here, welcome to this brand new series on head and neck
anatomy. Now we're going to cover a lot of great content here, and this material appears
on the Integrated National Board Dental exam, it also appears on the part I board exam,
and it also comes up on a lot of other exams both medical and dental. Now that being
said there are a lot of great resources out there to learn anatomy, and i'll be posting and
referencing those resources throughout this series if you ever want to check them out
for some more high quality information, but my job here is to present this information.
So that's easy to understand and gives you the high yield facts that you need to know for
your dental board exams. So with that let's get started with some embryology.

So we're going to start from the very beginning that being the germinal stage
otherwise known as the egg stage. now this is from fertilization to the second week
after fertilization, this is also when a miscarriage is most likely to happen. Now as we go
through the steps of this process, i'm going to have in the top right the week that we're
currently in and that week number is based off the starting time point being fertilization.
And fertilization occurs when the sperm and egg unite in the fallopian tube to create a
diploid cell called a zygote. Before this though ovulation had to happen which refers to
the release of an egg from the ovary. Now over the next few days that zygote cleaves
into a ball of two cells and then four cells and then eight cells and so on to form what's
called a morula, that morula will eventually develop an inner cavity or space called a
blastocoel at which point it becomes a blastula, it can also be called a blastocyst in
mammals. That blastocyst is going to eventually implant itself into the uterine wall,
implantation occurs when the blastula contacts the endometrium or that uterine wall.
Now we're still in week one here but the blastula is going to get a little bit more
complex. So we have an embryoblast which refers to the inner cell mass that's in
green, that will become much of the embryo proper. So basically it's going to be
differentiating and dividing into cells that become much of what we consider the
embryo. There's also the trophoblast that's this outer purple layer, and that outer cell
mass will form much of the placenta. So let's zoom in on this blastocyst and get a little
closer look.
So now we are two weeks in and at two weeks, we now have two layers, it's an
easy way to think of it, week two we have two layers. And that inner cell mass becomes
a
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bilaminar disc that consists of those two layers: an epiblast and a hypoblast. So if we
look at this image, we have two cell layers right at the center comprising this disc, the
upper layer is the epiblast, this lower layer is the hypoblast. Now you also notice two
cavities that have formed here, this white cavity up here is called the amniotic cavity
and that will house the developing baby, the yolk sac cavity - this yellow one down here
and that will provide nutrients and gas exchange before the placenta eventually takes
over, and that placenta remember is derived from the trophoblast from the last slide. So
the epiblast is going to do most of the work here, it's going to become the three germ
layers of the eventual embryo. The hypoblast not so much, it's going to disappear and
not really contribute to a whole lot amniotic cavity, and yolk sac cavity we talked about
those. And there's also what's called a primitive node and primitive streak on the
dorsal surface, on the caudal side of the embryo which basically identifies the midline
it separates right from left, we'll get a closer look at what that actually looks like in the
next slide. Also notice at this point in the process, implantation is now complete, the
entire egg is completely within the endometrium now. Also by the end of the second
week, we have this space that's kind of surrounding the developing egg that's called the
extraembryonic coelom or a chorionic cavity. And as that cavity expands we
eventually have this connecting stalk which eventually becomes the umbilical cord
that is suspending this developing egg.
So for week three, let's zoom in on this part of the diagram, the most exciting part
where most of the action is happening. So now that we're three weeks in, we have three
layers. So remember week two we had the epiblast and hypoblast, in week three we now
have three layers the ectoderm, mesoderm, and endoderm. But first now we have to
talk about a new period that we're in, we're no longer in the egg stage, now we're in the
embryonic period which goes from the third week to the eighth week after fertilization
so now we can call this the embryo. Now during this embryonic period, this is when the
organ systems are being established and also when major malformations can be caused
by genetic or environmental insults things like alcohol or retinoids. And so to start this
off we have this process called gastrulation, this refers to a transition from a single
sheet of cells to three distinct germ layers. Again we have the ectoderm in blue here and
that's on the dorsal side of this embryo, it's going to contribute to things like the
epidermis, the skin, the nervous system, the teeth and the facial skeleton. So really really
important stuff here. And the surface ectoderm specifically is going to form the enamel,
it's kind of more this part of the ectoderm and more this part, we're going to we're going
to talk a little bit more about neurulation in week four but the neural crest is going to
form the rest of the two structures. I talked more about tooth development -
odontogenesis in the first video of my pediatrics series so go check that one out if you
haven't already. Also notice this part right here that those arrows are pointing to that is
the primitive streak and this little tiny dot at the end is the primitive node, now these
things are located again on the caudal side of the embryo that's the tail side of the
embryo on the dorsal surface and. So that is just a really important kind of landmark to
determine right from left and it's mediating a lot of this development process. So to
cover the rest mesoderm contributes to body skeleton. So everything but the facial
skeleton all the muscles, all the connective tissue and then that leaves endoderm to do
the lining of the hollow organ systems like your gastrointestinal tract for instance.
This is a really good image from bioninja and talks about the different cells that
differentiate from these different these three different germ layers. A nice little image
there.
So this is a this is a really difficult thing to visualize but these images do a very
nice job of showing what goes on next from the transition from week three into week
four. So here we have the ectoderm, mesoderm, and the endoderm, that we just looked
at. And on the right, we have a few days later it says day 25, it's a little bit more further
along in development it's also a different view. So the left we have a cross-sectional
slice and we're kind of peeking in from the the caudal side, dorsals up here, ventrals
down here. Now on the right we also have dorsal appear ventral here but we're looking
at a side view. So cranial is up here, caudal is down this way and. So really on the left
we're taking like a cross section through this image. Now how this works is a lot of
things are going on right around here, and that's where that epiblast layer started,
remember that epiblast contributes to all three germ layers. So that layer is going crazy
and it's producing ectoderm cells that get migrated here, it's producing endoderm cells
that are being migrated here, and it's producing mesoderm cells that stay down here in
the middle, but they also spread out and create these nice little protective membranes
and coverings and there's just a lot going on a lot of differentiating going on. Now the
right image like I said, it's a little bit further along in development. So kind of what
happens structurally to get to this point, this is a very different looking thing and what
happens is this ectoderm in all three planes of space kind of grows these appendages
almost and it grows out and eventually is going to pinch in on this endoderm kind of like
a claw game like you'd see at a boardwalk or an arcade getting a prize, and so it's going
to push on either side of that endoderm and it's going to pinch a little piece and it's going
to involute into the actual embryo. So this is the pinching off point that little piece that's
getting pinched up here becomes the gut, the foregut, the midgut, and the hindgut over
here. The rest that gets left behind becomes the yolk sac. So that's basically what's
going on
here is there's this ectoderm that's pinching the endoderm and it's able to get that
endoderm internalized, and you can start to see how that might contribute to the lining
of the hollow organs within that body. So a lot of complex things happening in this week
three to four transition period, hopefully, this visualization and explanation helps you
out. The next we're going to zoom in on what's going on right at this part here.
So now we're in week four and this is the neurulation process. Neurulation is
happening in week four whereas gastrulation happened in week three. So neurulation
refers to the process where this flat neural plate rolls into a tube kind of like a yoga mat
that's being rolled up. And so I want to call your attention back to this picture where I
drew that black line again we're looking at the caudal side of the embryo with that
primitive node and primitive streak here. For neurulation, it's happening on the same
structure but it's happening on the cranial side, it's happening on the cranial side on the
dorsal surface, but on the cranial side of that embryo. So this is that same structure we
were just looking at just on the cranial side. So we start with a neural plate that's in
purple here, and a notochord which isn't shown but it's a little tube derived from
mesoderm that's sitting below everything going on here. The notochord is the signaling
device, is signaling this plate to start folding and start this process and that notochord is
going to eventually become the vertebral column. So again think of this plate kind of
like a yoga mat and you're bringing the ends together allowing that middle portion to
sag down. Now those edges in green once they come meeting together are called the
neural fold the neural folds that's in the sagging area in purple is called the neural
groove. So we have the neural plate, then we have the neural fold, and the neural groove
in this drawing. Now that right and left fold eventually converge into a point pinching off
into a tube of ectoderm tissue, and that tube is called the neural tube. The top of it that's
left behind these blue ends that eventually meet together contributes to the epidermis.
Now note that, that green portion is very special and it stays together and it's called the
neural crest. The neural crest that's what used to be the neural fold that part that
actually pinched together and stayed on top of the neural tube. So that neural crest
consists of cells that are going to migrate all over the place and contribute to some really
important structures that are far away from the dorsal surface. So again this top part is
the dorsal surface, it's the epidermis and those neural crest cells are going to be able to
be sent out all over the place to contribute to all sorts of structures, a lot of the tooth
again is formed from neural crest cells. So as all of this is happening, the aortic arch
vessels and corresponding pharyngeal arches and somites form in a cranial to caudal
sequence. So these are some really important things what we're going to spend most of
the rest of the video talking about. The pharyngeal arches are segments by which the
head and the neck develop, they start with we start with six pharyngeal arches and we
go down to five. The somites are segments by which the body develops, so the rest of the
body we start with about anywhere between 42 and 44 somites we eventually end with
37 individual somites. So 5 pharyngeal arches 37 somites, and they develop in a cranial
to caudal sequence from head to tail.
All right. So following neural tube closure. This buccopharyngeal membrane or
oral membrane perforates. So it finally opens allowing a communication with the
outside world between the outside world and the foregut. This primitive oral cavity is
called the stomodeum or stomatodium, it's a really really important word and comes
up on board exams all the time. Some other good terms I wanted to point out for you: the
optic placode that's the primitive eye, the otic placode somewhere up here is the
primitive ear, it pops up a little bit later in development, and the blastopore is where
the cloacal membrane eventually perforates to communicate with the hindgut to create
the primitive anal cavity.
All right. So let's focus on the pharyngeal arches, they're also called the
branchial arches, branchial for gills, and they're a series of these they kind of look like
gills but they're not they're a series of externally visible anterior tissue bands lying
under the early brain that give rise to head and neck structures. The sixth arch, you can't
see here, you can only see one two three four maybe five but five doesn't stay around for
a whole lot for a whole long time and eventually we're just left with arch one two three
four and six that contribute to really important structures all of which we're gonna talk
about very soon.
So each of these arches contains very specific structures, and if we're looking at
we're basically looking at a cross-section of the embryo and we see that each of these
physical rib like structures rib like arches has an internal area, this internal area in
yellow or orange that is called in a pouch. And that's endoderm tissue we have a
mesenchymal core that's on the inside of each of these arches you can see it blown up
on the right side, that's made of mesoderm and neural crest cells and that's going to
contribute to arteries nerves muscles and cartilage. We also have an outside layer, this
is an external ectodermal cleft. So this is coming from ectoderm tissue. So we have
endoderm on the inside of each of these arches, ectoderm on the outside of each of these
arches, and each of those arches has all of these components artery nerve muscle and
cartilage.
So let's unpack this a bit more in the next slide and talk about specifics for each
arch. All right. So I cannot stress how high yield this table is going to be for you. There
are so many possible test questions that can be asked on this material, and they
certainly
come up all the time. So a lot of this is honestly going to be just kind of rote
memorization using flash cards and things like that, i'm going to try to talk about some
things that might help you remember some of these things a little bit better. So how this
is laid out we have the five important pharyngeal arches: one, two, three, four, and six.
And then we have the nerve, the bones, the cartilage, the muscles and the ligaments
associated with each of those arches. So I want to go through the cranial nerves really
quick, we're going to have a separate video talking about each of the cranial nerves and
what they actually do. So don't worry too much about the function part of it but certainly
remember these numbers and these cranial nerves because it's just so important, it's
gonna inform a lot of the later things we talk about.
So the pharyngeal arch one is innervated by cranial nerve V, pharyngeal arch
two cranial nerve VII, three goes with IX, and 4 and 6 are both innervated by cranial
nerve X.. So V is trigeminal, VII is facial, IX is the glossopharyngeal, and X is the vagus
nerve. Again we'll talk about the specifics a little bit later but if you can remember V, VII,
IX, X,V, VII, IX, X. This is so so important. All right. So let's go now across the rows. The
first pharyngeal arch is also called the mandibular arch. This is in this red or orange
let's call it orange because I see red down here a little bit more. So the orange arch here
is the first one and it's called the mandibular for a good reason, some of the things that
are going to come from this arch are the meckel's cartilage, meckel's cartilage, maxilla,
mandible, malleus do you see where i'm going with this all of these m's are coming
from the mandibular arch, also the the incus is another inner ear bone, also the zygoma,
and the temporal bone of the skull also being contributed from this first arch. Over for
muscles, we have the all of the muscles of mastication, I call them the MOM - muscles
of mastication are the masseter, the temporalis, and the medial pterygoid, and
lateral pterygoid. We're gonna have a separate video uh just talking about those
muscles but those are all innervated by cranial nerve V, the third division of cranial
nerve five to be exact and they're all coming from pharyngeal arch one, also the
mylohyoid is coming from this arch. So just look at all the M, I think that's a really nice
quick way to remember some of these things for this first row, also the anterior
digastric and these two tensor muscles. The sphenomandibular ligament is the
ligament coming from this one. So again a lot of uh a lot of commonalities among that
row.
For the second one, hyoid, it's also called the hyoid arch, this one is coming up
with the Reichert's cartilage, the stapes that's the third inner ear bone that we got left
out from the first arch, the styloid process, hyoid rhymes with hyoid and the upper half
of the hyoid body, and the lesser cornu or lesser horns of that hyoid bone, the muscles
of facial expression the MFE come from this one. They're all innervated by the facial
nerve and then we have the posterior digastric. So the anterior digastric muscles
were for the first row the posterior for the second. We also have the stylohyoid muscle
and the stapedius muscle that goes along with the stapes and we have this stylohyoid
ligament. So a lot of you know oid and hyoid that appear in that row as well.
So hopefully some of those things can kind of stick out to you and help you at
least fill in some of this table because honestly this is like one of those really high yield
things that I would almost just reproduce on your scrap paper as soon as you start the
exam because so many things could refer back to this. The hyoid arch is in blue on this
right image, and then three is in yellow, four is in red, and finally six is in green down
here. So I won't go through all the rest of this but you certainly can look at this and
memorize it, one thing that's a little nice is that with the third arch, there's only one
muscle to remember, no ligaments and the skeleton is a little pretty straightforward. If
you get the second row done and you know its upper half of the hyoid and the lesser
horns, you just have to do the opposite lower half of the hyoid and the lesser horns to fill
in that arch. So there's some things that can help you out with reproducing this table,
again cannot stress enough how high yield this is. Now some people ask is there a fifth
arch, well yes and no in humans, the fifth pharyngeal arch exists only transiently during
this embryogenesis process eventually, it goes away and doesn't contribute to a whole
lot kind of like the hypoblast that we saw before.
All right. So once we understand the previous table, this table makes a whole lot
more sense. So this one looks at the ectodermal clefts, and the endodermal pouches that
we talked about before, and also I included the neurogenic placodes, these are focal
thickenings of the ectoderm layer that give rise to to neurons essentially. So let's look at
the placodes first because I think they're actually the most straightforward. So
remember I talked about the cranial nerves for each arch V, VII, IX, X. Well, guess what
for arch 1, we have the trigeminal ganglion which goes with cranial nerve V. The
geniculate ganglion is part of cranial nerve VII. And then we have the inferior sensory
ganglion of the ninth cranial nerve, inferior sensory ganglion of the 10th cranial nerve.
So if you just remember V, VII, IX, X, you already have everything you need with that
column. All right now let's go over to the clefs, so I just want to clarify the cleft of arch 1
is is really between arch 1 and 2. So each of these clefts and pouches are kind of between
the arches. So so cleft 1 is between these 2 cleft, two is between those two etc. So they're
really listed below the arch of the row that they're in. So the cleft of arch 1 which is
really between arch 1 and 2 is the external auditory meatus that's this opening right
over here, that's the opening of the outer ear, and as you'll soon see the outer ear
develops from three segments of pharyngeal arch1 and 3 segments of pharyngeal arch
2. So and
the fact that the opening is between these two arches makes perfect sense, of course
there's going to be one on the right side and one on the left side of the developing
embryo. Clefts 2,3 and 4 all contribute to the cervical sinus which is a temporary space
that eventually goes away. However if it doesn't go away there can be remnants of the
sinus located laterally along the anterior border of the sternocleidomastoid muscle of
the neck, and these cysts that don't go away it's called a branchial cyst or branchial
sinus. So if something goes wrong there, that's what that becomes. Lastly the pouches, so
there's a bit more going on in this column but I promise that it'll all make sense. So
remember cleft 1 was for the outer ear opening, now guess what pouch 1 is? It's the
inner ear opening. So right over here, we have the eustachian or auditory tube, and the
tympanic cavity in there. So it's all part of the inner ear and that's gonna obviously
connect with the outer ear opening. So together they form the entire ear canal. Now for
pouch number 2, we move further down along the back of the throat essentially and this
is where we get to the palatine tonsils, the palatine tonsils. Now for pouch 3 and 4, it's
where things get a little bit weird, basically everything in this area migrates and
descends from its starting position, and some things descend further down than others.
So some of these things aren't going to make a whole lot of sense where they start, it'll
make more sense where they finish. So pouch 3 makes the thymus which is an immune
organ where the T cells mature and. So here's the thymus over here, and that's going to
go way down that's going to migrate way down to eventually sit between the two lungs.
Now also from this arch or from this pouch I should say is the inferior parathyroids,
the inferior parathyroid glands, one on either side that are embedded within the thyroid
gland and these make a parathyroid hormone to regulate calcium and phosphorus
levels in the body. And those also descend those also descend but not quite as far as the
thymus does now. Pouch 4 contributes to the superior parathyroid glands, again 1 on
either side of the thyroid, and that's the confusing part because they don't migrate as far
down as the inferior ones did. So the inferior start out higher and then end up lower the
superior ones start out lower, but they don't have to migrate down as far. So they stay on
top of where those inferior glands end up.
The same thing with the ultimo-branchial body that's contributes to the
parafollicular cells or c cells of the actual thyroid gland. Those stay a little bit closer to
where they developed into where the thyroid gland eventually was going to end up. Now
if one of these pharyngeal pouches doesn't close properly, you can end up with a
tunnel of tissue or a branchial fistula that extends from a pharyngeal pouch to the
surface of the neck. So a branchial fistula. So a cyst is if a cleft messes up, a fistula as if a
pouch messes up. All right. So a lot of information there, hopefully all of that made sense.
I know some of the stuff going on with the third and fourth pouch is a little bit confusing
but as long as you figure out you know where they start versus where they end up. It
makes a little bit more sense.
All right. So how about the pituitary gland. Well remember back to our week
four setup over here where we had the roof of the oral cavity, we have the roof of the
oral cavity, the oral cavity is the stomodeum, and the floor of the forebrain are
essentially right next to each other, and each of these things contributes to the pituitary
gland formation. So a nice image from teach me anatomy, we have the floor of the
forebrain and the roof of the stomodeum or stomodium those are synonymous right
next to each other. Both of these things are going to basically fold up, and the rathke's
pouch is an imagination at the roof of the developing mouth, close to that
buccopharyngeal membrane that is eventually going to give rise to the anterior
pituitary. And then up here the roof of the forebrain, we have the diencephalon that's
the caudal part of the forebrain and that evaginates downward to merge with the
anterior pituitary and becomes the posterior pituitary. So the anterior part originates
from oral ectoderm, the posterior part originates from neural ectoderm. So pretty cool
how that how that happens.
So the pituitary gland developed from two entirely different tissues and the
tongue is another cool example because it's one organ that develops from four different
pharyngeal arches, and that explains why its innervation pattern is essentially all over
the place, we'll have a separate video dedicated, again, to all the cranial nerves but for
now, let's just cover how the tongue feels and moves. So the first two columns again
should look really similar, again we just follow the pattern V, VII, IX, X for those 4 arches.
We also have a fifth source that I want to mention for the tongue being not an arch but
actually occipital myotomes that's part of the somites that develop into muscles. So
let's move over to a diagram I made over on the right, and we'll start with general
sensation, general sensation so that's things like touch pain and temperature. In the
anterior two-thirds, that's this bottom part down here, the anterior two-thirds of the
tongue is innervated by V3 that's the third division or the mandibular branch of the
trigeminal nerve. The posterior third that's up here is innervated by cranial nerve IX,
and then the root or the base of the tongue as well as the epiglottis which is way back
there is innervated by cranial nerve X, and all that stuff is reiterated on the chart, this is
just a fun little visual tool that I like to reproduce on test day. Now for taste, we move
over to this column, the anterior two-thirds is innervated by cranial nerve VII - the facial
nerve. So that's different, an entirely different nerve is responsible for an entirely
different
sensation in the same region of the tongue, it just blows my mind how cool that is. And
then if we go to the posterior third as well as the base of the tongue, those two things are
the same as they were for sensation so cranial nerve IX is responsible for the posterior
third, cranial nerve X for the base, the root whatever you want to call it, those are
synonymous as well as the epiglottis. Now how about for a motor for actually moving the
tongue around. Well the vagus nerve once again plays a role here in innervating what's
called the palatoglossus muscle that is a tongue muscle that's innervated by cranial
nerve X, so X is the only cranial nerve here that does all three of these things for the
tongue. However that's the only tongue muscle that a pharyngeal arch contributes to and
the rest of the tongue muscles are from those occipital somites that are innervated by
cranial nerve XII - the hypoglossal nerve. Again we're going to talk more about cranial
nerves, we'll also talk more about these tongue muscles in an entirely separate video,
we're focusing more on the embryology part of it here. Again notice that the pituitary,
the tongue, and also a lot of the other things we're going to talk about in this video, all of
this is happening starting week four, week four is a really big week where a lot of organ
development is going on.
How about the thyroid gland, the thyroid gland so we talked about this a little bit
already, we talked about how the parafollicular cells originate and how they descend.
What about the rest of the thyroid gland, well it has a very interesting path of
development. So it actually develops from tissues at the base of the tongue which
actually makes perfect sense. The thyroid cartilage comes from arch 4 and the vast
majority of the thyroid comes from the cleft under arch 4. So it's only natural that the
thyroid would originate from tissue of the tongue that's innervated by the vagus nerve
which is also part of arch 4. So all of that kind of connects together. So from this view,
this is the same image I had in the last slide but i just re-masked it for some anatomy
labeling. So we have the median sulcus goes across the tongue, we have these big
circumvallate papillae that kind of form a V-shape at the end of our tongue, and then
we have this little dot here called the foramen cecum, and that's a vestigial depression
and it starts out as the development site for the primitive thyroid gland. So the thyroid
gland starts right there at the back of the tongue and it descends through the neck. So it
descends and it goes quite a distance carrying with it the thyroglossal duct, the
thyroglossal duct, and that makes sense because thyro thyroid and glossal for tongue, all
that goes together and that stays connected to the foramen cecum on the surface of the
tongue. The thyroids pyramidal gland that's right at the center right here, it kind of
sticks up a little bit usually extends up along the path of this duct at the midline, and
that's a result of the travel that the thyroid gland had to take. An undescended thyroid
gland might sit at the base of the tongue as a lingual thyroid. So that's pathology related
to a failure of this development process.
How about the ear, this happens a little bit later about week six and it develops
from six individual auricular hillocks from the first and second pharyngeal arches. And
that's three helix on either side of that ear opening. So three from first arch, three from
the second arch, and that little opening is going to happen right between those. So it all
again it all kind of comes together which is really really the cool thing about all of this. So
one here becomes the the tragus, we have three up here becomes the helix, four is the
anti-helix, six is the lobe and you don't have to remember all of those things but you
can see how kind of the one, two, and three form a good portion of that, four, five, and six
form this portion and. So you have the external auditory meatus that gets left in
between those two groups and that's how it all kind of works together. Now important
thing to know for a possible case question on a dental board exam, retinoic acid also
known as accutane is a medication that's used for severe acne, and it can cause first and
second arch defects that manifest if if the mother is taking it during this stage of
development, it can cause defects such as microtia which is a small ear, and it's
frequently accompanied by micrognathia which is a small mandible, again in the
context of embryology, it makes sense because they all share the same arch, portions of
the ear and the entire mandible are coming from arch number 1.
All right. So we've covered this content in our orthodontics series on cleft lip and
palate. I'll cover it again from an embryology standpoint. So a cleft is the result of a
failure of fusion of tissue during early development and we're still in the embryo stage
here. So let's start with cleft lip, lip formation occurs during weeks four, five, and six,
and the lip is derived from medial nasal prominence, the medial nasal prominence
that's in red in this diagram. And the maxillary prominence which is in green, the
lateral nasal prominence in blue forms the ala or the sides of the nose. Now cleft lip
occurs when the maxillary prominence fails to fuse with the medial nasal prominence
anteriorly. So if these two primitive tissues fail to fuse properly, that's how you get a
cleft lip. Now due to the location of these prominences and where they're fusing, that's
going to typically result in either a left side or a right side, a unilateral cleft but not
always, sometimes it can occur bilaterally sometimes even at the midline. Now let's go to
cleft palate, the palate is a little bit later primary palate forms at around six weeks in
utero, the secondary palate forms at around eight weeks in utero. So lip is four to six,
palate is six to eight. The primary palate is this red part up front, it also comes from the
medial nasal prominence, now we're looking at an axial view looking up at this baby's
palate and. So the primary palate can also be called the premaxilla, the intermaxilla or
the incisive bone
and it carries lateral incisor, to lateral incisor which explains why someone who has cleft
palate often has missing or malformed lateral incisors because those teeth develop right
next to where this junction is. The secondary palate is everything else, it's the green part
originally, these two palatal shelves one and two are developing vertically, they're
actually located lateral to the tongue in a vertical orientation. So think of them like doors
that are swung wide open and as the oral cavity grows taller the tongue relatively moves
downward and it allows those shelves to close to a horizontal position and fuse at the
midline like you see here. Now the palatal shelves begin to fuse starting at the incisive
foramen which is right here and they will zip together caudally or posteriorly. So a lot of
things happen in this kind of cranial to caudal or anterior to posterior development
direction. Now an incomplete cleft palate occurs when the palatal shelves fail to fuse
with each other a complete cleft palate. So that would be you know if the failure
diffusion ended up like that. Now you could also have a complete cleft palate where in
addition to that the primary palate fails to fuse with the palatal shelves. So there's a
clean break all the way through there between the left and right sides in a complete
palatal cleft. Now once you hit the end of week eight, the baby is considered a fetus
and we could go on and on with embryogenesis but the rest of it is just not as high
yields for dental board exams. So we're going to stop right here.
Now I do want to bring in some clinical stuff because I know everyone's always
asking me about some case questions and can we see more patient cases. Well here, we
have a case of a child with digeorge syndrome, it's a rare syndrome that's caused by
genetic or environmental influence on neural crest cells during development. So again
things like alcohol or retinoids could play a role, it's known as third and fourth pouch
syndrome, and now we have all the information we need to explain this it affects. The
third and fourth pharyngeal pouches if we go back to our chart we see the thymus and
the parathyroid glands are going to get hit the hardest and that's exactly what we see in
its manifestation. A great mnemonic to remember for this one is catch 22, catch 22. So
the C stands for cardiac abnormalities, A stands for abnormal facies, it's things like a
cleft palate, short philtrum, small mandible, hypertelorism the eyes are far apart, the
T stands for thymic aplasia again the thymus is getting hit hard because this is affecting
among other things the third and fourth pouches, cleft palate and hypocalcemia,
hypocalcemia results from a bad a parathyroid gland which means that there's no
parathyroid hormone being produced, if there's no parathyroid hormone you can't
increase your blood calcium levels. So the blood calcium stays low which is
hypocalcemia. And then it involves a 22q11 chromosomal deletion and. So catch 22 is
a really nice like clean mnemonic to remember for digeorge syndrome.
 And just to wrap things up, I just wanted to stress to you guys that it's. So
important for embryology and really everything anatomy is to draw it out to, draw it out,
make nice clean drawings and use lots of colors and play around with different views
and i think that's the best way to learn this stuff. So i just did this quick sketch a few
minutes before I recorded just to show you what you can kind of come up with and this
is just going through the things we talked about. Starting from ovulation, through
fertilization, the zygote, morula, blastula with that cavity the embryoblast which will
become the epiblast, and hypoblast that epiblast will kind of go crazy become our three
germ layers that we have here, then we have the pinching off of that gut to form this
more familiar cross section with the neural tube, notochord and the primitive gut. So
stuff like this it's just so helpful to draw it out look at those diagrams that I included
throughout the video and kind of make your own interpretations and drawings as you
go along and study this stuff.
All right well that's it for this video guys thank you. So much for watching please
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