In this newborn, the gums are not parallel with each other. This is due to in utero molding, when the head has been turned to one side (to the right in this baby) and the chin has been pushed up against the shoulder for some time. The angle is usually mild, but in some cases, it can be pronounced enough that the jaw subluxes with opening. Spontaneous resolution is expected.
photo by Janelle Aby, MD
Positional Deformity of the Jaw
A closer view of the same infant, the angle between the upper and lower jaws can be better appreciated with the gums closer together.
photo by Janelle Aby, MD
Positional Deformity of the Jaw
With a wider view, the asymmetry of the chin can be seen. The right side of the chin is more concave and fits nicely up against the right shoulder -- the position in utero. In contrast, the left side of the chin appears more full.
photo by Janelle Aby, MD
Epstein Pearl
The small white papule seen in the midline of the palate of this infant is an Epstein pearl. It represents epithelial tissue that becomes trapped during the palatal fusion. It is a very common and benign finding.
photo by Janelle Aby, MD
Epstein Pearl
Another infant has a group of pearls on the palate. On palpation, these are firm papules that can be appreciated when the infant is sucking on the examiner's finger.
photo by Janelle Aby, MD
Cleft Palate
In contrast to the normally formed palates in the previous two photos, this infant has a cleft palate. Here, only the lateral margins of the palate are visible. Because the mouth is wide open to the nasal cavity, the NG tube can be seen passing through the nasopharynx as well as the mouth. Cleft palate is not always this obvious. When examining the palate, the examiner should palpate both the hard and soft palate to check for submucosal and partial clefts, which are more easily missed.
photo by Janelle Aby, MD
Bifid Uvula
The appearance of bifid uvula can range from broad with a central indentation, as in this patient, or frankly duplicated. It is often an isolated finding but can be associated with submucosal cleft palate.
Cleft Lip
This infant has a normally formed, intact palate, but has a unilateral cleft on the left side of the lip. It is important to distinguish unilateral (or bilateral) cleft lip from the more unusual and concerning midline clefts that can occur. Midline clefts are often associated with underlying midline defects in the brain or other structures, whereas the type of cleft pictured above is more likely an isolated finding. Feeding can be impaired in infants with cleft lip (although the infant above was able to breastfeed sufficiently). If needed, a Haberman bottle feeder may be helpful.
photo by Janelle Aby, MD
Bohn's Nodules
The white bumps present on the upper gum in this infant are Bohn's nodules. The exact etiology is unknown, but they are thought to arise from remnants of the dental lamina or from heterotrophic salivary glands. Present either on the lateral aspect of the gum (as seen here) or on the periphery of the palate, these nodules are a benign finding and will disappear with time.
photo by Janelle Aby, MD
Bohn's Nodules
Here is another infant with the same finding. When the nodules are large, they are sometimes mistaken for teeth, but the position on the exterior surface of the upper gum is inconsistent with teeth. When natal teeth occur, they erupt from the alveolar ridge, and typically occur in the mandibular gum.
photo by Janelle Aby, MD
Salivary Glands
These vesicular-looking lesions were first noted by the mother as she was getting the baby latched on for feeding. These are minor salivary glands that are just more prominent than usual. No evaulation is needed.
photo by Janelle Aby, MD
Ankyloglossia
Tongue-tie occurs in approximately 4% of newborns. Many babies with this condition can breastfeed without difficulty, but in some cases, a tight frenulum makes latching on difficult. In those cases, frenotomy may be indicated. The Hazelbaker Assessment Tool for Lingual Frenulum Function is one tool that may be used to grade the severity of the tongue-tie objectively. (Video clip of assessment being done). There are no prospective trials on the outcome of speech in those infants identified at birth, so this is not currently an evidence based reason to clip the frenulum in the nursery. The impact on breastfeeding, however, is well documented.
photo by Janelle Aby, MD
Ankyloglossia
This is the same infant as in the previous photo, immediately after frenotomy. There is no bleeding, and the tongue is more mobile. Latching was significantly improved.
photo by Janelle Aby, MD
Normal Tongue
In contrast, this baby has no appreciable lingual frenulum, and has good mobility of the tongue with crying.
photo by Janelle Aby, MD
Natal Teeth
Natal teeth usually occur in this location in the mandibular gum. In this case, eruption cysts are still completely covering the teeth, but with palpation, 2 firm teeth can be appreciated. They are also partially visible as faint white streaks within the cysts. Natal teeth occur in 1:2000 - 1:3500 newborns. They are usually part of the primary dentition of the child, so they should not be removed unless they are mobile, presenting an aspiration risk, or causing secondary tongue ulceration as in Riga-Fede disease.
photo by Janelle Aby, MD
Natal Tooth
This infant's tooth is erupted and is clearly visible. When the tooth is mobile, it can easily be removed with a gauze and a twisting motion. In this case, the tooth was firmly seated in the gum and was not removed in the nursery.
photo by Janelle Aby, MD
Natal Teeth
Here is a third example of natal teeth. When palpated, these teeth could be moved slightly, but they were placed low enough in the gum that they do not currently present an aspiration risk. They were not removed.
photo by Janelle Aby, MD
Micrognathia
Micrognathia, or "small jaw", can often be best appreciated when looking at the profile of the infant. While many infants may appear to have a slightly recessed chin, the appearance above is clearly abnormal. Underlying genetic conditions should be considered in cases such as this; there are quite a few chromosomal conditions associated with this finding.
photo by Janelle Aby, MD
Normal Chin
For comparison, this is a normal newborn. Although the chin is less prominent than the upper lip, this is a normal profile for an infant.