Cleft lip and palate: recommendations for dental anesthetic procedure based on anatomic evidences

Patients with cleft lip and palate usually present dental anomalies of number, shape, structure and position in the cleft area and the general dentist is frequently asked to restore or extract those teeth. Considering that several anatomic variations are expected in teeth adjacent to cleft areas and that knowledge of these variations by general dentists is required for optimal treatment, the objectives of this paper are: 1) to describe changes in the innervation pattern of anterior teeth and soft tissue caused by the presence of a cleft, 2) to describe a local anesthetic procedure in unilateral and bilateral clefts, and 3) to provide recommendations to improve anesthetic procedures in patients with cleft lip and palate. The cases of 2 patients are presented: one with complete unilateral cleft lip and palate, and the other with complete bilateral cleft lip and palate. The patients underwent local anesthesia in the cleft area in order to extract teeth with poor bone support. The modified anesthetic procedure, respecting the altered course of nerves in the cleft maxilla and soft tissue alterations at the cleft site, was accomplished successfully and the tooth extraction was performed with no pain to the patients. General dentists should be aware of the anatomic variations in nerve courses in the cleft area to offer high quality treatment to patients with cleft lip and palate.

El nervio milohioideo en la inervación accesoria de los dientes inferiores / The milohioideo nerve in the accessory innervation of the inferior teeth

El nervio alveolar inferior (NAI) es responsable de la sensibilidad de la pulpa dentaria, papilas interdentales, periodonto, tejido óseo vecino a los dientes y, a través de las fibras que constituyen el nervio milohioideo (NM), de la inervación de los músculos milohioideo y vientre anterior del músculo digástrico. Sin embargo, hay polémica en cuanto a la participación del NM en la sensibilidad accesoria de los dientes inferiores. Nuestro objetivo fue estudiar la posibilidad de la participación del NM en la inervación accesoria de los dientes mandibulares. Estudiamos la anatomía de los NAI y NM, a través de la disección de las caras mediales de 12 mandíbulas de cadáveres adultos humanos. Identificados los NAI y NM realizamos la morfometría: A= distancia entre el origen del NM y el foramen mandibular; B= ancho del NAI antes de emitir elNM y C= ancho del NM; en milímetros. Los resultados presentaron los valores medios: A= 10,02 (+/- 4,14); B= 5, 67 (+/- 0,97); C= 2,95 (+/- 0,437). La medida A fue la que más osciló; las mandíbulas 8 y 11 presentaron pequeños ramos del NM penetrando en la cara medial del hueso. La variación de la medida A puede justificar la no inclusión del NM en una anestesia del NAI. Las medidas B y C ilustran aspectos topográficos de los nervios NAI y NM que pueden ser aplicados a la práctica odontológica. Los hallazgos de ramos nerviosos penetrando en la mandíbula, tienen correspondientes en la literatura. Este estudio, enfocando la morfometría de los NM y NAI y las relaciones entre NM y NAI, puede posibilitar hipótesis diagnósticas relativas a la inervación accesoria de los dientes inferiores.

The inferior alveolar nerve (IAN) is responsible to innervation for the dental pulp, papillae interdentals, periodontal, bone tissue neighbour to the teeth and through the nerve fibers of the Mylohyoid Nerve (MN) by innervation mylohyoid muscle and anterior belly of the digastric muscle. However there is controversy about the involvement of MN in auxiliary sensitiveness of the teeth downwards. Our objective is to study the possibility of involvement of MN in accessory innervation of mandibular teeth. Studie the anatomy of the IAN and MN through the dissection of the medial side of 12 mandibles of adult human cadavers. IAN and MN identified so perform the morphometry: A – distance between the origin of MN and mandibular foramen; B – width of the NAI before issuing the MN; C – width of MN; in millimeters. The results provide the average values: A= 10.02 +/- 4.14; B = 5.67 +/- 0.97; C = 2.95 +/- 0.437. Measure A was the most varied; the mandibles 8 and 11 showed smal branches of MN in penetrating the medial side of the bone. The change of measure A can to justify the not inclusion of MN in the anesthesia of IAN. Measures B and C illustrate aspects of topographical of MN and IAN nerves that can be applied to the dental practice. The findings of branchs of the MN penetracting in mandible has correspondents in the literature. This study focusing on the morphometry of the IAN and MN and relations between them can enable diagnostic hypotheses concerning accessory innervation of lower teeth.

Clinical significance of the supplementary innervation of the lower teeth: a dissection study of the lingual nerve / Significaçäo clínica da inervaçäo suplementar dos dentes inferiores: estudo anatômico do nervo lingual

Tendo em vista as opiniöes divergentes, encontradas na literatura, sobre a possível participaçäo do nervo lingual na inervaçäo de dentes inferiores, foi proposta uma tentativa de esclarecimento da questäo através de um estudo laboratorial. A distribuiçäo anatômica do nervo lingual foi pesquisada em 30 cadáveres, através de dissecaçöes sob lupa. Os resultados indicam que nenhuma ramificaçäo penetra na mandíbula através dos chamados forames vasculares; portanto, a hipótese da participaçäo do nervo lingual no suprimento de dentes parece estar descartada

Contribuiçäo ao estudo da inervaçäo suplementar dos dentes inferiores: uma revisäo bibliográfica / Supplementary innervation of the inferior teeth: a bibliographic review

Quando o paciente relata a persistência de dor, após um bloqueio do nervo alveolar inferior pela técnica correta, o profissional deve pensar na possibilidade de inervaçäo suplementar dessa regiäo que deverá ser bloqueada. Esta regiäo procura atualizar o conhecimento sobre essa inervaçäo suplementar. Nem todos os pacientes requerem este tipo de anestesia, no entanto, o profissional cirurgiäo-dentista deve estar bem consciente da sua existência