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.

Diagnóstico de fraturas do terço médio facial: Indicação da técnica radiográfica occipto-mental (Waters) com máxima abertura de boca / Midface fracture diagnosis: indication of the occipitomental radiograph (Waters? view) with maximum mouth opening

Objetivo: Este trabalho analisou as vantagens e limitações da técnica radiográfica occiptomental (Waters) com máxima abertura de boca para o diagnóstico de fraturas do terço médio da face. Descrição do caso: O diagnóstico de fraturas faciais é auxiliado por técnicas radiográficas após realização de exame clínico criterioso. Classicamente, no pronto-atendimento solicitam-se 4 a 5 incidências, que aumentam o tempo de atendimento, os custos e a dose total de radiação recebida pelo paciente. A técnica occipto-mental (Waters) originalmente descrita para seios de face permite avaliação da cavidade orbitária, processo alveolar, crista e corpo do zigomático. Recentemente, a literatura tem sugerido a técnica de Waters como única incidência a ser solicitada no exame inicial do paciente, substituindo as incidências descritas anteriormente; com isso, haveria a diminuição da dose de radiação, no tempo de atendimento ao paciente e nos custos por radiografia sem prejudicar o diagnóstico das fraturas do terço médio facial. Apesar de ser indicada como incidência única, a técnica de Waters gera sobreposição óssea na região inferior do terço médio, impedindo uma perfeita visualização desta porção. Conclusão: Indicamos uma variante desta técnica, com máxima abertura de boca, pois possibilita a avaliação da porção inferior do terço médio sem sobreposição, sendo uma das poucas incidências convencionais que permite a visualização de fraturas tranversais do palato.

Purpose: This paper reviews the advantages and limitations of the occipitomental view (Waters) with maximum mouth opening for the diagnosis of midfacial fractures. Case description: The diagnosis of facial fractures is supported by radiographic techniques after an accurate clinical exam. In Accident & Emergency departments (A&E) four or five radiographs often are taken, which increases clinical time, costs, and radiation exposure. The most used radiographic view is the occipitomental view (OM), which was first described for facial sinus and allows evaluation of the orbital floor, zigomatic processes, buttress, and arches. Recent literature has suggested the use of the OM view as a single radiographic exam for initial patient screening, reducing radiation exposure, clinical time, and costs without compromising the identification of midfacial fractures. However, the Water's technique generates bone image superimposition at the inferior midface, preventing perfect visualization of this region. Conclusion: We indicate a modified Water's view taken with maximum mouth opening, which allows proper evaluation of the inferior midface and the visualization of transversal palatal fractures.