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Gallagher N A general dental practitioner's role in treating patients with a cleft lip and/or palate. Br Dent J. 2020; 228:19-21 https://doi.org/10.1038/s41415-019-1116-7
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Bartkowska P, Komisarek O Scar management in patients after cleft lip repair – systematic review. Cleft lip scar management. J Cosmet Dermatol. 2020; 19:1866-1876 https://doi.org/10.1111/jocd.13511
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Considerations in dental local anaesthesia for the patient with cleft lip and palate Daniel Dilworth Edward Fahy Mishaim A Mian Emily Lordan Aisling O'Mahony Dental Update 2024 51:10, 707-709.
Authors
DanielDilworth
BDS, MFDS RCPS(Glasg), PGCert (ClinEd), Registrar in Restorative Dentistry, St James's Hospital, Dublin, Ireland
Patients who have had a history of surgical repair of cleft lip and palate can often develop scar tissue post-operatively that can make it more difficult for dentists to achieve sufficient local anaesthesia. In addition, the presence of a cleft can result in anatomical variation of nerve supply to the maxillary region, which can result in further complications for achieving sufficient anaesthesia. This article reviews the anatomical variations that can occur, and posits a technique to allow for more predictable and successful local anaesthesia in this cohort of patients.
CPD/Clinical Relevance:
GDPs may have difficulty in achieving sufficient local anaesthesia for patients with a cleft lip and palate.
Article
The incidence of cleft lip and/or palate (CLP) worldwide is about 1 in 700 live births.1,2 Clefts may be classed as unilateral or bilateral, as complete, incomplete or microform, and may involve the lip with or without the palate, or be isolated to the palate. A final group of patients with CLP present with atypical facial clefts and may occur in combination with other syndromes, e.g. Treacher Collins syndrome.3,4 Cleft lip, either with or without palatal involvement, is more common than isolated cleft palate,4 and isolated cleft palates occur more frequently among females than males.4 The aetiology of the orofacial cleft is unknown.5,6
The management of patients born with CLP usually requires multidisciplinary involvement almost immediately in the post-natal stage7 and can often require multiple surgeries to allow for correction of the relevant deficiencies. These often start at a young age to allow for repair of the defects and can include palatal repairs, bone grafting, cheiloplasty and repeated scar revisions.7 These surgeries can result in post-surgical contracture, hyperaesthesia and increased difficulty in achieving sufficient local anaesthesia in the dental setting.8
General dental practitioners (GDP) do not routinely treat patients with a history of CLP.9 This may be due to a reluctance on the part of these patients to attend a GDP or a reliance on hospital services to carry out dental examinations. However, GDPs should be capable of performing routine primary care, including restorative dentistry, periodontal treatment or single root endodontic treatment for repaired cleft lip and palate.9 This is complicated in this cohort of patients by anatomy and post-surgical factors.
Patients with CLP frequently exhibit alterations in the course of the anterior maxillary nerves.8,10 Surgical closure of a cleft can also result in scar tissue, which has been shown to negatively affect maxillary growth.11 This scar tissue is usually found in the anterior maxilla (Figure 1), where infiltrations of dental local anaesthetic can be quite painful owing to the thinner mucosa and the scarring associated with the anterior mucosa. Scar tissue in the lip makes retraction of the upper lip difficult, and can make infiltrations more uncomfortable for the patient.12
Figure 1. Scar tissue visible in labial sulcus apical to UL1 and UR1.
Parameter
Non-cleft
Cleft
Dental development
5% prevalence of anodontia, hypodontia and tooth alterations in shape form and number16
97% will have some anomaly, usually in the anterior area close to the cleft17
Caries rate
Twice as high in patients compared to their siblings, sex matched1,15
Difference in innervation patterns
Usual anatomy: anterior superior alveolar nerve innervates primary and permanent incisors. Nasopalatine nerve innervates anterior palatal mucosa and rarely innervates anterior incisors18
Median nasopalatine nerve innervates the anterior palatine cleft area in unilateral cleft lip and palate. Anterior superior alveolar nerve usually provides innervation to dentition on cleft side10 Median nasopalatine nerve innervates cleft area and anterior primary and permanent incisor pulps and incisive papilla in bilateral cleft8,10
It is the experience of the authors that patients with CLP disproportionately suffer from dental fear and many report traumatic episodes of local anaesthesia. This can be significantly reduced or eliminated by adjusting the technique for routine anaesthesia. The causative factors of this dental phobia can include the following:
Increased medical intervention at an earlier age leading to increased fear;13
More complex surgery resulting in more scar tissue and a tighter upper lip;12
More dental anomalies in the cleft area requiring more clinical procedures;14
Severity of cleft has been found to be related to degree of dental anomalies;14
Altered innervation of the cleft area making anaesthesia more difficult.8
It should also be noted that this cohort of patients has been found to have higher levels of caries and, as a result, an increased dental need.1,15
In this article, we propose standardization of the protocol for delivery of dental local anaesthesia for the patient with CLP.
Technique for anaesthetizing anterior teeth in patients with cleft lip and palate
To minimize discomfort and pain, we recommend anaesthetizing distal to the site of the scar tissue, for example in a unilateral cleft lip and palate, the local anaesthetic should be given initially in the premolar region.
The buccal mucosa close to the maxillary first premolar tooth is cleaned and dried. Topical anaesthesia (benzocaine or lidocaine) is applied to the mucosa for 2 minutes.
Initial infiltration of local anaesthetic (e.g. lidocaine or articaine) is given around the root apices of the maxillary first premolar tooth (Figure 2). This is left to work for 2 minutes to allow mesial spread of the local anaesthetic solution.
A second infiltration is given around the maxillary lateral incisor region and left to work for a further 2 minutes (Figure 3).
Further infiltration is administered around the root apices of the maxillary central incisor (if treatment is required at this site) (Figures 4 and 5).
Once this has taken effect, intrapapillary buccal and palatal infiltrations can be made if necessary.
If a maxillary central incisor is the tooth requiring treatment, consideration should be given to anaesthetizing the contralateral non-cleft side owing to the presence of anastomosing nerve fibres.
Figure 2. Initial administration of local anaesthesia at maxillary premolar region.Figure 3. Administration of local anaesthetic to maxillary lateral incisor region.Figure 4. Administration of local anaesthetic to maxillary central incisor region.Figure 5. Note blanching of mucosa on delivery of local anaesthetic to maxillary central incisor region.
Discussion
In the unilateral cleft palate, the left and right nasopalatine nerves descend along the vomer to the premaxilla. These nerves then anastomose and form the median nasopalatine nerve, which lies in the cleft site. A branch of the nasopalatine nerve then runs from the cleft to the palatal mucosa of anterior teeth on the cleft side, innervating palatal gingiva on that side. On the non-cleft side, the nasopalatine nerve innervates as usual (Figure 6).10 In the bilateral cleft palate, nasopalatine sensation is derived from bilateral bundles of nasopalatine nerve fibres that anastomose, sending fibres to the buccal mucosa, labial frenum and to the pulps of anterior primary and permanent incisor teeth (Figures 7 and 8).10 A further consideration when planning to administer local anaesthetic to the patient with a history of CLP is the composition of the scar tissue in the labial sulcus. This can be highly fibrotic and result in a particularly tight upper lip.8,12
Figure 6. Illustrating the course of the median nerve in unilateral cleft lip and palate. Adapted from Bøhn.10Figure 7.
(a,b) Course of the median nerve in bilateral CLP. Adapted from Bøhn.10Figure 8. Normal anatomy of the palate. Note the absence of the median nasopalatine nerve seen in the patient with CLP.
Dental anomalies, such as ectopically erupted anterior teeth, impacted canines, supernumerary teeth, dens invaginatus/evaginatus, are all far more common in patients with CLP than in the general population.16,17 DMFT/dmft is higher in cleft populations than among controls.1 Orthodontic treatment also encourages the accumulation of plaque and caries progression.19 All or some of these conditions may require treatment, and it is frequently necessary that these are treated in the community. It is thus necessary to provide detailed preventive advice to parents and patients.
After surgical correction, it may be difficult to notice any changes between the surgically treated patient and those who have had no surgery. However, plastic surgery only corrects the soft tissue, while the bone and nervous tissue underneath remain largely unchanged, and it is this concept that is worth remembering.20 It may be necessary to examine radiographs pre-operatively to assess the position of the roots of teeth radiographically with reference to the incisive foramen. A close radiographic examination can lead to correct identification of the best site to anaesthetize.20
It is important to be gentle while administering local anaesthetic. Topical anaesthetic should be used on dried mucosa for 2 minutes as stretching of the mucosa can cause pain, especially when inserting the needle for local anaesthetic into areas of scar tissue.8,20 It is necessary to approach the issue of anaesthetizing the anterior cleft area in two parts; first to anaesthetize the non-cleft segment, then to anaesthetize the accessory nerve supply via the median nerve. Occasionally, it may be necessary to anaesthetize the non-cleft side.20 Finally, as the delivery of the local anaesthetic to the scar tissue can cause significant distension to the soft tissues, it is imperative the clinician administers this in a slow and controlled manner to further alleviate any discomfort the patient may otherwise experience.
Conclusion
Successful administration of dental local anaesthesia to the cleft region in affected patients can be quite difficult owing to the presence of scar tissue and local anatomical variation of the nerve supply to the region as a result of the existence of the cleft. Ignorance of these difficulties can result in failure to fully anaesthetize the patient during routine dental procedures and may contribute to worsening dental phobia. It is imperative that all dental professionals be aware of these variations and be able to provide effective local anaesthesia to this cohort of patients.
