Techniques of Mandibular and Maxillary Anesthesia Dr. Mumena C.H

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Text of Techniques of Mandibular and Maxillary Anesthesia Dr. Mumena C.H

  • Techniques of Mandibular and Maxillary AnesthesiaDr. Mumena C.H

  • IntroductionChoice of anesthesiaMandibular techniqueMaxillary technique

  • Choice of LA3 Important factors;Specific nerve to be blocked,Onset of action,Duration action,

  • Duration of actionThe duration of action of LA may vary from 30min to 180 minutes or longer,Duration is related to dosage, increasing dosage increases duration,Duration can be increased by adding Epinephrine (vasoconstrictor) to the local anaesthesia,Duration of action differs for different agentsNB. Read the properties of each agent.

  • Nerve to be blockedSmall nerves are in general easier to be block than larger onces,Nerve endings and cutaneous nerves are easily and quickly blocked by low concentration of drug given by infiltration,

  • Onset of actionDepending on the type of operation, e.g acute pain then rapid onset required,

  • Review Anat. Trigeminal nerve5th cranial nerve.Major sensory of the face, mouth and nasal cavity.Motor and proprioceptive innervation to muscles of mastication.Origin-Sensory neurons-upper part of pons,Motor neurons-inferior surface of pons3 divisions Ophthalmic, maxillary, and mandibular).Successful practice of dentistry is based on blockade of the various branches of these nerves.

  • Mandibular nerve3rd and largest branch of trigeminal nerve.Composed of motor and sensory roots.Exits craniumforamen ovale.Motor innervation to the muscles of mastication.

  • Mandibular nerveSensory to mandibular teeth and gingiva, lower lip, cheek, anterior two thirds of the tongue, auricle and skin over temporal region.Braches Inferior alveolar nerve,Lingual nerveBuccal nerveMental nerveIncisive nerve

  • Inferior alveolar nerve block in DentalInferior alveolar nerve together with lingual nerve are anesthetized by the same or different injections.Lingual nerve mucous membrane of the floor of mouth, anterior 2/3 of tongue and lingual gingiva.I.A.n mandibular teeth and surrounding hard and soft tissue up to the midline, exception buccal soft tissues in the molar area.

  • Inferior alveolar nerve block in DentalAnatomical landmarks anterior border of ramus, external and internal oblique ridges, the coronoid notch, retromolar triangle and pterygomandibular ligament.Target area for injectionmandibular foramen located in the mid-portion of ramus and 1 cm above the occlusal plane. Sometimes found in the area between mid-portion of ramus and posterior 1/3 of ramus.

  • Inferior alveolar nerve block in Dental contSeveral technique elaborated difficulty of locating mandibular foramen hence LA failure.There is two techniques:Traditional technique, Direct techniqueIndirect technique Alternative technique;High ramus neck of condyle approach (Gow-gates technique) and Tuberosity approach (Akinos technique)-Tresmus.

  • Inferior alveolar Nerve Block AnesthesiaLower success rate than Maxillary anesthesia - approx. 80-85 %Related to bone densityLess access to nerve trunksMost commonly performed techniqueHas highest failure rate (15-20%)Success depends on depositing solution within 1 mm of nerve trunk

  • Inferior Alveolar Nerve BlockNot a complete mandibular nerve block.Requires supplemental buccal nerve blockMay require infiltration of incisors or mesial root of first molar

  • Inferior Alveolar Nerve BlockNerves anesthetized Inferior Alveolar Mental Incisive Lingual

  • Inferior Alveolar Nerve BlockAreas AnesthetizedMandibular teeth to midlineBody of mandible, inferior ramus Buccal mucosa anterior to mental foramen Anterior 2/3 tongue & floor of mouthLingual soft tissue and periosteum

  • Inferior Alveolar Nerve BlockIndicationsMultiple mandibular teethBuccal anterior soft tissueLingual anesthesia

  • Inferior Alveolar Nerve Block ContraindicationsInfection/inflammation at injection sitePatients at risk for self injury (eg. children)

  • Inferior Alveolar Nerve Block10%-15% positive aspiration

  • Inferior Alveolar Nerve BlockSupplemental injectionPeriodontal ligament injection (PDL)Intraseptal

  • Inferior Alveolar Nerve Block Target AreaInferior alveolar nerve, near mandibular foramen LandmarksCoronoid notchPterygomandibular rapheOcclusal plane of mandibular posterior teeth (molars).

  • Inferior Alveolar Nerve BlockPrecautionsDo not inject if bone not contactedAvoid forceful bone contactAvoid use of cold agents

  • Inferior Alveolar Nerve BlockFailure of AnesthesiaInjection too lowInjection too anteriorAccessory innervation -Mylohyoid nerve -contralateral Incisive nerve innervation

  • Inferior Alveolar Nerve BlockComplicationsHematomaTrismusFacial paralysis (Inject into parotid gland).

  • Inferior Alveolar Nerve BlockGeneral hints: TechniqueApply topicalArea of insertion:medial ramus, mid-coronoid notch,level with occlusal plane (1 cm above),3/4 posterior from coronoid notch to pterygomandibular rapheadvance to bone (20-25 mm)

  • Traditional technique of inferior alveolar nerve block-Direct techniquePalpate the oblique ridge in the oral vestibule with index finger.Follow it posteriorly to where it ascends as sharp anterior border of the ramus of mandible.Move the finger to the temporal crest (internal oblique line) of the mandible and is left in this position.The finger is now in the retromolar fossa with the finger nail backwards.

  • Traditional technique of inferior alveolar nerve block-Direct techniqueDraw an imaginary line from point between the occlusal surfaces of the two premolars in the opposite quadrant to the midpoint of the fingernail.This imaginary line when extended posteriorly ends just above the mandibular foramen.Therefore the syringe needle will be directed along this line.

  • Traditional technique of inferior alveolar nerve block-Indirect techniqueAfter locating the injection site the syringe is held parallel to the mandibular occlusal plane on the same side as the tooth to be blocked.The needle is directed approximately 1 cm (with the syringe) above the mandibular arch. Aspirate the needle and inject 0.5 ml of LA for lingual nerve.Then move the syringe to the other side of the arch over the opposite premolars teeth.

  • Alternative technique-More reliable.Gow gates technique;Also known as high ramus- neck of condyle approach.Penetration into the oral mucosa is along the medial border of the mandibular ramus lateral to the pterygomandibular depression, but medial to the temporalis muscle tendon.The needle inserted along a line extending from the corner of the mouth opposite the site of injectionThe needle should be 25G and usually 1in long.The needle should advanced until bone is contacted and then withdrawn 1 mm.Anesthetic solution deposited after negative aspiration

  • Alternative technique- contAkinos technique;Also known as Tuberosity approach.This technique is useful where patient has intense trismus.Mucosa is penetrated along the medial surface of the mandibular ramus.The mouth is kept closed (teeth in occlusion) with the cheek and muscles of mastication relaxed.The same needle side.The depth of penetration is 1 inches.

  • The Akinosi technique

  • The Akinositechnique

  • Avoiding self-inflicted traumareduce area of soft tissue anaesthesiaintraligamentary anaesthesiaintra-osseous anaesthesiapalatal approaches to pulp

  • Intraligamentary anaesthesiapulpdentineintraligamentaryinjectiongingivapdlalveolus

  • Intraligamentary anaesthesiapulpdentineintraligamentaryinjectiongingivaalveolus

  • Intraligamentary anaesthesiapulpdentineintraligamentaryinjectiongingivaalveolus

  • Intraligamentary anaesthesiapulpdentineintraligamentaryinjectiongingivaalveolus

  • Intraligamentary and intra-osseous anaesthesiapulpdentineintra-osseousinjectionintraligamentaryinjectionalveolusgingiva

  • Intraligamentary and intra-osseous anaesthesiapulpdentineintra-osseousinjectionintraligamentaryinjectionalveolusgingiva

  • Success of intraligamentary anaesthesia depends on:toothleast successful with lower incisorssolutiondependent upon vasoconstrictor concentration

  • self-aspiratingnon-aspirating

  • initial aspiration forcesubsequentforce

  • Buccal nerve blockAnterior branch of Mandibular nerve (V3)Provides buccal soft tissue anesthesia adjacent to mandibular molarsNot required for most restorative proceduresBuccal is blocked by the injection in the buccal mucosa right to the 3rd molar just above the occlusal plane.

  • Buccal Nerve BlockIndicationsAnesthesia required - mucoperiosteum buccal to mandibular molarsContraindications Infection/inflammation at injection site

  • Buccal Nerve BlockAdvantages Technically easy High success rate

    Disadvantages Discomfort

  • Buccal Nerve BlockAlternatives Buccal infiltration PDL Intraseptal

  • Buccal Nerve BlockLandmarks Mandibular molars

    Mucobuccal fold

  • Buccal Nerve BlockComplications Hematoma (unusual)

    Positive aspiration 0.7 %

  • Long Buccal Nerve BlockTechnique;Apply topicalRetract the cheek Insert the needle distal to the tooth with the syringe horizontal into the buccal fold.About 0.5 ml of LA solution is injected.The barrel of the needle should be facing downwards.

  • Mental nerve blockMental nerve exits mandible through mental foramen.The foramen is located between root apices of 1st and 2nd premolrs.Technique; Insert the needle at an angle to the bony canal towards the mental foramen.Inject 1-1.5 ml LA solution, another injection is required in the lingual gingiva and