Techniques of regional anesthesia

TECHNIQUES OF REGIONAL

ANESTHESIAIN

DENTISTRY

PRESENTED BY –DR. SHEETAL KAPSE

CONTENTS

1. Definition of LA

2. Basic injection techniques

3. Techniques of regional anesthesia

- for maxillary teeth

- for mandibular teeth

4. Conclusion

5. Recourses

DEFINITION

Reversible loss of sensation in a circumscribed area of the body caused by a depression of excitation in nerve ending or an inhibition of the conduction process in peripheral nerves.

MALAMED (1980)

CONTRAINDICATIONS

Hemophilia is the absolute contraindications of local anesthesia.

Thyrotoxicosis is the contraindication of local anesthesia with adrenaline.

BASIC INJECTION TECHNIQUE

• Nothing that is done by a dentist for a patient is of greater importance than the administration of the drug which prevents pain during dental treatment.

• Most of the emergency situations - vasodepressor syncope

(common faint)

• Local anesthetic can & should be administered in a non-painful or atraumatic manner .

The atraumatic injection technique was developed over many years by Dr. Nathan Friedman & the department of human behavior at the University of Southern California School of Dentistry.

There are 2 components to an atraumatic injections – 1. Technical aspect 2. Communication aspect

STEP 1 : USE A STERILIZED SHARP NEEDLE

• Stainless steel disposable needles.

• use of needle not wider than 25 gauge.

• patient can not differentiate among 25, 27

& 30 gauge needles.

• 23 gauge & larger needles are associated

with increased pain

STEP 2 : Check the flow of local anesthetic solution

• A few drops of local anesthetic solution should be expelled from the syringe to ensure the free flow of the solution.

STEP 3 : DETERMINE WHETHER OR NOT TO WARM THE ANESTHETIC

CARTRIDGE OR SYRINGE

This is for the cartridges stored in refrigerators or any cool areas, which should be brought to room temperature before use.

Holding the metal syringe in the palm for half a minute is sufficient.

STEP 4 : POSITION THE PATIENT

Physiologically sound position before & during the injection.

Vasodepressor syncope (common faint)

- Anxiety The sign & symptoms will be –

light headedness,

dizziness,

tachycardia & palpitation

unconsciousness

Medical condition of the patient

is considered.

STEP 5 : DRY THE TISSUE

2 x 2 inch gauze – • remove any debris .

• Retracting the lip .

STEP 6 : APPLY TOPICAL ANTISEPTIC (OPTIONAL)

At the site of injection . Betadine (povidene iodine), Merthiolate

(thimerosal) Alcohol containing antiseptics - burning

of soft tissue .

STEP 7A : APPLY TOPICAL ANESTHETIC

• Directly at the site of needle penetration with the cotton applicator.

• Excessive amount – large area of soft tissue anesthesia,

- unpleasant taste

• Remain in contact with mucosa for 2 minutes (minimum 1 minute).

• Anesthesia of the outermost

2-3 mm .

STEP 7B : COMMUNICATE WITH PATIENT

• Communicate with the patient in a positive way.

• Injection , shot, pain, hurt

STEP 8 : ESTABLISH A FIRM HAND REST

Tissue penetration may be accomplished readily, accurately & without inadvertent nicking of tissue.

Palm down

Palm up Palm up & finger support

• 2 techniques should be avoided –

No syringe stabilization of any kind

Placing the arm holding the syringe directly on patient’s arm or shoulder.

STEP 9 : MAKE THE TISSUE TAUT

This permits the sharp stainless steel needle to cut through the mucous membrane with minimum resistance.

Loose tissue are pushed & torn by the needle as it is inserted producing more discomfort on injection & more postoperative soreness.

STEP 10 : KEEP THE SYRINGE OUT OF THE PATIENT’S LINE OF

VISION Assistant should pass the syringe to the administrator behind the patient’s line of vision.

STEP 11A : INSERT THE NEEDLE INTO THE MUCOSA

The bevel of needle should be oriented towards the bone.

Gently insert.

With firm hand rest & adequate tissue penetration

Atraumatic procedure

STEP 11 B : WATCH & COMMUNICATE WITH THE PATIENT

• Patient’s face should be observed for evidence of any discomfort.

• Signs of discomfort – furrowing of brow or forehead & blinking of eyes.

• Communicate in a positive

manner.

STEP 12 : INJECT SEVERAL DROPS OF SOLUTION

(OPTIONAL)

The soft tissue in front of the needle may be anesthetized to with a few drops of local anesthetic solution.

Step 12 & 13 are carried out together.

Wait for 2-3 seconds for anesthesia to develop

advance the needle within tissue

Aspiration is not required .

Only 1 or 2 drop (<1 mg) .

STEP 13 : SLOWLY ADVANCE TRE NEEDLE TOWARDS THE TARGET

STEP 14 : DEPOSITE SEVERAL DROPS OF LOCAL ANESTHETIC BEFORE TOUCHING THE PERIOSTEUM

The periosteum is richly innervated.

Regional block techniques that requires this are –

1. Gow-Gates mandibular nerve block

2. Infraorbital nerve block

STEP 15 : ASPIRATE

Minimizes the possibility of an intravascular injections.

Care should be taken to remain the needle unmoved.

Any sign of blood is a positive aspiration.

Aspiration should be performed twice (rotate barrel of

syringe 45 degree for second aspiration test ).

STEP 16 A : SLOWLY DEPOSITE THE LOCAL ANESTHETIC SOLUTION

• Reason - Preventing the solution from tearing the tissue into which it is

deposited

• Ideal rate of deposition of solution – 1ml/60 sec.• 1.8 ml cartridge takes approximately 2 min.

• A more realistic time span in a clinical situation is 60 sec. for a full 1.8 ml cartridge.

• There is evidence in the surgical literature that the success of some techniques is increased with slower injection speeds.

Rucci F S, Pippa P, Boccaccini A, Barbagli R. Effect of injection speed on anaesthetic spread during axillary block using the orthogonal two-needle technique. Eur J Anaesth 1995; 12: 505-511.

STEP 17 : SLOWLY WITHDRAW THE SYRINGE

Cap it immediately by Scoop technique . Needles should not be reused. The acrylic needle holder can be used.

STEP 18 : OBSERVE THE PATIENT

Most adverse drug reactions - during injection or within 5-10 min.

Patient should never be left unattended after administration of a local anesthetic.

STEP 19: RECORD THE INJECTION ON PATIENT RECORD

Local anesthetic agent Vasoconstrictor used (if

any) Dose Needle used Injections given Patient’s reaction

TYPES OF INJECTION PROCEDURES

1. Local infiltration (0.6 – 1.0 ml)

small terminal nerve endings are anaesthetized.

2. Field block deposited in proximity to the

larger nerve branches

3. Nerve block(1.8 – 2.0 ml)

depositing the LA solution within close proximity to a main nerve trunk

4. Intraligamentary (0.2 ml) - depositing the LA solution within

PDL through gingival sulcus. - Provides 30-35 min of anesthesia. - Indicated in patient with bleeding

disorder & young handicapped patients .

5. Intraseptal (0.1 ml) It is used to avoid IANB to work

in mandibular primary molars.

6. IntrapapillaryFor palatal & lingual anesthesia.

7. Intrapulpal In case of pulp therapy when

other techniques have failed.

8. Intraosseous For 1 tooth when other

technique fails. Perforate within attach gingiva about 2 mm below the gingival margin of the adjacent teeth in the vertical plane bisecting the interdental papilla .

1. Supraperiosteal /Infiltration2. Posterior superior alveolar nerve

block3. Middle superior alveolar nerve block4. Anterior superior alveolar nerve

block5. Nasopalatine nerve block6. Greater palatine nerve block7. Infiltration of palatal tissue8. AMSA9. P-ASA

ANAESTHESIA FOR THE MAXILLARY TISSUE

SUPRAPERIOSTEAL / PARAPERIOSTEAL / INFILTRATION

ADVANTAGES

1. High success rate (>95 %)

2. Technically easy

3. Usually atraumatic

DISADVANTAGES1. Anesthesia for larger area

requires multiple penetrations – pain.

2. Larger volume of local anesthetic.

INDICATIONS

1. Maxillary teeth

2. 1-2 teeth

3. Soft tissue anesthesia

CONTRAINDICATIONS

1. > 2 teeth 2. Infection & inflammation

3. Dense bone

Technique -

• Area of insertion

• Target area

• Landmarks –

mucobuccal fold

crown of tooth

root contour of tooth

Wait for 3-5 min.

0.6 ml / 20 sec.

Sign & symptoms

SUBJECTIVE

Numbness over area of injection.

OBJECTIVE

No pain during procedure

FAILURE OF

ANESTHESIA

Needle tip is too low

Needle tip is too far

COMPLICATION

Pain while needle touches the periosteum.

POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK

Highly successful technique > 95%

Potential for hematoma formation

Short needle is recommended

Depth of needle insertion- 16-20 mm 10-14 m for children

Aspirate several times

ADVANTAGES

1. Atraumatic 2. High success rate (>95 %)

3. Less no. of penetration

4. Equivalent volume

0.6 x 3 = 1.8 ml

DISADVANTAGES

1. Hematoma formation

2. No bony landmark

3. Mesiobuccal root of 1M is not

anesthetized in 28% cases

INDICATIONS

1. 2 or more Maxillary molars

2. When supraperiosteal injection are contraindicated or failed

CONTRAINDICATION

Hemophilic patients

Technique -

• Area of insertion• Target area

• Landmarks –

mucobuccal fold

maxillary tuberosity

infratemporal surface of maxilla

Anterior border & coronoid process

of mandible

zygomatic process of maxilla

Deepth of needle penetration – 16 mm

Wait for 3-5 min.

0.9-1.8 ml / 30-20 sec.

Sign & symptoms

SUBJECTIVE

Numbness over area of injection.

OBJECTIVE


FAILURE OF

ANESTHESIA1. Needle tip is too low

2. Needle tip is too lateral

3. Needle tip is too posterior

4. Accessory innervation from greater palatine nerve.

COMPLICATIONS

Hematoma formationMandibular anesthesia

MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK

(MSA)

1.Limited use cause – absent in 30-54%

cases

ADVANTAGE

Less volume

DISADVANTAGE

none

INDICATIONS

1. Maxillary premolars

2. MB root of 1M

3. When infraorbital injection is failed

CONTRAINDICATIONS

1. Infection & inflammation

2. Absence of MSA

0.9 – 1.2 /30-40 sec.

Technique -


• Target area

• Landmarks –

mucobuccal fold above maxillary

2 PM

Wait for 3-5 min.

Sign & symptoms

SUBJECTIVE

Numbness of upper lip.

OBJECTIVE


FAILURE OF

ANESTHESIA

Needle tip is too high

Needle tip is too lateral

Thick zygomatic bone

COMPLICATIONS

Hematoma formation(rare)

ANTERIOR SUPERIOR NERVE BLOCK

orinfraorbital nerve block

1. Highly successful & extremely safe

2. Limited use cause – lack of

experience3. Requires less solution than

that of supraperiosteal technique

0.9 – 1.2 ml solution is required.

ADVANTAGES

1. Simple technique

2. Safe


4. Less volume

DISADVANTAGES

1. Psychological

Operator & patient

2. Anatomical

INDICATIONS

1. >2 Maxillary teeth


3. When supraperiosteal injection is contraindicated

CONTRAINDICATIONS

1. < 2 teeth 2. To achieve hemostasis

Technique -


• Target area

• Landmarks –

Infraorbital notch

Infraorbital ridge

Infraorbital depression

pupil

mucobuccal fold

crown of tooth

root contour of tooth

penetration depth – 16 mm

Wait for 3-5 min.

0.69-1.2 ml / 30-40 sec.

EXTRAORAL APPROACH

Sign & symptoms

SUBJECTIVE

Numbness over area supplied by ASA, MSA & IO nerve

OBJECTIVE


FAILURE OF


2. Needle tip is too medial

3. Needle tip is too lateral

4. Accessory innervation from nasopalatine nerve.

COMPLICATION

Hematoma over lower eyelid

(rare)

PALATAL ANESTHESIA

Generally painful Prepare the patient psychologically CCLAD – better results Adequate topical anesthesia Pressure anesthesia – ischemia , blanching Control over the needle 27 guage short needle Rapid injection should be avoided

5 types of palatal anesthesia -

1. Greater palatine nerve block

2. Nasopalatine nerve block3. Infiltration 4. AMSA 5. P-ASA

GREATER PALATINE NERVE BLOCK

Technically difficult but high success rate

>95%

0.45 – 0.6 ml solution

Profound palatal hard & soft tissue anesthesia

Potentially traumatic but less than Nasopalatine

nerve block.

0.45 – 0.6 ml solution is required.

ADVANTAGES


2. Less volume - 0.45 – 0.6 ml

DISADVANTAGES

1. No homeostasis except in the area of injection

2. Potentially traumatic

INDICATIONS

1. >2 Maxillary molars

2. Soft & hard tissue anesthesia for surgical procedure

CONTRAINDICATIONS

1. 1 - 2 teeth 2. Infection & inflammation

0.45-0.6 /30 sec.

Technique -

• Area of insertion• Target area

• Landmarks –• 2nd & 3rd maxillary molars• palatal gingival margine of 2M & 3M• Midline of palate • A line approximately 1cm towards

midline from free gingival margine

• Approach • Depth = <10 mm

Wait for 2-3 min.

Sign & symptoms

SUBJECTIVE

Numbness over posterior portion of palate

OBJECTIVE


FAILURE OF

ANESTHESIA

Technically difficult

Needle tip is too anterior

Inadequate anesthesia of PM

COMPLICATION

1. Ischemia & necrosis with strong vasoconstrictor

2. Hematoma (rare)

3. Occasionally soft palate anesthesia

4. Solution ma squirt back - bitter

NASOPALATINE NERVE BLOCK

Other common names

-

– incisive nerve block

0.3 ml solution is required.

ADVANTAGES


2. Less volume

DISADVANTAGES

1. No hemostasis

2. Most traumatic intraoral injection

INDICATIONS

1. >2 Maxillary teeth


CONTRAINDICATIONS

1. 1- 2 teeth 2. Infection & inflammation

Techniques -

1. Single puncture

2. Multiple puncture –

labial frenum

labial interdental papilla

incisive papilla (if neded)

0.45 ml / 15-30 sec.

Technique - 1


• Target area

• Landmarks –

maxillary central incisors

incisive papilla in midline of palate

• Wait for 2-3 min.

Technique - 2

Advantage –

Relative atraumatic

Amount of solution –

1. 0.3 ml / 30 sec in labial frenum

2. 0.3 ml / 30 sec in labial interdental papilla

3. 0.3 ml / 30 sec lateral to incisive papilla

Disadvantage –

1. Multiple penetration

2. Stablization of needle becomes difficult

3. Syringe comes in line of patient’s vision

• Wait for 2-3 min.

• Landmarks –

labial frenum

labial interdental papilla

incisive papilla

Technique - 2• Area of insertion

• Target area

Sign & symptoms

SUBJECTIVE

Numbness over area of anterior palate

OBJECTIVE


Precautions –

1. Against pain – don’t inject solution direct in papilla

too rapidly

too much volume

2. Against infection – depth of penetration not more than 5 mm

FAILURE OF ANESTHESIA

1. Unilateral anesthesia

2. Inadequate anesthesia to canine

COMPLICATION


2. Solution may squirt back - bitter

LOCAL INFILTRATION OF PALATE

ADVANTAGES

1. Acceptable hemostasis

2. Less area of numbness

DISADVANTAGES

1. Traumatic

2. Anesthesia for larger area requires multiple penetrations

INDICATIONS

1. Hemostasis

2. Palatogingival pain control

CONTRAINDICATIONS


2. > 2 teeth

0.2-0.3 ml

Technique -


• Target area

• Landmarks – attached gingiva , 5-10 mm from

free gingival margine

• Penetration depth = 3-5 mm

Sign & symptoms

SUBJECTIVE

Numbness over area of anterior palate

OBJECTIVE


FAILURE OF ANESTHESIA

However high success rate if vasoconstrictor is used but Inflamed tissue continue to

bleed

COMPLICATION


2. Solution may squirt back - bitter

ANTERIOR MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK

(AMSA)

Other common name – palatal approach anterior middle superior alveolar nerve anesthesia.

Newly described technique Reported by FRIEDMAN & HOCHMAN IN 1997,

along with development of CCLAD system. Real field block Dental pluxes near the apices of premolars

are of chief concern

INDICATIONS

1. With CCLAD system2. Anesthesia of multiple maxillary teeth

& soft tissue3. anterior asthetic restorative

procedures, priodontal scaling & root planning

4. When facial approach for supraperiosteal injection have failed.

CONTRAINDICATIONS


2. Thin palate

3. Patient can not tolerate 3-4 min of administration time

4. Procedure of > 90 min.

ADVANTAGES

1. pulpal anesthesia to multiple maxillary teeth with single site of injection

2. less no. of penetration

3. Less volume of solution

4. Muscles of facial expression are not anesthetized

5. Less postoperative inconvenience

6. Atraumatic with CCLAD system

DISADVANTAGES -

1. Requires experience & skill

2. Slow administration (0.5 ml/min)

3. Operator fatigue

4. May require supplemental anesthesia for incisors

5. Too rapid administration – excessive ischemia

0.5 ml/min. & 1.4-1.8 ml

Technique -


• Target area

• Landmarks –

between 1PM & 2PM

between midpalatine line & free

gingival margine

Sign & symptoms

SUBJECTIVE Numbness of teeth & soft

tissue extends from central incisor to distal part of 2PM on the side of injection.

OBJECTIVE• Blanching • No pain during

procedure

FAILURE OF

ANESTHESIA1. Additional anesthesia for

incisors

2. Inadequate solution reaches to pluxes.

COMPLICATION

1. Palatal ulcer

2. Unexpected contact with nasopalatine nerve

3. Solution may squirt back

PALATAL APPROACH ANTERIOR SUPERIOR ALVEOLAR NERVE BLOCK (P-ASA)

Other common name – palatal approach maxillary anterior field block.

Newly described technique Reported by FRIEDMAN & HOCHMAN IN 1997,

along with development of CCLAD system. 1st dental injection providing bilateral pulpal and

labial & palatal mucoperiostel anesthesia Dental pluxes near the apices of anteriors &

Nasopalatine nerve are of chief concern Along with CCLAD system – atraumatic

INDICATIONS

1. With CCLAD system2. Anesthesia of multiple maxillary

anterior teeth & soft tissue3. Bilateral anesthesia with single

injection.4. Anterior aesthetic restorative

procedures, periodontal scaling & root planning

5. When facial approach for supraperiosteal injection have failed.

CONTRAINDICATIONS

1. Canines with large root


3. Thin palate

4. Patient can not tolerate 3-4 min of administration time

5. Procedure of > 90 min.

ADVANTAGES

1. pulpal anesthesia to bilateral maxillary teeth with single site of injection



4. Muscles of facial expression are not anesthetized

5. Less postoperative inconvenience

6. Atraumatic with CCLAD system

DISADVANTAGES -


2. Slow administration (0.5 ml/min)

3. Operator fatigue

4. May require supplemental anesthesia for incisors

5. Too rapid administration – excessive ischemia

0.5 ml/min. & 1.4-1.8 ml

Technique -


• Target area

• Landmarks –

Incisive papilla

Sign & symptoms

SUBJECTIVE Numbness of teeth & soft

tissue extends from central incisor to distal part of canine bilaterally

OBJECTIVE• Blanching • No pain during

procedure

FAILURE OF

ANESTHESIA1. Additional anesthesia for

canine

2. Inadequate solution reaches to pluxes.

COMPLICATION

1. Palatal ulcer

2. Unexpected contact with Nasopalatine nerve

3. Solution may squirt back

MAXILLARY NERVE BLOCK

Other common name – maxillary nerve block,

2nd division block.

An effective method of achieving profound anesthesia of hemimaxilla.

2 approaches – greater palatine canal approach

- high tuberosity approach

INDICATIONS

1. Pain control in surgical procedures.

2. When anesthesia through supraperiosteal injection & nerve block have failed.

3. Diagnostic & therapeutic purpose.

CONTRAINDICATIONS

1. Inexperienced administrator

2. Pediatric patient

3. Unco-operative patients


5. Increased risk of hemorrhage – hemophilia

6. Greater palatine approach – inability to achieve access to canal

ADVANTAGES

1. Usually atraumatic.



4. High success rate

DISADVANTAGES -


2. Hematoma

3. Absence of bony landmark

4. Lack of hemostasis

5. Pain & Positive aspiration in <1%

– greater palatine canal approach

Techniques -

1. High tuberosity approach

2. Greater palatine approach

3. Extraoral approach

1.8 ml / min.

Technique – 1 high tuberosity approach


• Target area

• Landmarks –

mucouccal fold distal to 2M

maxillary tuberosity

zygomatic proccess of maxilla

• wait for 3-5 min.

1.8 ml / min.Technique – 2 Greater palatine canal approach


• Target area

• Landmarks –

- greater palatine foramen

- junction of alveolar process of

maxilla & palatine bone, distal to

2M

wait for 3-5 min.

Technique – 3 extraoral approach

• Landmarks –

- Midppoint of zygomatic arch 2-3 ml - zygomatic notch DEPTH – 4.5 cm

- coronoid process of ramus

- lateral pterygoid plate

Sign & symptoms

SUBJECTIVE

1. pressure behind upper jaw

2. tingling & numbness

OBJECTIVE

• No pain during procedure

FAILURE OF

ANESTHESIA1. Partial anesthesia due to

underpenetration

2. Inability to negotiate greater palatine canal.

COMPLICATIONS

1. Hematoma

2. If solution reaches to orbit – periorbital swelling & proptosis

3. VI cranial nerve block – diplopia

4. Retrobulbar block – mydriasis, corneal anesthesia & opthalmoplagia

5. Rarely –optic nerve block (blindness) & retrobulbar hemorrhage

6. Solution may go into nasal cavity

ANAESTHESIA FOR THE MANDIBULAR

TISSUE

1. Inferior alveolar nerve block a) classical/ direct technique b) indirect technique c) method of CLARKE & HOLMES d) method of ANGELO SARGENTI e) method of SUNDER J. VAZIRANI f) method of KURT THOMA (extraoral

technique)

2. Buccal nerve block3. Mental nerve block4. Incisive nerve block5. Mandibular nerve block Gow-Gate technique Vazirani-Akinosi technique Extraoral technique

INFERIOR ALVEOLAR NERVE BLOCK

Most frequently used injection technique

Highly percentage of clinical failure 15%-20%

Commonly but inaccurately known as –

MANDIBULAR NERVE BLOCK

Mental nerve

Incisive nerve

NERVES ANAESTHETIZED

• Body of mandible • Mandibular teeth• Mucous membrane and underlying tissue

anterior to molar

ADVANTAGES

1. Wider area of anesthesia with a single site of injection

INDICATIONS

1. Multiple teeth in 1 qurdrant CONTRAINDICATION1. Infection & inflammation

2. Children

3. Physically & mentally handicapped patients

4. Hemophilic patients

DISADVANTAGES

1. Inadequate anesthesia in 15-20 %

2. Positive aspiration in 10-15% (heighest)

3. Intraoral landmarks are not consistently reliable.

4. Younger patient – soft tissue injury

Anatomic Variations• Mandible

- Mandibular foramen in children 4 years old and less is below the plane of occlusion. The foramen moves superiorly in the ramus with the eruption of 6’s

Adults

Children

• Position of the patient-body of the mandible is parallel to the floor.

Technique – 1, DIRECT METHOD

Depth of penetration – 20-25 mm

1.5ml / 60 sec.

Wait for 3-5 min.

Technique – 2, INDIRECT METHOD

Technique – 3, METHOD OF CLARK & HOLMES 1959

Technique – 4, METHOD OF ANGELO & SARGENTI 1966

Technique – 4 METHOD OF SUNDER J. VAZIRANI 1960

Technique – 6 EXTERNAL APPORACH BY – KURT THOMA

Sign & symptoms

SUBJECTIVE

Numbness over area of supply of inferior alveolar nerve & lingual nerve

OBJECTIVE


FAILURE OF


2. Needle tip is too medial

3. Needle tip is too anterior

4. Accessory innervations from long buccal, lingual & mylohyoid, occasionally auriculotemporal

5. Anatomical variations

COMPLICATIONS

Hematoma formation

Trismus

Transient facial nerve paralysis

HOW TO OVERCOME FAILURE OF INFERIOR ALVEOLAR NERVEBLOCK

IANB SUCCESS

IANB

GOW GATE OR

VAZIRANI-AKINOSI

APPROACH

SUCCESS

SUCCESS

BUCCAL & LINGUAL INFILTRATION

INTRALIGAMENTARY

LINGUAL NERVE - is anterior and medial to inferior alveolar nerve

So withdraw the needle about 1mm and deposite the 0.5 ml of LA

Mental nerve

Icisive nerve

LONG BUCCAL NERVE

infiltration in the buccal sulcus distal to permanent molar tooth

Amount deposited-0.2-0.5 ml

MENTAL NERVE BLOCK

Areas anaesthetized

• Technique - intraoral

• Site of insertion of needle is mucobuccal fold at or just anterior to MENTAL FORAMEN (between roots of two premolar).

• 0.6 ml of solution is required.

Technique – extraoral

INCISIVE NERVE BLOCK

• Site of insertion of needle is mucobuccal fold at or just anterior to MENTAL FORAMEN (between roots of two premolar).

• 0.6 ml of solution is required.

MANDIBULAR NERVE BLOCK

INDICATIONS

1. Multiple teeth anesthesia

2. Buccal soft tissue anesthesia from third molar to midline along with lingual soft tissue anesthesia.

3. When conventional inferior alveolar nerve block is unsuccessful.

CONTRAINDICATIONS


2. Inexperienced administrator

3. Pediatric patient

4. Unco-operative patients

5. Trismus

ADVANTAGES -

1. High success rate (95%) – GOW-GATE TECHNIQUE

2. Less positive aspiration3. Overcomes case of bifid inferior

alveolar nerve & canal4. less no. of penetration

DISADVANTAGES -


2. Late onset of anesthesia

Mental nerve

Icisive nerve

Mandibular nerve

1. GEORGE ALBERT EDWARDS GOW-GATES (1973) 2. VAZIRANI -AKINOSI CLOSED MOUTH

MANDIBULAR BLOCK (1960-1977)3. EXTRAORAL APPROACH

Techniques -

1.8 ml+1.2ml / min.

Technique – 1 GEORGE ALBERT EDWARDS GOW-

GATES (1973) • Area of insertion

• Target area

• Landmarks –

soft tissue distal to 2M

mesiopalatal cusp of maillary 2M

intertragic notch

corner of mouth

Technique – 2 VAZIRANI -AKINOSI CLOSED MOUTH MANDIBULAR BLOCK (1960-1977)

Area of insertion: soft tissue overlying the medial border of the mandibularramus directly adjacent to maxillary Tuberosity.

Inject to depth of 25mm

1.5-1.8ml

• Landmarks – - mucogingival junction of maxillary last molar

- maxillary tuberosity

- coronoid notch

Technique – 3 Extraoral approach

• Landmarks – - Midppoint of zygomatic arch

- zygomatic notch

- coronoid process of ramus

- lateral pterygoid plate

DEPTH – 4.5 cm

Sign & symptoms

SUBJECTIVE

1. tingling & numbness over lower lip & tongue

OBJECTIVE

• No pain during procedure

FAILURE OF

ANESTHESIA1. Flaring nature of ramus

2. Needle is too low

3. Overinsertion or underinsertion

COMPLICATIONS

1. Hematoma <2% in GOW-GATE technique

<10% in VAZIRANI- AKINOSI technique

2. Trismus (rare)

3. Transient facial nerve paralysis.

RECENT ADVANCES

INLOCAL DRUG

DELIVARY SYSTEM

1. SPRAY S

1. 10% LIGNOCAINE HYDROCHLORIDE

2. ETHYL CHLORIDE

Onset of anesthesia = 1 min.Duration Of Action = 10 min.

2. TOPICAL GELS

• Mixture of lignocaine 2.5% & prilocaine 2.5%.

• anesthesia for intact skin.• Mild skin blanching & edema

may occur

• Contraindicated in infants under age of 6 months

- because the metabolites of prilocaine can cause methemoglobinemia.

3. EMLA (EUTACTIC MIXTURE OF LOCAL ANESTHETICS)

4. INTRAORAL LIGNOCAINE PATCH

(dentipatch)2 x 1 x 2

LIPOSOMES• Liposomes are comprised of lipid layers surrounded by aqueous layers.

• Penetrate the stratum corneum because they resemble the lipid bilayers of the cell membrane.

• available as an ELA-Max.

• Is used for the temporary relief of pain resulting from minor cuts and abrasions

4% Lidocaine cream in a liposomal matrix

• 0.5% tetracaine,• 0.05% epinephrine,• 1.8% cocaine, • was the first topical anesthetic mixture

found to be effective for nonmucosal skin lacerations.

• Not used now a days.

TAC (TETRACAINE, ADRENALINE, AND COCAINE)

5. IONTOPHORESIS

• (Electromotive Drug Administration (EMDA)) is a technique using a small electric charge to deliver a medicine or other chemical through the skin.

6. JET INJECTION

• This is a technique in which a small amount of local anesthetic solution is propelled as a jet into submucosa without the use of hypodermic needle.

7. COMPUTER CONTROLLED SYSTEM

• The wand local anesthesia system is a computer controlled injection device. The wand/compuDent system administers local anesthetic at two specific rates of delivery.

• The slow rate is 0.5ml/min and

• fast rate is 1.8ml/min .• There is a 4.5 seconds of

aspiration cycle.

8. COMFORT CONTROL SYRINGE

• electronic , preprogrammed delivery device that provides the control needed to make the patient’s local anesthetic injection experience as pleasant as possible

• Standard dental local anesthetic cartridges & dental needles may be used.

ON / OFF

ASPIRATION

DOUBLE RATE

9. ELECTRONIC DENTAL ANESTHESIA

• This method of achieving local anesthesia involves the use of the principle of TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) which causes relief of pain.

CONTRAINDICATIONS -

1. IMPLANTS2. NEUROLOGICAL DISORDERS - POST CEREBRAL STROKE - STATUS EPILEPTICUS - H/O TRANSIENT ISCHEMIC

ATTACK3. PREGNANCY4. IMMATURITY

ADVANTAGES -1. NO NEED FOR NEEDLE2. NO RESIDUAL ANESTHETIC EFFECT3. ANELGESIC EFFECT OVER SEVERAL

HOURS.

• 5 to 8 times more potent than Lidocaine.

• Available as 0.5 % solution form

• It is used for topical & infiltration anesthesia.

• In therapeutic dose there is no CNS & CVS adverse effect.

10. CENTBUCRIDINE

• Addition of SODIUM BICARBONATE

Causes increase in pH to the 7.2 which provides early onset of anesthesia.

• Too high pH causes rapid precipitation of drug base & decrease in shelf life of LA.

11. pH ALTERATION

13. HYALURONIDASE

• Enzyme that breaks down the intracellular cements, so helps in easy diffusion of LA.

• Added just before the administration of LA solution.

• Added as 1/8 th part of LA cartridge.

CONCLUSION

• The administrator of local anesthetics who adheres to these basic steps develops a reputation among patients as a PAINLESS DOCTOR.

• It is not possible to guarantee that every injection will be absolutely atraumatic because the reaction of both patient & doctor are far too variable.

REFERENCES

• BOOKS – MALAMAD 5TH EDITION - TEXTBOOK OF PEDODONICS -BY SHOBHA

TONDON

- LOCAL ANALGESIA IN DENTISTRY – BY D H ROBERTS

& J H SOWRAY

- MONHEIM’S LOCAL ANESTHESIA & PAIN CONTROL IN DENTAL PRACTICE – BY

RICHARD BENNET 7TH EDITION.

• Other sources – 1. Rucci F S, Pippa P, Boccaccini A, Barbagli R. Effect of

injection speed on anaesthetic spread during axillary block using the orthogonal two-needle technique. Eur J Anaesth 1995; 12: 505-511

2. How to overcome failed local anaesthesia J. G. Meechan Senior Lecturer/Honorary Consultant, Department of Oral and Maxillofacial Surgery, The Dental School, Framlington Place, Newcastle upon Tyne NE2 4BW REFEREED PAPER Received 31.03.98; accepted 17.08.98 © British Dental Journal 1999; 186: 15–20

Technology

Techniques of regional anesthesia