local anesthesia techniques
TRANSCRIPT
Local Anesthesia in Dentistry
Dr. Iyad Abou Rabii
Page 2
Reminder
The trigeminal nerve is the largest of the cranial nerves. It has both motor and sensory components
Page 3
Figure of trigeminal nerve
Page 4
Reminder
The ophthalmic nerve carries sensory information from the scalp and forehead, the upper eyelid, the conjunctiva and cornea of the eye, the nose (including the tip of the nose), the nasal mucosa, the frontal sinuses,
Page 5
Reminder : The maxillary nerve
The maxillary nerve carries sensory information from the lower eyelid and cheek, the nares and upper lip, the upper teeth and gums, the nasal mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and sphenoid sinuses, and parts of the meninges.
Page 6
Reminder; The maxillary nerve
The maxillary nerve continues into the infraorbital canal as the infraorbital nerve.
The zygomatic nerve emerges and branches into its two major terminal branches, the zygomaticofacial and zygomaticotemporal nerves, which innervate the lateral cheek and side of the forehead, respectively.
As it projects anteriorly, the infraorbital nerve gives off the anterior and middle superior alveolar nerves, innervating the upper teeth. It then exits the canal through the infraorbital foramen to innervate the upper lip, cheek and side of the nose.
Page 7
Reminder : Mandibular nerve
The mandibular nerve carries sensory information from the lower lip, the lower teeth and gums, the chin and jaw (except the angle of the jaw, which is supplied by C2-C3), parts of the external ear, and parts of the meninges.
Page 8
Reminder : Mandibular nerve
The buccal nerve innervates the mucosa of the mouth and gums.
The auriculotemporal nerve innervates the external auditory meatus and portions of the external surface of the tympanic membrane.
The lingual nerve provides general sensation to the anterior 2/3 of the tongue.
The inferior alveolar nerve enters the mandibular canal through the mandibular foramen to innervate the lower teeth and gums. Its terminal branch exits the mental foramen as the mental nerve, innervating the chin and lower lip.
Other several branchial motor nerves
Page 9
Tools
Dental Syringe
Dental Needles
Page 10
Page 11
Tools
Local anesthetics cartridges
Page 12
Local anesthetic cartridge color codes
Page 13
Indications
Parenteral local anesthetics are used for infiltration and nerve block anesthesia.
Because of variation in systemic absorption and toxicity, the ideal choice of local anesthetic and concentration depends on the intended procedure. – Infiltration anesthesia is often used for minor surgical and dental procedures.
– Nerve block anesthesia is used for surgical, dental, and diagnostic procedures and for pain management
nerve block anesthesia
Mandible
Page 15
IDB (inferior alveolar block)
Technique of choice for mandibular molars; also effective for premolars, canines, and incisors
Aim is to deposit solution around the inferior alveolar nerve as it enters the mandibular foramen
Page 16
Page 17
Page 18
IDB (inferior alveolar block)Technique
The patient's mouth must be widely open.
Palpate the landmarks of external and internal oblique ridges and note the line of the ptyerygomandibular raphe.
With the palpating thumb lying in the retromolar fossa, the needle should be inserted at the midpoint of the tip of the thumb slightly above the occlusal plane lateral to the ptyerygomandibular raphe.
The needle is inserted ~0.5 cm and if a lingual nerve block is required 0.5 ml of LA is injected at this point.
Page 19
IDB (inferior alveolar block)Technique
The syringe is then moved horizontally across the dorsum of the tongue and advanced to make contact with the lingula.
Once bony contact is made the needle is withdrawn slightly and the remainder of the LA injected.
It should never be necessary to insert the needle up to the hub.
Note that the mandibular foramen varies in position with age. In the edentulous, the foramen, and hence the point of needle insertion, is relatively higher than in the dentate.
Page 20
Nerve to mylohyoid
Page 21
Additional Block (higher injection) Why : the standard block often fails to anesthetize branches of cranial
nerve V3 that originate proximal to the injection site and provide accessory innervation to the mandibular teeth. The relatively distal location of the injection also leads to lack of anesthesia of soft tissues posterior to the mental foramen. That why a higher injection site technique are proposed
Gaw-Gates Technique
Akinosi Technique
Page 22
Gow-Gates Technique
Blocks sensation by depositing LA at head of condyle
Landmarks:– Corner of the mouth (contralateral side)
– Tragus of the ear
– Disto palatal cusp of the maxillary second molar
– AIMING FOR THE NECK OF THE CONDYLE
Page 23
Page 24
Page 25
Page 26
Efficacy of the Gow-Gates Technique
Author Year GG (%) IANB (%)
Watson and Gow-Gates
1976 98.4 85.4
Gow-Gates and Watson
1977 96.2 85.5
Levy 1981 96 65
Malamed 1981 97.5
Montagnese et al. 1984 35 38
Page 27
Akinosi Technique
LA deposited above lingua
Closed-mouth technique
Does not rely on a hard-tissue landmark
Parallel to occlusal plane, height of the mucogingival junction
Advanced until hub is level with distal surface of maxillary second molar
Delayed onset of anaesthesia
Page 28
Page 29
Page 30
Page 31
• Pain to puncture more than Akinosi
• More Effective
• Onset is more rapid
• Less effective• More accepted
by patients.
SCENE
5Gow Gates or Akinosi
Page 32
Mental nerve block
Mental nerve block The mental nerve emerges from the mental foramen lying apical to and between the first and second mandibular premolars.
LA injected in this region will diffuse in through the mental foramen and provide limited analgesia of premolars and canine, and to a lesser degree incisors on that side. It will provide effective soft-tissue analgesia.
Page 33
Mental nerve block
Place the lip on tension and insert the needle parallel to the long axis of the premolars angling towards bone, and deposit the LA.
Do not attempt to inject into the mental foramen as this may traumatize the nerve.
LA can be encouraged in by massage.
Page 34
Buccal Nerve Block
The buccal nerve is not anesthetized by an inferior alveolar nerve block.
This nerve innervates the tissues and periosteum buccal to the molars, so if these soft tissues are involved in treatment, the buccal nerve should be injected as well.
The additional injection is unnecessary when treating only the teeth.
A 25 gauge long needle is recommended
Page 35
Buccal Nerve Block(Continue)
The needle is inserted in the mucous membrane distal buccal to the last molar
Insert the needle to 2 to 4 mm to gently contact bone, and aspirate. If negative, slowly deposit about 1/8 of the solution in the cartridge.
Page 36
Sublingual nerve block
Sublingual nerve block An anterior extension of the lingual nerve can be blocked by placing the needle just submucosally lingual to the premolars, use 0.5 ml of LA.
nerve block anesthesia
Maxilla
Page 38
Nasopalatine block anaesthesia
Nasopalatine block Profound anaesthesia can be achieved by passing the needle through the incisive papilla and injecting a small amount of solution.
This is extremely painful
Page 39
Infra-orbital block
Infra-orbital block Rarely indicated.
A 25 gauge long needle is recommended and inserted with the bevel toward the bone in the muco-buccal fold over the first premolar.
Palpate the inferior margin of the orbit as the infra-orbital foramen lies ~1 cm below the deepest point of the orbital margin. Hold the index finger at this point while the upper lip is lifted with the thumb.
Inject in the depth of the buccal sulcus towards your finger, avoid your finger, and deposit LA around the infra-orbital nerve.
Page 40
Anterior Middle Superior Alveolar Block
If the infraorbital nerve block does not provide adequate anesthesia to the teeth distal of the canine or if the PSA injection does not provide anesthesia for the mesiobuccal root of the first molar, an MSA block injection should be administered.
A 25 gauge short needle is recommended with insertion in the mucobuccal fold by the maxillary second premolar.
About 1/2 to 2/3 of a cartridge of anesthetic is slowly deposited at the height of the apex of the second premolar after negative aspiration
Page 41
Anterior Middle Superior Alveolar Block (continue)
One injection site - Central to second premolar, palatal and buccal soft tissue
Is used to anesthetize pulp tissue and facial periodontium of the maxillary premolars and the mesiobuccal root of the first molar in some cases.
Page 42
Posterior superior alveolar block
The posterior superior alveolar (PSA) nerve block is a commonly used technique for achieving anesthesia for the maxillary molars
Posterior superior alveolar block A rarely indicated technique.
The short 25 or 27 gauge needle is recommended to decrease the risk of a hematoma
Needle is inserted distal to the upper second molar and advanced inwards, backwards, and upwards close to bone for ~2 cm.
LA is deposited high above the tuberosity after aspirating to avoid the ptyerygoid plexus
Page 43
Greater Palatine Nerve Block
The greater palatine nerve innervates the palatal tissues and bone distal of the canine on the side anesthetized.
Use a 27 gauge short needle with the bevel toward the palate.
Palpate the palate until the depression of the foramen is felt (usually somewhere medial to the second molar).
Dry the tissue, and apply antiseptic and topical anesthetic for 2 minutes. Apply pressure with the swab for 30 seconds.
Continue pressure with the swab until the injection is completed.
Page 44
Greater Palatine Nerve Block(Continue)
Place the bevel against the tissue and apply pressure enough to slightly bow the needle.
Inject a few drops of anesthetic.
Release the pressure of the needle and advance the tip of the needle into the tissue slightly.
Continue with this procedure of applying pressure to the bevel and depositing a few drops of anesthetic, then advancing, until the needle is in contact with the palatal bone.
Deposit less than a fourth to a third of a cartridge of anesthetic after negative aspiration is proven
Page 45
Maxillary Nerve Block
The maxillary (V2) nerve innervates half of the maxilla, including the buccal and palatal aspects.
This injection technique is used especially in quadrant surgery or when extensive treatment is indicated for a single appointment.
It is also used when another site of injection has failed or if there is an infection in the area
his technique is used more with adult patients. It is not for the inexperienced.
Page 46
Maxillary Nerve Block(continue)
Administration through the buccal aspect involves the possibility for hematoma.
The long 25 gauge needle is recommended with the bevel of the needle facing the bone.
The needle is inserted at the mucobuccal fold near the distal of the second molar after the usual protocol of tissue preparation.
The path of the needle is similar to that of the PSA nerve block, but is inserted approximately 30 mm to the pterygopalatine fossa.
Aspirate, then rotate the needle bevel 1/4 turn, reaspirate. If both aspirations are negative, slowly deposit one cartridge of anesthetic (deposit 1/4 then aspirate, then deposit 1/4 until the entire cartridge has been administered).
local infiltrations
Page 48
Infiltrations
The aim is to deposit LA supraperiosteally in as close proximity as possible to the apex of the tooth to be anaesthetized.
The LA will diffuse through periosteum and bone to bathe the nerves entering the apex.
Lower concentrations of local anesthetics are typically used for infiltration anesthesia.
Variation in local anesthetic dose depends on the procedure, the degree of anesthesia required, and the ndividual patient's circumstances.
Reduced dosage is indicated in patients who are desbilitated or acutely ill, very young or very old, and in patients with liver disease, arteriosclerosis, or arterial disease.
Page 49
Infiltrations Administrative techniques
The aim is to deposit LA supraperiosteally in as close proximity as possible to the apex of the tooth to be anaesthetized.
Patient comfort is essential during administration of local anesthetic agents.
Warming the local anesthetic solution prior to administration to 25-40o C has been recommended.
Reflect the lip or cheek to place mucosa on tension and insert the needle along the long axis of the tooth aiming towards bone.
Page 50
Infiltrations Administrative techniques (Continue)
At approximate apex of tooth, withdraw slightly to avoid sub- periosteal injection, LA is slowly deposited. .
For palatal infiltrations, achieve topical analgesia first and infiltrate interdental papillae; then penetrate palatal mucosa and deposit small amount of LA under force.
Page 51
Infiltration in Mandible
Buccal infiltration anaesthesia in the mandible can be effective in some areas.
Indeed in children this may the preferred technique when treating the deciduous dentition.
In adult patients buccal infiltrations may be effective in the mandibular incisor region.
Adjunctive Strategies for Infiltration
Page 53
Adjunctive Strategies
PDL Injection
Sub-periosteal injection
Intraosseous Injection
Intrapulpal Injection
Intraseptal Injection
Different anaesthetic
Page 54
PDL Injection
Technique:– needle inserted into the gingival sulcus at a 30 degree angle towards the tooth
– bevel placed towards bone
– advanced until resistance felt
– anaesthetic injected with continuous force for about 15 seconds.
– approx. 0.2 mL of solution
– 25 vs. 30 gauge needle
Page 55
Page 56
Page 57
PDL Injection
Conventional vs. specific PDL syringes: – Malamed (1982):
• similar rates of success
– D’Souza et al (1987):
• no sig. difference in anaesthesia achieved.
• using the pressure syringe resulted in more spread of anaesthetic to adjacent teeth
Page 58
PDL Injection: Primary Technique
Melamed 1982: 86% overall Faulkner 1983: 81% overall White 1988: variable, short duration esp. md. molars Walton 1990: “In reviewing the clinical and experimental literature…the
periodontal ligament injection does not meet all of the necessary requirements for a primary technique.”
Page 59
PDL Injection: Supplemental Technique
Walton and Abbott 1981:– Inadequate pulpal anaesthesia following IAB– 92% overall – included situations where multiple PDL injections required– most critical factor was to inject under strong resistance
Smith, Walton, Abbott 1983: – 83% overall with high pressure syringe
Page 60
PDL Injection: Anaesthetic Distribution
Garfunkel et al 1983, Smith and Walton 1983, Tagger et al 1994, Tagger et al 1994*– spread along path of least resistance
– influenced by anatomical structures and fascial planes
– through marrow spaces
– avoided PDL route
– appears to be a form of intraosseous injection
Page 61
PDL Injection: Effects on the Periodontium
Animal histological studies
Most studies: no long term evidence of tissue disruption or inflammation
Roahen and Marshall 1990: evidence of localized external resorption
Page 62
Adjunctive Strategies
PDL Injection
Sub-periosteal injection
Intraosseous Injection
Intrapulpal Injection
Intraseptal Injection
Different anaesthetic
Page 63
Sub-periosteal injection
Local anesthesia onset is more rapid than normal infiltration
Anesthesia Duration is less
Other possible negative effects include ischemia and necrosis of the periosteum tissue.
Rarely used
An advanced sub-periosteal dental anesthetic method involvs apparatus for motorized injection of anesthetic liquids
Page 64
Adjunctive Strategies
PDL Injection
Sub-periosteal injection
Intraosseous Injection
Intrapulpal Injection
Intraseptal Injection
Different anaesthetic
Page 65
Intraosseous Injection
Technique for mandibular infiltration
Perforate the cortical plate to introduce LA in medullary bone
Bathes the periradicular region in LA
2 commercial systems available:– Stabident (Patterson)
– X-Tip (Tulsa Dentsply)
Page 66
Stabident
Page 67
Stabident
Page 68
Stabident
Page 69
Stabident
Page 70
X-Tip
Page 71
Adjunctive Strategies
PDL Injection
Sub-periosteal injection
Intraosseous Injection
Intrapulpal Injection
Intraseptal Injection
Different anaesthetic
Page 72
Intrapulpal Anaesthesia
When a small access cavity is available into the pulp
a needle which fits snugly into the pulp should be chosen.
A small amount (about 0.1 ml) of solution is injected under pressure.
There will be an initial feeling of discomfort during this injection,
however this is transient and anesthetic onset is rapid.
Page 73
Intrapulpal Anaesthesia
When the exposure is too large to allow a snug needle fit
the exposed pulp should be bathed in a little local anaesthetic for about a minute
before introducing the needle as far apically as possible into the pulp chamber and injecting under pressure.
Page 74
Adjunctive Strategies
PDL Injection
Sub-periosteal injection
Intraosseous Injection
Intrapulpal Injection
Intraseptal Injection
Different anaesthetic
Page 75
Intraseptal Injection
The intraseptal injection is used for hemostasis, soft tissue anesthesia, and osseous anesthesia.
Prepare the tissues of the site with antiseptic and topical.
Use a 27 gauge short needle and insert it into the papilla of the area to be anesthetized at an angle of 90° to the tissue.
Slowly deposit 0.2 ml of solution.
Page 76
Adjunctive Strategies
PDL Injection
Sub-periosteal injection
Intraosseous Injection
Intrapulpal Injection
Intraseptal Injection
Different anaesthetic
Page 77
Articaine
What about a mandibular infiltration?
Recommended by Steve Buchanan
Kanaa et al. 2006– Cross-over design comparing articaine and lidocaine for mandibular infiltration
for first molars
– Anaesthesia measured
– Lidocaine 38% effective
– Articaine 65% effective
Adjunctive Strategies
Page 79
Topical Anaesthetic
Benzocaine or Lidocaine Effectiveness?
– Gill and Orr 1979: 15 second application no more effective than placebo
– Stern and Giddon 1975: 2-3 minutes=profound soft tissue anaesthesia
Page 80
Topical Anaesthetic
Recommendations:– Dry mucous membranes first
– 2-3 minutes, but concern with tissue sloughing
– Tip of the tongue
Page 81
Topical Anaesthetic
Benzocaine Spray
RCDSO Dispatch 21, 1, Feb/Mar 2007 pp.28-29– Advice to Dentists
– Benzocaine Sprays and Methemoglobinemia (MHb)
• Health Canada—9 suspected cases, none fatal
Page 82
Topical Anaesthetic
Benzocaine spray/Methemoglobinemia
Recommendations:– Avoid in patients with a history of MHb
– Consider lidocaine as an alternative
– Broken/inflamed tissue may promote uptake
– Use only amount deemed necessary
– If suspicious, send patient to hospital for methylene blue tx
– O2 won’t help, but give it anyways
Page 83
Feel free to use this PowerPoint presentation for your personal,educational and business.
Do
• Make a copy for backups on your harddrive or local network.• Use the presentation for your presentations and projects.• Print hand outs or other promotional items.
Don‘t
• Make it available on a website, portal or social network website for download.(Incl. groups, file sharing networks, Slideshare etc.)
• Edit or modify the downloaded presentation and claim / pass off as your own work.
All copyright and intellectual property rights, without limitation, are retained by Dr. Iyad Abou Rabii. By downloading and using this presentatione, you agree to this statement.
Please feel free to contact me, if you do have any questions about usage. Dr Iyad Abou [email protected]
Copyright notice