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DEPARTMENT OF
PERIODONTICS ANDORAL IMPLANTOLOGY
Seminar
LOCAL ANESTHETIC TECHNIQUES
Presented By:
V.L.PRANEETHA
II MDS
Contents
Introduction
Supplementary techniques
Conclusion
References
Introduction
Nothing that is done by dentist is of great importance than that of a
drug which prevents pain.
LA
anxiety or pain
30,000
Adequate aspiration necessitates that the tip of the needle remain unmoved.
Stabilization
Positive aspiration.blood
Performed twice before LA orientation of bevel changed
Serves two functions
prevents the solution from tearing the tissue into which it is deposited
Slow injection; deposition of 1ml of LA solution in not less than 60 sec. therefore a full
1.8ml cartridge requires 2min.
Malamed 84% of 200 respondents avg time to deposit 1.8ml < 20 sec.
More realistic time in clinical practice 60 sec for a full 1.8ml cartridge
Step 16B: Communicate with the patient
Step 17: Slowly withdraw the syringe
Scoop technique
McCormick and Berry etal
Local infiltration
Field block
Nerve block
Supraperiosteal injections:
The Supraperiosteal injection, more commonly called infiltration, is the most frequently used
technique for obtaining pulpal anesthesia in maxillary teeth. Although it is a simple procedureto
accomplish successfully, there are several valid reasons for using other techniqueswhenever
more than two or three teeth are involved in treatment.
Multiple Supraperiosteal injections necessitate numerous needle penetrations of the tissues,each
with the potential to produce pain, either during the procedure or after the anesthesia effect has
resolved. In addition, and perhaps even more important, using Supraperiosteal injections for
pulpal anesthesia on multiple teeth leads to the administrations of a larger volume of local
anesthetic solution, with an attendant increase in the risk of systemic and local complications.
The Supraperiosteal injection is indicated whenever dental procedures are confined to relatively
circumscribed area in either the maxilla or mandible.
Other common names local infiltration, paraperiosteal injection
Nerves anesthetized-large branches of the dental plexus
Areas anesthetized-the entire region innervated by the large terminal branches of this plexus:
pulp and root of the teeth,buccal periosteum, connective tissue, mucous membrane
Technique:
A 25-27 gauge needle is recommended , height of the mucobuccal fold above the apex of the
tooth being anesthetized, orient needle so bevel faces bone, lift the lip,pulling the tissue taut,
hold thesyringe parallel with the long axis of the tooth,insert the needle into the height of the
micobuccal fold over the target tooth. Advance the needle until its bevel is at or above the apical
region of the tooth. In most instances the depth of penetration is only few millimeters. Because
the needle is in soft tissue, there should be no resistence to its advancement,nor should there be
any patient discomfort with this injection.deposit 0.6ml over 20 seconds.
Signs and symptoms: feeling of numbness in the area of administration and absence of pain
during treatment
Complications : pain on needle insertion with the needle tip against periosteum,
Correct: withdraw the needle and reinsert it farther from the periosteum.
anesthetized:
pulps
of
the
maxillary
third,
second,
and
firstmolars(entire
Complcations:
Hematoma : this is commonly produced by inserting the needle too far posteriorly into pterygoid
plexus of veins. In addition, the maxillary artery may be perforated., use of short needle
minimizes the risk of pterygoid plexus puncture.
Mandibular anesthesia is often produced as it is located lateral to the PSA nerves.
Middle superior alveolar nerve block:
MSA nerve is preseent in only about 28% of the population,there by limiting the clinical
usefulness of this block.
Nerves anesthetized: middle superior alveolar and terminal branches
Areas anesthetized: pulps of maxillary second premolars, mesiobuccal root of the first
molar,buccal periodontal tissues and bone over the same teeth.
Technique :
A 25-guage short needle is recommended, height of mucobuccal fold above the maxillary second
premolar, slowly deposit 0.9ml 1.2ml over 20-30 seconds.
Signs and symptoms : absence of pain during procedure
Complications are rare
Amterior superior alveolar nerve block:
ASA nerve block provides profound pulpal and buccal soft tissue anesthesia from maxillary
central incisor through the premolars in about 72% of patient.
Other common names: infraorbital nerve block
Nerves anesthetized: ASA, MSA, infraorbital nerves
Areas anesthetized: pulps of the maxillary central incisor through the canine on the injected
side.,buccal periodontium and bone of the same teeth,lower eyelid,lateral aspect of the
nose,upper lip.
Technique :
A 25 guage needle is recommended, mucobuccal fold directly over first prmolar, feel the
infraorbital notch, move your finger downward from the notch,applying gentle pressure on
tissues, the bone immediately inferior to the notch is convex, this represents the lower border of
the orbit and the roof of the infraorbital foramen.as the finger continues inferiorly, a concavity is
felt; this is infraorbital foramen.insert the needle into the height of the mucobuccal fold over he
first premolar with a bevel facing bone ,aspirate and slowly deposit 0.9ml-1.2 ml over 30-40
seconds. The administrator is able to feel the anesthetic solution as it is deposite beneath the
finger on the foramen if the needle tip is in the correct positon.
Signs and symptoms:
Tingling and numbness of the lower eyelid ,side of the nose and upper lip indicate anesthesia of
the infraorbital nerve, numbness in the teeth and soft tissues along the direction of the ASA and
MSA nerves.and no pain during dental therapy.
Complications : Rare complications
Palatal anesthesia
Anesthesia of hard palate is necessary for dental procedures involving manipulation of palatl soft
or hard tissues. For many sental patients, palatal injections prove to be a very traumatic
experience. For many dentists the administration of palatal anesthesia is one of the most
traumatic procedures they perform in dentistry. The steps in the atraumatic administration of
palatal anesthesia are as follows:
1. Provide adequate topical anesthesia at the site of needle penetration
2. Use pressure anesthesia at the site before and during needle insertion and the deposition
of solution.
3. Maintain control over the needle.
4. Deposit the anesthetic solution slowly
Control over the needle is probably of greater importance in palatal anesthesia than in other
intraoral injections.
Greator palatine nerve block:
The greator palatine nerve block is useful for dental procedures involving the palatal soft tissues
distal to the canine. Minimum volumes of solution (0.45 to0.6 ml) provide profound hard and
soft tissue anesthesia. Although potentially traumatic, the greator palatine nerve block is less so
than the nasopalatine nerve block because the tissues surrounding the greator palatine foramen
are better able to accommodate the volume of solution deposited.
Nerves anesthetized: greator palatine nerves
Areas anesthetized: the posterior portion of the hard palate and its overlying soft
tissues,anteriorly as far as the first premolar and medially to the midline.
Technique :
A 25 guage needle is recommended,soft tissues slightly anterior to the greator palatine foramen,,
(the foramen is most frequently located distal to the maxillary second molar, but it may be either
anterior or posterior to its usual position),direct the syringe into the mouth from the opposite
side,deposit a small volume of anesthetic, the solution is forced against the mucous membrane,
and a droplet forms.
A 27 guage needle is recmmended, labial frenum in the midline between the maxillary central
incisors, interdental papilla between the maxillary central incisor,if needed palatal soft tissues
lateral to the incisive papilla.
Multiple needle penetrations :
Areas of insertion: labial frenum in the midline between the maxillary central incisors,
interdental papilla between the maxillary central incisors , if needed , palatal soft tissues lateral
to the incisive papila.
CCLAD systemin the mid 1990. The P-ASA injection shares several common elements with the
nasopalatine nerve block,but differs sufficiently to be considered a distict identity. The P-ASA
uses a similar tissue point of entry to the nasopalatine but differs in its final target;that is needle
position within the incisive canal. The volume of anesthetic recommended for the P-ASA is 1.41.8ml, administered at a rate of 0.5ml per minute.
Other common names: palatal approach ASA or palatal approach maxillary anterior field block
Nerves anesthetized:nasopalatine, anterior banches of ASA
Areas anestehetized: pulps of maxillary central incisors, lateral incisors and the canines, facial
periodontal tissues associated with these same teeth, palatal periodontal tissues associated with
the same teeth
Area of insertion: just lateral to the incisive papilla in the papillary groove , continue the slow
insertion tecnique into the nasopalatine canal.orientation of the needle sould be parallel to the
long axis of the central incisors.the needle is advanced to a depth of 6-10mm.
Technique :
Height of the mucobuccal fold above the distal aspect of the maxillary second molar, target areamaxillary nerve as it passes the pterygopalatine fossa, superior andmedial to the target area of the
PSA nerve block direct the syringe to the opposite side with the needle approaching the
injectonsite at a right angle .
Areas anesthetized: soft tissues and periosteum buccal to the mandibular teeth direct the syringe
toward the injection site with the bevel facing down toward bone and the syringe aligned parallel
with the occlusal plane on the side of injection but buccal to the teeth. Penetrate mucous
membrane at the injection site, distal and buccal to the last molar.
Mandibular nerve block:
Areas anesthetized: mandibuar teeth to the midline, buccal mucoperiosteum and mucous
membrane on the side of injection, anterior two thirds of the tongue and floor of the mouth,
lingual soft tissues and periosteum, body of the mandible, inferior portion of the ramus,skin over
the zygoma and posterior portions of the cheek and temporal regions.
Technique :
A 25 guage needle is recommended , mucous membrane on the mesial of the mandibular ramus,
on a line from the intertragic notch to the corner of the mouth,just distal to the maxillary second
molar,target area is lateral side of the condylar neck, just below the insertion of the lateral
pterygoid muscle.height of the inection established by placement of the needle tip just below the
mesiolingual cusp of the maxillary second molar,there are three positions used for a right and left
IAN, align the needle with the plane extending from the corner of the mouth to the intertragic
notch on the side of injectio. It should be parallel with the angle between the ear and the face.the
syringe barrel lies in the corner of the mouth over the premolars, but its position may vary from
molars to incisors, depending on the divergence of the ramus as assessed by the angle of the ear
to the side of the face.
Areas anesthetized: mandibular teeth to the midline,body of the mandible and inferior portion of
the ramus ,buccal mucoperiosteum and mucous membrane in front of the mental foramen,
anterior two thirds of the tongue and floor of the oral cavity,lingual soft tissues and
mucoperiosteum
Technique :
A 25 gauge needle is recommended ,area of insertion is soft tissues overlying the medial border
of the mandibular ramus directly adjacent to the maxillary tuberosity at the height of the
mucogingival junction adjacent to the maxillary third molar , the barrel of the syringe is held
parallel with the maxillary occlusal plane, the needle at the level of the mucogingival junction of
the maxillary third molar. Orient the bevel away from the maandibular ramus; thus as the needle
advances through tissues,needle deflection occurs toward the ramus and the needle rmains in
close proximity to the inferior alveolar nerve.,advance the needle 25mm into tissue ,this distance
is measured from the maxillary tuberosity. The tip of the needle should lie in the mid portion of
the pterygomandibular space,close to the branches of V3.
Mental nerve block
Areas anesthetized: buccal mucous membrane anterior to the mental foramen to the midline and
skin of the lower lipand chin.move your finger slowly anteriorly until the bone beneath your
finger feels irregular and some what concave ,I radiograph is available mental foramen , can be
located easily.
Technique :
Penetrate the mucous membrane at the injection site, at the canine first premolar, directing the
syringe toward the mental foramen. Advance the needle slowly until the foramen is reached. The
depth of penetration is 5-6mm.for the mental foramen to be successful there is no need to enter
the mental foramen.aspirate,if negative slowly deposit 0.6ml over 20 sec.
Signs and symptoms:
Subjective symptoms are tingling and numbness of the lower lip , objective symptoms are no
pain during the treatment.
Complcations:
Hematoma , blood may exit the needle puncture point into the buccal fold. To treat: apply
pressure with gauze directly to the area of bleeding for at least 2 minutes.
Incisive nerve block:
The incisive nerve is a terminal branch of the inferior alveolar nerve . originating as a drect
communcation of the inferior alveolar nerve at the mental foramen, the incisive nerve continues
anteriorly in the incisive canal, providing sensory innervation to these teeth located anterior to
the mental foramen.
Areas anesthetized: buccal mucous membrane anterior to the mental foramen, usually from the
second premolar to the midline, lower lip and skin of the chin,pulp nerve fibres to the premolars,
canine, and incisors.
Technique :
A 25 guaze needle is recommended, mucobuccal fold at or just anterior to the mental
foramen,advance the needle until the mental foramen is reached. The depth of penetraton is 56mm. there is no need to enter the mental foramen for the incisive nerve block to be successful.
Aspirate ,if negative , slowly deposit 0.6ml over 20 seconds. During the injection, maintain
gentel finger pressure directly over the injection site to increse the volume of solution entering
into the mental foramen.
Signs and symptoms:
Tinglng or numbness of the lower lip, and no pain during dental therapy.
Comlications: few of any consequences, hematoma formation.
Used as the sole technique for pain control for certain types of dental treatment. For example, the
periodontal ligamet injection,intraseptal, and intraosseous techniques provide effective pulpal
anesthesia without the need for other injections.
Interaosseous anesthesia
Periodontal ligament injection
It was not until the early 1980s that the intraligamentary or PDL injection regained popularity.
Credit for its increased interest must go to the manufactures of syringe devices designed to make
the injection easier to administer. These original devices, the peripress and Ligmaject, provide a
mechanical advantage that allows the adinstrator to deposit the anesthetic more easily.therefore
the PDL injection appears to produce anesthesia in much the same way as the IO and intraseptal
injection, by diffusion of anesthetic solution apically through marrow spaces in the intraseptal
bone
Areas anesthetized: Bone,soft tissue, and apical and pulpal tissues in the area of injection
Technique:
A 27 guage needle is recommended, long axis of the tooth to be treated on its mesial or distal of
the root.target area is depth of the gingival sulcus,landmarks are root(s) of the tooth, periodontal
tissues
Intra septal injection
Areas anesthetized: Bone,soft tissues, root structure in the area of injection.
Technique:
A 27 guage needle is recommended, area of insertion center of the interdental papila adjacent to
the tooth to be treated. Landmark of this technique is papillary triangle, about 2mm below the
tip, equidistant from adjacent teeth.
The stabident system consists of two parts: a perforator, a solid needle that perforates the cortical
plate of bone with a conventional slow-speed contra-angle handpiece, and an 8mm, 27-guage
needle that is inserted into this predrilled hole for anesthetic administration ,the 27 guage
ultrashort needle could then be easily placed into the hole. Cotton pliers leave a slight dimple.
Mark the perforation site. Activate the handpiece, using a gentle pecking motion on the
perforator until a sudden loss of resistance is left. Cortical bone will be perforated within 2
seconds. Hold the guide sleeve in place as the drill is withdrawn. It is easy to insert the needle
into the hole using an ultrashort needle. Perforation of linual plate of bone. Prevented by proper
technique. Bend the needle, if necessary, to gain to the canal.
DentalVibe
Stimulates the sensory receptors at the injection site, effectively closing the neural pain
gate, blocking the painful sensation of injections.
Accupal
Accupal provides pressure and vibrates the injection site 360 proximal to the needle
penetration, which shuts the pain gate,
COMPUTER-CONTROLLED LOCAL ANESTHETIC DELIVERY SYSTEMS
Wand/Compudent system
Accurately manipulate needle placement with fingertip accuracy and deliver the LA with
a foot-activated control.
Flow rates of LA delivery are controlled by a computer
Comfort control syringe
Five pre-programmed speeds for different injection techniques and can be used for all
injection techniques.
JET INJECTORS
Syrijet
MED-JET H III
Small orifice 7 times smaller than the smallest available needle in the world.
The system's uniqueness is its ability to utilize low pressure delivery methods without
compromising accuracy, convenience and ease of use.
References:
Strichartz, G.R. &Berde, C.B. (2005). Local Anesthetics. In R.D. Miller Millers
Anesthesia, 6th edition. Philadelphia: Elsevier Churchill Livingstone.