L.A 6 Flashcards
The insertion of the needle into the mucosa should be by …
- The bevel of the needle should be oriented toward bone.
Types of L.A injection
- Local infiltration: Deposition of L.A near the small terminal nerve
endings. - Field block: Deposition of L.A near the larger terminal nerve branches. ( although common usage identifies
them as infiltration or supraperiosteal). - Nerve block: L.A is deposited close to a main nerve trunk,
usually at a distance from the site of operative area. E.g. Inferior alveolar nerve block.
Techniques of maxillary L.A
- Supraperiosteal (infiltration).
- Periodontal ligament (PDL, intraligamentary)
injection, recommended as an adjunct to other
techniques or for limited treatment protocols. - Intraseptal injection, recommended primarily for
periodontal surgical techniques. - Intraosseous injection, recommended for single
teeth (lower molars) when other techniques have
failed. - Posterior superior alveolar nerve block, recommended
for management of several molar teeth in one quadrant. - Middle superior alveolar nerve block, recommended for
management of premolars in one quadrant. - Anterior superior alveolar(infraorbital) nerve block,
recommended for management of anterior teeth in one
quadrant. - Maxillary nerve block, recommended for extensive buccal,
palatal, and pulpal management in one quadrant. - Greater (anterior) palatine nerve block, recommended for
palatal soft and osseous tissue treatment distal to the
canine in one quadrant. - Nasopalatine nerve block, recommended for palatal soft
and osseous tissue management from canine to canine
The most frequently used technique for obtaining pulpal anesthesia in maxillary teeth.
Maxillary supraperiosteal injection
(infiltration)
Nerves anesthesthetized by Maxillary supraperiosteal injection
(infiltration)
the entire region innervated
by the large terminal branches as pulp and root area of
the tooth, buccal periosteum, alveolar bone,
connective tissue, mucous memebrane.
Technique: Maxillary supraperiosteal injection
25 or 27 gauge short needle is used.
The needle‘s bevel should be towards bone.
Maxillary supraperiosteal injection
(infiltration) , signs and symptoms
1- Subjective: feeling of numbness in the area of adminstration.
2. Objective: Absence of pain during treatment.
Maxillary Palatal Anesthesia can be ..
a painful injection
Posterior superior alveolar nerve
block , anaesthetise ?
pulpal tissue,
corresponding alveolar bone, and buccal gingival tissue to the maxillary
1st
, 2nd
, and 3rd
molar
Indications for PSA block
- When treatment involves 2 or more maxillary molars.
- Supraperiosteal injection is contraindicated (infection).
- When supraperiosteal inj. Is proved ineffective.
Posterior superior alveolar nerve
block advantages and disadvantages
Advantages:
1. Atraumatic.
2. High success rate.
3. Less number of injections.
4. Minimize amount of local used.
Disadvantages:
1. Risk of hematoma.
2. Does not anesthetize first molar completely.
3. No bony landmarks
Posterior superior alveolar nerve
block technique
- Technique
• 25 or 27 gauge, short needle.
• Area of insertion: height of the mucobuccal fold above the
maxillary second molar.
• Position patient and identify landmarks:
– Mucobuccal fold
– Maxillary tuberosity
– Zygomatic process of maxilla
• Advance needle about 15-20mm upward, inward and
backward.
• Aspirate, inject 1.8 ml of solution.
Posterior superior alveolar nerve
block complications
Complication:
• Hematoma: Needle too far posteriorly into
pterygoid plexus of veins or perforation of
maxillary artery.
• Mandibular anesthesia.
Short note Middle superior alveolar nerve block
• Used to anesthetize the
maxillary premolars,
corresponding alveolus, and
buccal gingival tissue
• Present in about 28% of the
population
• Used if the infraorbital block
fails to anesthetize
premolars.
Middle superior alveolar nerve block indications and disadvantages
- Anesthesia of maxillary premolars only.
- Infraorbital nerve block failure.
Disadvantages:
MSA nerve is only present 28% of the time.
Middle superior alveolar nerve block technique
• Position patient and
identify landmarks
- mucobuccal fold above the
maxillary 2nd premolar.
• Insert needle 5-10 mm at
the height of mucobuccal
fold in area of maxillary 2nd
premolar.
• Aspirate
• Inject 0.9-1.2 ml of
solution, slowly
Anterior superior alveolar nerve block
(Infraorbital nerve block) , nerves and areas ansethetized
-Nerves anesthetized:
1. Anterior superior alveolar n.
2. Middel superior alveolar n.
3. Infraorbital n. (inferior palpebral, lateral nasal, superior labial)
- Areas Anesthetized:
1. Maxillary canine, lateral incisor, central incisor, alveolus,
and labial mucosa on the injection side.
2. In about 72% of the patients, pulps of the maxillary 1st and
2nd premolars, and corresponding alveolar bone, and
buccal mucosa. Also the mesiobuccal root of the 1st molar.
3. Lower eyelid, lateral aspect of the nose, upper lip.
Anterior superior alveolar nerve block
(Infraorbital nerve block) indications
- Procedures involving more than
2 teeth. - Infection (which contraindicates
supraperiosteal inj. - Failure of supraperiosteal inj.
( dense cortical bone).
Anterior superior alveolar nerve block
(Infraorbital nerve block) Area of insertion is
the mucobuccal fold of the 1st premolar, and the needle should be parallel with the long axis of the tooth.
– Contact bone in infraorbital region
Greater palatine nerve block
Can be used to anesthetize the
palatal soft tissue of the teeth
posterior to the maxillary canine and corresponding alveolus/hard palate
Greater palatine nerve block technique
– Area of insertion is ~1cm medial from 2nd / 3rd maxillary
molars on the hard palate, anterior to the greater palatine
foramen.
– Palpate with needle to find greater palatine foramen.
– Depth is usually less than 10mm
– Utilize pressure with a cotton swab to desensitize region at
time of injection
– Inject 0.3-0.5cc of local anesthetic
Nasopalatine nerve block
Can be used to anesthetize the
soft and hard tissue of
the maxillary anterior palate from canine to canine.
Nasopalatine nerve block technique
– Area of insertion is lateral to the incisive papilla into
incisive foramen.
– Landmarks ( Central incisors, incisive papilla).
– Path of insertion is 45 degree angle towards the papilla.
– Inject 0.3-0.5cc of local anesthetic
– Can use pressure over area at time of injection to decrease
pain.
Maxillary nerve block (V2 block)
Can be used to anesthetize
maxillary teeth, alveolus, hard and soft tissue on the palate, gingiva, and skin of the lower eyelid, lateral aspect of nose, cheek, and upper lip skin and mucosa on side blocked (Hemimaxilla).
Maxillary nerve block (V2 block) indications
- Extensive (surgical, periodontal, restorative) procedures.
- Infection that contraindicate other techniques (e.g. Supraperiosteal inj., PSA and ASP blocks).
- Diagnostic or therapeutic procedures for neuralgias or tics of V2.
Maxillary nerve block (V2 block) disadvantages and technique
Disadvantages:
1. Risk of hematoma.
2. Absence of bony landmarks (high tuberrosity approach).
3. Lack of hemostasis.
4. Pain (greater palatine canal approach).
• Techniques:
1. High tuberosity approach
2. Greater palatine canal approa
High tuberosity approach technique:
– 25 gauge long needle to be used.
– Area of injection is height of mucobuccal fold of
maxillary 2nd molar.
– Landmarks(mucobuccal fold of maxillary 2nd molar,
maxillary tuberosity, zygomatic process of maxilla).
– Advance at 45° upward, inward, backward same as in
the PSA block.
– Insert needle ~30mm ( needle tip should lie in the
pterygopalatine fossa).
– Inject ~1.8cc of local anesthetic.
Greater palatine canal technique:
– 25 gauge long needle to be used.
– Area of insertion is greater palatine canal
– Target area is the maxillary nerve in the
pterygopalatine fossa.
– Perform a greater palatine block and wait 3-5 min.
– Then insert needle in previous area and pass it
into greater palatine foramen at 45 degree angle.
– Insert to depth of ~30mm
– Inject 1.8cc of local anesthetic
Maxillary nerve block (V2 block) Complications:
- Hematoma (injury to maxillary artery. During high tuberosity
approach). - Penetration of the orbit (during greater palatine approach).
- Penetration of the nasal cavity (during greater palatine canal
approach).
Techniques of mandibular L.A
- Supraperiosteal (infiltration).
- Periodontal ligament (PDL, intraligamentary) injection.
- Intraseptal injection.
- Intraosseous injection.
- Inferior alveolar nerve block (IANB).
- Lingual nerve block.
- Long Buccal nerve block.
- Gow-Gates mandibular nerve block(V3).
- Vazirani-Akinosi closed-mouth mandibular nerve block.
- Mental nerve block.
- Incisive nerve block.
Infiltration techniques for mandibular anaesthesia
(for posterior
teeth) do not work in the adult
mandible due to the dense cortical
bone.
Inferior alveolar nerve block techniques
– IANB.
– Akinosi.
– Gow-Gates.
IANB short note
• Most frequently used.
• The L.A in this technique is injected to Pterygomandibular space.
• Avoid, if possible, bilateral IANB.
IANB Areas anesthetized
- Mandibular teeth to the midline.
- Body of the mandible, inferior portion of the ramus.
- Buccal mucoperiosteum, mucous membrane anterior to the
mandibular first molar(mental n.). - Anterior 2/3 of the tongue and floor of the oral cavity
(lingual n.). - Lingual soft tissue and periosteum.
IANB contraindications
Contraindications:
1. Infection in the area of injection.
2. When there is a risk of lip or tongue bitting in very young
child or a mentally or physically handicapped patients.
(IANB)
• Disadvantages:
- Intraoral landmarks are not consistently reliable.
- Postive aspiration (10% to 15%, highest of all intraoral
inj.). - Lingual and lower lip anesthesia is discomfiting to many
patients and possibly dangerous for certain individuals. - Partial anesthesia possible where a bifid IAN and bifid
mandibular canals are present.
(IANB)
Technique:
• A 25-gauge long needle is used.
• Target Area
– Inferior alveolar nerve, near mandibular foramen.
(pterygomandibular space)
• Landmarks
– External oblique ridge
– Ascending ramus of the mandible.
– Coronoid notch
– Pterygomandibular raphe
– Occlusal plane of mandibular posteriors
• Mouth must be open for this technique, best to utilize
mouth prop.
• Inject ~0.5-1.0cc of local anesthetic.
• Continue to inject ~0.5cc on removal from injection
site to anesthetize the lingual branch.
• Inject remaining anesthetic into coronoid notch region
of the mandible in the mucous membrane distal and
buccal to most distal molar to perform a long buccal
nerve block.
Anatomical boundaries of the pterygomandibular
space:
- Superiorly: Lateral pterygoid muscle.
- Inferiorly: Attachment of medial pterygoid muscle with medial
surface of the angle of the mandible. - Medially: medial pterygoid muscle .
- Laterally: Medial surface of the ramus of the mandible.
- Anteriorly: Pterygomandibular raphe and oral mucosa.
- Posteriorly: Deep loop of parotid gland.
• Content: Infralveolar nerve, artery, and vein. Lingual nerve.
Mylohyoid nerve. Second part of maxillary artery. Loose areolar
C.T. Lymphatics.
IANB injection
1cm above the occlusal table of the
mandibular teeth.
• height 1cm above the occlusal table of the mandibular teeth.
• Anteroposterior plane- just lateral to the pterygomandibular raphe.
• Approach area of injection from contralateral premolar region ( between 2 premolars).
Success rate of Gow-Gates mandibular nerve block is
> 95%
Gow-Gates mandibular nerve
block(V3) advantages
Advantages:
1. Requires only one injection.
2. High success rate (> 95%).
3. Minimum aspiration rate.
4. Few post operative complications (e.g. Trismus).
5. Provide successful anesthesia where a bifid IAN and
bifid mandibular canals are present.
Gow-Gates mandibular nerve
block(V3)
• Technique
– Target area: Lateral side of the condylar neck
– Landmark:
a) Extraoral: Intertragic notch and corner of the mouth.
b) Intraoral: Just below the mesiopalatal cusp of maxillary 2nd molar.
– Penetration: Distal to the maxillary 2nd or 3rd molar
– Height: Mesiopalatal cusp of maxillary 2nd molar.
(10– 25mm from occlusal plane)
– Depth: 25mm with bone contact.
– Aspirate.
– Deposit: 1.8ml
– Time of onset:5-10”(IAN 3-5”)
Vazirani-Akinosi closed-mouth
mandibular block
• Useful technique for infected patients with
trismus
Vazirani-Akinosi closed-mouth
mandibular block
• Useful technique for infected patients with
trismus
Inject to depth of Vazirani-Akinosi closed-mouth mandibular block is
25mm (no bone contact)
Long buccal nerve block
• Anesthetize ?
Soft tissue and periosteum buccal to
the mandibular molar teeth.
Long buccal nerve block
insertion
Distal and buccal of last molar
Deposit : 0.3mL
Long buccal nerve block
insertion
Distal and buccal of last molar
Deposit : 0.3mL
Mental nerve block
• Indications
When buccal soft tissue anesthesia is necessary for procedures in the mandible anterior to the mental foramen
Mental nerve block
• Indications
When buccal soft tissue anesthesia is necessary for procedures in the mandible anterior to the mental foramen
Mental nerve block
Area anesthetized ?
Area of insertion ?
• Area anesthetized: buccal mucous membrane anterior to the
mental foramen, Lower lip and chin.
• Area of insertion: mucobuccal fold at or just anterior to the mental
foramen.
Incisive nerve block
• Indications:
– Pulpal anesthesia to teeth anterior to mental foramen.
– When inferior alveolar nerve block is not indicated
( e.g., canine to canine treatment)
Incisive nerve block
• Technique:
– A 25 gauge short needle is recommended.
Incisive nerve block
• Technique:
– A 25 gauge short needle is recommended.
Supplemental injection techniques
- Intraosseous anesthesia: anesthetic is deposited into the cancellous bone that supports the teeth.
• Periodontal Ligament Injection.
• Intraseptal Injection.
• Intraosseous Injection. - Intrapulpal Injection.
Periodontal Ligament Injection works by
Provides pulpal and soft-tissue anesthesia in a localized area (one tooth) without producing extensive soft-tissue (e.g. Tongue and lower lip) anesthesia.
• The solution should not forced apically , This could cause
avulsion of a tooth.
Periodontal Ligament Injection works by
Provides pulpal and soft-tissue anesthesia in a localized area (one tooth) without producing extensive soft-tissue (e.g. Tongue and lower lip) anesthesia.
• The solution should not forced apically , This could cause
avulsion of a tooth.
Indication of PDL injection
- Pulpal anesthesia of one or two teeth in a quadrant.
- Treatment of isolated teeth in 2 mandibular quadrants.
- Patients for whom residual soft-tissue anesthesia is undesirable.
- Situations in which regional block anesthesia is contraindicated.
Contraindications of PDL injection
- Infection or inflammation at the site of injection.
- Primary teeth, when the permanent tooth bud is present.
a. Enamel hypoplasia has been reported to occur in a developing permanent tooth when a PDL injection was administered to the primary tooth above it.
b. There appears to be little reason for use of PDL technique in primary teeth because infiltration anesthesia and the incisive nerve block are effective. - Patient who requires a “numb” sensation for psychological comfort.
Advantages of PDL Injections
- Prevents anesthesia of the lip, tongue, and other soft
tissues, thus facilitating treatment in multiple quadrants
during a single appointment. - Minimum dose of local anesthetic necessary to achieve
anesthesia (0.2 ml per root). - An alternative to partially successful regional nerve block
anesthesia.
Disadvantages of PDL Injections
- A special syringe may be necessary.
- Excessive pressure can produce focal tissue damage.
- Post injection discomfort may persist for several days.
- The potential for extrusion of a tooth exists if excessive
pressure or volumes are used.
PDL Injection Technique
Procedure
– Stabilize the syringe along the long axis of the root to be anesthetized
– With the bevel of needle on the root, advance the needle apically until
resistance is met.
– Deposit 0.2 ml of local anesthetic solution in a minimum of 20 sec.
– If tooth is multi-rooted, remove the needle and repeat the procedure on
the other roots
What to do in case of Failures of PDL Injection
Infected or inflamed tissues. In this case, remove the needle and reenter at a different site until 0.2ml of local anesthetic is deposited and retained in the tissues. Each root must be anesthetized with 0.2 ml of solution.
Intraseptal Injection Useful for
providing osseous and soft-tissue
anesthesia and hemostasis for periodontal curettage and surgical flap procedures.
Intraseptal Injection contraindicated in ?
infection or severe
inflammation at the injection site
Technique for Intraseptal
Injection
Area of insertion: center of the interdental papilla adjacent to
the tooth to be treat
Landmarks– papillary triangle, about 2 mm below the tip
Deposit 0.2-0.4 ml of local anesthetic in a minimum of 20 sec.
Intraosseous Injection , Deposition of local anesthetic solution into
the interproximal bone between two teeth
In Intraosseous Injection , Because of the high incidence of palpitations
noted when vasopressor-containing local
anesthetics are used, a… is recommended
“plain” local anesthetic
Intraosseous Injection Technique
1) Perforate 2 mm apical to the intersection of lines drawn
horizontally along the gingival margins of the teeth and a
vertical line through the interdental papilla.
2) Site should be located distal to the tooth to be treated.
Intrapulpal Injection indication
when pain control is necessary for
pulpal extirpation or other endodontic treatment the absence of adequate anesthesia from other techniques.
There are only two injections where bending the needle is acceptable because the needle can be easily retrieved if separated:
1) PDL Injection
2) Intrapulpal Injection
