Pain and Anxiety Week 4 Flashcards
3 divisions of the trigeminal nerve
V1 - ophthalmic
V2 - maxillary
V3 - mandibular
What are the major branches of V2? (6)
1) PSA
2) MSA
3) ASA
4) Greater palatine
5) Nasopalatine
6) Infraorbital
What are the 7 possible maxillary injections?
1) PSA
2) MSA
3) ASA
4) Greater palatine
5) Nasopalatine
6) Infraorbital
7) Supraperiosteal injection (local infiltration)
What does the MSA nerve block anesthetize?
Premolars
1st molar (primarily)
Buccal gingiva in premolar/1st molar regions
What is the target area for MSA nerve block?
Slightly apical to premolars (either 1st or 2nd)
How is the penetration of the mucosa made when giving MSA nerve block?
Along long axis of premolar to the apex of premolar
What needle is used for MSA, PSA, ASA, Greater Palatine, and Nasopalatine nerve blocks and Supraperiosteal Injection?
27 short
How much of the needle is inserted when giving MSA nerve block?
1/3 to 1/2 the needle length
Bevel is toward the _________ when giving MSA, PSA, ASA, Nasopalatine, and Infraorbital nerve blocks and Supraperiosteal Injection
(not Greater Palatine!!!)
bone
What does the PSA nerve block anesthetize?
1st molars (partial innervated by MSA)
2nd molars
3rd molars
Buccal gingiva in molar regions
What is the target area for PSA nerve block?
Apical to root of 3rd molar
How is the penetration of the mucosa made when giving PSA nerve block?
Lateral to 2nd molar
45 degree angle to long axis of tooth
At an angle approaching 45 degrees medially
What must you avoid when giving PSA nerve block?
Pterygoid plexus
How much of the needle is inserted when giving PSA nerve block?
1/2 the needle length
What does the ASA nerve block anesthetize?
Anterior teeth (centrals, laterals, canines)
Labial mucosa and inner lip to midline
What is the target area for ASA nerve block?
Apical and distal to canine
How is the penetration of the mucosa made when giving ASA nerve block?
Along long axis of canine to target area
Make sure to pull the _____ tight when giving ____ nerve block
lip; ASA
How much of the needle is inserted when giving ASA nerve block?
1/3 to 1/2 the needle length
What does the Greater Palatine nerve block anesthetize?
No teeth
Palatal soft tissue (from distal of canine to junction of hard and soft palate; medial to midline)
Palatal bone (same)
What is the Greater Palatine nerve block also called?
Anterior Palatine nerve block
What is the target area for Greater Palatine nerve block?
Greater palatine foramen
How is the penetration of the mucosa made when giving Greater Palatine nerve block?
Anterior to greater palatine foramen
1/2” medial to disto-palatal cusp of 2nd molar
Needle positioned perpendicular to mucosa
What do you use to located the greater palatine foramen?
Cotton tip
Make sure to apply pressure to the cotton tip applicator until the tissue ________
blanches
Keep pressure on cotton tip applicator during __________ and first couple drops; ease pressure as anesthetic is delivered
penetration
How much of the needle is inserted when giving Greater Palatine nerve block?
Until bevel is buried (~ 1/4”)
Bevel is positioned ________ toward _______ tissue when giving Greater Palatine nerve block
laterally; soft
What does the Nasopalatine nerve block anesthetize?
No teeth
Palatal soft tissue (anterior hard palate, from distal of canine to distal of canine)
Palatal bone (same)
What is the Nasopalatine nerve block also called?
Incisive nerve block
What is the target area for Nasopalatine nerve block?
Incisive foramen
How is the penetration of the mucosa made when giving Nasopalatine nerve block?
Lateral to incisive papilla toward posterior part of the papilla
45 degree angle to palatal bone
T/F: You need to use a cotton tip applicator when before and during Greater Palatine and Nasopalatine nerve block
True
How much of the needle is inserted when giving Nasopalatine nerve block?
Until bevel is buried (~ 1/8”)
What does the Infraorbital nerve block anesthetize?
Canine
Incisors (to midline)
*75% = premolars + part of 1st molar
Buccal gingiva of the above areas
Lower eyelid
Upper lip
Lateral aspect of nose
What is the target area for Infraorbital nerve block?
Near infraorbital foramen
Inferior to orbital rim
How is the penetration of the mucosa made when giving Infraorbital nerve block?
Parallel to 1st premolar
Angle toward infraorbital foramen
What size needle is used for Infraorbital nerve block?
25 long or 27 short
How much of the needle is inserted when giving Infraorbital nerve block?
Until bone is contacted; about 1/2 the needle length
What does the Supraperiosteal Injection anesthetize?
Pulpal anesthesia for 1-2 teeth
Soft tissue anesthesia of limited area
What is the Supraperiosteal Injection commonly called?
Local infiltration
What is the success rate of the Supraperiosteal Injection?
> 95%
What is the target area for Supraperiosteal Injection?
Apical region of the tooth being anesthetized
How is the penetration of the mucosa made when giving Supraperiosteal Injection?
Along long axis of tooth to target zone
When giving Supraperiosteal Injection, insertion is made at the _______ of the ______________ fold. Needle is then advanced to the apical region of the tooth
height; mucogingival
T/F You should always recap a needle by using the single handed technique
True
T/F You should always recap the penetrating end of the needle before disposing into sharps container
FALSE, you should NEVER recap the penetrating end
Which branch of V3?
Medial pterygoid branch
Dura mater branch
Undivided nerve
Which branch of V3?
Lateral pterygoid branch
Masseter muscle branch
Temporal muscle branch
Long buccal branch
Anterior division
Which branch of V3?
Auriculotemporal branch
Lingual nerve
IAN
Mental nerve
Incisive nerve - terminal branches
Posterior division
What are the 4 major branches of V3?
IAN
Lingual nerve
Long buccal nerve
Mental nerve
Which nerve is the most challenging area of the oro-facial complex to anesthetize?
IAN
Why is the IAN he most challenging area of the oro-facial complex to anesthetize?
- Structural complexity of V3
- Entire division is freely movable
- Bone is more compact
T/F: Local infiltration of anesthetic is very effective for IAN block
FALSE; the bone is more compact, so local infiltration is NOT effective for IAN
IAN descends _________ and __________ across the pterygoid space
inferiorly; laterally
What branches does IAN form after descending across the pterygoid space?
Lingual nerve (anteriorly)
Mylohyoid nerve (posteriorly)
What foramen does IAN enter after branching into lingual nerve and mylohyoid nerve?
Mandibular foramen
What foramen does the IAN enter after going through the mandibular foramen and transversing beneath roots of mandibular teeth?
Mental foramen
What does IAN divide into after entering the mental foramen?
Mental nerve (exits foramen)
Terminal IAN branches (remain in mandible)
Terminal IAN branches (incisive nerve) can cross the ___________ - usually opposite to incisors but can extend to opposite mandibular foramen
midline
Lingual nerve descends _____________ and ______________ between the ramus and medial pterygoid
inferiorly; medially
After descending, the lingual nerve runs ___________ and slightly __________ to the _________
anterior; medial; IAN
Lingual nerve runs just ________ and _________ to the ___ molar
distal; medial; 3rd
Lingual nerve extends inferiorly to the ____________
tongue
What does the lingual nerve provide innervation to?
Anterior 2/3rds tongue
Floor of mouth
Lingual gingiva
The long buccal nerve branches off the _____________ division of V3
anterior
Long buccal nerve descends ___________ to the _______ and ________ nerve
parallel; IAN; lingual
At the retromolar pad, the long buccal nerve swings ___________ and fans up and out over the buccal mucosa
laterally
What is the long buccal nerve also known as?
Buccal nerve
What does the long buccal nerve provide innervation to?
Buccal gingiva or molar/premolar area
Skin of cheek
T/F: Long buccal nerve provides innervation to the lip
FALSE
T/F: There is some overlap between terminal branches of long buccal nerve and mental nerve
True
In order to accomplish restorative and surgical procedures involving the tissues of the Mandibular Division, the following nerves and their respective branches must be anesthetized (using one anesthetic carpule) …
IAN
Lingual nerve
Long buccal nerve
T/F: Blocking the Mandibular Division nerves is subject to a high percentage of failure
True
Why is blocking the Mandibular Division nerves subject to a high percentage of failure?
- The dynamic nature of the target zone
- The relative difficulty in visualizing its 3D aspects
Name the 4 different types of mandibular blocks
Conventional
Uni-linear
Gow-Gates
Vazirani-Akinosi
What are the 2 target zones of the conventional mandibular block?
Posterior zone: IAN + lingual
Anterior zone: long buccal
T/F: The anterior zone of the conventional mandibular block is targeted in a separate injection from the posterior zone
True
What is the posterior target zone of the conventional mandibular block?
Retromolar triangle
(IAN as it passes down to mandibular foramen, but prior to entry)
What is the posterior target zone of the conventional mandibular block defined by?
- Pterygomandibular Raphe (medially)
- Anterior border of the Ramus (laterally)
- Hamular notch (superiorly)
What is the posterior target zone of the conventional mandibular block characterized by?
Dimple/depression found in the center of the retromolar triangle
What is the height of injection for the conventional mandibular block?
6-10 mm above occlusal plane
What is the anterior-posterior placement of the needle for the conventional mandibular block?
3/4 of the A-P distance from the coronoid notch back to deepest part of pterygomandibular raphe
What is the depth of penetration for the conventional mandibular block?
Until bone is contacted
(20-25 mm, or 2/3-3/4 depth of long needle)
What needle is used for the conventional mandibular block?
25 long
When doing the conventional mandibular block, align barrel of syringe with contralateral premolars, __________ with the occlusal plane
parallel
When doing the conventional mandibular block, insertion is made to about ______ to ________ needle length, until _____ is contacted
2/3 to 3/4; bone
When doing the conventional mandibular block, make sure the bevel is _________ the bone
toward
How common is positive aspiration when doing the conventional mandibular block?
10-15%
When doing the conventional mandibular block, once you reach the target, you want to ________ deposit the entire carpule except for ___ carpule
slowly; 0.2 cc
T/F: the posterior target zone of the conventional mandibular block is quite small, and is forgiving regarding the precision of needle placement as long as depth is reached
FALSE; should say the posterior target zone of the conventional mandibular block is quite LARGE
The posterior target zone of the conventional mandibular block lies along a line defined by the deepest extent of the ________ concavity of the ascending ramus, and the deepest extent of the __________ concavity of the ramus
mesial; posterior
Which injection can the lingula present a barrier to direct approach to the target zone of?
Mandibular conventional block
T/F: Lingula varies from patient to patient
True
What do you do if the lingula is a prominent barrier when trying to give a conventional mandibular nerve block?
- Penetrate “dimple”
- Swing barrel toward midline to reach posterior target area
What is the anterior target zone of the long buccal nerve block?
Anterior border of ramus
When doing the long buccal nerve block, penetration of the mucosa is made _______ and _________ to the most distal molar tooth in the arch
distal; buccal
When doing the long buccal nerve block, the needle is ___________ to the occlusal plane, but __________ to the teeth
parallel; buccal
What needle is used for the long buccal nerve block?
25 long
What is the correct way to reposition your needle if necessary (shallow tissue) when doing a long buccal nerve block?
45 degree angle laterally
When doing the long buccal nerve block, insert the needle until _______ is contacted, about _________mm
bone; 1-4mm
When doing the long buccal nerve block, make sure the __________ is buried; repositioning needle is often necessary
bevel
When doing the long buccal nerve block, bevel is __________ the bone
toward
How does the Gow-Gates target zone differ from the conventional block target zone?
Gow-Gates target zone is significantly superior
T/F: The Gow-Gates mandibular block has a high success rate (>95%), but requires experience
True
Which technique has a longer onset of anesthesia? Gow-Gates or Conventional?
Gow-Gates (5-10 mins vs 3-5 for conventional)
What is the aspiration rate for Gow-Gates?
Low (2%)
Which mandibular block technique results in successful anesthesia with bifid IAN/bifid mandibular canals?
Gow-Gates
Gow-Gates target zone is _____ cm superior to the conventional target zone
2 cm
Where is the target zone for the Gow-Gates mandibular block?
Anteromedial side of condylar neck
When doing the Gow-Gates mandibular block, the needle is placed just _______ to the maxillary 2nd molar at the height of the tip of the _______ cusp (3rd molar if present)
distal; ML
When doing the Gow-Gates mandibular block, the syringe barrel is aligned with the imaginary line between the _______________ _______ (injection side) and the __________ of the mouth (opposite side)
intertragus notch; corner
What should you do after injecting your patient using the Gow-Gates mandibular block technique?
Sit patient up for 5 mins with mouth open for 1-2 mins
What needle is used for the Gow-Gates mandibular block?
25 long
When doing the Gow-Gates mandibular block, insertion is made until _______ is contacted, about ______ needle length
bone; 3/4
When doing the Gow-Gates mandibular block, if bone is not contacted, you must retract slightly and redirect needle by moving syringe ___________, which will redirect the needle ___________
posteriorly; anteriorly
___________ _________ of needle is usual cause of missing bone when doing the Gow-Gates mandibular block
Medial deflection
T/F: The orientation of the needle bevel is very critical when doing the Gow-Gates mandibular block
FALSE; the orientation of the needle bevel is NOT critical
When doing the Gow-Gates mandibular block, _________ deposit a __________ carpule
slowly; full
T/F: The Uni-linear mandibular block utilizes a different target zone and less than half the anesthetic that is required for Gow-Gates
True
How many injections does the Uni-linear mandibular block require?
1
Uni-linear target zone is _____ cm superior to the conventional target zone
1 cm
Name the location where the IAN, lingual nerve, and long buccal nerve are closest together, meaning they are:
–running parallel
–in close proximity
–in a straight line
Uni-linear target zone → 1 cm above conventional target zone
When doing the Uni-linear mandibular block, you want to penetrate the mucosa ______ mm above dimple of posterior triangle
5 mm
When doing the Uni-linear mandibular block, you want to insert the needle ______ to ______ its length
1/2 to 2/3
When doing the Uni-linear mandibular block, swing barrel to opposite side (C/P area) and advance until _________ is contacted. Then withdraw ______ mm and deposit ________ carpule. Slowly withdrawal, and the deposit the remaining carpule (this anesthetizes lingual and long buccal)
bone; 2 mm; 3/4
Where is the target zone for the Vazirani-Akinosi mandibular block?
Medial border of ramus
(same height as Uni-lateral)
What should you be aware of when finding the target zone for the Vazirani-Akinosi mandibular block?
Lateral flare of ramus
T/F: When doing the Vazirani-Akinosi mandibular block, you want to make sure the patient’s mouth is closed with light occlusion
True
When doing the Vazirani-Akinosi mandibular block, the syringe barrel is _________ to maxillary occlusal plane
parallel
When doing the Vazirani-Akinosi mandibular block, needle is inserted at _______________ __________ of maxillary ______ molar (3rd if present) and advanced in a slightly _________ direction
mucogingival junction; 2nd; lateral
When doing the Vazirani-Akinosi mandibular block, ________ is NOT contacted
bone
T/F: When doing the Vazirani-Akinosi mandibular block, bone should always be contacted
FALSE; bone is NOT contacted
What needle is used for the Vazirani-Akinosi mandibular block?
25 long
When doing the Vazirani-Akinosi mandibular block, insertion is made to about ________ the needle length from the _________ _________
3/4; maxillary tuberosity
When doing the Vazirani-Akinosi mandibular block, bevel is _____________ from the bone
AWAY
T/F: When doing the Vazirani-Akinosi mandibular block, you should use a full carpule (1.8 cc) and sit pt upright
True
What is the target zone for the mental nerve block? Where can it be found?
Mental foramen, between apices of 1st and 2nd premolars
When doing the mental nerve block, penetration is made in depth of the _________, just anterior or posterior to ____________ bundle (palpate!)
vestibule; neurovascular
What needle is used for the mental nerve block?
25 long
27 short
When doing the mental nerve block, insertion is made deep enough to _________ the _______ of the needle (3-5 mm)
bury; bevel
When doing the mental nerve block, bevel is ___________ the bone
toward
When doing the mental nerve block, apply ___________ on the area that has “____________”
pressure; ballooned
What can the mylohyoid nerve provide innervation to?
Mandibular molars
When is the mylohyoid nerve block indicated?
When a successful block has been given, but pt still has sensation in some teeth (particularly molars)
“While it has been postulated that several nerves can provide accessory innervation to mandibular teeth, current thinking supports the ____________ as the likely culprit.”
mylohyoid
What is the target zone of the mylohyoid nerve block?
Medial to mandibular 2nd molar
(take a lingual approach)
When doing the mylohyoid nerve block, penetrate the depth of the lingual ___________
vestibule
When doing the mylohyoid nerve block, use a ______ degree angle to the long axis of the ________
45 degree; molar
What needle is used for the mylohyoid nerve block?
25 long
27 short
When doing the mylohyoid nerve block, insertion is made about _______ to ________ the needle length until ________ is contacted (lingual border of body of mandible)
1/4 - 1/3; bone
When doing the mylohyoid nerve block, bevel is _________ the bone
toward
