Week Four: Local Anaesthetic Techniques Flashcards
Name the first six steps of basic local anaesthetic.
- Identify structures that need to be anesthetised. 2. Decide upon most suitable technique for individual patient to achieve anaesthesia of identified structures. i. age ii. bone density 3. Choose local anaesthetic type. i. length of anaesthesia required ii. Client age iii. Client medical history (illness and medications) iv. identify any precautions that need to be taken 4. Prepare syringe: i. cartridge: load and engage with piston ii. needle short or long? iii. check flow. 5, Place patient in supine position.
Once the patient is in supine position what are the next steps in administering local anaesthetic?
- Visualise the bony target area 7. Identify soft tissue landmarks and orientation of syringe required to access this area 8. prepare tissue i. dry target area ii. Apply topical anaesthetic > 1-2mins 9. Retraction. i. Retract cheek/lip with mirror, pulling the tissues taught, to ensure can clearly see landmarks identifying target area 10. Orient needle so that bevel face bone 11. Insert needle gently into target area 12. Advance needle to required depth
Once you have inserted the needle into the required depth, what are your final last steps?
- Aspirate i. in two planes for blocks ii. +ve: (blood in cartridge) discard cartridge, do not deposit solution. New Cartridge required. iii. -ve: safe to deposit solution 15. Deposit suitable amount for target area 16. Withdraw 17. Dispose of needle safely 18. Wait for onset of action i. differs amongst types of LA, and site of administration ii. Assess client
What is the infiltration technique?
Infiltration technique is able to be performed in the maxilla due to the thin cortical bone permitting diffusion of anaesthetic solution through the bone to the target nerve. It involves injecting into tissues immediately adjacent to the site that you want to anaesthetise. In doing this you also subsequently anaesthetise terminal branches of a larger nerve trunk.
What are the two types of infiltration techniques?
Buccal infiltrations Palatal Infiltrations
What is an indication for using a buccal infiltration technique?
Suitable if you require pulpal anaesthesia of one or two teeth.
What nerve is targeted in a buccal infiltration of the Maxilla?
PSA (Posterior Superior Alveolar), MSA (Middle Superior Alveolar) and ASA (Anterior Superior Alveolar)
What area is anaesthetised in a buccal infiltration?
Terminal branches on the innervating nerve of the adjacent tooth This results in anaesthesia of local pulp, root, buccal periosteum, connective tissue, buccal gingiva and mucous membrane.
What is the target bony site for a buccal infiltration?
Slightly distal and superior to the apex of the target tooth.
What is the soft tissue landmark for a buccal infiltration?
The height of the mucobuccalfold fold of the vestibule adjacent to the target tooth.
What is the orientation of the syringe for a buccal infiltration?
The syringe should be parallel to the long axis of the tooth - if it is an anterior tooth. It becomes more oblique as you move posteriorly.
What needle length is suggested for a buccal infiltration?
Short needle
What is the insertion for a buccal infiltration?
Approx 3-5mm (anterior -posterior)
What amount is deposited for a buccal infiltration?
0.5ml-1ml - (1/4 cartridge to 1/2 cartridge)
What is this picture of?
Buccal infiltration
What is this also a picture of? IMAGE
Buccal infiltration
What is this a diagram of? IMAGE
Buccal infiltration
What else is a buccal infiltration called?
Supraperiosteal injection
What are some considerations for a supraperiosteal injection?
When injecting a deciduous tooth you must note that it has flared roots. You must do the distal injection first. You must also consider the shape of the maxilla and the shape of the tooth root, Upper laterals have a slight distal inclination - if it can not achieve pulpal anaesthesia from the buccal aspect you may need to deposit palatally. It is important to consider that there are areas of poor diffusion in the maxilla. i.e. Where the cortical bone is thicker (attachment of zygomatic arch - zygoma)
What’s a cool trick with a buccal infiltration if you want to anaesthetise two teeth?
You can inject interproximally between apices of two teeth to target both.
Consideration: Is there a chance at multiple innervation with a buccal infiltration?
Yes there is. e.g. 16/26 can occur.
Although buccal infiltrations are useful, to minimise the use of them what should you consider?
Consider a block technique instead. PSA block, MSA block, ASA Blocks.
What is the indication for a palatal infiltration?
Anaesthetises the palatal gingiva of the corresponding tooth only.
What nerve is targeted for a palatal infiltration?
It is dependant on the region you want to anaesthetise. However it is the nasopalatine or the greater palatine.
What are is anaesthetised in a palatal infiltration?
The terminal branches on innervating nerve resulting in anaesthesia of the local palatal gingiva.
What is the target bony site for a palatal infiltration?
The greatest angle of the palate - the junction of the palatine process of maxilla and alveolar process of maxilla.
What are the soft tissue landmarks for a palatine infiltration?
The maximum tissue thickness of the palate (curvature of the palate)
What is the orientation of the needle for a palatal infiltration?
Insert the needle at approx 45 degree angle to the palate at the junction
What need length should you use for a palatal infiltration?
Short
What is the insertion depth for a palatal infiltration?
1-2mm
How much LA do you deposit in a palatal infiltration?
0.1-0.3mls ( a few drops) deposit slowly, you will see blanching.
What is this an IMAGE of?
Palatal infiltration
What is this a diagram of?
A palatal infiltration.
What are considerations regarding the palatal infiltration?
• Height of maximum curvature is lower in anterior teeth, so injection is much closer to tooth, don’t inject into rugae • May want to consider nasopalatine block • Palatal injections can be very sensitive, if need to anaesthetise gingiva of more than 2 teeth may want to consider greater palatine and/or nasopalatine block
What is the block technique?
It involves the anaesthetising of the more proximal branches of the larger nerve trunk. Usually at a site more distant from the operative site Minimises the need for multiple infiltrations Must aspirate in two planes (achieved by rotating barrel of syringe) except for nasopalatine block.
There are several types of blocks. Name those of the maxilla.
- Posterior Superior Alveolar Block - Middle Superior Alveolar Block - Anterior Superior Alveolar Block - Nasopalatine Block - Greater Palatine Block
What is an indication for a posterior superior alveolar block?
Suitable if requiring a pulpal/gingival anaesthesia of more than one molar tooth
What nerve is targeted in a PSA?
The posterior superior alveolar nerve.
Which area is anaesthetised in a PSA block?
It is used to anaesthetise the pulp tissue, alveolar bone, CT, PDL and buccal gingiva corresponding to the maxillary 1st (excluding MB root) 2nd, 3rd molar on the ipsilateral side of the injection.
What is the target bony site for a PSA block?
Lower infratemporal surface of maxilla
What is the soft tissue landmark for the PSA block?
The height of the mucobuccalfold over the second molar
How should you orientate your needle for a PSA block?
45 degree angle directed superiorly, medially and slightly posteriorly (one continuous movement)
What needle length should you use for a PSA block?
Short
What is the insertion depth for a PSA block?
15mm
How much LA should you deposit for a PSA block?
Approx 1.0-1.5mls (between 1/2 & 3/4 of a cartridge) You should deposit this slowly, over 30-60 seconds.
What block is displayed in this diagram?
The PSA block.
What block is displayed in this image?
The PSA block.
Which foramen is the PSA block near?
The greater palatine foramen. IMAGE
What are some considerations of the PSA block?
• Injecting near the pterygopalatine space, risk of haematoma formation if accidentally puncture maxillary artery or pterygoid plexus • Aspirate in two planes • Be wary of injection here in clients with coagulation disorders due to increased vascularisation of this area.
What is an indication for the MSA block?
Suitable if you require pulpal/gingival anaesthesia of both premolars.
Which nerve is targeted in a MSA block?
The middle superior alveolar block.
What area is anaesthetised in a MSA block?
The MSA is used to anaesthetise the pulp tissue, alveolar bone, CT, PDL and buccal gingiva corresponding to the premolars and MB root of the maxillary 1st molar on the ipsilateral side of the injection.
What is the target bony site of the MSA?
Superior and slightly distal to the apex of the second premolar
What is the soft tissue landmark for the MSA?
Height of the mucobuccalfold over the second premolar
What is the orientation for a MSA block?
Same as a buccal infiltration
What is the needle length for a MSA block?
Short
What is the insertion for an MSA block?
Ensure that the tip depth is above the apex of the second premolar
What amount is deposited for an MSA block?
Approx 0.9-1.2mls (approx half a cartridge)
What is this an IMAGE of ?
An MSA block
What are some considerations of the MSA block?
The lateral aspect of the maxilla is slightly concave, may need to angle slightly medially The facial artery branches are present in this region, you must remember to aspirate The technique can become slightly angled as working towards the posterior region of the mouth
What is an indication for the ASA?
Suitable if requiring pulpal or gingival anaesthesia of more than one anterior tooth
What nerve is targeted in a ASA?
Anterior Superior Alveolar Nerve
What area is anaesthetised in a ASA?
- Pulp tissue - Alveolar bone - Connective Tissue - Periodontal Ligament - Buccal gingiva corresponding to the canine, lateral incisor and central incisor on the ipsilateral side of the injection
What is the target bony site for the ASA?
Distal to the lateral incisor close to the apex of the canine
What is the soft tissue landmark for the ASA?
Height of the mucobuccalfold in the area of the lateral incisor and canine
What is the orientation for an ASA?
Same as a Buccal infiltration
What is the needle length for the ASA?
Short
What is the insertion for an ASA?
10-15mm
How much LA do you deposit for a ASA?
0.9-1.2mls (approx half a cartridge)
What is this an image of?
ASA Location
What are some considerations for the ASA?
Also known as the ‘infraorbital nerve block’ - This is not in our scope of practice. The infraorbital nerve blocks the blocks MSA, ASA and PSA. When doing the ASA block we are targeting only those branches that run laterally to mesially through the anterior wall of the maxillary sinus.
What is an indication for the greater palatine block?
Suitable if you need anaesthesia of the molar/premolar region of the hard palate.
What nerve is targeted in the Greater palatine block?
The greater palatine
What area is anaesthetised in the greater palatine block?
Palatal gingiva and mucosa of the posterior 2/3 of the hard palate, ipsilateral to site of the injection
What is the target bony site for the GP block?
Greater palatine foramen
What are the soft tissue landmarks for the greater palatine block?
- Junction of the soft and hard palate (will be able to palpate) at the greatest angle of the hard palate. - Slightly distal and approx 1cm medial to the second molar - Can palpate with a cotton bud
What is the orientation of the GP block?
Advance the syringe from the opposite side, approx 45 degrees
What is the needle length for a GP block?
Short
What is the insertion for a GP block?
2-3mm
How much is deposited for a GP block?
0.25-0.5mls (under a quarter of a cartridge) you will see blanching
What is this an IMAGE of?
A greater palatine block
What is this a PICTURE of?
A greater palatine block
What block is this diagram dsiplaying?
A greater palatine block
What are some considerations of using the Greater palatine block?
- You will see tissue blanching - Can use pressure technique to minimise discomfort - Aspirate: Site of exit of the greater palatine artery
What is the indication for the nasopalatine block?
Suitable if requiring gingival anaesthesia of the anterior region of the hard palate
What is the nerve targeted for the nasopalatine block?
The nasopalatine
What area is anaesthetised for the nasopalatine?
Palatal gingiva and mucosa of the anterior 1/3 of the hard palate on the ipsilateral site of injection
What is the target bony site for the NP block?
Incisive foramen
What is the soft tissue landmark for the NP block?
- Incisive papilla, located posterior to the central incisors in the midline
What is the orientation for the NP block?
45 degree angle, just lateral to incisive papilla
What is the needle length for the NP?
Short
What is the insertion amount for the NP?
2-3mm
What is the amount deposited for the NP?
0.25-0.5mls (under a 1/4 of a cartridge) - you will see blanching.
What is this IMAGE displaying?
A nasopalatine block
What is this picture of?
A nasopalatine block
What block is this diagram displaying?
A nasopalatine block
What is the infiltration technique?
You are able to perform this is areas that permit diffusion of local anaesthetic in the mandible - this correlates to regions where the verve is not surrounded by a barrier of thick bone. - You inject into the tissues immediately adjacent to the site that you want to anaesthetise - this anaesthetises the terminal branches of the larger nerve trunk
What are the two types of infiltration techniques in the mandible?
Buccal and Lingual Infilitrations
What is an indication for a buccal infiltration?
suitable to anaesthetise the lower anteriors and deciduous molars prior to eruption of the sixes (E maybe difficult to target after this) - Mandible bone is relatively thin and porous in the anterior region - Incisive nerve does not run in the bony canal: This allows for diffusion of the anaesthetic through the incisive nerve
What nerve is targeted in a mandibular buccal infiltration?
The incisive nerve for the lower anteriors The IAN for deciduous E’s and D’s
What area is anaesthetised in a mandibular buccal infiltration?
- Terminal branches on the innervating nerve adjacent tooth - Resulting in anaesthesia of local pulp, root, buccal periosteum, connective tissue, buccal gingiva and mucous membrane
What is the technique for a mandibular buccal infiltatration?
Same as in the maxillary arch.
What is this diagram of?
A mandibular buccal infiltration
What is this image of?
A buccal infiltration
What is this image of?
A lingual infiltration
What is the technique for the lingual infiltration.
This technique is necessary if the lingual gingiva need to be anaesthetised. It is the same technique as the BI, however you insert the needle at the floor of the mouth and at an angle where the mucosa is reflected upon the gingiva.
Considerations in the lingual infiltration?
- Avoid pushing the needle into the periosteum - Avoid pricking FOM too often, as do not want to create a hematoma
What does a block technique involve in the mandible?
- Anaesthetising more of the proximal branches of the larger nerve trunk - Site more distant from the operative site - Must aspirate in two planes for IAN block
What is the indication for and IAN block?
Suitable if requiring pulpal anaesthesia or molar and premolar teeth
What nerve is targeted in an IAN?
Inferior Alveolar Nerve - In the pterygomandibular space: therefore incisive and mental terminal branches are also anaesthetised - The pterygomandibular space also has the lingual nerve, thus it is also targeted. by the IAN technique
What area is anaesthetised in the IAN?
Inferior Alveolar Nerve: Pulp of all mandibular teeth Buccal gingiva and periosteum Connective tissue Mucous membrane anterior to first molar Lingual nerve: Lingual gingiva, floor of the mouth and anterior 2/3 of the tongue **on ipsilateral side of the injection
What are these images displaying?
IAN nerve and the Lingual Nerve
What is this image displaying?
The target bony site of the IAN
What is the bony target of the IAN?
The bony target is superior to the lingula on the medial border of the ramus of the mandible.
Identify all of the structures on this diagram
P = M = R = TT = IAV = IAA = IAN = SML = MP = B = PMR = SCM =
What is the soft tissue landmark of the IAN?
Anterior border of the pterygomandibular space
How do you locate the soft tissue landmark of the IAN?
- Patient to open their mouth wide (looking for 2x landmarks) Medially: Identify the bulge from the mucosa overlying the pterygomandibular raphe Laterally: Mucosa overlying the coronoid notch (anterior border of the ramus) - place finger here than move medially - can palpate upper border of internal oblique ridge **INBETWEEN THESE TWO AREAS YOU WILL SEE A DEPRESSION - THIS IS THE INJECTION SITE
What is being identified in these images?
Pterygomandibular depression Coronoid notch Pterygomandibular fold
What is the orientation for the IAN?
Vertical: Height of injection is 1cm above lower occlusal plane. – Horizontal: Syringe barrel is over the premolars on the contralateral side
What is the needle length for the IAN?
Long
What is the insertion for the IAN?
25mm, until hit bone - withdraw slightly then aspirate
How much LA is deposited in the IAN?
1.5-1.8mls over 60 seconds
What is this diagram identifying?
The planes in which you orientate your syringe for an IAN
Name the identified markers in this image.
Coronoid notch H - PMR - L -
Identify which block is being used to create this area of anaesthetic
IAN and Lingual block
What are the considerations of using the IAN?
Size of buccal fat pad • Size of ramus, and how much it flares out • Morphology of lingula • Dental arch shape and alignment of teeth • If client says tongue not feeling numb, withdraw slightly from target area, aspirate and deposits 0.5ml to target lingual nerve. • Partial anaesthesia at midline due to nerve plexus and overlapping supply
What is the indication for the LB?
When requiring buccal anaesthesia for buccal gingiva of mandibular molars
What nerve is targeted in a LB?
The long buccal nerve
What area is anaesthetised in the LB?
Area anaesthetised = buccal gingiva of the lower posterior teeth and adjacent mucobuccalfold
What is the target bony site for the long buccal?
Anterior border of the ramus - targeting the nerve as it leaves the pterygomandibular space crossing the ramus of the mandible and before it pierces the buccinator
What are the soft tissue landmarks for the long buccal?
Mucous membrane distal and buccal to last molar in th arch
What is the orientation for the long buccal
Syringe is parallel to the occlusal plane on the side of the injection
What is the needle length for the long buccal?
Short of long
What is the insertion for the long buccal?
2-3mm, until you contact the bone
How much LA do you deposit for the LB?
0.2-0.3mls (a few drops)
What is this image identifying?
The location of the long buccal block
What is this a picture of?
Long Buccal
What block anaesthetised the area in this diagram?
Long buccal block
What is the indication for a incisive block?
Useful when treatment is limited to the mandibular anterior teeth, and full quadrant anaesthesia is not necessary
What nerve is targeted in the incisive mental block?
Both the incisive and mental nerves
What area is anaesthetised in the incisive block?
• Incisive nerve: Pulp, CT, PDL, buccal gingiva and soft tissue of premolars, canine and incisor teeth ipsilateral side to injection • Mental Nerve: lip skin, mucosa and muscles of lower lip ipsilateral side to injection
What is the target bony site for the incisive block?
The Mental foramen
What is the soft tissue landmark for the incisive block?
between the apices of the lower premolars
What is the orientation for the incisive block?
Syringe is parallel to occlusal plane on the side of the injection as for LB or it can be parallel to the long axis of the tooth as for BI
What is the needle length for the incisive block?
Short
What is the insertion for the insicve?
5-6mm
how much LA is deposited for the incisive?
0.5-0.6mls (1/4 cartridge) *Apply digital pressure for 2-3minutes after injection to aid diffusion of anaesthetic into mental foramen.
What is this image identifying?
Incisive mental block - Mental foramen - bony Target
What is this picture identifying?
incisive mental block
What block was used to anaesthetise this area?
Incisive mental block
What are considerations for the incisive block?
The patients age
What is the intraseptal/Interdental injection?
Targeting terminal nerve endings in soft tissue of nerve that anaesthetises the region • Placing in interdental papilla, 45 degrees to long axis of tooth • Deposit 0.2-0.3mls (a few drops) • Resistance and ischemia will follow
What is an intrapulpal injection?
• Involves the injection on anaesthesia into an exposed nerve (open pulp chamber) • Place needle into pulp chamber and deposit 0.2-0.3mls (a few drops)
