TECHNIQUES OF LOCAL ANAESTHESIA Dr.Mohamed A. Elsholkamy M.Sc - Ph.D.- T.Q.M. Lecturer of Oral & Maxillofacial Surgery L.

A can be produced by the action of L.A agent on either the free nerve endings , the terminal nerve endings or the main trunk of the nerve TOPICAL ANAESTHESIA It is the application of ointments or solution containing L.A agent to an accessible structures e.g skin or mucous membrane . Topical anaesthesia has a limited effect on the free nerve endings INFILTRATION ANAESTHESIA Infiltration anaesthesia is produced when the terminal nerve endings is flooded by the L.A solution I - Soft tissue infiltration anaesthesia Submucosal Para periosteal Sub-periosteal infiltration Field block (ring block) Soft tissue infiltration anaesthesia 1. Submucous infiltration : accomplished by inserting the needle beneath the mucosal layer and depositing the solution so that it diffuses in this particular plane. 2. Supra-periosteal (Para-periosteal) infiltration : accomplished by depositing the solution beside the periosteum and not above it. 3. 4. Sub-periosteal infiltration : difficult and painful Field block infiltration

Intra-bony infiltration 1. Intra-osseous infiltration : the cortical plate is penetrated and the solution is injected into the spongy bone, thus terminal nerve endings are anesthetized. 2. Inter-septal infiltration : needle is inserted into the thin porous interseptal bone on either side of the tooth to be anesthetized. The solution is then forced under pressure into the cancellous bone. NERVE BLOCK ANAESTHESIA The L.A solution is deposited in close proximity to the main nerve trunk supplying the operative field Factors that influence the choice of local anaesthetic technique 1) The area to be anaesthetized 2) Extent of the surgical procedures 3) Duration of the required anaesthesia 4) Haemostasis

5) Presence of infection 6) Age of the patient Injection procedure 1. Sterile the cartridge by 70 % alcohol then thaw to body temperature by water 2. The bevel of the needle towards bone 3. The syringe should contain no air 4. In critical areas with neighboring blood vessels, use aspiration syringe (aspirate twice in two planes) 5. Slow injection (rate of injection ?? ) 6. The site of injection should be disinfected 7. Stretch the tissues on injection. 8. Follow shortest way inside tissue. 9. Never bend needle to change direction 10. Use topical anesthesia to minimize patients apprehension Techniques of Nerve Block anaesthesia Maxillary nerve block Posterior superior alveolar N.B Infra Orbital N.B Nasopalatine N.B Greater palatine N.B Maxillary N.B Mandibular nerve block Mental N.B Inferior alveolar N.B Lingual N.B Mandibular N.B Posterior Superior Alveolar N.B Indications Advantages Disadvantages Treatment procedures involving two or more maxillary molars If paraperiosteal is contraindicated If paraperiosteal is proven ineffective Contraindications: Atraumatic High success rate < 95% Minimize number of injections Minimize volume of local anesthesia used

 Technique Landmarks

Risk of hematoma: diffuse Arbitrary technique: no bony landmarks 2nd injection is required in 28% of the patients Positive aspiration 3.1 % Alternative techniques Landmarks Area of insertion Target area Direction & depth of penetration Procedure: Patient position Operator position Preparation Needle type Volume deposited Mucobuccal fold Maxillary tuberosity Zygomatic process of maxilla

Position of the patient: The patient is placed with the maxillary occlusal plane is 45 degree with the floor Position of the operator: The operator stands on right side and front of the patient 8 o clock for right & 10 o clock for left Needle type: 25 G short or most likely 27

Volume deposited: 0.9 1.8 ml

Area anaesthetized : Pulp of the maxillary molars except mesio-buccal root And The buccal mucoperiosteum of the molar area Complications Hematoma

Mandibular anesthesia

Infra Orbital N.B Indications Advantages Treatment procedures involving two or more maxillary anterior teeth If paraperiosteal is contraindicated If paraperiosteal is proven ineffective Contraindications: Discrete areas Local hemostasis needed badly Comparatively simple Minimize number of injections Minimize volume of local anesthesia used

Disadvantages Psychological Difficulty in defining landmarks Positive aspiration 0.7 % Alternative techniques: paraperiosteal, PDL, V2 block

Landmarks Mucobuccal fold Infraorbital notch Infraorbital foramen Area of insertion Target area Direction & depth of penetration Position of the patient: The patient is placed with the maxillary occlusal plane is 45 degree with the floor Position of the operator: The operator stands on right side and front of the patient for right side injection and facing the patient in left side injection Needle type: 25 G long or short??

Volume deposited: 0.9 1.2 ml

Area anaesthetized : Pulps of the maxillary premolars and anteriors(and the mesiobuccal root of maxillary first molar) And

the buccal mucoperiosteum of the from midline to the area of maxillary second premolar Subjective signs: Greater palatine Nerve Block Detection of greater palatine foramen The index finger is moved (with slight pressure) from the palatal area opposite to Maxillary first molar Backwards until a Bleaching of the mucosa occurs . Landmarks: Detection of greater palatine foramen The needle is inserted in the bleached area , a drop is felt (greater palatine foramen) Area anaesthetized : Palatal mucoperiosteum from maxillary first premolar to the maxillary third molar nasopalatine Nerve Block Landmarks:

Alternative techniques: Single penetration: Multiple penetration tech. Maxillary nerve block (V2) TWO APPROACHES: HIGH TUBEROSITY INJECTION

GREATER PALATINE CANAL INJECTION Depth of penetration: 30 mm Mandibular nerve block 1) Mental N.B 2) Inferior alveolar N.B 3) Lingual N.B 4) Long buccal nerve 5) Mandibular N.B Mental N.B Position of the patient: The patient is placed in a position that when he opens his mouth widely the mandibullar occlusal plane is parallel to the floor Position of the operator: The operator stands on right side and behind the patient Area anaesthetized : Pulps of mandibular premolars and anteriors And Labial m.m from the mental foramen to the midline

Inferior alveolar N.B Landmarks Area of insertion Target area Direction & depth of penetration Procedure: Patient position Operator position Preparation Needle type Volume deposited

Landmarks Premolar area (v) Corner of the mouth (v) Occlusal plane (v) Pterygomandibular raphe (v) Coronoid notch (D) Symptoms of anaesthesia 1) Subjective Tingling and numbness of the lower lip in the injected site Objective instrumentation shows no pain of the related teeth and associated structires Failure Acessory innervation Errors during Inferior Alveolar Nerve Block High injection Numbness of the ear Injection near the auriculotemporal nerve Trismus Injection into the lateral pterygoid muscle Toxicity Injection into the pterygoid plexus of veins Low injection Trismus Injection into the medial pterygoid muscle Toxicity Injection into the posterior facial vein

Low & Deep injection Facial paralysis Injection into substance of the parotid gland (Facial nerve) Long buccal block Mandibular Nerve Block Gow - Gates technique Vazirani - Akinosi technique Gow-Gates technique Depth of penetration: 25 mm Operators position: The same as inferior alveolar Amount deposited: 1.8 ml or rather ?? Patient instructions: Keep mouth open for 1-2 min. Change position: Upright or semiupright position Time lapse wait: May reach 5-7 min. ??

Vazirani-Akinosi technique Depth of penetration: 25mm Operators position: 8 oclock for both sides Amount deposited: 1.5- 1.8 ml. Bevel orientation: Away from bone Patient positioning