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Techniques of Local Anesthesia
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Techniques of Local Anesthesia

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Anaesthesia & Exodontia
Third Year

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  • 1. TECHNIQUES OF LOCAL ANAESTHESIA Dr. Wael M. Talaat Assistant Professor of Oral and Maxillofacial Surgery
  • 2. Objectives Knowledge of the classification of local anesthesia 2. Indications for each technique 3. Details on how to perform different techniques of local anesthesia 1.
  • 3. 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
  • 4. TOPICAL ANAESTHESIA It is the application of ointments or solution containing L.A agent to accessible structures e.g skin or mucous membrane . Topical anaesthesia has a limited effect on the free nerve endings
  • 5. INFILTRATION ANAESTHESIA Infiltration anaesthesia is produced when the terminal nerve endings is flooded by the L.A solution
  • 6. INFILTRATION ANAESTHESIA I - Soft tissue infiltration anaesthesia Submucosal Para periosteal Sub-periosteal infiltration Field block (ring block) II – Intra bony(intraosseous) infiltration anaesthesia
  • 7. I - 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.
  • 8. 2. 3. 4. Supra-periosteal (Para-periosteal) infiltration : accomplished by depositing the solution beside the periosteum and not above it. Sub-periosteal infiltration : difficult and painful Field block infiltration
  • 9. Intra-bony infiltration 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 inter-septal bone on either side of the tooth to be anesthetized. The solution is then forced under pressure into the cancellous bone. 1.
  • 10. NERVE BLOCK ANAESTHESIA The L.A solution is deposited in close proximity to the main nerve trunk supplying the operative field
  • 11. Topical Free nerve endings Terminal nerve endings Main trunk Infiltration Nerve block
  • 12. 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
  • 13. Factors that influence the choice of local anaesthetic technique 4) Haemostasis 5) Presence of infection 6) Age of the patient
  • 14. Contraindications of local anaesthesia 1. 2. 3. 4. 5. 6. 7. Patient refusal due to fear and apprehension Presence of infection Allergy Uncooperative patient as epileptic or mental Major surgery Patients with hyperthyrodism in whom local anaesthia may precipitate a thyroid crysis Patients with severe renal or liver disease
  • 15. Advantages of local over general anaesthesia 1. 2. 3. 4. 5. 6. 7. Safety (intraoperatively and postoperatively) Ease of administration Less cost Co-operation of the patient Unlimited operating time Reduce bleeding during surgery Patient is unfit for general anesthesia
  • 16. Factors affecting the maximum effect of local anesthesia Distance of the nerve in contact with the drug : at least 8-10 mm of the nerve should be in contact with the drug ( 2-3 nodes of Ranvier 2. Size of the nerve fiber : the larger the fiber, the more difficult it is to be anesthetized 3. Drug concentration 1.
  • 17. Injection procedure 1. 2. 3. 4. 5. 6. 7. 8. 9. Sterile the cartridge by 70 % alcohol then thaw to body temperature by water The bevel of the needle towards bone The syringe should contain no air In critical areas with neighboring blood vessels, use aspiration syringe Slow injection The site of injection should be disinfected Stretch the tissues on injection. Follow shortest way inside tissue. Never bend to change direction
  • 18. Maxillary infiltration anaesthesia
  • 19. Buccal and labial injections  The needle is inserted into a point opposite to the tooth to be extracted, with the bevel facing the cortical bone.  The needle is inserted 2 mm away from the muco-buccal fold and at 45 degree to the outer cortical plate till it touchs bone.  About 1.5 ml of solution is injected.
  • 20. Position of the patient: The patient is placed with the maxillary occlusal plane 45 degree with the floor Position of the operator: The operator stands on right side and front of the patient
  • 21. Labial infiltration
  • 22. Labial infiltration
  • 23. Labial infiltration
  • 24. Palatal Injection  The point of insertion of the needle is located on the palatal side of the tooth, midway between the gingival margin and the middle line of the palate.  The needle should be at right angle to the vault of the palate. To achieve this, the needle is derived from the opposite side.  Only 0.3 ml of solution is slowly injected to avoid pain and ulceration.
  • 25. Palatal infiltration
  • 26. Palatal infiltration
  • 27. Mandibular infiltration anaesthesia
  • 28. Labial Injection:   Position of the patient: The chair is adjusted such that the mandibular occlusal plane is almost horizontal when the mouth is open. Position of the operator: The operator stands on right side and front of the patient
  • 29. Lingual Injection  The insertion of the needle should be just above the muco-lingual fold to avoid dissemination of the solution into the floor of the mouth, 0.2 – 0.3 ml of the solution is injected slowly.
  • 30. 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
  • 31. Maxillary nerve block 1)Posterior superior alveolar N.B 2)Infra Orbital N.B 3)Nasopalatine N.B 4)Greater palatine N.B 5)Maxillary N.B
  • 32. Posterior Superior Alveolar N.B (Tuberosity Injection)
  • 33. Posterior Superior Alveolar N.B Position of the patient: The patient is placed with the maxillary occlusal plane 45 degree with the floor Position of the operator: The operator stands on right side and front of the patient
  • 34. Posterior Superior Alveolar N.B Area anaesthetized : Pulp of the maxillary molars except mesiobuccal root And The buccal mucoperiosteum of the molar area
  • 35. Anaesthetized area 1. 2. 3. 4. 5. Upper third, second and first molar except the mesio-buccal root of the latter Associated periodontal membranes Investing alveolar bone Neighboring buccal mucosa Maxillary antrum
  • 36.  Injection site : distal aspect of the maxillary tuberosity above and behind the third molar.
  • 37. Technique 1. 2. 3. 4. Mouth should be partly closed Needle is inserted opposite the mesial root of the first molar at the deepest part of the mucobuccal fold Needle passes around the curvature of the posterior part of the maxillary tuberosity The needle should be kept close to the bone to avoid entering the pterygoid venous plexus
  • 38. Injection site
  • 39. Anaesthetized area
  • 40. Infra Orbital N.B
  • 41. Infra Orbital N.B Position of the patient: The patient is placed with the maxillary occlusal plane 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
  • 42. Infra orbital Nerve Block Solution is deposited at the orifice of the infra-orbital foramen, and will diffuse along the canal to involve both the anterior and middle superior alveolar nerve.
  • 43. Area anaesthetized : Pulps of the maxillary premolars and anteriors (and the mesiobuccal root of maxillary first molar) And the buccal mucoperiosteum from midline to the area of maxillary second premolar
  • 44. Technique Infra-orbital ridge is palpated and the infra-orbital notch located with the tip of the index finger, which then moves downward to lie over the infra-orbital foramen. 2. The tip of the needle is directed towards the foramen using any of 2 approaches : 1.
  • 45.  Approach A: 1- Direct the syringe in the line passing oblique from the mesioincisal angle of the central incisor, to the distocervical angle, and to the apical region of the root of the canine. 2- The needle is inserted at about 5 mm out in the mucobuccal fold above the tip of the root of the canine. 3- The needle is pushed till it contacts the boundary of the foramen
  • 46. Approach B: 1. By holding the syringe in the same line with the long axis of the upper second premolar 2. Insert the needle at the reflection of the mucobuccal fold, 5 mm out from the fold 
  • 47. Maxillary Nerve Block
  • 48. Area Anesthetized: The main trunk of the maxillary nerve and all its branches. 1. Maxillary teeth 2. Investing bone 3. Buccal mucoperiosteum 4. Palatal mucoperiosteum 
  • 49. Position of the patient: The patient is placed with the maxillary occlusal plane 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
  • 50. Technique Needle is inserted over the apices of the second molar, little distance away from the bone to clear the zygomatic process 2. The needle passes upwards and inwards till reaching the spheno-palatine fossa, with an angle 30 degrees 3. Four ml of anesthetic solution is deposited 1.
  • 51. Incisive (Nasopalatine) Injection ( Area Anesthetized: 1. Palatal alveolar plate opposite six anterior teeth 2. Overlying mucoperiosteum 
  • 52. Technique  Point of needle insertion: Marked by the incisive papilla in the midline, one cm posterior to the central incisor.  Direction of the needle is parallel to the long axis of maxillary central incisor.  0.5 ml of solution is injected very slowly
  • 53. Greater palatine Nerve Block
  • 54. 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 .
  • 55. Greater palatine Nerve Block Detection of greater palatine foramen The needle is inserted in the bleached area , a drop is felt (greater palatine foramen)
  • 56. Incisive foramen Greater palatine foramen
  • 57. Greater palatine Nerve Block Area anaesthetized : Palatal mucoperiosteum from maxillary first premolar to the maxillary third molar
  • 58. Techniques of mandibular nerve block
  • 59. Mandibular nerve block 1)Mental N.B 2)Inferior alveolar N.B 3)Lingual N.B 4)Mandibular N.B
  • 60. Mental N.B
  • 61. 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
  • 62. Mental Nerve Block Area anaesthetized : Labial m.m and skin from the mental foramen to the midline
  • 63. Inferior alveolar N.B
  • 64. Aim  To block the inferior dental and lingual nerve by deposition of the anesthetic solution around them when they are in the pterygomandibular space, and before the entrance of the inferior alveolar nerve to the mandibular foramen.
  • 65. Direct Mandibular Injection  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 in front of the patient for the right mandibular injection. And on right side and behind the patient for the left mandibular injection
  • 66. Point of needle insertion The index of the left hand is placed in the mucobuccal fold opposite the premolar area 2. The external oblique ridge and the anterior border of the ramus are located 3. The greatest depth of the anterior border of the ramus which is the coronoid notch is located 1.
  • 67. The index finger is rotated lingually to occupy the retromolar triangle, and the fingernail faces the lingual side 5. With the fingernail in this position, the finger tip will rest on the internal oblique ridge 6. The point of needle insertion is at 5 mm in front of the middle of the tip of the index finger 4.
  • 68. 7. 8. 9. 10. A syringe with a long needle is held over the premolar region of the opposite side and parallel with the mandibular occlusal plane. The needle is inserted to a depth 20 – 30 mm till it touches bone. 1.2 ml of solution is deposited slowly The needle is withdrawn about 10 mm and 0.3 ml of solution is deposited
  • 69. Long buccal nerve : Anesthetized by either : 1. Soft tissue infiltration 2. Long buccal nerve block: 0.3 – 0.5 ml of anesthesia is deposited in the midpoint of the retromolar triangle between the external and internal oblique ridges. 
  • 70. Inf.Alv N Lingual N
  • 71. Coronoid notch
  • 72. Symptoms of anaesthesia 1) Subjective Tingling and numbness of the lower lip in the injected site 2) Objective instrumentation shows no pain of the related teeth and associated structures
  • 73. Errors during Inferior Alveolar Nerve Block
  • 74. High injection Numbness of the ear Injection near the auriculotemporal nerve
  • 75. High injection Trismus Injection into the lateral pterygoid muscle
  • 76. High injection Toxicity Injection into the pterygoid plexus of veins
  • 77. Low injection Trismus Injection into the medial pterygoid muscle
  • 78. Low injection Toxicity Injection into the posterior facial vein
  • 79. Low & Deep injection Facial paralysis Injection into substance of the parotid gland (Facial nerve)
  • 80. High injection Low injection
  • 81. Mandibular Nerve Block 1) Gow Gates technique 2) Akinosi technique
  • 82. Mandibular Nerve Block 1) Gow Gates technique
  • 83. Aim  To anesthetize the inferior alveolar, mental nerve, incisive, lingual, mylohyoid, auriculotemporal and buccal nerves.
  • 84. Point of needle insertion Target area: The lateral aspect of the neck of the condyle 1. The patient is asked to extend the neck and open the mouth as wide as possible 2. Extraoral landmarks: • Intertragic notch • Corner of the mouth 
  • 85. The index finger is used to retract the tissues 4. Tissues at the side of injection are prepared 5. The barrel of the syringe is placed on the side opposite to that of injection 6. Needle penetration occurs at a site just distal to the maxillary second molar and at a height equal to the palatal cusp of the second molar 3.
  • 86. The needle is aligned to a plane extending from the corner of the mouth to the tragus 8. Needle is slowly advanced till bone is contacted 9. 1.8 ml of solution is deposited 7.
  • 87. Advantages 1. 2. 3. 4. 5. Increased success rate Constancy of landmarks Decreased positive aspiration rate Decreased incidence of trismus Only one injection is required
  • 88. Gow Gates technique
  • 89. Gow Gates technique
  • 90. Gow Gates technique
  • 91. Mandibular Nerve Block 2) Akinosi technique
  • 92. Aim  To anesthetize the inferior alveolar, mental, incisive and buccal nerve.
  • 93. Point of needle insertion Target area: Area between the vertical ramus and maxillary tuberosity 1. The patient is asked to close the teeth 2. Cheek is distended using the fingers of the left hand 3. The mucosa buccal and distal to upper third molar is wiped 
  • 94. The needle is positioned at the level of the maxillary marginal gingiva with the barrel parallel to the maxillary occlusal plane. 5. The needle penetrates the tissues in the embrasure between the vertical ramus and maxillary tuberosity 6. 2.5 – 3 cm of the needle is buried in the tissues 4.
  • 95. Advantages Painless 2. One prick of the needle 3. Rapid onset 4. Can be used in patients suffering from trismus 1.
  • 96. Akinosi technique
  • 97. Akinosi technique
  • 98. Akinosi technique
  • 99. THANK YOU
  • 100. Exam
  • 101. 1. 2. 3. 4. 5. Discuss Factors that influence the choice of local anaesthetic technique ? A surgeon is about to remove a lesion extending from upper left central incisor to upper left second premolar. Describe two local anesthetic techniques which can be used. Enumerate the 6 amide local anesthetics. State which is long, intermediate or short acting. Discuss the pain pathway. Enumerate complications of inferior alveolar nerve block.