This document summarizes new trends in dental local anesthesia presented by Dr. Atef Fouda. Some key points discussed include using physical means like cold or vibration during injections to decrease pain, as well as pharmaceutical advances like topical anesthetics. New injection techniques are mentioned like computer-controlled local anesthetic delivery and needle-free injections. Various local anesthetic drugs and their properties are reviewed, as well as maxillary and mandibular nerve block techniques and their effectiveness. Ultrasound-guided nerve blocks are presented as an innovative method that allows real-time visualization of the needle and nerve.

1. 1
Chapter 6
Dr/Atef fouda
Prof. Oral & Maxillofacial Surgery
Cairo University
Egypt
New trends in
dental local
anesthesia

2. Atef A. Fouda.
Prof of Oral & Maxillofacial Surgery
Cairo University

3. 3
Chapter V
New trends in dental local anesthesia

4. Goals
Decrease pain during injection.
Increase efficiency of LA agent.
Decrease post-op discomfort.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.
Modification of the techniques.
Increase safety.

5. Decrease pain during injection.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.
Physical means during injection
Cold application at injection site.
Apply pressure while injection.
Warm the anesthetic solution.
Pharmaceutical:
Use of topical anesthesia

6. BRAIN
Apply pressure
Or
Cold
Gate control
theory

7. Vibration at injection site.

8. VIBRO TACTILE:
VIBRATION AT THE INJECTION SITE.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

9. VibraJect:
Vibration of the needle.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

10. 22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

11. Needle free injection
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

12. Syrijet holds any 1.8 ml cartridge of
local anesthetic
liquids forced through very small
openings, called jets at very high
pressure [2000 psi] can penetrate
skin or intact mucous membrane.
This technique is particularly effective
for palatal injections.
needle-less injection
Syringe modification:
Jet syringe
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

13. Reduced doses of LA.
Less unwanted numbness.
Light in weight.
Easy to use.
Less fear from patient side.
No infected sharp materials “environment friendly”
long life
Needle free injection
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

14. Syrijet
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.
*Jet Syringes ($1,600)

15. 22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

16. Centbucridine:
It is a quinolone derivative with local anesthetic action. It has
vasoconstricting and anti-histaminic properties.
Centbucridine
in a concentration of 0.5% can be used effectively for infiltration
and nerve blocks with an anesthetic potency 4-5 times greater
than that of 2% lignocaine with longer duration of anesthesia that
last up to 2 hours.
It produced no side effects or toxic reactions and confirmed its
safety for use in medically compromised patients where Lignocaine
or adrenaline is contraindicated.
Local anesthetic drugs
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

17. Local anesthetic drugs
Dentipatch:
a patch that contains 10-20% lidocaine is placed on the dried
mucosa for 15 minutes.
Recommended for use in achieving topical anesthesia for both
maxilla and mandible.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

18. Local anesthetic drugs
Phentolamine: “under investigation”
Drug used for Reversal of effects of local anesthetic solutions. It is
available as a cartridge, It is administered following dental
procedure using the same location and techniques (infiltration /
block injection) employed for the administration of local
anesthetic solution.
This novel molecule is a recent innovation in reversal of local
anesthesia that will immensely benefit child patients and others
with special needs to prevent post-operative anesthesia induced
injuries.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

19. 22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.
INCREASE SAFETY.

20. Ultrasafe Syringe
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

21. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

22. 22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.
Local anesthetic techniques
Branches from IAN
IAN

23. Site of injection
IANB
Local anesthetic techniques
22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

24. Local anesthetic techniques
22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

25. 22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.
Site of Gow-
gates
technique
Local anesthetic techniques

26. 22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.
Local anesthetic techniques
IA nerve
Mylohyoid nerve
Lingual nerve
Long buccal nerve
Gow-Gates T

27. 2002
22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

28. 2011
22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

29. 2013
22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

30. Success rate 95% compared to 80% IA block.
Positive aspiration 2% compared with 10-15% IA NB.
Anesthesia extended to accessory innervations.
In most of cases no need for separate Long buccal
anesthesia.
Gow-Gates mandibular nerve block
22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

31. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

32. Anterior, Middle superior alveolar NB.
Infra-orbital NB.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

33. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.
A
S
A
M
S
A
A
M
S
A
P
S
A
M

34. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

35. Technique:
•Area of insertion in
mucobuccal fold
higher than root
length at the area of
lateral incisor and
canine.
•Inject about 1.2ml
Anterior superior Alv. N.
2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

36. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

37. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.
Technique:
•Area of insertion
in mucobuccal fold
higher than root
length at the area
of premolar
region.
•Inject about
1.2ml

38. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

39. 27-Nov-16 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

40. Technique:
1-Palpate infra-orbital notch
extra-orally.
2-place thumb or index finger on
that region.
3-Retract the upper lip and buccal
mucosa.
4-Area of insertion is 4-5 mm
from mucobuccal fold of the 1st
premolar/canine area.
5-Contact bone at infra-orbital
region.
6-Inject 0.9-1.2cc of local
anesthetic solution.
2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.
Infra-orbital NB.
Anterior, Middle superior alveolar NB. [ASMA].

41. [MSA]
[AMSA]
2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

42. Success rate of pulpal anesthesia after AMSA :
17% central incisors.
23% lateral incisors.
60% canine.
40% first premolar.
66% second premolar.
Inactivation of muscles of facial expression.
Lip numbness.[Trauma-inability for eating & drinking].
Disadvantages of infra orbital NB:
2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.
Anterior, Middle superior alveolar NB.Infra-orbital NB.

43. Proximal
Distal
MOLARS
PRE-MOLARS
Anterior
Terminal branches
2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.
Maxillary N.
Posterior S.A.
MSA
ASA

44. 2010
22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.
Anterior, Middle superior alveolar NB.Infra-orbital NB.

45. 2012
22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.
Anterior, Middle superior alveolar NB.Infra-orbital NB.

46. Success rate of pulpal anesthesia after AMSA :
17% central incisors.
23% lateral incisors.
60% canine.
40% first premolar.
66% second premolar.
In activation of muscles of facial expression.
Lip numbness.[Trauma-inability for eating & drinking].
Disadvantages of infra orbital NB:
22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.
Anterior, Middle superior alveolar NB.Infra-orbital NB.

47. Central incisor
Lateral incisor
Premolars
canine
Anterior, Middle superior alveolar NB.Infra-orbital NB.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

48. Anterior, Middle superior alveolar NB.Infra-orbital NB.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

49. Computer Controlled Local Anesthetic Delivery Devices – CCLAD.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

50. Base unit consists of a microprocessor and connects to the foot
pedal and Hand piece assembly that accepts the LA cartridge. LA
solution from the cartridge passes through the micro bore tubing in
the Hand piece assembly and attached needle into the target tissue.
Computer Controlled Local Anesthetic Delivery Devices – CCLAD.
Base unit,
Foot pedal and
Disposable Hand piece.
The system has 3 components:
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

51. foot pedal controls the rate of injection and if aspiration feature is
enabled, it prevents inadvertent intravascular injections.
Slow: 0.005ml/s – needle insertion, PDL injection, Palatal
administration.
Fast: 0.03ml/s – buccal infiltrations, nerve block
Rate of Injection:
Computer Controlled Local Anesthetic Delivery Devices – CCLAD.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

52. 1-Painless injection:
Ability to administer small quantities of LA solution continuously during
needle insertion, which anesthetizes the tissue immediately ahead of the
advancing needle.
2-Less fear of injection.
Pressure anesthesia was more accepted and preferred by 70% of the patients
than traditional needle anesthesia (20%). Both needle and pressure anesthesia
was equally effective for carrying out the dental procedures.
3- Ability to perform newer techniques
such as palatal approach to anterior superior alveolar block.
Advantages of CCLADs: The benefits of these devices is
attributed to
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

53. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

54. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

55. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

56. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

57. Intra-oral techniques
Extra-oral technique
2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

58. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

59. 2/22/2017 7:17 PM
Atef Fouda, Prof. of Oral and
maxillofac.Surg. & Local Anesthesia.

60. 2/22/2017 7:17 PM
Atef Fouda, Prof. of Oral and
maxillofac.Surg. & Local Anesthesia.

61. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

62. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

63. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

64. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

65. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

66. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

67. 22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.
Ultrasound-guided
nerve block

68. 2/22/2017 7:17 PM Atef Fouda, Prof. of Oral and maxillofac.Surg. & Local Anesthesia.

69. Proper nerve visualization:
"Ultrasound guidance enables us to see the nerve and to
direct the needle to the nerve and avoid other structures
the needle as it is being advanced in real-time.
Ultrasound Guidance Improves Anesthesia
" Such visualization also
reduces the likelihood of the
needle hitting another
anatomical structure such as
blood vessels.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

70. Ability to see anesthetic spread:
With ultrasound guidance, the anesthesiologist can see the spread
of the local anesthetic as it is occurring. "You get instant feedback
showing that you are surrounding the specific nerve with local
anesthetic.
Ultrasound Guidance Improves Anesthesia
Proper directioning of the needle:
This benefit also allows the
anesthesiologist to withdraw and reinsert
the needle as necessary to reach nerve
roots that may not have been bathed in
anesthetic during the first application.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

71. Faster onset and longer duration: of anesthetic effect:
Because the anesthesiologist can direct the anesthetic to the target
nerve, the desired anesthetic effect begins sooner and lasts longer.
Ultrasound Guidance Improves Anesthesia
Use of less anesthetic
solution:
Because the target nerve can be
accessed more quickly and
specifically, the anesthesiologist
can achieve sufficient blockage of a
nerve using less local anesthetic.
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

72. SUMMARY
The three main nerves of the face – Trigeminal– can easily be
blocked.
Using ultrasound-guidance is recommended.
Circling the nerve with local anaesthetic gives the greatest chance
of block success.
Ultrasound Guidance Improves Anesthesia
22 February 2017 Atef Fouda, Prof. of Oral and maxillofacial Surg. New trends on Local Anesthesia.

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