Dr.RehabElsharkawyBDS,MS,Ph.D.

y , ,
LecturerofOral&MaxillofacialSurgery FacultyofOral&DentalMedicineCairoUniversity

Anesthesia: itmeansthecompletelossofall
sensationsincludingthatofpain. sensations including that of pain
Local anesthesia: loss of sensation in a circumscribed area of th b d caused b i ib d f the body d by depression of excitation in nerve endings or an inhibition of conduction process in peripheral nerves
General anesthesia: it is a condition in which the patient does not react to any stimulus and does not have any memory of what has happened (unconscious).

Indicationsoflocalanesthesia:
Elimination of pain during treatment (painless dentistry). d ti t ) Diagnostic purposes for vague pain in and a ou d t e ace a d ec around the face and neck. To reduce hemorrhage (e.g. during surgery under general anesthesia). Control of pain in the post operative period.

Nothing that is done by a dentist for a patient is of g p g greater importance than the administration of a drug that prevents pain during dental treatment. Yet the act of administrating a local anesthetic frequently induces great anxiety or is associated with pain in the recipient recipient. Not only can the injection of LA produce fear or pain pain, it also may be a factor in the occurrence of emergency medical situations.

LAadministrationshouldnotbepainful LAadministrationshouldnotbepainful. Therearetwocomponentstoanatraumatic injection:acommunicative andatechnical aspect.

An injection may be routine for the dentist, but it is often an unpleasant experience for the p patient. Psychological support, y g pp , is essential, and will increase the patient`s confidence in his dentist.

Duringneedleinsertion. Duringneedlewithdrawal. g Duringsoln deposition.

General principles involved in injection procedures d

1. 2.

3.

Use a sterilized sharp needle needle. Check the flow of the local anesthetic solution. solution Use anesthetic cartridge and syringe with temperature as close to room temperature as possible.

4. Proper positioning of the patient.

Comfort to the patient p

Tight fitting garments may partially obstruct the flow of blood in the head and neck area. A blouse or shirt collar should be loosened to avoid this. this.

5. Dry the site of injection and remove any debris to obtain adequate visibility.

6 Apply topical antiseptic 6. antiseptic.

pp y p g 7. Apply the topical anesthetic agent (ointment or spray). Ointment is better as spray tend to taste
badly and it is difficult to be restricted.

8. Always communicate with the patient . using reassuring words and praise. praise. Never leave the patient alone after an injection. injection. Allergic or other reactions may occur instantaneously at any time. time.

9 Always establish a firm hand rest during 9. the injection procedure.

10 Stretch the tissue at the site of needle 10. penetration in areas with loose soft tissue. This allows the needle to penetrate with p less resistance.

11. Keep the syringe out of the patients sight as much as possible.

12 Slowly advance the needle through the 12. mucosa to desired target. 13. Always aspirate prior to deposition of the drug.

1ml/minute at least). Observe the patient during j injection. 15. Slowly withdraw the syringe. Cap the needle and discard. 16. 16 Never leave patients unattended following administration of local anesthetic. 17. Record the injection in the patients chart. 7 j p

i h local anesthetic solution.(e.g. l h i l i ( 14.Sl l d Slowly deposit the l

Basicinjectiontech

Topical anesthesia
In this method the free nerve endings, in an accessible structures as the skin and mucous membrane , are rendered incapable of stimulation by applying chemical ointment or solution which penetrates through the epithelium to reach the free nerve endings.

Infiltration Anesthesia
In local infiltration small terminal nerve endings in the area of the surgery are flooded di i th f th fl d d with local anesthetic solution, rendering them insensible to pain. p

Fi ld block Field bl k
The field block method of securing regional anesthesia consists of depositing a solution in proximity to the larger terminal nerve branches so that the area to be g anaesthetized is walled off or circumscribed to prevent the central passage of afferent impulses.

Nerve block Nerveblock

The term nerve block applies to that method of securing regional anesthesia by depositing a suitable local anesthetic solution within close proximity to a main nerve trunk, and thus p preventing afferent impulses from traveling g p g centrally beyond that point.

Themethodsofaccomplishingfieldblock andlocalinfiltrationare: and local infiltration are:

1. 2. 3. 4. 5.

Submucosal injections Paraperiosteal injections (infiltration) Intraosseous injections Intraseptal i j ti I t t l injections Intraligamentary injections (periodontal ligament, ligament PDL)

Advantages of nerve block anesthesia as compared with infiltration:

1. More profound anesthesia 2. Longer duration 3. No local ischemic effect from the vasoconstrictor

agent is present. Good blood supply helps quicker healing and less postoperative pain. 4. Fewer needle punctures 5. If infection is present, the possibility of infection dissemination by the infiltration needle is prevented 6. Large field of operation by the use of few volume of anesthetic solutions, thus decrease the chance for development of drug toxicity.

Factors that influence the choice of Factorsthatinfluencethechoiceof q theanaesthetic technique:

1. 2. 3. 4. 5. 6. 7. 7 8.

Area to be anaesthetized Profoundness required q Duration of anesthesia Presence of infection Age of the patient Condition of the patient Hemostasis, if needed H t i d d Skill of the operator.

Anesthesia of the upper jaw

TechniquesofMaxillaryAnesthesia q f y
. Supraperiosteal(Infiltration)technique. t at o ) tec que. 1. Sup ape ostea ( 2.Greater(anterior)palatinenerve. 3 3.Nasopalatinenerveblock. p 4.MiddleandAnteriorSuperioralveolar(AMSA, Infraorbital)nerveblock. 5.PosteriorSuperiorAlveolar(PSA)nerveblock. 6.Maxillarynerveblock.

Supraperiosteal Injection Para periosteal or local p infiltration

Technique 2527 gauge short needle. Lift the lip pulling the tissues taut. Hold the syringe parallel to the long axis of the tooth. Orient needle so bevel faces bone. Insert the needle in the area at the height of mucobuccal fold above the root apex.(Target area) Advance the needle until the bevel is at the apex. Aspirate then deposit o.6ml slowly over 20 sec.(dont permit the tissues to sec.(don t balloon). Slowly withdraw the needle. Wait for 35 min before starting the 35 procedure.

When contact is made with the bone, a slow injection of solution will effect anesthesia of the target teeth, and one, or both, of the adjacent teeth.

The injection of the solution will ensure adequate analgesia of the tooth pulp in this area. The area of soft tissue anesthesia corresponds to the coloured zone.

Spread of analgesia

Premolars

The Th premolars of th upper j l f the jaw are anaesthetized by infiltration in the buccal fold next to the teeth. After puncture, the needle is advanced axially.

Molars

Buccal I filt ti Infiltration

A 25gauge ( h ) needle is used. (short) dl d The point of insertion of the needle is located by the point of intersection of two imaginary lines. First is a vertical line parallel with the long axis of the tooth and dividing it into two equal halves. Second is a horizontal line made by the mucobuccal fold just above the apex of the root root. The needle should be directed at 45 degree angle to the plane of the outer cortical plate.

BuccalInfiltration
The needle is inserted through the mucous membrane and underlying connective tissue until it gently come in contact with the p periosteum with the bevel facing the bone. g

PalatalInfiltration a ata t at o

The p point of insertion of the needle is on the p palatal side of the tooth, midway between the cervical margin of the tooth and h d b h l f h h d the midline of the palate. The needle should be at right angel with the palate (it should be d b advanced f d from the opposite side), 0.2 to 0.3 ml. of the h i id ) l f h anesthetic solution is injected slowly. NB. Injection of large amount of the solution may cause sloughing and ulceration of th palatal mucosa d l hi d l ti f the l t l due t to separation of a large area of the dense palatal mucoperiosteum from the bone with subsequent loss of its blood supply.

Spread of analgesia

Teeth and bone, and soft tissue anesthesia after buccal fold injection of 1.0ml solution. After additional infiltration of the palatine nerves by injection at the palatal side.

To anaesthetize the palatal gingiva and mucosa in the premolar/molar region, insert the needle 0.51 cm above the gingival margin between second and third molars and at right angles to the mucosa. mucosa When the needle reaches bone withdraw it 1mm and inject about o.1 ml. slowly.

The infraorbital nerve block

The center of the inferior margin of the orbit is palpated with the index finger, then gently passed 1cm below the margin.

The upper lip is lifted with the index. The needle is introduced into the buccal fold directly over the first premolar. The needle is gently pushed forward near to the bone towards the tip of the index finger. Aspiration is performed. About 1ml of solution is slowly injected.

The injection of 1ml at the infraorbital foramen will anaesthetize the teeth and bone within the colored area. area

Posterior Superior Alveolar Nerve PosteriorSuperiorAlveolarNerve Block(PSA)

Indications: 1. When Supraperiosteal injection is contraindicated e.g. infection. i f i 2. When treatment involves two or more maxillary molars. molars Contraindications: When there is a risk of hemorrhage.

PosteriorSuperiorAlveolarNerveBlock p (PSA)
Technique: Technique A 25gauge long needle is recommended. The left index i moved over the Th l f i d is d h mucobuccal fold in a posterior direction from the premolar region till it reaches the zygomatic process till it rests on a concavity in the mucobuccal fold. The finger is rotated so that fingernail faces medially. Then the finger is moved to be at right angle to the maxillary occlusal plane and at 45 y p 45 angle to the sagittal plane.

PosteriorSuperiorAlveolarNerveBlock (PSA)
The needle is inserted into the height of mucobuccal fold over the second molar in a line parallel to the finger finger. The needle is slowly advanced for about 16 mm, to come close to the posterior alveolar f i l l foramen. Aspiration should be done carefully to avoid the pterygoid venous plexus. Slowly inject 0.9 to 1.8 ml of solution over one minute. l i i

Posterior Superior Alveolar Nerve Block PosteriorSuperiorAlveolarNerveBlock (PSA)

Complications: 1. Hematomaformation. 1 Hematomaformation 2. Intravenousinjection Prevention: 1. Theneedleshouldneverbeinsertedmorethan 2.5cmtoavoidpenetrationand/orinjectionofthe 5 p / j pterygoid venousplexus. 2. Aspirationbeforeinjection.