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Reminder
§ The trigeminal nerve is the largest of the cranial nerves. It has both motor
and sensory components
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Figure of trigeminal nerve
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Reminder
§ The ophthalmic nerve carries sensory information from the scalp and
forehead, the upper eyelid, the conjunctiva and cornea of the eye, the
nose (including the tip of the nose), the nasal mucosa, the frontal sinuses,
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Reminder : The maxillary nerve
§ The maxillary nerve carries sensory information from the lower eyelid
and cheek, the nares and upper lip, the upper teeth and gums, the nasal
mucosa, the palate and roof of the pharynx, the maxillary, ethmoid and
sphenoid sinuses, and parts of the meninges.
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Reminder; The maxillary nerve
§ The maxillary nerve continues into the infraorbital canal as the infraorbital
nerve.
§ The zygomatic nerve emerges and branches into its two major terminal
branches, the zygomaticofacial and zygomaticotemporal nerves, which
innervate the lateral cheek and side of the forehead, respectively.
§ As it projects anteriorly, the infraorbital nerve gives off the anterior and
middle superior alveolar nerves, innervating the upper teeth. It then exits
the canal through the infraorbital foramen to innervate the upper lip,
cheek and side of the nose.
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Reminder : Mandibular nerve
§ The mandibular nerve carries sensory information from the lower lip, the
lower teeth and gums, the chin and jaw (except the angle of the jaw,
which is supplied by C2-C3), parts of the external ear, and parts of the
meninges.
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Reminder : Mandibular nerve
§ The buccal nerve innervates the mucosa of the mouth and gums.
§ The lingual nerve provides general sensation to the anterior 2/3 of the
tongue.
§ The inferior alveolar nerve enters the mandibular canal through the
mandibular foramen to innervate the lower teeth and gums. Its terminal
branch exits the mental foramen as the mental nerve, innervating the chin
and lower lip.
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Tools
§ Dental Syringe
§ Dental Needles
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Tools
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Local anesthetic cartridge color codes
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Indications
§ Parenteral local anesthetics are used for infiltration and nerve block
anesthesia.
§ Because of variation in systemic absorption and toxicity, the ideal choice
of local anesthetic and concentration depends on the intended procedure.
– Infiltration anesthesia is often used for minor surgical and dental procedures.
– Nerve block anesthesia is used for surgical, dental, and diagnostic procedures and for pain management
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nerve block anesthesia
Mandible
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IDB (inferior alveolar block)
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IDB (inferior alveolar block)
Technique
§ The patient's mouth must be widely open.
§ Palpate the landmarks of external and internal oblique ridges and note the
line of the ptyerygomandibular raphe.
§ With the palpating thumb lying in the retromolar fossa, the needle should
be inserted at the midpoint of the tip of the thumb slightly above the
occlusal plane lateral to the ptyerygomandibular raphe.
§ The needle is inserted ~0.5 cm and if a lingual nerve block is required 0.5
ml of LA is injected at this point.
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IDB (inferior alveolar block)
Technique
§ The syringe is then moved horizontally across the dorsum of the tongue
and advanced to make contact with the lingula.
§ Once bony contact is made the needle is withdrawn slightly and the
remainder of the LA injected.
§ It should never be necessary to insert the needle up to the hub.
§ Note that the mandibular foramen varies in position with age. In the
edentulous, the foramen, and hence the point of needle insertion, is
relatively higher than in the dentate.
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Nerve to
mylohyoid
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Additional Block (higher injection)
§ Why : the standard block often fails to anesthetize branches of cranial
nerve V3 that originate proximal to the injection site and provide accessory
innervation to the mandibular teeth. The relatively distal location of the
injection also leads to lack of anesthesia of soft tissues posterior to the
mental foramen. That why a higher injection site technique are proposed
§ Gaw-Gates Technique
§ Akinosi Technique
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Gow-Gates Technique
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Efficacy of the Gow-Gates Technique
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Akinosi Technique
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SCENE
5
A •Onset is more
ki
no rapid
si •Less effective
•More accepted
by patients
•Pain to Go .
puncture more w
than Akinosi Ga
te
•More Effective s
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Mental nerve block
§ Mental nerve block The mental nerve emerges from the mental foramen
lying apical to and between the first and second mandibular premolars.
§ LA injected in this region will diffuse in through the mental foramen and
provide limited analgesia of premolars and canine, and to a lesser degree
incisors on that side. It will provide effective soft-tissue analgesia.
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Mental nerve block
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Buccal Nerve Block
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Buccal Nerve Block
(Continue)
§ The needle is inserted in the mucous membrane distal buccal to the last
molar
§ Insert the needle to 2 to 4 mm to gently contact bone, and aspirate. If
negative, slowly deposit about 1/8 of the solution in the cartridge.
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Sublingual nerve block
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nerve block anesthesia
Maxilla
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Nasopalatine block anaesthesia
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Infra-orbital block
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Anterior Middle Superior Alveolar Block
§ If the infraorbital nerve block does not provide adequate anesthesia to the
teeth distal of the canine or if the PSA injection does not provide
anesthesia for the mesiobuccal root of the first molar, an MSA block
injection should be administered.
§ A 25 gauge short needle is recommended with insertion in the
mucobuccal fold by the maxillary second premolar.
§ About 1/2 to 2/3 of a cartridge of anesthetic is slowly deposited at the
height of the apex of the second premolar after negative aspiration
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Anterior Middle Superior Alveolar Block (continue)
§ One injection site - Central to second premolar, palatal and buccal soft
tissue
§ Is used to anesthetize pulp tissue and facial periodontium of the maxillary
premolars and the mesiobuccal root of the first molar in some cases.
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Posterior superior alveolar block
§ The posterior superior alveolar (PSA) nerve block is a commonly used
technique for achieving anesthesia for the maxillary molars
§ Posterior superior alveolar block A rarely indicated technique.
§ The short 25 or 27 gauge needle is recommended to decrease the risk of
a hematoma
§ Needle is inserted distal to the upper second molar and advanced
inwards, backwards, and upwards close to bone for ~2 cm.
§ LA is deposited high above the tuberosity after aspirating to avoid the
ptyerygoid plexus
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Greater Palatine Nerve Block
§ The greater palatine nerve innervates the palatal tissues and bone distal
of the canine on the side anesthetized.
§ Use a 27 gauge short needle with the bevel toward the palate.
§ Palpate the palate until the depression of the foramen is felt (usually
somewhere medial to the second molar).
§ Dry the tissue, and apply antiseptic and topical anesthetic for 2 minutes.
Apply pressure with the swab for 30 seconds.
§ Continue pressure with the swab until the injection is completed.
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Greater Palatine Nerve Block
(Continue)
§ Place the bevel against the tissue and apply pressure enough to slightly
bow the needle.
§ Inject a few drops of anesthetic.
§ Release the pressure of the needle and advance the tip of the needle into
the tissue slightly.
§ Continue with this procedure of applying pressure to the bevel and
depositing a few drops of anesthetic, then advancing, until the needle is in
contact with the palatal bone.
§ Deposit less than a fourth to a third of a cartridge of anesthetic after
negative aspiration is proven
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Maxillary Nerve Block
§ The maxillary (V2) nerve innervates half of the maxilla, including the
buccal and palatal aspects.
§ This injection technique is used especially in quadrant surgery or when
extensive treatment is indicated for a single appointment.
§ It is also used when another site of injection has failed or if there is an
infection in the area
§ his technique is used more with adult patients. It is not for the
inexperienced.
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Maxillary Nerve Block
(continue)
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local infiltrations
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Infiltrations
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Infiltrations
Administrative techniques
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Infiltrations
Administrative techniques (Continue)
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Infiltration in Mandible
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Adjunctive Strategies for Infiltration
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Adjunctive Strategies
§ PDL Injection
§ Sub-periosteal injection
§ Intraosseous Injection
§ Intrapulpal Injection
§ Intraseptal Injection
§ Different anaesthetic
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PDL Injection
§ Technique:
– needle inserted into the gingival sulcus at a 30 degree angle towards the tooth
– bevel placed towards bone
– advanced until resistance felt
– anaestheticinjected with continuous force for about 15 seconds.
– approx. 0.2 mL of solution
– 25 vs. 30 gauge needle
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PDL Injection
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PDL Injection: Primary Technique
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PDL Injection: Supplemental Technique
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PDL Injection: Anaesthetic Distribution
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PDL Injection: Effects on the Periodontium
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Adjunctive Strategies
§ PDL Injection
§ Sub-periosteal injection
§ Intraosseous Injection
§ Intrapulpal Injection
§ Intraseptal Injection
§ Different anaesthetic
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Sub-periosteal injection
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Adjunctive Strategies
§ PDL Injection
§ Sub-periosteal injection
§ Intraosseous Injection
§ Intrapulpal Injection
§ Intraseptal Injection
§ Different anaesthetic
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Intraosseous Injection
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Stabident
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Stabident
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Stabident
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Stabident
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X-Tip
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Adjunctive Strategies
§ PDL Injection
§ Sub-periosteal injection
§ Intraosseous Injection
§ Intrapulpal Injection
§ Intraseptal Injection
§ Different anaesthetic
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Intrapulpal Anaesthesia
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Intrapulpal Anaesthesia
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Adjunctive Strategies
§ PDL Injection
§ Sub-periosteal injection
§ Intraosseous Injection
§ Intrapulpal Injection
§ Intraseptal Injection
§ Different anaesthetic
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Intraseptal Injection
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Adjunctive Strategies
§ PDL Injection
§ Sub-periosteal injection
§ Intraosseous Injection
§ Intrapulpal Injection
§ Intraseptal Injection
§ Different anaesthetic
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Articaine
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Adjunctive Strategies
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Topical Anaesthetic
§ Benzocaine or Lidocaine
§ Effectiveness?
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Topical Anaesthetic
§ Recommendations:
– Dry mucous membranes first
– 2-3 minutes, but concern with tissue sloughing
– Tip of the tongue
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Topical Anaesthetic
§ Benzocaine Spray
§ RCDSO Dispatch 21, 1, Feb/Mar 2007 pp.28-29
– Advice to Dentists
– Benzocaine Sprays and Methemoglobinemia (MHb)
• Health Canada—9 suspected cases, none fatal
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Topical Anaesthetic
§ Benzocaine spray/Methemoglobinemia
§ Recommendations:
– Avoid in patients with a history of MHb
– Consider lidocaine as an alternative
– Broken/inflamed tissue may promote uptake
– Use only amount deemed necessary
– If suspicious, send patient to hospital for methylene blue tx
– O2 won’t help, but give it anyways
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Dr Iyad Abou Rabii
Iyad.abou.rabii@qudent.edu.sa
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