Dental Anesthesia
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May 03, 2012
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About This Presentation
A simple Dental Guide on How to perform Dental Anesthesia
Slide Content
Local Anesthesia Techniques in Local Anesthesia Techniques in
Oral and Maxillofacial Surgery Oral and Maxillofacial Surgery
Sean M. Healy, D.D.S. Sean M. Healy, D.D.S.
Oral and Maxillofacial Surgery Oral and Maxillofacial Surgery Francis B. Quinn, M.D. Francis B. Quinn, M.D.
Otolaryngology Otolaryngology
––
Head and Neck Surgery Head and Neck Surgery
University of Texas Medical Branch University of Texas Medical Branch
October 2004 October 2004
Oral and Maxillofacial Surgery Oral and Maxillofacial Surgery
Sean M. Healy, D.D.S. Sean M. Healy, D.D.S.
Oral and Maxillofacial Surgery Oral and Maxillofacial Surgery Francis B. Quinn, M.D. Francis B. Quinn, M.D.
Otolaryngology Otolaryngology
––
Head and Neck Surgery Head and Neck Surgery
University of Texas Medical Branch University of Texas Medical Branch
October 2004 October 2004
Overview: Overview: ••
Purpose of local anesthesia Purpose of local anesthesia
••
Anatomy of maxillary and mandibular Anatomy of maxillary and mandibular nervous innervation nervous innervation
••
Techniques of local anesthesia blocks Techniques of local anesthesia blocks
••
Commonly used local anesthetics Commonly used local anesthetics
••
Complications with local anesthesia Complications with local anesthesia
Purpose of local anesthesia Purpose of local anesthesia
••
Anatomy of maxillary and mandibular Anatomy of maxillary and mandibular nervous innervation nervous innervation
••
Techniques of local anesthesia blocks Techniques of local anesthesia blocks
••
Commonly used local anesthetics Commonly used local anesthetics
••
Complications with local anesthesia Complications with local anesthesia
Local Anesthetics: Local Anesthetics: ••
Role: Role:
––
Decrease intraoperative and postoperative Decrease intraoperative and postoperative painpain
––
Decrease amount of general anesthetics used Decrease amount of general anesthetics used in the OR in the OR
––
Increase patients cooperation Increase patients cooperation
––
Diagnostic testing/examination Diagnostic testing/examination
Role: Role:
––
Decrease intraoperative and postoperative Decrease intraoperative and postoperative painpain
––
Decrease amount of general anesthetics used Decrease amount of general anesthetics used in the OR in the OR
––
Increase patients cooperation Increase patients cooperation
––
Diagnostic testing/examination Diagnostic testing/examination
Anatomical considerations: Anatomical considerations: ••
Trigeminal nerve: Trigeminal nerve:
––
Sensory divisions: Sensory divisions:
••
Ophthalmic division V1 Ophthalmic division V1
••
Maxillary division V2 Maxillary division V2
••
Mandibular div
isio
n
V3
Mandibular div
isio
n
V3
––
Motor division: Motor division:
••
Ma
sticatory
Ma
sticatory
--
masseter, temporalis, medial and lateral masseter, temporalis, medial and lateral
pterygoids pterygoids
••
Mylohyoid Mylohyoid
••
Anterior belly of the digastric Anterior belly of the digastric
••
Tensor tympani Tensor tympani
••
Tensor veli palatin
i
Tensor veli palatin
i
Trigeminal nerve: Trigeminal nerve:
––
Sensory divisions: Sensory divisions:
••
Ophthalmic division V1 Ophthalmic division V1
••
Maxillary division V2 Maxillary division V2
••
Mandibular div
isio
n
V3
Mandibular div
isio
n
V3
––
Motor division: Motor division:
••
Ma
sticatory
Ma
sticatory
--
masseter, temporalis, medial and lateral masseter, temporalis, medial and lateral
pterygoids pterygoids
••
Mylohyoid Mylohyoid
••
Anterior belly of the digastric Anterior belly of the digastric
••
Tensor tympani Tensor tympani
••
Tensor veli palatin
i
Tensor veli palatin
i
Maxillary Division (V2): Maxillary Division (V2): ••
Exits the cranium via foramen rotundum of the Exits the cranium via foramen rotundum of the greater wing of the sphenoid greater wing of the sphenoid
••
Travels at the superior most aspect of the Travels at the superior most aspect of the pterygopalatine fossa just posterior to the pterygopalatine fossa just posterior to the maxilla maxilla
••
Branches divided by location: Branches divided by location:
––
Inter Inter
--
cranial cranial
––
Pterygopalatine Pterygopalatine
––
Infraorbital Infraorbital
––
Facial Facial
Exits the cranium via foramen rotundum of the Exits the cranium via foramen rotundum of the greater wing of the sphenoid greater wing of the sphenoid
••
Travels at the superior most aspect of the Travels at the superior most aspect of the pterygopalatine fossa just posterior to the pterygopalatine fossa just posterior to the maxilla maxilla
••
Branches divided by location: Branches divided by location:
––
Inter Inter
--
cranial cranial
––
Pterygopalatine Pterygopalatine
––
Infraorbital Infraorbital
––
Facial Facial
Maxillary Division (V2): Maxillary Division (V2): ••
Branches: Branches:
––
Within the cranium Within the cranium
--
middle meningeal nerve middle meningeal nerve
providing sensory innervation to the dura providing sensory innervation to the dura mater mater
––
Within the pterygopalatine fossa Within the pterygopalatine fossa
--
••
Zygomatic nerve Zygomatic nerve
••
Pterygopalatine nerves Pterygopalatine nerves
••
Posterior superior alveolar nerve Posterior superior alveolar nerve
Branches: Branches:
––
Within the cranium Within the cranium
--
middle meningeal nerve middle meningeal nerve
providing sensory innervation to the dura providing sensory innervation to the dura mater mater
––
Within the pterygopalatine fossa Within the pterygopalatine fossa
--
••
Zygomatic nerve Zygomatic nerve
••
Pterygopalatine nerves Pterygopalatine nerves
••
Posterior superior alveolar nerve Posterior superior alveolar nerve
Maxillary Division (V2): Maxillary Division (V2): ••
Within the pterygopalatine fossa Within the pterygopalatine fossa
--
––
Zygomatic nerve: Zygomatic nerve:
••
Zygomaticofacial nerve Zygomaticofacial nerve
--
skin to cheek prominence skin to cheek prominence
••
Zygomaticotemporal nerve Zygomaticotemporal nerve
--
skin to lateral forehead skin to lateral forehead
––
Pterygopalatine nerves: Pterygopalatine nerves:
••
Serves as communication for the pterygopalatine Serves as communication for the pterygopalatine ganglion and the maxillary nerve ganglion and the maxillary nerve
••
Carries postganglionic secretomotor fibers through Carries postganglionic secretomotor fibers through the zygomatic branch to the lacrimal gland the zygomatic branch to the lacrimal gland
Within the pterygopalatine fossa Within the pterygopalatine fossa
--
––
Zygomatic nerve: Zygomatic nerve:
••
Zygomaticofacial nerve Zygomaticofacial nerve
--
skin to cheek prominence skin to cheek prominence
••
Zygomaticotemporal nerve Zygomaticotemporal nerve
--
skin to lateral forehead skin to lateral forehead
––
Pterygopalatine nerves: Pterygopalatine nerves:
••
Serves as communication for the pterygopalatine Serves as communication for the pterygopalatine ganglion and the maxillary nerve ganglion and the maxillary nerve
••
Carries postganglionic secretomotor fibers through Carries postganglionic secretomotor fibers through the zygomatic branch to the lacrimal gland the zygomatic branch to the lacrimal gland
Maxillary Division (V2): Maxillary Division (V2): ••
Within the pterygopalatine fossa Within the pterygopalatine fossa
--
––
Pterygopalatine nerves: Pterygopalatine nerves:
••
Orbital branches Orbital branches
--
supplies periosteum of the orbits supplies periosteum of the orbits
••
Nasal branches Nasal branches
--
supplies mucous membranes of supplies mucous membranes of
superior and middle conchae, lining of posterior superior and middle conchae, lining of posterior ethmoid sinuses, and posterior nasal septum. ethmoid sinuses, and posterior nasal septum.
––
Nasopalatine nerve Nasopalatine nerve
--
travels across the roof of nasal travels across the roof of nasal
cavity giving branches off to the anterior nasal septum cavity giving branches off to the anterior nasal septum and floor of nose. Enters incisive foramen and provides and floor of nose. Enters incisive foramen and provides palatal gingival innervation to the premaxilla palatal gingival innervation to the premaxilla
Within the pterygopalatine fossa Within the pterygopalatine fossa
--
––
Pterygopalatine nerves: Pterygopalatine nerves:
••
Orbital branches Orbital branches
--
supplies periosteum of the orbits supplies periosteum of the orbits
••
Nasal branches Nasal branches
--
supplies mucous membranes of supplies mucous membranes of
superior and middle conchae, lining of posterior superior and middle conchae, lining of posterior ethmoid sinuses, and posterior nasal septum. ethmoid sinuses, and posterior nasal septum.
––
Nasopalatine nerve Nasopalatine nerve
--
travels across the roof of nasal travels across the roof of nasal
cavity giving branches off to the anterior nasal septum cavity giving branches off to the anterior nasal septum and floor of nose. Enters incisive foramen and provides and floor of nose. Enters incisive foramen and provides palatal gingival innervation to the premaxilla palatal gingival innervation to the premaxilla
Maxillary Division (V2): Maxillary Division (V2): ••
Within the pterygopalatine fossa Within the pterygopalatine fossa
--
––
Pterygopalatine nerves: Pterygopalatine nerves:
••
Palatine branches Palatine branches
--
greater (anterior) and lesser greater (anterior) and lesser
(middle or posterior) palatine nerves (middle or posterior) palatine nerves
––
Greater palatine: travels through the pterygopalatine Greater palatine: travels through the pterygopalatine canal and enters the palate via t
h
e greater palatine
canal and enters the palate via t
h
e greater palatine
foramen. Innervates palatal tissue from premolars to foramen. Innervates palatal tissue from premolars to soft palate. Lies 1cm medial from 2 soft palate. Lies 1cm medial from 2
ndnd
molar region molar region
––
Lesser palatine: emerges from lesser palatine foramen Lesser palatine: emerges from lesser palatine foramen and innervates the mucous membranes of the soft palate and innervates the mucous membranes of the soft palate and parts of t
h
e tonsillar region
and parts of t
h
e tonsillar region
Within the pterygopalatine fossa Within the pterygopalatine fossa
--
––
Pterygopalatine nerves: Pterygopalatine nerves:
••
Palatine branches Palatine branches
--
greater (anterior) and lesser greater (anterior) and lesser
(middle or posterior) palatine nerves (middle or posterior) palatine nerves
––
Greater palatine: travels through the pterygopalatine Greater palatine: travels through the pterygopalatine canal and enters the palate via t
h
e greater palatine
canal and enters the palate via t
h
e greater palatine
foramen. Innervates palatal tissue from premolars to foramen. Innervates palatal tissue from premolars to soft palate. Lies 1cm medial from 2 soft palate. Lies 1cm medial from 2
ndnd
molar region molar region
––
Lesser palatine: emerges from lesser palatine foramen Lesser palatine: emerges from lesser palatine foramen and innervates the mucous membranes of the soft palate and innervates the mucous membranes of the soft palate and parts of t
h
e tonsillar region
and parts of t
h
e tonsillar region
Maxillary Division (V2): Maxillary Division (V2): ••
Within the pterygopalatine fossa Within the pterygopalatine fossa
--
––
Pterygopalatine nerves: Pterygopalatine nerves:
••
Pharyngeal branch Pharyngeal branch
--
exits the pterygopalatine exits the pterygopalatine
ganglion and travels through the pharyngeal canal. ganglion and travels through the pharyngeal canal. Innervates mucosa of the portions of the nasal Innervates mucosa of the portions of the nasal pharynx pharynx
••
Posterior superior alveolar nerve (PSA): branches Posterior superior alveolar nerve (PSA): branches from V2 prior to entrance into infraorbital groove. from V2 prior to entrance into infraorbital groove. Innervates posterior maxillary alveolus, periodontal Innervates posterior maxillary alveolus, periodontal ligament, buccal gingiva, and pulpal tissue (only ligament, buccal gingiva, and pulpal tissue (only for 1 for 1
stst
, 2, 2
ndnd
, and 3 , and 3
rdrd
molars) molars)
Within the pterygopalatine fossa Within the pterygopalatine fossa
--
––
Pterygopalatine nerves: Pterygopalatine nerves:
••
Pharyngeal branch Pharyngeal branch
--
exits the pterygopalatine exits the pterygopalatine
ganglion and travels through the pharyngeal canal. ganglion and travels through the pharyngeal canal. Innervates mucosa of the portions of the nasal Innervates mucosa of the portions of the nasal pharynx pharynx
••
Posterior superior alveolar nerve (PSA): branches Posterior superior alveolar nerve (PSA): branches from V2 prior to entrance into infraorbital groove. from V2 prior to entrance into infraorbital groove. Innervates posterior maxillary alveolus, periodontal Innervates posterior maxillary alveolus, periodontal ligament, buccal gingiva, and pulpal tissue (only ligament, buccal gingiva, and pulpal tissue (only for 1 for 1
stst
, 2, 2
ndnd
, and 3 , and 3
rdrd
molars) molars)
Maxillary Division (V2): Maxillary Division (V2): ••
Infraorbital canal branches: Infraorbital canal branches:
––
Middle superior alveolar (MSA): Middle superior alveolar (MSA):
••
Provides innervation to the maxillary alveolus, Provides innervation to the maxillary alveolus, buccal gingiva, periodontal ligament, and pulpal buccal gingiva, periodontal ligament, and pulpal tissue for the premolars only tissue for the premolars only
––
Anterior superior alveolar (ASA): Anterior superior alveolar (ASA):
••
Provides innervation to the maxillary alveolus, Provides innervation to the maxillary alveolus, buccal gingiva, periodontal ligament, and pulpal buccal gingiva, periodontal ligament, and pulpal tissue for the canines, lateral and central incisors tissue for the canines, lateral and central incisors
••
Branches 6 Branches 6
--
8mm posterior to the infraorbital nerve 8mm posterior to the infraorbital nerve
exit from infraorbital foramen exit from infraorbital foramen
Infraorbital canal branches: Infraorbital canal branches:
––
Middle superior alveolar (MSA): Middle superior alveolar (MSA):
••
Provides innervation to the maxillary alveolus, Provides innervation to the maxillary alveolus, buccal gingiva, periodontal ligament, and pulpal buccal gingiva, periodontal ligament, and pulpal tissue for the premolars only tissue for the premolars only
––
Anterior superior alveolar (ASA): Anterior superior alveolar (ASA):
••
Provides innervation to the maxillary alveolus, Provides innervation to the maxillary alveolus, buccal gingiva, periodontal ligament, and pulpal buccal gingiva, periodontal ligament, and pulpal tissue for the canines, lateral and central incisors tissue for the canines, lateral and central incisors
••
Branches 6 Branches 6
--
8mm posterior to the infraorbital nerve 8mm posterior to the infraorbital nerve
exit from infraorbital foramen exit from infraorbital foramen
Maxillary Division (V2): Maxillary Division (V2): ••
Facial branches: Facial branches:
––
Emerges from the infraorbital foramen Emerges from the infraorbital foramen
––
Branches consist of: Branches consist of:
••
Inferior palpebral Inferior palpebral
--
lower eyelid lower eyelid
••
External nasal External nasal
--
lateral skin of nose lateral skin of nose
••
Superior labial branch Superior labial branch
--
upper lip skin and mucosa upper lip skin and mucosa
Facial branches: Facial branches:
––
Emerges from the infraorbital foramen Emerges from the infraorbital foramen
––
Branches consist of: Branches consist of:
••
Inferior palpebral Inferior palpebral
--
lower eyelid lower eyelid
••
External nasal External nasal
--
lateral skin of nose lateral skin of nose
••
Superior labial branch Superior labial branch
--
upper lip skin and mucosa upper lip skin and mucosa
Mandibular division (V3): Mandibular division (V3): ••
Largest branch of the trigeminal nerve Largest branch of the trigeminal nerve
••
Composed of sensory and motor roots Composed of sensory and motor roots
••
Sensory root: Sensory root:
––
Originates at inferior border of trigeminal ganglion Originates at inferior border of trigeminal ganglion
••
Motor root: Motor root:
––
Arises in motor cells located in the pons and medulla Arises in motor cells located in the pons and medulla
––
Lies medial to the sensory root Lies medial to the sensory root
Largest branch of the trigeminal nerve Largest branch of the trigeminal nerve
••
Composed of sensory and motor roots Composed of sensory and motor roots
••
Sensory root: Sensory root:
––
Originates at inferior border of trigeminal ganglion Originates at inferior border of trigeminal ganglion
••
Motor root: Motor root:
––
Arises in motor cells located in the pons and medulla Arises in motor cells located in the pons and medulla
––
Lies medial to the sensory root Lies medial to the sensory root
Mandibular division (V3): Mandibular division (V3): ••
Branches: Branches:
––
The sensory and motor roots emerge from The sensory and motor roots emerge from the foramen ovale of the greater wing of the the foramen ovale of the greater wing of the sphenoid sphenoid
––
Initially merge outside of the skull and divide Initially merge outside of the skull and divide about 2 about 2
--
3mm inferiorly 3mm inferiorly
––
Branches: Branches:
••
Branches of the undivided nerve Branches of the undivided nerve
••
Branches of the anterior division Branches of the anterior division
••
Branches of the posterior division Branches of the posterior division
Branches: Branches:
––
The sensory and motor roots emerge from The sensory and motor roots emerge from the foramen ovale of the greater wing of the the foramen ovale of the greater wing of the sphenoid sphenoid
––
Initially merge outside of the skull and divide Initially merge outside of the skull and divide about 2 about 2
--
3mm inferiorly 3mm inferiorly
––
Branches: Branches:
••
Branches of the undivided nerve Branches of the undivided nerve
••
Branches of the anterior division Branches of the anterior division
••
Branches of the posterior division Branches of the posterior division
Mandibular division (V3): Mandibular division (V3): ••
Branches of the undivided nerve: Branches of the undivided nerve:
––
Nervus spinosus Nervus spinosus
--
innervates mastoids and innervates mastoids and
duradura
––
Medial pterygoid Medial pterygoid
--
innervates medial pterygoid innervates medial pterygoid
muscle muscle
••
Branches into Branches into
––
Tensor veli palatin
i
Tensor veli palatin
i
––
Tensor tympani Tensor tympani
Branches of the undivided nerve: Branches of the undivided nerve:
––
Nervus spinosus Nervus spinosus
--
innervates mastoids and innervates mastoids and
duradura
––
Medial pterygoid Medial pterygoid
--
innervates medial pterygoid innervates medial pterygoid
muscle muscle
••
Branches into Branches into
––
Tensor veli palatin
i
Tensor veli palatin
i
––
Tensor tympani Tensor tympani
Mandibular division (V3): Mandibular division (V3): ••
Branches of the anterior division: Branches of the anterior division:
––
Buccal nerve (long buccal and buccinator): Buccal nerve (long buccal and buccinator):
••
Travels anteriorly and lateral to the lateral Travels anteriorly and lateral to the lateral pterygoid muscle pterygoid muscle
••
Gives branches to the deep temporal (temporalis Gives branches to the deep temporal (temporalis muscle), masseter, and lateral pterygoid muscle muscle), masseter, and lateral pterygoid muscle
Branches of the anterior division: Branches of the anterior division:
––
Buccal nerve (long buccal and buccinator): Buccal nerve (long buccal and buccinator):
••
Travels anteriorly and lateral to the lateral Travels anteriorly and lateral to the lateral pterygoid muscle pterygoid muscle
••
Gives branches to the deep temporal (temporalis Gives branches to the deep temporal (temporalis muscle), masseter, and lateral pterygoid muscle muscle), masseter, and lateral pterygoid muscle
Mandibular division (V3): Mandibular division (V3): ••
Branches of the anterior division: Branches of the anterior division:
––
Buccal nerve (long buccal and buccinator): Buccal nerve (long buccal and buccinator):
••
Continues to travel in antero Continues to travel in antero
--
lateral direction lateral direction
••
At level of the mandibular 3 At level of the mandibular 3
rdrd
molar, branches exit molar, branches exit
through the buccinator and provide innervation to through the buccinator and provide innervation to the skin of the cheek the skin of the cheek
••
Branches also stay within the retromandibular Branches also stay within the retromandibular triangle providing sensory innervation to the buccal triangle providing sensory innervation to the buccal gingiva of the mandibular molars and buccal gingiva of the mandibular molars and buccal vestibule vestibule
Branches of the anterior division: Branches of the anterior division:
––
Buccal nerve (long buccal and buccinator): Buccal nerve (long buccal and buccinator):
••
Continues to travel in antero Continues to travel in antero
--
lateral direction lateral direction
••
At level of the mandibular 3 At level of the mandibular 3
rdrd
molar, branches exit molar, branches exit
through the buccinator and provide innervation to through the buccinator and provide innervation to the skin of the cheek the skin of the cheek
••
Branches also stay within the retromandibular Branches also stay within the retromandibular triangle providing sensory innervation to the buccal triangle providing sensory innervation to the buccal gingiva of the mandibular molars and buccal gingiva of the mandibular molars and buccal vestibule vestibule
Mandibular division (V3): Mandibular division (V3): ••
Branches of the posterior division: Branches of the posterior division:
––
Travels inferior and medial to the lateral Travels inferior and medial to the lateral pterygoid pterygoid
••
Divisions: Divisions:
––
Auriculotemporal Auriculotemporal
––
Lingual Lingual
––
Inferior alveolar Inferior alveolar
Branches of the posterior division: Branches of the posterior division:
––
Travels inferior and medial to the lateral Travels inferior and medial to the lateral pterygoid pterygoid
••
Divisions: Divisions:
––
Auriculotemporal Auriculotemporal
––
Lingual Lingual
––
Inferior alveolar Inferior alveolar
Mandibular division (V3): Mandibular division (V3): ••
Branches of the posterior division: Branches of the posterior division:
––
Auriculotemporal: all sensory Auriculotemporal: all sensory
••
Transverses the upper part of the parotid gland Transverses the upper part of the parotid gland and posterior portion of the zygomatic arch and posterior portion of the zygomatic arch
••
Branches: Branches:
––
Communicates with facial nerve to provide sensory Communicates with facial nerve to provide sensory innervation to the skin over areas of the zygomatic, innervation to the skin over areas of the zygomatic, buccal, and mandibular buccal, and mandibular
––
Communicates with the otic ganglion for sensory, Communicates with the otic ganglion for sensory, secretory, and vasomotor fibers to the parotid secretory, and vasomotor fibers to the parotid
Branches of the posterior division: Branches of the posterior division:
––
Auriculotemporal: all sensory Auriculotemporal: all sensory
••
Transverses the upper part of the parotid gland Transverses the upper part of the parotid gland and posterior portion of the zygomatic arch and posterior portion of the zygomatic arch
••
Branches: Branches:
––
Communicates with facial nerve to provide sensory Communicates with facial nerve to provide sensory innervation to the skin over areas of the zygomatic, innervation to the skin over areas of the zygomatic, buccal, and mandibular buccal, and mandibular
––
Communicates with the otic ganglion for sensory, Communicates with the otic ganglion for sensory, secretory, and vasomotor fibers to the parotid secretory, and vasomotor fibers to the parotid
Mandibular division (V3): Mandibular division (V3): ••
Branches of the posterior division: Branches of the posterior division:
––
Auriculotemporal: all sensory Auriculotemporal: all sensory
••
Branches: Branches:
––
Anterior auricular Anterior auricular
--
skin over helix and tragus skin over helix and tragus
––
External auditory meatus External auditory meatus
--
skin over meatus and skin over meatus and
tympanic membrane tympanic membrane
––
Articular Articular
--
posterior TMJ posterior TMJ
––
Superficial temporal Superficial temporal
--
skin over temporal region skin over temporal region
Branches of the posterior division: Branches of the posterior division:
––
Auriculotemporal: all sensory Auriculotemporal: all sensory
••
Branches: Branches:
––
Anterior auricular Anterior auricular
--
skin over helix and tragus skin over helix and tragus
––
External auditory meatus External auditory meatus
--
skin over meatus and skin over meatus and
tympanic membrane tympanic membrane
––
Articular Articular
--
posterior TMJ posterior TMJ
––
Superficial temporal Superficial temporal
--
skin over temporal region skin over temporal region
Mandibular division (V3): Mandibular division (V3): ••
Branches of the posterior division: Branches of the posterior division:
––
Lingual: Lingual:
••
Lies between ramus and medial pterygoid within Lies between ramus and medial pterygoid within the pterygomandibular raphe the pterygomandibular raphe
••
Lies inferior and medial to the mandibular 3 Lies inferior and medial to the mandibular 3
rdrd
molar alveolus molar alveolus
••
Provides sensation to anterior 2/3rds of tongue, Provides sensation to anterior 2/3rds of tongue, lingual gingiva, floor of mouth mucosa, and lingual gingiva, floor of mouth mucosa, and gustation (chorda tympani) gustation (chorda tympani)
Branches of the posterior division: Branches of the posterior division:
––
Lingual: Lingual:
••
Lies between ramus and medial pterygoid within Lies between ramus and medial pterygoid within the pterygomandibular raphe the pterygomandibular raphe
••
Lies inferior and medial to the mandibular 3 Lies inferior and medial to the mandibular 3
rdrd
molar alveolus molar alveolus
••
Provides sensation to anterior 2/3rds of tongue, Provides sensation to anterior 2/3rds of tongue, lingual gingiva, floor of mouth mucosa, and lingual gingiva, floor of mouth mucosa, and gustation (chorda tympani) gustation (chorda tympani)
Mandibular division (V3): Mandibular division (V3): ••
Branches of the posterior division: Branches of the posterior division:
––
Inferior alveolar: Inferior alveolar:
••
Travels medial to the lateral pterygoid and latero Travels medial to the lateral pterygoid and latero
--
posterior to the lingual nerve posterior to the lingual nerve
••
Enters mandible at the lingula Enters mandible at the lingula
••
Accompanied by the inferior alveolar artery and Accompanied by the inferior alveolar artery and vein (artery anterior to nerve) vein (artery anterior to nerve)
••
Travels within the inferior alveolar canal until the Travels within the inferior alveolar canal until the mental foramen mental foramen
••
Mylohyoid nerve Mylohyoid nerve
--
motor branch prior to entry into motor branch prior to entry into
lingula lingula
Branches of the posterior division: Branches of the posterior division:
––
Inferior alveolar: Inferior alveolar:
••
Travels medial to the lateral pterygoid and latero Travels medial to the lateral pterygoid and latero
--
posterior to the lingual nerve posterior to the lingual nerve
••
Enters mandible at the lingula Enters mandible at the lingula
••
Accompanied by the inferior alveolar artery and Accompanied by the inferior alveolar artery and vein (artery anterior to nerve) vein (artery anterior to nerve)
••
Travels within the inferior alveolar canal until the Travels within the inferior alveolar canal until the mental foramen mental foramen
••
Mylohyoid nerve Mylohyoid nerve
--
motor branch prior to entry into motor branch prior to entry into
lingula lingula
Mandibular division (V3): Mandibular division (V3): ••
Branches of the posterior division: Branches of the posterior division:
––
Inferior alveolar: Inferior alveolar:
••
Provides innervation to the mandibular alveolus, Provides innervation to the mandibular alveolus, buccal gingiva from premolar teeth buccal gingiva from premolar teeth
anteriorly anteriorly
, and , and
the the
pulpa
l
pulpa
l
tissue of all tissue of all
mandibular mandibular
teeth on side teeth on side
blocked blocked
••
Terminal branches Terminal branches
––
Incisive nerve Incisive nerve
--
remains within inferior alveolar canal remains within inferior alveolar canal
from mental foramen to midline from mental foramen to midline
––
Mental nerve Mental nerve
--
exits mental foramen and divides into 3 exits mental foramen and divides into 3
branches to innervate the skin
of the chin, lower lip and
branches to innervate the skin
of the chin, lower lip and
labial mucosa labial mucosa
Branches of the posterior division: Branches of the posterior division:
––
Inferior alveolar: Inferior alveolar:
••
Provides innervation to the mandibular alveolus, Provides innervation to the mandibular alveolus, buccal gingiva from premolar teeth buccal gingiva from premolar teeth
anteriorly anteriorly
, and , and
the the
pulpa
l
pulpa
l
tissue of all tissue of all
mandibular mandibular
teeth on side teeth on side
blocked blocked
••
Terminal branches Terminal branches
––
Incisive nerve Incisive nerve
--
remains within inferior alveolar canal remains within inferior alveolar canal
from mental foramen to midline from mental foramen to midline
––
Mental nerve Mental nerve
--
exits mental foramen and divides into 3 exits mental foramen and divides into 3
branches to innervate the skin
of the chin, lower lip and
branches to innervate the skin
of the chin, lower lip and
labial mucosa labial mucosa
Local anesthetic instruments: Local anesthetic instruments: ••
Anesthetic Anesthetic
carpules carpules
••
Syringe Syringe
••
Needle Needle
••
Mouth props Mouth props
••
Retractors Retractors
Anesthetic Anesthetic
carpules carpules
••
Syringe Syringe
••
Needle Needle
••
Mouth props Mouth props
••
Retractors Retractors
Local anesthetic instruments: Local anesthetic instruments: ••
Carpules Carpules
::
––
1.7 or 1.8cc 1.7 or 1.8cc
––
PrePre
--
made in blister made in blister
packs or canisters packs or canisters
––
Contains preservatives Contains preservatives for epinephrine and for epinephrine and local anesthetics local anesthetics
Carpules Carpules
::
––
1.7 or 1.8cc 1.7 or 1.8cc
––
PrePre
--
made in blister made in blister
packs or canisters packs or canisters
––
Contains preservatives Contains preservatives for epinephrine and for epinephrine and local anesthetics local anesthetics
Local anesthetic instruments: Local anesthetic instruments: ••
Syringe Syringe
––
Aspirating type Aspirating type
––
NonNon
--
aspirating type aspirating type
Syringe Syringe
––
Aspirating type Aspirating type
––
NonNon
--
aspirating type aspirating type
Local anesthetic instruments: Local anesthetic instruments: ••
Needle: Needle:
––
Multiple gauges used Multiple gauges used
••
25g25g
••
27g *used at
UTMB
27g *used at
UTMB
••
30g30g
––
Length: Length:
••
Short Short
--
26mm26mm
••
LongLong
--
36mm *used at 36mm *used at
UTMBUTMB
––
Monobeveled Monobeveled
Needle: Needle:
––
Multiple gauges used Multiple gauges used
••
25g25g
••
27g *used at
UTMB
27g *used at
UTMB
••
30g30g
––
Length: Length:
••
Short Short
--
26mm26mm
••
LongLong
--
36mm *used at 36mm *used at
UTMBUTMB
––
Monobeveled Monobeveled
Local anesthetic instruments: Local anesthetic instruments: ••
Topical anesthetic: Topical anesthetic:
––
Used prior to local Used prior to local anesthetic injection to anesthetic injection to decrease discomfort in decrease discomfort in nonnon
--
sedated patients sedated patients
––
Generally Generally
benzocaine benzocaine
(20%) (20%)
Topical anesthetic: Topical anesthetic:
––
Used prior to local Used prior to local anesthetic injection to anesthetic injection to decrease discomfort in decrease discomfort in nonnon
--
sedated patients sedated patients
––
Generally Generally
benzocaine benzocaine
(20%) (20%)
Local anesthetic instruments: Local anesthetic instruments:
Maxillary anesthesia: Maxillary anesthesia: ••
3 major types of injections can be 3 major types of injections can be performed in the maxilla for pain control performed in the maxilla for pain control
––
Local infiltration Local infiltration
––
Field block Field block
––
Nerve block Nerve block
3 major types of injections can be 3 major types of injections can be performed in the maxilla for pain control performed in the maxilla for pain control
––
Local infiltration Local infiltration
––
Field block Field block
––
Nerve block Nerve block
Maxillary anesthesia: Maxillary anesthesia: ••
Infiltration: Infiltration:
––
Able to be performed in the maxilla due to the Able to be performed in the maxilla due to the thin cortical nature of the bone thin cortical nature of the bone
––
Involves injecting to tissue immediately Involves injecting to tissue immediately around surgical site around surgical site
••
Supraperiosteal injections Supraperiosteal injections
••
Intraseptal injections Intraseptal injections
••
Periodontal ligament injections Periodontal ligament injections
Infiltration: Infiltration:
––
Able to be performed in the maxilla due to the Able to be performed in the maxilla due to the thin cortical nature of the bone thin cortical nature of the bone
––
Involves injecting to tissue immediately Involves injecting to tissue immediately around surgical site around surgical site
••
Supraperiosteal injections Supraperiosteal injections
••
Intraseptal injections Intraseptal injections
••
Periodontal ligament injections Periodontal ligament injections
Maxillary anesthesia: Maxillary anesthesia: ••
Field blocks: Field blocks:
––
Local anesthetic deposited near a larger Local anesthetic deposited near a larger terminal branch of a nerve terminal branch of a nerve
••
Periapical injections Periapical injections
--
Field blocks: Field blocks:
––
Local anesthetic deposited near a larger Local anesthetic deposited near a larger terminal branch of a nerve terminal branch of a nerve
••
Periapical injections Periapical injections
--
Maxillary anesthesia: Maxillary anesthesia: ••
Nerve blocks: Nerve blocks:
––
Local anesthetic deposited near main nerve Local anesthetic deposited near main nerve trunk and is usually distant from operative trunk and is usually distant from operative sitesite
••
Posterior superior alveolar Posterior superior alveolar
--
Infraorbital Infraorbital
••
Middle superior alveolar Middle superior alveolar
--
Greater palatine Greater palatine
••
Anterior superior alveolar Anterior superior alveolar
--
Nasopalatine Nasopalatine
Nerve blocks: Nerve blocks:
––
Local anesthetic deposited near main nerve Local anesthetic deposited near main nerve trunk and is usually distant from operative trunk and is usually distant from operative sitesite
••
Posterior superior alveolar Posterior superior alveolar
--
Infraorbital Infraorbital
••
Middle superior alveolar Middle superior alveolar
--
Greater palatine Greater palatine
••
Anterior superior alveolar Anterior superior alveolar
--
Nasopalatine Nasopalatine
Maxillary anesthesia: Maxillary anesthesia: ••
Posterior superior alveolar nerve block: Posterior superior alveolar nerve block:
––
Used to anesthetize the Used to anesthetize the
pulpal pulpal
tissue, tissue,
corresponding alveolar bone, and corresponding alveolar bone, and
buccal buccal
gingival tissue to the maxillary 1 gingival tissue to the maxillary 1
stst
, 2, 2
ndnd
, and 3 , and 3
rdrd
molars. molars.
Posterior superior alveolar nerve block: Posterior superior alveolar nerve block:
––
Used to anesthetize the Used to anesthetize the
pulpal pulpal
tissue, tissue,
corresponding alveolar bone, and corresponding alveolar bone, and
buccal buccal
gingival tissue to the maxillary 1 gingival tissue to the maxillary 1
stst
, 2, 2
ndnd
, and 3 , and 3
rdrd
molars. molars.
Maxillary anesthesia: Maxillary anesthesia: ••
Posterior superior alveolar nerve block: Posterior superior alveolar nerve block:
––
Technique Technique
••
Area of insertion Area of insertion
--
height of mucobuccal fold height of mucobuccal fold
between 1 between 1
stst
and 2 and 2
ndnd
molar molar
••
Angle at 45° superiorly and medially Angle at 45° superiorly and medially
••
No resistance should be felt (if bony contact angle No resistance should be felt (if bony contact angle is to medial, reposition laterally) is to medial, reposition laterally)
••
Insert about 15 Insert about 15
--
20mm20mm
••
Aspirate then inject if negative Aspirate then inject if negative
Posterior superior alveolar nerve block: Posterior superior alveolar nerve block:
––
Technique Technique
••
Area of insertion Area of insertion
--
height of mucobuccal fold height of mucobuccal fold
between 1 between 1
stst
and 2 and 2
ndnd
molar molar
••
Angle at 45° superiorly and medially Angle at 45° superiorly and medially
••
No resistance should be felt (if bony contact angle No resistance should be felt (if bony contact angle is to medial, reposition laterally) is to medial, reposition laterally)
••
Insert about 15 Insert about 15
--
20mm20mm
••
Aspirate then inject if negative Aspirate then inject if negative
Maxillary anesthesia: Maxillary anesthesia: ••
Middle superior alveolar nerve block: Middle superior alveolar nerve block:
––
Used to anesthetize the maxillary premolars, Used to anesthetize the maxillary premolars, corresponding alveolus, and buccal gingival corresponding alveolus, and buccal gingival tissue tissue
––
Present in about 28% of the population Present in about 28% of the population
––
Used if the infraorbital block fails to Used if the infraorbital block fails to anesthetize premolars anesthetize premolars
Middle superior alveolar nerve block: Middle superior alveolar nerve block:
––
Used to anesthetize the maxillary premolars, Used to anesthetize the maxillary premolars, corresponding alveolus, and buccal gingival corresponding alveolus, and buccal gingival tissue tissue
––
Present in about 28% of the population Present in about 28% of the population
––
Used if the infraorbital block fails to Used if the infraorbital block fails to anesthetize premolars anesthetize premolars
Maxillary anesthesia: Maxillary anesthesia: ••
Middle superior alveolar nerve block: Middle superior alveolar nerve block:
––
Technique: Technique:
••
Area of insertion is height of mucobuccal fold in Area of insertion is height of mucobuccal fold in area of 1 area of 1
stst
/2/2
ndnd
premolars premolars
••
Insert around 10 Insert around 10
--
15mm15mm
••
Inject around 0.9 Inject around 0.9
--
1.2cc 1.2cc
Middle superior alveolar nerve block: Middle superior alveolar nerve block:
––
Technique: Technique:
••
Area of insertion is height of mucobuccal fold in Area of insertion is height of mucobuccal fold in area of 1 area of 1
stst
/2/2
ndnd
premolars premolars
••
Insert around 10 Insert around 10
--
15mm15mm
••
Inject around 0.9 Inject around 0.9
--
1.2cc 1.2cc
Maxillary anesthesia: Maxillary anesthesia: ••
Anterior superior alveolar nerve block: Anterior superior alveolar nerve block:
––
Used to anesthetize the maxillary canine, Used to anesthetize the maxillary canine, lateral incisor, central incisor, alveolus, and lateral incisor, central incisor, alveolus, and buccal gingiva buccal gingiva
Anterior superior alveolar nerve block: Anterior superior alveolar nerve block:
––
Used to anesthetize the maxillary canine, Used to anesthetize the maxillary canine, lateral incisor, central incisor, alveolus, and lateral incisor, central incisor, alveolus, and buccal gingiva buccal gingiva
Maxillary anesthesia: Maxillary anesthesia: ••
Anterior superior alveolar nerve block: Anterior superior alveolar nerve block:
––
Technique: Technique:
••
Area of insertion is height of mucobuccal fold in Area of insertion is height of mucobuccal fold in area of lateral incisor and canine area of lateral incisor and canine
••
Insert around 10 Insert around 10
--
15mm15mm
••
Inject around 0.9 Inject around 0.9
--
1.2cc 1.2cc
Anterior superior alveolar nerve block: Anterior superior alveolar nerve block:
––
Technique: Technique:
••
Area of insertion is height of mucobuccal fold in Area of insertion is height of mucobuccal fold in area of lateral incisor and canine area of lateral incisor and canine
••
Insert around 10 Insert around 10
--
15mm15mm
••
Inject around 0.9 Inject around 0.9
--
1.2cc 1.2cc
Maxillary anesthesia: Maxillary anesthesia: ••
Infraorbital nerve block: Infraorbital nerve block:
––
Used to anesthetize the maxillary 1 Used to anesthetize the maxillary 1
stst
and 2 and 2
ndnd
premolars, canine, lateral incisor, central premolars, canine, lateral incisor, central incisor, corresponding alveolar bone, and incisor, corresponding alveolar bone, and buccal buccal
gingiva gingiva
––
Combines MSA and ASA blocks Combines MSA and ASA blocks
––
Will also cause anesthesia to the lower eyelid, Will also cause anesthesia to the lower eyelid, lateral aspect of nasal skin tissue, and skin of lateral aspect of nasal skin tissue, and skin of infraorbital region infraorbital region
Infraorbital nerve block: Infraorbital nerve block:
––
Used to anesthetize the maxillary 1 Used to anesthetize the maxillary 1
stst
and 2 and 2
ndnd
premolars, canine, lateral incisor, central premolars, canine, lateral incisor, central incisor, corresponding alveolar bone, and incisor, corresponding alveolar bone, and buccal buccal
gingiva gingiva
––
Combines MSA and ASA blocks Combines MSA and ASA blocks
––
Will also cause anesthesia to the lower eyelid, Will also cause anesthesia to the lower eyelid, lateral aspect of nasal skin tissue, and skin of lateral aspect of nasal skin tissue, and skin of infraorbital region infraorbital region
Maxillary anesthesia: Maxillary anesthesia: ••
Infraorbital nerve block: Infraorbital nerve block:
––
Technique: Technique:
••
Palpate infraorbital foramen extra Palpate infraorbital foramen extra
--
orally and place orally and place
thumb or index finger on region thumb or index finger on region
••
Retract the upper lip and buccal mucosa Retract the upper lip and buccal mucosa
••
Area of insertion is the mucobuccal fold of the 1 Area of insertion is the mucobuccal fold of the 1
stst
premolar/canine area premolar/canine area
••
Contact bone in infraorbital region Contact bone in infraorbital region
••
Inject 0.9 Inject 0.9
--
1.2cc of local anesthetic 1.2cc of local anesthetic
Infraorbital nerve block: Infraorbital nerve block:
––
Technique: Technique:
••
Palpate infraorbital foramen extra Palpate infraorbital foramen extra
--
orally and place orally and place
thumb or index finger on region thumb or index finger on region
••
Retract the upper lip and buccal mucosa Retract the upper lip and buccal mucosa
••
Area of insertion is the mucobuccal fold of the 1 Area of insertion is the mucobuccal fold of the 1
stst
premolar/canine area premolar/canine area
••
Contact bone in infraorbital region Contact bone in infraorbital region
••
Inject 0.9 Inject 0.9
--
1.2cc of local anesthetic 1.2cc of local anesthetic
Maxillary anesthesia: Maxillary anesthesia: ••
Greater palatine nerve block: Greater palatine nerve block:
––
Can be used to anesthetize the palatal soft Can be used to anesthetize the palatal soft tissue of the teeth posterior to the maxillary tissue of the teeth posterior to the maxillary canine and corresponding alveolus/hard canine and corresponding alveolus/hard palate palate
Greater palatine nerve block: Greater palatine nerve block:
––
Can be used to anesthetize the palatal soft Can be used to anesthetize the palatal soft tissue of the teeth posterior to the maxillary tissue of the teeth posterior to the maxillary canine and corresponding alveolus/hard canine and corresponding alveolus/hard palate palate
Maxillary anesthesia: Maxillary anesthesia: ••
Greater palatine nerve block: Greater palatine nerve block:
––
Technique: Technique:
••
Area of insertion is ~1cm medial from 1 Area of insertion is ~1cm medial from 1
stst
/2/2
ndnd
maxillary molar on the hard palate maxillary molar on the hard palate
••
Palpate with needle to find greater palatine Palpate with needle to find greater palatine foramen foramen
••
Depth is usually less than 10mm Depth is usually less than 10mm
••
Utilize pressure with elevator/mirror handle to Utilize pressure with elevator/mirror handle to desensitize region at time of injection desensitize region at time of injection
••
Inject 0.3 Inject 0.3
--
0.5cc of local anesthetic 0.5cc of local anesthetic
Greater palatine nerve block: Greater palatine nerve block:
––
Technique: Technique:
••
Area of insertion is ~1cm medial from 1 Area of insertion is ~1cm medial from 1
stst
/2/2
ndnd
maxillary molar on the hard palate maxillary molar on the hard palate
••
Palpate with needle to find greater palatine Palpate with needle to find greater palatine foramen foramen
••
Depth is usually less than 10mm Depth is usually less than 10mm
••
Utilize pressure with elevator/mirror handle to Utilize pressure with elevator/mirror handle to desensitize region at time of injection desensitize region at time of injection
••
Inject 0.3 Inject 0.3
--
0.5cc of local anesthetic 0.5cc of local anesthetic
Maxillary anesthesia: Maxillary anesthesia: ••
Nasopalatine nerve block: Nasopalatine nerve block:
––
Can be used to anesthetize the soft and hard Can be used to anesthetize the soft and hard tissue of the maxillary anterior palate from tissue of the maxillary anterior palate from canine to canine canine to canine
Nasopalatine nerve block: Nasopalatine nerve block:
––
Can be used to anesthetize the soft and hard Can be used to anesthetize the soft and hard tissue of the maxillary anterior palate from tissue of the maxillary anterior palate from canine to canine canine to canine
Maxillary anesthesia: Maxillary anesthesia: ••
Nasopalatine nerve block: Nasopalatine nerve block:
––
Technique: Technique:
••
Area of insertion is incisive papilla into incisive Area of insertion is incisive papilla into incisive foramen foramen
••
Depth of penetration is less than 10mm Depth of penetration is less than 10mm
••
Inject 0.3 Inject 0.3
--
0.5cc of local anesthetic 0.5cc of local anesthetic
••
Can use pressure over area at time of injection to Can use pressure over area at time of injection to decrease pain decrease pain
Nasopalatine nerve block: Nasopalatine nerve block:
––
Technique: Technique:
••
Area of insertion is incisive papilla into incisive Area of insertion is incisive papilla into incisive foramen foramen
••
Depth of penetration is less than 10mm Depth of penetration is less than 10mm
••
Inject 0.3 Inject 0.3
--
0.5cc of local anesthetic 0.5cc of local anesthetic
••
Can use pressure over area at time of injection to Can use pressure over area at time of injection to decrease pain decrease pain
Maxillary anesthesia: Maxillary anesthesia: ••
Maxillary nerve block (V2 block): Maxillary nerve block (V2 block):
––
Can be used to anesthetize maxillary teeth, Can be used to anesthetize maxillary teeth, alveolus, hard and soft tissue on the palate, alveolus, hard and soft tissue on the palate, gingiva, and skin of the lower eyelid, lateral gingiva, and skin of the lower eyelid, lateral aspect of nose, cheek, and upper lip skin and aspect of nose, cheek, and upper lip skin and mucosa on side blocked mucosa on side blocked
Maxillary nerve block (V2 block): Maxillary nerve block (V2 block):
––
Can be used to anesthetize maxillary teeth, Can be used to anesthetize maxillary teeth, alveolus, hard and soft tissue on the palate, alveolus, hard and soft tissue on the palate, gingiva, and skin of the lower eyelid, lateral gingiva, and skin of the lower eyelid, lateral aspect of nose, cheek, and upper lip skin and aspect of nose, cheek, and upper lip skin and mucosa on side blocked mucosa on side blocked
Maxillary anesthesia: Maxillary anesthesia: ••
Maxillary nerve block (V2 block): Maxillary nerve block (V2 block):
––
Two techniques exist for blockade of V2 Two techniques exist for blockade of V2
••
High tuberosity approach High tuberosity approach
••
Greater palatine canal approach Greater palatine canal approach
Maxillary nerve block (V2 block): Maxillary nerve block (V2 block):
––
Two techniques exist for blockade of V2 Two techniques exist for blockade of V2
••
High tuberosity approach High tuberosity approach
••
Greater palatine canal approach Greater palatine canal approach
Maxillary anesthesia: Maxillary anesthesia: ••
Maxillary nerve block (V2 block): Maxillary nerve block (V2 block):
––
High tuberosity approach technique: High tuberosity approach technique:
••
Area of injection is height of mucobuccal fold of Area of injection is height of mucobuccal fold of maxillary 2 maxillary 2
ndnd
molar molar
••
Advance at 45° superior and medial same as in the Advance at 45° superior and medial same as in the PSA block PSA block
••
Insert needle ~30mm Insert needle ~30mm
••
Inject ~1.8cc of local anesthetic Inject ~1.8cc of local anesthetic
Maxillary nerve block (V2 block): Maxillary nerve block (V2 block):
––
High tuberosity approach technique: High tuberosity approach technique:
••
Area of injection is height of mucobuccal fold of Area of injection is height of mucobuccal fold of maxillary 2 maxillary 2
ndnd
molar molar
••
Advance at 45° superior and medial same as in the Advance at 45° superior and medial same as in the PSA block PSA block
••
Insert needle ~30mm Insert needle ~30mm
••
Inject ~1.8cc of local anesthetic Inject ~1.8cc of local anesthetic
Maxillary anesthesia: Maxillary anesthesia: ••
Maxillary nerve block (V2 block): Maxillary nerve block (V2 block):
––
Greater palatine canal technique: Greater palatine canal technique:
••
Area of insertion is greater palatine canal Area of insertion is greater palatine canal
••
Target area is the maxillary nerve in the Target area is the maxillary nerve in the pterygopalatine fossa pterygopalatine fossa
••
Perform a greater palatine block and wait 3 Perform a greater palatine block and wait 3
--
5 mins 5 mins
••
Then insert needle in previous area and walk into Then insert needle in previous area and walk into greater palatine foramen greater palatine foramen
••
Insert to depth of ~30mm Insert to depth of ~30mm
••
Inject 1.8cc of local anesthetic Inject 1.8cc of local anesthetic
Maxillary nerve block (V2 block): Maxillary nerve block (V2 block):
––
Greater palatine canal technique: Greater palatine canal technique:
••
Area of insertion is greater palatine canal Area of insertion is greater palatine canal
••
Target area is the maxillary nerve in the Target area is the maxillary nerve in the pterygopalatine fossa pterygopalatine fossa
••
Perform a greater palatine block and wait 3 Perform a greater palatine block and wait 3
--
5 mins 5 mins
••
Then insert needle in previous area and walk into Then insert needle in previous area and walk into greater palatine foramen greater palatine foramen
••
Insert to depth of ~30mm Insert to depth of ~30mm
••
Inject 1.8cc of local anesthetic Inject 1.8cc of local anesthetic
Mandibular anesthesia: Mandibular anesthesia: ••
Infiltration techniques do not work in the adult Infiltration techniques do not work in the adult mandible due to the dense cortical bone mandible due to the dense cortical bone
••
Nerve blocks are utilized to anesthetize the Nerve blocks are utilized to anesthetize the inferior alveolar, lingual, and buccal nerves inferior alveolar, lingual, and buccal nerves
••
Provides anesthesia to the pulpal, alveolar, Provides anesthesia to the pulpal, alveolar, lingual and buccal gingival tissue, and skin of lingual and buccal gingival tissue, and skin of lower lip and medial aspect of chin on side lower lip and medial aspect of chin on side injected injected
Infiltration techniques do not work in the adult Infiltration techniques do not work in the adult mandible due to the dense cortical bone mandible due to the dense cortical bone
••
Nerve blocks are utilized to anesthetize the Nerve blocks are utilized to anesthetize the inferior alveolar, lingual, and buccal nerves inferior alveolar, lingual, and buccal nerves
••
Provides anesthesia to the pulpal, alveolar, Provides anesthesia to the pulpal, alveolar, lingual and buccal gingival tissue, and skin of lingual and buccal gingival tissue, and skin of lower lip and medial aspect of chin on side lower lip and medial aspect of chin on side injected injected
Mandibular anesthesia: Mandibular anesthesia: ••
Inferior alveolar nerve block (IAN): Inferior alveolar nerve block (IAN):
––
Technique involves blocking the inferior Technique involves blocking the inferior alveolar nerve prior to entry into the alveolar nerve prior to entry into the mandibular lingula on the medial aspect of mandibular lingula on the medial aspect of the mandibular ramus the mandibular ramus
––
Multiple techniques can be used for the IAN Multiple techniques can be used for the IAN nerve block nerve block
••
IANIAN
••
Akinosi Akinosi
••
GowGow
--
Gates Gates
Inferior alveolar nerve block (IAN): Inferior alveolar nerve block (IAN):
––
Technique involves blocking the inferior Technique involves blocking the inferior alveolar nerve prior to entry into the alveolar nerve prior to entry into the mandibular lingula on the medial aspect of mandibular lingula on the medial aspect of the mandibular ramus the mandibular ramus
––
Multiple techniques can be used for the IAN Multiple techniques can be used for the IAN nerve block nerve block
••
IANIAN
••
Akinosi Akinosi
••
GowGow
--
Gates Gates
Mandibular anesthesia: Mandibular anesthesia: ••
Inferior alveolar nerve block (IAN): Inferior alveolar nerve block (IAN):
––
Technique: Technique:
••
Area of insertion is the mucous membrane on the Area of insertion is the mucous membrane on the medial border of the mandibular ramus at the medial border of the mandibular ramus at the intersection of a horizontal line (height of injection) intersection of a horizontal line (height of injection) and vertical line (anteroposterior plane) and vertical line (anteroposterior plane)
••
Height of injection Height of injection
--
66
--
10 mm above the occlusal 10 mm above the occlusal
table of the mandibular teeth table of the mandibular teeth
••
Anteroposterior plane Anteroposterior plane
--
just lateral to the just lateral to the
pterygomandibular raphe pterygomandibular raphe
Inferior alveolar nerve block (IAN): Inferior alveolar nerve block (IAN):
––
Technique: Technique:
••
Area of insertion is the mucous membrane on the Area of insertion is the mucous membrane on the medial border of the mandibular ramus at the medial border of the mandibular ramus at the intersection of a horizontal line (height of injection) intersection of a horizontal line (height of injection) and vertical line (anteroposterior plane) and vertical line (anteroposterior plane)
••
Height of injection Height of injection
--
66
--
10 mm above the occlusal 10 mm above the occlusal
table of the mandibular teeth table of the mandibular teeth
••
Anteroposterior plane Anteroposterior plane
--
just lateral to the just lateral to the
pterygomandibular raphe pterygomandibular raphe
Mandibular anesthesia: Mandibular anesthesia:
Mandibular anesthesia: Mandibular anesthesia:
Mandibular anesthesia: Mandibular anesthesia: Mandibular anesthesia: Mandibular anesthesia: ••
Inferior alveolar nerve block (IAN): Inferior alveolar nerve block (IAN):
––
Mouth must be open for this technique, best to utilize Mouth must be open for this technique, best to utilize mouth prop mouth prop
––
Depth of injection: 25mm Depth of injection: 25mm
––
Approach area of injection from contralateral Approach area of injection from contralateral premolar region premolar region
––
Use the non Use the non
--
dominant hand to retract the buccal soft dominant hand to retract the buccal soft
tissue (thumb in coronoid notch of mandible; index tissue (thumb in coronoid notch of mandible; index finger on posterior border of extraoral mandible) finger on posterior border of extraoral mandible)
Inferior alveolar nerve block (IAN): Inferior alveolar nerve block (IAN):
––
Mouth must be open for this technique, best to utilize Mouth must be open for this technique, best to utilize mouth prop mouth prop
––
Depth of injection: 25mm Depth of injection: 25mm
––
Approach area of injection from contralateral Approach area of injection from contralateral premolar region premolar region
––
Use the non Use the non
--
dominant hand to retract the buccal soft dominant hand to retract the buccal soft
tissue (thumb in coronoid notch of mandible; index tissue (thumb in coronoid notch of mandible; index finger on posterior border of extraoral mandible) finger on posterior border of extraoral mandible)
Mandibular anesthesia: Mandibular anesthesia: ••
Inferior alveolar nerve block (IAN): Inferior alveolar nerve block (IAN):
––
Inject ~0.5 Inject ~0.5
--
1.0cc of local anesthetic 1.0cc of local anesthetic
––
Continue to inject ~0.5cc on removal from Continue to inject ~0.5cc on removal from injection site to anesthetize the lingual branch injection site to anesthetize the lingual branch
––
Inject remaining anesthetic into coronoid Inject remaining anesthetic into coronoid notch region of the mandible in the mucous notch region of the mandible in the mucous membrane distal and buccal to most distal membrane distal and buccal to most distal molar to perform a long buccal nerve block molar to perform a long buccal nerve block
Inferior alveolar nerve block (IAN): Inferior alveolar nerve block (IAN):
––
Inject ~0.5 Inject ~0.5
--
1.0cc of local anesthetic 1.0cc of local anesthetic
––
Continue to inject ~0.5cc on removal from Continue to inject ~0.5cc on removal from injection site to anesthetize the lingual branch injection site to anesthetize the lingual branch
––
Inject remaining anesthetic into coronoid Inject remaining anesthetic into coronoid notch region of the mandible in the mucous notch region of the mandible in the mucous membrane distal and buccal to most distal membrane distal and buccal to most distal molar to perform a long buccal nerve block molar to perform a long buccal nerve block
Mandibular anesthesia: Mandibular anesthesia: ••
Akinosi closed Akinosi closed
--
mouth mandibular block: mouth mandibular block:
––
Useful technique for infected patients with Useful technique for infected patients with trismus, fractured mandibles, mentally trismus, fractured mandibles, mentally handicapped individuals, children handicapped individuals, children
––
Provides same areas of anesthesia as the IAN Provides same areas of anesthesia as the IAN nerve block nerve block
Akinosi closed Akinosi closed
--
mouth mandibular block: mouth mandibular block:
––
Useful technique for infected patients with Useful technique for infected patients with trismus, fractured mandibles, mentally trismus, fractured mandibles, mentally handicapped individuals, children handicapped individuals, children
––
Provides same areas of anesthesia as the IAN Provides same areas of anesthesia as the IAN nerve block nerve block
Mandibular anesthesia: Mandibular anesthesia: ••
Akinosi closed Akinosi closed
--
mouth mandibular block: mouth mandibular block:
––
Area of insertion: soft tissue overlying the Area of insertion: soft tissue overlying the medial border of the mandibular ramus medial border of the mandibular ramus directly adjacent to maxillary tuberosity directly adjacent to maxillary tuberosity
––
Inject to depth of 25mm Inject to depth of 25mm
––
Inject ~1.0 Inject ~1.0
--
1.5cc of local anesthetic as in the 1.5cc of local anesthetic as in the
IANIAN
––
Inject remaining anesthetic in area of long Inject remaining anesthetic in area of long buccal nerve buccal nerve
Akinosi closed Akinosi closed
--
mouth mandibular block: mouth mandibular block:
––
Area of insertion: soft tissue overlying the Area of insertion: soft tissue overlying the medial border of the mandibular ramus medial border of the mandibular ramus directly adjacent to maxillary tuberosity directly adjacent to maxillary tuberosity
––
Inject to depth of 25mm Inject to depth of 25mm
––
Inject ~1.0 Inject ~1.0
--
1.5cc of local anesthetic as in the 1.5cc of local anesthetic as in the
IANIAN
––
Inject remaining anesthetic in area of long Inject remaining anesthetic in area of long buccal nerve buccal nerve
Mandibular anesthesia: Mandibular anesthesia: ••
Mental nerve block: Mental nerve block:
––
Mental and incisive nerves are the terminal Mental and incisive nerves are the terminal branches for the inferior alveolar nerve branches for the inferior alveolar nerve
––
Provides sensory input for the lower lip skin, Provides sensory input for the lower lip skin, mucous membrane, pulpal/alveolar tissue for mucous membrane, pulpal/alveolar tissue for the premolars, canine, and incisors on side the premolars, canine, and incisors on side blocked blocked
Mental nerve block: Mental nerve block:
––
Mental and incisive nerves are the terminal Mental and incisive nerves are the terminal branches for the inferior alveolar nerve branches for the inferior alveolar nerve
––
Provides sensory input for the lower lip skin, Provides sensory input for the lower lip skin, mucous membrane, pulpal/alveolar tissue for mucous membrane, pulpal/alveolar tissue for the premolars, canine, and incisors on side the premolars, canine, and incisors on side blocked blocked
Mandibular anesthesia: Mandibular anesthesia: ••
Mental nerve block: Mental nerve block:
––
Technique: Technique:
••
Area of injection mucobuccal fold at or anterior to Area of injection mucobuccal fold at or anterior to the mental foramen. This lies between the the mental foramen. This lies between the mandibular premolars mandibular premolars
••
Depth of injection ~5 Depth of injection ~5
--
6mm6mm
••
Inject 0.5 Inject 0.5
--
1.0cc of local anesthesia 1.0cc of local anesthesia
••
Message local anesthesia into tissue to manipulate Message local anesthesia into tissue to manipulate into mental foramen to anesthetize the incisive into mental foramen to anesthetize the incisive branch branch
Mental nerve block: Mental nerve block:
––
Technique: Technique:
••
Area of injection mucobuccal fold at or anterior to Area of injection mucobuccal fold at or anterior to the mental foramen. This lies between the the mental foramen. This lies between the mandibular premolars mandibular premolars
••
Depth of injection ~5 Depth of injection ~5
--
6mm6mm
••
Inject 0.5 Inject 0.5
--
1.0cc of local anesthesia 1.0cc of local anesthesia
••
Message local anesthesia into tissue to manipulate Message local anesthesia into tissue to manipulate into mental foramen to anesthetize the incisive into mental foramen to anesthetize the incisive branch branch
Local anesthetics: Local anesthetics: ••
Types: Types:
––
Esters Esters
--
plasma plasma
pseudocholinesterase pseudocholinesterase
––
Amides Amides
--
liver enzymes liver enzymes
••
Duration of action: Duration of action:
––
Short Short
––
Medium Medium
––
LongLong
Types: Types:
––
Esters Esters
--
plasma plasma
pseudocholinesterase pseudocholinesterase
––
Amides Amides
--
liver enzymes liver enzymes
••
Duration of action: Duration of action:
––
Short Short
––
Medium Medium
––
LongLong
Local anesthetics: Local anesthetics:
••
Agent: Agent:
Dose: Dose:
Onset/Duration: Onset/Duration:
••
Lidocaine Lidocaine
with with
epiepi
(1 or 2%) (1 or 2%)
7mg/kg 7mg/kg
Fast/medium Fast/medium
••
Lidocaine Lidocaine
without without
epiepi
4.5mg/kg 4.5mg/kg
Fast/short Fast/short
••
Mepivacaine Mepivacaine
without without
epiepi
(3%)(3%)
5.5mg/kg 5.5mg/kg
Fast/short Fast/short
••
Bupivacaine Bupivacaine
with with
epiepi
(0.5%) (0.5%)
1.3mg/kg 1.3mg/kg
Long/long Long/long
••
Articaine Articaine
with with
epiepi
(4.0%) (4.0%)
7mg/kg 7mg/kg
Fast/medium Fast/medium
*ADUL
T
DOSES IN PATIENTS WITHOUT CARDIAC HISTORY
*ADUL
T
DOSES IN PATIENTS WITHOUT CARDIAC HISTORY
••
Agent: Agent:
Dose: Dose:
Onset/Duration: Onset/Duration:
••
Lidocaine Lidocaine
with with
epiepi
(1 or 2%) (1 or 2%)
7mg/kg 7mg/kg
Fast/medium Fast/medium
••
Lidocaine Lidocaine
without without
epiepi
4.5mg/kg 4.5mg/kg
Fast/short Fast/short
••
Mepivacaine Mepivacaine
without without
epiepi
(3%)(3%)
5.5mg/kg 5.5mg/kg
Fast/short Fast/short
••
Bupivacaine Bupivacaine
with with
epiepi
(0.5%) (0.5%)
1.3mg/kg 1.3mg/kg
Long/long Long/long
••
Articaine Articaine
with with
epiepi
(4.0%) (4.0%)
7mg/kg 7mg/kg
Fast/medium Fast/medium
*ADUL
T
DOSES IN PATIENTS WITHOUT CARDIAC HISTORY
*ADUL
T
DOSES IN PATIENTS WITHOUT CARDIAC HISTORY
Local anesthetics: Local anesthetics: ••
Dosing considerations: Dosing considerations:
––
Patient with cardiac history: Patient with cardiac history:
••
Should limit dose of epinephrine to 0.04mg Should limit dose of epinephrine to 0.04mg
••
Most local anesthesia uses 1:100,000 epinephrine Most local anesthesia uses 1:100,000 epinephrine concentration (0.01mg/ml) concentration (0.01mg/ml)
––
Pediatric dosing: Pediatric dosing:
••
Clark’s rule: Clark’s rule:
––
Maximum dose=(weight child in lbs/150) X max adult dose Maximum dose=(weight child in lbs/150) X max adult dose (mg)(mg)
••
Simple method= 1.8cc of 2% lidocaine/20lbs Simple method= 1.8cc of 2% lidocaine/20lbs
Dosing considerations: Dosing considerations:
––
Patient with cardiac history: Patient with cardiac history:
••
Should limit dose of epinephrine to 0.04mg Should limit dose of epinephrine to 0.04mg
••
Most local anesthesia uses 1:100,000 epinephrine Most local anesthesia uses 1:100,000 epinephrine concentration (0.01mg/ml) concentration (0.01mg/ml)
––
Pediatric dosing: Pediatric dosing:
••
Clark’s rule: Clark’s rule:
––
Maximum dose=(weight child in lbs/150) X max adult dose Maximum dose=(weight child in lbs/150) X max adult dose (mg)(mg)
••
Simple method= 1.8cc of 2% lidocaine/20lbs Simple method= 1.8cc of 2% lidocaine/20lbs
Local anesthesia complications: Local anesthesia complications: ••
Needle breakage Needle breakage
••
Pain on injection Pain on injection
••
Burning on injection Burning on injection
••
Persistent anesthesia/parathesia Persistent anesthesia/parathesia
••
Trismus Trismus
••
Hematoma Hematoma
••
Infection Infection
Needle breakage Needle breakage
••
Pain on injection Pain on injection
••
Burning on injection Burning on injection
••
Persistent anesthesia/parathesia Persistent anesthesia/parathesia
••
Trismus Trismus
••
Hematoma Hematoma
••
Infection Infection
Local anesthesia complications: Local anesthesia complications: ••
Edema Edema
••
Tissue sloughing Tissue sloughing
••
Facial nerve paralysis Facial nerve paralysis
••
PostPost
--
anesthetic intraoral lesion anesthetic intraoral lesion
––
Herpes simplex Herpes simplex
––
Recurrent aphthous stomatitis Recurrent aphthous stomatitis
Edema Edema
••
Tissue sloughing Tissue sloughing
••
Facial nerve paralysis Facial nerve paralysis
••
PostPost
--
anesthetic intraoral lesion anesthetic intraoral lesion
––
Herpes simplex Herpes simplex
––
Recurrent aphthous stomatitis Recurrent aphthous stomatitis
Local anesthesia complications: Local anesthesia complications: ••
Toxicity Toxicity
––
Clinical manifestations Clinical manifestations
••
Fear/anxiety Fear/anxiety
••
Restlessness Restlessness
••
Throbbing headaches Throbbing headaches
••
Tremors Tremors
••
Weakness Weakness
••
Dizzines
s
Dizzines
s
••
Pallor Pallor
••
Re
spiratory difficulty/palpitation
s
Re
spiratory difficulty/palpitation
s
••
Tachycardia ( Tachycardia (
PVCsPVCs
, V, V
--
tac
h
tac
h
, V, V
--
fib)fib)
Toxicity Toxicity
––
Clinical manifestations Clinical manifestations
••
Fear/anxiety Fear/anxiety
••
Restlessness Restlessness
••
Throbbing headaches Throbbing headaches
••
Tremors Tremors
••
Weakness Weakness
••
Dizzines
s
Dizzines
s
••
Pallor Pallor
••
Re
spiratory difficulty/palpitation
s
Re
spiratory difficulty/palpitation
s
••
Tachycardia ( Tachycardia (
PVCsPVCs
, V, V
--
tac
h
tac
h
, V, V
--
fib)fib)
Local anesthesia complications: Local anesthesia complications: ••
Allergic reaction: Allergic reaction:
––
More common with ester based local More common with ester based local anesthetics anesthetics
––
Most allergies are to preservatives in pre Most allergies are to preservatives in pre
--
made local anesthetic carpules made local anesthetic carpules
••
Methylparaben Methylparaben
••
Sodium bisulfite Sodium bisulfite
••
metabisulfite metabisulfite
Allergic reaction: Allergic reaction:
––
More common with ester based local More common with ester based local anesthetics anesthetics
––
Most allergies are to preservatives in pre Most allergies are to preservatives in pre
--
made local anesthetic carpules made local anesthetic carpules
••
Methylparaben Methylparaben
••
Sodium bisulfite Sodium bisulfite
••
metabisulfite metabisulfite
References: References: ••
Evers, H and Haegerstam, G. Evers, H and Haegerstam, G.
Handbook Handbook
of Dental Local Anesthesia of Dental Local Anesthesia
. Schultz . Schultz
Medical Information. London. 1981. Medical Information. London. 1981.
••
Malamed, S. Handbook of Local Malamed, S. Handbook of Local Anesthesia. 3 Anesthesia. 3
rdrd
edition. Mosby. St. Louis. edition. Mosby. St. Louis.
1990. 1990.
••
Netter, F. Netter, F.
Atlas of Human Anatomy Atlas of Human Anatomy
. .
CIBA. 1989. CIBA. 1989.
Evers, H and Haegerstam, G. Evers, H and Haegerstam, G.
Handbook Handbook
of Dental Local Anesthesia of Dental Local Anesthesia
. Schultz . Schultz
Medical Information. London. 1981. Medical Information. London. 1981.
••
Malamed, S. Handbook of Local Malamed, S. Handbook of Local Anesthesia. 3 Anesthesia. 3
rdrd
edition. Mosby. St. Louis. edition. Mosby. St. Louis.
1990. 1990.
••
Netter, F. Netter, F.
Atlas of Human Anatomy Atlas of Human Anatomy
. .
CIBA. 1989. CIBA. 1989.
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