DEPT.

OF ORAL &MAXILLOFACIAL SURGERY

Presented By Dr Haneef

 History

Armamentarium
Definition &Classification Composition

Different Agents , Vasoconstrictors

Mechanism of Action Bio Transformation

Systemic Action

 Ancient time dental treatment associated with pain

Earliest pain relief Coca shrub mood elevator
Incas

Cocoa shrub foot hills of Andes

Introduced by Europeans to South America Cocaine

 1855 Gaedicke extracted alkaloid Erythroxylin

1860 Dr. Scherzer cocaine from this alkaloid

1844 Francis Rynd (Dublin)
Acetate of morphine + Creosote Skin incision TGN treatment First time liquid used - intradermally

1884 marks birth of LA

 Sigmund Freud Carl Koller

Cocaine for eye operation

William Steward Halsted

Cocaine for inferior dental nerve

1886 BDJ William Alfred Hunt et al

Cocaine - dental anesthetic documented

1901 E Mayers
Vasoconstrictor + cocaine

 1905
13 lives claimed addiction
A Einhorn & E Uhlfelder(Sweden) Synthesized Procaine hydrochloride Procaine sterilizable, non-additive, non-toxic

1943
N Lofgren(Sweden) Synthesized Anilide called Lignocaine Lignocaine amide linked synthetic derivative

 1946 Lignocaine introduced Dental practice 1948 Lignocaine ; published in BDJ Lofgren Sweden Birth place of newer LA agents
Bupivacaine Ropivacaine

 DEFINITION --

It is defined as an unpleasant emotional

experience usually initiated by a noxious stimulus and transmitted over a specific neural pathway to the central nervous system where it is interpreted as such.

 Accupuncture Analgesia - Originated-CHINA,between600BC to 200AD

Hypnotism
Still employedsusceptible patients, Time consuming, lasts for less time

Audio Analgesia
1959 Gardner and licklider Loud noise used to produce analgesia

Electric analgesia --

Peripheral nerve- Direct electric current

Elos-1,powered by 18v battery- Siemens Never more than 30 ma

 Syringe Breech loading, metallic cartridge-aspirating

Advantage
Visible cartridge
Aspiration- 1 hand Autoclavable Rust resistance, Long lasting

Disadvantage
Weight Size-Too big

Possibility of infection

PISTON WITH HARPOON

FINGER GRIP

NEEDLE ADAPTOR

SYRINGE BARREL
THUMB RING

 Breech loading plastic cartridge-aspirating

Advantage
Light weight Cartridge visible Rust resistance, Long lasting

Disadvantage
Size Too big / small
Possibility of infection Repeated autoclaving Plastic looses its properties

Low cost

PLASTIC REUSABLE SYRINGE

 Breech loading metallic cartridge-Self aspirating

Advantage
Cartridge visible
Autoclavable Easier to aspirate

Disadvantage
Weight
Possibility of infection Finger has to be moved from thumb ring to disc-Aspiration Takes time to accustom

Piston is scored Qty Known

SELF ASPIRATING SYRINGE

 Pressure syringe --

Advantage
Measured dose Overcomes tissue resistance Non threatening Cartridge protected

Disadvantage
Cost Inject too rapidly -Possibility

PRESSURE SYRINGE

WILCOX- JEWETT OBTUNDER

 Jet injectors

Advantage
Does not require needle
Very small volume Delivered Topical anesthesia-effective

Disadvantage
Inadequate Pulpal / Regional block Patient disturbed by jolt of jet. Cost

PDL damage common

JET INJECTOR

 Disposable syringe

Advantage
Single use Sterile-Till opened Light weight

Disadvantage
Does not accept Dental cartridge Aspiration Difficult 2 hands

 Needle
Type Stainless steel Disposable

Platinum Iridium platinum Ruthenium platinum

Parts Bevel

Shank Hub-Leur lock, Friction grip.

Aluminum cap

GLASS TUBE

NECK

Rubber diaphragm

RUBBER PLUNGER

 Additional Armamentarium
Topical antiseptic
Topical anesthetic Cotton Gauge Hemostat Applicator Stick.

It is defined as a transient loss of sensation to a

painful or potentially painful stimulus, resulting from a

reversible interruption of peripheral conduction along a specific neural pathway to its central integration and perception in the brain.

Its action must be reversible It must be nonirritating to the tissues and produce no secondary local reaction It should have a low degree of systemic toxicity It should have a potency sufficient duration to be advantageous. It should have a potency sufficient to give complete anesthesia without the

use of harmful concentrated solutions

It should have sufficient penetrating properties to be effective as a topical

anesthetic.
It should be relatively free from producing allergic reactions. It should be stable in solution and undergo biotransformation readily within

the body
It should be either sterile or capable of being sterlized by heat without

deterioration.

 ROOT CANAL TREATMENT FOR PULPAL

ANESTHESIA PERIODONTAL SURGERY ORTHODONTIC EXTRACTIONS EXTRACTION OF CARIOUS ,PRE PROSTHETIC EXTRACTIONS,MALPOSED AND IMPACTED TEETH. PREPROSTHETIC SURGERY SURGICAL EXCISION AND INSICION OF PATHOLOGICAL LESIONS. ORTHOGNATHIC SURGERY MAXILLARY ND MANDIBULAR # REDUCTIONS OPEN/CLOSED

ABSOLUTE:
DRUG ALLERGY OR HYPERSENSTIVITY REACTION

 IN HEPATIC FAILURE PATIENTS Amides are metabolized in

the liver. Patients with significant liver disease who have poor hepatic blood flow will have trouble metabolizing amides and other agents. Patients administered prilocaine may develop methemoglobinemia. HEART FAILURE (ASA IV OR VI) LIDOCAINE is used as an ACLS drug for patients with ventricular dysrythmias. However high levels of lidocaine will decrease contractility and cardiac output and can lead to circulatory collapse. Systemic actions on the central nervous system include CNS depression, seizures and analgesia. In addition, one of the metabolites of lidocaine may actually cause some sedation. These metabolites are excreted in the kidney.IN RENAL FAILURE PATIENTS HAS TO BE USED WITH CAUTION. ATYPICAL PSEUDOCHOLINESTERASE. BLEEDING DISORDERS PERTICULARLY REGIONAL BLOCKS

Topical Surface contact. Paste, ethyl chloride. May be adequate for simple incision and drainage, preinjection, Infiltration Deposition of solution at or close to site of surgery. a) Sub mucous - for simple soft tissue surgery - includes long buccal infiltration. Not suitable for pulpal anaesthesia. b) Supraperiosteal - the commonest technique - solution diffuses through cortical bone into apical area. Usually adequate especially in maxilla but adult mandibles to thick in posterior buccal cortex. c) Subperiosteal - painful! - use if (b) fails. d) Intraosseous - very painful! again use if (b) fails. Drill small access hole over appropriate tooth apex and deposit 0.25ml of local anaesthetic.

e) Intraseptal - variation of (d) - similar indications but inject through softer crestal bone to reach apex. f) Intraligamentous - painful but occasionally very useful especially for acute pulpitis where regional block fails to give adequate depth of anaesthesia. Must use special syringe to avoid breaking cartridge. Push needle along root surface to apex - inject small volume of solution - effect is rapid so proceed with surgery C.FIELD BLOCKS D.NERVE BLOCKS E.Regional Block: Remote from site of surgery.

Contraindicated in patients with bleeding diatheses even if controlled!Success depends on knowledge of local anatomy and good technique.

 Based on composition A) Natural eg cocaine. B) synthetic nitrogenous compd para amino benzoic acid-procaine, benzocaine. acetanilide lignocaine quinoline cinchocoline C) non Nitrogenous compounds benzyl alcohol D) miscellaneous clove oil , phenol .

 Based on intermediate group --

Esters
Benzoic acid Butane Cocaine Benzocaine Para Amino benzoic Acid Chloroprocaine Procaine Propoxycaine

Amides
Articaine

Bupivacaine
Dibucaine Lignocaine Mepivacaine Prilocaine

Hexylcaine
Tetracaine

 According to biological site and mode of action

Class A
Class B

Agents acting at receptor Biotoxin -eg site external surface. tetrodotoxin

Agents acting at receptor Quaternary amoniumsite- internal surface.. scorpion venom Agents acting at receptor Benzocaine independent physico chemical mechanism. Agents acting in combn Clinically useful agents Lignocaine etc of receptor and independent mechanism.

Class C
Class D

 Injectables - Ultra short acting <80 min eg Lignocaine

Short acting 45-50

Surface -*Soluble - eg Cocaine Lignocaine *Insoluble- eg Benzocaine

Min 2% ligno with 1:1 lakh VC Medium acting 90-150 2% ligno with Vc or 4% prilocaine with 1:2 epin Long acting > 180 Bupivacaine with 1:2 epin

 Local anesthetic agent This is the active ingredient in the solution, but despite the

constant development of new drugs, the ideal L.A. agent is yet to be introduced into clinical practice. Vasoconstrictor Merits Reduces toxic effects by retarding the absorption of the constituents By confining the anesthetic agent to a localized area it increases the depth and duration of anesthesia. It produces a relatively blood less field of operation for surgical procedures.

 Demerits In higher doses can cause systemic effects that are undesirable,

practically in individuals suffering from cardiovascular disease. Vasoconstrictor may also cause a delay in wound healing, edema and tissue necrosis. This is because sympathomimetic amines may increase O2 consumption of tissues. This, together with vaso constriction leads to hypoxia and local tissue damage. The vasoconstrictors in general uses are Adrenaline. Noradrenaline Felypressin

 Anti oxidant
Most often is sodium meta-bi sulphite Amount varies from 0.0065 to 0.002 mg/CC. Since this substance is more readily oxidized than adrenaline or noradrenaline it

protects their stability.

Preservative
Modern LA solutions are very stable and have a shelf life of 2 years or more. Most frequently used bacteriostatic agents are methylparaben, propylparaben

and chlorobutanol.
Fungicide Thymol is added. Vehicle The anaesthetic agent and the additives are dissolved in modified Ringers

solution. This automatic vehicle minimizes the discomfort during injection.

Anesthetic

pKa

Onset

Duration (with Epinephrine) in minutes 45 - 90 120 - 240 4 hours 8 hours 90 - 360 140 - 270

Max Dose (with Epinephrine) 8mg/kg 10mg/kg 4.5mg/kg 7mg/kg 2.5mg/kg 3mg/kg 5mg/kg 7.5mg/kg 4.0mg/kg 7mg/kg

Procaine Lidocaine Bupivacaine Prilocaine Articaine

9.1 7.9 8.1 7.9 7.8

Slow Rapid Slow Medium Rapid

 Lignocaine-- Classified under Amide

2-diethylamino 2,6 acetoxylidide hcl
1943 Nils Lofgrens- intro 1948(dentistry) Metabolised- Liver by microsomal fixed function oxidases

to monoethyl glycerine and xylidide Excretion -<10% unchanged, >80%-metab Vasodilaton ->Procaine, <Mepivacaine Pka 7.9 , ph(plain)-6.5,ph(with Vc)5 5.5,Onset of action 2-3 min,Anesthetic half life 1.6hrs,topical anesthetic -yes

CH3 NH.CO.CH2.N

C2H5 C2H5

CH3

LIGNOCAINE

 Recommended dose 7mg/kg not>500mg

with VC

4.4mg/kg not>300mg For children with VC 3.2 mg/kg Council for dental therapeutics- ADA 4.4mg/kg It is non allergic available in three formulations Ligno2% with out Vc Ligno2% with VC 1:80,000 Ligno2% with VC 1:100,000 Adverse reactions- CNS stimulation then Depression,Overdose causes unconsciousness and respiratory arrest.

 Bupivacaine Classified under amide

1-butyl 2,6 pipecoloxylidide Toxicity <4 times Lignocaine, Mepivacaine Metabolism Liver by Amidases

Excretion by kidney (16% unchanged)

Vasodilation- relatively significant Pka-8.1,ph(plain)- 4.5-6,

ph(vc)- 3-4.5

Onset of action 6-10 min,Anesthetic half life-2.7hrs,Dose 1.3mg/kg ,Maximum dose-not >40mg,Absolute maximum dose-not> 90mg

CH3

NH.CO
CH3 N C4H9

BUPIVACAINE

 Available as 0.5% soln 1:2,00,000 (vc) Indicaton- pulpal anesthesia->90- min.

Full mouth recontruction. Extensive perio surgery.

management of post op pain.

Duration Pulpal- 90- 180 min

Soft tissue-4-12 hrs

Contra indication- burning sensation at site of injecton, in children-

anticipating self trauma .

 Procaine- Classified under Esters

2Diethylamino ethyl 4aminobenzoate hcl
Metabolised-in Plasma by plasma pseudocholine esterases Excretion >2%unchanged, 90% -PABA,8% diethyl aminoethanol in

urine.
Pka-9.1,High degree of vasodilation, 2% procaine 15-30min soft

tissue LA no pulpal anesthesia , > incidence allergy, drug of choice for intra arterial injection and accidents.

 Mepivacine- classified -amide type

1 Methyl 2,6 pipecoloxylidide hcl Metabolism-microsomal fixed funcn oxidasea in liver. Maximum dose 4.4 mg/kg , absolute max dose-300mg. Excretion-1-10% unchanged urine. Pka-7.6,Anesthetic half life-90min, Mild vasodilator, 3% mepivacaine used in patients with vc

contraindicaton. Low reported cases-allergy.over dose CNS stimulation followed by depression.

 Articaine- classified- Amide

2 Carboxymethoxy 4 methylthiophene hcl Metabolised- Liver Excretion Kidney 10% - unchanged. Pka 7.8, Anesthetic half life-1.2-2 hrs, Maximum dose 1mg/kg , Absolute maximum dose 500mg first LA Agent with thiophene ring,little potential to diffuse through soft tissue. Adverse reaction-methymoglobinemia-Rx by using methylene blue 1mg/kg.

 Etidocaine- classified Amide

Metabolism Liver Excretion urine- Kidney

Pka 7.7 ,Anesthetic half life-56 min.

Maximum dose 8mg /kg, Absolute max dose 400 mg Employed mainly in epidural or caudal regional block.

 Added to counteract vasodilation effect of injectable

L.A
Decreases rate of absorption Reduces the risk of overdose reaction Increases duration of action Reduces bleeding at the site

Based on chemical stc (Catechol nucleus)

Catecholamines
Epinephrine Nor epinephrine Dopamine

Non catecholamines
Amphetamine Meta amphetamine

Based on mode of action

Direct acting
Epinephrine Nor epinephrine

Indirect acting
Amphetamine Tyramine

Mixed acting
Ephedrine

EPINEPHRINE Proprietar Adrenaline y name 1& receptors Mode of action Systolic & Systemic Diastolic pressure 1) CVS Heart rate

FELYPRESSIN Octopressin Direct stimulation of vasculature No direct effect on Myocardium Non-arrythmagenic High doses impaired coronary flow

Oxygen consumption Stroke volume

2) CNS

CNS stimulation Adrenergic nerve no effect Vasoconstriction coronary blood vessels Anti-diuretic action Oxytocin like action uterus

3) RS Bronchodilator 4) Vasculature 1 vasoconstriction 2 vasodilation oxygen 5)Metabolism consumption blood sugar level

6) Clinical Allergy, hemostasis

As vaso-constrictor in

application
7) Max 0.2 mg healthy

L.A
0.04mg

dose
8) Side

0.04mg CVS impaired

CVS & CNS symptoms Cerebral hemorrhage

effect

 Rate
Non-myelinated 1.2m/s
Myelinated 14.8 120m/s

Site of action
Outer bimolecular lipoprotein layer in nerve membrane

 Altering the basic RMP of nerve Altering the threshold potential Decreasing the rate of depolarization Prolonging rate of repolarization

 ACTEYLCHOLINE THEORY:
Involved in nerve conduction in addition to its role as a

neurotransmitter at nerve synapses

No such evidence

CALCIUM DISPLACEMENT THEORY:

L.A causes nerve block by displacement of Ca from some

membrane site that controls entry of Na

Varying conc. Of Ca in nerve not seen

 SURFACE CHARGE THEORY:

Action by binding to nerve membrane and changing its

electric potential.
Cationic molecules aligned at membrane water interface surface

elec potn more positively charged potn.

Demerits- RMP not altered by LA.

electric potn ,

threshold

LA act on nerve channel rather than surface cannot explain how uncharged LA molecule causes nerve blockage.

 Membrane expansion theory LA lipid soluble enters nerve membr and changes

configuration of membr. There by reduced space for sodium to enter and thus cause inhibition.
Explains how non ionised drug causes- blockade, nerve

membrane do expand and become more fluid when exposed to LA .

No evidence to tell that the whole blockade is due to this

phenomenon.

 Specific receptor theory

LA act by binding to specific receptors- sodium channel-on

external/ axoplasmic surface.

Once it binds there is no permeability of sodium- no conduction.

LA molecule replace calcium molecule at calcium gate thus prevent sodium entry.

This is by far the most accepted theory.

 All LA are available as acid salt of weak bases.

Weak base(BNHOH) combined with acid (HCL) to give

acid salt(BNHCL)& water.

In mucosa BNHCL dissociates into BNH and CL . Normal

tissue PH 7.4 is necessary for conversion of acid salt to free base.

BNH which is hydrophilic further dissociates to BN and H.

BN is now lipophilic.

 Lipophilic BN diffuses through nerve membrane (lipid).

Inside the nerve it combines with intrinsic H. (H in nerve formed by buffering action.)
Newly formed ionised BNH displaces calcium from the

sodium channel receptor site to cause conduction blockade.

LA Solution .

 Esters- eg- Procaine-

hydrolyzed to pseudo cholinesterase's

Para amino benzoic acid Diethyl amino alcohol

Excreted unchanged urine further transformed-urine

Atypical cholinesterase's --- increase toxicity

 Amide eg lidocaine --

Mono ethyl xylidide

Glycine xylidide Xylidide xylidide

Hydroxy xylidide.

Excreted kidney .

Significant renal diseases contra indication.

 CNS
Low levels no action Toxic dose tonic clonic convulsions Blood- 0.5-4.0 mg/ml-no complication 4.5-7.0 mg/ml-pre seizure sign/ symptom >7.5mg/ml-tonic clonic seizures. Anti convulsive property As it causes depression of CNS. Seizure threshold- excitability nerve

 CVS Action on Heart

Electrical excitability of myocardium . conduction rate Tone of contraction.

clinically effective level-1.8-5mg/ml anti arrhythmic used in premature ventricular contractures , arrhythmias.

 Action on vasculaturenormal value no change.

over dose- hypo tension.( myocardial contractility) Lethal dose- cardio vascular collapse ( myocardial contractility, massive peripheral vaso dilatation )

 Action on Respiratory system

Normal levels- no over dose- bronchial muscles relaxation .
Over dose Respiratory arrest due to CNS depression.

DEPT.OF ORAL &MAXILLOFACIAL SURGERY

Presented By Dr Haneef

 Anatomical considerations

Local anaesthesia technique- Maxilla

Local anaesthesia technique- Mandible Complications

Future trends

 The right and left trigeminal nerves provide among other

functions, the overwhelming majority of sensory innervation from the teeth, bone, soft tissues of the oral cavity. Two parts:i. Motor:- a. Masseter b. temporalis c. lateral/medial pterygoid
d. Mylohyoid e. Anterior belly of digastric f. Tensor tympani g. Tensor veli palatini ii. Sensory: V1 Opthalmic nerve V2 Maxillary division V3 mandibular division

 Use a Sterile Sharp Needle Check The flow of Solution Determine Whether to Warm solution before use or not. Position the patient Dry the tissue/ wipe once. Apply topical anesthetic

 Communicate with patient apply firm hand rest

Inject few drops of soln, communicate with patient, Advance to the target slowly ,aspirate , inject

Withdraw the needle slowly

Observe the patient & check for anesthetic symptoms

Intra Oral injection techniques Supraperiosteal injection Intralegimentry injection Intraspetal injection Intraosseus injection Posterior superior alveolar nerve block Middle superior alveolar nerve block Anterior superior alveolar nerve block Maxillary nerve block Greater palatine nerve block Nasopalatine nerve block Exta oral injection techniques Ifraorbital nerve block anterior, middle superior alveolar nerve block Maxillary nerve block

 Supra periosteal injection:

Anaesthetize buccal soft tissue & hard tissue
Nerves anaesthetized large terminal branches

Indication :
1 or 2 teeth need to be anaesthetized / small area

 Contra-indication :
Infection
Dense bone covering

Target area :
Behind apices of tooth

Landmarks :
Muco-buccal fold Crown & root length

 Area anaesthetized: Maxillary 3rd, 2nd & 1st molar (except mesio-buccal root of 1st molar Bone & periodontium over these Indication: Treatment of 2 or more molars required Supra-periosteal injection ineffective Acute inflammation

 Contra-indication: Pt with bleeding disorders Disadvantage: More of soft tissue landmarks used 2nd injection for 1st molar Landmarks: Mucobuccal fold Zygomatic process of maxilla Infratemporal surface of maxilla Anterior border and coronoid process of mandible Tuberosity of maxilla

 Complications:
Hematoma
Non visible - pterygoid plexus posteriorly Visible buccal aspect

Accidental mandibular Anaesthesia Orbital contents anaesthetized accidentally

Accidental - parotid gland facial nerve affected

Only in present in about 20% of the poplation thereby limiting its clinical usefulness of this block. Area anaesthetized:
Mesiobuccal root of the 1st molar, pulps of maxillary first 1st and

2nd premolar Buccal periodontal tissues

Indication: When ifra orbital block fails to provide anaesthesia to maxillary canine Dental procedures involving both maxillary premolars contraindication: When infection or inflammation

 Areas anaesthetized Pulp of maxillary C.Is Canine Buccal periodontium, lower eyelid, lateral aspect of nose Upper lip Indications More than 2 anterior teeth Contraindications Discreet treatment areas Hemostasis of localized area not adequately achieved

 Landmarks
Mucobuccal fold,lforamen supra orbital notch infra-orbital

notch, infra-orbital foramen, mental foramen

2 methods:
Intra-oral
Premolar approach Incisal approach

1.Nasopalatine nerve block/spenopalatine nerve block/ incisive nerve block

Areas anaesthetized Anterior portion of Hard palate and over lying structures back to the bicuspid area.

Indications Anterior palatal procedures supplementing infraorbital nerve blocks Anaesthesia of nasal septum Landmarks Central incisor & incisive papilla

 Complications
Hematoma
Necrosis

Technique
Single needle penetration
Multiple needle penetration

Usually most discomforting block for patient very painful

2.Greater palatine nerve block/ anterior palatine nerve block

Areas anaesthetized Palatal soft tissue posterior aspect Palatal hard tissue Indication Surgical procedures posterior portion of hard palate Palatal Anaesthesia in conjunction with posterior superior alveolar nerve block. Landmarks Greater palatine foramen junction of the maxillary alveolar process & palatine bone Between the 2nd & 3rd molars 1-1.5cms away from gingival margin

 First reported by freidman and hochman in 1997 during development of

CCLAD system Muscles of facial expression and upper lip anesthesized.

Nerves anesthetized ASA and MSA Areas anesthetized Pulpal anesthesia of maxillary incisors,canines and premolars Buccal and palatal attached gingiva Indications Performed with CCLAD When anterior cosmetic procedures are performed When anesthesia is desired from a single injection contraindications Patients with thin palatal tissues Patients who cannot tolerate the 3-4 minute adminstration time Long procedures >90 mins

 Advantage Less amount of LA is deposited 0.5ml/min Allows for accurate smile line assesment in case of aesthetic restorations Disadvantage Very slow adminstration Can cause operator fatigue Maybe uncomfortable for the patient Technique sensitive

 Nerve anaesthetized Maxillary division of trigeminal nerve Areas anaesthetized Pulpal Anaesthesia Maxillary teeth 1 side Periodontium / soft tissue 1 side Indications Extensive oral / periodontal / endodontal procedures Other regional nerve blocks not possible Therapeutic procedure to diagnose neuralgias

 Contra-indications Pediatric patients Inexperience operators Infection / inflammation Hemorrhage anticipated Greater palatine canal approach not possible bony obstr. Landmarks Mucobuccal fold distal to maxillary 2nd molar Maxillary tuberosity Zygomatic process Greater palatine foramen

 Complications Hematoma Penetration into orbit

proptosis, 6th nr block diplopia, transient loss of vision, optic nerve blocked, retrobulbar block producing mydriasis, corneal anesthesia / hemorrhage, opthalmoplegias (common) Penetration into nasal cavity Patient complains LA running down the throat to prevent keep mouth wide open
Technique High tuberosity approach Greater palatine canal approach

Volume displaces orbital structures, periorbital swelling,

I. Anterior and middle superior alveolar nerve block

Nerves anaesthetized Infraorbital nerve Inferior palpebral, lateral nasal and superior labial nerves Area anaesthetized Incisors and bicuspids on the effected side Labial alveolar plate and associated tissues Anatomical landmarks Pupil of the eye Infraorbital ridge Infrorbital notch Infraorbital depression Indications When Intra oral route is not feasable When attempts of intra oral anaesthesia have been ineffective

II. Maxillary nerve block

Areas anaesthetised Anterior temporal & zygomatic region Lower eyelid Side of nose Anterior cheek Upper lip Maxillary teeth / alveolar bone & overlying structures 1side Hard & soft palate Tonsils parts of pharynx Nasal septum floor of nose

 Indications
Extensive surgery 1 half of maxilla Others blocks not possible Therapeutic purposes

Technique
mid point of zygomatic process Needle gently contact lateral pterygoid plate Maximum length of 4.5cms directed slightly upward & forward

Note:
In final position internal maxillary artery inferior to needle Temporal vessels on either sides Posteriorly foramen ovale with mandibular nerve & foramen spinosum

with middle meningeal artery Anteriorly pterygomaxillary fissure

INFERIOR ALVEOLAR NERVE BLOCK

Other common name- Mandibular block Different techniques are:
DIRECT METHOD

INDIRECT METHOD. METHOD OF CLARKE & HOLMES METHOD OF ANGELO SARGENTI VAZIRANI- AKINOSI TECHNIQUE GOW-GATES TECHNIQUE

KURT THOMA EXTERNAL APPROACH

 Classical inferior alveolar nerve block Nerves anaesthetised- inferior alveolar nerve block and its subdivisions
Areas anaesthetised Mandibular teeth upto midline Body of mandible Inferior portion of ramus Buccal periosteum & mucous membrane Lingual soft tissue Anterior 2/3rd of tongue Indications Multiple mandibular teeth procedures Buccal / Lingual soft tissue anaesthesia

 Contraindications Infection / acute inflammation Young children / mentally handicapped Landmarks Coronoid notch Mucobuccal fold External oblique ridge Retromolar triangle Internal oblique ridge Pterygomandibular raphe Occlusal plane of posterior mandibular teeth Complication Hematoma Trismus Transient facial paralysis (parotid gland)

 Anatomical structures - final position

Disadvantages:

Rate of indequate anesthesia is high 10-20% Intra oral landmarks are not consistently reliable Highest positive aspiration of about 10-20% Partial anesthesia where bifid inferior alveolar nerve and bifid mandibular canal are present

Stages in the indirect technique :- Initial insertion of the

needle more laterally,thus immediately strikes the bone, needle is partially withdrawn after touching the bone, syringe is moved parallel to the lower molars on the other side, insertion of the needle beyond theinternal oblique ridge, the syringe is returned to its original direction, ie over the lower premolars and deposit 1.5ml of solution in the pterygomandibular space.

It involves deposition of solutions @ a higher level than usual. It is a

modification of indirect technique. In the standard direct/indirect technique, the analgesic is placed immediately behind the mandibular foramen, which is 1cm above the occlusal plane of molar teeth. At this level the nerve is concealed by lingula & sphenomandibular ligament. Depositing the solution at a higher level causing complete anesthesia.

This technique is a modification of direct method. The difference is that the nerve is approached from a higher level than usual. TECHNIQUE: Syringe with 1 5/8 inch 26gauge needle is used.The index finger is placed in the retro molar fossa with nail facing lingually. The needle is inserted opposite to the mid point of the finger nail. The barrel of the syringe is now placed between and in contact with the upper premolars of the opposite side. Needle is slowly inserted in a downwards & backwards direction until it touches the bone, depth is 1cm. 1.5ml of solution is deposited.

 Nerves anesthetized inferior alveolar nerve, lingual nerve

buccinator nerves Area anesthetized

one half of mandible upto mid line including lingual tissue and inferior

portion of the ramus of the mandible.

Land mark occluding plane of the teeth. Muco gingival junction maxillary teeth. Antr border of ramus. Orientation of bevel must be oriented away from the bone of mandibulaar ramus (bevel faces toward mid line). More popular now Land marks easy One prick mandibular, buccal, lingual n anesthetised. Patient more comfortable.

 Advantages

Atraumatic, pats. with restricted mouth opening. fewer post op complications.

Disadvantages

Difficult to visualize the path of needle and depth of insertion.

Complications

hematoma, transient facial n. paralysis.

Nerves anaesthetised inferior alveolar, mental, incisive, lingual, mylohyoid, auriculotemporal and buccal.
Area all mandibular hard and soft tissue Upto mid line. Indications- multiple procedures on mandibular teeth,

buccal soft tissue anaesthesia from third molar to midline, conventional inf. alv. n. block is unsuccessful. Contraindications infection or acute inflammation in the area of infection, pats. with restricted mouth opening.

 Land marks-

Extraoral- corner of mouth, lower border of the tragus, intertragic

notch

Intraoral height of injection established by placement of

needle tip just below the mesiolingual cusp of max. 2nd molar, penetration of soft tissue distal to 2nd molar at the same height.
Final position needle is just inferior to condyle and insertion of lateral

pterygoid.
Gained popularity single needle penetration, relies on soft tissue landmarks differ from patient to patient

OTHER NAME Buccal nerve block or buccinator nerve block. TARGET AREA Buccal nerve as it passes over the anterior border of the ramus LAND MARKS External oblique ridge Retromolar triangle Distal to 3rd molar TECHNIQUE 1 25 gauge needle is inserted in to the buccal mucosa just distal to the lower 3rd molar. 0.25 to 0.5ml of solution is deposited.

 Lingual nerve block

Area anaesthetised Anterior 2/3rd tongue, floor of mouth, lingual mucoperiosteum Only used singly to operate on tongue, floor of mouth

Buccinator / long buccal nerve block

Area anaesthetised Buccal mucosa & mandibular molar mucoperiosteum
Land marks External oblique ridge, retromolar triangle

 Mental & Incisive nerve block

Area anaesthetised Mandibular hard & soft tissue labial aspect with lower lip
Landmarks Bicuspid teeth, lower ridge of body of mandible Supra & infra orbital notch Pupil of the eye

2 inch 22 gauge needle used & introduced slightly anteriorly & downwards

 Mandibular nerve
Area anaesthetised Temporal region with auricle of ear & external auditory meatus TMJ, salivary glands Anterior 2/3rd of tongue Mandible hard & soft tissue midline Landmarks mid point of zygomatic arch Zygomatic notch Cornoid process of mandible Lateral pterygoid plate

 Indications
When need to anaesthetise entire mandibular nerve Infection / trauma makes terminal anaestheisa not possible

Diagnostic / therapeutic

The needle is pointed posteriorly & to a greater depth of 5 cms

This technique is used when there is severe limitation of opening of the jaws in case of ankylosis of TMJ. Anatomical land marks/ surface markings: Lowest point on the anterior border of the masseter Tragus Posterior border of the ascending ramus Anterior border of masseter is located by clenching the teeth.The point is marked and a line drawn connecting this with the tragus of the ear.The mid point of this line shows the position of the mandibular foramen. Needle Used 21 gauge,7 to 8cm long.

 Definition
An anaesthetic complication may be defined as any

deviation from the normal expected pattern during or after securing regional anaesthesia
2 types
Local Systemic

 LOCAL COMPLICATIONS
Needle breakage
Pain on injection Burning on injection Persistent anaesthesia or paresthesia

Trismus
Hematoma Sloughing of the tissue / soft tissue injury Facial nerve paralysis

 SYSTEMIC COMPLICATIONS
Toxicity Idiosyncracy

Allergy
Anaphylactoid reaction

Syncope

 Classification
Primary / secondary
Primary caused & manifested at time of anaesthesia Secondary manifested later

Mild / severe
Mild exhibit slight change from normal expected pattern

- reverses itself without treatment

Severe manifests itself pronounced deviation

- requires specific treatment

 Transient / permanent
Transient is one that is severe at occurrence no residual

effects
Permanent residual effect; lasts for a life time even though it is

mild Complications could be a combination of any of the above mentioned types Majority are either Primary Mild & Transient or Secondary Mild & Transient

 Complications
Attributed to solutions toxicity, allergy, idiosyncrasy,

anaphylactoid reaction, local irritation

Attributed to technique / needle syncope, muscle trismus,

pain, edema, hematoma

 Cause
Unexpected movement patient (if patient movement is

opposite to path of needle insertion)

Multiple used needle Defective manufacture of needles/barbed needles smaller gauge more likely to break

 Prevention
Correct gauge 25 gauge
Long needles prevent penetration till hub Not to redirect when in tissue

Management
Patient not to move hand in the mouth mouth open Fragment visible remove it Fragment not visible inform patient not necessary for

intervention immediately Radiograph suggested

 Precautions

Avoid bony contact

Avoid heavy pressure

Avoid movement of needle and patient

 Causes
Careless injection technique Multiple used needle Rapid deposition

Problems Pain patient anxiety unexpected movements Prevention Proper technique sharp needles Enter topical anaesthetics Inject slowly solution sterilized Check temperature of solution

 Causes
Due to pH of solution 5 (LA) 3 (LA+VC)
Rapid injection Contamination Warm solution

Problems
pH disappears upon LA action no residual effect Contaminated solution other complications trismus,

edema, paraesthesia

 Prevention
Slow injection 1ml / minute Cartridge stored at room temperature away from containers with

alcohol / other agents

 Causes

Direct trauma to nerve bevel of needle LA solution containing neurotoxic substance alcohol Injection of wrong solution Hemorrhage / infection near to nerve

Problem
Persistent anaesthesia usually rare Biting / thermal / chemical insult without patient

awareness When lingual nerve is involved taste impaired

 Prevention
Proper care & handling of dental cartridge Adherence to injection protocol

Management
Usually resolve in 8 weeks Periodic recall & check up of patients Persistence consult neurosurgeon TENS Recall patient every 2 months for check up

 Definition

difficulty in opening the jaws due to muscle spasm

Causes

Trauma muscle / blood vessel Irritating solution hemorrhage Infection Multiple needle punctures LA have been known to have slight myotoxicity Excessive volume distension of tissues

Problems
Pain / hypomobility

 Prevention
Use of sharp, sterile, disposable needle Aseptic technique Practice atraumatic methods Avoid repeated injections Use minimum volume Control infection

 Management Heat therapy

Warm saline rinses, moist hot packs

Analgesics Aspirin, Codeine (30-60mg), muscle relaxants Initial physiotherapy Thrice a day Antibiotic regime Possibility of infection

 effusion of blood into extra-vascular spaces Causes Arterial & venous puncture common in PSA & Inf. Alv. nerve blocks Patients with bleeding disorders Problem Bruise may / may not be visible extra-orally Complications pain & trismus Swelling & discoloration Prevention Knowledge of normal anatomy proper technique Shorter needle PSA, minimize the number of penetration Discard defective needles- barbed needles

 Management Immediate apply firm pressure 5-10minutes

Inf. Alv. Nr. Block medial aspect of ramus Infra orbital, Mental, Incisive block directly over foramen PSA pressure on soft tissue with finger as posteriorly as tolerated by

patient medial superior direction Patient to be reviewed after 24 hours, advice analgesics, cold application upto 4-6 hours, warm- pack application next day

 Comparitively rare complication Instrument needle solution to be as aseptic as possible Area & operative hands cleaned Avoid passing needle through infected area Use disposable syringes

 Causes
Trauma during injection
Infection, hemorrhage Allergy (Angioedema)

Injection of irritating solution

Problems
Pain & dysfunction

Airway obstruction

 Prevention Proper care & handling of armamentarium Atraumatic injection technique Complete medical evaluation prior to injection Management Trauma resolve in few days without therapy Hemorrhage resolve slowly 7-14 days Allergy life threatening, airway impairment basic life support, call medical help, Epinephrine 0.3mg, Antihistamine, Corticosteroids Total airway obstruction Tracheostomy / Cricothyroidectomy

 Causes
Epithelial desquamation topical anaesthesia long time,

heightened sensitivity to LA Sterile abscess secondary to prolonged ischemia VC in LA site hard palate
Problems
Pain & infection

Prevention
Topical for not more than 1-2 minutes VC minimal concentration in solution

 Management

Symptomatic pain analgesia Epithelial desquamation resolve few days

Sterile abscess resolve 7-10 days

 Causes
Trauma occurs frequently mentally / physically challenged

children Primary cause significantly longer duration of action

Problem
Pain & swelling Infection of soft tissue

Prevention
Cotton roll between lip & teeth Patient guarded against eating / drinking Warning sticker

 Cause
LA solution into parotid gland usually while giving Inf

Alv Nr. Block, Akinosis technique

Problem
Ipsilateral loss of motor control Buccinator muscle Inability to raise the corner of Mouth, close Eye lid

Prevention
Needle tip to contact bone, redirection of needle to be done

only after complete withdrawal

 Management Reassure the patient Resolves after action of LA is over Eye patches to the affected eye drops Contact lenses if any removed

 Toxicity / toxic overdose

Signs and symptoms that result from an overly high blood

level of a drug in various target organs and tissues Predisposing factors

Age any age Weight greater the body weight greater is the amount of dose

tolerated before overdose reaction Sex during pregnancy renal function disturbed females more affected at this time Diseases hepatic & renal dysfunction reduced breakdown Congestive heart failure less liver perfusion Genetics pseudocholinesterase deficient toxicity - Ester LA

 Drug factors Vasoactivity vasodilation increase in blood

concentration
More concentration greater risk
Dose- smaller dose should always be preferred Route of Administration Intravascular increased toxicity Rate of injection slower rate preferred Vascularity of injection site more vascular greater absorption Presence of Vasoconstrictor with VC less absorption

 Causes of toxicity Biotransformation usually slow Drug slowly eliminated by kidney Too large a total dose Absorption from injection site - rapid Accidental intra-vascular injection Symptoms CNS cerebral cortical stimulation talkative, restless, apprehensiveness, convulsions Cerebral cortical depression lethargy, sleepiness, unconsciousness Medullary stimulation increased B.P, Pulse rate, Respiration

 Medullary depression mild fall in B.P severe cases drops to 0 ,

Pulse , Respiration similar effect

Treatment Mild overdose reaction slow onset reaction > 5 mins administer Oxygen (prevent acidosis), monitor vital signs, in case of convulsions anti-convulsants (diazepam/midazolam infusion) Slower onset - >15 mins same procedure Severe overdose reaction rapid onset 1 minute unconsciousness with or without convulsion, patient in supine position, convulsions protect hand, leg, tongue, BLS, administer anti-convulsant,use of vasopressor(phenyl ephrine) i.m if hypotensiom presists. post seizure CNS depression usually present

 It is an adverse response that is neither an overdose

nor an allergic reaction

Common cause some underlying

pathology/psychological /genetic mechanism

Psychotherapy may be helpful
Treatment symptomatic ..ABC

 transient loss of consciousness that is caused due to cerebral

ischemia (neurogenic shock)

Anxiety increased blood supply to muscles, sitting position

2mm Hg, less pressure cerebral arteries

Clinically pallor, light headedness, dizziness, tachycardia &

palpitation may further lead to Unconsciousness

Treatment discontinue procedure, supine position-

(trendelenburg position), deep breathing, O2 administration if required, BLS

 hypersensitive state acquired through exposure to a

particular allergen reexposure to which produces a heightened capacity to react 1 % of all reaction in LA is allergy Predisposing factors
Hyper sensitivity to ester more common-procaine
Most of patients allergic to methyl paraben Recently allergy to sodium meta bi sulfide is also increasing

Precautions--Ho of allergy to be recorded Ho any asthmatic attack to be noted. Always better to test the patient for allergy before treatment.

 Consultation and allergy testing

Refer doubtful cases for allergic skin test sub cutaneous test most

sensitive. Informed consent that includes cardiac arest end death to be included.
Signs and symptoms of allergy.
Dermatological------ urticaria wheal and smooth elevated patch seen, ---

---angio oedemalocalised swelling face hands, common Respiratory broncho spasm, respiratory distress,
dysnea, wheezing, flushing, tachycardia etc.

 Laryngeal edema type of angio neurotic oedema-

life threating.
Edema upper air way laryngeal edema Lower air way affect broncioles- small.

 Management skin reactions Delayed non life threatening - oral histamine

blockers- 50 mg diphenhidramine,10 mg chlorpheniramine 3-4 days. Immediate reactionwith conjunctivitis rhinitisvigorous management. 0.3 mg epinephrine. IM 50 mg diphenhydramine Im medical help summoned.

 Observe patient for minimum of 60 min

Oral histamine blockers for 5 days. Respiratory reaction patient in comfortable position. administer - oxygen Admn epinephrine- bronchodilator Observe for 60 min , advise anti histamines to prevent relapse. Histamine blockers Im

Laryngeal edema Patient position ,oxygen, broncho-dilator, iv anti histamines. If condition not improving cricothyrotomy - achieve patent air way if necessary give artificial ventilation.

 Patient with confirmed allergy status if patient allergic to any one type of anesthetic ester /

amide use the other. Use histamine blocker like diphenhydramine as anesthetic. General anesthesia alternative method of pain control
electric anesthesia / hypnosis.

 Efforts have been made to improve to increase the ability

of the anesthetic to cross intact skin Attempts at making the experience more comfortable for the patients The addition of hyalurodinase for deeper penetration than plain solutions Local anaesthesia without the use of needles Exploring the possibility of reversing local anaesthesia at the conclusion of dental procedure

Centbucridine 5-8 time potency of lidocaine Doesnt effect CNS or CVS except in large doses When adminstered in overdose the drug acts as a true stimulant of nervous system 0.5% concentratio effective to 2% lignocaine Ropivacaine Amide anaesthetic similar to mepivicaine and bupvicaine Has greater margin of safety Decrease cardiotoxicity as compared to others

 Its an oil in water emulsion containing high concentrations

of lidocaine and prilocaine in base form Provides enouh anaesthesia of intact skin to permit a venipuncture Consists of 5% cream containing 25mg/g lidocaine and prilocaine respectively

 The adminsteration of local anaesthetic is usually

uncomfortable for the patient due to difference in PH Addition of sodium bicarbonate provides more rapid onset of block, but it has decreased stability CO2 enhances diffusion, as it increase intracellular PH. Unstable solution, has short life

 First used described in 1949

Provides more rapid onset of anaesthesia

Decrease duration of action Possibility for allergic reactions

 Precursor for TENS It acts by working at low frequency of 2 Hz It serotonin, endomorphin levels in blood It takes about 10 minutes for sufficient rise of blood levels It causes dilation of vessels

It can be used to reverse partially of totally the effects of local

anaesthesia Can be used in patients who have needle phobia Its being used with increasing success in chronic TMJ pain Its contraindicated in patients having cardiac pacemakers, pregnancy, young and old age patients

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