TYPES OF ANESTHESIA

presented by:
Pratima Sharma
What is anesthesia ?
 It is defined as a pharmacologically induced and
reversible state of amnesia, analgesia , loss of
responsiveness , loss of skeletal muscle reflexes or
decreased stress response or all simultaneously.
Why we need anesthesia?

PAIN……

It is an unpleasant sensory and emotional experience associated

with actual or potential tissue damage
It is most common reason for doctor consultation; it is a major
symptom in many conditions & can significantly interfere with
patient’s quality of life and general functioning.

Anesthesia,thus, helps in reducing the pain temporarily for

various treatment procedures to be carried out smoothly and
successfully.
Anesthesia can be classified broadly as:

 General Anesthesia.
 Local Anesthesia.
GENERAL ANESTHESIA
 It means complete loss of consciousness, loss of pain and
muscle relaxation.
 It is given when patient has to be unconscious and immobile.
e.g. maxillofacial surgeries.
 Depending on drugs used to produce GA,it can be:

1. Inhalational anesthesia- where we use inhalational agents

like halothane, isoflurane etc.

2. Intravenous anesthesia- where onlyn IV drugs are used

like thiopentone, ketamine, propofol etc.
 But before giving GA, a proper pre-anesthetic check up is
must.
 PRE-ANESTHETIC ASSESSMENT: In this we cover:
1. Relevant information about the patient’s medical
history,physical & mental conditions.
2. To obtain an informed consent.
3. To educate the patient about anesthesia, pre-operative care
& pain treatment for reducing anxiety & facilitating recovery.
Also, general physical examination, routine & specific
investigations alongwith airway assessment should be done.
In airway assessment we look for loose artificial
dentures,mobility of neck, external trauma, nostril
size & patency, jaw malformations, mouth opening.
After pre-operative assessment, patients are
prepared before surgery. If any medical problem
persists,appropriate treatment is instituted.
After this preliminary assessment, in non-emergency
cases patients are advised to keep fasting for
atleast 6hrs,empty bladder & bowel, remove
artificial dentures & ornaments.
Pre-Anesthetic Medication

It is administered 1-2hrs before surgery depending

on the route of administration.
Aims of premedication are:
- Reduction of fear & anxiety.
- Reduction of saliva secretion.
- Prevention of vagal stimulation.
- To produce amnesia.
- For specific therapeutic effects-e.g.
antiemetics,H2 blockers.
- For pain relief in painful conditions e.g fractures.
Drugs used for Premedication:

 Sedatives- barbiturates, BZDs, phenothiazines.

 Analgesics- narcotics like morphine,pethidine or long
acting NSAIDS e.g ketoprofen.
 Neuroleptics- e.g opiods.
 Anticholinergics- Atropine,glycopyrrolate.
 Oral antacids- H2 blockers.
Timings for pre-medication is very important;
If given too late- watch should be kept for possible
respiratory depression after induction.
If given too early- If >3hrs delay,atropine is to be
repeated IV if vagal blockade is required.
There are 3 phases during successful
anesthetic delievery:
 INDUCTION.
 MAINTENANCE.
 RECOVERY.
Induction Of GA:

 Depending upon drugs used there are 2 types of

induction techniques:
1.) Inhalational Induction: It is achieved using
gases & anesthetic vapours,the partial pressure of
these agents exerted in the brain determines
depth of anesthesia.
Usually a mixture of N2O & O2 is used alongwith
vapours like halothane,isoflurane. But in poor risk
patients, O2 alone can be used alongwith
vapours.
Indications:
 Small uncooperative patients.
 A compromised air-way due to tumors.
 Where IV drugs are contraindicated.
 Restricted or immobile jaw.
TECHNIQUE: patient is breathed with 2:1 mixture of N2O & O2 &
then vapour is added, gradually increasing the percentage until
required level of anesthesia is reached. Patient is then maintained
on inhalation agent by mask or endotracheal intubation with O2 &
N2O as carrier gases.
In cases like pregnancy or patients with poor cardio-respiratory
reserve, pre-oxygenation with 100% O2 for 5 min before induction
helps to wash out N2 off the lungs & also helps to tide over any
hypoxic insult that can occur during induction.
2.) Intravenous Induction:

 Most preferred method because induction is

rapid,smooth & pleasant.
 Commonly used drugs include thiopentone sodium,
ketamine,propofol etc.
 These conditions are specifically indicated in:
- Gastric regurgitation & aspiration problem.
- In non-fasting patients
- Head injury & other trauma vitims.
- Diabetic & uremic patients.
- Pregnant patients.
- Patients with reflux disease.
 Thiopentone is most common drug available
& in use. Patient is ventilated with 100% O2
preferably before induction for 5min & then
anesthetic is injected.

Once anesthesia is induced depending upon

circumstances, airway may have to be
maintained by putting an ENDOTRACHEAL
TUBE.
Endotracheal Intubation(ETI)
 Airway maintenance is foremost indication of ETI
especially after introduction of skeletal muscle relaxants
which makes controlled ventilation mandatory.
 INDICATIONS:
1. Head & neck surgeries.
2.To maintain a clear airway in difficult circumstances,
e.g unconscious patients.
3. To prevent contamination of ENT.
4. Prolonged artificial ventilation in all major surgeries &
respiratory care; to maintain adequate oxygenation also.
 Instruments required include Laryngoscope
with all size blades, proper size endotracheal
tubes, magill’s forceps, stylets & mouth gag
etc.
 Types of ETI are:
- Nasal: guided under anesthesia.
- Oral: guided under anesthesia with
laryngoscope.
Stages of GA :

These were based on a progressive increase of

muscular paralysis(eye-ball muscles,inter- costals,
diaphragm) & a progressive abolition of reflex
response.
 STAGE 1- (stage of analgesia)
characterised by analgesia from the beginning of
induction. Patient experiences disorientation;
respiration is quiet but often irregular. As
consciousness & eyelash reflex are lost, patient
passes onto next stage.
STAGE 2(stage of excitement or
delirium):
 It lasts from loss of consciousness to the
onset of surgical anesthesia.
 Patient gradually becomes unconscious but
all reflexes are intact; at times patient is
uncooperative & violent.
 To avoid vagal stimulation at this stage
patient is pre-medicated with atropine.
 The eyelid reflex disappears when patient
goes from stage 2 to 3.
STAGE 3( stage of surgical anesthesia)

 This stage is commonly divided into 4 planes:

a.) Plane 1: respiration becomes irregular,
movements of extremities stop; eyelid reflex is
lost; eyeballs movements are incoordinated
conjuctival reflex lost; laryngeal reflex intact
however pharyngeal reflex is lost.
b.) Plane 2: eyes become centrally fixed; pupils are
constricted; laryngeal reflex lost; muscle tone
decreased but respiratory muscles are
functioning.
c.) Plane 3:

 Pupillary light reflex lost; muscle relaxation

with onset of paralysis of intercostal muscles.
Repiration is largely diaphragmatic.
d.) Plane 4: respiration gradually becomes
depressed; increase in diaphragmatic paralysis.
STAGE 4: (stage of medullary paralysis)
This stage is possible by overdosage of
anesthetic drug; respiration is gasping & finally
arrested; pupils are widely dilated; BP is very
low & pulse is feeble.
MAINTENANCE OF GA

 Once anesthesia is induced & endotracheal

intubation is done, it has to be maintained till
the end of surgical procedure.
 All the requirements of GA i.e. hypnosis,
analgesia & muscle relaxation should be met
during maintenance period.
WITHDRAWAL OF ANESTHESIA
 Extubation: performed when patient is deeply
anesthetised or nearly fully awake; deep or anesthetised
extubation is performed only after muscle relaxants have
been fully reversed & patient is maintaining an acceptable
respiratory rate & depth.
 Reversal: It is antagonisation of the muscle relaxation
produced by non-depolarising relaxants using specific
drugs.e.g. anticholine esterase like neostigmine,
edrophonium etc.
- Clinical signs of adequate reversal are judged by various
tests to assess the motor power & neuro muscular function
like sustained head lift for >5 sec considered most reliable
- Failure to breath after reversal may be caused by low CO2
 Recovery: It is the period from cessation of
anesthesia until patient is awake & regained
protective reflexes.
- complications encountered during
extubation & recovery phase are airway
obstruction, laryngospasm, aspiration,
pharyngitis & laryngitis, laryngeal oedema &
stridor.
LOCAL ANESTHESIA

 It has been defined as a loss of sensation in

circumscribed area of the body caused by a
depression of excitation in nerve endings or an
inhibition of the conduction process in
peripheral nerves.
Classification of LA:

 There are 2 types of LA:

1.) Esters esters of benzoic acid
esters of paraamino benzoic acid

2.) Amides

3.) Quinoline
LA can also be classified as:

 Low potency,short duration: e.g procaine,

chloroprocaine.
 Intermediate potency & duration: e.g
lignocaine, prilocaine.
 High potency, long duration: e.g tetracaine,
bupivacaine, ropivacaine etc.
Indications

 To reduce anxiety and pain during dental

procedure.
 Any procedure requiring localized, short-term
anesthesia, including a broad range of
medical and minor surgical procedures.
 Can be used as an anti-arrhythmic drug.
 Helpful in treating refractory cases of status
epilepticus.
Contraindications

 The presence of inflammation/infection.

 The presence of acute tissue injury.
 Bleeding disorder.
 Reported allergy to the solution.
 Liver disease
 Pseudocholinestrase deficiency
 Heart blocks / bradycardia cases.
 Large target areas requiring large doses of
anesthesia.
Compositon Of Local anesthesia

 It consist of:
1. Local anesthetic agent(lignocaine)- 2%
2. vasoconstrictors(epinephrine bitarte)-
1:80,000.
3. Buffering agent- NaCl- 6mg
4. Reducing agent(sodium metabisulphite)-
0.5 mg/ml.
5. Preservative(methyparaben)- 1mg
6. Distilled water(used as vehicle).
Types of syringe:

 Non-disposable
a. Breech-loading,mettalic,cartridge-type,
aspirating.
b. Breech-loading,plastic,cartridge-type, aspirating.
c.Breech-loading.mettalic,cartridge-type,self-
aspirating.
d.Pressure
e.Jet injector
 Disposable.
 “Safety” syringes.
ADA criteria for LA syringes

 They must be durable and able to withstand

repeated sterilization without damage.
 They should be capable of accepting a wide
variety of cartridge and needles.
 They should be inexpensive,self contained,
light weight & simple to use with one hand.
 They should provide for effective aspiration &
be constructed so that blood may be easily
observed in cartridge.
Needle types
 When needles are selected for use in various injection
techniques,there are 2 factors of importance that must
be considered:
-GAUGE
-LENGTH.
GAUGE: It refers to diameterv of lumen of the needle; the
smaller the number,the greater is diameter of lumen.
There is growing trend toward the use of smaller diameter
or higher gauge needles on the supposition that they are
less atraumatic. However it is observed that patients
can’t differentiate among 23,25, 27 & 30 gauge needles.
 Advantages of large-gauge needles over smaller gauge
needles are:
- Less deflection as the needle passes through the tissue.
- Greater accuracy & thus increased success rates.
- Needle breakage is less likely to occur.
 The most commonly used needles in dentistry are 25,27 & 30
gauge.
 25 gauge needle preferred for all injections posing a high risk
of positive aspiration.
 27 gauge can be used for all injection techniques provided
aspiration percentage is very low & tissue penetration depth
is not great.
Length of needle:
 These are available in 2 lengths:
- long( approx 40 inches).
- short(approx. 25mm).
Needles should not be inserted into tissues to their hubs
unless absolutely necessary for the success of the
injection.
Long needles are preferred for all injection techniques
requiring penetration of significant thicknesses of soft
tissue.
Short needles may be used for injections that do not require
the penetration of significant depths of soft tissues.
In dentistry, local anesthesia is used to anesthetise
the nerves supplying the teeth to carry out various
procedures. E.g. extraction,root canals,flap surgery.
Various methods of anesthetising the
nerves are:
 Nerve block: depositing the anesthetic solution in close
proximity to a main nerve trunk.
 Field block: when solution is deposited in proximity to larger
terminal nerve branches.
 Local infiltration: when small terminal nerve endings are
anesthetised.
 Intraligamentary technique: forcing the anesthetic solution
into PD membrane space under pressure to provide single tooth
anesthesia.
 Topical analgesia: anesthetising free nerve endings in
accessible structures where stimulation by application of solution
directly to the surface is not suitable.
NERVE BLOCKS
 These are classified as:
1.) Maxillary blocks: It consist of
a. Posterior superior alveolar block
b. Infraorbital block
c. Nasopalatine block
d. Greater palatine block.
2.) Mandibular nerve blocks: It consist of
a. Inferior alveolar block.
b. Long buccal nerve block.
c. Lingual nerve block.
d. Mental block.
e. Incisive block.
Maxillary nerve blocks
 Posterior superior alveolar block:
Anatomical landmarks are:
1. muccobuccal fold & its concavity.
2. zygomatic process
3. infratemporal surface of maxilla.
4. anterior border & coronoid process of ramus of
mandible.
5. tuberosity of maxilla.

Indications: For operative procedures on molars & supporting

structures but must be combined with palatal injection.

No subjective symptoms appeared.

Technique:
The operator moves left fore-finger over muccobuccal fold
in a posterior direction from bicuspid area until zygomatic
process & rest fingertip in concavity in the fold; here finger
is rotated & hand is lowered to keep it in a plane at right
angle to occlusal surface of maxillary teeth & at 45’ to
patient’s sagittal plane. Needle is inserted in a line parallel
with this finger at 45’ in upward,inward & backward
direction.

Always aspirate before injecting so as to avoid injecting

solution into vessels.
Solution deposited – 1.8 ml
Infraorbital block

Anatomical landmarks are:

1. Infraorbital ridge.
2. Infraorbital depression.
3. supraorbital notch.
4. Infraorbital notch.
5. Anterior teeth.
6. pupils of eye.
Indications: any procedure to be performed on 5
anterior maxillary teeth on same side of median
line.
Technique:
 Patient is tilted so that maxillary occlusal plain is at 45’ angle to
floor;locate the infraorbital notch & finger should be moved downward
about o.5 cm,where a shallow depression will be felt. Then thumb of
operator is placed over located infraorbital foramen & index finger is
used to retract lip; now either of 2 directions can be used.
In bicuspid approach, needle is inserted in a line parallel with supraorbital
notch,pupil of eye, notch & 2nd bicuspid.
In central incisor approach, needle bisects the crown of central incisorfrom
mesioincisal angle to distogingival angle
 Needle shouldn’t be inserted more than 5mm.
 Solution deposited -2 ml
 Subjective symptoms – numbness of upper lip,lower eyelid & nose on the
affected side.
Nasopalatine block

 Anatomical landmarks are:

1.) central incisor
2.) Incisive papilla in midline of palate.
 Indications: for palatal anesthesia –
a.) to supplement the ASA & PSA blocks.
b.) to complete anesthesia of nasal septum.
 Solution deposited – 0.25 to o.5ml
Technique:

 It is extremely painful injection unless preparatory

injection is made. The preparatory injection is
made by inserting the needle at right angle to
labial plate between the central incisors & 0.25ml
solution is deposited. Needle is then withdrawn &
reinserted in crest of papilla advancing slowly into
incisive foramen & 0.25 ml solution is deposited.
 Subjective symptoms – numbness in palate when
contacted with tongue.
Greater palatine block

 Anatomical landmarks are:

1.) 2nd & 3rd maxillary molars.
2.) palatal gingival margin of 2nd & 3rd maxillary
molars.
3.) midline of palate.
 Indications:
1.) For palatal anesthesia used in conjuction
with PSA & ASA blocks.
2.) For surgery of posterior portion of hard
palate.
Technique:

 The greater palatine foramen is approached from

opposite side which is situated 1 cm from palatal
gingival margins of 2nd & 3rd maxillary molars
towards the midline. The needle should be kept as
near to a right angle as possible.
 This nerve may be blocked at any point along its
anterior course after emergence from foramen
 Solution deposited- 0.25 to 0.5 ml
 Subjective symptoms – numbness felt in posterior
palate when contacted with the tongue.
Mandibular Blocks
 Inferior alveolar nerve block
Anatomical landmarks are:
1. mucobuccal fold.
2. external oblique ridge.
3. anterior border of ramus of mandible.
4. retromolar triangle.
5. internal oblique ridge.
6. pterygomandibular raphe.
7. buccal pad
Indications:

 Analgesia for operative dentistry on all

mandibular teeth.
 Surgical procedures on mandibular teeth &
supporting structures when supplemented by
lingual or buccal nerve block.
 Diagnostic & therapeutic purposes.
Technique:
 Operator palpates the mucobuccal fold with left index
finger;it is then moved posteriorly with external oblique ridge
on anterior border of ramus. Finger is then moved up to the
coronoid notch; slowly move the finger lingually across
retromolar triangle & onto internal oblique ridge.
 Needle is then inserted parallel to the occlusal plane of
mandibular teeth from opposite side of mouth at a level
bisecting the finger penetrating pterygomandibular
depression.
 Solution deposited – 1.8 to 2 ml
 Subjective symptoms- tingling & numbness of lower lip &
when lingual nerve is also affected,tip of tongue.
Lingual nerve block
 Anatomical landmarks are same as for the inferior
alveolar nerve.
 Indications –
for surgical procedures of anterior 2/3rd of the
tongue,floor of the oral cavity & mucous membrane
on lingual side of the mandible.
 Technique: same as for IAN block.
 Subjective symptoms: tingling & numbness of
anterior 2/3rd of the tongue.
Long Buccal nerve block

 Anatomical landmarks are:

1. external oblique ridge.
2. retromolar triangle.
 Indications: surgery on mandibular buccal
mucosa & to supplement IAN block.
 Technique- needle is inserted into the buccal
mucosa just distal & buccal to last molar.
 Solution deposited- 0.25 to 0.5 ml.
 No subjective symptoms appeared.
Mental nerve block

 Anatomical landmarks are- mandibular bicuspids

 Indications- For surgery on lower lip or mucous
membrane in mucolabial fold anterior to mental
foramen when IAN block in not indicated.
 Technique- apices of bicuspid are estimated &
needle is inserted into muolabial fold after cheek
has pulled to buccal side.
 Solution deposited- 0.5 to 1 ml
 Subjective symptoms- numbness of lower lip on
injected side.
Incisive nerve block

 Anatomical landmarks are same as for mental

nerve block.
 Indications- for anesthesia of labial mandibular
structures,anterior to mental foramen & lower
lip when IAN block is not indicated.
 Technique- it is same as for mental nerve block
except needle should penetrate into the mental
foramen
 Subjective symptoms- numbness of lower lip.
Local Infiltration
 No anatomical landmarks are required.
 Indications:Anesthesia of restricted area of the
mucous membrane for limited soft tissue surgery.
 Technique- needle is inserted beneath the mucous
membrane into the underlying connective tissue &
the area is infiltrated with anesthetic solution.
 No subjective symptoms are observed.
SUPPLEMENTAL ANESTHESIA
 There are three techniques which are used:
1. Intraligamentary injection.
2. Intraosseous injection.
3. Intrapulpal injection.

1.Intraligamentary injection:In this solutions are forced

through the cribriform plate into the marrow spaces
around the tooth.
Operator experiences strong back-pressure while injecton.
The WAND(new technology for intraligamentary technique):
A computer assisted LA delivery system was introduced
that can be used to administer intraligamentary injection.
2. Intraosseous injection: (Stabident & X-tip
systems)
It delievers a LA solution directly into the
cancellous bone adjacent to the tooth to be
anesthetised.
Infiltration injections are not effective for
anesthesia in mandibular molars teeth
bacause of the thickness of the cortical
plate.
2 intraosseous systems have been
clinically studied:
 Stabident system.
 X-tip system.

1.Stabident system: it is composed of a slow speed

handpiece driven perforator,a solid 27 gauge wire
with a bevelled end that drills a small hole through
the cortical plate. The solution is delievered to the
cancellous bone through the 27 gauge ultrashort
injector needle placed into the hole made by the
perforator.
2. X-tip system:

 This system consists of an X-tip that separates

into 2 parts, the DRILL & the GUIDE SLEEVE.
The drill is a special hollow needle leads the
guide sleeve through cortical plate,
whereupon it is separated & withdrawn.
The remaining guide sleeve is designed to
accept a 27 gauge needle for injection. The
guide sleeve is removed after the intraosseous
injection is complete.
 Inspite of proper techniques followed &
proper solution used, there are many
conditions which lead to inadequate or
incomplete anesthesia.
Inadequate anesthesia:
 Reasons are:
1. Presence of inflammation or infection leads to acidic pH
thus resulting in inactive cationic form of anesthetics.
2. Morphological changes in nerve trunk central to the
periphery.
3. Shifting of sodium channel expressions from TTX sensitive
to TTXr during neuroinflammatory reactions & TTXr
sodium channels play a role in sensitising C fibres &
creating inflammatory hyperalgesia.
4. Anatomic limitations such as dense bony plates, aberrant
distribution of neural bundles or accessory innervation .
5. It may also result from not allowing enough
time for the anesthesia to work.

So in resistant cases alternative anesthetics

should be used eg. Bupivacaine
In cases of anatomic limitations we can use
supplementary intraligamentary or intraosseous
injections.
Hot tooth
 The term "hot tooth" is a common
name given to an infected tooth
which exhibits severe pain.
Sometimes, hot teeth have living
nerve tissue inside of them, but the extent of inflammation
prevents the tooth from being able to recover. Such teeth
are generally diagnosed with irreversible pulpitis.
 Many times hot teeth will no longer be vital (i.e. they no
longer have living tissue inside of them). Such teeth are
termed necrotic, and have hollow root canals open to the
inside of the body.
 If bacteria gain access to the root canals of necrotic
teeth, they can create a significant colony before
the body's immune system even knows they are
present. Large bacterial colonies are capable of
producing a significant amount of tissue destroying
enzymes and acids, and when the immune system
begins to fight the infection, the bone and soft
tissues around the tooth can be extremely tender
even to light finger pressure.
 Hot teeth & the area around them can be
difficult to anesthetize,due to the acidic
environment & the amount of infectious fluid
present. It shifts the sodium channel
expressions to TTXr(resistant) frm TTX sensitive.
 Many times treating the tooth comfortably
requires localizing the infection with antibiotic
medication prior to performing endodontic
(root canal) procedures on the tooth.
Anesthesia is of great importance in routine
dentistry. But these solutions should be
cautiously used as it may cause toxicity or
complications either because of lack of
operator’s skill or contaminated anesthetic
solution.
Thank you…!!!!