: 2006-7 ,

2......................................................................................................................
9............................................................................................................
12....................................................................................................................................
14...............................................................................................................
30...................................................................................................................
35..................................................................................................................................
37................................................................................... Basic Injection Technique
40................................................................................ Local Anesthetic Technique -
49..................................................................................
55..................................................................................................................
62................................................................................................................
67....................................................................................................................
72.................................................................................................................................
- 78.................................................................................................................................

27.11.06
,Dr. Gabi Chaushu .
.
. .
.

.handbook of local anesthesia / Stanley F. Malamed
- "
. .

.
' : . .
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.
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.
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. .
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. , .
, .

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, .

.
:
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.
, .

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.
. .


. ,
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.
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.
.
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, -

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.
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, - .
- ,

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, .70mV-

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0.7".

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-.

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.

.

, .

500,000 , .

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.epineural sheath .

. .

,
.
,
.
, , , ,
.
:
.1 .
.2 - .
.3 - mantle bundles
, .
,
,
- , .
- .
,Mantle Bundles- Core Bundles - ,
- , .
, .

- , .
.ECM-
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.

, " -
-.


.
.

pH - . pH - .

, , , ,
. .

.
, .
.

, ,
.

, .
- .
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.
.
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- .
.tachyphilaxis .
. ,
.
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,
. .
, ,
.
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.
.
.
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, ,
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, .

pH . ,
.

, .
, , .

.1 -
.2 - . ,

.3 " . ,
" .
, .



" . .
. :
.1 .
.2
.3 .

PO
, 30%,
, .

Topical -
. . ,
,
, , .
- ,
, .IV ,
, , .

Injection -
" . .
, )
( , .

IV , .
' . IV
.

, :






, ,
.

Distribution

.
.
" ,
, .
-
.

 )
.

Distribution

- (T 50%

LA- BBB .
LA- , .
) (local anesthetic .
, .
" .
, ,
. , .

.
" .

" .Acetyl Cholin Esterase

.
.
,PABA ,
, .

,
.

" , ,
.
, .
,
, , .
,
.

, :
CNS Central Nervous System
CVS CardioVascular System
.
CNS
BBB
.
,
- .

10

 , ,CNS-
.
"" " " .
, .
, .
CVS

, :
.
o
.
o
,
, . .
.
.
. , .Hypotension

, .
,
.
. .
, , ,
- .
, ,
.

.
respiratory arrest .CNS-
" .
" - , "
- . .

11


. . , ,
.
. 30%
, . ,
.
:
.1 .
.2 LA.
.3 .
.4 .
.5 .
= .

: ,
, .

.1
.2
:
. OH 3 .4
, . :
: , , : .

.isoproterenol, Levonordefrin :

, .
: , .
. NH2.

.1 . " .
. , .
.2 . "
. .
.3 .
.

Receptors . .

- Receptors .

" , .

12

 .
- , .
- , .

,
, .
,
.
.
- ,
.
.

.
".
" )
(.
1:1000 1 1000-".
1:200,000
. 5 ) 1.8"
9 (
,
" , ,
, .
,
,
.CO
.

13

4.12.2006

Pharmacology of Vasoconstrictors.ppt :

CHEMICAL STRUCTURE
MODES OF ACTION
Adrenergic Receptors

Release of Catecholamines

DILUTIONS OF VASOCONSTRICTORS
PHARMACOLOGY OF SPECIFIC AGENTS
Epinephrine

SELECTION OF A VASOCONSTRICTOR
Length of the Dental Procedure

Requirement for Hemostasis

Medical Status of the Patient

.
:
.
) (.
.
.

)Peak Level (g/ml
Without Vasoconstrictor
With Vasoconstrictor
4.7
3
4.3
3
2.8
2.6
1.4
1.3

)Dose (mg
500
400
400
300

Local Anesthetic
Mepivacaine
Lidocaine
Prilocaine
Etidocaine

.
, .
:
.1 .
.2 LA-.
.3 .
.4 .
.5 .
:


.
:
.Chemical Structure
.Mode of action

14


.
.
: , ,
.
, . . ,
. ,
, .Sodium Bisulfite
, , .
)( ,36-
, 18 . , . 18
) ( .
, , ,
.
- 1:50,000 .1:200,000-
,
.1:200000
, .
.1:100,000

.
- .

, .

:
CO" ) (.
o
. .
o
.
:
VT (ventricular tachycardia), PVC (premature ventricular :
o
).contraction
:
" , ; .
o
":
"
o
:

o
:
.
o

:
) : (.

15

)Cartridges (Rounded off

Patient with significant
Cardiovascular disease (ASA III
)or IV
1
2
4

)Normal. Healthy Patient (ASA I

5.5
11
22

Epinephrine concentration
)1:50,000 (36
)1:100,000 (18
)1:200,000 (9

]
-ASA .
- 1ASA .1P ,.
- 2ASA , .
- , " ,
.
: " , COPD , , ,
2 Atrial Fibrillation , . .
1- .2-
:3ASA .
: 1 ,
COPD ," 2-3 .
.
- 4ASA .
- 5ASA 24 .

- 6ASA [ .

.
.
- , ,
.

.

.
,
.
48 , 40.

.

.
. ,
. .
.
. .

,
.
Block Inferior Alveolar Nerve-
.
16

 . ,
) 1:200,000 (.

Requirement for Hemostasis

Vasoconstrictors used to achieve hemostasis must be deposited locally into the surgical
site (area of bleeding) to be effective
They act directly on receptors in the vascular smooth muscle
Only small volumes of LA with vasoconstrictor are required to achieve hemostasis
-

) (.
Receptors .

, ,
,
'.
- Post Surgical Bleeding
Rebound Effect . , ,
Receptors .
.
, 4-5 .
, ".
- Phenylephrine .

- Norepinephrine ,

.
Felypressin .

:
1:50,000 1:100,000 .1:100,000
, 1:50,000 .

Medical Status of the Patient

:
.ASA 3- 4

,MAO .

:
.

.Reduce Incidence of systemic reaction

17

 :
.1 .
.2 ) , ( .IV
.

18

 , :

Pharmacology of specific agents

Epinephrine

.
.
.
.Sodium Bisulfite
36- ,
) 18(.

.
) Levorotatory , ( ) Dextrorotatory-
, ( . Levorotatory - .15

, .

.Beta1 CO . HR-.

.Beta1 . ,
.

. 2
. Receptors-
.

Cardio Vascular Dynamics

:
.
o
).(CO
o
).(Stroke Volume
o
).(Heart Rate
o
.
o
.
o
.
" ,
.1:100,000 4 1:100,000 " .

-.
, .
.2
2 ,
.

19

Hemostasis .
, Receptors .
2
. 6-
) .(Post Surgical Bleeding Post Surgical Pain-
Delayed wound healing .

Respiratory System .
.Acute Asthmatic Episodes-

Central Nervous System .

.

Metabolism .
. . .150-200pg/ml
4 .1:100,000

Termination of action and elimination Reuptake

. Reuptake-
COMT MAO- . )-
.(1%

Side effects and overdose CNS-

, , , , , , , , ,
.
) ( ,
.
.
.
.

Clinical Applications
.
.
.
.
.
.
.
Availability in Dentistry
, . :
Lidocaine
Articaine
Bupivacaine
Etidocaine
Mepivacaine
Prilocaine

20

Maximum Doses
.
.
1:100,000
1:200,000 1:300,000 .
:
)Cartridges (Rounded off
Patient with significant
Cardiovascular disease (ASA III
)or IV
1
2
4

Normal. Healthy Patient

5.5
11
22

Epinephrine concentration
)1:50,000 (36
)1:100,000 (18
)1:200,000 (9

. American Heart Association -

.
:
.
.
.
Hemostasis
LA . 1:50,000
1:100,000 ,
.
1:50,000 , ,100,000
) ,ASAIII & ASA IV (.

)Norepinephrine (Levarterenol

. .
18.
Acetone Sodium Bisulfite .

.
) Levorotatory , ( ) Dextrorotatory-
, ( . Levorotatory - .40
.

. Receptors . Receptors
4 .

.1 Receptors

21

. 1
.Receptors

,
.

. Receptors
.

- Cardiovascular Dynamics
:
.
o
.
o
.
o
.
o
.
o
) (.
o

Vasculator .
) ,48 (5 Palate-
.

Central Nervous System ,

. ,CNS
, .

, .Basal metabolic rate-

) (
.

Termination of action and elimination

Reuptake .MAO
COMT .
Side Effects and Overdose
. .CNS-
-
, Hemorrhagic Stroke , .
.
.

.
.
.

22


Clinical Action of Specific Agents.ppt :

DURATION
MAXIMUM DOSES OF LOCAL ANESTHETICS
ESTER-TYPE LOCAL ANESTHETICS
AMIDE-TYPE LOCAL ANESTHETICS
Lidocaine HCl

Mepivacaine HCl

Articaine HCl

Bupivacaine HCl

ANESTEHETICS FOR TOPICAL APPLICATION

Benzocaine

Lidocaine

EMLA (Eutectic Mixture of Local Anesthetics

SELECTION OF A LOCAL ANESTHETIC

.
.
:
- Short-Duration Drugs 30 -.

- Intermediate-Duration Drugs 60

- Long-Duration Drugs 90.

5

- Articaine , .
Bupivacaine .
Lidocaine , .
- Mepivacaine ,
.
Prilocaine .
.

- ,
.
.
.
, ,
.

.pH -
.
.

23


.
Local Anesthetic
Lidocaine HCl 2%: no vasoconstrictor
Mepivacaine HCl 3%: no vasoconstrictor
Prilocaine HCl 4%: no vasoconstrictor
Etidocaine HCl 1.5% + epinephrine 1:200000

)Infiltration (min.
5-10
5-10
10-15
15

)Block (min.
10-20
20-40
40-60
90-180

.
70" .

30 , .
.
:
MRD A .
MRD M . .
.MRD A-
Local Anesthetic
MRD
mg/Kg mg
Articaine
With Vasoconstrictor
7.0
500
Bupivacaine
With Vasoconstrictor
1.3
90
Lidocaine
No Vasoconstrictor
4.4
300
With Vasoconstrictor
4.4
300
Mepivacaine
No Vasoconstrictor
4.4
300
With Vasoconstrictor
4.4
300
Prilocaine
No Vasoconstrictor
6.0
400
With Vasoconstrictor
6.0
400
.70
.
.
10
) 1.8"(
:
1.8" . 4%- 40" , 1.8- 72-
" . .
..." : , , "...
Local Anesthetic
Articaine
Bupivacaine
Lidocaine
Mepivacaine
Prilocaine

%
4
0.5
2
2
3
4

mg/ml
40
5
20
20
30
40

X1.8ml Cartridge
72
9
36
36
54
72

24

Ester-Type Local Anesthetic

Procaine HCl .
Propoxycaine HCl
Procaine HCl + Propoxycaine HCl

Amide-Type Local Anesthetic

Lidocaine HCl
.
Classification: Amide
.FDA Approved: 1948 .
Metabolism .
:Excretion
Kidneys
o
> unchanged 10% 10%- .
o
< various metabolites 80% 80%-
o
.
2-3 ,.

.2% :

90 : . .

Topical Anesthetic Action ,

.5% -
HCL , Gold Standard -

.
14

. ,

25

 . , ,
. .
HCL ,
70" . ) (
70" )
(.
.
,
.
.
, 2% 8.
Mepivacaine HCl
.Classification - Amide

- FDA Approved .1960-

Metabolism

.
Excretion ,

16%-1% .
- Onset of Action ,

1.5-2.
2% -

3% - .
1.9 -.

- Topical Anesthetic Action

.
3%- Gold-

Standard
.
3% . 5.5
8 , .
:Mepivacaine HCl 3% without vasoconstrictor
)Weight (kg
10
20
30
40
50
60
70
80
90
100

mg
44
88
132
176
220
264
300
300
300
300

Cartridges
1
1.5
3
4
4.5
5.5
5.5
5.5
5.5
5.5

Articaine HCl
Classification . .

.FDA Approved 2000

26

Metabolism Plasma
,Esterase .
- Excretion 10%-5%
.
Onset of Action . 1-3.
Effective Dental Concentration 4%
.
Anesthetic Half Life .
- Topical Anesthetic Action .
- Comments
.
o
:
o
) .(Paresthesia
.
o

Bupivacaine HCl
Classification.
.FDA Approved 1972
Metabolism .Amidase
Excretion , 16%-
.
- Onset of Action
6-10 ,.
.Effective dental concentration - 0.5%
.Anesthetic half-life - 2.7 hours .
.
Comments
:

Lengthy dental procedures

.
Management of postoperative pain

Anesthetic for topical application

. , "" .
) Effective only on surface tissues (2-3mm 2-3 ," .
Deep tissues poorly anesthetized .
- Surface anesthesia allows for a-traumatic needle penetration of the mucous membrane
, , .
, ,
. .
Mepivacaine- 15%-
.

:
Benzocaine
o

27

Lidocaine
o
.
.
, .
.
.

31-32
Benzocaine
Ester-type .
.
Poor solubility in water .
Poor absorption into the CVS
-.
Systemic toxic (overdose) reactions virtually unknown
.
Remains at the site of application longer, providing a
prolonged duration of action
.
Localized allergic reactions may occur after prolonged or
- repeated use
.
- Availability . .
Not suitable for injection .

Lidocaine
.Amide-type .

.Lidocaine base 5%; lidocaine hydrochloride 2%

.5%
.Low incidence of allergic reactions

.
MRD 200 mg

- Availability

.
.

EMLA Eutectic Mixture of Local Anesthetic

.

2.5%.

2.5%.

, 1-2 .

28

.
EMLA-
.
.

:
:
.

)(.

LA Armamentarium
.
.
.
.

- Short-duration pulpal anesthesia .
.Mepivacaine 3% .
- Intermediate-duration pulpal anesthesia .
:
.HCL 2%
o
- 4% .
o
- Long-duration pulpal anesthesia .
).Marcaine 0.5% (Bupivacaine
o
.
.
o

29


Handbook of Local Anesthesia / Stanley F. Malamed
Chapter 10
Physical and Psychological Evaluation
"
, . .

.
.

-




.

,
. , .

.Vasodeppressor Syncope

.
:
, .

:
.

90%
.

)(American society of anesthesiologists
) ,(ASA ).(AcCarthy & Malamed

ASA 1 . .
.
ASA 2 )
( . .
ASA 3 .
.

30

ASA 4
, .
.

. Lidocaine- ,Mepivacaine- .

:
Congestive Heart Failure

. .
) 15% 30% ( ,

.
.

Post Acute MI
.ASA4 -

, .
.

MI .ASA4 -

ASA 3 - ASA2.

) .(ASA IV

Angina Pectoris
: .

.
:

.ASA 3
o
) ASA 4 ( . .
o
, , .

.
. :
.1
.2 ,
.3
.4
.5
.6
.
.
.
] : [.

31


" , 5.
.140/90-
"
- ,.

,.

ASA :
- ASA 1 .140/90
ASA 2 BP = 140 to 159 / 90 to 94 . .
.
ASA 3 BP = 160 to 199 / 95 to 114 ASA 3a - .ASA 3b -
ASA3a- .ASA 3b-
- ASA 3b to 114 105 - .to 199 180
. 3a- ,
3 , 3b- 2- ).(1:100,000
.ASA 4 BP > 200/115 .
.
. .

:
.
.
. .
, .
.200/115
: 2 2% .1:100,000
" , :
1.8" 0.018 100" . , .
4- .1:200,000
Heart Murmur
.
.
- Mitral Valve Prolapse .
Artificial heart valve
.
.
.
Heart pacemaker
.
,Demand Type .
.
,.

32


:
.
o
: . .
o
.
o
.
.
,
.
.
Anemia
.
.
.

Methemoglobinemia .
Prilocaine .Articaine - , +3-
+2 .

CVA - stroke
) CVA (CerebroVascular Accidet ) TIA (Transient Ischemic Attack
.
,4ASA - , .
" .
2-3 .
.1:100,000 .

Kidney Trouble
.
Local
.Anesthetic
, , ,
.
) ,(Hay Fever ,
, .

".

:





'


.
.

33

 :
, .
) ( .
, -
) Bupivacaine (.
Pain in Jaw Joints
, ) Gow-Gates Inferior
.(Alveolar Nerve Block
Vasirani-Akinosi Closed
Mouth Mandibular Block .Extraoral Nerve Blocks
.
, A ,B- , ,Drug Addiction ,
, .
.
A B- . , ,
.
A ,B- , , .
, .

.
- .
.
.
IV .grand mal
.

.
.
:
.
o
.MAO
o
.
, MAO , .
Bruise Easily

.
:
.Inferior Alveolar nerve block
o
.Posterior Superior Alveolar Nerve Block
o
.Mental or Incisive Nerve Block
o

.

34


149.
CimetidineLidocaine-
.2H .
.
.
Congestive Heart Failure .3ASA
. ,
.
, .

- .
) (.
,
. ,
.

-Blockers

.
- 0.04-0.35" 2-16 . .1:100000
3
.1:100,000
1
.
" .
5-10 ) Levonordefrin ( , 2
"
.
. .

Levonordefrin .TCA
0.05" , 5.4" 3-4 ,1:100,000
.
MAO Inhibitors
, .OCD -
" ) MAO
(.
, .Levonordefrin-
PhenothiazineEpinephrine-
.
.postural hypotension .
.
".
1

TCA Reuptake- , .

35

,
.

Cocaine Epinephrine-
.
reuptake .
- , " , ,
.
,
.

36

11.12.06
"
)Chapter 11; Basic Injection Technique (p. 159

Basic Injection Technique

19 , :
.
.

:
19 .
Sterile Sharp Needle .1
. ,
.Hooked
.Check flow for Local Anesthetic (L.A.) Solution .2
.
.a
, , .
.b
, , . .
.Temperature of LA Solution .3
) 22-(.
.a
.
.b
:
.c
.i .
.ii , .
.Position of the patient .4
.
.a
.
.b
.
.Dry the tissue .5
.
.Apply topical Antiseptic (Optional) .6
.
.Applicator-
.a
, .
.b
.Apply Topical Anesthetic .7
.
.a
2 40- .
.b
.Communicate with the Patient .8
, .
.a
:
.b
.i
.ii

.iii
:Use :
.c
.i

37

 .ii.
.Establish a firm hand rest .9
.
.a
.
.b
.
.c
.
.d

.e
. ,
.
.f
.g

:
Finger Rest .i .
Elbow Rest .ii .
:
.i .
.ii . .

) Make the tissue taut .10 (.

.
.a
, ,
. , ,
, .
.
.b
, .
.c
.Keep syringe out of patients sight .11 .
.
Insert the needle into the mucosa .12 ,:
.
.a
. .
.b
. .
.c
. , .
.
.d
.
.e
!
.f
.Watch and communicate with the patient .13
. , , ,
.a
. , .
.
.b
" .i "
" .ii "
.SLOWLY advance needle to target .14
.
.a
:
.b
.i . ,
, .
.ii .
.Aspiarte .15
!!! .
.a
. .
.b

38

.c

. , , , .
.

.Deposit LA slowly .16

:
.a
.i . ,
- , ,
. - ,
.
.ii !
.1ml/min
.b
.1.8ml/min
.c
.Slowly withdraw and recap the needle .17 .
Cap- .
.a
, " Cap- . .
) Sharps Container- (.
.b
.Watch the patient .18
.
.a
:
.b
.i .
5-10 .ii .
.Record the injection .19 . :
.
.a
.
.b
.
.c
.
.d

39

 Local Anesthetic Technique -

Types of injection
Local Infiltration , . .
. ."
.
- Field Block . .
- Nerve Block . .
, .

.
.
' ) (V ,
, ] . [.
:
Maxillary
o
Block .
Posterior Superior alveolar nerve

,
) ,
.(Middle Superior -
7 ,8- .6-
Middle Superior Alveolar nerve ,

. 5 ,6- .4- .
- Anterior Superior Alveolar Nerve .

2 ,3.1-

40

 :
Supraperiosteal .
.
.PSAN Block Posterior Superior Alveolar Nerve Block
MSAN Block Middle Superior Alveolar Nerve
ASAN Block Infraorbital Anterior Superior Alveolar Nerve Block
Greater Palatine Nerve Block
Naso-Palatine Nerve Block
.Maxillary Block
:
Periodontal Ligament (PDL, Intraligamentary) .PDL- .
Intraseptal . , .

Supraperiosteal Injection

.
, ,
. , .
4 - , 4 .
,
.

41

, .
.

, ,
.
, , ) (.

)PSAN Block (Posterior Superior Alveolar Nerve Block

. )< .(95% ,
.
)( ) .(6,7,8 ,
, .
.Middle Superior Alveolar Nerve- ,
," .Supraperiosteal

)
10-14( . ,
. , "" , ,
.
, .

,
MucoBuccal Fold- .PSA Nerve-
16" ) 20-"( .
.
,gauge short needle 25-
27gauge , .
.

42

 ,Gauge" '.

.Tuberosity Block, Zygomatic Block

PSA Nerve.

)( , ) 72%- ,
o
28%- (.
.
o

.
o
) Supraperiosteal Injection- (.
o
Supraperiosteal Injection .
o
, .
o

) ( . Supraperiosteal- PDL
.Injection

Atraumatic .
o
"" .
High Success Rate 95% .
o
Minimum Number of necessary Injection .
o
.
.
o

o
o
o

3.1%-.

Supraperiosteal PDL Injection .

o
.
o
.Maxillary Nerve Block
o

o
o
o
o

- .
"" .
28% - .

- ,gauge 25
) gauge 27 (.
- ) (.
) .Posterior Superior Alveolar Nerve (PSAN ,
.

Mucobuccal Fold

Maxillary Tuberosity

43

o
o

Zygomatic Process of the Maxilla

:Bevel - .
194-195.

" . .
o
.
o

, .
o
.
o

. .
.

. .
o
. .
o
. .
o

.
o
" .Pterygoid Plexus of Veins -

, . .
.

.
.

(.
.Mandibular Anesthesia
o
)'( .PSA Nerve-

."F
.
:
, . PSAN- Maxillary -
.Tuberosity
, 45 - 45 . ,
, .
. -
.Maxillary Process of the Zygomatic arch .

.
.
15-16 -" . .
21".
32".
!
.

44

)MSAN Block (Middle Superior Alveolar Nerve Block

Middle Superior Alveolar Nerve- 28%- , .
Infraorbital Block - MSAN Block-
- .
.
Nerves Anesthetized
Middle Superior Alveolar Nerve.
:Areas Anesthetized
.Pulp of MesioBuccal root of 1st molar & 1st and 2nd premolars
Buccal Periodontal Tissues and Bone .

)Infraorbital Nerve Block (Anterior Superior Alveolar Nerve Block

.ASAN .1
.MSAN .2
Infraorbital Nerve .3 :
.Inferior palpebral
.a
.Lateral Nasal
.b
.Superior Labial
.c

, , ,
, , 72%-
) Middle Superior Alveolar Nerve- (.

.
.
:
, , ,.
. .
, . ,
. . .
, .
, . .
, ,
.

, .
:

.
Supreperiousteal Injection-
Supreperiousteal Injection .
. .
.
.

45

 16".
.
. , .
,
, , , .
infraorbital block -
, .
. , . ,
.

Grater Palatine Nerve Block

.
.
Greater -
.Palatine Foramen ,
, .
.
Greater Palatine Nerve Block- , .
,Greater Palatine Foramen-
.
.
, .
.
.

) "( .
. ,WAND - ,
. , , 1000-
. 8 ,
.

, )!( . .
.

Nasopalatine Nerve Block

.
.
Nasopalatine Nerve- Incisive Foramen -
. .Incisive Papilla -

. )
( . .
.
, Incisive Papilla-
.
, .
2-3 , .
:
.1 .

46

 .2 Incisive Papilla- .Nasopalatine Nerves-

.3 .
, , .Nasopalatine Nerve-

Maxillary block
" ) .(posterior superior alveolar nerve block-
.
,
.
:
,
.
.

) (
)( ' . )(.
, .
.
:
.
.
, .
:
- Greater Palatine Canal greater palatine canal- .greater palatine fossa
.
- High Tuberosity .high tuberosity-
.
:Maxillary Block
,4 . 4:
PSAN block
o
Infraorbital nerve block
o
Greater palatine nerve block
o
NasoPalatine Nerve Block
o
, .85%
.
Greater Palatine Canal Technique
.1 27G.
.2 .
.3 30-" .
.4 , ,
, . !
.5 .

47

 .6 3-5.

High Tuberosity Technique

.1 27G.
.2 .PSAN Block-
.3 30-" .
.4 .
.5 .
.6 3-5.
.

48

49


- Malamed ,14 .227
Regional Anesthesia of the mandibular nerve and its subdivisions
. " ,
.
! ) (20%-15% ,
, ).(10%
.
, .
Inferior dental nerve block .1
Direct
.a
Indirect
.b
Extraoral
.c
Mandibular Blocks .2 .
.Gow Gates .
.a
) Vasirani (1960) Akinosi (1977 .
.b
.Extraoral
.c

Inferior Dental Nerve Block

Direct Method
:

, , .
, .
:

- Coronoid Notch .
o
.Occlusal plane mandibular teeth
o
Pterygomandibular Raphe Buccinator ,Superior Pharengyal -
o
.Constrictor
. Retromolar fossa
, .Coronoid notch

50

 .raphe
, .

, ,
) .(9
:

,coronoid notch- .
.
" - , .
" ,
, .
.
, .
.
,
.

, .
,
.

.Coronoid Notch-
raphe
.

51

 - 32" , 25".
Indirect method

, .
.1
.2
.3
.4
.5

- Initial Needle Insertion -

,external oblique-
.
- Partial Withdrawal .
Syringe moved parallel to molars
.
- Needle Advanced to lingula ,
.
- Syringe returned to original position
,1 , ,
, ,.

,
. .
.
.

Mandibular Nerve Block

Vazirani/akinosi closed mouth technique
.
15" ,
Muco-Gingival junction ,
.
.
,
,
,
, ,
.
, .
. ,
, .
, , Onset- .
Gow gates , .Vazirani/Akinosi-
:
.

:
.

52

.
.
.

:
, 25-".

, , .
40-90 , 5.
Gow gates technique
" , .
.

.
.
75% -.
.
.

, , , ,Temporalis- .

Gow-Gates- . , .
, ,
, 5 .

.
- 95% - , .
.
.
.

:
5.

53

2% . .10%

:
:
.
o
.Tragus
o
.Intertragic Notch
o

:
. .
o
.
o

:
.
. .
25".
.
internal maxillary artery : . ,
o
.
: .
o
1-2.
3-5 5-7 :

54

 .
o
.
o
3 .

Buccal nerve block

V3 .Inferior Alveolar Nerve Block
.
) ( ,100%-
.

, ) .(V3 ,

.
: .
: .
: .Mucobuccal Fold ,
:
.
.

)Mental nerve block (& Incisive

Inferior Alveolar Nerve- Mental Foramen- , .
.
.
, .
, - .
.
, , ,
, ,
. , .
5 , .
, .

55

18.12.2006

,Systemic Complications ,18 Handbook of local anesthesia / :
Stanley F. Malamed
, .
. -
.
.
."
. , . ,
.
, .
, , .
. ,
.
, .
, .
.
, ,
.

,
.
. , . .
. Hepato-Toxicity
" .
.
, , ,
.

.
.

.
.

. .
.
Idiosycrasy .
.
.
. .

56

 :
.1
.
.
.2 . .
.
. .
.
.3 - ,
Novocain .
.
. , )
, ( .
.
"
.
.
, .
, ,
.
" ) ,(Over Dose 99%-
. .
OD , OD . .

, . ,
,
. OD
.
, , " .
, ,
, ,
.
.
- .
.
,
.
.
Mental Attitude , ,
. ,
,
.

Overdose

.Over DOSE- OD- .
,
.

.
,

57

,
.

.
.
.

, 2% .4% ?
(All or None) 2%- .
- OD .
.
.
OD . .
.
.
, . .
.OD- .
. 0Inf.-
.Alveolar N. Block . OD- -
.IANB , .

Over Dose
, , .
,
. .

. ,
.
.
OD ) ( .
."
. "
,
.
.
.OD
.Atrial Fibrillation -
.
) ,
, ( . ,-
,OD .
.
, . 7 .
.
, , ,
.
, . .

" .
," .

58

. .
.
, 27G
. 30G
. .
Gauge- 27 .
.
! 1.8cc 80.
OD
.
OD
".
60-160mg ) 160" (
g/ml. 160 0.5-2.0" 7.
1.8" , .2% " , 36".
0.5-2.0 " 60-160"
.

CNS Central Nervous System

CVS Cardiovascular System

Adverse Drug Reaction

.
> g/ml 0.5 0.5- " OD .

g/ml 0.5-4.0 .
.4.5 g/ml - Excitation<
7.5 g/ml < .
, .
OD- , .
,
. ) 5 "( .
,CO- ....
10 " .

.
.
, 0.5-2.0 . 7-8-.
) 0.5-4.0" "(.
, ,
, Cardiac Arrest-
.

? :OD

59

'

"

."
OD
. OD- .
OD
.OD

. "
. OD- .
, OD .
. .
Fast Onset
Slow Onset , 15-.
Fast Onset
5- , , , ,
, , . .
.
. ,
.
Slow Onset
" .
, , .
, ,
. , .
.
, ,,
, . .
Over Dose , OD 5-15
.
. ,
, , . .
. ,
, CVA .

60

Severe Over Dose

" .
, ,OD .
Severe Overdose-
.1 .
.2 )( , , .
.3 .
.4 , .
.5 5 - .
" . " .
- Postseizures CNS Depression .6 , ,
:


Airways - , .
" .
,
,
, .
.7 " ,.
- Recovery Period .8 .Recovery
, .
OD :
Too Large Dose

Rapid Absorption

Abnormal Biotransformation

.Renal Dysfunction

.

,Airway .
" )( 3cc 1:1,000
, 0.3cc- 1:10,000 .

:Overdose
.1 .
.2 .

61

 .OD- .
.OD Local Ansthetic-
.

," .
.
:
Bronchspasm


:





. .
- .
- .
-- , ,
) ( .
.
,
.
:
.

, , .
, .

, , 1cc
. ,Challenge Test 1cc ,
.
. "
.

, :
.
.
.
.
.
.
, .
.
.
.
.

62


Local Complications.ppt :

:
NEEDLE BREAKAGE
PERSISTENE ANESTHESIA OR PARESTHESIA
FACIAL NERVE PARALYSIS
TRISMUS
SOFT-TISSUE INJURY
HEMATOMA
PAIN ON INJECTION
BURNING ON INJECTION
INFECTION
EDEMA
SLOUGHING OF TISSUES
POSTANESTHETIC INTRAORAL LESIONS

3-10

. .
,IANB .
.
, . .
.
: , .
, , .
. .
, .
, .
.
. 5-"
.
.
. , .
.
:
.1 :
, .
.a
.
, ,
.b
, .
.2 .
.3
, , .
.a
. .
.b
,
.c
.

-PERSISTENT ANESTHESIA OR PARESTHESIA

Causes

63

. .
.

:
Self inflicting injury .
, .
:

.
8.
, .
.
.
.
) ' ,
(.
.
17
, .
18
, , .
.
19

, .
. .
20
, TLC . ...
21

TRISMUS
Causes
.Definition difficulty in opening the jaws due to muscle spasm
.
:
- Injection into the medial pterygoid muscle
o
Haematoma
o
Infection
o
,

.
.
.

64

.
) (.

, " .
.
.

, . , ,
, , .
. .
.
25

SOFT TISSUE INJURY

.
"" . .
, .
, .
.

, .
29

.2-11%
, .Pterygoid Venous Plexus-
.
.
, . 24 .
.Infra Orbital Block , .
30

PSA-

.

65

Immediate - apply local pressure

Ice
The swellings disappear within 48 hours
Antibiotics must be instituted promptly to prevent infection
The patient should be recalled for review within 24 hours

33

Pain on Injection
.
Careless injection technique .1
, A needle can become dull from multiple injections .2
. .
. , , .
. . Rapid deposition of the LA .3
.Needles with barbs (from impaling bone) may produce pain as they are withdrawn from tissue .4
.
. .
:
Adhere to proper techniques of injection, both anatomical and psychological .1
Use sharp needles .2
Use topical anesthetic properly before injection .3
Use sterile local anesthetic solution .4
Inject local anesthetic slowly .5
Be certain that the solution temperature is correct .6
20 . .
. .

BURNING ON INJECTION
Causes
:
. pH- pH
.

INFECTION
Rare after injection
Most common pterygomandibular space
Injection of LA in an infected area

66

 , ,22
.
)
(.
.

.
.
.

POSTANESTHETIC INTRAORAL LESIONS

. :
.RAS Recurrent Aphtous Stomatitis

.HSV Herpes Simplex Virus .

:
Topical anesthesia

Local steroids

Kenalog orbase .
" . ,
.
45

Failure to obtain anesthesia

. .
, , .
:Causes

.

.
:
pH , .
. .
49
.
.

67

Blanching

68

A result of the combination between increased tissue tension due to the deposition of fluid and
use of vasoconstrictor
The ischemia is transitory (0.5-30 min)
No treatment is needed

:
. ,
. ,
.
.
The introduction of disposable stainless-steel needles reduced greatly the incidence of this n
complication
Most cases following IAN block n
.In most cases the needle had been bent by the dentist n
.In all cases the needle had been inserted into the soft tissue its entire length n
Weakening of the dental needle by bending
Sudden unexpected movement by the patient as the needle penetrates muscle or contacts
periosteum
Needle breakage is not a problem as long as it can be retrived without surgical intervention
Needles within the tissue
Become encased in scar tissue

Localized or systemic infection rare

Leaving the needle is mostly better than extensive surgery

Large-gauge needles
Needles break at hub. A needle should never be embedded completely within the tissues. At
least 5 mm must project outside
Bended needles should be discarded The needle must be kept straight during its passage
through the tissues
Do not redirect a needle once it is inserted into tissues
Do not use excessive force

:
n
n
:
n
n

:
n
n
n
n
n

: .1
,
bite block . , ,
. ,
. ,
If the needle is los (not visible) and cannot be readily retrieved .2
Do not proceed with an incision or probing
.a
Calmly refer the patient; attempt to allay fears and apprehension
.b
Note the incident on the patients chart. Keep the remaining needle fragment. Inform
.c
your insurance carrier immediately
Refer the patient to an OMS (chirurg) for consultation, not for removal of the needle
.d
When a needle breaks, consideration should be given to its immediate removal, under the .3
:following conditions
The needle is superficial and easily located through radiological and clinical examination;
.a
removal by an OMS is possible

69

.b
.c
n
n
n

Despite its superficial location, attempted retrieval is unsuccessful with a reasonable

length of time; it is then prudent to abandon the attempt and allow the needle fragment
to remain
The needle is located in deeper tissues or it is hard to locate; it should be permitted to
remain without an attempt at removal

-:
Direct trauma from the bevel of the needle n
Injection of a solution contaminated with a neurotoxic substance such as alcohol - Use clearly n
labeled cartridges
: Hemorrhage and infection prompt antibiotic therapy n
.
n -
:Hyperesthesia or dysesthesia - a painful sensation to usually nonnoxious stimuli n
.
:

, , , ,
, .
, ,
, .
:

infr. Alveolar nerve block .
, .
: 10- , .
- ,
, - .
:
, .
, , .
, ,
, .
:
.
, , .
:
......
, -.
:
:Immediate - apply local pressure n

70

 ":Ice
The swellings disappear within 48 hours
Antibiotics must be instituted promptly to prevent infection
The patient should be recalled for review within 24 hours

n
n
n
n

:
Careless injection technique
, :A needle can become dull from multiple injections
. , , , ,
. ,
. , :Rapid deposition of the LA
Needles with barbs (from impaling bone) may produce pain as they are withdrawn from tissue

.1
.2
.3
.4

:
Increases patient anxiety and may lead to sudden unexpected movement, increasing the risk of
needle breakage

:
Adhere to proper techniques of injection, both anatomical and psychological
Use sharp needles
Use topical anesthetic properly before injection
Use sterile local anesthetic solution
Inject local anesthetic slowly
20 - ' ' : Be certain that the solution temperature is correct
. 20

.1
.2
.3
.4
.5
.6

:
:
. :pH of the solution
Rapid injection
Contamination of LA cartridge
Warm solutions

n
n
n
n

:
Indicates that tissue irritation is occuring
:Greater likelihood of complication as
Trismus

Edema

Paresthesia

n
n

:
Slow injection
Room temperature
pH

n
n
n

:
Rare after injection
Most common pterygomandibular space
Injection of LA in an infected area

71

n
n
n

 . . ,
!! !!!

:
Rare after injection
Most common pterygomandibular space
Injection of LA in an infected area

n
n
n

:
Disposable needles
Avoid needle or cartridge contamination
. :Prepare tissue before injection
Management - antibiotics

.1
.2
.3
.4

:
:
Trauma during injection
Infection
Allergy
Hemorrhage
Irritating solution

.1
.2
.3
.4
.5

: -
1 recurrent aphtous stomatitis (RAS) :
, , ",
.
. , ,

:
Symptomatic
Topical anesthesia

. . :Local steroids

.kenalog orabase E ,

:
The most common problem encountered during the use of local anesthesia
The incidence decreases as the experience increases
In most cases the onset of anesthesia is delayed

n
n
n
Cause

Faulty technique
Inadequate amount of local anesthetic deposited in close proximity of the nerve

Injection into a blood vessel

Solution
Repeat the injection after carefully checking the anatomical landmarks

72

. , ,
Cause - Injection in a purulent environment
Failure to obtain anesthesia due to pH

Risk of spreading infection beyond the defensive barriers

Cause
:Use of an anesthetics solution after the expiration date

. ,
-Solution
Ensure that the stock of anesthetic cartridges is not excessive and is used in strict

rotation

Cause (very rare)

Individual resistance to the effects of certain drug

-Solution
Use an alternative drug of different chemical composition

n
n

Intra-vascular injection
, , -
. . ,
An aspirating syringe should always be used
Aspiration is mandatory
If blood is seen the needle must be reinserted in a slightly different position
Systemic response due to either LA or vasoconstrictor

n
n
n
n
.

73

25.12.06

"

/
: , -
, , - ,
, .
: ,
.
- .

.1
.2

.3
.4

:
:regional blocks

:Neuroaxial blocks ,

, .

: .

)(Hypnosis
)(Analgesia
)(Muscle Relaxation
)(Amnesia

:
:
:
: . - -
.

.1 :
.a : , . "
, . ,
. GABA
, GABAa . , .
, .
, .
.b : , .
. . , ,
, .
,GABAA ,
, : , .
- ,

74

.2
.3
.4
.5

.
. .
.c
,IV , "
: .
:

)( :


"


"
, .
)( ::


PO, IV IM
, IM.
-, .

)( :


, ,
Propofol
.

.
o
. .
o
' . .
.
.
o
. .
o
.
1" .
, .

. .
.
.
.

75

. ,
.

Etomidate
. , , .

) ( 60/30 .
) (Perfusion Ratio .
, )(.

, .

Ketamine
, .NMDA

IV, IM .PO

, . .

.
.

, .

) (.
, .

" ) ( . .

.
. .

Opiates

, . ,
. ,
. 3-4
, , High Dose 50- 100.
. .
) .(K-
.
5 .
.Naloxone
.
.
.
.
)
(.
.
Remifentanil ) (.
, .
.
:
.
o

76

 :
CNS
CNS .
, , - ,
.

, CO , , " , .
, , ,
'.

, .
- .

:
, , ,
!
, .
.
2:
Depolarizing .a
Non-depolarizing .b
L:

2
, , .
:Depolarizing
: )(

, , -
, , 2-3 , ,
.
" ,plasma cholin esterase ,
, . , screening

:
, ,
- .

:
:
, ,
,

77

 - , .
. .
.
.malignant hyperthermia : , ,
" , , , ,
, , . ,
, -
, , . ,
, 100% , , ,
.

:Non-depolarizing


,

: - , ,
, ,.
,
.

Pancuronium , . " .
Vecorunium , .
Rocuronium )>( , .
Atracurium , ) pH( ,
.

:

: .
,
: , .
.
- : , .
" ,
.

:N2O :

:
: , ,
: ,
, .
.
,
.
, ,
. , .
. .

78

 Sevoflurane :halothane .
sevoflurane :desflurane -
:isoflurane ,
:Halothane , .

79

 -
B&S
Inch
Millimeter
Inch
B&S
Inch
Millimeter
Inch
Gauge (Decimal)
(mm)
(Fraction) Gauge (Decimal)
(mm)
(Fraction)
1
0.289
7.348
.
17
0.045
1.149
.
2
0.258
6.543
.
18
0.040
1.024
.
.
0.250
6.350
1/4
19
0.036
0.912
.
.
0.234
5.953
15/64
20
0.032
0.812
.
3
0.229
5.827
.
.
0.031
0.795
1/32
.
0.219
5.556
7/32
21
0.028
0.723
.
4
0.204
5.189
.
22
0.025
0.644
.
.
0.203
5.154
11/64
23
0.023
0.573
.
.
0.188
4.762
3/16
24
0.020
0.511
.
5
0.182
4.621
.
25
0.018
0.455
.
.
0.172
4.366
11/64
26
0.016
0.405
.
6
0.162
4.115
.
.
0.016
0.396
1/64
.
0.156
3.969
5/32
27
0.014
0.360
.
7
0.144
3.664
.
28
0.013
0.321
.
.
0.141
3.572
9/64
29
0.011
0.286
.
8
0.128
3.263
.
30
0.010
0.255
.
.
0.125
3.175
1/8
31
0.0089
0.226
.
9
0.114
2.906
.
32
0.0080
0.200
.
.
0.109
2.778
7/64
33
0.0071
0.180
.
10
0.102
2.588
.
34
0.0063
0.160
.
.
0.094
2.381
3/32
35
0.0056
0.142
.
11
0.091
2.304
.
36
0.0050
0.130
.
12
0.081
2.052
.
37
0.0045
0.114
.
.
0.078
1.984
5/64
38
0.0040
0.100
.
13
0.072
1.828
.
.
.
.
.
14
0.064
1.628
.
.
.
.
.
.
0.063
1.588
1/16
.
.
.
.
15
0.057
1.449
.
.
.
.
.
16
0.051
1.291
.
.
.
.
.
.
0.047
1.191
3/64

80