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Local Anesthesia in Endodontics

Dr. Soliman Kamha

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The dentist has many techniques available for controlling pain: topical anesthesia, local anesthesia, regional anesthesia or nerve blocks, and of supplemental forms anesthesia.
Dr. Soliman Kamha 2

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TOPICAL ANESTHESIA
• It is the topical application of anesthetics for various reasons. The principal means by which topical anesthesia is administered are liquids, troches, gels, sprays, and cooling. • This type of anesthesia is indicated for desensitizing the mucosa to needle pricks, which would be necessary for local infiltration.
Dr. Soliman Kamha 3

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Dr. Soliman Kamha

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thus. Dr.Slide 5 LOCAL INFILTRATION • Local infiltration may be defined as a technique by which an anesthetic solution is deposited within the treatment area. or any other tooth that has a palatal root.mandibular incisors. a buccal infiltration alone may not suffice. it is advisable to perform a palatal infiltration after the vestibular infiltration. Soliman Kamha 5 Slide 6 • To anesthetize the nerve fibers that innervate the palatal root of the upper molars or premolars. Soliman Kamha 6 . Dr. • This technique permits rapid.all the maxillary teeth and . • The palatal root is usually closer to the palatal than vestibular cortical bone. effective anesthesia for: .

Soliman Kamha 8 .Slide 7 • Palatal infiltration is quite painful. thus blocking the afferent impulses from travelling proximal to that point.5 ml) under adequate pressure. however. it more precisely anesthetizes the entire distribution of a specific nerve. Soliman Kamha 7 Slide 8 REGIONAL ANESTHESIA OR NERVE BLOCKS • Regional anesthesia or nerve block involves a larger area than infilteration. Dr. it should be performed slowly by steadily depositing a small amount of anesthetic (0. Therefore. Dr. • It is achieved by depositing the local anesthetic near the trunk of a major nerve.

Slide 9 • The success of this method depends on the dentist’s precision in depositing the anesthetic solution at a pre-selected anatomical point. Dr. • It serves to anesthetize all the mandibular nerves of the same quadrant. Soliman Kamha 10 . because the lower central incisors may be innervated by the controlateral hemiarch. Soliman Kamha 9 Slide 10 Inferior alveolar nerve block • This is usually called “mandibular nerve block”. • The anesthetic diffuses from this point in sufficient amounts and concentrations to produce the desired effect. Dr. it is preferable to anesthetize them by a vestibular infiltration to obtain more certain results. • However.

Soliman Kamha 12 . Soliman Kamha 11 Slide 12 • Adequate anesthesia is indicated by tingling and numbness of the lower lip and. when the lingual nerve is affected.Slide 11 Dr. Dr. which are innervated by the buccinator nerve. the tip of the tongue. • This technique does not achieve anesthesia of the vestibular mucosa or periostium associated with the molars.

• The needle is inserted in the alveolar mucosa between the two premolars. thus sparing the patient pointless paresthesiae.Slide 13 Mental nerve block • Anesthesia of the canine and lower first premolar can be achieved at the level of the mental foramen. • This has the advantage of taking effect sooner and avoiding anesthesia of the tongue. at the level of the mental foramen. Dr. Soliman Kamha 14 . Soliman Kamha 13 Slide 14 • It is performed by depositing the anesthetic solution near the mandibular canal. Dr. about 1 cm external to the vestibular surface of the mandible. rather than mandibular spine.

Soliman Kamha 16 . Soliman Kamha 15 Slide 16 • Particular attention must be paid to not injuring the mental nerve with the point of the needle.Slide 15 Dr. Dr. It must not be introduced in the mental foramen.

In the region of the canine. Soliman Kamha 18 . and injecting the anesthetic under pressure. Dr. • Course of the nasopalatine nerve after its emergence from the incisive foramen.Slide 17 Nasopalatine nerve block • The innervation of the soft tissues of the anterior one third of the palate arises from the nasopalatine nerve. next to the incisive papilla. • This procedure may be quite painful. which emerges from the incisive foramen. Soliman Kamha 17 Slide 18 • Anesthesia is achieved by introducing the needle into the palatine surface. However. terminal branches of this nerve are superimposed on terminal branches of the anterior palatine nerve. Dr. it is usually necessary in the case of extractions or other surgical procedures in this area.

Soliman Kamha 19 Slide 20 Anterior palatine nerve block • The innervation of the soft tissues of the posterior two-thirds of the hard palate arises from the anterior palatine nerve. • This nerve emerges from the greater palatine foramen. half-way between the alveolar crest and midline of the palate.Slide 19 Dr. Soliman Kamha 20 . Dr. which lies between the second and third molars.

Soliman Kamha 21 Slide 22 Dr.Slide 21 • Course of the anterior palatine nerve after its emergence from the greater palatine foramen • Anesthesia is achieved by introducing the needle near the point of emergence of the nerve from the foramen. Soliman Kamha 22 . Dr.

Dr. Soliman Kamha 24 . the needle is introduced into the lingual gingiva about halfway between the gingival margin and the base of the fornix.Slide 23 • This procedure is also quite painful and is used for extractions or surgical procedures. Dr. when anesthesia of the soft tissues of the hard palate from the tuberosity to the region of the canine or from the midline of the hard palate to the gingival margin is required. Soliman Kamha 23 Slide 24 SUPPLEMENTAL ANESTHETIC TECHNIQUES • Lingual infiltration It is useful in lower first molars with pulpitis. • Holding the syringe parallel to the occlusal plane.

Soliman Kamha 25 Slide 26 • The development of a whitish area of ischemia assures that the technique is correct. the technique is incorrect. Dr.Slide 25 Dr. Soliman Kamha 26 . • The approach must be repeated by inserting the needle more occlusally. a bubble-like collection of anesthetic forms in the lingual fornix. If. instead.

Soliman Kamha 27 Slide 28 Dr. Soliman Kamha 28 . Dr.4 ml).2-0. distally to the tooth to be anesthetized.Slide 27 • Intraseptal injection • This is accomplished at the level of the bony septum by introducing the needle into the dental papilla and injecting a minimum amount (0.

• For this reason. Soliman Kamha 29 Slide 30 • Because this type of anesthesia must be performed directly within the cancellous bone. together with a 27-gauge short needle. the dentist must overcome high pressures with the injection. Dr. such as Peripress. the use of an appropriate pressure syringe. is recommended.Slide 29 Dr. Soliman Kamha 30 .

in order to avoid systemic effects. Soliman Kamha 31 Slide 32 • As for all the intraosseous injections.Slide 31 Dr. Soliman Kamha 32 . • This anesthesia is indicated when the periodontal involvement precludes the use of the intraligamental injection. Dr. it is advisable to use an anesthetic solution without vasoconstrictor.

there is no lip and tongue anesthesia.Slide 33 • The advantages of the intraseptal anesthesia are several: only a minimum volume of solution is required. Dr. immediate onset of action (less than 30 seconds) and presents very few postoperative complications. and this has to be into consideration during endodontic treatment. Dr. Soliman Kamha 33 Slide 34 • Intraligamental infiltration • Injection into the space of the periodontal ligament is most effective when the local anesthesia achieved with traditional techniques is incomplete. • The pulpal anesthesia has a short duration. Soliman Kamha 34 .

Soliman Kamha 36 . Dr. Soliman Kamha 35 Slide 36 Dr. according to some authors. Citoject . according to others. by introducing the small needle (27-gauge) into the space of the periodontal ligament. or Ligmaject. the root of the tooth so as not to damage the radicular cementum. making sure that the needle’s bevel faces the bone of the alveolar crest.Slide 35 • This type of anesthesia is performed with the appropriate syringe.or. such as Peripress.

• The size of the needle has little relation to the anesthetic effect. Soliman Kamha 38 .Slide 37 • The needle must be forced to the point of maximal penetration.30 mm in diameter). • The indroduction of the needle should always be in the interproximal areas. and the anesthetic must be injected under high pressure. but these tend to bend easily. Dr. • The manufacturers of pressure syringes recommend very thin needles (0. • Better results are obtained with short. the anesthesia must be repeated for each root. Soliman Kamha 37 Slide 38 • The anesthetic effect is immediate and prolonged. never on the buccal. Dr. • In multirooted teeth. 25/27-gauge needles.

Slide 39 • Contraindications to the intraligamental injection include infection or severe inflammation at the injection site and primary teeth. Dr. • Brannstrom et al. • Other advantages of intraligamental anesthesia are that it does not require special equipment. following the administration of the periodontal ligament injection. reported the development of enamel hypoplasia in permanent teeth. • It may be done with a pressure syringe. Soliman Kamha 39 Slide 40 • In contrast to intrapulpal anesthesia. which is always painful for the patient. Soliman Kamha 40 . intraligamental anesthesia is painless if done after standard anesthesia. but may also be done with the same syringe and needle used for the standard injection Dr.

Dr. since they may attain pressures more than twice as high as regular syringes. Dr. it is not necessary to remove or lift it. the use of appropriate syringes is recommended. • Furthermore. Soliman Kamha 42 . since the vial is sheathed in a metallic or Teflon container. they better protect the patient against accidental rupture of the glass vial. • The opening of the rubber dam may be stretched slightly to identify the space into which to insert the needle. which can occur as a result of the high pressure generated. Soliman Kamha 41 Slide 42 • If it becomes necessary to use this type of anesthesia when the rubber dam is already in position.Slide 41 • Nevertheless.

the use of anesthetics containing catecholamines for intraligamental anesthesia is inadvisable in patients with ischemic heart disease or hypertension. Soliman Kamha 44 . Dr. intraligamental anesthesia may also be performed with the rubber dam in place. it needs only be stretched aside • Regarding the anesthetic solution’s distribution tissues.Slide 43 • If the need arises. in the intraligamental anesthesia must be considered all effects an to intraosseous anestesia. Soliman Kamha 43 Slide 44 • The injected solutions are rapidly absorbed by the systemic circulation • For this reason. Dr. There is no need to remove the rubber sheet.

• It requires the injection of anesthetic through as small an opening as possible in the roof of the pulp chamber. Soliman Kamha 46 . the intrapulpal injection is the next option Dr. the preferred supplemental technique to obtain profound pulpal anesthesia if the standard block or infiltration injection is not effective.Slide 45 • In conclusion. Soliman Kamha 45 Slide 46 • Intrapulpal infiltration • The intrapulpal injection assures certain results in 100% of cases. at this time is the periodontal ligament injection. Dr. • If even the periodontal ligament injection does not effect profound pulpal anesthesia.

Soliman Kamha 47 Slide 48 • It is important that the chamber opening be small and that the needle be well engaged. This assures good pressure within the chamber itself. profound anesthesia.Slide 47 Dr. • The pressure thus transmitted to the pulp tissue causes instantaneous. Dr. even for very prolonged endodontic procedures. Soliman Kamha 48 .

Slide 49 • In multi-rooted teeth. however. Soliman Kamha 50 . Soliman Kamha 49 Slide 50 Intra-osseous anesthesia • It is a supplemental technique where the solution is deposited directly into cancellous bone adjacent to the affected tooth. Dr. Dr. but the sensitivity will last for only a few seconds. • It suffices to inject a few drops of anesthetic under pressure to obtain the desired effect. it may be necessary to repeat this type of anesthesia in the individual canals. • The anesthesia may be painful.

Soliman Kamha 51 Slide 52 • A special perforator is used to penetrate though bone. Dr. anesthesia of the attached gingiva 2. Dr.Slide 51 • The technique involves three simple steps: 1. cortical bone perforation 3. Soliman Kamha 52 . deposition of anesthetic solution into cancellous bone. then a guide sleeve is left through which the needle is inserted and the solution deposited slowly.

Soliman Kamha 54 . Dr. The duration ranges between 15 to 30 minutes which is quite sufficient to remove pulpal tissue. Soliman Kamha 53 Slide 54 • The duration of anesthesia in ALL SUPPLEMENTAL injections is shorter than with standard infiltration or nerve block. the vasoconstrictor will enter the circulation and cause palpitations that will resolve in few minuites.Slide 53 • Since it is directly inside bone. Dr.

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