tec. regional anesth vijay

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Techniques Techniques of of Regional Regional anaesthesia anaesthesia Presented by Dr.R.VIJAYAKUMAR

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Page 1: Tec. regional anesth vijay

TechniquesTechniques of of

Regional Regional anaesthesiaanaesthesia

Presented byDr.R.VIJAYAKUMAR

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ContentsContents

Introduction Introduction Evaluation of the patientEvaluation of the patient Basic injection techniqueBasic injection technique Infiltration techniquesInfiltration techniques Field block and nerve blockField block and nerve block Nerve blocks for maxillary nerve subdivision and Nerve blocks for maxillary nerve subdivision and

its branchesits branches Nerve blocks for mandibular nerve subdivision and Nerve blocks for mandibular nerve subdivision and

its branchesits branches

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IntroductionIntroduction

Anaesthesia :-Anaesthesia :-

““an” means “with out;” an” means “with out;” ““aisthetos” means “sensation”aisthetos” means “sensation”

Local anaesthesia:-Local anaesthesia:- Loss of sensation in a circumscribed area of the body by a Loss of sensation in a circumscribed area of the body by a

depression of excitation of nerve endings or an inhibition of depression of excitation of nerve endings or an inhibition of conduction process in peripheral nerves without loss of conduction process in peripheral nerves without loss of consciousnessconsciousness

Regional anaesthesia:-Regional anaesthesia:- Loss of pain sensation as well as interruption of all other Loss of pain sensation as well as interruption of all other

forms of sensation including temperature, pressure and motor forms of sensation including temperature, pressure and motor functions over a specific area of the body.functions over a specific area of the body.

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Evaluation of the patientEvaluation of the patient

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Basic injection techniqueBasic injection technique

1. Use a sterilized sharp needle.1. Use a sterilized sharp needle.

2. Check the flow of local anesthetic solution.2. Check the flow of local anesthetic solution.

3. Determine whether to warm the anesthetic 3. Determine whether to warm the anesthetic cartridge or syringe.cartridge or syringe.

4.Position the patient.4.Position the patient.

5.Dry the tissue. 5.Dry the tissue.

6.Apply topical antiseptic (optional).6.Apply topical antiseptic (optional).

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Basic injection techniqueBasic injection technique

7a. Apply topical anesthetic.7a. Apply topical anesthetic. b. Communicate with the patient.b. Communicate with the patient. 8 . Establish a firm hand rest.8 . Establish a firm hand rest. 9 . Make the tissue taut.9 . Make the tissue taut.10 . Keep the syringe out of the patient's line 10 . Keep the syringe out of the patient's line

of sight of sight 11 a. Insert the needle into the mucosa.11 a. Insert the needle into the mucosa. b. Watch and communicate with the patient.b. Watch and communicate with the patient.

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Basic injection techniqueBasic injection technique

12. Inject several drops of local anesthetic 12. Inject several drops of local anesthetic solution (optional).solution (optional).

13. Slowly advance the needle toward the 13. Slowly advance the needle toward the target.target.

14. Deposit several drops of local anesthetic 14. Deposit several drops of local anesthetic before touching the periosteum.before touching the periosteum.

15. Aspirate.15. Aspirate.

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Basic injection techniqueBasic injection technique

16a.Slowly deposit the local anesthetic solution.16a.Slowly deposit the local anesthetic solution.

16b.Communicate with the patient.16b.Communicate with the patient.

17. Slowly withdraw the syringe. Cap the needle 17. Slowly withdraw the syringe. Cap the needle and discard.and discard.

18. Observe the patient after the injection.18. Observe the patient after the injection.

19. Record the injection on the patient's chart.19. Record the injection on the patient's chart.

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Classification of techniques of Classification of techniques of regional anaesthesiaregional anaesthesia

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Surface or topical anaesthesiaSurface or topical anaesthesia

Indications Indications Forms of surface anesthesiaForms of surface anesthesia

1.1. Spray – 10% - 20% lignocaine HCl in water Spray – 10% - 20% lignocaine HCl in water base, ethyl chloride base, ethyl chloride

2.2. Ointment – 5% lignocaine HCl Ointment – 5% lignocaine HCl

3.3. Emulsion – 2% lignocaine HCl Emulsion – 2% lignocaine HCl

4.4. Jet injection – with hypodermic needle.Jet injection – with hypodermic needle.

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Infiltration techniquesInfiltration techniques

Nerves and areas anaesthetizedNerves and areas anaesthetized IndicationsIndications Contraindications Contraindications AdvantagesAdvantages DisadvantagesDisadvantages Applications Applications

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Technique of InfiltrationTechnique of Infiltration

Needle: gauge 25, 27 or 30 Needle: gauge 25, 27 or 30 Length: 1" or 25 mm.Length: 1" or 25 mm. Bevel of the needle: facing towards the Bevel of the needle: facing towards the

bone.bone. Point of insertion: In the middle of the area Point of insertion: In the middle of the area

to be operated.to be operated. Depth of penetration: Beneath the mucous Depth of penetration: Beneath the mucous

membrane into the connective tissue.membrane into the connective tissue.

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Types of Infiltration AnaesthesiaTypes of Infiltration Anaesthesia

Conventional Conventional 1. Submucosal or subcutaneous anaesthesia 1. Submucosal or subcutaneous anaesthesia 2. Paraperiosteal or supraperiosteal anaesthesia 2. Paraperiosteal or supraperiosteal anaesthesia 3. Subperiosteal anaesthesia 3. Subperiosteal anaesthesia 4. Palatal infiltration4. Palatal infiltration

Supplementary Supplementary 1. Intraligamentary (Periodontal ligament) anaesthesia1. Intraligamentary (Periodontal ligament) anaesthesia 2. Intrapulpal anaesthesia2. Intrapulpal anaesthesia 3. Intraosseous anaesthesia 3. Intraosseous anaesthesia 4. Intraseptal anaesthesia4. Intraseptal anaesthesia

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Submucosal or subcutaneous Submucosal or subcutaneous anaesthesia anaesthesia

TechniqueTechnique The solution is deposited in the immediate The solution is deposited in the immediate

submucosal tissue layers submucosal tissue layers The solution diffuses through the interstitial tissues The solution diffuses through the interstitial tissues

and reaches the terminal fibres of the nerve .and reaches the terminal fibres of the nerve .ProcedureProcedure The needle is inserted beneath the mucosal layers. The needle is inserted beneath the mucosal layers. Excessive amounts injected superficially may lead to Excessive amounts injected superficially may lead to

sloughing of the overlying tissues. sloughing of the overlying tissues. 0.25-0.5 ml of the local anaesthetic solution is 0.25-0.5 ml of the local anaesthetic solution is

deposited.deposited.

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Paraperiosteal or supraperiosteal Paraperiosteal or supraperiosteal anaesthesiaanaesthesia

Commonly used injection technique Commonly used injection technique for obtaining anesthesia in the region of all for obtaining anesthesia in the region of all maxillary teeth and mandibular anterior teeth. maxillary teeth and mandibular anterior teeth.

By this method the local anaesthetic solution is By this method the local anaesthetic solution is deposited just above and besides the deposited just above and besides the periosteum.periosteum.

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Paraperiosteal or supraperiosteal Paraperiosteal or supraperiosteal anaesthesiaanaesthesia

Dr. Nevin’s TechniqueDr. Nevin’s Technique

All maxillary incisors can be anaesthetized by All maxillary incisors can be anaesthetized by making the initial puncture over canine on making the initial puncture over canine on each side and passing the needle horizontally each side and passing the needle horizontally towards central incisors infiltrating the apices towards central incisors infiltrating the apices of individual teeth.of individual teeth.

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Paraperiosteal or supraperiosteal Paraperiosteal or supraperiosteal anaesthesiaanaesthesia

AdvantagesAdvantages DisadvantagesDisadvantages Nerves anaesthetizedNerves anaesthetized Areas AnaesthetisedAreas Anaesthetised IndicationsIndications ContraindicationsContraindications

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Paraperiosteal or supraperiosteal Paraperiosteal or supraperiosteal anaesthesiaanaesthesia

TechniqueTechnique Needle: 25 or 27 G short needle .Needle: 25 or 27 G short needle . Point of insertion:Point of insertion: At the height of the mucobuccal fold .At the height of the mucobuccal fold . Target area:Target area: The apical region or above the apex of the The apical region or above the apex of the

tooth to be anaesthetized.tooth to be anaesthetized. Depth of insertion: Few millimeters.Depth of insertion: Few millimeters. Bevel: Should be facing towards the bone.Bevel: Should be facing towards the bone.

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Paraperiosteal or supraperiosteal Paraperiosteal or supraperiosteal anaesthesiaanaesthesia

Landmarks:Landmarks:1.1. Mucobuccal fold in the region of the tooth to be Mucobuccal fold in the region of the tooth to be

anaesthetizedanaesthetized2.2. Crown of the toothCrown of the tooth3.3. Root contour of the toothRoot contour of the tooth

Procedure Procedure Position of the patientPosition of the patient Position of the operatorPosition of the operator Preparation of the tissuesPreparation of the tissues

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Subperiosteal anaesthesiaSubperiosteal anaesthesiaTechniqueTechnique NeedleNeedle Length is 1" and the gauge is 25.Length is 1" and the gauge is 25. The needle is inserted midway between gingival The needle is inserted midway between gingival

margin and the approximate apex of the tooth and at margin and the approximate apex of the tooth and at right angle to the buccal alveolar plate.right angle to the buccal alveolar plate.

As the needle progresses, about 0.3-0.5 ml of local As the needle progresses, about 0.3-0.5 ml of local anaesthetic solution is injected slowly.anaesthetic solution is injected slowly.

The periosteum will force the solution through the The periosteum will force the solution through the cortical plate and into the cancellous bone.cortical plate and into the cancellous bone.

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Subperiosteal anaesthesiaSubperiosteal anaesthesia

AdvantagesAdvantages1.1. More appropriate, more specific.More appropriate, more specific.2.2. No great traumaNo great trauma3.3. SafeSafe4.4. Less solution is required [0.3-0.5 ml]Less solution is required [0.3-0.5 ml]5.5. The onset of action is rapid. The onset of action is rapid.

DisadvantagesDisadvantages

AdvantagesAdvantages1.1. More appropriate, more specific.More appropriate, more specific.2.2. No great traumaNo great trauma3.3. SafeSafe4.4. Less solution is required [0.3-0.5 ml]Less solution is required [0.3-0.5 ml]5.5. The onset of action is rapid. The onset of action is rapid.

DisadvantagesDisadvantages

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Supplementary TechniquesSupplementary Techniques

Intraligamentary (Periodontal ligament) Intraligamentary (Periodontal ligament) anaesthesiaanaesthesia

Intrapulpal anaesthesiaIntrapulpal anaesthesia Intraosseous anaesthesia Intraosseous anaesthesia Intraseptal anaesthesiaIntraseptal anaesthesia

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Intraligamentary (Periodontal ligament) Intraligamentary (Periodontal ligament) anesthesiaanesthesia

The name suggests, the local anaesthetic The name suggests, the local anaesthetic solution is deposited into the periodontal solution is deposited into the periodontal ligament or membrane. ligament or membrane.

AdvantagesAdvantages DisadvantagesDisadvantages

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Intraligamentary (Periodontal ligament) Intraligamentary (Periodontal ligament) anaesthesiaanaesthesia

TechniqueTechnique

Needle: 25 gauge.Needle: 25 gauge. The solution is injected along periodontal The solution is injected along periodontal

membrane of teeth, usually 0.2 ml, delivered via a membrane of teeth, usually 0.2 ml, delivered via a specifically designed system which comprises of specifically designed system which comprises of high pressure syringes and ultrafine needles. high pressure syringes and ultrafine needles.

This technique can anaesthetise only single This technique can anaesthetise only single individual toothindividual tooth

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Intraligamentary (Periodontal Intraligamentary (Periodontal ligament) anaesthesialigament) anaesthesia

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Intrapulpal AnaesthesiaIntrapulpal Anaesthesia

Indication : for obtaining anaesthesia Indication : for obtaining anaesthesia which require direct instrumentation of the which require direct instrumentation of the pulp tissue. pulp tissue.

25 or 27G needle is inserted directly into 25 or 27G needle is inserted directly into the pulp chamber. The needle should be the pulp chamber. The needle should be held firmly or wedged into the pulp held firmly or wedged into the pulp chamber or the root canal. chamber or the root canal.

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Intrapulpal AnaesthesiaIntrapulpal Anaesthesia

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Intraosseous Injection TechniqueIntraosseous Injection Technique

The local anaesthetic solution is deposited The local anaesthetic solution is deposited directly into the cancellous bone adjacent to directly into the cancellous bone adjacent to the tooth to be anaesthetised, between the two the tooth to be anaesthetised, between the two cortical plates of bone .cortical plates of bone .

Intraosseous injection is usually an adjunct, Intraosseous injection is usually an adjunct, and is used when conventional methods have and is used when conventional methods have been Tried and failed.been Tried and failed.

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Intraosseous Injection TechniqueIntraosseous Injection Technique

Advantage:Advantage:

It produces profound single tooth It produces profound single tooth anaesthesia.anaesthesia.

Disadvantage:Disadvantage:

Specialized equipment and technique is Specialized equipment and technique is needed.needed.

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Intraosseous Injection TechniqueIntraosseous Injection Technique

TechniqueTechnique The soft tissues overlying the apex of the tooth are The soft tissues overlying the apex of the tooth are

first anaesthetised with Paraperiosteal injections. first anaesthetised with Paraperiosteal injections. A small opening or perforation is made in the outer A small opening or perforation is made in the outer

cortical layer of bone with the help of round bur. The cortical layer of bone with the help of round bur. The drill is similar to 25 G needle.drill is similar to 25 G needle.

The solution is placed through outer cortical plate The solution is placed through outer cortical plate into cancellous bone with the help of a needle, which into cancellous bone with the help of a needle, which is inserted through the perforation.is inserted through the perforation.

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Intraosseous Injection TechniqueIntraosseous Injection Technique

ProcedureProcedure Preliminary infiltration: In order to prevent Preliminary infiltration: In order to prevent

trauma, a few drops of infiltration is made trauma, a few drops of infiltration is made before making a perforation.before making a perforation.

Incision is made and mucoperiosteum is Incision is made and mucoperiosteum is elevated and buccal alveolar plate is elevated and buccal alveolar plate is perforated with a round bur at an angle of 45° perforated with a round bur at an angle of 45° to the long axis of the teeth directing palatally to the long axis of the teeth directing palatally or lingually.or lingually.

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Intraosseous Injection TechniqueIntraosseous Injection Technique

Drill the external plate until it reaches Drill the external plate until it reaches cancellous bone. The drill should not enter cancellous bone. The drill should not enter more than 2 or 3 mm.more than 2 or 3 mm.

The needle is inserted into the opening The needle is inserted into the opening created; and 0.5-1 ml of solution is slowly created; and 0.5-1 ml of solution is slowly injected under pressure.injected under pressure.

Anaesthesia by this method will be of short Anaesthesia by this method will be of short durationduration..

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Intraosseous Injection TechniqueIntraosseous Injection Technique

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Precautions to be takenPrecautions to be taken Deposition of too much solution rapidly may Deposition of too much solution rapidly may

produce signs and symptoms of toxic reactionsproduce signs and symptoms of toxic reactions it is easy to find the drill hole, and inject a small it is easy to find the drill hole, and inject a small

amount of solution, if operation to be postponed to a amount of solution, if operation to be postponed to a later date . later date .

Never attempt to anaesthetise more than one tooth on Never attempt to anaesthetise more than one tooth on each side of the drill opening. This requires too each side of the drill opening. This requires too much of local anaesthetic solution which may much of local anaesthetic solution which may produce toxic symptoms.produce toxic symptoms.

In Mandible: make drill opening in the retromolar In Mandible: make drill opening in the retromolar triangletriangle

Intraosseous Injection TechniqueIntraosseous Injection Technique

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Intra septal AnaesthesiaIntra septal Anaesthesia

A needle is forced gently into the porous A needle is forced gently into the porous interseptal bone on either side of the tooth interseptal bone on either side of the tooth under pressure into the cancellous bone. under pressure into the cancellous bone.

More effective in children and young adults.More effective in children and young adults.

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IndicationIndication

where the intraligamentary anaesthesia is not where the intraligamentary anaesthesia is not quite effective.quite effective.

Technique (1)Technique (1)

The injection is given in the septum of two The injection is given in the septum of two adjoining teeth, in between the two cortical adjoining teeth, in between the two cortical plates..plates..

Intra septal AnaesthesiaIntra septal Anaesthesia

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Intra septal AnaesthesiaIntra septal Anaesthesia

Technique (2)Technique (2) The needle is inserted into the opening made The needle is inserted into the opening made

and few drops of local anaesthetic solution are and few drops of local anaesthetic solution are injected slowly, under pressure.injected slowly, under pressure.

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Local Infiltration of the PalateLocal Infiltration of the Palate Palatal injections are potentially painful.Palatal injections are potentially painful. Informing the patient prior to injection about the pain Informing the patient prior to injection about the pain

during the injection helps in preparing the patient during the injection helps in preparing the patient psychologically.psychologically.

Precautions to be TakenPrecautions to be Taken Deposition of excessive solution causes blanching of Deposition of excessive solution causes blanching of

overlying soft tissues and results in necrosis.overlying soft tissues and results in necrosis. Highly concentrated vasoconstrictors in local Highly concentrated vasoconstrictors in local

anaesthetic agents can lead to ischaemic necrosis and anaesthetic agents can lead to ischaemic necrosis and sloughing of the soft tissues.sloughing of the soft tissues.

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Local Infiltration of the PalateLocal Infiltration of the Palate

Measures to Reduce DiscomfortMeasures to Reduce Discomfort

1. Provide adequate topical anaesthesia at the 1. Provide adequate topical anaesthesia at the site of injection.site of injection.

2. Use pressure anaesthesia at the site before and 2. Use pressure anaesthesia at the site before and during needle insertion and the deposition of during needle insertion and the deposition of the solution.the solution.

3. Maintain control over the needle3. Maintain control over the needle

4. Deposit the local anaesthetic solution slowly.4. Deposit the local anaesthetic solution slowly.

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Local Infiltration of the PalateLocal Infiltration of the Palate Nerves AnaesthetisedNerves Anaesthetised Terminal branches of greater palatine and naso Terminal branches of greater palatine and naso

palatine nerves.palatine nerves. Areas AnaesthetisedAreas Anaesthetised Soft tissues and bony hard palate in the vicinity of the Soft tissues and bony hard palate in the vicinity of the

injection.injection. IndicationsIndications Anaesthesia in a small area of injection Anaesthesia in a small area of injection Haemostasis in the area of surgery.Haemostasis in the area of surgery. ContraindicationsContraindications Presence of acute inflammation or infectionPresence of acute inflammation or infection Provides a small area of anaesthesia.Provides a small area of anaesthesia.

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Local Infiltration of the PalateLocal Infiltration of the Palate

AdvantagesAdvantages

1.1. It provides good haemostasis if It provides good haemostasis if vasoconstrictor is used along with the local vasoconstrictor is used along with the local anaesthetic agent.anaesthetic agent.

2.2. As it involves a small area of anaesthesia, it As it involves a small area of anaesthesia, it gives minimum discomfort to the patient. gives minimum discomfort to the patient.

DisadvantageDisadvantage

Potentially painful injection Potentially painful injection

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Local Infiltration of the PalateLocal Infiltration of the Palate

TechniqueTechnique Needle: Needle: Usually 27 or 30 G needle, 25 G needle can Usually 27 or 30 G needle, 25 G needle can

also be used.also be used. Point of insertion: Point of insertion: In the mucoperiosteum on a line In the mucoperiosteum on a line

1 cm from the gingival margin, 1 cm from the gingival margin, Target area:Target area: Mucogingival tissues in the area of Mucogingival tissues in the area of

injectioninjection Path of insertion: Path of insertion: From the opposite side at an angle From the opposite side at an angle

of 45° to the palate.of 45° to the palate. Bevel: Bevel: Facing towards the palatal soft tissues and Facing towards the palatal soft tissues and

bonebone

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Local Infiltration of the PalateLocal Infiltration of the Palate

ProcedureProcedure Position of the operator: Position of the operator: right-sided injections - in front of the patientright-sided injections - in front of the patient left-sided injection - side of the patient.left-sided injection - side of the patient. Position of the patient: Position of the patient: The occlusal plane of the The occlusal plane of the

maxillary teeth is at 45° to the floor. The patient is maxillary teeth is at 45° to the floor. The patient is requested to keep his mouth wide open and the neck requested to keep his mouth wide open and the neck extended. extended.

Preparation of the tissuesPreparation of the tissues: antiseptic and topical : antiseptic and topical anaesthetic solutions.anaesthetic solutions.

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Local Infiltration of the PalateLocal Infiltration of the Palate

Take a preloaded syringe, and insert the Take a preloaded syringe, and insert the needle at the point of insertion from the needle at the point of insertion from the opposite side at an angle of 45° to the bony opposite side at an angle of 45° to the bony surface. surface.

Deposit about 0.25-0.5 ml of the solution in Deposit about 0.25-0.5 ml of the solution in the vicinity of the area to be anaesthetised. the vicinity of the area to be anaesthetised. Withdraw the needle slowly. Withdraw the needle slowly.

Wait for a few minutes before the surgical or Wait for a few minutes before the surgical or the dental procedure.the dental procedure.

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Local Infiltration of the PalateLocal Infiltration of the Palate

Signs and SymptomsSigns and Symptoms Numbness .Numbness . Lack of pain with instrumentation.Lack of pain with instrumentation. Absence of pain during the procedure.Absence of pain during the procedure.

ComplicationsComplications Sloughing and ischaemic necrosisSloughing and ischaemic necrosis

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FIELD BLOCKFIELD BLOCKAnaesthetic solution is deposited in proximity to Anaesthetic solution is deposited in proximity to

the larger terminal nerve branchesthe larger terminal nerve branches

Anaesthetic solution is deposited at or above the Anaesthetic solution is deposited at or above the apex of the tooth to be treatedapex of the tooth to be treated

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FIELD BLOCKFIELD BLOCK

Nerves anaesthetised:-Nerves anaesthetised:- Terminal nerve branches in the vicinity of the Terminal nerve branches in the vicinity of the

areaarea

Areas anaesthetised: Areas anaesthetised: The areas anaesthetised by the field block will The areas anaesthetised by the field block will

be larger and circumscribed. be larger and circumscribed. These areas include the pulps of the teeth and These areas include the pulps of the teeth and

the tissues distal to the site of injectionthe tissues distal to the site of injection

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FIELD BLOCKFIELD BLOCK

IndicationsIndications

1. All maxillary teeth1. All maxillary teeth

2. Mandibular anterior teeth2. Mandibular anterior teeth

ContraindicationsContraindications

1. Presence of infection or acute 1. Presence of infection or acute inflammation inflammation

2. Mandibular posterior teeth due to thick and 2. Mandibular posterior teeth due to thick and dense bonedense bone

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FIELD BLOCKFIELD BLOCK

TechniqueTechnique The local anaesthetic solution is deposited near The local anaesthetic solution is deposited near

the larger terminal nerve branches. the larger terminal nerve branches.

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NERVE BLOCK OR NERVE BLOCK OR CONDUCTION ANAESTHESIACONDUCTION ANAESTHESIA

By this method, a nerve trunk is By this method, a nerve trunk is blocked at some point between the blocked at some point between the periphery and the brain, thereby periphery and the brain, thereby depriving the area of sensation depriving the area of sensation distal to the point where the nerve distal to the point where the nerve is blocked.is blocked.

The local anaesthetic agent is The local anaesthetic agent is deposited close to a main nerve deposited close to a main nerve trunk usually at a distance from trunk usually at a distance from the site of surgical procedure.the site of surgical procedure.

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NERVE BLOCKNERVE BLOCK

Methods: Methods:

(1) Intraoral (1) Intraoral

(2) Extraoral(2) Extraoral Nerve blocks for maxillary subdivision and its Nerve blocks for maxillary subdivision and its

branches branches Nerve blocks for mandibular subdivision and Nerve blocks for mandibular subdivision and

its branches its branches

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Nerve blocks for maxillary Nerve blocks for maxillary subdivision and its branchessubdivision and its branches

a. a. Intraoral nerve blocksIntraoral nerve blocks:: (i) Infraorbital nerve block,(i) Infraorbital nerve block, (ii) Posterior superior alveolar nerve block, (ii) Posterior superior alveolar nerve block, (iii) Greater palatine nerve block.(iii) Greater palatine nerve block. (iv) Nasopalatine nerve block, and(iv) Nasopalatine nerve block, and (v) Maxillary nerve block, (v) Maxillary nerve block, b. b. Extraoral nerve blocksExtraoral nerve blocks: : (i) Infraorbital nerve block, and (i) Infraorbital nerve block, and (ii) Maxillary nerve block.(ii) Maxillary nerve block.

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Nerve blocks for mandibular Nerve blocks for mandibular subdivisionsubdivision

a. a. Intraoral nerve blocksIntraoral nerve blocks: : (i) Pterygomandibular nerve block- Direct and Indirect (i) Pterygomandibular nerve block- Direct and Indirect

techniques,techniques, (ii) Lingual nerve block,(ii) Lingual nerve block, (iii) Long buccal nerve block, (iii) Long buccal nerve block, (iv) Mental nerve block, (iv) Mental nerve block, (v) Gow-Gates nerve block (v) Gow-Gates nerve block (vi) Vazirani-Akinosi nerve block (vi) Vazirani-Akinosi nerve block b. b. Extraoral nerve blocksExtraoral nerve blocks:: Mandibular nerve block.Mandibular nerve block.

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NERVE BLOCKNERVE BLOCK

IndicationsIndications

1. Extensive oral and periodontal surgical 1. Extensive oral and periodontal surgical procedures.procedures.

2. Restorative procedures.2. Restorative procedures.

3. Extensive maxillofacial soft and hard tissue 3. Extensive maxillofacial soft and hard tissue procedures.procedures.

ContraindicationsContraindications Presence of acute inflammation or infectionPresence of acute inflammation or infection

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NERVE BLOCKNERVE BLOCK

AdvantagesAdvantages 1. Avoids multiple penetration of the needle.1. Avoids multiple penetration of the needle. 2. Avoids deposition of large volume of local 2. Avoids deposition of large volume of local

anaesthetic agent.anaesthetic agent.

DisadvantagesDisadvantages 1. Larger area than required is anaesthetised.1. Larger area than required is anaesthetised. 2. Additional local infiltration is required if 2. Additional local infiltration is required if

haemostasis is required at the site of surgery.haemostasis is required at the site of surgery.

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INJECTION TECHNIQUES FOR INJECTION TECHNIQUES FOR MAXILLARY NERVE AND ITS MAXILLARY NERVE AND ITS

BRANCHESBRANCHES

INFILTRATIONSINFILTRATIONS NERVE BLOCKSNERVE BLOCKS

a. Intraoral blocks anda. Intraoral blocks and

b. Extraoral blocks.b. Extraoral blocks.

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INTRAORAL INTRAORAL NERVE BLOCKSNERVE BLOCKS

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Infra orbital nerve blockInfra orbital nerve block

Two approaches :Two approaches : the bicuspid and the central incisior.the bicuspid and the central incisior.

Other names: Other names: Anterior superior alveolar nerve block.Anterior superior alveolar nerve block.

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Infra orbital nerve blockInfra orbital nerve block

Nerves anaesthetisedNerves anaesthetised Anterior superior alveolar nerve.Anterior superior alveolar nerve. Middle superior alveolar nerve.Middle superior alveolar nerve. Infraorbital nerve Infraorbital nerve

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Infra orbital nerve blockInfra orbital nerve blockAreas anaesthetisedAreas anaesthetised1. Maxillary central and lateral incisors, and canine 1. Maxillary central and lateral incisors, and canine

2. Maxillary premolars and mesiobuccal root of 2. Maxillary premolars and mesiobuccal root of first molar first molar

3. Supporting alveolar bone and the labial or buccal 3. Supporting alveolar bone and the labial or buccal periodontium periodontium

4. Overlying labial or buccal mucoperiosteum.4. Overlying labial or buccal mucoperiosteum.

5. Skin of lower eyelid and both surfaces of 5. Skin of lower eyelid and both surfaces of conjunctiva, skin of lateral aspect of the nose, conjunctiva, skin of lateral aspect of the nose, and skin and mucosa of upper lipand skin and mucosa of upper lip

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Infra orbital nerve blockInfra orbital nerve block

IndicationsIndications1. 1. Apicoectomies, alveolectomies of maxillary anterior regions, Apicoectomies, alveolectomies of maxillary anterior regions,

impacted canines, and cysts.impacted canines, and cysts.2. Restorative and endodontic procedures involving more than 2. Restorative and endodontic procedures involving more than

two maxillary teeth.two maxillary teeth.3. Presence of acute inflammation or infection 3. Presence of acute inflammation or infection 4. Presence of dense cortical bone that makes any infiltration 4. Presence of dense cortical bone that makes any infiltration

technique ineffective.technique ineffective.

ContraindicationsContraindications1. Discrete treatment areas (one or two teeth only).1. Discrete treatment areas (one or two teeth only).2. When haemostasis in the area of surgery is desirable. 2. When haemostasis in the area of surgery is desirable.

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Infra orbital nerve blockInfra orbital nerve block

AdvantagesAdvantages1. Simple, easy and safe.1. Simple, easy and safe.

2. Minimise the volume of solution to be 2. Minimise the volume of solution to be injected and number of needle punctures injected and number of needle punctures

3. The incisor approach lessens possibility of 3. The incisor approach lessens possibility of inadvertently entering orbit.inadvertently entering orbit.

4. Permits deeper penetration into the 4. Permits deeper penetration into the infraorbital canal.infraorbital canal.

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Infra orbital nerve blockInfra orbital nerve block

DisadvantagesDisadvantagesBicuspid approachBicuspid approach Psychological : Fear of injury to the patient’s eye.Psychological : Fear of injury to the patient’s eye.

Anatomical : Difficulty in defining landmarks Anatomical : Difficulty in defining landmarks

Incisor approachIncisor approach Higher chances of injuring the infraorbital Higher chances of injuring the infraorbital

neurovascular bundle with deeper penetration into the neurovascular bundle with deeper penetration into the infraorbital canal.infraorbital canal.

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Infra orbital nerve blockInfra orbital nerve blockAnatomical landmarksAnatomical landmarksBicuspid approachBicuspid approach: : (1) infraorbital margin, (1) infraorbital margin, (2) infraorbital depression, (2) infraorbital depression, (3) infraorbital foramen, (3) infraorbital foramen, (4) first bicuspid,(4) first bicuspid,(5) mucobuccal fold in the region of this tooth, (5) mucobuccal fold in the region of this tooth, (6) pupil of the ipsilateral eye in the forward gaze,(6) pupil of the ipsilateral eye in the forward gaze,(7) angle of the nose and (7) angle of the nose and (8) mental foramen.(8) mental foramen.

Page 66: Tec. regional anesth vijay

Infra orbital nerve blockInfra orbital nerve block

Two approachesTwo approaches

cuspid and the central incisor.cuspid and the central incisor. Nerves and areas anaesthetised, indications, Nerves and areas anaesthetised, indications,

contraindications, advantages are same for contraindications, advantages are same for both the approaches.both the approaches.

Other names: Anterior superior alveolar nerve Other names: Anterior superior alveolar nerve block.block.

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Infra orbital nerve blockInfra orbital nerve block

Approaches:Approaches: Bicuspid approachBicuspid approach: This technique is : This technique is

comparatively easy .comparatively easy . The needle passes through the mucosa and The needle passes through the mucosa and

areolar tissue and during insertion should pass areolar tissue and during insertion should pass beneath and lateral the facial artery and facial beneath and lateral the facial artery and facial vein.vein.

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Infra orbital nerve blockInfra orbital nerve block

Technique:Technique: Position of the patientPosition of the patient: Maxillary occlusal plane is at an : Maxillary occlusal plane is at an

angle of 45° to the floor.angle of 45° to the floor. Position of the operatorPosition of the operator: For right-sided block- right side of : For right-sided block- right side of

patientpatient For the left-sided block- in front of the patient For the left-sided block- in front of the patient Preparation of the tissuesPreparation of the tissues: with an antiseptic.: with an antiseptic.

Page 69: Tec. regional anesth vijay

Infra orbital nerve blockInfra orbital nerve block

NeedleNeedle: Long and 25 gauge : Long and 25 gauge BevelBevel: facing the bone.: facing the bone. Depth of penetrationDepth of penetration: ¾ th of an inch of the : ¾ th of an inch of the

needle penetrates the soft tissuesneedle penetrates the soft tissues Area of insertionArea of insertion: At the height of : At the height of

mucobuccal fold in the region of first bicuspid.mucobuccal fold in the region of first bicuspid. Target areaTarget area: Infraorbital nerve as it comes : Infraorbital nerve as it comes

out of infraorbital foramenout of infraorbital foramen

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Infra orbital nerve blockInfra orbital nerve block

ProcedureProcedurePalpation of the anatomical landmarks:Palpation of the anatomical landmarks: Locate the infraorbital margin..Locate the infraorbital margin.. Take a preloaded syringe, and insert the needle into the height Take a preloaded syringe, and insert the needle into the height

of the mucobuccal fold over the first bicuspid with the bevel of the mucobuccal fold over the first bicuspid with the bevel facing bone.facing bone.

Orient the syringe towards the infraorbital foramen.Orient the syringe towards the infraorbital foramen. The needle should be held parallel to the long axis of the tooth The needle should be held parallel to the long axis of the tooth Advance the needle until bone is gently contacted.Advance the needle until bone is gently contacted. Care should be taken to protect the eye with thumb/finger to Care should be taken to protect the eye with thumb/finger to

limit the Passage of the needle towards the eyelimit the Passage of the needle towards the eye

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Infra orbital nerve blockInfra orbital nerve block

Central incisor approachCentral incisor approach: : The needle passes through mucosa and areolar The needle passes through mucosa and areolar

tissue and beneath the levator labii superioris tissue and beneath the levator labii superioris (angular head of the quadratus labii superioris) (angular head of the quadratus labii superioris) muscle. It then passes anterior to the origin of muscle. It then passes anterior to the origin of levator anguli oris (caninus) muscle and levator anguli oris (caninus) muscle and beneath the facial artery and facial vein.beneath the facial artery and facial vein.

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Infra orbital nerve blockInfra orbital nerve block

TechniqueTechnique • • There are certain steps which are common to There are certain steps which are common to

both the approaches. such as position of the both the approaches. such as position of the patient, position of the operator, preparatior. of patient, position of the operator, preparatior. of the tissues, configuration of the needle, and the tissues, configuration of the needle, and palpation of the anatomical landmarks; and are palpation of the anatomical landmarks; and are mentioned with the bicuspid approach.mentioned with the bicuspid approach.

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Infra orbital nerve blockInfra orbital nerve block • • Area of insertion: In the central incisor approach, the Area of insertion: In the central incisor approach, the

direction of the needle is such that it bisects the crown of direction of the needle is such that it bisects the crown of the ipsilateral cenfra incisor from the mesioincisal angle to the ipsilateral cenfra incisor from the mesioincisal angle to the distogingival angle. The area of insertion is at the height the distogingival angle. The area of insertion is at the height of mucobuccal fold, or 4-5 mms away froir the labial cortex of mucobuccal fold, or 4-5 mms away froir the labial cortex of maxilla in the region of ipsilateral canine. The needle is of maxilla in the region of ipsilateral canine. The needle is inserted about 5 mms from the mucobuccal fold in the inserted about 5 mms from the mucobuccal fold in the regior. of ipsilateral canine.regior. of ipsilateral canine.

• • Target area: Infraorbital nerve as it comes out of Target area: Infraorbital nerve as it comes out of infraorbital foramen. between levator labii superioris infraorbital foramen. between levator labii superioris muscle above and levator anguli oils muscle below.muscle above and levator anguli oils muscle below.

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Infra orbital nerve blockInfra orbital nerve block

ProcedureProcedure Palpation of the anatomical landmarksPalpation of the anatomical landmarks. This is . This is

done in the same way as for the bicuspid approach.done in the same way as for the bicuspid approach. In either approach the needle should not penetrate In either approach the needle should not penetrate

more than 3/4th of an inch. Approximately, 1 ml of more than 3/4th of an inch. Approximately, 1 ml of solution is slowly deposited in the area and the thumb solution is slowly deposited in the area and the thumb is held in position until the injection is completedis held in position until the injection is completed

Wait for 3-5 minutes after completion of the injection Wait for 3-5 minutes after completion of the injection before commencing the dental procedure.before commencing the dental procedure.

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Infra orbital nerve blockInfra orbital nerve block

Signs and symptomsSigns and symptomsa. a. SubjectiveSubjective: Tingling and numbness of the : Tingling and numbness of the

lower eyelid, side of the nose and upper lip.lower eyelid, side of the nose and upper lip.b. b. ObjectiveObjective::1. Comparing the sensation produced with 1. Comparing the sensation produced with

tapping of anaesthetised and adjacent un tapping of anaesthetised and adjacent un anaesthetised teeth with an instrument.anaesthetised teeth with an instrument.

2. No pain during oral surgical or periodontal 2. No pain during oral surgical or periodontal surgical procedures or dental therapy.surgical procedures or dental therapy.

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Infra orbital nerve blockInfra orbital nerve block

Complications:Complications: 1. Haematoma: May rarely develop.1. Haematoma: May rarely develop. 2. Paresis of face: It occurs when the injection 2. Paresis of face: It occurs when the injection

is given superficially, when the needle lies in is given superficially, when the needle lies in the vicinity of muscles of facial expression or the vicinity of muscles of facial expression or the nerves innervating them. the nerves innervating them.

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Infra orbital nerveInfra orbital nerve blockblock

Failure to obtain anaesthesiaFailure to obtain anaesthesia Poor surgical techniquePoor surgical technique::

i. Needle contacting bone below the infraorbital i. Needle contacting bone below the infraorbital foramen..foramen..

ii. Needle deviation medial or lateral to the ii. Needle deviation medial or lateral to the infraorbital foramen. infraorbital foramen.

Intravascular administrationIntravascular administration: Deposition of : Deposition of the local anaesthetic solution into a vessel.the local anaesthetic solution into a vessel.

Page 79: Tec. regional anesth vijay

Anterior middle superior alveolar nerve block

This technique performed by the use of CCLAD system

This technique provides pulpal anesthesia on multiple maxillary teeth (incisors, canine & premolars ) from a single injection site.

Other common names:- Palatal approach AMSA nerve block

Page 80: Tec. regional anesth vijay

Nerves anesthetized:- ASA MSA Sub mental dental plexus of the anterior middle

superior alveolar nerves.Areas anesthetized:-1. Pulpal anesthesia of maxillary incisors, canines &

premolars.2. Buccal gingiva.3. Attached palatal tissues from midline to free

gingival margin on the associated teeth.

Anterior middle superior alveolar nerve block

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Indications:- Is easier to perform with a CCLAD system Procedures involving the maxillary teeth When a facial approach supra periosteal

injection has been ineffective .Contraindications:- Patients with unusually thin palatal tissues. Procedures requiring more than 90 min.

Anterior middle superior alveolar nerve block

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Advantages:-

1. Provides anesthesia of multiple maxillary teeth with a single injection.

2. Minimize volume of anesthetic.

3. Eliminates the post operative inconvenience of numbness to the upper lip & muscles of facial expression.

Anterior middle superior alveolar nerve block

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Disadvantages:- Requires a sloe administration time (0.5 ml/ min). Uncomfortable to patient & operator because of long

administration time. Need supplemental anesthetic for central & lateral incisors. Causes ischemia if administer too rapidly. Caution should be taken when performing this injection with

4% L.A.( prilocaine HCl, articaine HCl.). Use of local anesthesia containing with a concentration of

1:50000 is contraindicated. Positive aspiration is less than 5%.

Anterior middle superior alveolar nerve block

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Technique:- 27 G; Short needle or 30 G, extra short needle. Area of insertion is on the hard palate about half way

along an imaginary line connecting the mid palatal suture to the free gingival margin.

Location of line is at the contact point between the 1st & 2nd premolars.

Target area palatal bone at injection site. Bevel needle placed against the epithelium held at

45 degrees to the palate.

Anterior middle superior alveolar nerve block

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Anterior middle superior alveolar nerve block

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Procedures:-

a. Position of the operator 9 or 10’o clock position.

b. Position of the patient supine with slight hyper extension of head & neck.

Pre puncture technique:- Apply the bevel of needle towards palatal tissue,

place sterile cotton applicator on top of the needle tip, apply light pressure on the cotton applicator to create a ‘seal’ of the needle bevel.

By using CCLAD system a slow rate of delivery of the local anesthetic maintained.

Anterior middle superior alveolar nerve block

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An anesthetic pathway technique can be utilized.

Slowly advance the needle into the tissues. Rotating the needle allows the needle to

penetrate into the tissues more efficiently. Advance the needle slowly into the palatal

tissue until it contacts with bone. Then aspirate and deliver anesthetic solution at a rate of 0.5 ml/min to the final dosage of 1.4 – 1.8 ml.

Anterior middle superior alveolar nerve block

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Subjective symptoms:- Numbness of teeth & palatal tissues from the

central incisor to 2nd premolar.

Objective signs:- Blanching of the soft tissues extending from

central incisor to the premolar regoin. No pain during dental therapy.

Anterior middle superior alveolar nerve block

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Failures of anesthesia:- May need supplemental anesthesia for

incisors

a. Adequate volume of L.A may not reach dental branches

b. To correct, add more L.A or supplement in proximity to these teeth from the palatal approach.

Anterior middle superior alveolar nerve block

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Complications:-

1. Palatal ulcer at injection site developing 1 – 2 days post operative.

2. Unexpected contact with the nasopalatine nerve.

3. Density of injection site causing squirt back of anesthetic & bitter taste.

Anterior middle superior alveolar nerve block

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Posterior Superior Alveolar Nerve Posterior Superior Alveolar Nerve BlockBlock

Other names:Other names:(i) Tuberosity block, (ii) Zygomatic (i) Tuberosity block, (ii) Zygomatic

block.block. Nerves anaesthetisedNerves anaesthetised:: Posterior superior alveolar nerve Posterior superior alveolar nerve

and ii branches.and ii branches. Areas anaesthetisedAreas anaesthetised1. Pulps of maxillary third, second 1. Pulps of maxillary third, second

and first molar (except the and first molar (except the mesiobuccal root).mesiobuccal root).

2. Adjoining alveolar bone of these 2. Adjoining alveolar bone of these teeth, buccal periodontium, and teeth, buccal periodontium, and buccal mucoperiosteum.buccal mucoperiosteum.

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Posterior Superior Alveolar Nerve Posterior Superior Alveolar Nerve BlockBlock

Indications:Indications:1. Oral surgical or periodontal surgical procedures in the area of 1. Oral surgical or periodontal surgical procedures in the area of

maxillary molars. maxillary molars. 2. Restorative procedures involving two or more maxillary 2. Restorative procedures involving two or more maxillary

molars.molars.3. When paraperiosteal injection is contraindicated as in the 3. When paraperiosteal injection is contraindicated as in the

presence of acute inflammation or infection.presence of acute inflammation or infection.4. When paraperiosteal injection has failed for any reason.4. When paraperiosteal injection has failed for any reason.Contraindication:Contraindication: When the risk of haemorrhage is high as in a Case of When the risk of haemorrhage is high as in a Case of

haemophilic. In such cases, a paraperiosteal or intraligament haemophilic. In such cases, a paraperiosteal or intraligament injection is recommended.injection is recommended.

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Posterior Superior Alveolar Nerve Posterior Superior Alveolar Nerve BlockBlock

AdvantagesAdvantages(1) Atraumatic (1) Atraumatic (2) High success rate (2) High success rate (3) Minimises the number penetrations required.(3) Minimises the number penetrations required.(4) Minimises the total volume of anaesthetic solution injected.(4) Minimises the total volume of anaesthetic solution injected.DisadvantagesDisadvantages(1) Risk of haematoma. (1) Risk of haematoma. (2) Technique is somewhat arbitrary(2) Technique is somewhat arbitrary (3) Second injection is required for anaesthetising the first (3) Second injection is required for anaesthetising the first

molar.molar.

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Posterior Superior Alveolar Nerve Posterior Superior Alveolar Nerve BlockBlock

Technique:Technique: NeedleNeedle :25 G short needle of 25 mm length. :25 G short needle of 25 mm length. BevelBevel: should be facing the bone: should be facing the bone Point of InsertionPoint of Insertion: at the height of mucobuccal fold : at the height of mucobuccal fold

in the region of the distal surface of maxillary second in the region of the distal surface of maxillary second molar.molar.

Depth of insertionDepth of insertion: approximately 16 mms.: approximately 16 mms. Target areaTarget area: The posterior superior alveolar nerve, : The posterior superior alveolar nerve,

located posterosuperior and medial to maxillary located posterosuperior and medial to maxillary tuberosity.tuberosity.

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Posterior Superior Alveolar Nerve Posterior Superior Alveolar Nerve BlockBlock

Anatomical landmarksAnatomical landmarks:: Mucobuccal fold in the region of maxillary Mucobuccal fold in the region of maxillary

second molarsecond molar Maxillary tuberosityMaxillary tuberosity Zygomatic process of maxilla or the buttress Zygomatic process of maxilla or the buttress

of zygomaof zygoma Infratemporal surface of maxillaInfratemporal surface of maxilla Anterior border and coronoid process of the Anterior border and coronoid process of the

ramus of the mandibleramus of the mandible

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Posterior Superior Alveolar Nerve Posterior Superior Alveolar Nerve BlockBlock

ProcedureProcedure Position of the patientPosition of the patient: semi-supine position with : semi-supine position with

maxillary teeth occlusal plane at 45° to the floormaxillary teeth occlusal plane at 45° to the floor Position of the operatorPosition of the operator i. For right-sided injection - the side of the patient.i. For right-sided injection - the side of the patient. ii. For left-sided injection - in front of the patient.ii. For left-sided injection - in front of the patient. Preparation of the tissuesPreparation of the tissues: antiseptic,topical : antiseptic,topical

anaesthetic.anaesthetic. Partially open the patient’s mouth, pulling the Partially open the patient’s mouth, pulling the

mandible to the side of injection and maxillary mandible to the side of injection and maxillary occlusal plane at 45° to the floor.occlusal plane at 45° to the floor.

Retract the cheek, pulling the tissue taut.Retract the cheek, pulling the tissue taut. Palpation of the landmarksPalpation of the landmarks ..

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Posterior Superior Alveolar Nerve Posterior Superior Alveolar Nerve BlockBlock

Technique ITechnique I The prominence of the buttress of the zygoma is located The prominence of the buttress of the zygoma is located

above the first molar. Pass the finger over the prominence and above the first molar. Pass the finger over the prominence and it will dip superiorly in the sulcus posterior to the buttress..it will dip superiorly in the sulcus posterior to the buttress..

The point of the needle in this position should be located in the The point of the needle in this position should be located in the depth of the sulcus, above the roots of the third molar, and depth of the sulcus, above the roots of the third molar, and anterior to the maxillary tuberosity close to the lateral surface anterior to the maxillary tuberosity close to the lateral surface of the maxilla.of the maxilla.

The needle is inserted into the tissue in a line parallel to the The needle is inserted into the tissue in a line parallel to the index finger and bisecting the fingernail with the bevel of the index finger and bisecting the fingernail with the bevel of the needle facing the bone.needle facing the bone.

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Posterior Superior Alveolar Nerve Posterior Superior Alveolar Nerve BlockBlock

Technique IITechnique II

Insert the needle at the height of the mucobuccal fold, in the Insert the needle at the height of the mucobuccal fold, in the region of maxillary second molar.region of maxillary second molar.

Advance the needle slowly Advance the needle slowly Superiorly: At an angle of 45° to the occiusal plane.Superiorly: At an angle of 45° to the occiusal plane. Medially: At an angle of 45° to the sagittal plane.Medially: At an angle of 45° to the sagittal plane. Posteriorly: At an angle of 45° to the coronal plane.Posteriorly: At an angle of 45° to the coronal plane. In an adult of normal size, penetration to a depth of 16 mms In an adult of normal size, penetration to a depth of 16 mms

will place the needle tip in the target area, will place the needle tip in the target area, Aspirate & deposit 0.5-1 ml of solution slowly.Aspirate & deposit 0.5-1 ml of solution slowly. Withdraw Wait for 3-5 minutes and start the procedure..Withdraw Wait for 3-5 minutes and start the procedure..

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Posterior Superior Alveolar Nerve Posterior Superior Alveolar Nerve BlockBlock

Signs and symptoms:Signs and symptoms: SubjectiveSubjective: It is difficult to determine the : It is difficult to determine the

extent of anaesthesia subjectively. Feeling of extent of anaesthesia subjectively. Feeling of numbness in the area of distribution of PSA numbness in the area of distribution of PSA nerve.nerve.

ObjectiveObjective: Absence of pain with : Absence of pain with instrumentation and during procedure.instrumentation and during procedure.

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Posterior Superior Alveolar Nerve Posterior Superior Alveolar Nerve BlockBlock

Failure to achieve anaesthesiaFailure to achieve anaesthesiaPoor surgical techniquePoor surgical techniqueIntravascular administrationIntravascular administration:: Deposition of the local anaesthetic solution in Deposition of the local anaesthetic solution in

pterygoid plexus of veins. pterygoid plexus of veins.

ComplicationsComplications HaematomaHaematoma: It is due to insertion of the needle too : It is due to insertion of the needle too

far posteriorly into the pterygoid plexus of veins. far posteriorly into the pterygoid plexus of veins. Mandibular anaesthesiaMandibular anaesthesia: Deposition of local : Deposition of local

anaesthetic agent lateral to the desired location can anaesthetic agent lateral to the desired location can produce varying degrees of mandibular anaesthesia.produce varying degrees of mandibular anaesthesia.

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Nasopalatine Nerve BlockNasopalatine Nerve Block

Incisive nerve block, Incisive nerve block, sphenopalatine nerve sphenopalatine nerve blockblock..

It is a potentially painful It is a potentially painful injection.injection.

Nerves anaesthetisedNerves anaesthetised: : Nasopalatine nerves bilaterally..Nasopalatine nerves bilaterally..

Areas anaesthetisedAreas anaesthetised: Anterior : Anterior portion of the hard palate portion of the hard palate (palatal mucosa) from the (palatal mucosa) from the mesial of the right canine/first mesial of the right canine/first premolar to the mesial of the premolar to the mesial of the left canine/first premolarleft canine/first premolar

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Nasopalatine Nerve BlockNasopalatine Nerve Block

IndicationsIndications1 During oral surgical or periodontal procedures 1 During oral surgical or periodontal procedures

involving palatal soft and hard tissues.involving palatal soft and hard tissues.2. For any restorative procedure on more than 2. For any restorative procedure on more than

two teeth.two teeth.ContraindicationsContraindications1. Presence of acute inflammation or infection .1. Presence of acute inflammation or infection .2. Whenever there are smaller areas of dental or 2. Whenever there are smaller areas of dental or

surgical procedures (one or two teeth).surgical procedures (one or two teeth).

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Nasopalatine Nerve BlockNasopalatine Nerve Block

AdvantagesAdvantages minimise mutiple needle penetrations & minimise mutiple needle penetrations &

reduces the volume of solution.reduces the volume of solution. minimises patient discomfort.minimises patient discomfort.

DisadvantagesDisadvantages no haemostasis except in the immediate area no haemostasis except in the immediate area

of injection.of injection. most painful intraoral injection.most painful intraoral injection.

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Nasopalatine Nerve BlockNasopalatine Nerve Block

Anatomical landmarksAnatomical landmarks• • Maxillary central incisor teethMaxillary central incisor teeth• • Incisive papilla in the midline of the palateIncisive papilla in the midline of the palate• • Incisive foramen.Incisive foramen.TechniqueTechnique• • Needle:Needle: 25 or 27G, length 1” or 25 cm. 25 or 27G, length 1” or 25 cm.• • Area of penetration:Area of penetration: The palatal mucosa or surrounding the The palatal mucosa or surrounding the

incisive papilla.incisive papilla.• • Target area:Target area: The nasopalatine nerve as it comes out of incisive The nasopalatine nerve as it comes out of incisive

foramen, beneath the incisive papilla.foramen, beneath the incisive papilla.• • Path of insertion:Path of insertion: Making an angle of 45° to the incisive papilla, Making an angle of 45° to the incisive papilla,

approaching from the side.approaching from the side.• • Bevel:Bevel: It is facing the palatal soft tissues or facing the palatal It is facing the palatal soft tissues or facing the palatal

bone.bone.

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Nasopalatine Nerve BlockNasopalatine Nerve BlockProcedureProcedure Preparatory injectionsPreparatory injections:: These make the entrance into These make the entrance into

papilla less painful.papilla less painful. a. Labial approacha. Labial approach: The preparatory injection is : The preparatory injection is

made by inserting the needle into the labial made by inserting the needle into the labial intraseptal tissues in between the maxillary central intraseptal tissues in between the maxillary central incisors. The needle is inserted at a right angle to the incisors. The needle is inserted at a right angle to the labial plate and passed into the tissues until resistance labial plate and passed into the tissues until resistance is felt. Then 0.25 ml of solution is depositedis felt. Then 0.25 ml of solution is deposited

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Nasopalatine Nerve BlockNasopalatine Nerve Block

b. Palatal approachb. Palatal approach: The tip of the needle : The tip of the needle should be placed in the halo or the depression should be placed in the halo or the depression surrounding incisive papilla and a small surrounding incisive papilla and a small amount or a few drops of solution is injected amount or a few drops of solution is injected until papilla blanchesuntil papilla blanches

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Nasopalatine Nerve BlockNasopalatine Nerve Block

Signs and symptomsSigns and symptoms (1) Numbness in the anterior portion of the palate. (1) Numbness in the anterior portion of the palate. (2) No pain during surgical procedures or dental (2) No pain during surgical procedures or dental

therapy.therapy.

ComplicationsComplications 1. Necrosis of soft tissues is possible when highly 1. Necrosis of soft tissues is possible when highly

concentrated vasoconstrictor solution is used for concentrated vasoconstrictor solution is used for haemostasis.haemostasis.

2. The solution may “squirt” back out of the needle, 2. The solution may “squirt” back out of the needle, because of the density of soft tissuesbecause of the density of soft tissues

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Greater Palatine Nerve BlockGreater Palatine Nerve BlockOther common namesOther common names: :

Anterior palatine nerve block.Anterior palatine nerve block.Nerves anaesthetisedNerves anaesthetised:: Greater Greater

palatine nerve (anterior palatine palatine nerve (anterior palatine nerve)nerve)

Areas anaesthetisedAreas anaesthetised:: The The posterior part of the hard palate posterior part of the hard palate and its overlying soft tissues, and its overlying soft tissues, anteriorly as far as the canine/first anteriorly as far as the canine/first premolar and medially upto the premolar and medially upto the midline or the median palatine midline or the median palatine raphe.raphe.

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Greater Palatine Nerve BlockGreater Palatine Nerve Block

IndicationsIndications 1. During oral surgical or periodontal procedures 1. During oral surgical or periodontal procedures

involving the palatal soft and hard tissues.involving the palatal soft and hard tissues. 2. For restorative therapy on more than two teeth.2. For restorative therapy on more than two teeth.

ContraindicationsContraindications 1. Presence of acute inflammation or infection.1. Presence of acute inflammation or infection. 2. Smaller areas of surgical procedures or restorative 2. Smaller areas of surgical procedures or restorative

therapy (one or twotherapy (one or two teeth )teeth )

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Greater Palatine Nerve BlockGreater Palatine Nerve Block

AdvantagesAdvantages Minimises the volume of solution and the Minimises the volume of solution and the

number of needle penetrations.number of needle penetrations. Simple & easy techniqueSimple & easy technique High success rateHigh success rateDisadvantagesDisadvantages1. It is a potentially painful injection.1. It is a potentially painful injection.2. No haemostasis. 2. No haemostasis.

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Greater Palatine Nerve BlockGreater Palatine Nerve Block

Anatomical landmarksAnatomical landmarks

• • Greater palatine foramenGreater palatine foramen

• • Maxillary second and third molarsMaxillary second and third molars

• • Palatal gingival margin of second Palatal gingival margin of second and third maxillary molarsand third maxillary molars

• • Median palatine rapheMedian palatine raphe

• • An area, approximately at a An area, approximately at a distance of 1 cm from the palatal distance of 1 cm from the palatal gingival margin towards the gingival margin towards the median palatine raphe.median palatine raphe.

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Greater Palatine Nerve BlockGreater Palatine Nerve Block

TechniqueTechnique• • Needle:Needle: 25 or 27 G and 25 mm length. 25 or 27 G and 25 mm length.• • Point of insertion:Point of insertion: Palatal soft tissues slightly anterior to the Palatal soft tissues slightly anterior to the

greater palatine foramen.greater palatine foramen.• • Target area:Target area: The greater palatine nerve as it comes out from The greater palatine nerve as it comes out from

the greater palatine foramen, and passes anteriorly between the the greater palatine foramen, and passes anteriorly between the palatal mucoperiosteum and the bone of the hard palate.palatal mucoperiosteum and the bone of the hard palate.

• • Bevel of the needle:Bevel of the needle: Facing the palatal soft tissues. Facing the palatal soft tissues.• • Location of anatomical landmarks:Location of anatomical landmarks: Most frequently located Most frequently located

distal to the maxillary second molar about 1 cm from the distal to the maxillary second molar about 1 cm from the palatal gingival margin towards the midline.palatal gingival margin towards the midline.

• • Path of insertion:Path of insertion: The greater palatine foramen is approached The greater palatine foramen is approached from the opposite side at right angle to the curvature of the from the opposite side at right angle to the curvature of the palatal bone.palatal bone.

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Greater Palatine Nerve BlockGreater Palatine Nerve Block

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Greater Palatine Nerve BlockGreater Palatine Nerve Block

ProcedureProcedure

• • The needle is inserted slowly until the palatal bone is The needle is inserted slowly until the palatal bone is contacted.contacted.

• • Aspirate & Deposit 0.25-0.5 m solution.Aspirate & Deposit 0.25-0.5 m solution.

• • The nerve may be blocked at any point along its The nerve may be blocked at any point along its anterior course after emergence from the foramen.anterior course after emergence from the foramen.

Signs and symptomsSigns and symptoms

1.1. Numbness in the posterior portion of the palate.Numbness in the posterior portion of the palate.

2.2. No pain during surgical procedure.No pain during surgical procedure.

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Greater Palatine Nerve BlockGreater Palatine Nerve Block

ComplicationsComplications1. Ischaemia and necrosis of soft tissues 1. Ischaemia and necrosis of soft tissues

2. Discomfort: If the soft palate becomes anaesthetised.2. Discomfort: If the soft palate becomes anaesthetised.

3. Haematoma: Is rare, as the palatal mucoperiosteum is 3. Haematoma: Is rare, as the palatal mucoperiosteum is firmly adherent to the bone of the hard palate.firmly adherent to the bone of the hard palate.

4. Failures to obtain anaesthesia4. Failures to obtain anaesthesia Poor surgical technique:Poor surgical technique: In the area of the maxillary first premolar there is In the area of the maxillary first premolar there is

overlapping of fibres from the nasopalatine nerve.overlapping of fibres from the nasopalatine nerve.

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Nerve Blocks for Maxillary NerveNerve Blocks for Maxillary Nerve

A. Intraoral maxillary nerve blockA. Intraoral maxillary nerve block

B. Extra oral maxillary nerve block.B. Extra oral maxillary nerve block.

IndicationsIndications Extensive oral and periodontal surgical Extensive oral and periodontal surgical

procedures. procedures. Restorative procedures involving a quadrant Restorative procedures involving a quadrant

of maxilla.of maxilla.

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lntraoral Nerve Blocks for Maxillary lntraoral Nerve Blocks for Maxillary NerveNerve

ApproachesApproaches High tuberosity approach High tuberosity approach Greater palatine canal approach.Greater palatine canal approach.

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

Major difficultiesMajor difficulties The difficulty in locating the canalThe difficulty in locating the canal Higher incidence of haematoma in high Higher incidence of haematoma in high

tuberosity approachtuberosity approach

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

Nerves anaesthetised: Maxillary Nerves anaesthetised: Maxillary division of trigeminal division of trigeminal nerve nerve

Areas anaesthetised: Areas anaesthetised: The pulps of all maxillary The pulps of all maxillary

teethteeth The bone of the hard palate, The bone of the hard palate,

and part of the soft palate, and part of the soft palate, maxillary sinus, and the maxillary sinus, and the lateral wall of nasal cavity.lateral wall of nasal cavity.

Skin of the lower eyelid, side Skin of the lower eyelid, side of the nose, cheek and the of the nose, cheek and the upper lipupper lip

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

IndicationsIndications Control of painControl of pain When other nerve nerve blocks are contraindicated in presence When other nerve nerve blocks are contraindicated in presence

of infectionof infection Diagnostic and therapeutic procedures for trigeminal neuralgiaDiagnostic and therapeutic procedures for trigeminal neuralgia

ContraindicationsContraindications.. Child patients,uncooperative patients.Child patients,uncooperative patients. Presence of acute inflammation or infection at the site of Presence of acute inflammation or infection at the site of

injectioninjection Increased possibility of hemorrhage, especially in a Increased possibility of hemorrhage, especially in a

hemophilic.hemophilic.

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

AdvantagesAdvantages The high tuberosity approach is less painful.The high tuberosity approach is less painful. Success rate is high.Success rate is high. It minimises the number of needle penetrations.It minimises the number of needle penetrations. It minimises the total volume of local anaesthetic It minimises the total volume of local anaesthetic

solutionsolution DisadvantagesDisadvantages Increased risk of haematoma Increased risk of haematoma The high tuberosity approach is arbitraryThe high tuberosity approach is arbitrary Lack of haemostasis.Lack of haemostasis. The greater palatine approach is painful.The greater palatine approach is painful.

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Intraoral nerve Blocks for Maxillary Intraoral nerve Blocks for Maxillary NerveNerve

TECHNIQUE TECHNIQUE High tuberosity approachHigh tuberosity approach NeedleNeedle: 25 G, length 1 5/8 of an inch or 40-42 mms.: 25 G, length 1 5/8 of an inch or 40-42 mms. Bevel Bevel : facing the bone.: facing the bone. Point of insertionPoint of insertion: at the height of mucobuccal fold : at the height of mucobuccal fold

above the distal aspect of maxillary second molar above the distal aspect of maxillary second molar toothtooth

Depth of insertionDepth of insertion: 1 ¼” of an inch: 1 ¼” of an inch Target area:Target area: It is the maxillary nerve as it passes It is the maxillary nerve as it passes

through the pterygopalatine fossa. through the pterygopalatine fossa.

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Intraoral nerve Blocks for Maxillary Intraoral nerve Blocks for Maxillary NerveNerve

Anatomical landmarksAnatomical landmarks Maxillary second molar Maxillary second molar

tooth.tooth. Height of mucobuccal Height of mucobuccal

fold above the distal fold above the distal aspect of the crown of aspect of the crown of maxillary second molar maxillary second molar tooth.tooth.

Maxillary tuberosity.Maxillary tuberosity. Zygomatic process of Zygomatic process of

maxilla or buttress of the maxilla or buttress of the zygoma zygoma

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

ProcedureProcedure

• • Marking the length of the needleMarking the length of the needle: To be inserted in : To be inserted in the soft tissues (about 30 mm).the soft tissues (about 30 mm).

• • Position of the patientPosition of the patient: Supine or semisupine: Supine or semisupine

• • Position of the operatorPosition of the operator: :

For the right-sided block- side of the patientFor the right-sided block- side of the patient

For the left-sided block- in front of the patient.For the left-sided block- in front of the patient.

• • Preparation of the tissuesPreparation of the tissues: by application of topical : by application of topical antiseptic and topical anaesthetic agents.antiseptic and topical anaesthetic agents.

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

Retract the cheek & needle is placed in the soft Retract the cheek & needle is placed in the soft tissues at the height of mucobuccal fold above the tissues at the height of mucobuccal fold above the distal aspect of maxillary second molar tooth.distal aspect of maxillary second molar tooth.

Advance the needle slowly in a superior, medial, and Advance the needle slowly in a superior, medial, and posterior direction to a depth of 30 mm. posterior direction to a depth of 30 mm.

At this depth the tip of the needle lies in At this depth the tip of the needle lies in pterygopalatine fossa in the proximity to the pterygopalatine fossa in the proximity to the maxillary division of trigeminal nerve.maxillary division of trigeminal nerve.

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

Greater palatine canal approachGreater palatine canal approach• • Location of greater palatine foramenLocation of greater palatine foramen..• • Needle:Needle: 25 G ,length is 1 5/8” or 40-42 mms. 25 G ,length is 1 5/8” or 40-42 mms.• • Bevel of the needleBevel of the needle: facing the palatal soft tissues: facing the palatal soft tissues• • Point of insertionPoint of insertion: The palatal soft tissues directly over the : The palatal soft tissues directly over the

greater palatine foramen.greater palatine foramen.• • Palpation of the area of insertionPalpation of the area of insertion: Needle is inserted into : Needle is inserted into

palatal mucosa in a posterolateral direction at a level of distal palatal mucosa in a posterolateral direction at a level of distal half of maxillary I molar.half of maxillary I molar.

• • Target areaTarget area: The maxillary nerve as it passes through the : The maxillary nerve as it passes through the pterygopalatine fossa. The needle passes through the greater pterygopalatine fossa. The needle passes through the greater palatine canal to reach pterygopalatine fossa.palatine canal to reach pterygopalatine fossa.

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

Anatomical landmarksAnatomical landmarks:: Greater palatine Greater palatine

foramen foramen Maxillary second Maxillary second

molar toothmolar tooth Palatal gingival Palatal gingival

margin in the area of margin in the area of this tooththis tooth

Median palatine Median palatine raphe.raphe.

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

ProcedureProcedure Length Length : mark the length of the needle (30-35 mm): mark the length of the needle (30-35 mm) Position of the patientPosition of the patient : the occlusal plane of : the occlusal plane of

maxilary teeth should be at an angle of 45maxilary teeth should be at an angle of 45° to the ° to the floor.floor.

Position of the operatorPosition of the operator : : For right sided block – in front of the patientFor right sided block – in front of the patient For left sided block – side of the patientFor left sided block – side of the patient Mouth Mouth : wide open & neck extended: wide open & neck extended Location of the foramenLocation of the foramen : at the distal aspect of : at the distal aspect of

palatal root of maxillary 2 nd molarpalatal root of maxillary 2 nd molar

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

Preparation of the tissuesPreparation of the tissues : By application of topical : By application of topical antiseptic and topical anaesthetic agents antiseptic and topical anaesthetic agents

Insertion of the needleInsertion of the needle : From the opposite side at an : From the opposite side at an angle of 45° to the palatal bone posteriorly, and enter angle of 45° to the palatal bone posteriorly, and enter the greater palatine foramen.the greater palatine foramen.

BevelBevel: Against the soft tissues over the foramen.: Against the soft tissues over the foramen. Penetrate the needle into the mucosa. Deposit a small Penetrate the needle into the mucosa. Deposit a small

volume of solution.volume of solution.

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

Advance the needle slowly into the greater palatine Advance the needle slowly into the greater palatine canal to a depth of 30-35 mm.. If resistance is felt, canal to a depth of 30-35 mm.. If resistance is felt, withdraw the needle slightly and change the angle withdraw the needle slightly and change the angle slightly and advance it further into the canal.slightly and advance it further into the canal.

Aspirate and deposit about 1 ml of solution slowly..Aspirate and deposit about 1 ml of solution slowly.. Withdraw the needle slowlyWithdraw the needle slowly Wait for 3-5 minutes and commence with the surgical Wait for 3-5 minutes and commence with the surgical

or the dental procedureor the dental procedure..

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

Signs and symptomsSigns and symptoms1. Numbness of lower eyelid, side of the nose, and 1. Numbness of lower eyelid, side of the nose, and

upper lip.upper lip.2. Numbness in the teeth, buccal and palatal soft tissues 2. Numbness in the teeth, buccal and palatal soft tissues 3. Absence of pain during the procedure.3. Absence of pain during the procedure.PrecautionsPrecautions1. Overinsertion of the needle1. Overinsertion of the needle: It is less likely with : It is less likely with

greater palatine canal approach and more likely with greater palatine canal approach and more likely with high tuberosity approach. high tuberosity approach.

2. Resistance to insertion of the needle2. Resistance to insertion of the needle: It is found in : It is found in the greater palatine canal approach. the greater palatine canal approach.

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

Failures of anaesthesiaFailures of anaesthesia

1. Partial anaesthesia1. Partial anaesthesia::

due to under penetration of the needle..due to under penetration of the needle..

2.2. Inability to negotiate the greater palatine canalInability to negotiate the greater palatine canal . .

In the presence of obstruction in the canal, it is In the presence of obstruction in the canal, it is advisable to try with tuberosity approach.advisable to try with tuberosity approach.

The greater palatine canal approach is successful The greater palatine canal approach is successful if the needle is penetrated atleast 2/3if the needle is penetrated atleast 2/3rdrd of its length of its length into the canal.into the canal.

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Intraoral Nerve Blocks for Maxillary Intraoral Nerve Blocks for Maxillary NerveNerve

ComplicationsComplications

1. 1. Haematoma:Haematoma: It occurs due to the injury to the It occurs due to the injury to the maxillary artery & injury to the pterygoid plexus of maxillary artery & injury to the pterygoid plexus of veins, via the tuberosity approachveins, via the tuberosity approach

2. 2. Penetration of orbitPenetration of orbit: Rare. It may occur in patients : Rare. It may occur in patients with small sized skulls.with small sized skulls.

3. 3. Penetration of the nasal cavityPenetration of the nasal cavity: The needle may : The needle may penetrate the thin medial wall of the pterygopalatine penetrate the thin medial wall of the pterygopalatine fossa and thus the needle enters the nasal cavityfossa and thus the needle enters the nasal cavity

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Extraoral Nerve Blocks for Extraoral Nerve Blocks for Maxillary NerveMaxillary Nerve

IndicationsIndications1. Wounds sustained due to accidents1. Wounds sustained due to accidents2. Swellings of head and neck etc2. Swellings of head and neck etc3. Presence of trismus due to various reasons3. Presence of trismus due to various reasons Extraoral injectionsExtraoral injectionsi. Are not difficult than intraoral injectionsi. Are not difficult than intraoral injectionsii. The technique can be mastered easilyii. The technique can be mastered easilyiii. Have easier accessibilityiii. Have easier accessibilityiv. Have easier achievement of asepsisiv. Have easier achievement of asepsisv. Larger areas can be anaesthetised.v. Larger areas can be anaesthetised.

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Extraoral Nerve Blocks for Extraoral Nerve Blocks for Maxillary NerveMaxillary Nerve

Infraorbital Nerve BlockInfraorbital Nerve Block

The nerves and the areas anaesthetised are the The nerves and the areas anaesthetised are the same as that for the intra oral technique.same as that for the intra oral technique.

IndicationsIndications 1. When the anterior and middle posterior 1. When the anterior and middle posterior

superior alveolar nerve are to be anaesthetised; superior alveolar nerve are to be anaesthetised; and the intraoral approach is not possible nand the intraoral approach is not possible n

2. When the intraoral methods are ineffective2. When the intraoral methods are ineffective

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Infraorbital Nerve BlockInfraorbital Nerve Block

Anatomical landmarksAnatomical landmarks

(1) Infraorbital margin(1) Infraorbital margin

(2) Infraorbital depression (2) Infraorbital depression

(3) Infraorbital foramen(3) Infraorbital foramen

(4) Pupil of the ipsilateral eye.(4) Pupil of the ipsilateral eye.

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Infraorbital Nerve BlockInfraorbital Nerve Block

TechniqueTechnique• • Preparation of skinPreparation of skin: with an antiseptic.: with an antiseptic.• • Location of the infraorbital foramenLocation of the infraorbital foramen: With the help : With the help

of the anatomical landmarks of the anatomical landmarks • • Anaesthesia of the skin and the subcutaneous Anaesthesia of the skin and the subcutaneous

tissuetissue: achieved by deposition of a few drops of : achieved by deposition of a few drops of solution below the skin.solution below the skin.

• • NeedleNeedle: Long or short 25 G. : Long or short 25 G.

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Infraorbital Nerve BlockInfraorbital Nerve Block

ProcedureProcedure Skin and subcutaneous tissues are anaesthetised by local Skin and subcutaneous tissues are anaesthetised by local

infiltrationinfiltration The needle is inserted at an angle of about 45The needle is inserted at an angle of about 45° ° through the skin through the skin

medially and inferiorly to the foramen medially and inferiorly to the foramen The opening of the foramen is located and the needle is directed The opening of the foramen is located and the needle is directed

slightly upward and laterally to facilitate its entry into the slightly upward and laterally to facilitate its entry into the foramen. foramen.

Incisors and canine are most easily anaesthetised, as solution is Incisors and canine are most easily anaesthetised, as solution is injected close to anterior superior alveolar nerves.injected close to anterior superior alveolar nerves.

Carefully aspirate and slowly deposit 1 ml of solution.Carefully aspirate and slowly deposit 1 ml of solution. Withdraw the needle slowly, wait for about 10 minutes, and Withdraw the needle slowly, wait for about 10 minutes, and

begin with the procedure.begin with the procedure.

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Infraorbital Nerve BlockInfraorbital Nerve Block

AdvantagesAdvantages: :

More preciseMore precise

RelationsRelations The needle passes through the following structures -The needle passes through the following structures - Skin, subcutaneous tissue, and quadratus labii superioris Skin, subcutaneous tissue, and quadratus labii superioris

muscle.muscle. When the needle is in final position the important structures in When the needle is in final position the important structures in

the vicinity of the tip of the needle are - the vicinity of the tip of the needle are - Facial artery and facial vein.Facial artery and facial vein. When the tip of the needle is in the canal, it is very close to When the tip of the needle is in the canal, it is very close to

the infraorbital nerve and vessels.the infraorbital nerve and vessels.

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Infraorbital Nerve BlockInfraorbital Nerve Block

Care should be takenCare should be taken

(1) to advance slowly,(1) to advance slowly,

(2) to aspirate as needle is advanced, (2) to aspirate as needle is advanced,

(3) t ensure that needle remains in the confines (3) t ensure that needle remains in the confines of the canal, of the canal,

(4) aspiration and deposit 1-2 ml of the (4) aspiration and deposit 1-2 ml of the solution.solution.

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Infraorbital Nerve BlockInfraorbital Nerve Block

Signs and symptomsSigns and symptomsa. Subjectivea. Subjective:: Tingling and numbness of the lower eyelid, side Tingling and numbness of the lower eyelid, side

of the nose and upper lip.of the nose and upper lip.b. Objective:b. Objective: (1) Demonstration of absence of pain with (1) Demonstration of absence of pain with

instrumentation instrumentation (2) No pain during the surgical procedure or (2) No pain during the surgical procedure or

the dental therapythe dental therapy

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Maxillary Nerve BlockMaxillary Nerve Block

Areas anaesthetisedAreas anaesthetised:: Anterior temporal and Anterior temporal and

zygomatic regions, zygomatic regions, lower eyelid,lower eyelid, side of the nose, side of the nose, upper lip, upper lip, maxillary teeth,maxillary teeth, maxillary alveolar maxillary alveolar

bone,bone,

hard palate,hard palate, part of soft palatepart of soft palate tonsils,tonsils, part of the pharynx,part of the pharynx, nasal septum ,nasal septum , floor of the nose and floor of the nose and

mucosa of the posterior mucosa of the posterior lateral part of the lateral lateral part of the lateral wall of the nosewall of the nose

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Maxillary Nerve BlockMaxillary Nerve Block

Anatomical Anatomical landmarkslandmarks

• • Midpoint of Midpoint of zygomatic archzygomatic arch

• • Zygomatic notchZygomatic notch• • Coronoid process of Coronoid process of

the ramus of the the ramus of the mandiblemandible

• • Lateral pterygoid Lateral pterygoid plate plate

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Maxillary Nerve BlockMaxillary Nerve Block

IndicationsIndications

1. Where anaesthesia of the entire distribution of the 1. Where anaesthesia of the entire distribution of the maxillary nerve is required for extensive surgery.maxillary nerve is required for extensive surgery.

2. When it is desirable to block all the subdivisions of 2. When it is desirable to block all the subdivisions of the maxillary nerve with only one needle insertion; the maxillary nerve with only one needle insertion; and with a minimum of solution.and with a minimum of solution.

3. When local infection, trauma, etc make nerve blocks 3. When local infection, trauma, etc make nerve blocks of terminal branches ineffectiveof terminal branches ineffective

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Maxillary Nerve BlockMaxillary Nerve Block

TechniqueTechnique..

• • Palpation of the landmarksPalpation of the landmarks: The midpoint of the zygomatic : The midpoint of the zygomatic arch is located and the depression in its inferior surface is arch is located and the depression in its inferior surface is marked. The coronoid process of the ramus of the mandible is marked. The coronoid process of the ramus of the mandible is located by opening and closing the lower jaw.located by opening and closing the lower jaw.

• • Needle:Needle: 25G, a skin wheal is raised just below this mark in the 25G, a skin wheal is raised just below this mark in the depression.depression.

• • Mark the needleMark the needle: 4” (8.8 cm), 22 G needle attached to a : 4” (8.8 cm), 22 G needle attached to a leuerlock type of syringe, the operator measures 4.5 cm and leuerlock type of syringe, the operator measures 4.5 cm and marks with a rubber markermarks with a rubber marker

Insertion of the needleInsertion of the needle: through the skin wheal, perpendicular : through the skin wheal, perpendicular to the skin surface and to the median sagittal plane. to the skin surface and to the median sagittal plane.

Withdraw & aspirate, 1-2 ml of solution is slowly injected.Withdraw & aspirate, 1-2 ml of solution is slowly injected.

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Maxillary Nerve BlockMaxillary Nerve Block

RelationsRelations The needle passes through the following structures: The needle passes through the following structures: skin, subcutaneous tissue,masseter muscle, sigmoid skin, subcutaneous tissue,masseter muscle, sigmoid

notch, and lateral pterygoid muscle.notch, and lateral pterygoid muscle. When the needle is in contact with the lateral pterygoid plate When the needle is in contact with the lateral pterygoid plate

the structures in its vicinity:the structures in its vicinity: Superiorly - the base of the skull.Superiorly - the base of the skull. Inferiorly – crosses internal maxillary arteryInferiorly – crosses internal maxillary artery Superficially – transverse facial arterySuperficially – transverse facial artery Posteriorly – mandibular nerve & middle Posteriorly – mandibular nerve & middle

meningeal arterymeningeal artery Anteriorly – pterygomaxillary fissureAnteriorly – pterygomaxillary fissure

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Maxillary Nerve BlockMaxillary Nerve Block

Signs and symptomsSigns and symptoms

1. 1. Subjective symptomsSubjective symptoms: Tingling and : Tingling and numbness of upper lip, side of the nose, lower numbness of upper lip, side of the nose, lower eyelid, and in some instances anaesthesia of eyelid, and in some instances anaesthesia of soft palate and pharynx, with gagging soft palate and pharynx, with gagging sensation.sensation.

2. 2. Objective symptomsObjective symptoms: Absence of pain : Absence of pain sensation with instrumentationsensation with instrumentation

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Injection Techniques forInjection Techniques for

Mandibular Nerve and its BranchesMandibular Nerve and its Branches

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Injection Techniques forInjection Techniques forMandibular Nerve and its branchesMandibular Nerve and its branches

1. Infiltration techniques1. Infiltration techniques..

2. Nerve blocks2. Nerve blocks: :

Intra oral Intra oral Inferior alveolar nerve block Inferior alveolar nerve block

Gow-gates mandibular nerve Gow-gates mandibular nerve blockblock

Akinosi mandibular nerve blockAkinosi mandibular nerve block

Extra oral nerve blocks.Extra oral nerve blocks.

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INTRAORAL NERVE BLOCKSINTRAORAL NERVE BLOCKS

Inferior alveolar nerve blockInferior alveolar nerve block Mandibular nerve block /Mandibular nerve block / Pterygomandibular Block/Pterygomandibular Block/ Fischer 1,2,3 technique/Fischer 1,2,3 technique/ 3 positional technique3 positional technique

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Inferior alveolar nerve blockInferior alveolar nerve block

Nerves AnaesthetisedNerves Anaesthetised

a. Inferior alveolar nerve, along with its terminal a. Inferior alveolar nerve, along with its terminal branches such as incisive nerve and mental branches such as incisive nerve and mental nervenerve

b. Lingual nerve ( commonly ).b. Lingual nerve ( commonly ).

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Inferior alveolar nerve blockInferior alveolar nerve block

Areas anaesthetisedAreas anaesthetised 1. 1. Inferior alveolar nerve:-Inferior alveolar nerve:-

Pulps of all mandibular teeth till the Pulps of all mandibular teeth till the midlinemidline

Body of the mandibleBody of the mandible Inferior portion of the ramus of the Inferior portion of the ramus of the

mandiblemandible Buccal muco periosteum, in the region Buccal muco periosteum, in the region

of mandibular anteriors, anterior to of mandibular anteriors, anterior to mandibular second premolar or anterior mandibular second premolar or anterior to the mental foramento the mental foramen

Skin of the chin, skin of lower lip, and Skin of the chin, skin of lower lip, and mucosa of lower lipmucosa of lower lip

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Inferior alveolar nerve blockInferior alveolar nerve block

2.2. Lingual nerve:- Lingual nerve:- Mucosa of anterior 2/3 of tongue.Mucosa of anterior 2/3 of tongue. Mucosa of floor of the oral cavity.Mucosa of floor of the oral cavity. Lingual muco periosteum from the last molar tooth to Lingual muco periosteum from the last molar tooth to

central incisor in the midline.central incisor in the midline. Sub lingual salivary gland.Sub lingual salivary gland.

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Inferior alveolar nerve blockInferior alveolar nerve blockIndications:-Indications:- Surgical procedures in the mandibular teeth in one quadrant Surgical procedures in the mandibular teeth in one quadrant when buccal anesthesia in the region posterior to when buccal anesthesia in the region posterior to

mandibular 2mandibular 2ndnd premolar is required. premolar is required. When lingual soft tissue anesthesia is required.When lingual soft tissue anesthesia is required. Restorative procedures in mandibular 2Restorative procedures in mandibular 2ndnd premolar& molars. premolar& molars.Contra indications:-Contra indications:- Presence of acute inflammation or infection (rarely).Presence of acute inflammation or infection (rarely). In young children or mentally challenged patients as they In young children or mentally challenged patients as they

may bite their lip or tongue.may bite their lip or tongue.

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Inferior alveolar nerve blockInferior alveolar nerve blockAnatomical land marks:-Anatomical land marks:- Muco buccal fold in the region of premolars and molarsMuco buccal fold in the region of premolars and molars Anterior border of ramus of the mandibleAnterior border of ramus of the mandible External oblique ridgeExternal oblique ridge Coronoid processCoronoid process Coronoid notchCoronoid notch Retro molar triangle or fossaRetro molar triangle or fossa Internal oblique ridgeInternal oblique ridge Pterygo mandibular raphaePterygo mandibular raphae Pterygo mandibular spacePterygo mandibular space Occulasal plane of mandibular molarsOcculasal plane of mandibular molars Contralateral premolars Contralateral premolars Buccal pad of fatBuccal pad of fat

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Inferior alveolar nerve blockInferior alveolar nerve block

Approximating structures when needle is in the final position:-Superior to the following Inferior alveolar vessels Inferior alveolar nerve Insertion of Medial pterygoid muscle Mylohyoid vessels, nerveAnterior to the deeper lobe of parotid glandMedial to the inner surface of the ramus of the mandible.Lateral to the following: Lingual nerve Medial pterygoid muscle, Sphenomandibular ligament

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Technique:- Body of the mandible should be parallel to the ground.

Operator stands at 7 o’ clock position. With left index finger or thumb palpate the mucobuccal

fold. Then finger passed posteriorly to palpate external

oblique ridge & anterior border of the ramus. Identify the greatest depth of ramus of the mandible by

moving finger up & down i.e coronoid notch, it is in a direct line with mandibular sulcus.

Then finger is moved lingually across the Retromandibular triangle & on to the internal oblique ridge.

Classical Inferior alveolar nerve Classical Inferior alveolar nerve blockblock

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The finger is moved to the buccal side taking with it the buccal pad of fat. This gives better exposure to the pterygomandibular raphae & pterygomandibular depression.

When palpating the intra oral land marks the operator may place the index finger extra orally behind the ramus of the mandible to asses the width of ramus of mandible.

With 25 G & 1 5/8 inch needle if inserted parallel to Occlusal plane of mandibular teeth from opposite of mouth at a level of bisecting the finger penetrating the tissues of the pterygotemporal depression, & entering the pterymandibular space.

Classical Inferior alveolar nerve Classical Inferior alveolar nerve blockblock

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During insertion of the needle patient is asked to kept his mouth wide open. The needle is penetrated into the tissues until gently contacting bone on the internal surface of ramus.

This should be in the area of mandibular sulcus which funnels into the mandibular foramen.

The needle is then withdrawn about 1 mm & 1 – 1.8 ml of solution deposited slowly ( 1 ½ – 2 min).

The needle is now withdrawn slowly about one half of its inserted depth, reminder of the solution is injected in this area to anaesthetize lingual nerve.

Classical Inferior alveolar nerve Classical Inferior alveolar nerve blockblock

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Classical Inferior alveolar nerve Classical Inferior alveolar nerve blockblock

Ianb.mov

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modification of ianb.mov

Modified Inferior alveolar nerve Modified Inferior alveolar nerve blockblock

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Inferior alveolar nerve blockInferior alveolar nerve blockFischer 1,2,3 positoinal Technique:-Fischer 1,2,3 positoinal Technique:-1.1. Direct techniqueDirect technique2.2. Indirect techniqueIndirect techniqueDirect technique:-Direct technique:- Carried in 3 positions Carried in 3 positions 11stst position—the direction is from the opposite side position—the direction is from the opposite side

—for inferior alveolar nerve —for inferior alveolar nerve 2nd position—the direction is from the same side—2nd position—the direction is from the same side—

for lingual nerve.for lingual nerve. 3rd position—the direction is from the opposite 3rd position—the direction is from the opposite

side—to inject between the external and internal side—to inject between the external and internal oblique ridges—for long buccal nerve.oblique ridges—for long buccal nerve.

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Inferior alveolar nerve blockInferior alveolar nerve block

DIRECT TECHNIQUE

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Inferior alveolar nerve blockInferior alveolar nerve block

Indirect technique:Indirect technique: 1st position—the direction is from the opposite 1st position—the direction is from the opposite

side—to inject between the external and side—to inject between the external and internal oblique ridges—for long buccal nerve.internal oblique ridges—for long buccal nerve.

2nd position—the direction is from the same 2nd position—the direction is from the same side—for lingual nerve.side—for lingual nerve.

3rd position—the direction is from the 3rd position—the direction is from the opposite side—for inferior alveolar nerve opposite side—for inferior alveolar nerve

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Inferior alveolar nerve blockInferior alveolar nerve block

INDIRECT TECHNIQUE

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Inferior alveolar nerve blockInferior alveolar nerve block

Signs & symptoms:-:- Tingling & numbness of the lower lipTingling & numbness of the lower lip Tingling & numbness of half of the tongueTingling & numbness of half of the tongue Abscence of pain during surgical procedures.Abscence of pain during surgical procedures.

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Inferior alveolar nerve blockInferior alveolar nerve block

FAILURES OF ANESTHESIAFAILURES OF ANESTHESIA Deposition of solutionDeposition of solution

below the level of mandibular foramenbelow the level of mandibular foramen

too far anteriorly on the ramus.too far anteriorly on the ramus. Accessory innervation in the mandibular teethAccessory innervation in the mandibular teeth Cross innervation of mandibular central Cross innervation of mandibular central

incisors due to contra lateral inferior alveolar incisors due to contra lateral inferior alveolar nerve innervation.nerve innervation.

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Inferior alveolar nerve blockInferior alveolar nerve block

COMPLICATIONS:-COMPLICATIONS:- (i) Haematoma (i) Haematoma (ii) Trismus(ii) Trismus (iii) Transient facial paresis(iii) Transient facial paresis

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Inferior alveolar nerve blockInferior alveolar nerve block

Advantages:- One injection provides a wide area of

anaesthesia

Disadvantages:- Wide area of anaesthesia Positive aspiration( 10%-15%) Lingual & Lower lip anaesthesia

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The long buccal nerve is usually anesthetised The long buccal nerve is usually anesthetised as a part of pterygomandibular nerve block in as a part of pterygomandibular nerve block in indirect technique.indirect technique.

Other Common NamesOther Common Names Buccinator nerve block, Buccal nerve block.Buccinator nerve block, Buccal nerve block.

Nerves AnaesthetisedNerves Anaesthetised Long buccal branch of the mandibular nerve.Long buccal branch of the mandibular nerve.

Long buccal nerve blockLong buccal nerve block

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Long buccal nerve blockLong buccal nerve block

Areas AnaesthetisedAreas Anaesthetised Mucoperiosteum buccal to the mandibular Mucoperiosteum buccal to the mandibular

molar teeth, vestibular mucosa and adjacent molar teeth, vestibular mucosa and adjacent part of buccal mucosa.part of buccal mucosa.

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Indications When anaesthesia of buccal soft tissues in the When anaesthesia of buccal soft tissues in the

mandibular molar region is required mandibular molar region is required Contraindications:- Presence of inflammation or infectionPresence of inflammation or infection Advantages:-Advantages:- High success rate, and Technically easy.High success rate, and Technically easy.Disadvantages:- It is a potentially painful injection.It is a potentially painful injection. Positive aspiration rate is 0.5%Positive aspiration rate is 0.5%

Long buccal nerve blockLong buccal nerve block

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Anatomical landmarksAnatomical landmarks Ascending ramus of the mandibleAscending ramus of the mandible External oblique ridgeExternal oblique ridge Retromolar triangleRetromolar triangle Internal oblique ridgeInternal oblique ridge Last molar tooth.Last molar tooth.

Long buccal nerve blockLong buccal nerve block

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Technique:-Technique:-• • Area of insertion: It is the area of mucous membrane Area of insertion: It is the area of mucous membrane

distal and buccal to the most distal tooth or the last distal and buccal to the most distal tooth or the last molar tooth.molar tooth.

Target area: The long buccal nerve as it crosses the Target area: The long buccal nerve as it crosses the anterior border of the ramus.anterior border of the ramus.

Needle: A 1 inch 25 gauge needle is inserted into the Needle: A 1 inch 25 gauge needle is inserted into the mucosa just distal and buccal to the last molar tooth mucosa just distal and buccal to the last molar tooth between the external and internal oblique ridges, and between the external and internal oblique ridges, and 0.25 to 0.5 ml of solution is deposited in this area.0.25 to 0.5 ml of solution is deposited in this area.

Long buccal nerve blockLong buccal nerve block

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Long buccal nerve blockLong buccal nerve block

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Alternative techniques:-Alternative techniques:- 1. Insert the needle and deposit the solution directly into the 1. Insert the needle and deposit the solution directly into the

retrornolar triangle.retrornolar triangle. 2. Insert the needle in the mucoperiosteum just buccal to the 2. Insert the needle in the mucoperiosteum just buccal to the

last molar tooth.last molar tooth.

Signs and SymptomsSigns and Symptoms i. The patient rarely experiences any subjective symptoms:i. The patient rarely experiences any subjective symptoms: ii. Lack of demonstration of pain with instrumentation in the ii. Lack of demonstration of pain with instrumentation in the

anaesthetised area anaesthetised area

Complications:-Complications:- HaematomaHaematoma

Long buccal nerve blockLong buccal nerve block

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Nerve AnaesthetisedNerve Anaesthetised The terminal branches of inferior The terminal branches of inferior

alveolar nerve:alveolar nerve: (i) mental nene and incisive nerve.(i) mental nene and incisive nerve.

Areas AnaesthetisedAreas Anaesthetised 1. Labial mucous membrane anterior to 1. Labial mucous membrane anterior to

the mental foramen, usually from the the mental foramen, usually from the first premolar up to the midline.first premolar up to the midline.

2. Skin of the lower lip and chin.2. Skin of the lower lip and chin. 3. Pulpal nerve fibres of the first 3. Pulpal nerve fibres of the first

premolars, canines and incisors.premolars, canines and incisors. 4. The periodontium and the supporting 4. The periodontium and the supporting

alveolar bone of these teeth.alveolar bone of these teeth.

Mental Nerve Block and Incisive Mental Nerve Block and Incisive Nerve BlockNerve Block

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IndicationsIndications 1. Dental restorative procedures requiring pulpal 1. Dental restorative procedures requiring pulpal

anaesthesia of mandibular anterior teeth.anaesthesia of mandibular anterior teeth. 2. When inferior alveolar nerve block is not indicated2. When inferior alveolar nerve block is not indicated 3. When buccal soft tissue anaesthesia is required for 3. When buccal soft tissue anaesthesia is required for

procedures in the mandible anterior to the mental procedures in the mandible anterior to the mental foramen (i) soft tissue biopsies. and foramen (i) soft tissue biopsies. and

(ii) suturing of soft tissues.(ii) suturing of soft tissues.

ContraindicationsContraindications Presence of acute inflammation or infection in the Presence of acute inflammation or infection in the

area of injection.area of injection.

Mental Nerve Block and Incisive Mental Nerve Block and Incisive Nerve BlockNerve Block

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AdvantagesAdvantages i. High success rate.i. High success rate. ii. Technically easy.ii. Technically easy. iii. Usually entirely a traumatic.iii. Usually entirely a traumatic. iv. Produces pulpal anaesthesia, as well as soft and hard tissue iv. Produces pulpal anaesthesia, as well as soft and hard tissue

anaesthesia without lingual anaesthesia. It is useful in stead of anaesthesia without lingual anaesthesia. It is useful in stead of bilateral inferior alveolar nerve blocks.bilateral inferior alveolar nerve blocks.

DisadvantagesDisadvantages 1. It does not produce lingual anaesthesia1. It does not produce lingual anaesthesia 2. Partial anaesthesia may develop at the midline because the 2. Partial anaesthesia may develop at the midline because the

nerve fibres overlap with those of the opposite side.nerve fibres overlap with those of the opposite side. Positive aspiration 5.7%Positive aspiration 5.7%

Mental Nerve Block and Incisive Mental Nerve Block and Incisive Nerve BlockNerve Block

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Anatomical LandmarksAnatomical Landmarks Mandibular bicuspids; since the mental foramen usually lies Mandibular bicuspids; since the mental foramen usually lies

below the apex of the second bicuspid or below and between below the apex of the second bicuspid or below and between the apices of first and second bicuspids.the apices of first and second bicuspids.

TechniqueTechnique The apices of the bicuspid teeth should be estimated.The apices of the bicuspid teeth should be estimated. A 1 inch, 25 gauge needle is inserted into the mucobuccal A 1 inch, 25 gauge needle is inserted into the mucobuccal

fold after the cheek has been pulled laterally.fold after the cheek has been pulled laterally. The tissue is penetrated until the periosteum of the mandible The tissue is penetrated until the periosteum of the mandible

is gently contacted slightly anterior to the apex of the second is gently contacted slightly anterior to the apex of the second bicuspid.bicuspid.

About 0.5 to 1 ml of local anaesthetic solution is deposited in About 0.5 to 1 ml of local anaesthetic solution is deposited in the areathe area

Mental Nerve Block and Incisive Mental Nerve Block and Incisive Nerve BlockNerve Block

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Mental Nerve Block and Incisive Mental Nerve Block and Incisive Nerve BlockNerve Block

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Signs and SymptomsSigns and Symptoms i. Tingling or numbness of the lower lip.i. Tingling or numbness of the lower lip. ii. Lack of pain during the surgical or dental restorative ii. Lack of pain during the surgical or dental restorative

procedure.procedure.

Failure of AnaesthesiaFailure of Anaesthesia 1. Inadequate volume of anaesthetic solution in the mental 1. Inadequate volume of anaesthetic solution in the mental

foramen, with subsequent lack of pulpal anaesthesia.foramen, with subsequent lack of pulpal anaesthesia. 2. Inadequate diffusion of the solution into the mental 2. Inadequate diffusion of the solution into the mental

foramen. To correct this, apply firm pressure over the injection foramen. To correct this, apply firm pressure over the injection site for 2 minutes in order to force anaesthetic solution into the site for 2 minutes in order to force anaesthetic solution into the mental foramen.mental foramen.

ComplicationsComplications Complications are rare, with rare occurrence of haematoma.Complications are rare, with rare occurrence of haematoma.

Mental Nerve Block and Incisive Mental Nerve Block and Incisive Nerve BlockNerve Block

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Gow-gates mandibular nerve blockGow-gates mandibular nerve block

Nerves anaesthetised: Nerves anaesthetised: The entire mandibular branch of trigeminal nerve is The entire mandibular branch of trigeminal nerve is

anaesthetised anaesthetised

(i) inferior alveolar nerve along with its terminal (i) inferior alveolar nerve along with its terminal branches; mental and incisive nerves branches; mental and incisive nerves

(ii) lingual(ii) lingual

(iii) mylohyoid (iii) mylohyoid

(iv) auriculotemporal, and(iv) auriculotemporal, and

(v) long buccal nerves (v) long buccal nerves

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Areas anaesthetisedAreas anaesthetised (1) All mandibular teeth up to the midline on the side of (1) All mandibular teeth up to the midline on the side of

injection injection (2) Buccal mucoperiosteum on the side of injection(2) Buccal mucoperiosteum on the side of injection (3) Mucosa of the anterior 2/3rds of the tongue and floor of (3) Mucosa of the anterior 2/3rds of the tongue and floor of

the mouththe mouth (4) Lingual mucoperiosteum from the last standing molar (4) Lingual mucoperiosteum from the last standing molar

tooth up to the central incisor in the midlinetooth up to the central incisor in the midline (5) Body of the mandible, and inferior portion of the ramus, (5) Body of the mandible, and inferior portion of the ramus, (6) Skin over the zygoma, posterior portion of the cheek and (6) Skin over the zygoma, posterior portion of the cheek and

temporal regionstemporal regions

Gow-gates mandibular nerve blockGow-gates mandibular nerve block

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IndicationsIndications 1. Surgical procedures on mandibular body and the ramus.1. Surgical procedures on mandibular body and the ramus. 2. When buccal soft tissue anaesthesia from the third molar up 2. When buccal soft tissue anaesthesia from the third molar up

to the midline is required.to the midline is required. 3. Surgical procedures in the tongue and the floor of the 3. Surgical procedures in the tongue and the floor of the

mouth.mouth. 4. When conventional inferior alveolar nerve blocks are 4. When conventional inferior alveolar nerve blocks are

unsuccessful.unsuccessful. 5. Restorative procedures on multiple teeth.5. Restorative procedures on multiple teeth.

ContraindicationsContraindications 1. Presence of infection or acute inflammation in the area of 1. Presence of infection or acute inflammation in the area of

injection,injection, 2. Patients who might bite either their lip or the tongue, such 2. Patients who might bite either their lip or the tongue, such

as young children and mentally challenged adults.as young children and mentally challenged adults.

Gow-gates mandibular nerve blockGow-gates mandibular nerve block

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Anatomical landmarksAnatomical landmarksa. Extraoral landmarksa. Extraoral landmarks•• External earExternal ear•• Intertragic notch of the earIntertragic notch of the ear•• Corner of the mouthCorner of the mouthb.b. Intraoral landmarksIntraoral landmarks•• Anterior border of the ramus of the mandibleAnterior border of the ramus of the mandible•• Tendon of temporalis muscleTendon of temporalis muscle•• Mesiopalatal cusp of maxillary second molarMesiopalatal cusp of maxillary second molar

Gow-gates mandibular nerve blockGow-gates mandibular nerve block

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TechniqueTechnique Target area: Lateral side of the condylar neck, Target area: Lateral side of the condylar neck,

just below the insertion of the lateral pterygoid just below the insertion of the lateral pterygoid muscle.muscle.

ProcedureProcedure • • Position of the patient: semi-supine positionPosition of the patient: semi-supine position • • Position of the operator: Position of the operator:

in front of the patient- for right-sided in front of the patient- for right-sided block block by the side of the patient for left-by the side of the patient for left-sided blocksided block

Gow-gates mandibular nerve blockGow-gates mandibular nerve block

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Identification of the Identification of the land marks:-land marks:-

an imaginary line an imaginary line drawn from the corner drawn from the corner of of mouth to the inter mouth to the inter tragic notch of the eartragic notch of the ear

Needle Needle 25 G ;Length 25 G ;Length 40 mm40 mm

Gow-gates mandibular nerve blockGow-gates mandibular nerve block

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gow gate.mov

gow gates-conti.mov

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• • Signs and SymptomsSigns and Symptoms 1. Numbness or tingling sensation of the lower 1. Numbness or tingling sensation of the lower

lip.lip. 2. Numbness or tingling sensation of the 2. Numbness or tingling sensation of the

tongue.tongue. 3. No pain felt during surgical procedure.3. No pain felt during surgical procedure.

Gow-gates mandibular nerve blockGow-gates mandibular nerve block

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Complications:-Complications:- HaematomaHaematoma TrismusTrismus Temporary paralysis of cranial nerves II, IV, VI.Temporary paralysis of cranial nerves II, IV, VI.

Failure of anaesthesia:Failure of anaesthesia:a. Too little volume of local anaesthetic solution is a. Too little volume of local anaesthetic solution is

deposited.deposited.

b. Anatomical difficulties.b. Anatomical difficulties.

Gow-gates mandibular nerve blockGow-gates mandibular nerve block

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Akinosi (Closed Mouth) Mandibular Akinosi (Closed Mouth) Mandibular Nerve BlockNerve Block

Described by Joseph Akinosi in 1977.Described by Joseph Akinosi in 1977.Nerves AnaesthetisedNerves Anaesthetised The entire mandibular branch of trigeminal nerve is The entire mandibular branch of trigeminal nerve is

anaesthetised, except the long buccal nerve.anaesthetised, except the long buccal nerve. Areas AnaesthetisedAreas Anaesthetised• • All mandibular teeth on the side of injection up to the midline.All mandibular teeth on the side of injection up to the midline.• • Body of the mandible and inferior portion of the ramus.Body of the mandible and inferior portion of the ramus.• • Buccal mucoperiosteum and mucous membrane in front of the Buccal mucoperiosteum and mucous membrane in front of the

mental foramen.mental foramen.• • Mucous membrane of the anterior 2/3rds of the tongue and Mucous membrane of the anterior 2/3rds of the tongue and

floor of the oral cavity.floor of the oral cavity.• • Lingual soft tissues and periosteum.Lingual soft tissues and periosteum.

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Akinosi Mandibular Nerve BlockAkinosi Mandibular Nerve Block

IndicationsIndications1. Limited mandibular opening.1. Limited mandibular opening.2. Multiple procedures on mandibular teeth.2. Multiple procedures on mandibular teeth.3. Inability to visualise the landmarks for inferior 3. Inability to visualise the landmarks for inferior

alveolar nerve blockalveolar nerve blockContraindicationsContraindications1. Presence of acute inflammation or infection in the 1. Presence of acute inflammation or infection in the

area of injectionarea of injection2. Patients who might bite their lip or tongue, such as 2. Patients who might bite their lip or tongue, such as

young children an I mentally challenged adults.young children an I mentally challenged adults.3. Inability to visualise or gain access to the lingual 3. Inability to visualise or gain access to the lingual

aspect of the ramusaspect of the ramus

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Akinosi Mandibular Nerve BlockAkinosi Mandibular Nerve BlockAdvantages1. Relatively atraumatic.1. Relatively atraumatic.2. Patient need not be able to open mouth.2. Patient need not be able to open mouth.3. Minimal post operative complications.3. Minimal post operative complications.4.Lower aspiration rate than with IAN block 4.Lower aspiration rate than with IAN block 5. Provides successful anaesthesia where a bifid inferior alveolar 5. Provides successful anaesthesia where a bifid inferior alveolar

nerve and bifid mandibular canals are present.nerve and bifid mandibular canals are present.Disadvantages1. Difficult to visualise the path of the needle and the depth of 1. Difficult to visualise the path of the needle and the depth of

insertion.insertion.2. No bony contact, so the depth of penetration is somewhat 2. No bony contact, so the depth of penetration is somewhat

arbitrary.arbitrary.3. Potentially painful if the needle is too close to periosteum3. Potentially painful if the needle is too close to periosteum

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Anatomical Landmarks 1. Occlusal plane of teeth in occlusion.1. Occlusal plane of teeth in occlusion. 2. Mucogingival junction of maxillary molar 2. Mucogingival junction of maxillary molar

teeth.teeth. 3. Anterior border of ramus of the mandible.3. Anterior border of ramus of the mandible. 4. Maxillary tuberosity.4. Maxillary tuberosity.

Akinosi Mandibular Nerve BlockAkinosi Mandibular Nerve Block

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Technique • • Needle: 25G, length 1 5/8” or 40-42 mmNeedle: 25G, length 1 5/8” or 40-42 mm • • Bevel: facing away from the bone of mandibular Bevel: facing away from the bone of mandibular

ramus and towards the midline.ramus and towards the midline. • • Height of injection: With Akinosi’s technique it is Height of injection: With Akinosi’s technique it is

below that of Gow-Gates’ technique but above that of below that of Gow-Gates’ technique but above that of inferior alveolar nerve block.inferior alveolar nerve block.

• • Target area: The soft tissues on the medial border of Target area: The soft tissues on the medial border of ramus of the mandible in the region of inferior ramus of the mandible in the region of inferior alveolar nerve, lingual nerve, and mylohyoid nerves alveolar nerve, lingual nerve, and mylohyoid nerves and vessels.and vessels.

Akinosi Mandibular Nerve BlockAkinosi Mandibular Nerve Block

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Procedure • • Position of the patient: The patient is seated in semi Position of the patient: The patient is seated in semi

reclining position with head, neck and shoulder reclining position with head, neck and shoulder adequately supported.adequately supported.

• • Position of the operator: The operator stands in Position of the operator: The operator stands in front of the patient for both right-sided as well as left-front of the patient for both right-sided as well as left-sided block.sided block.

• • Preparation of the tissues: The site of penetration is Preparation of the tissues: The site of penetration is prepared by topical application of antiseptic and prepared by topical application of antiseptic and anaesthetic solutions.anaesthetic solutions.

• • The patient is asked to bring teeth in occlusion The patient is asked to bring teeth in occlusion

Akinosi Mandibular Nerve BlockAkinosi Mandibular Nerve Block

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Akinosi Mandibular Nerve BlockAkinosi Mandibular Nerve Block

Akhinosi.mov

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Signs and Symptoms1. Numbness or tingling sensation of the lower lip.1. Numbness or tingling sensation of the lower lip.2. Numbness or tingling sensation of the tongue.2. Numbness or tingling sensation of the tongue.3. No pain felt during surgical procedure. 3. No pain felt during surgical procedure.

Complicatlons:-I. HaematomaI. Haematoma2. Trismus, 2. Trismus, 3. Transient facial nerve paresis due to over insertion of 3. Transient facial nerve paresis due to over insertion of

the needle and deposition of the solution into the the needle and deposition of the solution into the body of the parotid gland.body of the parotid gland.

Akinosi Mandibular Nerve BlockAkinosi Mandibular Nerve Block

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Failure of Anaesthesia 1. Failure to appreciate the flaring nature of the ramus 1. Failure to appreciate the flaring nature of the ramus

which deflects the needle more medially if internal which deflects the needle more medially if internal oblique ridge is not negotiated by keeping the syringe oblique ridge is not negotiated by keeping the syringe nearly at an angle of 90° (perpendicular) to fur medial nearly at an angle of 90° (perpendicular) to fur medial surface of ascending ramus. This can be easily surface of ascending ramus. This can be easily achieved by retracting the angle of the mouth achieved by retracting the angle of the mouth posteriorly with the barrel of the syringe.posteriorly with the barrel of the syringe.

2. Needle insertion point too low.2. Needle insertion point too low. 3. Under insertion or overinsertion of the needle as no 3. Under insertion or overinsertion of the needle as no

bone is contacted in this technique, the depth of soft bone is contacted in this technique, the depth of soft tissue penetration is somewhat arbitrary. tissue penetration is somewhat arbitrary.

Akinosi Mandibular Nerve BlockAkinosi Mandibular Nerve Block

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Extra Oral Technique For Extra Oral Technique For Mandibular NerveMandibular Nerve

Nerves Anaesthetised Mandibular nerve and its subdivisions; Mandibular nerve and its subdivisions;

Areas Anaesthetised The entire region innervated by mandibular The entire region innervated by mandibular

nerve and its subdivisions,nerve and its subdivisions, Temporal region,Temporal region, auricle of the ear, auricle of the ear, external auditory meatus, external auditory meatus,

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temporomandibular joint, temporomandibular joint, salivary glands, salivary glands, anterior 2/3rds of the tongue, anterior 2/3rds of the tongue, floor the mouth, floor the mouth, mandibular teeth, gingiva, buccal mucosa, mandibular teeth, gingiva, buccal mucosa,

lower portion of the face (except the angle of lower portion of the face (except the angle of the jaw).the jaw).

Extra Oral Technique For Extra Oral Technique For Mandibular NerveMandibular Nerve

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Indications 1. Presence of acute inflammation or infection at the site of 1. Presence of acute inflammation or infection at the site of

injection for the subdivisions of mandibular nerve.injection for the subdivisions of mandibular nerve. 2. Presence of trauma that would contraindicate or make it 2. Presence of trauma that would contraindicate or make it

difficult or impossible to anaesthetize the subdivisions of difficult or impossible to anaesthetize the subdivisions of mandibular nerve.mandibular nerve.

3. Whenever there is need to anaesthetize the entire 3. Whenever there is need to anaesthetize the entire mandibular m and its subdivisions, with one single penetration mandibular m and its subdivisions, with one single penetration and minimum ot local anesthetic solution for extensive and minimum ot local anesthetic solution for extensive surgical procedures.surgical procedures.

4. For diagnostic and therapeutic purposes.4. For diagnostic and therapeutic purposes.

Extra Oral Technique For Extra Oral Technique For Mandibular NerveMandibular Nerve

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Anatomical Landmarks These are common to those for extraoral These are common to those for extraoral

maxillary nerve block; and are as follows:maxillary nerve block; and are as follows: • • Midpoint of zygomatic arch.Midpoint of zygomatic arch. • • Coronoid process of the ramus of the Coronoid process of the ramus of the

mandible; and prominence of the lateral pole mandible; and prominence of the lateral pole of the condyle; which is located by having the of the condyle; which is located by having the patient open and close his mouth.patient open and close his mouth.

• • Lateral pterygoid plate.Lateral pterygoid plate.

Extra Oral Technique For Extra Oral Technique For Mandibular NerveMandibular Nerve

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Technique The technique for mandibular nerve block is The technique for mandibular nerve block is

essentially the same as that for maxillary nerve block. essentially the same as that for maxillary nerve block. The difference is that the marker is placed i the The difference is that the marker is placed i the needle at a distance of 5 cm.needle at a distance of 5 cm.

The needle contacts the lateral pterygoid plate, then it The needle contacts the lateral pterygoid plate, then it is with drawn exactly in the same way as in the is with drawn exactly in the same way as in the maxillary nerve block.maxillary nerve block.

It is reinserted, the needle is directed upward and It is reinserted, the needle is directed upward and slightly posteriorly in order for the needle to pass slightly posteriorly in order for the needle to pass posterior to lateral pterygoid plate. The needle should posterior to lateral pterygoid plate. The needle should not be introduced to a depth greater than measured 5 not be introduced to a depth greater than measured 5 cm. cm.

Extra Oral Technique For Extra Oral Technique For Mandibular NerveMandibular Nerve

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Approximating Structures:-a. a. Structures through which the needle passes:

Skin, subcutaneous tissue, masseter muscle, Skin, subcutaneous tissue, masseter muscle, sigmoid notch, lateral pterygoid muscle.sigmoid notch, lateral pterygoid muscle.

bb. . Structures in the vicinity of the needle when the needle is in contact with lateral pterygoid plate.

•• Superiorly: Base of the skull.Superiorly: Base of the skull.•• Internal maxillary artery; as it crosses interiorly Internal maxillary artery; as it crosses interiorly

and curves upwards anterior to it, entering the and curves upwards anterior to it, entering the lower part of pterygomaxillary fissure.lower part of pterygomaxillary fissure.

•• Temporal vessels for internal maxillary artery that Temporal vessels for internal maxillary artery that may lie on either side of it.may lie on either side of it.

Extra Oral Technique For Extra Oral Technique For Mandibular NerveMandibular Nerve

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Superficially: The transverse facial artery which Superficially: The transverse facial artery which may lie above ormay lie above or

below it.below it.•• Posteriorly: Foramen ovale and posterior to it Posteriorly: Foramen ovale and posterior to it

foramen spinosum.foramen spinosum.•• Anteriorly: Pterygomaxillary fissure through Anteriorly: Pterygomaxillary fissure through

which the needle maywhich the needle may pass into pterygopalatine fossa.pass into pterygopalatine fossa.

Extra Oral Technique For Extra Oral Technique For Mandibular NerveMandibular Nerve

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Signs and Symptomsa. Subjective: Tingling sensation and numbness of lower lip a. Subjective: Tingling sensation and numbness of lower lip

and anterior 2/3rd of the tongue.and anterior 2/3rd of the tongue.b. Objective:b. Objective:i. Demonstration of difference in feeling of lower teeth while i. Demonstration of difference in feeling of lower teeth while

opening and closing the jaws.opening and closing the jaws.ii. Lack of demonstration of pain with instrumentation.ii. Lack of demonstration of pain with instrumentation.iii. Absence of pain during surgical procedure. iii. Absence of pain during surgical procedure.

Complications1. Failure of anaesthesia, and1. Failure of anaesthesia, and2. Trismus.2. Trismus.

Extra Oral Technique For Extra Oral Technique For Mandibular NerveMandibular Nerve

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Computer controlled local Computer controlled local anaesthetic deliveryanaesthetic delivery

Also called as CCLAD. Introduced in 1997. Wand designed to improve on the ergonomics &

precession of the dental syringe. The system enables a dentist to accurately

manipulate needle placement with finger tip accuracy & deliver the L.A solution with a foot activated control.

Light weight hand piece provides increased tactile sensation & control.

L.A solution delivery is computer control.

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Available CCLAD systems:- The wand/ compudent system Comfort control syringe.The wand/ compudent system:-~ utilizes a single use safety hand piece~ Luer - Lok needle is attached to the handle ~ The handle attaches to a catridge holder via a 60

inch micro tube which can hold a volume of less than 0.2 ml of fluid.

Computer controlled local Computer controlled local anaesthetic deliveryanaesthetic delivery

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~ The system administers local anesthetics at 2 specific rates of delivery.

~ The slow rate is 0.5 ml /min.

~ The fast rate is 1.8 ml/min.

~ ~ An aspiration test can be activated at any time by releasing the pressure on the foot rheostat starting a 4.5 sec aspiration cycle.

Computer controlled local Computer controlled local anaesthetic deliveryanaesthetic delivery

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Advantages:- Precise control of flow rate & pressure produces a

more comfortable injection even in tissues with low elasticity eg. palate, attached gingiva & PDL.

Increased tactile feel & ergonomics from the light weight hand piece.

Non threatening Automatic aspiration Rotational insertion technique minimizes needle

deflection

Computer controlled local Computer controlled local anaesthetic deliveryanaesthetic delivery

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Disadvantages:- Requires additional armamentarium. Cost.

Computer controlled local Computer controlled local anaesthetic deliveryanaesthetic delivery

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Comfort –Control syringe:- This is an electronic pre programmed delivery

device that provides the operator with the control needed to make the patients local anesthetic injection experience as pleasant as possible.

It has 2 stage delivery system. The injection begins at an extremely slow rate to

prevent pain associated with quick delivery. After 10 sec the CCS automatically increases

speed to the preprogrammed rate.

Computer controlled local Computer controlled local anaesthetic deliveryanaesthetic delivery

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Computer controlled local Computer controlled local anaesthetic deliveryanaesthetic delivery

Comfort – control syringe

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Advantages:- Familiar ‘syringe’ type of delivery system. Inexpensive disposables. Allows selection of various rates of delivery. Disadvantages:- Requires additional armamentarium More bulky than other CCLADs. Vibrations may bother some users and Cost.

Computer controlled local Computer controlled local anaesthetic deliveryanaesthetic delivery

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Electronic dental anesthesia

History:- 46 AD Scribonius Largus, physician

to the emperor Claudius, used tarpedo fish to releave the pains of gout.

DESENSOR hand piece (1970) – a high speed device that carried low voltage current through a bur directly on to the tooth.

Trance cutanious electric nerve stimulation (TENS) & Electronic dental anesthesia developed since the mid 1960’s into techniques.

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Mechanism of action of TENS :- Low frequency electricity (2 Hz) Produces measurable changes in the blood

levels of L tryptophan, cerotonin, & beta endorphins which possesses analgesic actions, elevating the pain reaction threshold.

Electronic dental anesthesia

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Electronic dental anesthesia

Medical uses of TENS:- Causalgia Phantom limb pain post herpetic neuralgia intractable cancer pain Lower back pain Spinal cord injury Ileus

Peripheral nerve injury Bursitis Parturition Polycythemia vera Cervical back pain Postoperative pain Diabetic ulceration

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TENS in dentistry:-

1. Temporomandibular joint (TMJ) or myofacial pain dysfunction By low frequency extra oral stimulation of the area.

2. Acute dental pain By high frequency electronic stimulation.

Electronic dental anesthesia

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Indications:- Used as a technique in pain control ( needle

phobia ) Ineffective local anesthesia Instances where local anesthetics cannot be

administered.

Electronic dental anesthesia

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Indications of EDA in dentistry:-

1. TMJ / MPDS.

2. Administration of local anesthesia.

3. Non surgical periodontal procedures.

4. Restorative dentistry.

5. FPD procedures.

6. Endodontics.

Electronic dental anesthesia

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Contraindications:- Cardiac pace makers Neurological disorders

a. Status post cerebrovascular accident ( stroke)

b. H/o transient ischemic attacks.

c. H/o epilepsy. Pregnancy Immaturity Very young patients & old patients with senile

dementia.

Electronic dental anesthesia

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Advantages:- No need for needle. No need for injection of drugs. Patient is in control of the anesthesia. No residual anesthetic effect at the end of the

procedure. Residual analgesic effect remains for several hours. Post surgical pain & swelling can be minimized

through the use of EDA after surgical procedures ( a low frequency setting for 30 – 60min ).

Electronic dental anesthesia

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HANDBOOK OF LOCAL ANAESTHESIA – HANDBOOK OF LOCAL ANAESTHESIA – S.F.MALAMEDS.F.MALAMED

LOCAL ANAESTHESIA AND PAIN CONTROL LOCAL ANAESTHESIA AND PAIN CONTROL IN DENTAL PRACTICE – MONHEIMSIN DENTAL PRACTICE – MONHEIMS

MANUAL OF LOCAL ANESTHESIA IN MANUAL OF LOCAL ANESTHESIA IN DENTISTRY – A.P. CHITREDENTISTRY – A.P. CHITRE

ORAL & MAXILLOFACIAL SURGERY - ORAL & MAXILLOFACIAL SURGERY - SRINIVASANSRINIVASAN

LOCAL ANAESTHESIA IN DENTAL PRACTICE-LOCAL ANAESTHESIA IN DENTAL PRACTICE-MEECHAMMEECHAM

REFERENCESREFERENCES

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