Clinical tips in dental local anesthesia

Dr.Elhawary
Clinical Tips In Dental Local Anesthesia
• Hesham El-Hawary
• 1998
• Assoc Prof. OMFS
– Cairo University
– MSA University
– Umm AL-Qura University
• Email:
hesham@elhawarydentalclinic.com
Hesham.elhawary@dentistry.cu.edu.eg
• Slide share:
– www.slideshare.nethesham_elhawary
• Website :
– www.elhawarydentalclinic.com

Dr.Elhawary
Clinical Tips Dental
Local Anesthesia

Dr.Elhawary
Pre-anesthetic evaluation of the
patient
1. Case History
2. Local Examination
3. Patient Grouping and sensitivity test
4. Discussing with the patient the Treatment Plan

Dr.Elhawary
Classification of the patients according to their physical
condition
According to the American Society of Anesthesiologists (ASA)
Type I : Normal patient
Type II : Mild to moderate systemic disease
Type III: Sever systemic disease limiting patient activity
Type IV: Sever systemic disease threatening life
Type V : Morbid patient

Dr.Elhawary
Treatment options
1. Office treatment
• ASA type I
• ASA type II
2. Hospitalization
• ASA type III
3. Hospitalization and emergency treatment only
• ASA type IV
4. Hospitalization and palliative treatment
• ASA type V

Dr.Elhawary
Sensitivity Test
• Intranasal sensitivity test
• Skin sensitivity test

Dr.Elhawary
Skin Sensitivity Test

Dr.Elhawary
• Explain your treatment plan in a simple way
• No
– Scary
– Scientific words
• Never deny a procedure
• Never lie to a child patient

Dr.Elhawary
Armamentarium and Preparation
for basic injection

Dr.Elhawary

Dr.Elhawary
Dental Syringe

Dr.Elhawary
Pressure Syringe

Dr.Elhawary
Jet injector
Needle-less syringe

Dr.Elhawary
Preparation of the site of
injection and Needle insertion

Dr.Elhawary
1. Use suitable Syringes and Needles
2. Hands of the operator: cleaned and disinfected
3. Anesthetic carpules: warmed, clean and disinfected
4. Patient's mouth: cleaned, rinsed
5. Site of injection: dried and disinfected
6. Insertion of the needle:
1. The patient should be aware that he is going to have the injection but not exactly when
2. Mucosa Stretched as possible to facilitate insertion of the needle
3. The syringe is held in a pen grasp
4. The needle should not be bent to change its direction inside the tissues
5. The needle should always follow the simplest way inside the tissues
6. After insertion of the needle, aspirate a little to be sure that the needle is not within a
blood vessel
7. The anesthetic solution is then deposited at a rate of not more than 2 ml/min
8. meanwhile the patient should be watched carefully for any adverse reaction

Dr.Elhawary
Innervation

Dr.Elhawary
The maxillary nerve

Dr.Elhawary
Pulp , Investing structures & Labial (buccal)
mucoperiosteum
Anterior superior alveolar nerve
Anterior teeth
(1,2,3)
Middle superior alveolar nerve
Premolars
(4,5) &
MB root of 1st
molar(6)
Posterior superior alveolar nerve
Molars except
MB root of 1st
molar(6)
Nerve supply of Maxillary teeth

Dr.Elhawary
Palatal mucoperiosteum
Nasopalatine nerve
Anterior
teeth
(1,2,3)
Greater ( Anterior) palatine nerve
Premolars
(4,5)
&
Molars
(678)
Nerve supply of Maxillary teeth

Dr.Elhawary
The accessory innervations of the teeth
• The buccal mucoperiosteum, the pulp and
investing structures of upper anterior teeth cross
innervation may take place i.e. branch from the anterior
superior nerve of the other side
• The palatal mucoperiosteum of the upper canine is
supplied by interlacing fibers between the greater
palatine nerve and the nasopalatine nerve

Dr.Elhawary
Nerve supply to the mandibular teeth
Pulp , Investing structures
Incisive nerve
Anterior teeth
(1,2,3)
Inferior alveolar nerve
Premolars
(4,5) &
Molars (678)

Dr.Elhawary
Labial (buccal) mucoperiosteum
Mental nerve
Cutaneous coli nerve
( branch of cervical plexus C2 & c3 ) gives
additional sensory supply for premolars ( 4 , 5 )
in about 20 % of the pt.
Anterior teeth
(1,2,3)
&
Premolars (45)
Long buccal nerveMolars (678)

Dr.Elhawary
Lingual mucoperiosteum
Lingual nerve
Anterior teeth
(1,2,3) Premolars
(4,5) & Molars
(678)

Dr.Elhawary
1 2 3 4 5 6 7 8
L MB Lingual Nerve
P Is Incisive Nerve IAN
B
MB
Mental Nerve
Long Buccal Nerve

Dr.Elhawary
The accessory innervations of the teeth
• The pulp and investing structures of the lower
anterior teeth cross innervation may take place i.e.
branch from the incisive nerve of the other side
• The buccal mucoperiosteum of the lower premolar
may receive additional nerve supply from the cutaneous
coli nerve (branch from the cervical plexus of nerves)
• The pulp and investing structures of the lower
molars may receive additional nerve supply from the
nerve to mylohyoid

Dr.Elhawary
PHARMACOLOGY OF LOCAL
ANESTHESIA

Dr.Elhawary
ANESTHETIC CARPULE
Pharmacology of Local Anesthesia

Dr.Elhawary
Anesthesia with V.C.
1. Local anesthetic agent
( L.A.)
2. Vasoconstrictor agent
( V.C.)
3. Preservative for V.C.
agent
(anti- oxidant)
4. Vehicle to make solution
isotonic
( 0.9%NaCl)
Plain Anesthesia
(without V.C.)
1. Local anesthetic agent
( L.A.)
2. Vehicle to make solution
isotonic
( 0.9%NaCl)

Dr.Elhawary
Keep in mind
• The main agent in the carpule is the L.A. agent
• The other ingredients of the local anesthetic
carpule are added :
1. To potentiate the action of the L.A. agent
2. To prevent deterioration of the contents

Dr.Elhawary
Anesthetic Techniques

Dr.Elhawary
Local Anesthesia
1. Topical anesthesia
2. Local infiltration
3. Nerve block

Dr.Elhawary
Local Anesthesia
3. Nerve block
 Ointments, gels, sprays and
pastes
 Applied on mucous
membrane or skin
 Allows for easy and painless
insertion of needle
 Affects free nerve endings

Dr.Elhawary
Local Anesthesia
3. Nerve block
 Flooding of the terminal
nerve endings with local
anesthetic solution
 Infiltiration above a tooth
apex is an example of a field
block

Dr.Elhawary
Local Anesthesia
3. Nerve block
 The anesthetic solution is
deposited close to a main
nerve trunk
 Usually at a distance from
the operative site before the
nerve divided into terminal
branches

Dr.Elhawary
Factors affecting selection of the
technique to be used
1. Area to be anesthetized
2. Extent of surgical procedure
3. Duration and profoundness of anesthesia
4. Age of the patient
5. Homeostasis
6. Presence of infection
7. Skills of the operator
8. Presence of the suitable equipment

Dr.Elhawary
Types of maxillary injections
Maxillary
anethesia
Infiltration
anesthesia
Buccal inf
Palatal inf
Nerve block
anesthesia
Infraorbital NB
Incisive NB
Greater Palatine
NB
Posterior
Superior Alv NB
Maxillary NB

Dr.Elhawary
Points
• Chair position
• Dentist position
• Syringe
• Needle
• Areas/Nerves to be anesthetized - Landmarks
• Point of insertion
• Direction of injection
• Checking the anesthesia

Dr.Elhawary
Checking the anesthesia
Subjective findings Objective findings

Dr.Elhawary
MAXILLARY BUCCAL INFILTRATION
ANESTHESIA
Maxillary Anesthetic Techniques

Dr.Elhawary
Confirming the Anesthesia
• Subjective findings
– No subjective findings
• Objective findings
– Probing does not lead to pain

Dr.Elhawary
MAXILLARY PALATAL INFILTRATION
ANESTHESIA
Maxillary Anesthetic Techniques

Dr.Elhawary
Palatal Infiltration Technique
The point of needle insertion

Dr.Elhawary
Palatal Infiltration Technique
Direction of needle insertion

Dr.Elhawary
Variations in these techniques
Buccal anesthesia
 Injection for the maxillary
third molar
 Upper centrals
Palatal anesthesia
• Injection for maxillary third
molar
• Upper centrals and laterals

Dr.Elhawary
NERVE BLOCK TECHNIQUES IN THE
MAXILLA

Dr.Elhawary
Local Anesthesia
• Nerve Block
– The anesthetic solution
is deposited close to a
main nerve trunk
– Usually at a distance
from the operative site
before the nerve
divided into terminal
branches

Dr.Elhawary
Mandibular Anesthetic
techniques

Dr.Elhawary
Types of mandibular injections
Mandibular
anethesia
Infiltration
anesthesia
Anterior labial
infl anesth
Anterior lingual
inf anesth
Long buccal inf
anesth
Nerve block
anesthesia
IA and L NB
Mental NB
Long Buccal NB

Dr.Elhawary
Infiltration Anesthesia

Dr.Elhawary
Anteriors’ labial Infiltration Anesthesia
The point of needle insertion

Dr.Elhawary
Anteriors’ Labial Infiltration Anesthesia
Direction of needle insertion

Dr.Elhawary
Confirming the Anesthesia
• Subjective findings
– Numbness of the lower lip
• Objective findings
– Probing does not lead to pain

Dr.Elhawary
Infiltration Anesthesia
Anteriors’ lingual Infiltration
Anesthesia

Dr.Elhawary
Indirect technique of lingual
infiltration of right anteriror teeth

Dr.Elhawary
MANDIBULAR ANESTHETIC TECHNIQUES
IA & L NERVE BLOCK ANESTHESIA

Dr.Elhawary
Techniques
• Standard technique
• Gaw-Gates Technique
• Akinozi Technique

Dr.Elhawary
STANDARD TECHNIQUE

Dr.Elhawary
Patient position
• Head , neck and trunk on the
same straight line
• The back of the chair is tilted so
that it make a 45 degree angle
with the floor
• So that when the patient open his
mouth the occlusal plane of the
mandibular teeth becomes
parallel to the floor
• The occlusal plan of mandibular
teeth near to the operator’s
elbow
Dentist position
• Right side:
– From infront and to the right
• Left side:
using
• Cross hand technique
• Using left hand
– From right rear position using
• From behind technique

Dr.Elhawary
Ocland DVD of Head and Neck Anatomy

Dr.Elhawary
Points
• Chair position
• Syringe
• Needle
• Nerves to be anesthetized
– Incisive Nerve
– Mental nerve
– Inferior alveolar nerve
– Lingual nerve
• Areas to be anesthetized
• landmarks

Dr.Elhawary
Points
• Chair position
• Syringe
• Needle
– All the pulp and investing structures of lower posterior teeth in the side of anesthesia
– Buccal mucoperiosteum of the anterior teeth and premolars
– The lingual mucoperiosteum of the same side
– Floor of the mouth of the same side
– Half the tongue of the same side
• landmarks

Dr.Elhawary
Points
• Chair position
• Syringe
• Needle
• landmarks

Dr.Elhawary
landmarks
• Soft tissue landmarks • Bony landmarks

Dr.Elhawary
Steps for right mandibular injection
• Right handed operator
• The operator is positioned from infront and to
the right

Dr.Elhawary
Deposited into the constrictor
muscle of pharynx : disphagya

Dr.Elhawary
Narrow angle of flare

Dr.Elhawary
Wide angle of flare

Dr.Elhawary
Points
• Chair position
• Syringe
• Needle
• landmarks
– Subjective findings
• Numbness of the lower lip
– Objective findings
• Probing does not lead to pain

Dr.Elhawary
Steps for left mandibular injection
• Right handed operator
The operator is positioned on the right front of the
patient
• Cross hand technique
• Left hand technique
– Right rear position
• From behind technique

Dr.Elhawary
Cross Hand Technique

Dr.Elhawary
From Behind Technique

Dr.Elhawary
Left Hand Technique

Dr.Elhawary
Errors during injection
• Too high injection
• Too low injection
• Too deep injection
• Too medial injection
– Anesthesia of the
auriclotemporal nerve :
Numbness of the ear
– Injection into lateral
pterygoid muscle : Soreness
and trismus

Dr.Elhawary
• Failure of anesthesia

Dr.Elhawary
– Deposited in parotid gland
– Temporary facial nerve
paralysis
– Parotitis
– Deposited into the
posterior facial vein :
– Toxicity
– Deposited into medial
pterygoid muscle
– Pain
– Trismus

Dr.Elhawary
– Deposited into the
constrictor muscle of
pharynx : disphagya

Dr.Elhawary
Complications
Of Local Anesthesia

Dr.Elhawary
• A: Airway
» Clear
» Adequate Respiration
• B: Bleeding
» Stopped
» Achieve inlet to vessels
• C: Circulation
» Fluids if needed
• D: Drugs to treat the present condition

Dr.Elhawary
• Call medical emergency service
• The patient position
– Placed in horizontal position on his back
– Tilt the patient in a slightly head down position
or
– elevate the legs to help increase cerebral circulation
• Adequate oxygenation
• Check the patient's cardiac and cardiovascular status
• Start I.V. fluids (e.g. 5% dextrose in H2O)
• Drugs according to the condition
• If complete circulatory standstill
– IV injection of atropine
– Stimulation of the heart by introducing a needle directly into it
– Intracardiac injection of epinephrine 0.1 ml of 1.1000 solution

Dr.Elhawary
Complications from local Anesthesia
I. Complications associated to the
absorption of the solution used
II. Complications associated with
needle insertion

Dr.Elhawary
Complications associated with absorption of the
anesthetic solution
1. Systemic drug reactions due to the local anesthetic agent:
1. Toxicity
2. Allergy
3. Anaphylactic reactions
4. Idiosyncrasy
2. Local reactions:
1. Infections due to contaminated solutions
2. Local tissue irritation

Dr.Elhawary
Complications associated with needle insertion
• Fainting and syncope
• Needle breakage
• Prolonged anesthesia
• Pain
• Edema
• Trismus
• Hematoma
• Sloughing and ulceration
• Infection
• Bizarre neurological symptoms

Clinical tips in dental local anesthesia

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