LA Sheet #10 By Ibrahim Al-Omari

by **Sura** 15/12/2011, 12:13 am

http://www.mediafire.com/?az5x7110e28j0e9

by **Shadi Jarrar** 24/12/2011, 12:18 am

Mandibular anesthesia

It's very important because it's most challenging ….

Now what make the mandibular anesthesia harder than the maxillary one that we can make infiltration in the maxilla better than the maxilla because of :

1-the mandibular bone is 7 times more dense than the maxillary one

2- the mandibular bone is not porous

3- the anatomical landmarks are difficult to be located (subjected to age changes , and to variations between people )

1-Mental nerve block

2-Incisive nerve block

3-Lingual nerve block

4-Inferior alveolar nerve block

5-long buccal nerve block

6-Gow-Gates method

7-Vazirani-Akinosi method and others

The last two are supplemental that means to overcome the failure in the previous methods

Infiltration means just deposit near the area of interest … it means we lit the anesthesia to go throw bone foramens and pores to do their work … like the incisive nerve block we lit the anesthesia to go throw the mental foramen to reach it …. Or in children younger than 6 years of age (because their bone are porous so we deposit the anesthesia near the tooth apex )

Note in children the Inferior alveolar nerve block is contra indicated because they may injure their tongue or lips

Paresthesia is related to the high concentration of anesthesia not to the type of anesthesia itself ( some reports said that articaine in 4% could cause paresthesia >> but then they found in 3% no signs of paresthesia >>> so it's related to the concentration not to the type )

Mental and incisive nerve block

we will talk about them as one technique but the aim is totally different

Mental block >> for mental nerve (for the soft tissues )>> for suture of the lower lip incisive " used in surgery of the chin, lower lip and buccal mucosa from midline to the second premolar (wiki)"

Incisive block >> for the incisive nerve (mean the dental not soft tissues ) like extraction( although every incisive nerve block is a mental nerve block because of the anatomy )

Mental and incisive nerves are a branches of the posterior trunk of the inferior alveolar nerve, which is itself a branch of the mandibular division of the trigeminal nerve >>> they are the terminal branches of the inferior alveolar nerve

the idea of mental or incisive nerve block is giving the anesthesia just close to the mental foramen ( now the deference between the two techniques :

when we want to a incisive >> we try to push the anesthesia inside the canal by applying finger pressure over the injection site in order to enforce the L.A. inside the canal " that’s why it has a high failure ratio>> sometimes the finger pressure in not adequate "

when we want to do a mental >>> we just leave it outside " don’t push it" )

now we have to locate the landmark to locate the site of injection to give a good anesthesia

(note : failure is related to infection or technique "site of injection" but smoking is not that much related and only considered if the patient was heavy smoker and drinker and tacking opioid )

Now the landmark for us is the mental foramen , we have to locate it in anterior posterior position and in vertical position

Now the anterio-posterior position is between the first and the second premolar but closer to the second ….. but we have to understand that there is anatomical variations >> it could be anterior (closer to the first premolar ) or more posterior (distal to the second premolar apex )>>> this variations has a clinical significant that when we anesthetized the incisive nerve we reach the distal segment of inferior alveolar nerve and the second premolar is anesthetized(second premolar supplied by the distal segment of inferior alveolar nerve) … but if the foramen is too anterior we can't reach the distal segment soo the second premolar is not affected by the anesthesia >>> so the success of second premolar anesthesia depends on the site of mental foramen

Now the vertical position of the mental foramen :
1- in dentate patient :in the mid way between the inferior border of the mandible and the alveolar crest bone

2-in edentulous patient : more superior or superficial ( due to the loss of teeth and alveolar bone ) >>> could cause burning sensation to when they wear their dentures

3-in children : one third from the lower border (more inferior ) because the lower bone is not completely developed

Hint about the vertical position : if you give it superior or superficial is better than if you give it inferior or deep because the local anesthesia could go deep by the gravity but impossible to go superior

Due to this variations the failure rate is high

now how could we locate the mental foramen :
1- if we draw a line from the pupils of the eye to the mouth it locate it , when the patient look directly forward >>> in this way we can locate the antrioposterior potion

2- by palpation by the index finger when you feel a kind of roughness and concavity on the bone (this is the mental foramen ) in relation to the nearby bone (the doctor do not recommend it could lead to a discomfort because of the pressure )

3- by radiograph (ORTHOPANTOGRAM "OPG" OR MENTAL APICAL FILMS )

Now the technique to give the block :
tow methods
1^st . (the old one ) we stand behind the patient , we retract the cheek , insert the tip of the needle toward the estimated position of the mental foramen

Why it's old ??

A- This method could cause trauma to the neurovascular bundle >>> cause the needle can go inside the foramen and cause damage( the foramen face upwards )

B-It's in the patient line of sight

2^nd.(the new way) we come from the in front of the patient and the needle goes horizontal
so the neurovascular bundle is protected and the needles is out of the line of sight

Now we said that the difference between the incisive and the mental nerve block ( in technique ) is enforcing the local anesthesia inside the foramen by figure pressure
this pressure must extend for two minutes (extra oral or intraoral ) and in the right side clockwise and in the left side anticlockwise

Central incisor you might need to do infiltration because the contralateral innervation from the other side if there is incomplete anesthesia

The indication :

For incisive :
when you need to do a bilateral I.D BLOCK (like when you need to extract from canine to canine ) …. So give an ID on one-side and incisive + lingual on the other side >> cause if you give a bilateral ID the patient may injure his tongue of suffocate with it

From the book :1- where dental treatment involves bilateral procedure on mandibular premolars and anterior teeth , bilateral incisive nerve block can be administered . Pulpal , buccal soft tissues , and bone is readily obtained.

2-when inferior alveolar nerve block(INAB) is not indicated

Lingual not anesthetized with this block. ( for lingual either by lingual nerve block or by infiltration on the mesial and distal aspect of the tooth being treated ).

Q . how can you anesthetize the lingual side if the patient have trismus or a child who refuse the palatal injection ??
A. you insert the needle throw the papilla (after you anesthetize the buccal side) look at the page 250 figure 14-33 to understand it more (sorry I did not find a pic on the net )

(from the book) Advantages : 1-provide pulpal and hard tissue anesthesia without lingual anesthesia (which is uncomfortable and unnecessary for many patients); useful in place of bilateral INABs

2-high success rate
disadvantages : 1- dose not provide lingual anesthesia . the lingual tissues must be injected directly if anesthesia is desired.

2-parial anesthesia my develop at the midline because of nerve fiber overlap with the opposite side(extremely rare ). Local infiltration on the buccal f the mandibular central incisors may be necessary for complete pulpal anesthesia to be obtained

For mental : ( kol elly jay mn el ktab)

When buccal mucous membrane anterior is necessary for procedures in the mandibular anterior to the mental foramen , such as the following :

1-soft tissues biopsies

2-suturing of soft tissues

ADVANTAGES: 1- high success rate 2-technically easy 3- Usually entirely atraumatic / DISADVANTAGES : Hematoma

Contraindications (for both) : Infection or acute inflammation in the site of injection

Q. what I the difference between anterior superior alveolar nerve block and infraorbital nerve block ??

A. the same difference between mental and incisive nerve block ( it's equivalent )

In anterior superior alveolar nerve block we should make pressure to make it and in infraorbital we don’t need it

Long buccal nerve block & infiltration (hon ba6alna mn el ktab)

Branch of the anterior division of the mandibular nerve crosses over the anterior border of the ramus 1 cm above the occlusal plane (injection here called block) , finally it divide into three branches (buccal cheek , depth of the buccal sulcus , and in the gingival ) injection here called infiltration

Now always inject distal (not mesial) to the tooth that you want to work on in the long buccal nerve infiltration to achieve anesthesia

Inferior alveolar nerve block

Has the highest failure ratio (about 15-20%) and the highest intraoral injection with positive aspiration (10-15%)
and the highest success rate is done by surgeon

We have to give the injection near the mandibular foramen
the first land mark to locate the site of injection is the occlusal plane :
1^st. in dentate adult patient 1 cm above the occlusal plane

2^nd. In old ages and retrognathic above 1 cm
3^rd. children at the occlusal plane or 4-5 mm above it

4^th. In prognathic mandible below the occlusal plane

The second land mark the coronoid notch:

Place your thump in the depth of the buccal sulcus until you feel the anterior border of the ramus then you direct your finger medially (rest your fingers retract the cheek )

The third land mark the pterygomandibular raphe

Now the point that connect the vertical and horizontal length will be the deepest point

The line that connect the tip of your finger(thump >> coronoid notch )and the deepset point of the pterygomandibular raphe would the estimated vertical position

Two thirds from the tip of your finger to the deepest point of the pterygomandibular raphe will be the insertion point (the horizontal position I think)

Depth of the needle that you insert inside the tissue is very important to prevent breakage of it ( which is 1/3 of the needle )

هالقسم الاول من الشيت مراجع بأغلبه من الكتاب(اذا في اشي بالخطوات العملي بتقدروا تراجعو الصور بالكتاب افضل) بس من بعد
buccal nerve block and infiltration
هاد لسه ما راجعته بوعدكم اني اراجعه انشاء الله و انزله

بالعلم انه التشابتر مو كثير كبير و اغلبه اشي احنا سويناه بالعيدات

Chapter 14 page227

10^th anesthesia

Done by Ibrahim al omari

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LA Sheet #10 By Ibrahim Al-Omari

LA Sheet #10 By Ibrahim Al-Omari

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