DH128 Exam 2

Which anesthetic lasts the longest and penetrates bone better?

Septocaine (articaine)

When would you want to use mipivocaine (carbocaine)

If epi is contraindicated

Why would you use lidocaine (xylocaine)?

To keep the anesthetic localized and last longer without needing it to last a REALLY long time like septocaine

What nerve is anesthetized for a Nasopalatine Nerve Block?

right & left nasopalatine nerves

What area is anesthetized for a NP?

Anterior portion of hard palate

Soft & hard tissues from mesial of right 1st bicuspid to mesial of left 1st bicuspid

NP Indications

When palatal soft tissue anesthesia is needed

NP Contraindications

Infection at injection site

What needle do you use for NP?

27 gauge short

What is the point of insertion for NP?

just lateral to incisive papilla

What is the path of insertion for NP?

needle at 45 degrees to point of insertion

What is the target area for NP?

Incisive foramen

What are the target areas for NP?

Central incisors and Incisive papilla

What is the procedure for NP?

Apply pressure for 30 seconds with stick prior to penetration

Pressure is applied during the entire injection

Insert needle

Aspirate and drip one drop

Advance ~3mm further

Aspirate

Deposit about 1-2 stoppers in 15-30 seconds

Signs and symptoms of NP

Ischemia of tissue at site

Significant resistance to delivery of solution

Numbness on anterior portion of hard palate

Complications for NP

Solution may "squirt back" out of point of insertion during administration OR as needle is being withdrawn

Hematoma

What nerves are anesthetized for an Infraorbital nerve block

ASA nerve, MSA nerve, and Branches of infraorbital nerve

What area is anesthetized for an IO?

Pulpal anesthesia: central through 2nd bicuspid

MB root 1st molar (80% of population)

Labial periodontium & bone of same teeth

Lower eyelid, lateral aspect of nose and upper lip

Indications for IO

Dental procedures of more than 2 teeth & tissue

Inflammation/infection that contraindicates supraperiosteal injections

If dense cortical bone results in failure of supraperiosteal injection

Contraindications for IO

Only 1 or 2 teeth being treated

Need hemostasis of localized area

What needle do you use for an IO?

25 gauge long

What is the point of insertion for an IO?

height of mucobuccal fold over 1st bicuspid

What is the target area for an IO?

infraorbital foramen, below infraorbital notch

What are the landmarks for an IO?

Mucobuccal fold

Infraorbital notch

Infraorbital ridge

Infraorbital depressione

Infraorbital foramen

What should the orientation of the bevel be for IO?

Toward the bone

Procedure for IO

Locate infraorbital foramen PRIOR to injection

Have patient look forward

Foramen is located in a straight line with the pupil

Place topical

Retract lip with insertion site taut

Place finger with gentle pressure just below infraorbital notch (superior to foramen)

Insert in height of mucobuccal fold, over 1st bicuspid

Aspirate, drip & count to 5 as you advance to site of deposition

Approximate depth of penetration ½ length of a long needle (16mm)

estimate depth with finger in vestibule & at notch

Site of deposition is reached when needle touches bone

Once bone is contacted, back off approximately 1-2 mm.

Deposit (1/2 - 2/3 carp)

Maintain firm pressure with external finger on site (for 1 min post deposit)

Mandibular block involves which 3 blocks?

1. Inferior Alveolar NB

2. Lingual NB

3. Buccal NB

The trigeminal nerve (CNV )

Ophthalmic (V1)

Maxillary (V2)

Mandibular (V3)

The inferior alveolar (IA) nerve

the inferior alveolar nerve is one of the three branches of the posterior division of the mandibular nerve (V3)

The terminal branches of IA nerve include

the mylohyoid mental & incisive nerves

Inferior alveolar nerve (IA)

IA is a sensory nerve that enters through the mandibular foramen to innervate the mandibular teeth, the lips, and the mucosa and gingiva anterior to the first molar

IA: Areas anesthetized

Pulp of mandibular teeth to midline

Body of mandible & inferior portion of ramus except buccal of molars

Buccal mucoperiosteum & mucous membrane anterior to mandibular 1st molar

The lingual nerve

It is also important to note that the lingual nerve lies medial to the IA.

It innervates the anterior 2/3 of the tongue, floor of the mouth and the lingual soft tissue and periosteum

Buccal nerve

The buccal nerve innervates the soft tissues and periosteum buccal to the molars

When is the Mandibular Block (IANB) indicated?

When anesthesia to the mandibular teeth, hard and soft tissues are needed

Mandibular Block: Disadvantages

Rate of inadequate anesthesia= 15-20%

Intraoral landmarks not consistent

Highest positive aspiration rate of all injections (10-15%)

Lingual & lower lip anesthesia uncomfortable to many patients & dangerous for others

Injection site for the IANB

The goal is to deposit the local anesthetic as the inferior alveolar nerve enters the mandibular foramen

Want to aim superiorly and posteriorly to the mandibular lingula at themandibular foramen

Technique for IANB

Position your patient in a semi- supine position with their feet slightly elevated

Apply topical anesthetic in the area of the pterygoid mandibular depression

Locate pterygomandibular raphe

Locate pterygomandibular depressions or triangle (between internal oblique ridge and raphe)

Ask patient to open as wide as they can comfortably

Locate the coronoid notch with your thumb (located on anterior border oframus)

Place thumb/finger in the deepest depression of coronoid notch superior to occlusal plane.

Technique continued

The syringe is directed from the contralateral premolar area 6-10 mm above and parallel to the occlusal plane with the window of the syringe facing you

The needle is inserted lateral to the pterygoid mandibular raphe at the height of an imaginary line created by bisecting the thumb nail that is placed in the coronoid notch

The needle should be inserted slowly until bone is contacted (about 2/3 the length of your long needle)

Once bone is contacted the needle is withdrawn about 1mm and the syringe is aspirated twice

Once two negative aspirations are noted deposit 2/3 of the local anesthetic slowly over approximately 1 min

After depositing 2/3 carpule for the IA, withdraw the needle ½ the distance of the initial penetration

Aspirate and deposit ½ of the remaining solution

Technique summary for mandibular block

Prepare tissue Advance/aspirate/drip/count to 5

Do this until bone is contacted

Depth of penetration=2/3 to entire length of needle

Once target site is reached (bone is contacted), withdraw 1mm

Perform 2 aspirate & if both are negative deposit 2/3 carpule

Buccal nerve block target area

Buccal nerve as it passes over anterior border of ramus

Buccal nerve block Point of insertion

mucous membrane distal & buccal to the most distal molar in the arch, adjacent to the retromolar pad

Technique for buccal nerve block

Locate landmarks

Prepare tissue

Retract buccal mucosa and with your syringe parallel to the occlusal plane gently penetrate tissue

Aspirate/drip/count

Advance slowly with the barrel parallel to the occlusal plane and buccal to molars

Injection about 3mm distal and buccal to the last molar in that quadrant (Average depth of penetration =2-4 mm.)

May contact bone, if so withdraw 1mm

After a negative aspiration deposit remaining solution in carpule

What needle do you use for the mandibular block?

25/27 gauge LONG

Mental nerve block area anesthetized

Buccal mucosa anterior to mental foramen to midline

Lower lip

Chin

Indications for mental nerve block

When you only need soft tissue anesthesia

What is the percentage of positive aspiration for a mental nerve block?

5.7%

What needle do you use for the mental nerve block?

25 gauge short

What is the point of insertion for the mental nerve block?

mucobuccal fold at or just anterior to the mental foramen

What is the target area for the mental nerve block?

Mental nerve as it exits the mental foramen (mental nerve is located on the OUTSIDE of the bone)

Usually found between apices of 1st & 2nd bicuspids

What are the landmarks for the mental nerve block?

1st & 2nd bicuspids

Mucobuccal fold

Mental nerve block procedure

Locate mental foramen

Prepare tissue (dry + topical)

Insert, aspirate, drip, count

Advance needle about 5-6 mm

Aspirate

Deposit 1/3 carpule

Deposition time=30 seconds

Incisive nerve block nerves anesthetized

mental & incisive nerves

Mental nerve located on the outside of the bone; Incisive nerve located on the...

INSIDE of the bone

Area anesthetized for an incisive nerve block

Buccal tissue (anterior to mental foramen to midline)

Lower lip

Chin

Pulp from bicuspids to central incisor on that side of the mouth

Indications for an incisive nerve block

When mandibular block is not indicated (when molars are missing or, you're only scaling teeth #20-24 or #25-29)

Advantages of an incisive nerve block

Pulpal anesthesia without lingual anesthesia

What is the percentage of positive aspiration for an incisive nerve block?

5.7%

Incisive nerve block procedure

Same as mental nerve block, EXCEPT volume of solution is more (1/3 -1/2 carpule)

After withdrawing needle for an incisive nerve block, what do you do?

PRESSURE is placed over mental foramen for 30-60 seconds to push fluid into the foramen

Gow Gates nerves anesthetized

Inferior alveolar

Mental

Incisive

Lingual

Mylohyoid

Auriculotemporal

Buccal (75%)

Gow Gates area anesthetized

Pulpal to midline

Buccal mucoperiosteum & mucosal membrane

Anterior 2/3 of tongue & floor of oral cavity

Lingual soft tissue & periosteum

Body of mandible & periosteum

Body of mandible & inferior portion of ramus

Skin over zygoma & posterior cheek & temporal regions

Contraindications to Gow Gates

Patients unable to open mouth wide

Patients who might injure lip/tongue- pedo, Intellectual or physical disabled

What are the advantages of the Gow Gates?

One injection gets all (V3) before it splits into its branches (lingual, buccal, alveolar branch)

High success rate (95%)

Target area is less vascularized- aspiration = 2%

Why is there a longer onset of action for Gow?

Larger nerve trunk

The nerve is located a considerable distance away from site of deposition

What is the target for Gow?

Medial aspect of condyle

What are the extraoral landmarks for Gow?

Corner of mouth

Intertragic notch on the lower border of tragus of ear

What are the intraoral landmarks for Gow?

Height: just below mesiolingual cusp of maxillary second molar and just distal to the molar

Look for pterygomandibular depression/crease

What size needle do you use for Gow Gates?

Use a 25 or 27 gauge long needle

Procedure for Gow Gates

Place finger in intertragic notch

Patient's mouth should be open WIDE

Place finger/thumb on coronoid notch on ramus to retract buccal tissue

Finger in intertragic notch

Do NOT deposit unless bone is contacted

If bone is not contacted, withdraw & redirect (barrel moves towards anteriors)

Once bone is contacted , withdraw 1mm , and deposit 1.8ml

Patient should keep mouth open WIDE 1-2 mins

What is the point of insertion for the Gow Gates?

Mucous membrane on medial border of ramus

Distal to max 2nd molar at height cusp of the tip of its mesiolingual cusp

At point parallel to line drawn from intertragic notch of ear

What is the path of insertion for Gow Gates

Syringe- opposite corner of mouth (lower bicuspids)

Angle of syringe same as angle of line from intertragic notch to corner of mouth (vertical angle)

What is the average depth of penetration for Gow?

25mm (same as IA)