anesthesiaaa mandibularr

7/28/2019 anesthesiaaa mandibularr

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Lower success rate than Maxillary anesthesia -approx. 80-85 %

Related to bone density

Less access to nerve trunks


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Inferior alveolar

Mental - Incisive

Buccal

Lingual

Gow-Gates

Akinosi


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Most commonly performed technique

Has highest failure rate (15-20%)

Success depends on depositing solution within 1mm of nerve trunk


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Not a complete mandibular nerve block.

Requires supplemental buccal nerve block

May require infiltration of incisors or mesial rootof first molar


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Nerves anesthetized

Inferior Alveolar

Mental

Incisive

Lingual


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Areas Anesthetized

Mandibular teeth to midline

Body of mandible, inferior ramus

Buccal mucosa anterior to mental foramen

Anterior 2/3 tongue & floor of mouth

Lingual soft tissue and periosteum


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Indications

Multiple mandibular teeth

Buccal anterior soft tissue

Lingual anesthesia


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Contraindications

Infection/inflammation at injection site

Patients at risk for self injury (eg. children)


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10%-15% positive aspiration


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Alternatives

Mental nerve block

Incisive nerve block

Anterior infiltration


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Alternatives (cont.)

Periodontal ligament injection (PDL)

Gow-Gates

Akinosi

Intraseptal


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Technique

Apply topical

Area of insertion:

medial ramus, mid-coronoid notch,

level with occlusal plane (1 cm above),

3/4 posterior from coronoid notch to

pterygomandibular rapheadvance to bone (20-25 mm)


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Target Area

Inferior alveolar nerve, near mandibularforamen

Landmarks

Coronoid notch

Pterygomandibular rapheOcclusal plane of mandibular posteriors


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Precautions

Do not inject if bone not contacted

Avoid forceful bone contact


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Failure of Anesthesia

Injection too low

Injection too anterior

Accessory innervation

-Mylohyoid nerve

-contralateral Incisive nerve innervation


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Complications

Hematoma

Trismus

Facial paralysis


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Anterior branch of Mandibular nerve (V3)

Provides buccal soft tissue anesthesia adjacent to

mandibular molars

Not required for most restorative procedures


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Indications

Anesthesia required - mucoperiosteum buccalto mandibular molars

Contraindications



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Advantages

Technically easy

High success rate

Disadvantages

Discomfort


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Alternatives

Buccal infiltration

Gow-Gates

PDL

Intraseptal


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Technique

Apply topical

Insertion distal and buccal to last molar

Target - Long Buccal nerve as it passes anteriorborder of ramus

Insert approx. 2 mm, aspirate

Inject 0.3 ml of solution, slowly

- 25-27 gauge needleArea of insertion:


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Landmarks

Mandibular molars

Mucobuccal fold


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Complications

Hematoma (unusual)

Positive aspiration

0.7 %


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Terminal branch of IAN as it exits mentalforamen

Provides sensory innervation to buccal soft tissueanterior to mental foramen, lip and chin


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Indication

Need for anesthesia in innervated area

Contraindication



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Advantages

Easy, high success rate

Usually atraumatic

Disadvantage

Hematoma


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Alternatives

Local infiltration

PDL

Intraseptal

Inferior alveolar nerve block

Gow Gates


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Complications

Few

Hematoma

Positive aspiration

5.7 %


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Terminal branch of IAN

Originates in mental foramen and proceedsanteriorly

Good for bilateral anterior anesthesia

Not effective for anterior lingual anesthesia


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Nerves anesthetized

Incisive

Mental


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Areas Anesthetized

Mandibular labial mucous membranes

Lower lip / skin of chin

Incisor, cuspid and bicuspid teeth


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Indication

Anesthesia of pulp or tissue required anteriorto mental foramen

Contraindication



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Advantages

High success rate

Pulpal anesthesia w/o lingual anesthesia

Disadvantages

Lack of lingual or midline anesthesia


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Complications

Hematoma

Positive aspiration

5.7 %


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Local anesthetic complications can be dividedinto two areas.

There are local complications and systemiccomplications.

Local complications are the result of themechanics of the injection or the properties ofthe anesthetic drug on the local environment.

Systemic complications are those general

complications occurring as a result of thedrug used or a local problem that can lead tosystemic sequela.


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A.Needle Breakage

1. Causes- needle size, smaller more likely, priorbending of needle,unexpected patient movement,defective needles

2. Problems, if retrievable, if not retrievable easily

3. Prevention - larger gauge for deep penetratinginjections, longer needles, do not insert to hub, do notbend needle, do not redirect needle when in deeptissue.


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4. Management - calm, no panic, informpatient, no movement patient, keep mouthopen. Use hemostat to retrieve if possible. If not

visible refer to competent surgeon. Ifsuperficial and easily identified surgeonremoves. May have to leave in if deep ordifficult to find. However it is better to have it

removed if possible.


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1. Causes - Careless injection technique, dull

needle, rapid injection, barbed needles.

2. Problems - anxiety increase, unexpectedmovement and its sequela.

3. Prevention - proper injection technique,

sharp needles, topical, sterile LA soln., slow

injection, room temperature anesthetic soln.4. Management - prevention is management.


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Causes - ph LA Soln, rapid injection,contamination cartridge, rapid injections,

warmed soln.

Problem - none if due to ph, (usually), if

due to contamination tissue damage,

trismus, edema, parasthesia.

Prevention - prevention, slow injection,

(ideal, 1ml/min, recommended not more

than 1.8ml/min)

Management - specific problems that ariseare managed.


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-Anesthesia lasts for longer than expected. Some

patients are hyper reactors, longer anesthesia.

However some anesthesia lasts week, months,

years. Longer lasting increases problems.Parasthesia, anesthesia may not be preventable.

1. Causes - alcohol contamination LA, solutions.

Sterilizing solution contamination LA. Trauma to

nerve with needle. Inserting a needle into aforamen increases risk of nerve trauma.

Hemorrhage in and around neural sheath

secondary to trauma.


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2. Problem - patient can injure

anesthetized area.Bite, burn, chemical injury. Lingual nerve

damage effect taste.

Can get hyperesthesia or dysesthesia.

Prilocaine apparently involved inparesthesia more often than other LA

agents.

3. Prevention - observe protocol forhandlingand care of LA cartridges. Parasthesia can

still occur.


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4. Management - most parasthesias resolve in

about 8 weeks without treatment. Sever damagemay lead to permanent anesthesia, rare.

In general dentistry most parasthesias involve

tongue. Reassure patient, you speak directly to

patient.Explain paresthesia to patient and usual

course.

Examine patient. Chart location and depth.

Avoid dental injections in same area of injury tonerve. Steroids may be indicated at time of or

shortly after injury.

If you are aware of the nerve injury at the time of

surgery steroids also may be indicated


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Prolonged spasm of the jaw muscles. Restriction ofopening. Can be chronic and difficult to manage.

1. Cause - Most common cause from dental injections

is the trauma to blood vessels or muscles in the

infratemporal fossa.

Contaminated cartridges, with alcohol or sterilizingsolution cause tissue damage. Intramuscular

injections LA.

Hemorrhage in area. Infection post injection.Multiple

injections in same area. Barbed needles. Barbedneedles. Large amounts of LA solution in same area.

2. Problems - limitation usually minor and transient.

Can become sever and chronic.

Can require extensive therapy and or surgery.


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3. Prevention - sharp needles, care of

cartridges, aseptic technique, atraumaticinjection, know anatomy, avoid multiple

injections same area, use minimum

effective volume.4. Management - Pain and trismus usuallyoccurs 1-6 days post injection.

Rx. Analgesics, heat, warm rinses and muscle

relaxants if indicated. Initiate physical therapy.

Opening and closing. Use of tongue blades to

stretch. Gum chewing. Antibiotics if indicated. If

severe and no response within 2-3 days no

antibiotics, and 5days with antibiotics.


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Causes - puncture artery or vein.

Problem - Swelling, discoloration, bruise,

trismus, pain and infection rare

Prevention - Knowledge of the anatomy.

Certain blocks more likely. PSA most. Inf.

Alveolar, mental. Modify technique for smalleradults. Reduce number of punctures. Do not

probe with needle.


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4. Management

direct pressure immediate. Two minutes.

Inf. Alveolar against medial portion mandible.

Infra orbital, skin over foramen.

PSA side of face. Ice to face. Intraoral pressure at site of injection. Usually

can be large hematoma.

Inform patient of sequeli.

No heat four to six hours post injection.

Can use ice or cold rinses.

Usually resolves 7-10 days.


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1. Causes - Needle contamination. Usually not

from local flora. Usually from improper handling of

the injection set up. Injecting through a aninfected area to non infected

2. Problem - Low-grade infection in deeper

tissue. Trismus possible. Must recognize

infection.


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3. Prevention - Disposable needles. Handle

cartridges well. Do not contaminate cartridge

solution. Cap needle. Do not touch to non sterile

surface. Wipe diaphragm with sterile disposablealcohol let dry.

4. Management - Difficult to diagnose. Trismus may

be sign. Treat trismus. No response in three days

then place on antibiotic. Use penicillin or appropriateantibiotic if allergic to penicillin for at least seven

days.


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Swelling of the tissue. Sign of other disorder.

1. Causes -Trauma, infection, allergy and

hemorrhage.

2. Problem - swelling usually not a problem.Some pain discomfort. Angioneurotic edema

may be life threatening. Can compromise

airway.

3. Prevention - handling injection equipment.

Atraumatic injection. Complete medical

evaluation patient.


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Management - traumatic may be small and self-

resolving. Bleeding requires pressure, ice.

Infection usually requires antibiotics or other

treatment. Allergy induced edema can be lifethreatening. Airway may be compromised. If

unconscious provide basic life support, call 911,

secure airway if possible. Epinephrine,

Corticosteroid, Antihistamine, possible

cricothyrotomy. Later evaluate cause.


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1. Causes - Epithelial Desquamation, sterile

abscess.

2. Problem - Pain

3. Prevention - Use topical anesthetic as

directed. Do not use high concentration

vasoconstrictor.

4. Management - Symptomatic for pain.Systemic analgesics, topical orabase.


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1. Causes - self inflicted, children, mentally or

physically disabled. Soft tissue anesthesia.

2. Problem - swelling, pain. Infection rare.

3.Prevention - Select LA for duration ofprocedure. Instruct parents or patient. Sticker

warning on children.

4.Management-Analgesics,antibiotics,


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Paralysis of branches of the seventh nerve.

Causes - Infraorbital block, Maxillary canine infiltration,Inferior alveolar injection into parotid gland.

Problems Pt. Anxiety, unable to close eye. Unilateral

facial paralysis, (secondary to inferior alveolar in parotid

gland.

Prevention

Know anatomy. With Inferior alveolar touchbone. If using Vazarani- Akinosi know landmarks, with gow

gates know landmarks.

Management Paralysis shows up quickly. Reassure

patient. Explain. Eye patch. Instruct in eye care. Lubricateeye. Record incident. Stop procedure.


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Usually several days after injections in

area of injection.

Causes recurrent aphthous ulcers or

herpes simplex. Trauma needles, swab,

and may activate latent forms.

Problem pain, sensitivity

Prevention not known. Can treat

prodromel syndrome with antiviral agents.Usually runs its course.

Management Reassure patient. Not

bacterial. Will run course. Follow patient.

Can occuragain


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anesthesiaaa mandibularr

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