8. Infiltration technique in maxilla r.pdf

L8: Infiltration Technique in the Maxilla 24/10/2023 Dr. Mohammed Amjed Alsaegh Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 1 Objectives: - Important tips for painless & safe anesthesia Techniques for Maxillary Anesthesia - Principle of infiltration anesthesia - Infiltration of the maxilla - Pri...

L8: Infiltration Technique in the Maxilla 24/10/2023 Dr. Mohammed Amjed Alsaegh Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 1 Objectives: - Important tips for painless & safe anesthesia Techniques for Maxillary Anesthesia - Principle of infiltration anesthesia - Infiltration of the maxilla - Principle of block anesthesia Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 2 Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 3 Whatarethezcomponents of AtraumaticInjection An atraumatic injection has two components: a technical aspect and a communicative aspect I Patients Rate A Dentist “Who Does Not Hurt” And One Who Can “Give Painless Injections” As Meeting The Second And First Most Important Criteria Used In Evaluating Dentists Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 4 Important tips for painless & safe anesthesia L notmorethan 3 or 4times t 1. Disposable needles are sharp on first insertion. However, with each succeeding penetration, their sharpness diminishes. By the third or fourth penetration, the operator can b feel an increase in tissue resistance to needle penetration. Clinically, this is evidenced by increased pain on penetration and increased postanesthetic tissue discomfort. Therefore, it is recommended that stainless steel disposable needles be changed after every three or four tissue penetrations. sensitive area dog'etager very a 2. Topical anesthetics produce anesthesia of the outermost 2 or 3 mm of mucous membrane; this tissue is quite sensitive. Ideally the topical anesthetic should remain in contact with the tissue for 2 minutes to ensure effectiveness. A minimum application time of 1 minute is recommended. I 3. Determine whether to warm the anesthetic cartridge or syringe 200 250 best temptoinject 4. Use words that prevent stress! word freeze ! Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 5 Important tips for painless & safe anesthesia 5. Establish a firm hand rest Hand positions for injections A. Palm down: poor control over the syringe; not recommended. pBestgrip B. Palm up: better control over the syringe because it is supported by the wrist; recommended. Best C. Palm up and finger support: greatest stabilization; highly recommended. NOTE: Never place hand on patients shoulder, patient may have sudden jerk movements which causes breakage of needle and pain so Support from ring nger on barrel and index nger support the chin ◦If you can’t then chest support is recommended Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 6 Important tips for painless & safe anesthesia shout fingers dangerous of gudement e long fingers thebarrel ringfingeron r Persons with long fingers can use finger rests on the patient's face for many injections; those pinkyonthechin with shorter fingers may need elbow rests Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 7 Important tips for painless & safe anesthesia 6. Make the tissue taut. The tissues at the site of needle penetration should be stretched before insertion of the needle Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 8 Important tips for painless & safe anesthesia 7. Keep the syringe out of the patient's line of sight Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 9 Important tips for painless & safe anesthesia ifbevelaway Some companies put indicator for bevel Bevel toward the bone is painful we will inject subperiosteam Direct bevel toward the bone subpereostal puff indicator forthebevel somecompanies infiltration during bone is towards the peter 8. Insert the needle into the mucosa. With the needle bevel properly oriented. During infiltration technique, the bevel of the needle should be oriented toward bone SETTE'tifIda'satiajyithia.ggtggionsgf Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 10 Important tips for painless & safe anesthesia 9. Watch and communicate with the patient. During the injection, the patient should be watched and communicated with; the patient's face should be observed for evidence of discomfort during needle penetration. b Signs such as furrowing of the brow or forehead and blinking of the eyes may indicate discomfort. No change will be noticed in the patient's facial expression at this time (indicating a painless, or atraumatic, needle insertion). Patients who are apprehensive about injections of local anesthetics are likely to react to any sensation as though it were painful 11 Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 Important tips for painless & safe anesthesia 10. During the aspiration test. Adequate stabilization is mandatory. Beginners have a tendency to pull the syringe out of the tissues while attempting to aspirate (specially with positive aspiration technique). A slight reddish discoloration at the diaphragm end of the cartridge on aspiration usually indicates venous penetration. Reposition the needle, re-aspirate, and, if negative, deposit the solution. Myong Mn cartridge Bright red blood rapidly filling the cartridge usually indicates arterial penetration. e During deposition it depends on teh dentist It can either be fast or slow deposition Slow deposition is better during injection and post operative is less painful. Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 12 Important tips for painless & safe anesthesia duringinj postoperatively painful 11. Slowly deposit the local anesthetic solution. Slow injection prevents the solution from tearing the tissue into which it is deposited. Rapid injection results in immediate discomfort (for a few seconds) followed by prolonged soreness (days) when the numbness provided by the local anesthetic dissipates later. Slow injection is defined ideally as the deposition of 1 mL of local anesthetic solution in not less than 60 seconds. Therefore, a full 1.8 mL cartridge requires approximately 2 minutes to be deposited. Bestpractices1mL in 1min Some dentists place teh patoent in an upright position and pateint is in vasovagal attack in this situation theres a re ex the LA goes to the muscle nerves to the veins In vasovagal attack pateint lose conscious ( falling down is a defense mechanism) so when you place the patient in upright position you will kill them. Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 13 Important tips for painless & safe anesthesia 12. Position of the patient on the dental chair: Ideally the patient should be fully it upright supine…..Why? better semisupinethanfullysupinebeptfeels vulnerable I to aid cranial blood flow and prevent fainting. Some the uncomfortable patients may be or feel vulnerable in this semi supine position. A compromise is to tilt the chair back at least thirty degrees to the vertical. Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 14 13. Buffering the local anesthesiawhenatidyternjitt - By using this method, the injection will achieve a more profound anesthesia with a minimum amount of discomfort. and'amamitteffeggatted butter - As adrenaline is stable for lengthy phases in an acidic environment, the pH of commercially available lidocaine with epinephrine (pH 3.3-5.5) is lower than that of plain lidocaine (pH 5.7-6.5). The acidity can give rise to tissue irritation, which may be felt by patients as a stinging or burning pain Buffer is added to the carpule, when epinephrine is placed a reducing agent is placed a reducing agent will prevent acidity, a ph of LA reaches 3 - 3.5 this causes tissue irritation upon injection so buffer will prevent irrational and cause deeper penetration of anesthesia Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 15 Q What are the 1. Infiltration, simplesttech of injection maxilla 2. Regional block, inmaxilla mandible but MANDIBLE Mainly 3. Supplimantary: like Intraligamentary, Intra-osseous and Intrapulpal anaesthesia. Whats the The primary method in maxilla is infiltration anaesthesia. Buccal in ltration is to insert the needle submucously 2-3 mm and deposit the LA in that area which is teh peri apical area Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 • LA is going to spread through the bone to the pulp, if the bone is dense the buccal in letration is not useful • In the maxillary arch the buccal bone is thin so this technique is useful • In the anterior of teh mandble its porous so we can use in ltertaion in this area if mandible only ( lower k9 is questionable) 16 a wifey.at Buccal Infiltration Anaesthesia FInthckYdenYet T won'treach the - The term infiltration has been in common usage in dentistry to pulp won define an injection in which the local anesthetic solution is thiffuse deposited at or above the apex of the tooth to be treated. Really, alsocalled T this technique is a field block work y imma depose Gperiapical area Bone - Solution deposited at the buccal side of the maxillary alveolus can infiltrate through to the nm pulps of the teeth to produce dental anaesthesia. Ff - Cortical plate on the buccal side of the maxilla is thin. reasoumaagihti.i t - Hold the syringe parallel with the long axis of the tooth → Advance the needle until its bevel is at or above the apical region of the tooth. Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 17 • When injecting we have entry pint and travel point ◦Entry point is easy we 5- 30 mm • An advantage of buccal in ltertaion is that its called “ eld block” meaning it anesthesizes the whole area • Remember we are dealing the nerve ending not teh nerve itself! • When we use this technique with adrenaline it causes vasoconstriction to teh site Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 18 Buccal Infiltration Anaesthesia Retraction - The operator pulls the cheek or lip in a the tissues and the p superior direction to stretch s d needle is inserted through the taut Finger tissues of the buccal fold. This stretching of the lip or cheek may be performed by holding the tissues between the operator’s fingers or by retraction with a mirror. Taitung a mint - The former method affords more control; the latter reduces the chances of needle-stick injury. The choice is personal. Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 19 Buccal Infiltration Anaesthesia bedoesn't go in too goparalleltothemaxillaryboneet there's 4 Technique affiration smatter - The syringe is fitted with a 27 or 30 gauge needle. Usually a 20–25 mm-long needle is employed (short needle). Qwhere - Area of insertion: height of the mucobuccal fold above the apex of the tooth being anesthetized. Target area: apical the region of the tooth to be anesthetized Qwhen's is I J How can we - Access to this region is easiest when the patient has the mouth only partly open (specially in the posterior region). Whattodo notfully - Prior to injection this area should be cleaned with a gauze swab (could be disinfected also) and a topical anaesthetic may be applied. deposit approximately 0.6 mL – 1 mL slowly over 20 seconds. E I Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 20 Buccal Infiltration Anaesthesia Depth: In most• Only1instances, the depth of penetration is only a few cm never more! millimeters Too superficial or too deep? The needle must be inserted into a plane deeper than the epithelium. Injecting into the epithelium produces a distinct blister. This produces discomfort and, if noted, the needle is advanced to a deeper level. Bone does not need to be contacted. If bone is touched the needle should be withdrawn slightly so that the point is not subperiosteal. An injection underneath the periosteum is painful at the time and in the postanaesthetic stage. Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 21 Epelisonlytewmmr than epithelium Needle is injecteddeeper blisters placengedger it it were at epi Needle should never contact bone if it does its subperiosteal gangs Panther LA wearsoff Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 22 Buccal Infiltration Anaesthesia ADVANTAGES OF INFILTRATION ANAESTHESIA ARE O 1. Simple technique which is easy to master 2. When successful, anaesthetizes all nerve endings in the area of deposition independent of the nerve source. sometimes known as fieldblock be anesthetize thewhole 3. Avoid damage to nerve trunks field area 3 be verysuperficial notdeep 4. Reduce chance of intravascular injection 5. Provide hemostasis where it is required (with adrenaline) site be epi produce vasoconstriction atthe Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 23 Buccal Infiltration Anaesthesia The disadvantages are: Egtmedggguauses infiteringgrain 1. Localized infection may be spread if an infected area is infiltrated not morethan Iam M 2. Only a limited zone of anaesthesia per injection F 3. Only effective in obtaining pulpal anesthesia when diffusion through cortical bone occurs (it requires a thin cortical bone to infiltrate) blockwould begiven in this case • In some cases upper 6 have zygomatic bone so we give 2 injection not 1 or give block • Insert in parallel technique meniang go parallel to the maxillary bone so 45 degrees and insert till 2-3mm Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 24 Problems with buccal infiltration anaesthesia # Buccal infiltrations may fail if there is collateral supply to the pulp from the greater palatine or nasopalatine nerves. This is overcome by supplementing the injection with one of the palatal techniques. # Another reason for failure may be due to a thick cortical plate reducing the spread of solution through bone. This may occur in the region of the zygomatic buttress causing failure of anaesthesia in upper first molars. This is overcome by infiltrating mesially and distally to the buttress or by using the regional block methods described. O can'tbypass D O g # If there is localised infection at the site of an infiltration it is unwise to inject at this zone. • Q. Why do we give palatal in ltertaion? To anetshtiseze soft tissue palatal during extraction not lling \ • Palatal bone is diffuse to in ltrate and we dont give to much anesthesia we will blanching Amjed of teh tisseu Dr.see Mohammed Alsaegh, UOS, 2023/2024 canbypass itby injectingfaraway fromit 25 Palatal Infiltration - When working on the tissues distal to the canine the palatal soft tissue can be anaesthetised by infiltration or regional block anaesthesia. Infiltration of around 0.2 mL of solution into the palatal mucosa just distal to the tooth of interest will anaesthetize the palatal mucosa and periodontium anterior to the point of infiltration up to the canine region. - The exception is the upper third molar when the solution should be deposited at the anterior aspect of the tooth. This is because the greater palatine foramen lies anterior to the third molar tooth and the nerve supplying this region travels in a posterior direction. mid µ fitting's FIH pald inject in in theEstiest softest - The point of infiltration is in the fleshiest part of the palate around 5 to 15 mm from the gingival margin. b -Palatal injections can be uncomfortable owing to the poor i compliance of the tissue. Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 D n y 26 Palatal infiltration distinct ofthe toothy Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 27 Regional Block Methods Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 28 Regional Block Methods arethedisadvantages of infiltration The advantages of regional block techniques are: 1. They produce widespread anaesthesia from one injection 2. the anesthetic can be deposited away from infected areas w outcausing are theadv ofinf caitthction The disadvantages of block injections are: 1. Technically more difficult than infiltration anaesthesia 2. Do not anaesthetize nerve endings from different trunks (for example, in the mid-line where crossover may occur). 3. May cause deep hemorrhage in patients with bleeding diathesis 4. Although rare, the potential for direct injury to a nerve trunk is possible 5. Increased risk of intravascular injection compared to infiltration anesthesia Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 29 When I g Regional block methods in the maxilla Regional block anaesthesia may be used in the maxilla É 1. If infiltration methods are ineffective ( presence of abscess) 2. To avoid multiple injections when a large area of anaesthesia is needed. intraoral approaches. It is possible to approach the maxillary nerve and O some of its branches from extraoral approaches but these are not recommended in dental practice. Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 30 Regional block methods useful in the maxilla include: • Posterior superior alveolar nerve block • Middle superior alveolar nerve block • Anterior superior alveolar nerve block • Infra orbital nerve block • Anterior middle superior alveolar nerve block • Greater palatine nerve block • Nasopalatine (long sphenopalatine nerve) block • Maxillary nerve block Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 31 Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 32 THE END Dr. Mohammed Amjed Alsaegh, UOS, 2023/2024 33