LA Sheet #8 By yasmin Hijazy

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LA Sheet #8 By yasmin Hijazy

Post by Sura on 17/12/2011, 5:48 pm

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Sura

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تاريخ التسجيل : 2010-09-29

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Re: LA Sheet #8 By yasmin Hijazy

Post by Shadi Jarrar on 15/1/2012, 3:02 pm

LOCAL ANESTHESIA IN MAXILLA

The technique for applying local anesthesia in maxilla is
infiltration and it's called sub-periosteal injection or para-periosteal injection.

The roots of the teeth in maxilla are kept separated from the soft tissue in buccal aspect by bone that can be found in cortical plate, this is the reason why infiltration in maxilla and block in mandible .

The same buccal cortical plate doesn't represent avarient * of local anesthetic solution..***

The objective of infiltration of the anesthesia is to deposite the L.A close to the pulpal nerve supply before it enters the apex of the root. so we orient the needle to the apex of the tooth angulated 45 degree at the level of muco-buccal fold.

There's a difference btwn pulpal anesthesia and soft tissue anesthesia. >>> Pulpal anesthesia : has short duration. >>> soft tissue anesthesia : means any soft tissue surrounds the tooth .. buccal tissues, palatel tissues , upper lip .. has long duration; it's the last one to recover from anesthesia.

Technique of buccal infiltration : patient is reclined 30 degree to vertical and it's up to the dr. to sit or stand up at the right side of the patient. (it's better to stand)

the dr. said that there are different positions for patient and dr. but the most important thing that the dr. and patient must be in comfortable position .( you can find in the book a lot about positioning the patient and the dentist)

the patient must open his mouth widely to allow the operator to insert his finger/ thumb into the buccal sulcus .. we can depend in this way for retraction.

During the injection the mouth should be half opened.

*Two methods are used for retraction of the lip and cheek !! the dr. can do retraction by himself or if there's an assistant , he can do the retraction.

holding the tissues by using 2 fingers thumb and index or using middle finger alone between the index finger and the thumb act as a rest for the syringe. (retraction of the soft tissues and resting the syringe on the hand is very important)

The needle is short one .. angulation of the needle is about 45 degree..the length of the needle that must be inserted in the tissue.

When u give sub-periosteal injection, actually u anesthetize the nerve terminal of the dental plexus.

We know that innervations of the maxilla by maxillary nerve but what we anesthetize by infiltration is the nerve endings of the dental plexus. We have anterior superior alveolar nerve, middle superior alveolar nerve ( which is very commonly absent) and posterior superior alveolar nerve

(all 3 buccally). While on the platal side we divide the maxilla into premaxilla and posterior area: anteriorly nasopalatine nerve ad posteriorly the greater palatine nerve.

Important steps must be followed during giving injection :

- Retract the tissues.

- Stretch the tissues to make the penetration on of the needle less painful. (tighten the tissues)

- Dry the tissues .

- Topical anesthetic as a gel applied in the area of injection (optional step).

- Direct the needle to the site of injection.

- Giving LA slowly.. start by giving few drops then draw the needle back just a little for seconds then complete the injection and continue applying LA slowly.

( why to give LA slowly: 1- less painful 2- decrease the adverse effect of LA in case of systemic diseases )

aspiration in infiltration technique is not highly imp. Coz the possibility of giving LA in major vessel is not that much high.

After giving LA ,we must be aware of any unexpected movement from the patient and the eyes of the patient or the dentist are injured by the needle.. so :

1- u have to give the patient instruction before and tell him that the injection maybe painful.

2- during the anesthesia, u have to communicate with the patient specially in the palatal injection .. (why?) coz it's painful .

3- After anesthesia , if ballooning occurred (usually in buccal mucosa) , u make swabbing (the doctor said swabbing, she means that u have to massage the tissue where the ballooning accured) motion to distribute the LA. (ballooning is not occurred in palatal injection coz the periostum is firmly adherent to the underlying tissues)

After applying LA , u have to monitor ur patient .. coz many patients may have vasovagal attack.

When we want to extract upper or lower left central as an example, u will give LA in the mucobuccal fold on the left side but here we have to give LA on the right side also, coz we have decussating nerve fibers.. so in this way, we ensure that the procedure is pain free.

The lip and cheek must be retracted upward and outward to view buccal sulcus

Stretch the mucosa ,, stretching gives better and sharper penetration.(to be pierced by the needle)

Needle is always given to tight tissue.

Small tissue similar to frenum should be avoided.

Use 30 gauge , short needle in the infiltration in the buccal sulcus .

Point of penetration is high in the buccal sulcus to achieve pulpal anesthesia to allow deposition of LA in loose submucosal tissue.

 

In upper ant. Teeth is advanced to apex by lining tissue parallel to the long axis of the tooth in mesio-distal plane .. we know that the teeth are set in a curve not in a straight line and when u'll be at the level of incisors u will be parallel to the long axis.

The plane that u have to be parallel to at first is the mesio-distal plane then u get the direction labially (the needle is angeled toward the apex in the labio palatal plane).

Point of needle entry is dried with gause , topical anesthesia is applied with cotton roll

Needle is inserted to mucosa at the depth of few mm.

Aspiration is done >> touch the bone the draw the needle back then deposite LA slowly (20-60 seconds).

If bleeding occurs >>> apply pressure with gause for 2-3 minutes.

Pressure is the 1
st line of management of bleeding

Bleeding occurs coz the patient may have sever perio disease (coz the tissues are inflamed) , dentist injured minor vessel during giving anesthesia or injured the periosteum.

PALATAL INJECTION :

At the 1
st, give few drops of anesthesia until blanching is seen (coz the periosteum is firmly adherent to the underlying tisse , so when u increase the pressure by LA , tissues start blanching ).

Always, do not inforce the needle.

Two methods for giving palatal anesthesia:

Infiltration : that u go 5mm away from the gingival margin and give anesthesia.

Decussation : draw 2 lines . 1st line cross palatal fold and the 2nd line cross the mid palatal suture connect them and go perpendicular to the bisecting line.

____ 1
st line _ _ _ 2nd line arrow is the bisecting line

In the palatal anesthesia, LA will diffuse to anesthetise distal of concern and the adjacent teeth , buccal gingival, buccal periodontium , buccal bone , mucosa and part of the teeth.

If u want to treat a tooth endodontically , u have to anesthetise buccaly

If u want to extract a tooth, u anesthetise buccaly and palataly.

if the pulp was necrotic we don't anesthetise it.

Greater palatine nerve(GPN) anesthesia:

We divided the palatal maxilla to premaxilla and posterior part.

GPN innervates palatal mucosa adhjacent to molar, pre molar and canine.

It's anesthetized by infiltration or block.

Block : GPN anesthetized in a skin approach.

Infiltration : as the dr. taught us before.

GP foramen is located palataly to the distal aspect of upper 2
nd molar .. this injection is more uncomfortable than buccal infiltration.

Needle is inserted few mm.

aspiration is performed

there are GPN bundle

0.2 ml is enough to anesthetise GPN.. as we said before that we need few drops of anesthesia to anesthetise palataly.

***

The injection of LA will anesthetise the soft tissue and bone of the hard palate on one side of the midline up to canine region

Some fibers of the naso palatine nerve (NPN) maybe found in canine region . (it may encroach that area)

A question is asked : as the GP foramen is distal to the upper 2
nd molar and we want to extract the 3rd molar.. do we anesthetise GPN?

Dr answeres: yes coz there's an extension of the GPN to the area of the 3
rd molar.

Infiltration injection of the GPN :

When operating on one tooth.. insert needle ,make aspiration then inject few drops of solution in the palate and between the midline of the palate and gingival margin distal to the tooth of concern will be blocked.

Palatal infiltration of the 3
rd molar is given mesial to the tooth coz if u inject distally u may anesthetize soft palate and causing gag-reflex and the patient start feeling of suffocation.

All the palatal teeth in infiltration injection u go distal of the tooth.. except the 3
rd molar , u go mesially.

Naso palatine nerve (NPN) anesthesia :

NPN can be anesthetized by block or infiltration.

Mouth is wide opened

The neck is slightly extended.

Topical anesthesia are applied by a cotton tip with slight pressure on the incisive papilla.

Needle is inserted 3 mm in the incisive papilla.

Aspiration necessary to be done

0.2 ml is enough to be injected.

( u inject more LA in infiltration rather than in block )

Infiltration of few drop of solution in the incisive papilla or we just go palatal to the lateral incisor or canine and give infiltration there.

NPN anesthesia may extend to soft tissue and the bone of ant. Hard palate adjacent to the 6 anterior teeth

Some fibers from greater palatine may serve as accessory supply

Palatal-papillary injection technique.:

In this technique, we go through papille

By this technique , the palatine gingival margine is anesthetized by buccal papilla approach.( this papille are previously anesthetized )

We use this technique , when the patient can't bear the palatal injection.

U start anesthetize the buccal papilla then u go to the palatal papilla through buccal one.

Use extra short needle to be introduced to the disto-buccal papille at right angel .

The needle is advanced to interdental space toward the palatal papilla while still injecting

Then the same is repeated to the mesio buccal of the papille to get ring anesthesia .

At the end, sry for being late .. this lect. was recorded by mobile.. and the voice was not that good.. I tried to do my best to write everything but still there are missings .. I pointed to them with a * ..

A big thanx to
YASMIN HZAYEN for her help…

DONE BY : YASMIN HIJAZI

Lect. 9

Dr. sukaina
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Shadi Jarrar
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عدد المساهمات : 997
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تاريخ التسجيل : 2009-08-28
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الموقع : Amman-Jordan

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