Maxillary Infiltration Technique ( infiltration vs block)

Bismillah..

Kita masih lagi bercakap taju yg sama iaitu maxillary infiltration technique.

cuma kali ini kita ini tak guna infiltration. Kita guna block

Persoalannya..bila masa kita nak guna maxillary block ni?will not work

>Bila mana ada local imflammatory abscess..so local infiltration disebabkan byk faktor..anataranya acidic environment.

jadi kita guna block anesthesia kat kawasan yang distal to tooth atau in large procedures.

Supra periosteal infiltration injection.

Nerve anesthesized: large terminal branch of dental plexus.

Area anesthesized: pulp and root area of buccal periosteum, connective tissue and mucus membrane

Area of insertion: height of the mucobuccal fold (mucogingival junction) above the apex of the tooth anesthesized> buccal or slightly distal to the apex of the tooth so it will anesthesize it.

cukup ke kalau buat pulpal anesthesia?
> kalau buat anesthesia utk extraction, kena infiltrate both sides bucally and palatally
> kalau buat conservative treatmen: buccal infiltration cukup je sbb dia akan bagi pulpal anesthesia
> kalau utk central incisor: boleh jadi yes or no..sbb? ada sesetengah kes,, you dont get good pulpal anesthesia after bone infiltration, kena buat infiltration kat opposite CI

Maxillary block anesthesia

either we give to

1. maxillary nerve
2. posterior superior alveolar nerve
3. middle SAN
4. ant SAN
5. infraorbital nerve 
6. palatal nerve (nasopalatine posteriorly and greater palatine anteriorly)

Post SAN block

-innervates roots of max 7 &8 and distal and mesiobuccal root of upper 6

-area of insertion: height of the mucobuccal fold between first and second molars.  

-angle of insertion: 45 degree upward and backward (1-1.5cm) so you will not get a bony contact.

-we insert it a little bit medially, then we inject 1 carpule to get anesthesia of post SAN

-insert about 15-20mm

penting nak kena study pasal anatomy ni. contohnya kalau kat post SAN if you insert 2cm instead of 1 cm so you will anesthesize whole maxillary nerve.

you may anesthesize the branch only or the main trunk by controlling the insertion

Middle SAN block

- anesthesize maxillary premolars and mesiobuccal root of upper 6, corresponding alveolus and buccal gingival tissue

-ada kat 28% population. kalau xde ni maknanya teeth are innervated by ant SAN

-area of insertion: height of mucobuccal fold between first and second premolar. sama macam infiltration tapi a little bit higher.

-insert about: 10-15 mm

-inject around: 0.9-1.2 cc

kdg2 bila kita infiltrate upper 4, upper 5 is anesthesized. Ini disebabkan infiltration and block in the same area.

kalau kita buat infiltration to the middle SAN and it didnt work so kita buat infraorbital block. this means that the middle superior alveloar is absent.

Ant SAN block.

used to anesthesize max canine, LI, CI, alveolus and buccal gingiva.

area of insertion: height of mcobuccal fold in area of LI and canine> distal aspect of LI.

Lagi cerita tentang mandibular LA

Bismillah...

Kalau tersilap dalam anesthesize orang mc mne?

-too deep injection may cause transient hemifacial paralysis Facial and Palsy.

-kalau pg dalam sgt nti boleh reach parotid gland..kalau dah sampai tahap ini memang dah posterior sangat..huhu

so apa masalahnya?
-nti kena kat facial nerve..bukan IDN so sebab tu jadi facial palsy.

-too superficial injection will not work..makanya: bersederhanalah:)

Bilateral anesthesia in the mandible

It is preferable to avoid bilateral ID and lingual blocks. Use combinations of different technique whenever possible.

x digalakkan buat untuk pediatric patient sbb he may bite his tongue or lips and make trauma to himself.

nerve yang supply motor innervation to the tongue is hypoglossal nerve bukan lingual nerve.

bila buat bilateral block to the ID nerve, lingual nerve will be anesthesized so if the patient is a child , there maybe a risk of trauma to his lips, but in adult no problem:)

scienctifically, there is no any medical contraindication to do bilateral ID block.

Mental block(incisive block)

aim: nak anesthesize insicive nerve bukan mental nerve
sbb mental nerve dah anesthesized waktu buat ID block lagi.

location of mental foramen: between 4 and 5
it is given to avoid giving ID block.

Technique
*put the needle in 45 at the depth of vestibule between 4 and 5
* insert the needle until touch the bone.
*go little bit away from the bone
*give infiltration: 1 ml of anesthesia

Anesthesia of incisor teeth.

Infiltration sama macam maxilla.
-anesthesia of incisor teeth is done by infiltration because the bone in that area is thin.

-kalau nak cabut gigi depan, kena bagi infiltration and kena bagi juga ID block that you give posteriorly

-infiltration dah mencukupi tapi kalau dah bagi ID block kena bagi infiltration jugak la..

cross innervation: central and lateral incisors is innervated from both sides left and right.

Mandibular anesthesia in chlidren.

children buccal plate of bone is much less dense than that of adults.

great variation: xsure sama ada infitration cukup atau x so kita guna :

rule of 10

1) each tooth is allocated a score ( A=1, B=2, C=3, D=4, E=5)

2)add the score to the most distal tooth to be restored  to the child's age (rounded up to the nearest year)

3) _> 10: ID block is indicated
4)_< 10 infiltration is suffiecient

Example:

A 4-years old child needs to extract B & E
The score of the most distal tooth 5 + 4= 9 ( 9<10~ infiltration is sufficient)

This rule is not a must just nak bg senang je.

kalau score 9 nak buat ID block pun okay je tp better bg infiltration  sbb lagi convenient.

Anesthesia of surrounding gingivae.

simple procedures:
* Infiltration in the sulcus
* Infiltration in the gingival papillae

more extensives procedures
*long buccal block
*lingual nerve block.

Long buccal nerve

Branches from the mandibular nerve high in the infratemporal fossa.

Crosses the anterior aspect of the ramus from medial to lateral in the coronoid notch region.

can be anesthesized by:
* block technique distobuccal to the third molar
* infiltration opposite to the target tooth.

kalau simple procedure mcm small procedures in the gingiva, kita kena bagi long buccal block, but not ID sbb ia utk bone.

Lingual nerve
 usually blocked with ID injection.

you anesthesize the lingual nerve when you do ID block as they are in same space.

its terminal branches can be anesthesized by infiltration in the lingual sulcus opposite to the target tooth

The inferior dental nerve block

Bismillah..

The inferior dental nerve block

needle: 35 mm
kenapa panjang sgt???
- because it will go through too many structures "medial pterygoid muscle, buccinator till reaches its space.

The nerve is usually blocked at the mandibular foramen, jadi patient should be seated with the mouth widely open. For the right-handed operator:

right ID block: stand in front of the patient

left ID block: stand behind the patient

kalau left-handed: sebaliknya.

macam mana nak cari pterygomandibular space?
-kena cari landmarks

1)maximum concavity on the anterior and post aspect of the ascending ramus.

2) pterygomandibular raphe

prominent soft tissue band yang connect antara mandible and maxilla

consist of muscular fibers: supr constrictor muscle

buccinator muscle insert in it.

pterygomandibular space:

lateral: ant border of mandible
medial: pterygomandibular raphe

3)buccal pad of fat

4)mandibuar occlusoplane.

place the thumb (intraorally) and index finger (extraorally) of your left hand on the max concavities of the ramus.

kat mne perlu inject local anesthesia?
-inject inside the pterygomandibular space (exactly between the ant border of the mandible & the pterygomandibular raphe) not to the nerve itself, so it will anesthesize the trunk itself.

how does it give its action?
-pterygomandibular space is surrounded by muscle so when injecting a solution to the space it will rach all the tissues in the space.
-sbb tu kalau anesthesize, kita aim to reach the space not the nerve.

Entry point of the needle.

1) the thumb is in the mouth ( ant border of the ramus of mandible)
2) index is outside the mouth on the post border of ramus of mandible
3) injection will be between the raphe and your fingers.

lat to the pterygomandibular raphe

medial to the ascending ramus

at the tip of buccal pad of fat above the mandibular occlusal approx 5-10mm

at the level of the maximum concavities of the ramus. (at the tip of the midpoint of your thumb)

approach from the opposite premolar region.

advance the needle until it touches the bone.

aim to touch bone midway between your thumb and index finger.

aspirate

inject around 2 ml of anesthethic solution (the amount of anesthesia to achieve the block is 2ml

try to give some anesthesia while you are entering or while advancing the needle. this reduces the pain.

wait up until 5 minutes and ask for altered sensation in the lower lip.

Mandibular Anesthesia Techniques

Bismillah..

Nak buat anesthesia ni mmg kena banyak practice. Bukan sekadar teori practice makes perfect :)

Infiltration techniques tak berkesan pun kat mandible org dewasa sbb mandible dyorg ada dense cortical bone. kalau maxilla lain la sbb dia cancellous bone je. Infiltration may be used for lower incisors.

Guna kat budak boleh la sbb bone dia thinner lagi.

Nerve block technique: hitting the area where the root of the nerves gets off- will anesthesize the nerve and all its branches.

kat bahagian mana IDN free from bone?
pterygomandibular foramen
-jadi kalau kita hit the nerve at that area before it gets into the foramen, we will anesthesize the main trunk and nerve after the trunk.

more challenging than maxillary anesthesia

requires good knowledge of local anatomy

nerve blocks are utilized to anesthesize IAN, lingual nerve, buccal nerve

provide anesthesia to the pulpal, alveolar, lingual and buccal gingival tissue and skin of lower lip and medial aspect of chin on side injected.

Fascial space

fascia ye bukan face..hee

apa tu fascia?
-potential spaces which means they aren't real spaces. bukan empty space
-ada boudaries, maknanya lies within substructures which make that area ease to be isolated from other areas.

jadi..kalau one of these space kena infection habisla yg lain sbb infection will be easily infiltrate to the whole space, but it will be difficult to spread...why????

-each space ada borders or walls that made from muscles or bones, jadi infection stay in place and takes a longer time to go to other place.

Submandibular space

anterior & lateral: medial surface of mandible

posterior: hyoid bone

inferior & lateral: skin, superficial fascia, platysma muslce, and superficial layer of deep cervical fascia.

medial: anterior belly

superior: mylohyoid muscle

gambar screenshot je mampu..hee

Pterygomandibular space.

-is the fascia space that contains the IAN and the lingula borders.

Ant: pterygomandibular raphe and fibers of the superior constrictor and the buccinator muscles inserted in.

Post: parotid gland

Lateral wall: the inner surface of  the ascending ramus

Medial (floor) and deep boundary: medial pterygoid muscle.

medial pterygoid muscle
-origin: medial surface of lateral plate of pterygoid muscle
-insert: angle of mandible( from inside:medially)

the lingual nerve is ada je dalam pterygomandibular space ni..so it will be anesthesized as well when u give the ID block coz it will be escorting the ID nerve.

Roof (superiorly) : lateral pterygoid muscle
note: masseter muscle inserts in the lateral surface of the mandible

Medial: medial pterygoid muscle and above the lateral pterygoid

Mandibular LA & Complication

Bismillah..

3)inferior alveolar nerve (IAN/IDN)

-Medial: lateral pterygoid
-Posterior: lingual nerve
-Enters mandible at the lingula: the IAN come beside the lingula then run in the canal; the lingual determine the area where the mandibular foramen open.
-the lingula: a bony projection: where there is a tendon attached to it.( gives attachment to sphenomandibular ligament)

-ditemani oleh IA artery and vein ( artery di depan nerve)

-travels within the inf alveolar canal until mental foramen.

- in the 1st 1/3 canal: mainly medial

-angle of mandible: canal become exactly at the middle of the mandible in the central

-then, it goes laterally (outside)

-finally,: open in small opening called mental foramen; then IDN dived into incisive nerve and mental nerve.

-incisive nerve: continues inside mandible canal, innervates mandibular canines and incisors

-mental nerve(sensory): gives sensation to lips and chin

-mental nerve branch of IDN, IDN branch of V3

-mental nerve emerges at the mental foramen (between base of 4 & 5, its mainly soft tissue nerve)

-kalau nak anesthesize  mental nerve kita guna mental block( utk extract lower 4) sbb nanti dia anesthesize sekali main nerve ID and insicive branch.

4) nerve to mylohyoid( motor nerve)

IDN provides innervation to the mandibular teeth pulp + buccal + lingual bone + buccal gingiva of the anterior teeth by mental nerve

buccal gingiva of posterior teeth: innervated by long buccal nerve.

kalau nak cabut lower 6, kena anesthesize(ID block) : long buccal nerve, and lingual nerve.

Terminal branches of IVN:
1) insicive nerve- remains within incisive canal from mental foramen to midline

2) mental nerve: exits mental foramen and divides into 3 branches: innervate skin, lips and labial mucosa.

Mandibular Local Anesthesia & Complications

Bismillah..

Mand branch

> branch yg paling besar

composed of sensory and motor roots (mixed)

sensory root
* originates at anterioborder of trigeminal ganglion

motor root
* arises in motor cells located in the pons and medulla lies medial to sensory.

The sensory and motor of the mandibular branch merge from foramen ovale of greater wing of sphenoid.

initially merge outside of the skull and divide about 2-3 mm inferiorly.

branches:
undivided nerve (main trunk)
*nerve spinosus (meningeal branch)
* medial pterygoid motor

anterior division (trunk)
*buccal nerve (long buccal ) sensory
*deep temporal nerve
*masseteric nerve

posterior division (trunk)
* auriculotemporal sensory
*lingual snsory
*inferior alveolar mixed
*mylohyoid nerve (motor)

Main trunk..
1) Branch go up > Nerve spinosus: innervates mastoids and dura
2)Branch go down > media pterygoid: innervates medial pterygoid msucle

ada jugak branches to tensor veli palatini and tensor tympani.

Rule:
1) Anterior trunk ada 3 motor nerves and 1 sensory nerve
( innervates muslce of mastication)

muscle of mastication(mylohyoid) yg innervated by post trunk  called : nerve to mylohyoid

a) Buccal nerve (long buccal): sensory
-kalau nak anesthesize inject 2mm distobuccal to the tooth that you want to extract.

Travels anteriorly and lateral to the lateral pterygoid muslce

kat mand 3rd molar: exit through buccinator and provide innervation to skin of cheek.

branches also stay within the retromandibular triangle providing sensory innervation to the buccal gingiva of mand molars and buccal vestibule.


b) Muscles of mastication

V3: gives branches to deep temporal muslce (temporalis muscle), masseter and lateral pterygoid muscle (motor branches of ant division of V3

Post trunk: 3 sensory 1 motor nerve

So kat ant of V3 sensory: buccal nerve...yg lain tu motor (nerves to mastication muscle)

travels inferior and mesial to lateral pterygoid

1) lingual nerve

lies between ramus and medial pterygoid within pterygomandibular raphe.

provide sensation to ant 2/3 rds of tongue, lingual gingiva, floor of mouth mucosa and gustation (chorda tympani)

carries nerve yg bukan part of trigeminal nerve including chorda tmypani nerve of the facial nerve, which provides special sensation (taste) to anterior 2/3 part of tongue)

sgt ada kaitan dgn mandible, esp in the mandibular posterior wisdom area.

lies inferior and mesial to mand 3rd molar
descend from post trunk of V3> go down to lingual plate "lingual cortex"

sgt berisiko utk terkena nerve ni bila cabut 3rd molar(gigi bongsu).

kalau nerve ni rosak ggu sensation

auriculotemporal nerve (sensory)
-depan telinga
- transverses the upper part of parotid gland and post portion of zygomatic arch.

Branches: supply

Anterior auricular: skin over helix and tragus

External auditory meatus: skin over meatus and tympanic

communicates with facial nerve to provide sensory innervation to the skin over areas of zygomatic, buccal and mandibular.

communicates with otic ganglion for sensory, secretory and vasomotor fibers to the parotid gland a

articular-posterior TMJ sensation to the capsule of TMJ.

superficial temporal - skin over temporal region.

TO BE CONTINUE....

Maxillary Injection Technique

Bismillah..

Seperti yang kita tahu utk beri bius pada orang ni bukan senang.Dentist memang kena kuasai nerve (urat) lagi2 yang dekat muka dengan kepala. Kalau tersalah nerve boleh menyebabkan patient merana seumur hidup..naudzubillah

doakan aku agar aku boleh menguasai ilmu dgn baik ;)

Selalu technique yang kita pakai untuk maxilla ni infitration..tapi boleh je kalau nak pakai block anesthesia pun.

First and foremost mesti kena tahu tentang anatomy dulu.

Trigeminal nerve

ha itula trigeminal nerve. Kira nerve besar jugakla..sbb ada 3 branches.

V1: Opthlamic division (sensory)
V2: Maxillary division (sensory)
V3:  Mandibular division (motor and sensory)

V2: Maxillary division

exit melalui foramen rotundum of greater wing of sphenoid

Branches: divided by location.

1) intercranial: within cranium ( before getting out from foramen rotundum).
.middle meningeal nerve- providing sensory innervation to the dura matter

2) pterygopalatine  ( within pterygopalatine fossa)
a-Zygomatic nerve

zygomaticofacial nerve- skin to cheek prominence
zygomaticotemporal nerve- skin to lateral forehead

b-pterygopalatine nerve: serve as communication for the pterygopalatine ganglion and the maxillary nerve. Carry postganglionic secretomotor fibers through the zygomatic branch to the lacrimal gland.

orbital branch: supply periosteum of the orbits.
nasal branch: supply mucous membranes of superior and middle conchae, lining of posterior ethmoid sinuses and posterior nasal septum.

Nasopalatine nerve: travels across the roof of nasal cavity giving branches off to the anterior nasal septum dan floor of nose. Enters incisive foramen and provides palatal gingival innervation of premaxilla.

Palatine branches: greater (ant) and lesser (middle or post) palatine nerves

Greater palatine: travels through the pterygopalatine canal , enters the palate via greater palatine foramen. Innervates palatal tissue from premolars to soft palate.

Lesser palatine: merges from lesser palatine foramen and innervates the mucous membranes of soft palate and parts of tonsillar region.

Pharyngeal branch: exits the pterygopalatine ganglion and travels through the pharyngeal canal. Innervates mucosa of the portions of nasal pharynx

Nerve paling penting: Nasopalalatine, greater palatine and lesser palatine..sbb apa?

they innervate the palate. boleh buat sama ada guna infiltration or block.

c)Post sup alveolar nerves.

into infraorbital groove- innervates molars

infraorbital (within the infraorbital fissure)

infraorbital branch: middle, anterior

middle: innervates premolars

anterior: ant teeth

branches from 6-8 mm posterior to the infraorbital nerve exit from infraorbital foramen.

facial: emerge from infraorbital foramen

inferior palpebral: lower eyelid
external nasal: lateral skin of the nose
superior labial branch: upper lip skin and mucosa

 

Selection of syringes and needles

Bismillah

nak inject orang kena pilih jarum@needle yg sesuai..dan nak biar pilihan itu kena tgk beberapa faktor..

Antara cirinya ialah..

1) either shirt, long or ultrashort
2)high/low gauge
3)block anesthesia>long needles
4)infiltartion anesthesia> short needles
5) children> ultrashort
6)the higher the gauge the shorter the needle

dentist kena la pilih needle berdasarkan standard America Dental Association (ADA)

short needle kita guna utk soft tisuue yang mempunyai ketebalan kurang daripada 20mm

23-through 30 gauge needle boleh digunakan utk intraoral injections blood can be aspirated through them, aspiration akan jadi susah kalau guna smaller gauge

extra-short, 30-gauge digunakan utk infiltration injections.

amaran: jangan sesekali bengkokkan jarum

Local Anesthesia

Local AnesthesiaJ

Local anesthesia ni kalau nak mudah faham ia berkaitan dengan bius.Kalau ktorg nak senang panggil LA je..hee.. Bius setempat. Ada banyak jenis LA ni. Antaranya surface anesthesia, Infiltration anesthesia dan regional block anesthesia.

Ni yang main type punya. Jadi kita go through satu2..

Surface anesthesia

Nama lain kita panggil topical anesthesia..sebab dia berkaitan kulit kan..

Ada banyak form, mcm: ointments, gelly,spray dan cream

Most common ointment: EMLA (2.5%: lidocaine, 2.5%: prilocaine =5%)

 Gelly banyak flavor and selalu guna utk intraorally (dalam mulut) dan untuk budak2..

LA spray: 10%

Ethyl chloride spray: produce surface anesthesia by cooling.

Infiltration anesthesia.

Yang ni banyak..tapi cara aku ingat macam ni..conventional injection technique

Periosteal ada 3: supra, para and sub

Intra ada 2: osseous and ligamental

Submucosal

Yang paling common: supra periosteal.

Regional block anesthesia

Conduction anesthesia

Nak bius orang bukan senang.kena tahu technique. Salah technique je boleh menyebabkan patient merana seumur hidup..naudzubillah.

Dan ni antara yang biasa @ conventional injection technique.

LA technique:

Target: small nerve ending. (flooded with LA solution)

Selalu guna: maxillary teeth and mandibular incisors(lower anterior)

Nerve block technique: conduction technique

Target: main trunk

So bila dah block main trunk..maka nye terblock la jugak

v  Nasopalatine nerve

v  Greater palatine nerve

v  Lesser palatine nerve

v  Buccal nerve

v  Lingual nerve(mandible)

v  Buccal nerve

Kenapa guna block anesthesia dekat mandible and infiltration dekat maxilla?

Ø  Sebab anesthesia solution tak boleh penetrate masuk ke compact vestibular bone in the mandible jd LA tak successful..

Ø  Mandible: thick cortical plates..and infiltration tak kan penetrate cortex to reach the apices of teeth.

Ø  Maxilla: tulang dia soft and thin( spongy) bone jadi infiltration sufficient je

Disadvantage block anesthesia.

·         Increased risk of trauma of nerve trunk.

·         Accidental intravascular injection in of LA solution.

Ada technique lain juga..(other technique)

1)Periodontal Ligament, PDL technique

Selalu guna: mandibular molars (alternative pada nerve block technique)mungkin sbb ID block tak working so bagi je la technique ni.

Technique ni simple je; hanya inject LA solution within periodontal ligament space. Perlu small amount (0.2ml)  sbb PDL ni kecik je.

Letak needle dkt gingical sulcus and advances along the root surface until resistance is met. Masa inject tu patient akan rasa slight pressure because it is very small space.

Injection ni  tak sakit and anesthethic effect dia hnaya pada pulp and desmodontal nerve

Duration: 10-15 minutes

PDL injection ni sesuai utk extremely anxious patients and children

2) Intrapulpal injection.

Guna injection ni bila block and infiltration tak  berkesan

Small quantity (0.1ml)

Duration: 10 minutes

Fast and sakit sikit masa mula2 introduce injection.

3) Intraosseous injection.

Force the needle in cortical plate and cancellous bone

Guna injection ni kalau block ansthesia pun tak berkesan pada mandible. Sesuai guna untuk mandible sebab perforate the cortex then introduce wthin the bone.

Mcm mana perforate the cortex?

·         Guna hand-piece with a very fine bur. There is small piece will guide the hanpiece where to drill, then the needle will go through the same piece to get the anesthesia inside the bone.

4) Jet injection( non-needle, needle-less dentistry)

Very recent technique

Principle jet instrument: small quantities of liquids forced through very small opening under high pressure can penetrate mucus membrane or skin without causing tissue trauma.

Good utk surface anesthesia

One jet injection : hold 1.8 ml cartridge of LA, it can be adjusted to expel (0.05-0.2 ml solution under 2000 psi pressure.