1. LOCAL ANESTHETICS DR SEEMI GULL ASSOCIATE PROFESSOR 2. t1/2 Elimination (h) Vdss (L) CL (L/min) Bupivacaine 28 3. 5 72 0.

.47 Lidocaine 10 1.6 91 0.95 Mepivacaine 7 1.9 84 0.78 Prilocaine 5 1.5 261 2.84 Ropivacaine 23 4.2 47 0.44 2

3. Local Anesthesia: Definition: Local anesthesia is any technique to render part of the body insensitive to pain without affecting consciousness. LOCAL ANESTHETICSThese are are the agents which produce transient and reversible loss 3

4. CONTINUED The following terms are often used interchangeably: Local anesthesia, is anesthesia of a small part of the body such as a tooth or an area of skin. Regional anesthesia is aimed at anesthetizing a larger part of the body such as a leg or arm. Conduction anesthesia is a comprehensive term which encompasses a great variety of local and regional anesthetic techniques. 4

5. Local anesthetics:amides vs. esters Common structure Aromatic ring Tertiary amine Alkyl chain Linking bond Amide bond (see lidocaine) Ester bond (see procaine) 5

6. Types of Local Anesthetics ESTERS: Procaine chloroprocaine tetracaine Cocaine Benzocaine AMIDES: Etidocaine (Duranest) Lidocaine (Xylocaine) Mepivacaine (Carbocaine) Prilocaine (Citanest) Ropivacaine Bupivacaine (Marcaine) 6

7. Pharmacokinetics: PKa And Onset of Action: Local anesthetics with a pKa closest to physiological pH will have a higher concentration of nonionized base that can pass through the nerve cell membrane, and generally a more rapid onset. pKa > 7.4 more cations, pKa < 7.4 more anions 7

8. Duration and Protein binding: Amides: Esters: Bupivacaine, Etidocaine Chloroprocaine and and Ropivacaine- very Procaine- have low potency high potency and lipid and lipid solubility and also low solubility, very long

duration and protein binding. duration and protein binding also. Cocainehas intermediate Lidocaine, Prilocaine potency and solubility and and Mepivacaine- have intermediate duration and intermediate potency protein binding and lipid solubility and Tetracaine- has high potency intermediate duration of action and protein and lipid solubility along with a binding. long duration of action and high protein binding 8 9. Systemic absorptionRate of systemic absorption: Intravenous > tracheal > intercostal > caudal > paracervical > epidural> brachial plexus > sciatic > subcutaneous High tissue binding also decreases the rate of absorptionMetabolism: Amides N-dealkylation and hydroxylation P450 enzymes, liver, slower process than esterase activity Prilocaine>lidocaine>mepivacaine>ropivacaine>bupivacaine Esters Pseudocholinesterase 9 10. Pharmacokinetics: AGENT Pot. Onset pKa %PB P. coefProcaine 0.51% (Novocain) 1 Rap 8.9 5.8 0.02Chloroprocaine 2-3% (Nesacain) 4 Rap 8.7 ? 0.14Tetracaine 0.1-0.5% (Pontocain) 16 Slow 8.5 75.6 4.1Lidocaine 1-5% (Xylocaine) 1 Rap 7.9 64.3 2.9Mepivacaine 1.5% (Carbocaine) 1 Mod 7.6 77.5 0.8Bupivacaine 0.25-0.75% (Marcainesensorcaine) 4 Slow 8.1 95.6 27.5Etidocaine 0.5-1.5% (Duranest) 4 Rap 7.7 94 141Prilocaine 1 7.9 55 0.9 10Ropivacaine 0.75% (Naropin) 4 Mod 8.1 94 2.9 11. Mechanism of Action Voltage & time dependent blockade of resting membrane sodium channels binding to sodium channel receptors inside the cell Inc threshold for excitation Slowing of impulse conduction Decreased rate of rise of action potential inhibiting action potentials in a given axon. 11 12. 12 13. CONTINUED If the resting potential encounters the proper chemical, mechanical or electrical stimuli to reduce the membrane potential to less than -55 mV then an action potential is produced that allows the influx of sodium ions. LA act here to block the Na influx. The influx allows the

membrane potential to further increase to +35mV temporarily. Sodium and potassium channels along with the sodium/potassium pump eventually returning a given axon back to its resting membrane potential after an action potential. 14 14. Regional anesthesia Definition: Rendering a specific area of the body, e.g. foot, arm, lower extremities, insensate to stimulus of surgery or other instrumentationUses: Provide anesthesia for a surgical procedure Provide analgesia post-operatively or during labor and delivery Diagnosis or therapy for patients with chronic pain syndromes 15 15. Types: Application of local anesthetic to mucous membrane - cornea, nasal/oral mucosa: Uses : awake oral, nasal intubation, superficial surgical procedure Advantages : technically easy minimal equipment Disadvantages : potential for large doses leading to toxicity 17 16. Subcutaneously Application of local subcutaneously to anesthetize distal nerve endings Uses: Suturing, minor superficial surgery, more extensive surgery with sedation Advantages: minimal equipment, technically easy, rapid onset Disadvantages: potential for toxicity if large field 18 17. IV Block Injection of local anesthetic intravenously for anesthesia of an extremity Uses any surgical procedure on an extremity Advantages: technically simple, minimal equipment, rapid onset Disadvantages: duration limited by tolerance of pain, toxicity 19 18. Peripheral nerve block Injecting local anesthetic near the course of a named nerve Uses: Surgical procedures in the distribution of the blocked nerve Advantages: relatively small dose of local anesthetic to cover large area; rapid onset Disadvantages: technical complexity 20 19. NERVE BLOCK ANESTHESIA 21 20. Plexus Blockade Injection of local anesthetic adjacent to a plexus, e.g cervical, brachial or lumbar plexus Uses : surgical anesthesia or post-

operative analgesia in the distribution of the plexus Advantages: large area of anesthesia with relatively large dose of agent Disadvantages: technically complex, potential for toxicity and neuropathy. 22 21. PLEXUS BLOCK 23 22. Central neuraxial blockade - Spinal Injection of local anesthetic into CSF Uses: profound anesthesia of lower abdomen and extremities Advantages: technically easy, high success rate, rapid onset Disadvantages: high spinal, hypotension due to sympathetic block, post dural puncture headache. 24 23. 25 24. SPINAL ANESTHESIA 27 25. Central Neuraxial Blockade -epidural Injection of local anesthetic in to the epidural space at any level of the spinal column Uses: Anesthesia/analgesia of the thorax, abdomen, lower extremities Advantages: Controlled onset of blockade, long duration when catheter is placed, post-operative analgesia. Disadvantages: Technically complex, toxicity, spinal headache 28 26. 29 27. Systemic Toxicity of LocalAnesthetics Drugs-not a great difference in toxicity between equally potent local anesthetics-one of low toxicity when a large dose is required Site of injection-vascular sites lead to rapid absorption accidental I.V. injection is the most common cause of toxicity 30 28. Signs and Symptoms ofLocal/Regional Anesthesia Toxicity CNS Toxicity: Unconsciousness Generalized convulsions Coma Apnea Numbness of the mouth and tongue, metal taste in the mouth 31 29. Light-headednes Tinnitus Visual disturbance Muscle twitching Irrational behavior and speech 32

30. Cardiovascular toxicity slowing of the conduction in the myocardium myocardial depression peripheral vasodilatation usually seen after 2 to 4 times the convulsant dose has been injected 33

31. Hypersensitivity/Allergy: true allergy is very rare. esters ---- sensitivity to their metabolite, para- aminobenzoic acid (PABA), and does not result in cross-allergy to amides.. allergy to paraben derivatives, which are often added as preservatives to local anesthetic solutions. 34

32. Methemoglobinemia: prilocaine metabolite, o-toluidine, is known to cause methemoglobinemia. . Seen with larger not recommended for use in infants. 35

33. Prevention and Treatment ofLocal/Regional Anesthesia ToxicityPrevention: use recommended dose Aspirate through the needle or catheter before injecting the local anesthetic. large quantity required, divide the dose into small increments, increasing the total injection time inject slowly (<10 ml/min) 36

34. Treatment: Manage airway and give oxygen Stop convulsions if they continue for more than 15 to 20 seconds Thiopental 100 mg to 150 mg IV or Diazepam 5 mg to 20 mg IV 37

35. Drug Interactions Chloroprocaine may interfere with the analgesic effects of intrathecal morphine Opioids and 2 agonists potentiate LAs Propranolol and cimetidine decrease hepatic blood flow and decrease lidocaine clearance Pseudocholinesterase inhibitors decrease Ester LA metabolism Dibucaine (amide LA) inhibits pseudocholinesterase used to detect enzyme potentiate nondepolarizing muscle relaxant blockade 38

36. THE END 39 1. Local Anesthetics PharmacologyIyad M.Abou Rabii February , 2010

2. What are local anesthetics? Local anesthetic: produce loss of sensation to pain in a specific area of the body without the loss of consciousnessPage 2

3. History Genus Erythroxylum discovered in South America, Venezuela, Bolivia, and Peru since pre- Columbian periods Coca leaves from the genus Erythroxylum contain high concentration of alkaloid up to 0.7-1.8% In 1571, Pedro Pizarro, a conquistador of Inca, observed nobles and high rank officials of the Inca empire consumed the coca plant. After the fall of the Inca empire, coca consumption spread widely to the populationPage 3

4. Development of general and local anesthesia Took place in Western Europe from 1750 to 1850 Chemists and physicians collected sample of coca leaves for experiments Isolated active principle of coca leaf, synthesized to a drug for patients to feel more relief of pain when taking surgeries In 1860, German chemist Albert Niemann successfully isolate the active principle of coca leaf; he named it cocainePage 4

5. Development of general and local anesthesia (cont.) Niemann discovered the effect of numbness of the tongues caused by alkaloid in 1860 Based on Niemanns discovery, Russian physician Basil Von Anrep did experiments on animals, such as rats, dogs, and cats. He injected small quantity of 1% solution to his tongue; tongue became insensitive He concluded cocaine is a good drug for surgical anesthetic William Steward Halsted and Richard John Hall developed the inferior dental nerve block techniques for dentistryPage 5

6. Cocaine Addiction An ophthalmologist Carl Koller realized the importance of the alkaloids anesthetic effect on mucous membranes In 1884, he used the first local anesthetic on a

patient with glaucoma In 1898, Professor Heinrich Braun introduced procaine as the first derivative of cocaine, also known as the first synthetic local anesthetic drug Trade name is NovocainePage 6 7. Procaine replaced cocaine (Problems) Took too long to set (i.e. to produce the desired anesthetic result) Wore off too quickly, not nearly as potent as cocaine Classified as an ester; esters have high potential to cause allergic reactions Caused high conc. of adrenaline resulted in increasing heart rate, make people feel nervous Most dentists preferred not to used any local anesthetic at all that time; they used nitrous oxide gas.Page 7 8. Lidocaine In 1940, the first modern local anesthetic agent was lidocaine, trade name Xylocaine It developed as a derivative of xylidine Lidocaine relieves pain during the dental surgeries Belongs to the amide class, cause little allergenic reaction; its hypoallergenic Sets on quickly and produces a desired anesthesia effect for several hours Its accepted broadly as the local anesthetic in United States todayPage 8 9. Cell Membrane ReceptorsPage 9 10. Membrane potential and neurotransmission: Neuron transmits information mainly by two mechanisms: chemical and electrical signals. Information within a neuron is mainly transmitted by electrical signals. Electrical signals are propagated by the mechanism called action potential.Page 10 11. neurotransmission: Resting Potential Resting neurons maintain an intracellular negative membrane potential. Na+/K+ ATPase (sodium pump) transports intracellular Na+ to extracellular in exchange of entry of K+ into cells. This creates a concentration gradients of Na+ and K+Page 11

12. neurotransmission: Resting Potential The resting neuron cell membrane contains much more open K+ channels than open Na+ and Cl- channels or channels for other ions. K+ flows to the outside down the concentration gradient, resulting in a negative potential inside the cell.Page 12

13. neurotransmission: Resting PotentialPage 13 14. neurotransmission: Action Potential (Depolarisation) When stimulated (electrically or chemically), a depolarization of the membrane potential in the neuron (axon) membrane opens voltage- gated Na+ channels. This leads to a burst of flow of Na+ into the cell down the concentration gradient, causing a reverse of the membrane potential (from negative inside to positive inside).Page 14

15. neurotransmission: Action Potential (Depolarisation)Page 15 16. neurotransmission: Action Potential (Repolarisation) Eventually, the influx of Na+ is stopped when Na+ concentration gradient is balanced by the reversed potential gradient. Na+ channels are closed by the voltage-sensitive regulatory domain Subsequently, voltage-gated K+ channels open, allowing accelerated outflow of K+. The membrane potential returns to resting statePage 16

17. neurotransmission: Action Potential (Repolarisation)Page 17 18. Membrane potential and neurotransmission: Action potential at one site of the neuron causes partial depolarization of neighboring region, activates voltagegated Na+ channels in the neighboring region and thus causes propagation of the action potential (electrical signals) along the axon to synapses.Page 18

19. MechanismPage 19

20. MechanismPage 20 21. MechanismPage 21 22. How Local Anesthetics Work Altering the basic potential of the nerve membrane Altering the threshold or firing level Decrasing the rate of depolarization Prolonging the rate of repolarizationPage 22

23. LOCAL ANESTHETICS CALSIFICATION Esters Cocaine, Procaine Chlore procaine ,Tetracaine . Amids : Lidocaine Mepivacaine, Prilocaine Articaine Popivacaine, Etidocaine. Ketons :Dyclon. Quinoline: Centbucridine .Page 23

24. Differences of Esters and Amides Two classes of local anesthetics are amino amides and amino esters. Amides: Esters: -Amide link b/t intermediate --Ester link b/t intermediate chain and chain and aromatic ring aromatic ring --Metabolized in liver and very --Metabolized in plasma --Cause allergic reactionsPage 24

25. Differences of Esters and Amides All local anesthetics are weak bases. Chemical structure of local anesthetics have an amine group on one end connect to an aromatic ring on the other and an amine group on the right side. The amine end is hydrophilic (soluble in water), and the aromatic end is lipophilic (soluble in lipids)Page 25

26. Structures of Amides and Esters The amine end is hydrophilic (soluble in water), anesthetic molecule dissolve in water in which it is delivered from the dentists syringe into the patients tissue. Its also responsible for the solution to remain on either side of the nerve membrane. The aromatic end is lipophilic (soluble in lipids). Because nerve cell is made of lipid bilayer it is possible for anesthetic molecule to penetrate through the nerve membrane.Page 26

27. Structures of Amides and EstersPage 27 28. Structures of Amides and EstersPage 28 29. Pharmacokinetics Following injection into the area of nerve fibers to be blocked, local anesthetics are absorbed into blood. Ester-linked local anesthetics are quickly hydrolyzed by butyrylcholinesterase in blood. Amide-linked local anesthetics can be widely distributed via circulation. Amide- linked local anesthetics are hydrolyzed by liver microsomal enzymes. Thus, half lifes of these drugs are significantly longer and toxicity is more likely to occur in patients with impaired liver function.Page 29

30. Pharmacokinetics Absorption of local anesthetics is affected by following factors: dosage, site of injection, drug-tissuebinding and Presence of vaso-constricting drugsPage 30

31. Factors Affect the Reaction of Local AnestheticsLipid solubility All local anesthetics have weak bases. Increasing the lipid solubility leads to faster nerve penetration, block sodium channels, and speed up the onset of action. The more tightly local anesthetics bind to the protein, the longer the duration of onset action. Local anesthetics have two forms, ionized and nonionized. The nonionized form can cross the nerve membranes and block the sodium channels. So, the more nonionized presented, the faster the onset action.Page 31

32. Factors Affect the Reaction of Local Anesthetics pH influence Usually at range 7.6 8.9 Decrease in pH shifts equilibrium toward the ionized form, delaying the onset action. Lower pH, solution more acidic, gives slower onset of actionPage 32

33. Factors Affect the Reaction of Local Anesthetics (cont.) Vasodilation Vasoconstrictor is a substance used to keep the anesthetic solution in place at a longer period and prolongs the

action of the drug vasoconstrictor delays the absorption which slows down the absorption into the bloodstream Lower vasodilator activity of a local anesthetic leads to a slower absorption and longer duration of action Vasoconstrictor used the naturally hormone called epinephrine (adrenaline). Epinephrine decreases vasodilator. Side effects of epinephrine Epinephrine circulates the heart, causes the heart beat stronger and faster, and makes people feel nervous.Page 33 34. Toxicity Toxicity is the peak circulation levels of local anesthetics Levels of local anesthetic concentration administered to patients are varied according to age, weight, and health. Maximum dose for an individual is usually between 70mg to 500mg The amount of dose also varied based on the type of solution used and the presence of vasoconstrictor Example: ---For adult whose weight is 150lbs and up, maximum dose Articaine and lidocaine is about 500mg ---For children, the dosage reduced to about 1/3 to depending on their weight. The doses are not considered lethal. Some common toxic effects: --light headedness ---shivering or twitching --seizures --hypotension (low blood pressure)Page 34 --numbness 35. Drugs used in dental anesthesia The most common local anesthetic used is called lidocaine. Others might include mepivacaine, bupivacaine and prilocaine. All of the drugs will most likely end with a caine. Procaine, which is commonly known as novacaine is no longer used as the other drugs mentioned here are more effective as numbing agent.Page 35 36. Drugs used in dental anesthesia Bupivicaine (Marcaine-Produce very long acting anesthetic effect to delay the post operative pain from the surgery for as long as possible--0.5% solution with vasoconstrictor--toxicity showed by the pKa is very basic--Onset time is longer than other drugs b/c most of the

radicals (about 80%) bind to sodium channel proteins effectively-most toxic local anesthetic drugPage 36 37. Drugs used in dental anesthesia Prilocaine (Citanest)-Identical pKa and same conc. with lidocaine--Almost same duration as lidocaine--Less toxic in higher doses than lidocaine b/c small vasodilatory activity Articaine (Septocaine)--newest local anesthetic drug approved by FDA in 2000--Same pKa and toxicity as lidocaine, but its half life is less than about of lidocaine--Used with vasoconstrictor.--Enters blood barrier smoothly--The drug is widely used in most nations todayPage 37 38. Anesthetic pKa Onset Duration Max Dose (with (with Epinephrine) Epinephrine) in minutes Procaine 9.1 Slow 45 - 90 8mg/kg 10mg/kg Lidocaine 7.9 Rapid 120 - 240 4.5mg/kg 7mg/kg Bupivacaine 8.1 Slow 4 hours 8 2.5mg/kg hours 3mg/kg Prilocaine 7.9 Medium 90 - 360 5mg/kg 7.5mg/kg Articaine 7.8 Rapid 140 - 270 4.0mg/kg 7mg/kgPage 38 39. The Other Drugs in a Local Anesthesia Carpule The dentist will make a solution for the local anesthesia to be administered prior to the surgery. Some of the other drugs in the solution may contain an antioxidant to prevent a breakdown of the vasoconstrictor, sodium hydroxide to adjust the acidity of the anesthetic so it works more effectively, sodium chloride, to help the solution enter the bloodstream more effectively and sometimes epinephrine which also works to narrow blood vessels to help the anesthetic last longer.Page 39 40. Vasoconstrictors Vasoconstrictors, such as epinephrine and norepinephrine, are commonly contained in local anesthetics to decrease systemic toxicity and prolong the duration of action by retarding anesthetic absorption.Page 40

41. Clinical ConsiderationThese catecholamines have varying degrees of and adrenergiceffects, resulting in cardiac and hemodynamic changesIn cardiac patients, the administration of low concentration of epinephrinemight be necessary according to the degree of severity of the disease.These doesn`t mean the use of epinephrine free local anesthetics but tomake sure that it is not directly administrated in the blood.Page 41

42. How is it administered? There are two local anesthesia injections a dentist will use. There is something called an infiltration injection which numbs a small area and there is a block injection which numbs a larger region. All of the injections are done in the interior of the mouth.Page 42

43. Side Effects: One possible side effect is hematoma, which is a blood filled swelling that can form when the needle accidentally punctures a blood vessel. You may also feel numbness outside the targeted area and this may cause drooping in your eyelid or lips. The effects of drooping will disappear when the anesthesia wears off. Allergic reactions are also rare; however it is important to tell your doctor about any medication you are taking.Page 43

44. Side Effects: Some of the side effects include a numb mouth, which is of course the point of the anesthetic in the first place but other effects include dizziness and the feeling that you have a fat or swollen lip. Other than that, side effects are very rare, which is part of the reason the local anesthetic is so popular in dental procedures.Page 44

45. References Calatayud Jess and Gonzlez ngel. History of the Development and Evolution of Local Anesthesia Since the Coca Leaf. 2003 American Society of Anesthesiologists Volume 98(6) June 2003 pp 1503-1508. Peter C. Meltzer, Shanghao Liu, Heather S. Blanchette, Paul Blundell, Bertha K. Madras. Design

and Synthesis of an Irreversible Dopamine-Sparing Cocaine Antagonist. @ Bioorganic & Medicinal Chemistry Volume 10, Issue 11 , November 2002, Pages 3583-3591 Shigeki Isomura, Timothy Z. Hoffman, Peter Wirsching, and Kim D. Janda. Synthesis, Properties, and Reactivity of Cocaine Benzoylthio Ester Possessing the Cocaine Absolute Configuration. J. AM. CHEM. SOC. 2002, Issue 124, p.3661-3668 Mazoit, Jean-Xavier; Dalens, Bernard J. Pharmacokinetics of local anesthetics in infants and children. Clinical Pharmacokinetics (2004), 43(1), 17-32. Alejandro A. Nava-Ocampo and Angelica M. Bello-Ramirez. Lipophilicity Affects the Pharmacokinetics and Toxicity of Local Anaesthetic Agents Administered by Caudal Block. Clinical and Experimental Pharmacology and Physiology (2004) 31, 116-118. Don R Revis, Jr. Local Anesthetics. October 14,2004: (Medline) http://www.emedicine.com/ent/topic20.htmPage 45 46. Copyright notice Feel free to use this PowerPoint presentation for your personal, educational and business. Do Make a copy for backups on your harddrive or local network. Use the presentation for your presentations and projects. Print hand outs or other promotional items. Dont Make it available on a website, portal or social network website for download. (Incl. groups, file sharing networks, Slideshare etc.) Edit or modify the downloaded presentation and claim / pass off as your own work. All copyright and intellectual property rights, without limitation, are retained by Dr. Iyad Abou Rabii. By downloading and using this presentatione, you agree to this statement. Please feel free to contact me, if you do have any questions about usage. Dr Iyad Abou Rabii Iyad.abou.rabii@qudent.edu.saPage 46 1. Maxillary Anesthetic TechniquesMaxillary Anesthetic Techniques Dr Hesham El-Hawary Elwww.elhawarydentalclinic.com ELHAWARY

2. Maxillary Anesthetic TechniquesThe main factors are:1. Selection of a suitable syringe and needle2. Utilization of the proper L.A. drug3. Insertion of the needle in the correct site for injection ELHAWARY

3. Maxillary Anesthetic Techniques1. Middle meningeal nerve2. Twiges to the sphenopalatine ganglion3. Posterior superior alveolar nerve4. Zygomatic nerve5. Infra-Orbital Nerve 1. Middle superior alveolar nerve 2. Anterior superior alveolar nerve 3. Terminal branches 1. Inferior palpebral nerve 2. External nasal nerve 3. Superior labial nerve ELHAWARY

4. Maxillary Anesthetic Techniques Nerve supply of Maxillary teeth Pulp , Investing structures & Labial (buccal) mucoperiosteum Anterior teeth Anterior superior alveolar nerve (1,2,3)Premolars (4,5) & MB root of 1st Middle superior alveolar nerve molar(6)Molars except MB root of 1st Posterior superior alveolar nerve molar(6) ELHAWARY

5. Maxillary Anesthetic TechniquesNerve supply of Maxillary teeth Cont. Palatal mucoperiosteumAnterior teeth Nasopalatine nerve (1,2,3) Premolars (4,5) Greater ( Anterior) palatine nerve &Molars (678) ELHAWARY

6. Maxillary Anesthetic Techniques Local Anesthesia1. Topical anesthesia2. Local infiltration3. Field block4. Nerve block ELHAWARY

7. Maxillary Anesthetic Techniques Local Anesthesia Topical Anesthesia Ointments, gels, sprays and pastes on mucous membrane or skin Application of a topical anesthetic agent on the mucosa allows for the easy and painless insertion of the sharp needle Affects free nerve endings ELHAWARY

8. Maxillary Anesthetic Techniques Local Anesthesia Local Infiltration Flooding of the small terminal nerve endings with local anesthetic solution ELHAWARY

9. Maxillary Anesthetic Techniques Local Anesthesia Field Block Referred to as local infiltration local anesthetic solution is deposited in the vicinity of larger terminal nerve fiber so a circumscribed area is anesthetized Local anesthesia injection above a tooth apex is an example of a field block, in spite of being referred to as paraperiosteal or supraperiosteal infiltration anesthesia ELHAWARY

10. Maxillary Anesthetic Techniques Local Anesthesia Subperiosteal injection Not be attempted Because of Liability of needle breakage Difficulty of forcing the anesthetic agent between periosteum and bone ELHAWARY

11. Maxillary Anesthetic Techniques Local Anesthesia Nerve Block The anesthetic solution is deposited close to a main nerve trunk Usually at a distance from the operative site before the nerve divided into terminal branches ELHAWARY

12. Maxillary Anesthetic Techniques Buccal inf. Infiltiration Palatal inf. Incisive N.B.Maxillary anesthesia Anterior & Middle Sup. Alv. N.B. Post. Sup. Alv. Nerve block N.B. Palatine N.B. Maxillary N.B. ELHAWARY

13. Maxillary Anesthetic Techniques Factors affecting selection of the technique to be used1. Area to be anesthetized Depending on the type of bone (density of bone) Maxilla and anterior mandibular region are mainly formed of cancellous bone with thin cortical layer above allowing infiltration anesthesia or field block anesthesia reaches the nerve filaments inside the cancellous bone Posterior mandible is covered with thick and dense cortical layer, thus nerve lock anesthesia is indicated ELHAWARY

14. Maxillary Anesthetic Techniques Factors affecting selection of the technique to be used Cont.2. Extent of surgical procedure In multiple extractions, nerve block anesthesia is preferable to Allow anesthesia of the entire operative area Prevent multiple needle punctures to attain the same anesthesia through infiltration ELHAWARY

15. Maxillary Anesthetic Techniques Factors affecting selection of the technique to be used Cont.3. Duration and profoundness of anesthesia Nerve block anesthesia produces a more profound and longer duration than infiltration anesthesia4. Age of the patient Older individuals have dense bone, thus it is more difficult for infiltration anesthesia to penetrate into the bone ELHAWARY

16. Maxillary Anesthetic Techniques Factors affecting selection of the technique to be used Cont.5. Homeostasis When required for the procedure, infiltration anesthesia is recommended to allow the vasoconstrictor present with the local anesthetic to act directly on the blood vessels and reduce bleeding ELHAWARY

17. Maxillary Anesthetic Techniques Factors affecting selection of the technique to be used Cont.6. Presence of infection Infiltration anesthesia should be avoided to prevent injection into an infected area which can spread the infection7. Skill of the operator ELHAWARY

18. Maxillary Anesthetic TechniquesMaxillary Anesthetic TechniquesINFILTRATION ANESTHESIA ELHAWARY

19. Maxillary Anesthetic Techniques The most commonly used technique It is divided into Soft tissue infiltration Submucosal Paraperiosteal Bony infiltration ELHAWARY

20. Maxillary Anesthetic TechniquesSoft tissue infiltration anesthesiaIn this technique anesthesia is deposited intothe soft

tissue in close proximity to bonewhich is then absorbed via pores in the bonesurface till it reaches the nerve filamentsinside the cancellous bone ELHAWARY 21. Maxillary Anesthetic Techniques Soft Tissue InfiltrationSubmucosal anesthesia Paraperiosteal Anesthesia Needle is inserted at a slight Called local infiltration depth just below the Mostly used for anesthetizing mucous membrane All maxillary teeth In cases just need Lower anterior mandibular teeth superficial anesthesia Its action depends on the Hypertrophied tissue diffusion of the L.A. solution High muscle attachment through the periosteum and the minute foramina in the cortical bone ELHAWARY 22. Maxillary Anesthetic Techniques Paraperiosteal AnesthesiaAdvantages Disadvantages1. High success rate Not suitable for large areas2. Technically it is an easy Needs multiple punctures injection Administeration of large3. Usually it is entirely amount of L.A. solution atraumatic ELHAWARY 23. Maxillary Anesthetic TechniquesMaxillary Anesthetic TechniquesMAXILLARY BUCCAL INFILTRATIONANESTHESIA ELHAWARY 24. Maxillary Anesthetic Techniques Buccal infiltration anesthesiaPatient position Dentist position Head , neck and trunk on the From infront and to the same straight line right The back of the chair is tilted so that it make a 45 degree angle with the floor So that when the patient open his mouth the occlusal plane of the maxillary teeth makes 45 degree with the floor The occlusal plan of maxillary teeth near to the operators shoulder ELHAWARY 25. Maxillary Anesthetic Techniques Buccal infiltration anesthesia Cont. Needle: 25-27 gauge Short needle Syringe Non-

Aspirating syringe The target area The apical region of the tooth to be anesthetized ELHAWARY 26. Maxillary Anesthetic Techniques Buccal Infiltration Technique Cont.The point of needle insertionThe point of intersection of 2 imaginary lines 1st line is a vertical line parallel to the long axis of the tooth 2nd line is a horizontal line along the mucobuccal fold ELHAWARY 27. Maxillary Anesthetic Techniques Buccal Infiltration Technique Cont.Direction of needle insertion 45 with the buccal cortical plate of bone ELHAWARY 28. Maxillary Anesthetic Techniques Steps for buccal infiltration The lip/cheek is retracted using dental mirror or your finger to make almost a right angle with the labial/buccal aspect of the jaw The point of insertion is determined as mentioned The needle is inserted with its bevel toward the bone and making an angle of 45 with the buccal aspect The needle is pushed through the soft tissue until the bone is reached (within 2mm) ELHAWARY 29. Maxillary Anesthetic Techniques Steps for buccal infiltiration Cont. The needle is held firmly and 1.5cc of the solution is slowly deposited for buccal/labial injection, and 0.3 cc for lingual anesthesia The needle is then withdrawn gently and recap it Wait 2-3 minutes before starting your dental procedure Check your anesthesia using the dental probe (objective finding) ELHAWARY 30. Maxillary Anesthetic Techniques Confirming the Anesthesia Subjective findings No subjective findings Objective findings Probing does not lead to pain ELHAWARY

31. Maxillary Anesthetic TechniquesMaxillary Anesthetic TechniquesMAXILLARY PALATAL INFILTRATIONANESTHESIA ELHAWARY

32. Maxillary Anesthetic TechniquesWhen you are performing any dental workexcept extraction then the buccal infiltration isenough butwhen it comes to extraction then also a Palatalinjection is to be given ELHAWARY

33. Maxillary Anesthetic Techniques Palatal Infiltration TechniqueThe point of needle insertion Midway between the gingival margin of the tooth and the median palatine raphe Along the long axis of the tooth ELHAWARY

34. Maxillary Anesthetic Techniques Palatal Infiltration Technique Cont.Direction of needle insertion 90 to the palatine bone 90 ELHAWARY

35. Maxillary Anesthetic Techniques Steps for palatal infiltration A mirror is used to retract the tongue and reflect the light to the point of insertion The point of insertion is determined as mentioned The needle is inserted from the opposite side making 90 degree with the palate The needle is pushed through the soft tissue until the bone is reached (within 2mm) On touching the palatal bone deposit 0.3 ml. SLOWLY ELHAWARY

36. Maxillary Anesthetic Techniques Confirming the Anesthesia Subjective findings No subjective findings Objective findings Probing does not lead to pain ELHAWARY

37. Maxillary Anesthetic Techniques Variations in these techniquesBuccal anesthesia Palatal anesthesia Injection for the maxillary Injection for maxillary third third molar molar should be at the Made opposite to the palatal root of the maxillary maxillary second molar second molar to avoid tooth to avoid injury to the

anesthesia of the lesser pterygoid plexus of veins palatine nerves which upper centrals supply the soft palate and may lead to gagging Inject a few drops to the sensation apical area of the other central incisor ELHAWARY 38. Maxillary Anesthetic Techniques Variations in these techniques Cont.Buccal anesthesia Palatal anesthesia Upper centrals Upper centrals and laterals Inject a few drops to the Given 0.5 mm along the apical area of the other palatal long axis of the central incisor tooth while entering from the opposite side ELHAWARY 39. Maxillary Anesthetic Techniques Bony infiltration anesthesia In this technique anesthesia is deposited directly into the bone in close proximity to the nerve filaments inside the cancellous bone Very rarely used ELHAWARY 40. Maxillary Anesthetic Techniques Bony Infiltration Anesthesia (Intra osseous)Techniques Advantages A special needle is used to 1. Very profound anesthesia drill and pierce the outer 2. When other techniques have cortical plate failed Using rose head round bur (#2) Disadvantages 1. The needle easily get clogged 2. The needle could fracture 3. Painfull 4. Cause infection inside the bone ELHAWARY 41. Maxillary Anesthetic TechniquesMaxillary Nerve Block Techniques Posterior superior alveolar nerve block Anterior and middle superior alveolar nerve block Incisive nerve block Greater palatine nerve block Maxillary nerve block ELHAWARY 42. Maxillary Anesthetic TechniquesMaxillary anesthetic TechniquesPOSTERIOR SUPERIOR ALVEOLARNERVE BLOCK(ZYGOMATIC/TUBEROSITY NERVE BLOCK) ZYGOMATIC/ ELHAWARY

43. Maxillary Anesthetic Techniques This technique is used to anesthetize the Posterior Superior Alveolar Nerve before it enters the posterior surface of the maxilla while it is in the infra-temporal fossa infra- It will anesthetize the pulp, investing structures and buccal mucoperiosteum of the maxillary molars except for the mesio-buccal root of the 1st molar ELHAWARY

44. Maxillary Anesthetic TechniquesPosterior superior alv. N.B. TechniquePatient position Dentist position Head , neck and trunk on In the left p.s.a. sits in a 10 the same straight line oclock position The back of the chair is In the right p.s.a. he sits in tilted so that it make a 45 an 8 oclock position degree angle with the floor So that when the patient open his mouth the occlusal plane of the maxillary teeth makes 45 degree with the floor ELHAWARY

45. Maxillary Anesthetic TechniquesPosterior superior alv. N.B. Technique alv. Cont. Needle: 25-27 gauge Long needle Syringe Aspirating syringe ELHAWARY

46. Maxillary Anesthetic TechniquesPosterior superior alv. N.B. Technique alv. Cont. Landmarks Muccobuccal fold Maxillary tuberosity Zygomatic process ELHAWARY

47. Maxillary Anesthetic TechniquesPosterior superior alv. N.B. Technique alv. Cont. Technique 1. Retract the cheek and prepare site of injection 2. The needle is introduced into the height of the mucobuccal fold above the 2nd molar 3. Advance the needle slowly upward, backward and inward 4. The needle shouldnt touch bone, and the max. depth allowed is the length of the long needle, then ASPIRATE 5. If blood comes out then retract and try again, but if you get blood also the next time then abort the technique 6. If no blood comes out then deposit 1.5 ml of the anesthetic solution, wait 3-5 minutes before working ELHAWARY

48. Maxillary Anesthetic Techniques Confirming the Anesthesia Subjective findings No subjective findings Objective findings Probing does not lead to pain ELHAWARY

49. Maxillary Anesthetic TechniquesMaxillary anesthetic TechniquesMAXILLARY NERVE BLOCK ELHAWARY

50. Maxillary Anesthetic Techniques The purpose of this technique is to block the main trunk of the maxillary nerve as it traverses the pterygopalatine fossa after emerging from foramen rotandum ELHAWARY

51. Maxillary Anesthetic Techniques Maxillary Nerve Block To accomplish this the same landmarks as the post. Sup. Alv. N. block is used but you have to enter the needle about 2/3 of its length A larger amount is used in this case where 4ml are deposited slowly and after aspiration to achieve a successful result It is very rare to be done ELHAWARY

52. Maxillary Anesthetic Techniques Confirming the Anesthesia Subjective findings Numbness of: The palate Upper lip Lateral aspect of the nose Lower eye lid Objective findings Probing does not lead to pain in the palate and buccal mucosa in any aspect ELHAWARY

53. Maxillary Anesthetic TechniquesMaxillary anesthetic TechniquesINFRAORBITAL NERVE BLOCK(ANTERIOR AND MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK) ELHAWARY

54. Maxillary Anesthetic Techniques Infra Orbital N. BLOCK The aim is to deposit the anesthetic solution into the infraorbital canal through the infraorbital foramen The foramen is shaped like a flattened funnel with the opening directed downwards and medially. Thus the needle should approach the foramen from the

medial side This is to anesthetize the anterior and middle superior alveolar nerves ELHAWARY 55. Maxillary Anesthetic Techniques Infra Orbital N. BLOCK Cont. In this technique the anterior & middle superior alveolar nerves are anesthetized in 80% of cases In the remaining 20% the middle sup.alv. nerve has to be given a separate injection ELHAWARY 56. Maxillary Anesthetic Techniques Infra Orbital N. BLOCK Cont. Area to be anesthetized: The upper lip The lateral aspect of the nose The lower eyelid The buccal mucosa of the upper anterior teeth and premolars Pulp and investing structures of upper anterior teeth and premolars ELHAWARY 57. Maxillary Anesthetic Techniques Infraorbital N.Block Technique Cont.Patient position Dentist position Head , neck and trunk on the Stands on the right side same straight line The back of the chair is tilted so infront of the patient that the patient is in a supine for a right side injection position Along side the patient The occlusal plan of maxillary teeth for a left side injection Near to the operators shoulder At a 45 degrees angle to the floor ELHAWARY 58. Maxillary Anesthetic Techniques Infraorbital N.Block Technique Cont. Needle: 25-27 gauge Long needle Syringe Aspirating syringe ELHAWARY 59. Maxillary Anesthetic Techniques Infraorbital N.Block Technique Cont.The point of needle insertionThe infraorbital foramen ELHAWARY 60. Maxillary Anesthetic Techniques Infraorbital N.Block Technique Cont.Direction of needle insertion Will be discussed in the technique ELHAWARY

61. Maxillary Anesthetic Techniques Steps for Infraorbital N.Block Technique Cont.1. Clean the tissue to be injected with sterile gauze2. Apply topical antiseptic followed by topical anesthetic3. Pull the upper lip taut4. Locate the infraorbital foramen which is About 5mm below the infraorbital ridge between the middle and inner thirds The foramen also lies in one vertical line with the pupil when the patient gazes forwards ELHAWARY

62. Maxillary Anesthetic Techniques Steps for Infraorbital N.Block Technique Cont.5. There are 3 acceptable methods of approaching the infraorbital foramen: First technique A vertical imaginary line is drawn from the inner canthus of the eye until it intersects with another imaginary line drawn in the mucobuccal fold forming a right angle A 25 gauge needle is inserted in the mucobuccal fold about 5 mm lateral to the maxillary alveolar bone directing it to bisect this imaginary right angle ELHAWARY

63. Maxillary Anesthetic Techniques Steps for Infraorbital N.Block Technique Cont.5. There are 3 acceptable methods of approaching the infraorbital foramen: Second technique The crown of the central incisor on the side of the tooth to be operated on is bisected by the needle from the mesioincisal edge to the distogingival angle with the point of insertion 5 mm out from the mucobuccal fold to the level of the canine apex ELHAWARY

64. Maxillary Anesthetic Techniques Steps for Infraorbital N.Block Technique Cont.5. There are 3 acceptable methods of approaching the infraorbital foramen: Third technique The syringe and needle are lined up with a vertical line with the longitudinal axis of maxillary 2nd premolar in line with the pupil of the eye while patient gazes forwards The needle is inserted 5mm out in the mucobuccal fold ELHAWARY

65. Maxillary Anesthetic Techniques Steps for Infraorbital N.Block Technique Cont.6. The needle is oriented with bevel towards bone and advanced slowly till it contacts the upper rim of the infraorbital foramen The depth of penetration should not exceed 20 mm6. Aspirate, if negative deposit the anesthetic solution slowly7. Wait 3-5 minutes before commencing dental procedure ELHAWARY

66. Maxillary Anesthetic Techniques Confirming the Anesthesia Subjective findings Numbness of The lower eye lid Lateral wall of the nose Upper lip Objective findings Probing does not lead to pain in the mucosa opposite to the anterior teeth and premolars ELHAWARY

67. Maxillary Anesthetic TechniquesMaxillary anesthetic TechniquesINCISIVE CANAL NERVE BLOCK(NASOPALATINE NERVE BLOCK) ELHAWARY

68. Maxillary Anesthetic Techniques Incisive canal N.Block This is a painful injection so it is better to give a few drops of anesthesia superficially before proceeding with the rest of the injection The aim is to anesthetize the nasopalatine nerve inside the incisive canal Area to be anesthetized: The mucosa of the Anterior part of the palate opposite to the anterior teeth ELHAWARY

69. Maxillary Anesthetic TechniquesIncisive canal N.Block Technique Cont.Patient position Dentist position Head , neck and trunk on the The operator will sit same straight line The back of the chair is tilted so from infront and to the that the patient is in a supine right position The occlusal plan of maxillary teeth near to the operators shoulder ELHAWARY

70. Maxillary Anesthetic TechniquesIncisive canal N.Block Technique Cont. Needle: 25-27 gauge Short needle Syringe Non-Aspirating syringe ELHAWARY

71. Maxillary Anesthetic TechniquesIncisive canal N.Block Technique Cont.The point of needle insertionThe incisive foramen i.e. the crest of the incisive papilla ELHAWARY

72. Maxillary Anesthetic TechniquesIncisive canal N.Block Technique Cont.Direction of needle insertion The needle is inserted into the crest of the incisive papilla From between the upper centrals making an angle of 45 degrees to the palatal mucosa ELHAWARY

73. Maxillary Anesthetic Techniques Steps for incisive canal N.Block Technique Cont.1. Ask patient to open wide2. A labioginigval crest injection is made to anesthetize the incisive papilla first3. The needle is oriented parallel with the labial alveolar plate with the needle directed towards the crest of the incisive papilla i.e. The needle approach is from between the upper centrals making an angle of 45 degrees to the palatal mucosa4. The needle is inserted into the crest of the incisive papilla for a distance of 4 mm5. Inject 0.3 ml of anesthetic solution ELHAWARY

74. Maxillary Anesthetic Techniques Confirming the Anesthesia Subjective findings Numbness of the anterior 1/3 of the palate Objective findings Probing does not lead to pain in the anterior 1/3 of palate ELHAWARY

75. Maxillary Anesthetic TechniquesMaxillary anesthetic TechniquesGREATER PALATINE NERVE BLOCK ELHAWARY

76. Maxillary Anesthetic TechniquesGreater Palatine N.Block Technique The aim of this technique is to block the greater palatine nerve as it comes out of its foramen Its foramen usually lies distal to the upper 2nd molar, but it can be more anterior Areas to be anesthetized: Palatal mucosa of the molars and premolars ELHAWARY

77. Maxillary Anesthetic TechniquesGreater Palatine N.Block Technique Cont. Patient position Dentist position Head , neck and trunk on the The operator will sit same straight line The back of the chair is tilted so from infront and to the that the patient is in a supine right position The occlusal plan of maxillary teeth near to the operators shoulder ELHAWARY

78. Maxillary Anesthetic TechniquesGreater Palatine N.Block Technique Cont. Needle: 25-27 gauge Short needle Syringe Non-Aspirating syringe ELHAWARY

79. Maxillary Anesthetic TechniquesGreater Palatine N.Block Technique Cont. The point of needle insertion The greater palatine foramen distal to the palatal aspect of the second molar ELHAWARY

80. Maxillary Anesthetic TechniquesGreater Palatine N.Block Technique Cont. Direction of needle insertion from the opposite side to which the injection is to be made The needle approaching the site of injection at right angle ELHAWARY

81. Maxillary Anesthetic Techniques Steps for Greater Palatine N.Block Technique Cont.1. Ask patient to open wide2. Palpate the position of the greater palatine foramen till you feel its depression3. Clean the tissue to be injected with sterile gauze4. Apply topical antiseptic followed by topical anesthetic5. A 27 gauge needle is inserted from the opposite side to which the injection is to be made with the needle approaching the site of injection at right angle The needle is advanced through soft tissue until bone is contacted6. About 0.5 ml of the anesthetic solution is deposited7. Withdraw syringe and recap needle8. Wait 2-3minutes before commencing dental procedure ELHAWARY

82. Maxillary Anesthetic Techniques Confirming the Anesthesia Subjective findings Numbness of the posterior 2/3 of the palate Objective findings Probing does not lead to pain ELHAWARY

83. Maxillary Anesthetic TechniquesMaxillary Anesthetic TechniquesTHANK YOU ELHAWARY