1. LECTURE 2 Local anesthesia. Indications and contraindications
LECTURE 2 Local anesthesia. Indications and contraindications. Technique. Complications of local anesthesia, their treatment and prophylaxis. Removal of the teeth: instruments, indications and contraindications, patient preparation, complications during tooth extraction and in the postoperative period, their treatment and prophylaxis.

2. Local Anesthesia Local infiltration Nerve block
type of injection that anesthetizes a small area (one or two teeth and asscociated areas)
anesthesia deposited at nerve terminals
Nerve block
type of injection that anesthetizes a larger area
anesthesia deposited near larger nerve trunks

3. Local anaesthesia Methods: Reducing temperature.
Is used only to produce surface anaesthesia e.g. ethyl chloride spray.
Physical damage to nerve trunk e.g. nerve sectioning.
Unsafe for therapeutic uses, only in Trigeminal Neuralgia.
Chemical damage to nerve trunk e.g. neurolytic agents.
Silver nitrate, Phenol - Unsafe for therapeutic use.

4. Local anaesthesia Methods: Cont
Anoxia or hypoxia resulting in lack of oxygen to nerve.
Unsafe as well.
Stimulation of large nerve fibres, blocking the perception of smaller diameter fibres.
includes Acupuncture and TENS (Transcutaneous Electronic Nerve Stimulation)
Drugs that block transmission at sensory nerve endings or along nerve fibres.
There action is fully reversible and without permanent damage to the tissues.

5. Classification:
Classified according to their chemical structures and the determining factor is the intermediate chain, into two groups:
Ester Amide
They differ in two important respect:
Their ability to induce hypersensitivity reaction.
Their pharmacokinetics - fate and metabolism.

7. Types of Nerve Anesthesia
Maxillary
posterior superior alveolar block
middle superior alveolar block
anterior superior alveolar block
greater palatine block
infraorbital block
nasopalatine block
Mandibular
inferior alveolar block
buccal block
mental block
incisive block
Gow-Gates mandibular nerve block

8. Considerations
dental procedures can usually commence after 3 – 5 minutes
failure requires re-administration using another method
never re-administer using the same method
keep in mind the total # of injections and the dosages
never inject into an area with an abcess, or other type of abnormality

9. Maxillary Nerve Anesthesia
Chart 9-1
pulpal anesthesia: through anesthesia of each nerve’s dental branches as they extend into the pulp tissue (via the apical foramen)
periodontal: through the interdental and interradicular branches
palatal: soft and hard tissues of the palatal periodontium (e.g. gingiva, periodontal ligaments, alveolar bone)
PSA block: recommended for maxillary molar teeth and associated buccal tissues in ONE quadrant
MSA block: recommended for maxillary premolars and associated buccal tissues
ASA block: recommended for maxillary canine and the incisors in ONE quadrant
greater palatine block: recommended for palatal tissues distal to the maxillary canine in ONE quadrant
nasopalatine block: recommended for palatal tissues between the right and left maxillary canines

10. PSA Nerve Block figures 9-2 through 9-7
pulpal anesthesia of the maxillary 3rd, 2nd and 1st molars
required for procedures involving two or more molars
sometimes anesthesia of the 1st molar also required block of the MSA nerve
associated buccal periodonteum overlying these molars
including the associated buccal gingiva, periodontal ligament and alveolar bone
useful for periodontal work on this area

11. PSA Nerve Block target: PSA nerve
as it enters the maxillar through the PSA foramen on the maxilla’s infratemporal service – Figure 9-2 & 9-3
into the tissues of the mucobuccal fold at the apex of the 2nd maxillary molar (figures 9-4 and 9-5)
mandible is extended toward the side of the injection, pull the tissues at the injection site until taut
needle is inserted distal and medial to the tooth and maxilla
depth varies from 10 to 16 mm depending on age of patient
no overt symptoms (e.g. no lip or tongue involvement)
can damage the pterygoid plexus and maxillary artery

12. MSA Nerve Block limited clinical usefulness
can be used to extend the infraorbital block distal to the maxillary canine
can be indicated for work on maxillary pre-molars and mesiobuccal root of 1st molar (Figure 9-8)
if the MSA is absent – area is innervated by the ASA
blocks the pulp tissue of the 1st and 2nd maxillary premolars and possibly the 1st molar + associated buccal tissues and alveolar bone
useful for periodontal work in this area
to block the palatine tissues in this area – may require a greater palatine block

13. MSA Block
target area: MSA nerve at the apex of the maxillary 2nd premolar (figures 9-8 and 9-9)
mandible extended towards injection site
stretch the upper lip to tighten the injection site
needle is inserted into the mucobuccal fold
tip is located well above the apex of the 2nd premolar
figure 9-11
harmless tingling or numbness of the upper lip
overinsertion is rare

14. ASA Block figures 9-12 through 9-14
can be considered a local infiltration
used in conjunction with an MSA block
the ASA nerve can cross the midline of the maxilla onto the opposite side!
used in procedures involving the maxillary canines and incisors and their associated facial tissues
pulpal and facial tissues involved – restorative and periodontal work
blocks the pulp tissue + the gingiva, periodontal ligaments and alveolar bone in that area

15. ASA Block
target: ASA nerve at the apex of the maxillary canine – figures 9-12 & 9-13
at the mucobuccal fold at the apex of the maxillary canine – figure 9-13
harmless tingling or numbness of the upper lip
overinsertion is rare

16. Infraorbital Nerve Block
figures 9-15 through 9-17
anesthetizes both the MSA and ASA
used for anesthesia of the maxillary premolars, canine and incisors
indicated when more than one premolar or anterior teeth
pulpal tissues – for restorative work
facial tissues – for periodontal work
also numbs the gingiva, periodontal ligaments and alveolar bone in that area
the maxillary central incisor may also be innervated by the nasopalatine nerve branches

17. IO Block
target: union of the ASA and MSA with the IO nerve after the IO enters the IO foramen – figure 9-15
also anesthesizes the lower eyelid, side of nose and upper lip
IO foramen is gently palpated along the IO rim
move slightly down about 10mm until you feel the depression of the IO foramen – figure 9-16
locate the tissues at the mucobuccal fold at the apex of the 1st premolar
place one finger at the IO foramen and the other on the injection site – figure 9-17
locate the IO foramen, retract the upper lip and pull the tissues taut
the needle is inserted parallel to the long axis of the tooth to avoid hitting the bone
harmless tingling or numbness of the upper lip, side of nose and eyelid

18. Greater Palatine Block
figures 9-19 through 9-21
used in restorative procedures that involve more than two maxillary posterior teeth or palatal tissues distal to the canine
also used in periodontal work – since it blocks the associated lingual tissues
anesthetizes the posterior portion of the hard palate – from the 1st premolar to the molars and medially to the palate midline
does NOT provide pulpal anesthesia – may also need to use ASA, PSA, MSA or IO blocks
may also need to be combined with nasopalatine block

19. Greater Palatine Block
target: GP nerve as it enters the GP foramen
located at the junction of the maxillary alveolar process and the hard palate – at the maxillary 2nd or 3rd molar – figure 9-19
palpate the GP foramen – midway between the median palatine raphe and lingual gingival margin of the molar tooth – figure 9-21
can reduce discomfort by applying pressure to the site before and during the injection
produces a dull ache to block pain impulses
also slow deposition of anesthesia will also help
needle is inserted at a 90 degree angle to the palate – figure 9-22

20. Nasopalatine Block figure 9-23 through 9-26
useful for anesthesia of the bilateral portion of the hard palate
from the mesial of the right maxillary 1st premolar to the mesial of the left 1st premolar
for palatal soft tissue anesthesia
periodontal treatment
required for two or more anterior maxillary teeth
for restorative procedures or extraction of the anterior maxillary teeth – may need an ASA or MSA block also
blocks both right and left nerves

21. Nasopalatine Block
target: both right and left nerves as they enter the incisive foramen from the mucosa of the anterior hard palate – figure 9-23 & 9-25
posterior to the incisive papilla
injection site is lateral to the incisive papilla – figure 9-26
head turned to the left or right
inserted at a 45 degree angle about 6-10 mm – gently contact the maxillary bone and withdraw about 1mm before administering
can reduce discomfort by applying pressure to the site before and during the injection
produces a dull ache to block pain impulses
also slow deposition of anesthesia will also help
can anesthetize the labial tissues between the central incisors prior to palatal block
can block some branches of the nasopalatine prior to injection

22. Mandibular Blocks Chart 9-2
infiltration is not as successful as maxillary anesthesia
substantial variability in the anatomy of landmarks when compared to the maxilla
pulpal anesthesia: block of each nerve’s dental branches
periodontal: through the interdental and interradicular branches
Inferior Alveolar block: for mandibular teeth + associated lingual tissues and for the facial tissues anterior to the mandibular 1st molar
Buccal block: tissues buccal to the mandibular molars
Mental block: facial tissues anterior to the mental foramen (mandibular premolars and anterior teeth)
Incisive block: for teeth and facial tissue anterior to the mental foramen
Gow-Gates: most of the mandibular nerve
for quadrant dentistry

23. Inferior Alveolar Block
also called the mandibular block
most commonly used in dentistry
for restorative, extraction and periodontal work
pulpal anesthesia for extractions and restorative
lingual periodonteal anesthesia
facial periodonteal anesthesia of anterior mandibular teeth and premolars
may be combined with the buccal block
can overlap with the incisive block
local infiltrations in the anterior area are more successful than posterior injections
variability in the location of the mandibular foramen on the ramus can lessen the success of this injection
usually avoid bi-lateral injections since they will completely anesthetize the entire tongue and can affect swallowing and speech

24. IA Block
target: slightly superior to the mandibular foramen – figure 9-27
the medial border of the ramus
will also anesthetize the adjacent anterior lingual nerve – figure 9-30
injection site is found using hard landmarks
palpate the coronoid notch – above the 3rd molar
imagine a horizontal line from the coronoid notch to the pterygomandibular fold which covers the pterygomandibular raphe – figure 9-32
this fold becomes more prominent as the patient opens their mouth wider
refer to video notes
figure 9-33
needle is inserted into the pterygomandibular space until the mandible is felt – retract about 1 mm
average depth: 20-25mm
diffusion of anesthesia will affect the lingual nerve

25. IA block
symptoms: harmless tingling and numbness of the lower lip due to block of the mental nerve
tingling and numbness of the body of the tongue and floor of mouth – lingual nerve involvement
complications:
failure to penetrate enough can numb the tongue but not block sufficiently
lingual shock – involuntary movement as the needle passes the lingual nerve
transient facial paralysis – facial nerve involvement if inserted into the deeper parotid gland – figure 9-34
inability to close the eye and drooping of the lips on the affected side
hematoma can occur
some muscle soreness
patient-inflicted trauma – lip biting etc...

26. Buccal Block figures 9-36 and 9-37
for buccal periodonteum of mandibular molars, gingiva, periodontal ligament and alveolar bone
for restorative and periodontal work
buccal nerve is readily located on the surface of the tissue and not within bone

27. Buccal block
target: buccal nerve as it passes over the anterior border of the ramus through the buccinator – figure 9-36
injection site is the buccal tissues distal and buccal to the most distal molar – on the anterior border of the ramus as it meets the body – figure 9-37
pull the buccal tissue tight and advance the needle until you feel bone – only about 1 to 2mm
figure 9-38
patient-inflicted trauma – lip biting etc...

28. Mental Block figures 9-39 through 9-41
for facial periodonteum of mandibular premolars and anterior teeth on one side
for restorative work – incisive block should be considered instead

29. Mental Block
target site: mental nerve before it enters the mental foramen where it joins with the incisive nerve to form the IA nerve – figure 9-39
palpate the foramen between the apices of the 1st and 2nd premolars
palpate it intraorally – find the mucobuccal fold between the apices of the 1st and 2nd premolars – figure 9-42
in adults, the foramen faces posterosuperiorly
may be anterior or posterior
can be found using radiographs
insertion site is the mucobuccal fold tissue directly over or slight anterior to the foramen site
avoid contact with the mandible with the needle
depth is 5 to 6mm
no need to enter the foramen

30. Incisive Block
for pulp and facial tissues of the teeth anterior to the mental foramen
same as the mental block except pulpal anesthesia is provided also
restorative and periodontal work
IA block indicated for extractions – no lingual anesthesia with an incisive block
target: mental foramen – figure 9-43

31. Incisive Block injection site: figure 9-44
same as for the mental block
directly over or anterior to the mental foramen
in the mucobuccal fold at the apices of the 1st and 2nd premolars
pull the buccal tissues laterally
more anesthesia is used for this block when compared to the mental block
pressure is applied during the injection – forces for anesthetic solution into the foramen and block the deeper incisive nerve
the increased injection solution may balloon the facial tissues

32. Gow-Gates figures 9-45 through 9-50
blocks the IA, mental, incisive, lingual, mylohyoid, auriculotemporal and buccal nerves – figure 9-28 and 9-45
used for quadrant dentistry
buccal and lingual soft tissue from most distal molar to the midline
greater success than an IA block

33. Gow-Gates
target site: anteromedial border of the mandibular condylar neck – figure 9-46
just inferior to the insertion of the lateral pterygoid muscle
injection site is intraoral
locate the intertragic notch and labial commisure extraorally
draw a line from the tragus/intertragic notch to the labial commisure – figure 9-47
place your thumb on the condyle (just in front of the tragus when the mouth is open)
pull buccal tissue away
place the needle inferior to the mesiolingual cusp of the MAXILLARY 2nd molar
the needle penetrates distal to the maxillary 2nd molar
see the video

34. Indications and contra-indications to removal of permanent teeth.
Indications to planned tooth removal:
1.)Unsuccessfulness of endodonthyc treatment with presence of the chronic inflammation of periodontium and adjoining tissues of a bone. This intervention is especially indicated in case of chronic intoxications of the patient with odontogenic intoxication centres (chroniosepsis)
2.) Impossibility of conservative treatment through considerable crown destruction or the technical obstacles connected with anatomic features, treatment errors, caused by root perforation.

35. 3.) Total destruction of crown part of the tooth, impossibility of using the root for tooth prosthetics.
4.) Mobility of ІІІ degree and tooth promotions as a result of resorption of bone round a cell with presence of heavy forms of a periodontosis and parodontitis.
5.) Atypically placed teeth which injure a mouth mucous membrane, tongue, and which can't be treated by ortodonthic treatment.
6.) Unteethed in time or partially teethed teeth which predetermine inflammatory processes in adjoining tissues, which cannot be liquidated some other way.

36. 7.) Placed in crisis cracks, teeth do impossible reposition of fragments and can't be treated by conservative treatment.
8.) Outstanding as a result of loss of the antagonist teeth, teeth which convergence and divergence, disturb embarrass the process of manufacturing tooth prosthetics. treatment. For elimination of anomalies of a bite (occlusion) during the orthodontic treatment, intact teeth removal is also indicated.

37. Contra-indications. A number of inflammatory and local diseases, and also some physiologic conditions are contra-indications to this intervention. Removal of tooth at such patients can be done after preparation and treatment.

38. Relative contra-indications to operations of tooth removal are:
1.) Cardiovascular diseases (preinfarction conditions and 3-6 month after the infarction of a myocardium, hypertonic illness in crisis. IHD(ischemic heart disease), paroxysm, blinking arhythmia, paroxysmal tachycardia, acute septic endocarditis);
2.) Acute diseases of parenchymatosic organs - liver, kidneys, pancreas (an infectious hepatitis, (glomerunonephritis);
3.) Haemorragical diseases (a hemophilia, illness of Verlgof, agranulocytosis, acute leukemia);
4.) acute infectious diseases (a flu, ARVD(acute respiratoric virus disease), a pneumonia);

39. 5.) disease of CNS (central neuronic system), (acute disorder of encephal blood circulation, a meningitis);
6.) Mental (psychological) diseases in an aggravation period (a schizophrenia, a psychosis, an epilepsy);
7.) acute radiation sickness І - ІІІ degrees;
8.) disease of a mucous membrane of a mouth (a stomatitis, gingivitis, cheilitis).

40. Preparation of tooth removal:
-Inspection.
-Preparation of the patient.
-Preparation of doctor’s hands.
-Preparation of the operation field.

41. Technique of tooth removal:
Tooth removal consists in violent rupture of tissues which connect root with walls of a cell and gums, and its deducing from a cell. During removal of the distorted roots from a cell, its walls are being replaced and the entrance to it extends. Tooth removal is being made by special tools, forceps and elevators. In certain cases tooth extraction by using this tool is impossible. Then a drill for bone removal is used. (operation of root cutting)

42. Forceps and elevetaors for teeth removal:
Forceps. Under the process teeth removal a lever principle is used. Forceps consists of: cheeks, handles and the lock. In some kind’s of forceps between cheeks and the lock there is a transitive part. Cheeks are used to cover the root or a crown. The handle – a part which is used to hold the forceps. The lock is placed between the handle and a cheek.
For the best fixing of tooth or a root, cheeks have fillets with longitudinal cutting from the inside. The external surface of handles on significant length is relief, internal - smooth. The form of forceps is not the same. Construction depends on anatomical structure of the tooth and it’s place in row of teeth.

43. Forceps for maxilla

44. Forceps for the root’s of maxillar teeth

45. Forceps for mandibula

46. Structure of the forceps, about the surface

47. Types of correct forceps handling

48. Luxation and rotation during teeth removal

49. Correct and incorrect forceps positions

56. Types of elevators:

57. Lekljuz elevator

58. Types of elevators:

59. Stages of operation of removal of tooth:
Operations of removal of tooth,are being led by forceps, also consists of several serial stages:
1.) Superimposing of forceps
2.) Advancement of forceps
3.) Interlocking of forceps (fixing)
4.) A tooth Dislocation (luxation or tooth rotation)
5.) Deduction of tooth from a cell (traction)

61. Complication, that can occur during, and after tooth exraction.
Root crisis can be prevented by using the method of section and separation of gums, with the following chisel debridement of cell wall, to one third of length, and also by using forceps for root extraction.
Damage of soft tissues, occurs during careless, rough manipulations of physician, disorder of tooth extraction technique.
When insufficient gums dislayering, before tooth extraction, rupture of mucous membrane often occurs during operation;
In case of wrong tooth extraction technique, when a doctor imposes forceps directly on a mucous membrane, dislayered it not enough from the cell process, or a part.
In case of careless dislocating of roots, by direct elevator, tissue damage of the bottom of oral cavity, tongue(when removing the roots of lower molars) and palate(when removing the roots of upper molars) occurs.

62. On a background of the damage of soft tissues, bleeding occurs, which complicates the work of a doctor, while tooth extracting; In postoperative period, inflammatory complications can occur.
A technique of granting of the urgent help: a stop of a bleeding and suturing the wound.

63. a fragment break of cell parts (more often on the bottom jaw) - damage of tisses arises:
- Under condition of an union of a tooth root with cell walls;
- In case of deep imposing cheeks of nippers on cell walls - thus tooth removes together with a bone tissues.
Technique of granting the urgent medical aid: to smooth down (if necessary - to remove) sharp, unequal edges of a cell of tooth, to suture a mucous membrane.
Break of a tuber of the top jaw arises during removal of the third top molar, as a result of deep imposing forceps cheeks on walls of a cell, or a rough dislocation of tooth by straight elevator:
In such case, there is a broken off fragment of a tuber of the top jaw on extracted tooth (roots)
-a considerable bleeding occurs;
-If the maxillar sinus is damaged, vials of air from the extracted tooth cell occure during attempt to blow air through closed with fingers nose.
The technique of granting urgent help: smoot keen edges of tooth cell by bone spoon, mobilize and suture tightly a mucous membranem so that a bone wound would be completely closed. If the stomatologist cannot independently stop a bleeding, and suture a wound, he put iodoform tampon and transport’s the patient immediately in a surgical stomatologic department.

64. Perforation of the bottom of maxillar sinus arises during removal of the first top molar, sometimes - the second and premolar.
It is explained, that tops of the given teeth are closely located to the bottom of sinus.
Perforation of the bottom of maxillar sinus can occur, when:
- Traumatic removal of the named teeth (if rough manipulation in a tooth cell is done), and during careless manipulations;
- Owing to anatomic features, when the root is located under a sinus mucous membrane;
- When inflammatory process on a top of a root has destroyed a sinus bottom.
Diagnostics:
During careful tubage of a cell, the instrument gets for the length more than the deepnes of the cell.
On the basis of passage of the air from the oral cavity, into a nasal cavity, ot contrary. The patient, having clamped fingers on his nose, should try to blow the air throughout it. Thus air through an aperture (perforation) of the bottom of maxillar sinus leaves it with a whistle and goes into oral cavity, or blood vials of air from a cell of extracted tooth occur;
Radiological research is conducted (an aim picture).

65. Technique of granting urgent medical aid in case of perforation of maxillar sinus:
- In the presence of a purulent antritis (pus is goin out from a tooth cell, through a perforated aperture) in entrance of cell iodoform tampon and hospitalization of the patient in maxillofacial deparment;
- In case of pushing a root through in a sinus, its removal in the conditions of a hospital is indicated;
- In case of a healthy sinus (when radiological research does not reveal a root in a sinus) it is necessary to close a perforated aperture (a cell of extracted tooth) by a mucosial rag, taken from a vestibular surface of cell process. If the doctor has not mastered this technique, he should tightly suture a cell (to Impose 2-3 seams of polyamides).

66. The bleeding arises after operation of removal of tooth
The bleeding arises after operation of removal of tooth. Distinguish early bleedings and late. Early bleedings, arise right after removals of tooth (trauma).
Late bleedings can arise:
1) In some hours after tooth removal, for example in case of adrenaline overdose.
2) For some days after operation which becomes complicated by an inflammatory process.

67. THANK YOU FOR ATTENTION