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Maxillary Nerve Block—A New Approach Using a Computer-Controlled Anesthetic Delivery System for Maxillary Sinus Elevation Procedure

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Maxillary Nerve Block—A New Approach Using a Computer-Controlled Anesthetic Delivery System for Maxillary Sinus Elevation Procedure Surgery Maxillary nerve block—A new approach using a computer-controlled anesthetic delivery system for maxillary sinus elevation procedure. A prospective study Devorah Schwartz-Arad, DMD, PhDVEran Dolev, DMD^/Wayne Williams. BDS, MChD^ Objective: The maxiilary (or second division) nerve block is an effective method cf achieving profound anesthesia of a hemimaxilla. This block can be used for procedures involving the maxillary sinus, including the maxillary sinus elevation procedure. Tfie purpose of this study was to evaluate a computer-controlled anesthetic delivery system (Wand) fcr maxillary nerve block injection to attain maxillary sinus anesthesia for sinus floor elevation procedure. Method and materials: The study population consisted of 61 iiealthy adult patients, ranging in age from 40 to 72 years (mean 45 years), who received 76 maxillary nerve blocks (17 having both right and left maxillary blocks) by means of the Wand system via the greater pala- tine nerve approach, for sinus ficor elevation procedure. Two patients |37o) were excluded from the study due to the inability to negotiate the greater palatine foramen. For each block, two cartridges of 2% lido- caine hydrochloride with adrenaline (1:100,000) were administered, using a 27-gauge-long needle. After ensuring the anesthetized areas (waiting time 2.5 minutes), the sinus elevation procedure was performed. Parameters recorded were the success cr failure cf anesthesia, positive (blocd) aspiration, bony obstruc- tions in the greater palatine canal, and complications. Results: The use cf this technique increased tde ability to more easily locate the greater palatine foramen. A local infiltration (at the incisor region) was needed in 13 (17%) of the blocks, and seven (9.2%) sites required an extra infracrtital block injection in addition to the maxillary nerve block. One block had a positive aspiration. There were nc bony obstructions demonstrated in the canal interfering with the injection, and no complications were recorded. Conclusion: The Wand appears to offer a number of advantages over the hand-held syringe when the greater paiatine block technique for the maxillary nerve block is used. It is suggested that, when indicated, and with the re- quired knowledge and respect for the associated anatomy, this technique should be considered with greater ease and more confidence. (Quintessence Int 2004:35:477-480) Key words: comptJter-controlled anesthetic delivery system, hemimaxilla, maxillary nerve block he maxiüaty nerve block (MNB) is an effective greater palatine canal (GPC) and the high tubcrosity Tmethod of achieving profound anesthesia of a approach (HT). The major difficulty encountered with hemimaxilla. It is useful in procedures involving quad- use of the respective techniques is locating the canal rant dentistry or in extensive maxillary surgical proce- for the GPC technique and the higher incidence of dures. One of two approaches is available to gain ac- hematoma for the HT.' Few studies on the MNB have cess to the terminal point for anesthetic delivery-the been published in recent literature. The technique is seldom used for dental procedures in the ofGce, and when used, it is conducted with extreme caution. 'Lecturer and Coordinator, Department of Orai and MaxiiiDfaciai Surgery, Before attempting this block, the operator should de- The Maurice and Gabriela Goldschleger School of Oental Medicine, Tel velop sufficient confidence and cooperation from the Aviv Universily, Tel Aviv, Israei. patient. A sudden movement from the patient due to Clinical Instructor, Department cf Prcsttietic Dentistry, TTie Maurice ard painful stimulus could compromise the safety of the Gabriela Goldscfiieger School ot Dental Medicine, Tel Aviv University, Tei technique or lead to unwanted complications,^ Aviv, Israel, The ahility to better predict and easily anesthetize 'Session Appointments, Department of Restorative Oentlstry, university of Pretoria, Pretoria, South Africa: and Clinical Director, Milestone Scientific the maxillary netre and its branches with a single in- Inc, Livingstone, New Jersey. jection could make it possible to perform surgical pro- Heprint requests: Dr Devorati Schwartz-Arad, Department of Oral and cedures, such as maxillary sinus elevation for dentai Maxillofaciai Surgery, The Maurice and Gabriela Goldsohieger School of implants in the posterior maxilla, as routine proce- Dental Medicine, Tel Aviv University, Tei Aviv, Israel. E-maii: dubisfi© dures in the private clinic. post.taL.ao.il Quintessence International 477 • Schwartz-Ar ad et al Fig 1 (lefl) Greater palatine foramen: A palatal view of a dry skull Fig 2 (below) Palatal view of the ma«illary nerve blook througli the greater palatine foramen approach using the compuler-as- sisted anesthetic delivery system. Note the blood spot on Ihe con- tralateral side immediately after injection. The use oí a computer-controlled anesthetic deliv- onds was perfortned immediately after ensuring that ery system for maxillary sinus elevation procedure via the needle was located in the GPC at the terminal the GPC approach is described. needle position. After injecting the first cartridge (1.8 mL), a second cartridge was inserted into the machine without re- PARTICIPANTS AND METHODS moving the needle from its position in the GPC. The device should be located at head level or beneath to The study was conducted in a private clinic using a ensure that air does not penetrate into the delivery comptiter-controlled device {Wand, Milestone system. Lidocaine hydrochloride {HCI) (2%) with epi- Scientific) by a senior oral and maxillofacial surgeon. nephrine (1:100,000) as a vasoconstrictor {Lidocadren Since October 1999, 61 aduU healthy patients, ranging 2%, TEVA Pharmaceutical) was administered for each in age from 40 to 72 years {mean 45 years) received 76 block using a total injection volume of 2.1 cartridges maxillary nerve blocks (17 had both right and left {range 2 to 5). A 27-gaugc, 1 'A-inch-long (30 mm) maxillary blocks) by means of the Wand, a computer- needle was used (Becton Dickinson). controlled anesthetic delivery system, via the GPC ap- Successful anesthesia was considered to be present proach. Two patients (3%) were excluded from the when the entire hemimaxilla was anesthetizeti. After study due to an inability to negotiate the greater pala- ensuring that the indicated areas for surgery were ade- tine foramen. Indication for using regional maxillary quately anesthetized (average waiting time 2.5 min- nerve anesthesia was to perform sinus floor elevation utes), the sinus elevation procedure was performed. procedures (on one or both sides). Parameters recorded were the success or failure of A detailed technique for maxillary block injection anesthesia, positive (blood) aspiration, bony obstruc- via the greater palatine foramen has been previously tions in the greater palatine canal, and complications. described.' Briefly, the palatal soft tissue, directly over the greater palatine foramen {GPF), is the area of insertion. A landmark for the GPF is the junction RESULTS of the maxillary alveolar process and palatine hone (Fig 1). The needle is oriented toward the palatal soft The success of anesthesia administration was exam- tissues (Fig 2). Immediately prior to the bevel con- ined by probing the gingival buccal aspect of the hemi- tacting the soft tissue, the foot switch is activated to maxilla on the same side as the injection. Of the 76 the slow ñow-rate position to ensure a positive flow MNB, 13 (17%) required an additional local infiltra- of anesthetic at the moment the needle penetrates the tion of the anterior superior alveolar nerve, ana in tissue. During needle insertion (approximately three seven blocks {9.2%), an additional infraorbital nerve fourths of its length), continuous, controlled, positive block was delivered. Positive (blood) aspiration was pressure delivers an anesthetic drip that precedes the recorded in one block (Fig 3). There were no bony ob- needle, creating an anesthetic pathway without the structions in the canal interfering with the needle use of a topical anesthetic. Auto-aspiration (simple pathway, and no complications were observed or re- removal of the foot from the foot pedal) set at 12 sec- ported during or after injection. 478 Volume 35, Number 6. 2004 • Schwartz-Arad et ai Hg 3 Positive blood aspiration. Fig 4 The Wand tiandpiece, rnicrotube, and cartridge tiolder. DISCUSSION should be used, with a minimal waiting time of 2.5 minutes hefore beginning the procedure. The maxillary nerve block compared to infiltration The computerized delivery system aflows an empty anesthesia provides a greater scope for surgery by cartridge to he replaced outside of the oral cavity with- anesthetizing the hemimaxilla with one needle pene- out having to withdraw and reinsert the needle during tration (injection site). Patients accept this approach injection. In this way, the two recommended cartridges better than a technique that requires several in- can be delivered by a single penetration, thus, signifl- jections.5 A common problem encountered with the cantly decreasing potential complications. In addition, use of the MNB technique is the inability to obtain there is no need for cartridge sterilization when using profound anesthesia, which is frequently caused by this system because cartridge replacement is via an ex- the operator's inability to flnd the greater palatine traoral manipulation of the cartridge holder at a point foramen,^ far removed from the handpiece and needle. The
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