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Physiologic Factors for Dental Anesthesia Injections

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Physiologic Factors for Dental Anesthesia Injections ARE YOU NUMB YET? THE ANATOMY OF LOCAL ANESTHESIA PART 2: TECHNIQUES PHYSIOLOGIC FACTORS FOR DENTAL ANESTHESIA Alan W. Budenz, MS, DDS, MBA INJECTIONS Dept. of Biomedical Sciences and Vice Chair of Diagnostic Sciences & Services, Dept. of Dental Practice University of the Pacific, Arthur A. Dugoni School of Dentistry San Francisco, California Success versus Failure [email protected] Failed Anesthetic: Measuring the Problem Physiology of Anesthetic Agents One of every three patients is not properly numb when the dentist or hygienist is ready to start (or actually starts) a dental procedure. How do we assess anesthesia? Is this “failed anesthetic”? 60% Question the patient Soft tissue only 50% * Probe the area 46% Average 40% 42% 41% Failure 38% Rate is Cold test 30% 29% Pulpal tissue 31% Electric pulp tester 20% 19% 20% 17% 15% How is anesthetic success defined in studies? 10% Frequency Frequency Anesthetic Failedof Ideal: 2 consecutive 80/80 readings with EPT within 15 0% IAN Blocks - 15 min. after injection Maxillary infiltrations - 10 min. after injection minutes of injection (and sustained for 60 mins) Delayed pulpal onset: occurs in the mandible of 19 – 27% Slide courtesy Dr. Mic Falkel of patients (even though soft tissue is numb) Delayed over 30 minutes in 8% Nusstein J et al. The challenges of successful * Average failure rate reported across 38 published studies mandibular anesthesia, Inside Dentistry, May 2008 Physiology of Anesthetic Agents Blocks versus Infiltrations Onset of anesthesia: Advantages of infiltrations 1. Dependent upon anesthetic agent 1. Faster onset Concentration 2. Diffusion to the site Simple Lipid solubility 3. Safe Protein binding to receptor sites 4. Good hemostasis (with vasoconstrictor) 2. Dependent upon technique, block versus infiltration Disadvantages of infiltrations Infiltration has faster onset 1. Multiple injections for multiple teeth Block has longer duration 2. Shorter duration of anesthesia 1 Blocks versus Infiltrations Blocks versus Infiltrations Duration of pulpal anesthesia: Dental anesthetic agents: all amides Infiltration Injections 70 2% Lidocaine plain 1. Lidocaine – plain or with vasoconstrictor 60 4% Prilocaine plain 2. Mepivacaine – plain or with vasoconstrictor 50 3% Mepivacaine plain 3. Prilocaine – plain or with vasoconstrictor 2% Lidocaine w/ vaso 4. Articaine – with vasoconstrictor Minutes 40 2% Mepivacaine w/ vaso 5. Bupivacaine – with vasoconstrictor 30 4% Prilocaine w/ vaso 20 4% Articaine w/ vaso 10 0.5% Bupivacaine 0 Manufacturer’s Product Inserts; Malamed, Handbook of Local Anesthesia, 5th Ed, Elsevier, 2004; Jastak, Yagiela, Donaldson, Local Anesthesia of the Oral Cavity, WB Saunders Co, 1995 Blocks versus Infiltrations Duration of pulpal anesthesia: Blocks versus Infiltrations Duration of anesthesia:and onset: Infiltration Block Injection 1. Dependent upon anesthetic agent 70 300 2% Lidocaine plain Concentration 60 250 4% Prilocaine plain DiffusionDiffusion fromto/from the thesite site 50 3% Mepivacaine plain 200 Lipid solubility 40 2% Lidocaine w/ vaso Protein binding to receptor sites 150 2% Mepivacaine w/ vaso 30 2. Dependent upon technique, block versus 100 4% Prilocaine w/ vaso 20 infiltration 4% Articaine w/ vaso 10 50 0.5% Bupivacaine 3. Dependent upon vasoconstrictor presence, but 0 0 NOT vasoconstrictor concentration* Manufacturer’s Product Inserts; Malamed, Handbook of Local Anesthesia, 5th Ed, Elsevier, 2004; *Malamed, Handbook of Local Anesthesia, 5th Ed, Elsevier, 2004 Jastak, Yagiela, Donaldson, Local Anesthesia of the Oral Cavity, WB Saunders Co, 1995 Physiology of Anesthetic Agents Physiology of Anesthetic Agents 1. Overall diameter (size) of the nerve bundle 3. Critical length = 3 nodes minimum (5 mm) 2. Amount of myelin (lipid) sheath present Anesthetic volume, tissue space & density Time for entire nerve bundle to be penetrated Central Core Theory: Peripheral fibers anesthetized first To most proximal structures (molars) Central fibers anesthetized last To most distal structures (incisors) DeJong RH, Physiology and Pharmacology Node of Ranvier Critical length of Local Anesthesia, 1970 Jastak, Yagiela, Donaldson, Local Anesthesia of Evers & Haegerstam, Introduction to Dental the Oral Cavity, WB Saunders Co, 1995 Local Anesthesia, Mediglobe, 1990 2 Physiology of Anesthetic Agents Reasons for Anesthetic Failures The “right” volume depends on many 1. Anatomical/physiological variations variables For infiltration injections, ½ to ¾ cartridge is 2. Technical errors of administration generally ideal 3. Patient anxiety Brunetto et al, Anesthetic efficacy of 3 volumes of lidocaine with epinephrine in maxillary infiltration anesthesia, Anesth Prog 55, 2008 4. Inflammation and infection For an inferior alveolar nerve block, 5. Defective/expired solutions Less than ½ cartridge tends to be ineffective ¾ – 1 cartridge is ideal Nusstein et al, Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocks, Gen Dent 50, 2002 Wong MKS & Jacobsen PL, Reasons for local anesthesia failures, JADA Vol 123, Jan 1992 Reasons for Anesthetic Failures Reasons for Anesthetic Failures 1. Anatomical/physiological 2. Technical errors of administration variations Too high Wide flaring mandible Too low Wide flaring ramus Too anterior Long (A - P) ramus Too posterior Bulky musculature Too medial Large buccal fat pad Too lateral Class III occlusion Missing teeth Intravascular Children Accessory or anomalous nerve pathways Reasons for Anesthetic Failures 1. Anatomical/physiological variations REVIEW OF ANATOMY 2. Technical errors of administration These two are General Anatomy and Landmarks for closely related: Mandibular Anesthesia We will solve by reviewing the anatomy and landmarks McMinn, Hutchings & Logan, Color Atlas of Head & Neck Anatomy, 2nd Ed, Mosby, 1994 3 The Masticator Space The Masticator Space Includes the Temporal and Infratemporal Fossae The Infratemporal Fossa Boundaries: A = Maxillary tuberosity P = Styloid process M = Lateral pterygoid plate L = Ramus of mandible Agur & Lee, Grant’s Atlas of Anatomy, 10th Ed, Liebgott, The Anatomical Basis of Dentistry, 2nd Ed, Mosby, 2001 Lippincott Williams & Wilkins, 1999 Liebgott, The Anatomical Basis of Dentistry, 2nd Ed, Mosby, 2001 Infratemporal Fossa The Masticator Space Contents Muscles of mastication Medial Lateral Mandibular division of A Fascial Compartment: Trigeminal nerve, V 3 Derived from investing Chorda tympani layer of deep cervical branch of Facial nerve fascia Maxillary artery and vein Envelopes mandible and muscles of mastication Agur & Lee, Grant’s Atlas of Anatomy, 10th Ed, Lippincott Williams & Wilkins, 1999 Hollinshead, Anatomy for Surgeons, Vol 1, The Head & Neck, 3rd Ed, Harper & Row, 1982 The Muscles of Mastication The Muscles of Mastication Four total: 2 superficial Four total: 2 superficial 1. Temporalis 1. Temporalis 2. Masseter Liebgott, The Anatomical Basis of Dentistry, 2nd Ed, Mosby, 2001 Liebgott, The Anatomical Basis of Dentistry, 2nd Ed, Mosby, 2001 4 The Muscles of Mastication The Muscles of Mastication Four total: 2 superficial; 2 deep Four total: 2 superficial; 2 deep 1. Temporalis 1. Temporalis 2. Masseter 2. Masseter 3. Medial 3. Medial pterygoid pterygoid 4. Lateral pterygoid Liebgott, The Anatomical Basis of Dentistry, 2nd Ed, Mosby, 2001 Liebgott, The Anatomical Basis of Dentistry, 2nd Ed, Mosby, 2001 Accessory Muscles of Mastication: Innervation of the Muscles of Facial Expression Infratemporal Fossa Oral musculature Levator labii superioris V3 Mandibular Levator anguli oris Division of the Zygomaticus major Trigeminal Nerve Buccinator Risorius The nerve of the first branchial arch, which gives origin to the Mentalis maxillary & mandibular arches Depressor anguli oris and the muscles of mastication Depressor labii inferioris Orbicularis oris Platysma Agur, Grant’s Atlas of Anatomy, 9th Ed, Netter, Atlas of Human Anatomy, 2nd Ed, Novartis, 1997 Lippincott Williams & Wilkins, 1991 V : Short stem, then splits into V : Sensory & Motor Innervation 3 3 2 divisions Stem: Motor to the 1. Medial Muscles of pterygoid nerve Mastication 2. Tensor tympani nerve Sensory to all teeth 3. Tensor and oral tissues palatini nerve 4. Meningeal Enters through the branch Foramen Ovale Agur & Lee, Grant’s Atlas of Anatomy, 10th Ed, Agur & Lee, Grant’s Atlas of Anatomy, 10th Ed, Lippincott Williams & Wilkins, 1999 Lippincott Williams & Wilkins, 1999 5 V3: Anterior division V3: Posterior division Motor branches: Sensory branches: 1. Deep temporal 1. Auriculotemporal nerves (2) nerve 2. Masseteric nerve 2. Lingual nerve 3. Lateral pterygoid 3. Inferior alveolar nerve nerve - mylohyoid One sensory branch: - mental Long Buccal nerve - incisive All sensory except Fehrenbach & Herring, Illustrated Anatomy Lateral View of the Head & Neck, WB Saunders Co, 1996 Mylohyoid nerve Fehrenbach & Herring, Illustrated Anatomy of the Head & Neck, WB Saunders Co, 1996 Additional Innervation in the V : Posterior division 3 Infratemporal Fossa Sensory branches: 1. Auriculotemporal Chorda tympani: nerve • Branch of CN VII • Carries taste fibers 2. Lingual nerve from anterior tongue 3. Inferior alveolar nerve • Secretomotor fibers to - mylohyoid salivary glands - mental - incisive Joins lingual nerve of All sensory except V3 in ITF Fehrenbach & Herring, Illustrated Anatomy mylohyoid nerve Fehrenbach & Herring, Illustrated Anatomy of the Head & Neck, WB Saunders Co, 1996 Medial View of the Head & Neck, WB Saunders Co, 1996 Medial
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