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Are You Numb Yet? ARE YOU NUMB YET? Patients rate “painless injections” as PROBLEM-SOLVING THE DELIVERY the most important criteria in evaluating OF LOCAL ANESTHESIA their dentist or dental hygienist de St Georges J, How dentists are judged by patients, Dentistry Today, Vol. 23, August 2004 Alan W. Budenz, MS, DDS, MBA Professor, Dept. of Biomedical Sciences and Interim Chair, Dept. of Diagnostic Sciences University of the Pacific, Arthur A. Dugoni School of Dentistry San Francisco, California 90% of all patients report being anxious [email protected] about going to the dentist or dental hygienist Friedman & Krochak, Using a precision-metered injection and receiving a shot. system to minimize dental injection anxiety, Compend Contin Educ Dent, Vol. 19(2), Feb 1998 Reasons for Anesthetic Failures Reasons for Anesthetic Failures 1. Anatomical/physiological 1. Anatomical/physiological variations variations 2. Technical errors of administration Wide flaring mandible Wide flaring ramus 3. Patient anxiety Long (A - P) ramus 4. Inflammation and infection Bulky musculature Large buccal fat pad 5. Defective/expired solutions Class III occlusion Missing teeth Children Wong MKS & Jacobsen PL, Reasons for local anesthesia failures, J Am Dent Assoc, Vol 123, Jan 1992 Accessory or anomalous nerve pathways Reasons for Anesthetic Failures Reasons for Anesthetic Failures 1. Anatomical/physiological 2. Technical errors of administration variations Too high Too low 2. Technical errors of Too anterior administration Too posterior These two are Too medial closely related: Too lateral We will solve by Intravascular reviewing the anatomy and landmarks McMinn, Hutchings & Logan, Color Atlas of Head & Neck Anatomy, 2nd Ed, Mosby, 1994 1 The Masticator Space REVIEW OF ANATOMY Includes the Temporal and Infratemporal Fossae General Anatomy and Landmarks for Mandibular Anesthesia Liebgott, The Anatomical Basis of Dentistry, 2nd Ed, Mosby, 2001 The Masticator Space Infratemporal Fossa The Infratemporal Fossa Boundaries: Contents A = Maxillary tuberosity Muscles of mastication P = Styloid process Mandibular division of M = Lateral pterygoid Trigeminal nerve, V plate 3 L = Ramus of mandible Chorda tympani branch of Facial nerve Maxillary artery and vein Agur & Lee, Grant’s Atlas of Anatomy, 10th Ed, Lippincott Williams & Wilkins, 1999 Agur & Lee, Grant’s Atlas of Anatomy, 10th Ed, Lippincott Williams & Wilkins, 1999 Liebgott, The Anatomical Basis of Dentistry, 2nd Ed, Mosby, 2001 The Masticator Space The Muscles of Mastication Four total: 2 superficial Medial Lateral A Fascial Compartment: 1. Temporalis Derived from investing layer of deep cervical fascia Envelopes mandible and muscles of mastication Hollinshead, Anatomy for Surgeons, Vol 1, The Head & Neck, 3rd Ed, Harper & Row, 1982 Liebgott, The Anatomical Basis of Dentistry, 2nd Ed, Mosby, 2001 2 The Muscles of Mastication The Muscles of Mastication Four total: 2 superficial Four total: 2 superficial 1. Temporalis 1. Temporalis 2. Masseter 2. Masseter Netter, Atlas of Human Anatomy, 2nd Ed, Novartis, 1997 Liebgott, The Anatomical Basis of Dentistry, 2nd Ed, Mosby, 2001 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: The Muscles of Mastication Muscles of Facial Expression Four total: 2 superficial; 2 deep Oral musculature Levator labii superioris 1. Temporalis Levator anguli oris 2. Masseter Zygomaticus major 3. Medial Buccinator pterygoid Risorius 4. Lateral Mentalis pterygoid Depressor anguli oris Depressor labii inferioris Orbicularis oris Platysma Netter, Atlas of Human Anatomy, 2nd Ed, Novartis, 1997 Netter, Atlas of Human Anatomy, 2nd Ed, Novartis, 1997 3 Innervation of the Infratemporal Fossa V3: Sensory & Motor Innervation V3 Motor to the Mandibular Muscles of Division of the Mastication Trigeminal Nerve The nerve of the first branchial Sensory to all teeth arch, which gives origin to the and oral tissues maxillary & mandibular arches and the muscles of mastication Enters through the Foramen Ovale Agur & Lee, Grant’s Atlas of Anatomy, 10th Ed, Agur, Grant’s Atlas of Anatomy, 9th Ed, Lippincott Williams & Wilkins, 1999 Lippincott Williams & Wilkins, 1991 V3: Short stem, then splits into 2 divisions V3: Anterior division Stem: Motor branches: 1. Medial 1. Deep temporal pterygoid nerve nerves (2) 2. Tensor 2. Masseteric nerve tympani nerve 3. Lateral pterygoid 3. Tensor nerve palatini nerve 4. Meningeal One sensory branch: branch Long Buccal nerve Fehrenbach & Herring, Illustrated Anatomy Agur & Lee, Grant’s Atlas of Anatomy, 10th Ed, of the Head & Neck, WB Saunders Co, 1996 Lippincott Williams & Wilkins, 1999 V3: Posterior division V3: Posterior division Sensory branches: Sensory branches: 1. Auriculotemporal 1. Auriculotemporal nerve nerve 2. Lingual nerve 2. Lingual nerve 3. Inferior alveolar 3. Inferior alveolar nerve nerve - mylohyoid - mylohyoid - mental - mental - incisive - incisive Lateral View All sensory except All sensory except Mylohyoid nerve Fehrenbach & Herring, Illustrated Anatomy mylohyoid nerve Fehrenbach & Herring, Illustrated Anatomy of the Head & Neck, WB Saunders Co, 1996 of the Head & Neck, WB Saunders Co, 1996 Medial View 4 Additional Innervation in the Blood Supply to the Infratemporal Fossa Infratemporal Fossa Chorda tympani: Maxillary artery: • Branch of CN VII 3 parts • Carries taste fibers from anterior tongue 1. Mandibular 3. • Secretomotor fibers to 2. 2. Pterygoid salivary glands 3. Pterygopalatine 1. Joins lingual nerve of V3 in ITF Fehrenbach & Herring, Illustrated Anatomy Agur & Lee, Grant’s Atlas of Anatomy, 10th Ed, of the Head & Neck, WB Saunders Co, 1996 Medial View Lippincott Williams & Wilkins, 1999 Blood Supply to the Blood Supply to the Infratemporal Fossa Infratemporal Fossa Maxillary artery Maxillary artery Part 1: Mandibular Part 2: Pterygoid 1. Deep auricular 1. Deep temporal (2) 2. Anterior tympanic 2. Medial pterygoid 3. Middle meningeal 3. Lateral pterygoid 4. Accessory middle 4. Masseteric meningeal 5. Buccal 5. Inferior alveolar 6. Lingual - mylohyoid, mental, & incisive branches Liebgott, The Anatomical Basis of Dentistry, 2nd Ed, Mosby, 2001 Al-Faraje L, Surgical and Radiologic Anatomy for Oral Implantology, Quintessence Publishing Co, 2013 Blood Supply to the Blood Supply to the Infratemporal Fossa Infratemporal Fossa Maxillary artery Part 3: Pterygopalatine Pterygoid Venous 1. Posterior superior Plexus alveolar 2. Infraorbital 3. Artery of pterygoid Primary drainage to canal Maxillary vein 4. Pharyngeal branch 5. Descending palatine 6. Sphenopalatine Liebgott, The Anatomical Basis of Dentistry, 2nd Ed, Mosby, 2001 Liebgott, The Anatomical Basis of Dentistry, 2nd Ed, Mosby, 2001 5 Blood Supply to the View of infratemporal fossa Infratemporal Fossa with mandible resected Pterygoid Venous Plexus Connections to: 1. Cavernous sinus 2. Facial vein 3. Inferior ophthalmic vein 4. Pharyngeal plexus Agur & Lee, Grant’s Atlas of Anatomy, 10th Ed, Netter’s Atlas, 4th Ed, Saunders/Elsevier, 2006 Lippincott Williams & Wilkins, 1999 View of infratemporal fossa fully dissected MANDIBULAR ANESTHESIA Conventional and Alternative Techniques Agur & Lee, Grant’s Atlas of Anatomy, 10th Ed, Lippincott Williams & Wilkins, 1999 Mandibular Infiltration Anesthesia Pharmacology of Anesthetic Agents Works well for the maxilla, but for the mandible… Works fairly well for anteriors and bicuspids A Practical Armamentarium: More variable predictability for molars From a meta-analysis of 13 clinical trials: Greater success using articaine & faster onset Evidence strongly supported articaine’s superiority Lidocaine 45 – 67%; articaine 75 – 92% over lidocaine for infiltration anesthesia Lidocaine 6.1 – 11.1 minutes; articaine 4.2 – 4.7 minutes Evidence was weak for any significant difference between lidocaine and articaine for block anesthesia Brandt RG et al, The pulpal anesthetic efficacy of articaine versus lidocaine in dentistry: A meta-analysis, J Am Dent Assoc, Vol 142(5), May 2011 Why not infiltrate Articaine was 4 times more effective, with greater both buccally and lingually? duration, than lidocaine as an infiltration injection Use ½ - 1 cartridge of when used for teeth diagnosed with irreversible articaine for each Facial Lingual pulpitis Ashraf H et al, Efficacy of articaine versus lidocaine in block and infiltation anesthesia administered in Robertson et al, The anesthetic efficacy of articaine in buccal infiltration of mandibular posterior teeth, JADA, Vol 138 No 8, 2007 teeth with irreversible pulpitis: A prospective, randomized, double-blind study, JOE, Vol 39(1), Jan 2013 Meechan, Practical Dental Local Anesthesia, Quintessence, 2002 6 Mandibular Anesthesia Mandibular Anesthesia Mandible: Nerve blocks Mandible: Landmarks Coronoid notch Inferior alveolar nerve block Mandibular notch Lingual nerve block Neck of condyle Long buccal nerve block Coronoid process Mental (& incisive) nerve block Coronoid notch Mylohyoid nerve block External oblique ridge Complete mandibular division Internal oblique ridge/ nerve block mylohyoid line Gow-Gates mandibular division Mandibular foramen & block lingula Vazirani – Akinosi mandibular Mental foramen division block Jastak, Yagiela & Donaldson, Local
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