Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_110_библиотеки_им_акад_М_И_Перельмана
.pdf
Basic Injection Technique
https://t.me/med1917
232
subconscious use of both sides during chewing. It is also
important to be careful with very hot drinks and
cigarettes (risk of burn).
3) Children. Stress both to them and their parents or
guardians that they must not bite their tongue, lips, or
buccal mucosa while they are anesthetized, since it will
hurt and they could injure themselves. Little children
tend to bite themselves repeatedly when they see that it
does not hurt. A trick used by many pediatric dentists is
to place a cotton roll between the lips or between the
cheek and the gum for as long as the anesthetic lasts to
remind children not to bite themselves (Mink and
Spedding1966).
4) With respect to the dose of anesthetic, it is important to
remember the following:
● Topical anesthesia also contributes to the total dose
administered (Cannell1996; Meechan1998).
● When it is necessary to inject a large quantity of anes‑
thetic solution, try to reserve 20–25% of the absolute
maximum dose to address unexpected events
(Meechan1998).
● Do not dispose of the empty cartridges after adminis-
tration. Keep them until the procedure is complete in
order to know exactly how much anesthetic has been
administered, especially in cases where it is necessary
to administer new injections halfway through treat‑
ment (Meechan1998).
● Remember the patient’s height and weight, especially
in the case of children and small adults (often elderly
persons) to minimize the risk of overdose (Goodson
and Moore1983; Hersh et al.1991; Virts 1999). See
Annex 10 on maximum doses.
5) Used needles should be disposed of in a safe container
for sharps and contaminated instruments (Dentists’
Desk1983).
2) The advance of the needle across the soft tissue until it
reaches its target in truncal block (Annex 23 and
Appendix). The pain can be relieved with a continuous
monolog and the rapid advance of the needle toward its
objective with counter‑ stimulus maneuvers.
3) Injection of acidic solutions (low pH). Solutions
containing sympathomimetic vasoconstrictors, such as
epinephrine also contain antioxidants (sulfites), which
reduce the pH (Annex 14). This leads to an initial sensa‑
tion of stinging and burning, as shown in clinical trials
(Oikarinen et al. 1975; Moorthy et al. 1984; Kramp
etal.1999; Wahl etal.2001). Fortunately, this effect dis‑
appears quickly, since tissue fluids contain buffers
which neutralize the pH. A smooth and short massage
can help to relieve this sensation.
4) The speed of the injection. This factor has been consid‑
ered important since the early years of dental local
anesthesia (Lewis 1919), and this remains the case
today (Malamed 1986; Roberts and Sowray 1987;
Linscott et al. 1978). Clinical trials have clearly proven
this impression (Mamiya et al. 2001; Primosch and
Brooks2002; Kudo2005; Kanaa etal.2006; Whitworth
etal.2007), especially in buccal infiltrations (Annex 23).
The explanation is that a rapid injection leads to a sud‑
den distension of the tissues, which increases pressure
and is painful. This specific factor is more painful than
the needle insertion (Nist etal.1992; Quarnstrom and
Libed1994; Carr and Horton2001a; Kennedy etal.2001;
Wiswall etal.2014). It can be mitigated by slow injec‑
tion and a continuous monolog.
FactorsThatPlayaRoleinPain
Regardless of the objective causes of pain, a series of factors
contribute to the perception that pain is more intense.
CausesofPainDuringtheInjection
Below, we analyze the real causes of pain, factors that play
a role in pain, and factors that are of almost no importance
but that many dentists still believe to be relevant.
FactorsThatCausePain
1) The injection. Insertion/penetration of the needle into
the mucosa is the main cause of pain during the
injection (Annex 19). It can be mitigated by the follow‑
ing: (i) using topical anesthetic before the injection and
(ii) distracting the patient with counter‑ stimulus
maneuvers (traction, stretching, pressure) and a
continuous monolog.
1) The part of the mouth where the injection is performed.
The clinical impression is that the palate is the part
where most pain is felt (Kramp et al. 1999; Wahl
etal.2001; Primosch and Brooks2002); this impression
is confirmed in the literature (Annexes 19 and 23).
Furthermore, it is known that pain is most intense in
the anterior part of the hard palate than in the posterior
part (Meechan etal.2005; Ozec etal.2010). Other sites
where pain is more intense include buccal periapical
infiltrations in the anterior teeth of the maxilla; in con‑
trast, buccal periapical infiltrations in the posterior
teeth of the maxilla are the least painful (Annex 23).
2) The patient’s age and sex. Most anxiety and sensitivity
to pain during injection of local anesthetic and dental
treatment in general is observed with women (LeClaire
etal.1988; Liddell and Locker1997; Baht etal. 2000;
t.me/Dr_Mouayyad_AlbtousH
233
https://t.me/med1917
Van Wijk and Hoogstraten2006; Meechan etal.2005),
and adolescents and young adults (Kleinknecht and
Berstein 1978; LeClaire et al. 1988; Liddell and
Locker 1997; Wahl et al. 2001; Maggirias and
Locker2002; Gazal2015).
3) Intense anxiety reduces the pain tolerance threshold
and makes it more likely that nonpainful stimuli (e.g.
pressure) are interpreted as painful, therefore anxious
patients overestimate the degree of pain that dental
treatment causes (Wepman 1978; Corah et al. 1979;
Woolgrove1983; Sokol etal.1985; LeClaire etal.1988;
Maggirias and Locker2002; Van Wijk and Makkes2008)
and can enter a vicious cycle of overestimating pain and
increasing anxiety.
4) The dentist. Many physicians agree that the main factor
in reducing pain during the administration of anesthe‑
sia is the dentist him/herself (Mollen etal.1981; Goodell
etal.2000; Saloum etal.2000; Nusstein and Beck2003;
Ram and Peretz2003), for two key reasons:
● The dentist’s touch, skill, and ability when adminis‑
tering local anesthetic. Many of these small details
have been addressed in this chapter during the 10
phases of injection, where emphasis was placed on
safety, psychology, careful management of oral tis‑
sues, and the ways pain can be reduced during the
injection. It is of critical importance that the that cli‑
nician maintains an optimistic demeanor before, dur‑
ing, and after the injection process (Kravitz2006).
● The dentist’s management of the interpersonal rela‑
tionship, improved communication, and use of psy‑
chological strategies that increase patient satisfaction
(Gale etal.1984; Maggirias and Locker2002). Patient
satisfaction may even be high in treatments that are
painful (Lindemann etal.2008) owing to the dentist’s
positive and professional approach (i.e. not appearing
indifferent or being on the defensive) and the fact that
he/she gives the patient encouragement, especially at
difficult points during the procedure. While not
within the scope of this book, some aspects are wor‑
thy of mention (Gale etal.1984):
– Welcome the patient and ask him/her to sit in the
dental chair.
– Explain what is going to be done.
– Approach the patient carefully.
– Talk about things in general when administering
the anesthetic.
– Explain to the patient during the treatment that
everything is going well. Even if a problem arises,
we can say something like “This is interesting, but
we’ll have it fixed in second.” Note the use of the
euphemism “interesting” and not words such as
“problem” and “difficulty.”
– Converse with the patient on completion of treat‑
ment and say goodbye.
Patient expectations of pain and anxiety are not mod‑
ified by a simple pain
exposures to pain
‑ free procedure; however, repeated
‑ free treatment attenuate expectations
of anxiety and pain (Maggirias and Locker2002).
Finally, it is important to remember that the two princi‑
pal factors by which patients judge dentists are whether
they administer the injection without pain and whether
there is pain during the procedure (St Georges2004).
UnimportantCauses(Myths)
There are two myths that, unfortunately, are widespread
among dentists with respect to the cause of pain during
injection. They are of little relevance.
1) The needle caliber myth. Most dentists think that
smaller calibers (30G and 27G) cause less pain during
the insertion and the injection (Smith1968; Cooley and
Robinson1979; Mollen et al. 1981; Van der Bijl1995).
However, clinical studies seem to indicate that there is
little difference with respect to perception of pain (see
Chapter11). Six clinical trials found no statistically sig‑
nificant differences in pain with the different calibers of
needle (30G, 27G, and 25G), and a further two trials
showed that the finest
‑ gauge needle (30G) caused less
pain than the 27G needle. The clinical differences were
very small but statistically significant (Table 11.3,
Chapter11).
To verify differences between the calibers, we must
use thicker needles (20G or 22G), such as those used in
intramuscular injections or those that were once used
in dental injections (Smith1920).
2) The cartridge temperature myth. Even in the earliest
texts on dental local anesthesia, authors insisted that
solutions be at body temperature (around 36 °C) to
prevent pain during the injection (Fischer 1912;
Lewis1919).
Clinical trials have shown that patients cannot distin‑
guish between ambient temperature (20–21 °C) and
injections at body temperature (35–37 °C) (Oikarinen
etal.1975; Rood1977; Ram etal.2002).
Furthermore, heating the cartridges for a short time
is harmless, although storing them at body temperature
for long periods deteriorates sympathomimetic vaso‑
constrictors such as epinephrine (Gerke etal.1977; Fry
and Ciarlone1980; Thoma and Struve1986; Hondrum
etal.1993).
If the cartridge is cold (less than 20 °C=68 °F), it can
be heated up before placing it in the syringe by holding
it in the hand for 30 seconds (Malamed2004).
t.me/Dr_Mouayyad_AlbtousH
Basic Injection Technique
iltration
https://t.me/med1917
234
Terminology
Below, we classify dental anesthesia and comment on the
terms used to define the different anesthetic techniques
(Jorgensen and Hayden 1970; Allen 1979; Jastak
etal.1995).
● Classification of anesthesia with respect to the
periosteum:
– Infraperiosteal or subperiosteal. When the needle goes
below the periosteum to deliver the anesthetic solu‑
tion at this level. The technique was used many years
ago, when anesthetic solutions were weak, so that they
could cross a barrier (the periosteum), penetrate more
deeply, and thus cross the cortical bone to reach the
cancellous bone. The approach is complicated by pain
during penetration of the periosteum and post
operative pain.
– Supraperiosteal or paraperiosteal. When the needle
remains above the periosteum and does not cross it.
Today, all techniques are supraperiosteal because mod‑
ern anesthetic solutions cross the periosteum well.
● Classification of anesthesia according to basic techniques
(Figure13.11):
– Topical or surface anesthesia, which results from
application of the anesthetic on the oral mucosa with‑
out administering an injection.
– Infiltrative anesthesia, which involves injection of
anesthetic solution into the tissues to be treated.
Several nerve endings (many of which are micro‑
scopic) are anesthetized. Anesthesia is limited to the
area reached by the solution.
– Nerve or truncal block, which involves anesthesia of a
whole nerve or nerve trunk (macroscopic), such as the
inferior alveolar nerve (mandibular block). The advan‑
tage of this approach is that it anesthetizes at some
distance and thus covers a large anatomical area.
Note: Nerve blocks can be of smaller secondary trunks;
some authors call these blocks “field blocks” or “regional
blocks.” We refer to them all as nerve blocks, for example
maxillary nerve block (V
) via the high tuberosity (main
2
nerve trunk) and anterior superior alveolar nerve block
via the infraorbital nerve (secondary trunk) (see
Chapter14).
● Variants of infiltrative techniques:
– Periapical or para‑ apical anesthesia. The filtration
placed at the apex of the teeth (buccal infiltration).
– Intrapapillary anesthesia. Infiltration in the interden‑
‑
tal papilla (Figure13.12).
– Plexus anesthesia. Anesthetic administered by infiltra‑
tion of the superior dental plexus or superior alveolar
nervous plexus in the maxilla at the level of or above
the apexes of the teeth at the junction of the posterior,
medial, and anterior alveolar nerves, and even the
nasopalatine nerve in the anterior part (see Chapter2).
– Transpapillary technique. Infiltration of the interden‑
tal papilla to anesthetize the palate through the buc‑
cal part.
– Intrapulpal anesthesia. Injection directly into the open
dental pulp.
– Intraosseous anesthesia. Penetration of the needle
into the cancellous bone after crossing the periosteum
and cortical bone to inject directly into the trabecular
or cancellous bone.
Figure13.11 Basic techniques in dental local anesthesia: (1)
topical anesthesia; (2) infiltrative anesthesia; (3) nerve trunk
block; and (3b) smaller, secondary nerve trunk block (field or
regional anesthesia or field block). Source: Redrawn from Allen
(1979) and Jastak etal. (1995).
3 Block
3 b Block
2 Inf
1 Topical
Figure13.12 Intrapapillary infiltrative anesthesia.
t.me/Dr_Mouayyad_AlbtousH
235References
https://t.me/med1917
– Intraligamentous anesthesia or anesthesia of the peri‑
odontal ligament. A pressure injection across the peri‑
odontal ligament.
– Intraseptal anesthesia. Penetration of the needle into
the interdental papilla to perforate the interdental
bone crest and inject the anesthetic solution into the
cancellous bone. This is a variant of the intraosseous
and intraligamentous techniques.
Appendix
Data from McCarney etal. (2007).
Mandibular block. Pain in scale of none, mild, moderate,
and severe. Pain during advance of the needle (needle
placement) in a group with deposition of anesthetic
References
Addelston, H.K. (1959). Child patient training. Fortn. Rev.
Chic. Dent. Soc. 38 (2): 7–9, 27–29.
Adriani, J. and Campbell, D. (1956). Fatalities following
topical application of local anesthetics to mucous
membranes. JAMA 162 (17): 1527–1530.
Adriani, J., Campbell, D., and Yarberry, D.H. Jr. (1959).
Influence of absorption on systemic toxicity of local
anesthetic agents. Anesth. Analg. 38 (5): 370–377.
Aggarwal, V., Singla, M., Miglani, S. etal. (2012). A prospective
randomized single‑ blind evaluation of effect of injection
speed on anesthetic efficacy of inferior alveolar nerve block
in patients with symptomatic irreversible pulpitis. J. Endod.
38 (12): 1578–1580.
Allegretti, C.E., Sampaio, R.M., Horliana, A.C.R.T. etal.
(2016). Anesthetic efficacy in irreversible pulpitis: a
randomized clinical trial. Braz. Dent. J. 27 (4): 381–386.
Allen, G.D. (1979). Dental Anesthesia and Analgesia (Local
and General), 2e. Baltimore: Williams and Wilkins.
86–89, 95–96.
Alling, C.C. and Christopher, A. (1974). Status report on
dental anesthetic needles and syringes. Council on dental
materials and devices and council on dental therapeutics.
J. Am. Dent. Assoc. 89 (5): 1171–1176.
American Academy of Pediatric Dentistry (AAPD) (2020).
Use of Local Anesthesia for Pediatric Dental Patients. The
Reference Manual of Pediatric Dentistry. Chicago IL:
American Academy of Pediatric Dentistry. 318–323.
Annex 10. Maximum doses of dental local anesthetics solutions.
Annex 14. Injectable anesthetic solutions pH.
Annex 19. Topical anesthesia I. Results of clinical trials.
Annex 22. Positive aspirations.
Annex 23. Pain resulting from injection techniques.
solution (anesthetic given) and a group without deposition
(no anesthetic given).
None,mild,
Anesthetic given
No anesthetic
given
Severepain
20 (35%) 38
5 (11%) 39 44
25 77 102
moderatepain Total
58
The worse pain is experienced during deposition of the
anesthetic solution during the advance of the needle (anes‑
thetic given). Fisher exact test=0.0099 (two sides P value).
Molar with irreversible acute pulpitis.
Armbrecht, E.C. and Schwetz, W.S. (1962). A case report.
Recovery of a broken needle. West Virginia Dent. J. 36: 120–121.
Baht, E.I., Baht, R., Kozlovsky, A., and Simon, H. (2000).
Effect of gender on acute pain prediction and memory in
periodontal surgery. Eur. J. Oral Sci. 108 (2): 99–103.
Bartlett, S.Z. (1972). Clinical observations on the effects of
injections of local anesthetic preceded by aspiration. Oral
Surg. Oral Med. Oral Pathol. 33 (4): 520–526.
Batinac, T., Tokmadzic, V.S., Peharda, V., and Brajac, I. (2013).
Adverse reactions and alleged allergy to local anesthetics:
analysis of 331 patients. J. Dermatol. 40 (7):522–527.
Bennett, C.R. (1984). Monheim’s Local Anesthesia and Pain
Control in Dental Practice, 7e. St Louis (Missouri): The CV
Mosby Co. 106, 165.
Berggren, U. and Meynert, G. (1984). Dental fear and
avoidance: causes, symptoms, and consequences. J. Am.
Dent. Assoc. 109 (2): 247–251.
Blair, G.S. and Meechan, J.G. (1985). Local anesthesia in
dental practice I. A clinical study of self
Br. Dent. J. 159 (3): 75–77.
Bos, A.L., Coppes, L., Determann, E.J. etal. (1971).
Aspiration control in the administration of local anesthesia
in dentistry. Ned. Tijdschr. Tandheelkd. (Suppl 6): 24–38.
Bourne, J.G. (1957). Fainting and cerebral damage. Dosage in
patients kept upright during dental gas anesthesia and
after surgical operations. Lancet 273 (6994): 499–505.
Bourne, J.G. (1970). Deaths with dental anesthetics.
Anaesthesia 25 (4): 473–481.
Burgess, J.O. (1988). The broken dental needle– a hazard.
Special Care Dent. 8 (2): 71–73.
Campbell, D. and Adriani, J. (1958). Absorption of local
anesthetics. JAMA 168 (7): 873–877.
‑ aspirating system.
t.me/Dr_Mouayyad_AlbtousH
Basic Injection Technique
https://t.me/med1917
236
Cannell, H. (1996). Evidence of safety margins of lignocaine
local anaesthetics for perioral use. Br. Dent. J. 181 (7):
243–249.
Carr, M.P. and Horton, J.E. (2001a). Evaluation of transoral
delivery system for topical anesthesia. J. Am. Dent. Assoc.
132 (12): 1714–1719.
Carr, M.P. and Horton, J.E. (2001b). Clinical evaluation and
comparison of 2 topical anesthetics for pain caused by
needle sticks and scaling and rootplaning. J. Periodontol.
72(4): 479–484.
Certosimo, A.J. and Archer, R.D. (1996). A clinical evaluation
of the electric pulp tester as an indicator of local
anesthesia. Oper. Dent. 21 (1): 25–30.
Chavarria‑ Bolaños, D., Rodríguez‑ Wong, I., Noguera‑
Gonález, D. etal. (2017). Sensitivity, specificity, predictive
values, and accuracy of three diagnostic tests to predict
inferior alveolar nerve blockade failure in symptomatic
irreversible pulpitis. Pain Res. Mange. 2017: 3108940.
Cheatham, B.D., Primosch, R.E., and Courts, F.J. (1992). A
survey of local anesthetic usage in pediatric patients by
Florida dentists. J. Dent. Child. 59 (6): 401–407.
Childers, M., Reader, A., Nist, R. etal. (1996). Anesthesia
efficacy of the periodontal ligament injection after an
inferior alveolar nerve block. J. Endod. 22 (6): 317–320.
Cleveland, J.L., Barker, L.K., Cuny, E.J. etal. (2007).
Preventing percutaneous injuries among dental health care
personnel. J. Am. Dent. Assoc. 138 (2): 169–178.
Cohen, H.P., Cha, B.Y., and Spangberg, L.S.W. (1993).
Endodontic anesthesia in mandibular molars: a clinical
study. J. Endod. 19 (7): 370–373.
Cooley, R.L. and Robinson, S.F. (1979). Comparative
evaluation of the 30
Med. Oral Pathol. 48 (5): 400–404.
Corah, N.L., Gale, E.N., and Illig, S.J. (1979). Psychological
stress reduction during dental procedures. J. Dent. Res.
58(4): 1347–1351.
Council on Clinical Affairs (2015). Guideline on use of local
anesthesia for pediatric dental patients. Pediatr. Dent.
37(Special issue): 199–205.
Council on Dental Therapeutics. Chicago: American Dental
Association. 1957: 109.
Cowan, A. (1972). A new aspirating syringe. Br. Dent.
J. 133(12): 547–548.
Daubländer, M., Müller, R., and Lipp, M.D.W. (1997). The
incidence of complications associated with local anesthesia
in dentistry. Anesth. Prog. 44 (4): 132–144.
David, H.T., Aminzadeh, K.K., Kae, A.H., and Radomsky,
S.C. (2007). Instrument retraction to avoid needle
injuries during intraoral local anesthesia. Oral Surg. Oral
Med. Oral Pathol. 103 (3): e11–e13.
De Jong, R.H. (1977). Local Anesthetics, 2e. Springfield (IL):
Charles C Thomas Publisher. 61.
‑ gauge dental needle. Oral Surg. Oral
‑ stick
De Souza Melo, M.R., Sabey, M.J.S., Lima, C.J. etal. (2015).
The effect of 2injection speeds on local anesthetic
discomfort during inferior alveolar nerve blocks. Anesth.
Prog. 62 (3): 106–109.
Dentists’ Desk (1983). Reference: Materials, Instruments and
Equipment, 2e. Chicago: American Dental Association.
351–356.
Dreven, L.J., Reader, A., Beck, M. etal. (1987). An evaluation
of an electric pulp tester as a measure of analgesia in
human vital teeth. J. Endod. 13 (5): 233–238.
Dubner, R. (1978). Neurophysiology of pain. Dent. Clin.
N. Am. 22 (1): 11–30.
Eickbohm, J.E., Wulf, H., Hoffmann, C., and Becker,
C.H. (1991). Klinische Pharmakokinetik von Lidocain
nach intraoraler Leitungsanästhesie. Dtsch. Zahnärtztl.
Z. 46 (12): 812–814.
Ellis, R.K., Berg, J.H., and Raj, P.P. (1990). Subjective signs of
efficacious inferior alveolar nerve block in children.
J. Dent. Child. 57 (5): 361–365.
Evers, H. and Haegerstam, G. (1981). Handbook of Dental
Local Anesthesia. Copenhagen: Schultz Medical
International. 65, 75, 171.
Fa, B.A., Gupta, S., and Bhattacharyya, M. (2016). Operator
preference of retraction method during anesthesia delivery.
Stomatol. EDU J. 3 (1): 10–15.
Firestein, S.K. (1976). Patient anxiety and dental practice.
J. Am. Dent. Assoc. 93 (6): 1180–1187.
Fischer, G. (1912). Local Anesthesia in Dentistry. With Special
Reference to the Mucous and Conductive Methods. A Concise
Guide for Dentists, Surgeons and Students. Philadelphia:
Lea and Febiger. 51, 135.
Forrest, J.O. (1959). Notes on aspiration before injection of
local anesthetics using dental cartridges. Br. Dent. J. 107
(3): 259–262.
Frasier, I.M. (1967). Local anesthetics. In: Premedication,
Local and General Anesthesia in Dentistry (ed.
A.B. Jorgensen and J. Hayden). Philadelphia: Lea and
Febiger. 89–96.
Fry, B.W. and Ciarlone, A.C. (1980). Concentrations of
vasoconstrictor in local anesthetics during storage in
cartridges heaters. J. Dent. Res. 59 (7): 1136.
Fuller, N.P., Menke, R.A., and Meyers, W.S. (1979). Perception
of pain to three different intraoral penetrations of needles.
J. Am. Dent. Assoc. 99 (5): 822–824.
Fuss, Z., Towbridge, H., Bender, I.B. etal. (1986). Assessment
of reliability of electrical and thermal pulp testing agents.
J. Endod. 12 (7): 301–305.
Gale, E.N., Carlsson, S.G., and Jontell, M. (1984). Effects of
dentists’ behavior on patients’ attitudes. J. Am. Dent. Assoc.
109 (3): 444–446.
Gazal, G. (2015). Comparison of speed of action and injection
discomfort of 4% articaine and 2% mepivacaine for pulpal
t.me/Dr_Mouayyad_AlbtousH
References
https://t.me/med1917
237
anesthesia in mandibular teeth: a randomized, double‑
blind cross‑ over trial. Eur. J. Dent. 9 (2): 201–206.
Gerke, D.C., Crabb, G.A., Frewin, D.B., and Frost, B.R. (1977).
The effect of storage on the activity of adrenaline in local
anesthetic solutions: an evaluation using bioassay and
fluorometric techniques. Aust. Dent. J. 22 (6): 423–427.
Ghoddusi, J., Zarrabi, M.H., Daneshvar, F., and Naghavi,
N. (2018). Efficacy of IANB and Gow
madibular molars with symptomatic irreversible pulpitis: a
prospective randomized double blind clinical study. Iran.
Endod. J. 13 (2): 143–148.
Gill, C.J. and Orr, D.L. II. (1979). A double
comparison of topical anesthetics. J. Am. Dent. Assoc.
98(2): 213–214.
Goldman, V. and Gray, W. (1963). A clinical trial of a new
local analgesic agent. Br. Dent. J. 115 (2): 59–65.
Goodell, G.G., Gallager, F.J., and Nicoll, B.K. (2000).
Comparison of controlled injection pressure system with a
conventional technique. Oral Surg. Oral Med. Oral Pathol.
90 (1): 88–94.
Goodson, J.M. and Moore, P.A. (1983). Life
reactions after pedodontic sedation: an assessment of
narcotic, local anesthetic, and antiemetic drug interaction.
J. Am. Dent. Assoc. 107 (2): 239–245.
Hersh, E.V., Helpin, M.L., and Evans, O.B. (1991). Local
anesthetic mortality: report of case. J. Dent. Child. 58 (6):
489–491.
Hersh, E.V., Moore, P.A., Papas, A.S. etal. (2008). Reversal of
soft‑ tissue local anesthesia with phentolamine mesylate in
adolescents and adults. J. Am. Dent. Assoc. 139 (8): 1080–1093.
Holst, A. and Evers, H. (1985). Experimental studies of new
topical anaesthetics on the oral mucosa. Swed. Dent. J. 9
(5): 185–191.
Hondrum, S.O., Seng, G.F., and Rebert, N.W. (1993). Stability
of local anesthetics in the dental cartridge. Anesth. Pain
Control Dent. 2 (4): 198–202.
Horowitz, J., Almong, Y., Wolf, A. etal. (2005). Ophthalmic
complications of dental anesthesia: three new cases.
J. Neuroophthalmol. 25 (2): 95–100.
Hsiao‑ Wu, G.W., Susarla, S.M., and White, P.P. (2007). Use of
the cold test as a measure of pulpal anesthesia during
endodontic therapy: a randomized, blinded, placebo‑
controlled clinical trial. J. Endod. 33 (4): 406–410.
Jackson, E. (1974). Managing dental fear’s: a tentative code of
practice. J. Oral Med. 29 (4): 96–101.
Jastak, J.T., Yagiela, J.A., and Donaldson, D. (1995). Local
Anesthesia of the Oral Cavity. Philadelphia: WB Saunders
Co. 161–162, 185–186.
Jones, C.M., Heidmann, J., and Gerrish, A.C. (1995).
Children’s ratings of dental injection and treatment pain,
and influence of the time taken to administer the injection.
Int. J. Paediatr. Dent. 5 (2): 81–85.
‑ Gates techniques in
‑ blind crossover
‑ threatening
Jorgensen, N.B. and Hayden, J. Jr. (1970). Anestesia
odontológica. Mexico, DF: Editorial Interamericana
SA. (Spanish translation of: Jorgensen, N.B. and Hayden,
J. Jr. (1967). Premedication, Local and General Anesthesia
in Dentistry. Philadephia: Lea and Febiger). 24, 33.
Kämmerer, P.W., Schneider, D., Pacyna, A.A., and Daubländer,
M. (2016). Movement control during aspiration with
different injection systems via video monitoring– an
invitro model. Clin. Oral Investig. 21 (1): 105–110.
Kanaa, M.D., Meechan, J.G., Corbett, I.P., and Whitworth,
J.M. (2006). Speed of injection influences efficacy for
inferior alveolar nerve blocks: a double
controlled trial in volunteers. J. Endod. 32 (10): 919–923.
Karkut, B., Reader, A., Drum, M. etal. (2010). A comparison
of the local anesthetic efficacy of the extraoral versus
intraoral infraorbital nerve block. J. Am. Dent. Assoc.
141(2): 185–192.
Kaufman, E., Gaharian, S., and Katz, Y. (2000). Adverse
reactions triggered by dental local anesthetics: a clinical
survey. Anesth. Prog. 47 (4): 134–138.
Kelly, J.R. and Cohen, M.E. (1984). Injectable debris
associated with dental anesthetic delivery. J. Am. Dent.
Assoc. 108 (4): 621–624.
Kelly, J.F. and Patterson, R. (1974). Anaphylaxis. Course,
mechanisms and treatment. J. Am. Med. Assoc. 227 (12):
1431–1436.
Kennedy, M., Reader, A., Beck, M., and Weaver, J. (2001).
Anesthetic efficacy of ropivacaine in maxillary anterior
infiltration. Oral Surg. Oral Med. Oral Pathol. 91 (4): 406–412.
Kennedy, S., Reader, A., Nusstein, J. etal. (2003). The
significance of needle deflection in success of the inferior
alveolar nerve block in patients with irreversible pulpitis.
J. Endod. 29 (10): 630–633.
Klein, R.M. (1983). Components of local anesthetic solutions.
Gen. Dent. 31 (6): 460–465.
Kleinknecht, R.A. and Berstein, D.A. (1978). The assessment
of dental fear. Behav. Ther. 9 (4): 626–634.
Kleinknecht, R.A., Klepac, R.K., and Alexander, L.D. (1973).
Origins and characteristic of fear of dentistry. J. Am. Dent.
Assoc. 86 (4): 842–948.
Kohli, N., Ngan, O., Crout, R., and Lindscott, C.C. (2001).
Asurvey of local and topical anesthesia use by pediatric
dentists in the United States. Pediatr. Dent. 23 (3): 265–269.
Kramp, L.F., Eleazer, P.D., and Acheetz, J.P. (1999).
Evaluation of prilocaine for the reduction of pain
associated with transmucosal anesthetic administration.
Anesth. Analg. 46 (2): 52–55.
Kravitz, J. (2006). The palatal press and roll anesthesia
technique. Pract. Proced. Aesthet. Dent. 18 (4): 242–245.
Kudo, M. (2005). Initial injection pressure for dental local
anesthesia: effects on pain and anxiety. Anesth. Prog.
52(3): 95–101.
‑ blind randomized
t.me/Dr_Mouayyad_AlbtousH
Basic Injection Technique
https://t.me/med1917
238
LeClaire, A.J., Skidmore, A.E., Griffin, J.A. Jr., and Balaban,
F.S. (1988). Endodontic fear survey. J. Endod. 14 (11):
560–564.
Lesch, C.A., Squier, C.A., Cruchley, A. etal. (1989). The
impermeability of human oral mucosa and skin to water.
J. Dent. Res. 68 (9): 1345–1349.
Lewis, D.N. (1919). Pain following local anesthesia. Dent.
Cosmos 61 (5): 407–408.
Liddell, A. and Locker, D. (1997). Gender and age differences
in attitudes to dental pain and dental control. Community
Dent. Oral Epidemiol. 25 (4): 314–318.
Lim, S. and Julliard, K. (2004). Evaluating the efficacy of
EMLA topical anesthetic in sealant placement with rubber
dam. Pediatr. Dent. 26 (6): 497–500.
Lindemann, M., Reader, A., Nusstein, J. etal. (2008). Effect of
sublingual triazolam on the success of inferior alveolar
nerve block in patients with irreversible pulpitis. J. Endod.
34 (10): 1167–1170.
Lindsay AW. The direct approach technique in mandibular
block anesthesia. Thesis. Faculty of Dentistry, University
of Toronto. 1929; 34–35.
Linscott, C., Kohli, K., Ngan, P., and Crout, R. (1978). Local
anesthesia practices among United States pediatric dentists.
J. Dent. Res. 77 (Special Issue A): 290. (abstract no 1479).
Lipp, M.D.W., Dick, W.F., Daubländer, M. etal. (1988).
Examination of the central
during local dental infiltration and block anesthesia using
‑ marked epinephrine as vasoconstrictor.
tritium
Anesthesiology 69 (3A‑ Suppl): A371.
Lipp, M., Dick, W., Daubländer, M. etal. (1993). Exogenous
and endogenous plasma levels of epinephrine during dental
treatment and local anesthesia. Reg. Anesth. 18(1): 6–12.
Lloyd, J.M. (1992). Aspiration in dental local anaesthesia
(letter). Br. Dent. J. 172 (4): 136.
Lopez, J. and Rosello, X. (1995). Anestesiatroncular del
nerviodentario inferior. Porcentaje de
aspiracionespositivas. Rev. Eur. Odontoestomatol.
(Barcelona) 7 (6): 353–356.
Lustig, J.P. and Zusman, S.P. (1999). Immediate
complications of local anesthetic administered to 1,007
consecutive patients. J. Am. Dent. Assoc. 130 (4): 496–499.
Maggirias, J. and Locker, D. (2002). Psychological factors and
perception of pain associated with dental treatment.
Community Dent. Oral Epidemiol. 30 (2): 151–159.
Majstorovic, M. and Veerkamp, J.S.J. (2004). Relationship
between needle phobia and dental anxiety. J. Dent. Child.
71 (3): 201–205.
Malamed, S.F. (1986). Handbook of Local Anesthesia, 2e.
St.Louis (Missouri): The CV Mosby Co. 116–127.
Malamed, S.F. (2004). Handbook of Local Anesthesia, 5e.
St.Louis (Missouri): Elsevier‑ Mosby. 115, 160, 166–167,
309–311.
‑ nervous epinephrine level
Mamiya, H., Katagiri, N., Ichinohe, T., and Kaneko, Y. (2001).
The effects of the injection speed of local anesthesia.
J. Dent. Res. 80 (Special Issue): 667. (abstract no 1122).
Maragakis, G.M. and Musselman, R.J. (1996). The time used
to administer local anesthesia to 5 and 6 year olds. J. Clin.
Pediatr. Dent. 20 (4): 321–323.
Marks, R.B., Carlton, D.M., and McDonald, J. (1984).
Management of a broken needle in the
pterygomandibular space: report a case. J. Am. Dent.
Assoc. 109 (2): 263–264.
Martin, M.D., Ramsay, D.S., Whitney, C. etal. (1994). Topical
anesthesia: differentiating the pharmacological and
psychological contribution to efficacy. Anesth. Prog.
41(2): 40–47.
McCarney, M., Reader, A., and Beck, M. (2007). Injection
pain of the inferior alveolar nerve block in patients with
irreversible pulpitis. Oral Surg. Oral Med. Oral Pathol.
104(4): 571–575.
McClure, D.B. (1968). Local anesthesia for the preschool
child. J. Dent. Child. 35 (6): 441–448.
McDonogh, T. (1996). An unusual case of trismus and
dysphagia. Br. Dent. J. 180 (12): 465–466.
Meechan, J. (1998). How to avoid local anaesthesia toxicity.
Br. Dent. J. 184 (7): 334–335.
Meechan, J.G. (2008). Intra oral topical anesthesia.
Periodontology 46: 56–79.
Meechan, J.G. and Blair, G.S. (1989). Clinical experience in
oral surgery with 2 different automatic aspirating syringes.
Int. J. Oral Maxillofac. Surg. 18 (2): 87–89.
Meechan, J.G. and Rood, J.P. (1992). Aspiration in dental
local anesthesia. Br. Dent. J. 172 (2): 40.
Meechan, J.G., Gowans, A.J., and Welbury, R.R. (1998). The
use of patient
stimulation (TENS) to decrease the discomfort of regional
anaesthesia in dentistry: a randomized controlled clinical
trial. J. Dent. 26 (5–6): 417–420.
Meechan, J.G., Howlett, P.C., and Smith, B.D. (2005). Factors
influencing the discomfort of intraoral needle penetration.
Anesth. Prog. 52 (3): 91–94.
Melzack, R. and Wall, P.D. (1965). Pain mechanism: a new
theory. Science 150 (3699): 971–979.
Messer, J.G. (1977). Stress in dental patients undergoing
routine procedures. J. Dent. Res. 56 (4): 362–367.
Milgrom, P., Coldwell, S.E., Getz, T. etal. (1997). Four
dimensions of fear of dental injections. J. Am. Dent. Assoc.
128 (6): 756–762.
Miller, S.O., Johnson, J.D., Allemang, J.D., and Strother,
J.M. (2004). Cold testing through full‑ coverage
restorations. J. Endod. 30 (10): 695–700.
Mink, J.R. and Spedding, R.H. (1966). An injection
procedure for the child dental patient. Dent. Clin. N. Am.
10: 309–325.
‑ controlled transcutaneous electronic nerve
t.me/Dr_Mouayyad_AlbtousH
References
https://t.me/med1917
239
Mollen, A.J., Ficara, A.J., and Provant, D.R. (1981). Needles–
25gauge versus 27
‑ gauge– can patients really tell? Gen.
Dent. 29 (5): 417–418.
Moore, P. (1992). Preventing local anesthetic toxicity. J. Am.
Dent. Assoc. 123 (9): 60–64.
Moorthy, A.P., Moorthy, S.P., and O’Neil, R. (1984). A study of
pH of dental local anesthetic solutions. Br. Dent. J. 157 (11):
394–395.
Munshi, A.K., Hegde, A.M., and Latha, R. (2001). Use of
®
: is it an injection free alternative? J. Clin. Pediatr.
EMLA
Dent. 25 (3): 215–219.
Nakamura, S., Matsuura, N., and Ichinohe, T. (2013). A new
method of topical anesthesia by using anesthetic solution
in a patch. J.Endod. 39 (11): 1369–1373.
Nanitsos, E., Vartuli, R., Forte, A. etal. (2009). The effect of
vibration on pain during local anaesthesia injections. Aust.
Dent. J. 54 (2): 94–100.
Nist, R.A., Reader, A., Beck, M., and Meyers, W.J. (1992). An
evaluation of the incisive nerve block and combination
inferior alveolar and incisive nerve blocks in mandibula
anesthesia. J. Endod. 18 (9): 455–459.
Nordenram, A. (1971). Manuel d’anesthésie locale
enpractiquedentaire. Mölndal (Sweden): Lindgren and
Söner. Bofors Nobel‑ Pharma. 24, 39.
Nusstein, J.M. and Beck, M. (2003). Effectiveness of 20%
benzocaine as a topical anesthetic for intraoral injections.
Anesth. Prog. 50 (4): 159–163.
Nusstein, J., Reader, A., Nist, R. etal. (1998). Anesthetic
efficacy of the supplemental intraosseous injection of 2%
lidocaine with 1:100,000 epinephrine in irreversible
pulpitis. J. Endod. 24 (7): 487–491.
Nusstein, J., Steinkruger, G., Reader, A. etal. (2006). The
effects of a 2‑ stage technique on inferior alveolar nerve
block injection pain. Anesth. Prog. 53 (4): 126–130.
Oikarinen, V.J., Ylipaavalniemi, P., and Evers, H. (1975). Pain
and temperature sensations related to local analgesia. Int.
J. Oral Surg. 4 (4): 151–156.
Oliver, L.P. (1974). Local anesthesia –a review of practice.
Aust. Dent. J. 19 (5): 313–319.
Orr, D.L. II. (1983). The broken needle: report of case. J. Am.
Dent. Assoc. 107 (4): 603–604.
Ozec, I., Tasdemir, U., Gümüs, C., and Solak, O. (2010). Is it
possible to anesthetize palatal tissues with buccal 4%
articaine injection? J. Oral Maxillofac. Surg. 68 (5):
1032–1037.
Persson, G., Keskitalo, E., and Evers, H. (1974). Clinical
experiences in oral surgery using a new self‑ aspirating
injection system. Int. J. Oral Surg. 3 (6): 428–434.
Piesold, J., Müller, W., and Dreiβig, J. (1998). An experimental
study on the aspirating reliability of different types of
injection syringes with regard to formation of punch
cylinders. Br. J. Oral Maxillofac. Surg. 36 (1): 39–43.
Primosch, R.E. and Brooks, R. (2002). Influence of anesthetic
flow rate delivered by the wand local anesthetic system on
pain response to palatal injections. Am. J. Dent. 15
(1): 15–20.
Quarnstrom, F. and Libed, E.N. (1994). Electronic anesthesia
versus topical anesthesia for the control of injection pain.
Quintessence Int. 25 (10): 713–716.
Ram, D. and Peretz, B. (2002). Administering local anesthesia
to paediatric dental patients– current status and prospects
for future. Int. J. Paediatr. Dent. 12 (2): 80–89.
Ram, D. and Peretz, B. (2003). The assessment of pain
sensation during local anesthesia using a computerized
local anesthesia (wand) and a conventional syringe.
J. Dent. Child. 70 (2): 130–133.
Ram, D., Hermida, L.B., and Peretz, B. (2002). A comparison
of warmed and room
‑ temperature anesthetic for local
anesthesia in children. Pediatr. Dent. 24 (4): 333–336.
Rankin, J.A. and Harris, M.B. (1985). Patient’s preferences
for dentists’ behaviors. J. Am. Dent. Assoc. 110 (3):
323–327.
Reader, A., Nusstein, J., and Drum, M. (2011). Successful Local
Anesthesia. For Restorative Dentistry and Endodontics.
Chicago: Quintessence Publishing Co, Inc. 132.
Roberts, D.H. and Sowray, J.H. (1987). Local Analgesia in
Dentistry, 3e. Bristol (UK): Wright. 74–77, 87.
Roghani, S., Duperon, D.F., and Barcohana, N. (1999).
Evaluating the efficacy of commonly used topical
anesthetics. Pediatr. Dent. 21 (3): 197–200.
Rood, J.P. (1977). The temperature of local anesthetic
solutions. J. Dent. 5 (3): 213–214.
Rousseau, W.H., Clark, S.J., Newcomb, B.E. etal. (2002). A
comparison of pain levels during pulpectomy, extractions,
and restorative procedures. J. Endod. 28 (2): 108–110.
Saloum, F.S., Baumgartner, J.C., Marshall, G., and Tinkle,
J. (2000). A clinical comparison of pain perception to the
wand and a traditional syringe. Oral Surg. Oral Med. Oral
Pathol. 89 (6): 691–695.
Scott, D.B. (1986). Toxic effects of local anesthetic agents on
the central nervous system. Br. J. Anaesth. 58 (7): 732–735.
Shannon, I.L. and Feller, R.P. (1972). Contamination of local
anesthetic carpules by storage in alcohol. Anesth. Prog. 19
(1): 6–8.
Shannon, I.L. and Wescott, W.B. (1974). Alcohol
contamination of local anesthetic cartridges. J. Acad. Gen.
Dent. 22 (11): 20–21.
Shira, R.B. (1962). Changing concepts in the practice of
exodontic and oral surgery. J. Ontario Dent. Assoc. 39
(1): 8–13.
Simon, J.F., Peltier, B., Chambers, D., and Dower, I. (1994).
Dentist troubled by the administration of anesthetic
injections: long
‑ term stresses and effects. Quintessence Int.
25 (9): 641–646.
t.me/Dr_Mouayyad_AlbtousH
Basic Injection Technique
https://t.me/med1917
240
Smith, A.E. (1920). Block Anesthesia and Allied Subjects. With
Special Chapters on the Maxillary Sinus, the Tonsils, and
Neuralgias of the Nervous Trigeminus for Oral Surgeons,
Dentists, Laryngologists, Rhinologists, Otologists, and
Students. St Louis (MO): CV Mosby Company. 380–524.
Smith, N. (1968). An investigation of the influence of gauge
on some physical properties of hypodermic needles. Part I.
The relation between gauge and flexibility of the needle.
Aust. Dent. J. 13 (2): 158–161.
Snawder, K.D. (1987). Manual de Odontopediatría clínica.
Barcelona: Editorial Labor SA (Spanish translation of:
Handbook of clinical pedodontics. St. Louis: The CV
Mosby Co. 1982). 81–82.
Sokol, D.J., Sokol, S., and Sokol, C.K. (1985). A review of
nonintrusive therapies used to deal with anxiety and pain
in the dental office. J. Am. Dent. Assoc. 110 (2): 217–222.
Spedding, R.H. and Mink, J.R. (1964). An approach to the
injection procedure for the child patient. J. N. J. State Dent.
Soc. 35: 161–168.
St Georges, J. (2004). How dentists are judged by patients.
Dent. Today 23 (8): 96–99.
Stacy, G.C., Orth, D., and Hajjar, G. (1994). Barbed needle and
inexplicable paresthesias and trismus after dental regional
anesthesia. Oral Surg. Oral Med. Oral Pathol. 77 (6):
585–588.
Steinkruger, G., Nusstein, J., Reader, A. etal. (2006). The
significance of needle bevel orientation in achieving a
successful inferior alveolar nerve block. J. Am. Dent. Assoc.
137 (12): 1685–1691.
Thoma, K. and Struve, M. (1986). Untersuchungerzur Photon
und Thermostabilität von Adrenlin
MitteilungzurStabilität von Adrenalin
Acta Helv. 61 (1): 2–9.
Trapp, L.D. and Davies, R.O. (1980). Aspiration as a function
of hypodermic needle internal diameter in the invivo
human upper limb. Anesth. Prog. 49 (2): 49–51.
Tucker, G.T. and Mather, L.E. (1979). Clinical
pharmacokinetics of local anesthetics. Clin.
Pharmacokinet. 4 (4): 241–278.
Tzafalia, M. and Sixou, J.
anesthetics using metal syringes. An exvivo study. Anesth.
Prog. 58 (2): 61–65.
‑ L. (2011). Administration of
‑ Lösungen. 1.
‑ Lösungen. Pharm.
Van der Bijl, P. (1995). Injection needles for dental local
anesthesia. Compend. Contin. Educ Dent. 16 (11):
1106–1115.
Van Wijk, A.J. and Hoogstraten, J. (2006). Reducing fear of
pain associated with endodontic therapy. Int. Endod.
J. 39(5): 384–388.
Van Wijk, A.J. and Makkes, P.C. (2008). Highly anxious
dental patients report more pain during dental injections.
Br. Dent. J. 205 (3): 142–143.
Virts, B.E. (1999). Local anesthesia toxicity review. Pediatr.
Dent. 21 (6): 375.
Visconti, R.P., Tortamano, I.P., and Buscariolo, I.P. (2016).
Comparison of the anesthetic efficacy of mepivacaine and
lidocaine in patients with irreversible pulpitis: a double
blind randomized clinical trial. J. Endod. 42 (9): 1314–1319.
Vreeland, D.L., Reader, A., Beck, M. etal. (1989). An
evaluation of volumes and concentrations of lidocaine in
human inferior alveolar nerve block. J. Endod. 15 (1): 6–12.
Wahl, M., Overton, D., Howell, J. etal. (2001). Pain on
injection of prilocaine with epinephrine. A prospective
double
‑ blind study. J. Am. Dent. Assoc. 132 (10): 1396–1401.
Watson, J.E. and Colman, R.J. (1976). Interpretation of
aspirating test in local anesthetic injections. J. Oral Surg. 34
(12): 1069–1074.
Wepman, B.J. (1978). Psychological components of pain
perception. Dent. Clin. N. Am. 22 (1): 101–113.
Whitworth, J.M., Kanaa, M.D., Corbett, I.P., and Meechan,
J.G. (2007). Influence of injection speed on the
effectiveness of incisive/mental nerve block: a randomized,
controlled, double
J. Endod. 33 (10): 1149–1154.
Williams, M.J.R. and Simm, W. (1975). Practical aspiration for
local anaesthesia. Dent. Update 2 (1): 23–27.
Wiswall, A.T., Bowles, W.R., Lunos, S. etal. (2014). Palatal
anesthesia: comparison of four techniques for decreasing
injection discomfort. Northwest Dent. 93 (4): 25–29.
Woolgrove, J. (1983). Pain perception and patient
management. Br. Dent. J. 154 (8): 243–246.
Zelster, R., Cohen, C., and Casap, N. (2002). The implications
of a broken needle in the pterygomandibular space:
clinical guidelines for prevention and retrieval. Pediatr.
Dent. 24 (2): 153–156.
‑ blind study in adult volunteers.
‑
t.me/Dr_Mouayyad_AlbtousH
14
https://t.me/med1917
Maxillary Anesthesia I: Pulpal Anesthesia
241
Introduction
This chapter on pulpal anesthetic methods for the upper
arch (maxillary) teeth addresses the following procedures.
● Buccal infiltration anesthesia and the variation known
as the modified cotton roll approach.
● Intra- and extraoral infraorbital nerve block as an
approach to block the anterior superior alveolar nerve.
● Posterior superior alveolar nerve block (PSA) and the
variation known as the modified Adatia technique.
● High tuberosity approach to block the maxillary nerve
) through the mucobuccal fold.
(V
2
● Transpalatal approach (also known as the greater palatine
canal technique) to block the maxillary nerve (V
The chapter also reviews certain aspects affecting the
anesthesia of maxillary teeth to provide a fuller understanding of the anesthetics used.
Maxilla
The thin layer of porous cortical bone in the maxilla is
perforated by many small foramina through which the
anesthetic solution can diffuse (DuBrul1988). As the tooth
apices are very close to the cortical surface (Table 2.7,
Chapter2), the technique of choice in most cases is buccal
infiltration, in light of its efficacy, simplicity, and safety.
Another advantage to the technique is that more than one
tooth can be anesthetized with more infiltration.
Maxillary Nerve (V2)
The second division of the trigeminal (cranial nerve V), the
maxillary nerve, distributes to three superior alveolar nerves
(anterior, middle, and posterior) that innervate the dental
pulp. In over 80% of individuals these branches intermingle
).
2
in a superior dental plexus at the dental apices (Table2.3,
Chapter2), although the middle superior alveolar nerve is
missing in just under 50% (Table2.2, Chapter2). As those
circumstances render independent block of each branch
very difficult, the procedure actually used is buccal infiltration near the apex of the teeth, which affects all three.
Buccal Anesthesia ofthe Upper Molars
Inserting the needle in the buccal cavity around the upper
molars may involve three types of anesthetic techniques,
depending on needle depth and angle (Figure 14.1): the
deeper the penetration and the wider the angle, the greater
the number of teeth affected, although the risk of causing
hematomas by penetrating pterygoid plexus vessels is also
greater.
● Buccal infiltration of the molars is the simplest and most
effective technique for anesthetizing molar pulp. As the
needle need not be inserted very deeply, the risk of
hematoma is minimal.
● PSA (Posterior superior alveolar nerve block) or the
tuberosity approach is a more complex technique because
the needle is inserted higher and at a wider angle to skirt
around the posterior wall of the maxilla (tuberosity) and
reach the foramina through which the one to four
branches forming this nerve trunk transmit. This technique anesthetizes molars as well as premolars, albeit
less effectively. The likelihood of causing hematoma is
logically greater with this method and part of its clinical
efficacy is due to the buccal infiltrative effect, for the
solution diffuses across the molars.
● The high tuberosity approach is designed to block the
maxillary nerve (V
) in the pterygopalatine fossa. This
2
technique is even more difficult and arbitrary than the
tuberosity approach due to the lack of osseous references
to guide the needle during injection. The needle is
Local Anesthesia in Dentistry: A Locoregional Approach, First Edition. Jesús Calatayud and Mana Saraghi.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Calatayud/local
t.me/Dr_Mouayyad_AlbtousH
Соседние файлы в папке Библиотека им академика М.И. Перельмана