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Vailland, J.- P. (1985). Use technique originale d’anesthésie
mandibulaire la méthode d’Akinosi. Inform. Dent. 67 (18):
1851–1852.
Vazirani, S.J. (1960). Closed mouth mandibular nerve block:
a new technique. Dent. Digest. 66 (1): 10–13.
Via, W.F. (1953). The pterigomandibular space relation to
effective mandibular block anesthesia for children. J. Dent.
Child. 20: 105–110.
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.
Waikakul, A. and Punwutikorn, J. (1991). A comparative
study of the extradirect technique for inferior alveolar nerve block. J. Oral
Maxillofac. Surg. 49 (8): 804–808.
intraoral landmark technique and the
Watson, J.E. (1973). Appendix: some anatomic aspects of the
Gow-
Gates technique for mandibular anesthesia. Oral
Surg. Oral Med. Oral Pathol. 36 (3): 328–330.
Watson, J.E. and Gow-
evaluation of the GowN. Z. Dent. J. 72 (330): 220–223.
Yamada, A. and Jasstak, J.T. (1981). Clinical evaluation of
the Gow106–109.
Zandi, M. and Sabounchi, S.S. (2008). Design and
development a device for facilitation of Gow- Gates
mandibular block and evaluation of its efficacy. Oral
Maxillofac. Surg. 12 (3): 149–153.
Gates block in children. Anesth. Prog. 28 (4):
Gates, G.A.E. (1976). A clinical
Gates mandibular block technique.
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17
Mandibular Anesthesia II: Complementary Anesthesia
Introduction
Mandibular block does not always lead to anesthesia of
the lingual nerve, and, therefore, of the tissue in the area
of the tongue. Similarly, it does not anesthetize the buccal
nerve or the tissues of the buccal area of the molars
(Annex 29). Consequently, when working on the soft and
hard tissue in this area, it is appropriate to anesthetize
these nerve trunks.
The potency of anesthetic solutions – in terms of the
anesthetic itself and the concentration of anesthetic and
vasoconstrictor– is not important for surgery will be successful, since the buccal and lingual nerves are very superficial and not covered by periosteum, cortex, or aponeurosis.
They therefore become anesthetized with a small volume
of anesthetic solution. In this chapter, we review the following techniques:
● lingual nerve block
● buccal nerve block.
Indications
These techniques do not aim to achieve pulpal anesthesia
but rather complementary anesthesia for mandibular block
in the following cases:
1) Oral surgery and extractions.
2) Scaling and root planning.
3) Subgingival preparations in the following cases:
○ Subgingival restorations.
○ Restorations by cervical caries.
○ Placement of a retraction cord.
○ Retraction of the gingiva at the level of the papilla.
4) Insertion of subgingival matrix bands.
5) Placement of clamps for a rubber dam that penetrate or
pinch the gum in the buccal or lingual area.
Lingual Nerve Block
The lingual nerve is generally anesthetized using mandibular block techniques (Annex 29). However, when this
approach is unsuccessful or it is necessary to anesthetize
the lingual nerve only, the technique is simple and almost
100% successful because the nerve is both superficial and
accessible.
Anesthetized Area
The anesthetized area corresponds to the whole area supplied by the lingual nerve (see Chapter3). This includes the
following:
● Fibromucosa (alveolar mucosa and attached gum), bone,
and periosteum in the lingual area of the whole ipsilateral hemimandible up to the midline.
● Fibromucosa of the floor of the mouth on the ipsilateral
side up to the midline.
● Anterior two- thirds of the tongue, on the ipsilateral side
up to the midline. The nerve also provides proprioceptive
sensation to the musculature of the tongue (Barker and
Davies1972).
Technique
● Use a long needle (35 mm) owing to the very posterior
position to be reached (here, the depth of the insertion is
not important). The caliber used is 25G or 27G: as the
technique is often complementary to mandibular block,
we generally use the same needle.
● Position of the dentist and patient.
○ Dentist at 8:00–9:00 o’clock.
○ Patient semireclined with the head slightly turned
toward the dentist. The patient’s mouth is held
wideopen so that the dentist can reach the floor of
the mouth.
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
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● Separation of the tongue. Using a mirror in the support
hand (left hand in right-
handed persons), the dentist
gently separates the tongue from the lingual surface of
the second and third mandibular molars, thus revealing
the floor of the mouth at this level (Figure17.1).
● The point of insertion of the needle is located on the floor
of the mouth alongside the second and third molars
(Sicher 1946) because at this level the lingual nerve
enters the floor of the mouth relatively close to the lingual bone plate. The nerve then courses forward within
the floor of the mouth, pulling away from the lingual
bony plates, and advances toward the center/interior to
reach the base of the tongue (Figure17.2).
● The needle is inserted 2–4 mm into the floor of the
mouth. The insertion is short since the nerve runs below
the mucous membrane but above the mylohyoid muscle
(Figure3.4, Chapter3), which forms the base of the floor
of the mouth.
● The injection is performed following the minimum
intervention technique (minimum volume/minimum
injection time), which considerably reduces the pain
caused by the injection. The procedure is as follows:
1) Initially inject only one or two drops of anesthetic
solution in 1–2
seconds and wait 60 seconds after
withdrawing the needle. Thus, the soft tissue is anesthetized at the injection site.
2) Perform a second injection at the same site (the blood
spot formed by the first injection may be visible).
Again, inject one or two drops over 1–2 seconds. This
time wait only 30
seconds after removing the needle.
3) After aspiration, perform a third injection at the same
site. However, this time the amount of anesthetic is
Course of
ve
Te rminal
branches
Figure17.2 Course of the lingual nerve along the floor of the
mouth and its terminal branches.
Figure17.1 Anesthesia of the lingual nerve. Injection site.
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314
larger (±1/8 of a cartridge, 0.2–0.25 ml) and is injected
slowly over 7–10
● Aspiration is positive in 1% of cases (Annex 22).
● Subjective symptoms of soft tissue anesthesia, defined by
seconds. Wait 30 seconds.
patients as dullness, numbing, tingling, and swollen
tongue sensation (Table13.1, Chapter13) in the anterior
and lateral areas of the tongue, appears after a few minutes and lasts 1–2
hours.
Complications ofthis Technique
1) Local hematoma at the injection site owing to extrava-
sation of blood from a vessel injured by the tip of the
needle. The lesion is asymptomatic and resolves in a
few days.
2) Rarely, the patient may experience an intense burning
or electric shock sensation that appears suddenly on
half of the tongue or at the tip on the same side as the
injection. This is caused by contact between the needle
and the lingual nerve. There are no sequelae.
3) Very rarely the parapharyngeal area is reached. This
occurs when the needle is placed deep in the mouth, the
insertion is behind the second mandibular molar on
the floor, and the injection is made under a certain
degree of pressure, with the mouth wide open. In this
situation, the tip of the needle passes behind the posterior border of the mylohyoid muscle, and the anesthetic
spreads throughout the area of the carotid triangle, thus
anesthetizing the hypoglossal nerve (XII cranial nerve),
the thyroid nerve, and the internal and external pharyngeal nerves far as the carotid body. This leads to a sensation of anesthesia and swelling in the neck on the
relevant side, thus making it difficult to swallow and
creating a sensation of chest tightness. The heart rate
may also increase (palpitations), as may arterial blood
pressure (Dormer and Barker1976).
Partial Variant asComplementary Anesthesia
The lingual nerve can be partially anesthetized by anesthetizing the floor of the mouth as far as the distal part of the
tooth or the area to be treated (Allen1979; Haglund and
Evers1985; Roberts and Sowray1987). To do so, it is useful
to deflect the needle a little along the shaft to reach the relevant areas easily, especially in the area of the mandibular
incisors, and to insert the needle into the floor of the mouth
alongside the lingual surface of the alveolar process of the
tooth to be reinforced.
This complementary measure is frequently used in the area
of the anterior teeth (Nordenram1971) (Figure17.3) owing to
the presence of cross- innervation and supplementary innervation (see Chapter19). The injection can also be performed
Figure17.3 Anesthesia of the lingual nerve, more anterior
partial variant.
at the level of the premolars (Sutton1974) or second molar
(Murnane1971) to block– in addition to the lingual nerve–
the mylohyoid nerve, which courses in contact with the bone
along a canal in the internal surface of the mandibular body
and immediately under the mylohyoid muscle, which is the
floor of the mouth (Figure3.4, Chapter3).
In any case, complementary lingual anesthetic is precisely that, a complement, since it is fairly unsuccessful as
a technique for achieving pulpal anesthesia (Table17.1).
Buccal Nerve Block
In some older books, this technique is also known as long
buccal nerve block (Sloman1939; Roberts and Sowray1987)
and buccinator nerve block (Sloman1939), both of which
names are incorrect. The buccal nerve is frequently anesthetized using mandibular block techniques (Annex 29),
although when anesthesia is not achieved or only this
nerve must be anesthetized, the technique is simple and
almost 100% successful because the nerve is both superficial and accessible.
This technique is usually applied as a complement to
mandibular block, therefore it is administered after con-
firming soft tissue anesthesia in the lower lip (sign that the
inferior alveolar nerve has been anesthetized and that mandibular block is successful). Previously blocking the buccal
nerve carries a risk of overlap with anesthesia of thelower
lip and may mask a possible failure of mandibular block.
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Table17.1 Percentage of pulpal anesthesia achieved by
complementary lingual anesthesia at the level of the mandibular
molars, when used as the only anesthetizing technique.
Study data
Pulpal
Tooth Reference
Second
molar
Clark etal.
(1991)
Clark etal.
Sample
size ml/LAS
30 1.8/L- 100 7%
30 1.8/L-
anesthesia
(%)
100 17%
(1991)
First
molar
Sillanpää
etal. (1988)
Clark etal.
29 1.8/P-
30 1.8/L-
03 21%
100 7%
(1999)
Second
premolar
LAS, local anesthetic solution; L- 100, lidocaine 2% with epinephrine
1:100 000 (10 μg/ml); P- 03, prilocaine 3% with felypressin 0.03 IU/ml
(0.54 μg/ml).
Clark etal.
(1999)
30 1.8/L-
100 10%
Anesthetized Area
The anesthetized area corresponds to the area supplied by
the buccal nerve (see Chapter3), as follows:
● Fibromucosa (alveolar mucosa and gum), bone, and per-
iosteum in the buccal area of the lower molars, although
this can vary. Thus, in 10% of cases the nerve only supplied the buccal area of the retromolar trigone (Hendy
and Robinson1994); in contrast, in less than 1% of cases
it can reach the buccal area of the lower canine (Stewart
and Wilson1928; Stewart1932; Sicher1950; Singh1981)
(Figure3.3, Chapter3).
● The buccal mucosa of the posterior part of the mouth
and the upper part of this area in many cases.
● In 80–90% of cases, this nerve is mainly sensitive, provid-
ing a motor supply to the lateral pterygoid muscle
(external) (Kim etal.2003).
● It can occasionally give off branches to supply the pulp
of the mandibular molars (Schejtman et al. 1967;
Sutton1974; Ossenberg1986).
Technique
● The technique requires a long needle (35 mm) owing to
the need to reach back into the oral cavity (depth of
insertion is not important). The caliber can be 25G or
27G. Since the technique very often complements mandibular block, the same needle is generally used.
● Position of the dentist and patient.
○ Dentist at 8:00–9:00 o’clock.
○ Patient semireclined with the head turned slightly
toward the dentist. The mouth is moderately open in
order to separate the cheek tissue.
● The dentist uses the fingers of his/her support hand (left
hand in right-
handed dentists) to separate the buccal
mucosa in order to better view the area.
○ On the patient’s right side, the dentist puts the index
finger inside the mouth.
○ On the left side of the patient, the dentist puts his
thumb inside the mouth and tends to embrace the
patient’s head with his arm.
● The syringe is placed parallel to the occlusal plane of
the molars.
● Insertion point. Various approaches are possible
(Sloman1939), although we have selected the most common (Figure17.4):
○ High insertion point. The needle is inserted into the
anterior border of the ramus of the mandible, close to
and within the oblique line (external) and at the level
of the occlusal plane of the inferior molars or somewhat higher. In this area, the buccal nerve crosses the
anterior border of the ascending branch and is superficial, at some 2 mm below the mucous membrane
(Sloman1939; Phillips1943).
○ Low insertion point. The needle is inserted into the
bottom of the buccal area alongside the inferior
molars, generally in the alveolar mucosa below the
mucogingival line of the last molar, although it can be
inserted below any of the molars. This block usually
anesthetizes terminal branches.
● Insert the needle 2–4 mm. If it touches the bone, it should
be withdrawn 1–2
● Inject the solution following the minimum intervention
mm.
technique (minimum volume/minimum injection time),
which considerably reduces the pain caused by the injection. The procedure is as follows:
1) Initially inject only one or two drops of anesthetic
solution in 1–2 seconds and wait 60 seconds after
withdrawing the needle. Thus, the soft tissue is anesthetized at the injection site.
2) Perform a second injection at the same site (the blood
spot formed by the first injection is sometimes visible). Again, inject one or two drops over 1–2 seconds.
This time wait only 30 seconds after removing
the needle.
3) Then perform a third injection at the same site.
However, this time the amount of anesthetic is larger
(±1/8 of a cartridge, 0.2–0.25 ml) and is injected
slowly over 7–10 seconds after aspiration. Wait
30 seconds.
● Aspiration is positive in 1% of cases (Annex 22).
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2
1
2
1
1
Figure17.4 Anesthesia of the buccal nerve. (1) High insertion in the anterior border of the ramus; (2) low insertion in the buccal area
of the inferior molars.
● Subjective symptoms of soft tissue anesthesia, defined by
patients as dullness, numbing, tingling, and swollen lip
sensation (Table13.1, Chapter13), are rarely felt by the
patient or are only felt weakly in the lower lip, therefore
it is advisable to wait 2–3 minutes for the anesthetic to
take full effect. The duration of anesthesia is 1–2
hours
Specific Complications ofthis Technique
The most common complication is hematoma at the injection site resulting from extravasation from a vessel injured
by the tip of the needle. The lesion is asymptomatic and
resolves spontaneously in a few days.
References
Allen, G.D. (1979). Dental Anesthesia and Analgesia (Local
and General), 2e. Baltimore: Williams and Wilkins. 114.
Annex 22. Positive aspirations.
Annex 29. Mandibular block VI. Lingual and buccal nerve
anesthesia.
Barker, B.C.W. and Davies, P.L. (1972). The applied anatomy
of the pterygomandibular space. Br. J. Oral Surg.
10(1): 43–55.
Clark, S., Reader, A., Beck, M., and Meyers, W. (1991).
Evaluation of mylohyoid and myloyoid/IAM blocks in
human mandibular anesthesia. J. Endod. 17 (4): 194.
(abstract no. 28).
Clark, S., Reader, A., Beck, M., and Meyers, W.J. (1999).
Anesthetic efficacy of the mylohyoid nerve block and
combination inferior alveolar nerve block/mylohyoid
nerve block. Oral Surg. Oral Med. Oral Pathol. 87 (5):
557–563.
Dormer, B.J. and Barker, B.C.W. (1976). A rare local
anesthetic misadventure. Case report and anatomic
considerations. Oral Surg. Oral Med. Oral Pathol. 41 (3):
300–307.
Haglund, J. and Evers, H. (1985). Local Anaesthesia in Dentistry,
6e. Södertäleje (Sweden): Astra Läkemedel AB. 46, 49.
Hendy, C.W. and Robinson, P.P. (1994). The sensory
distribution of the buccal nerve. Br. J. Oral Maxillofac.
Surg. 32 (6): 384–386.
Kim, H.J., Kwak, H.H., Hu, K.S. etal. (2003). Topographic
anatomy of the mandibular nerve branches distributed on
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the two heads of the lateral pterygoid. Int. J. Oral
Maxillofac. Surg. 32 (4): 408–413.
Murnane, T.W. (1971. Cited by: Frommer J, Mele FA, and
Monroe CW (1972).). The possible role of the mylohyoid
nerve in mandibular posterior teeth sensation. J. Am. Dent.
Assoc. 85 (1): 113–117.
Nordenram, A. (1971). Manuel d’anesthesie locale
enpractiquedentaire. Mölndal (Sweden): Lindgren and
Söner. Bofors Nobel- Pharma. 29.
Ossenberg, N.S. (1986). Temporal crest canal: case report and
statistics on a rare mandibular variant. Oral Surg. Oral
Med. Oral Pathol. 62 (1): 10–12.
Phillips, W.H. (1943). Anatomic considerations in local
anesthesia in dental surgery. Anesth. Analg. 22 (1): 5–14.
Roberts, D.H. and Sowray, J.H. (1987). Local Analgesia in
Dentistry, 3e. Bristol (UK): Wright. 124.
Schejtman, R., Devoto, F.C.H., and Arias, N.H. (1967). The
origin and distribution of the elements of the human
mandibular retromolar canal. Archs. Oral Biol. 12 (11):
1261–1267.
Sicher, H. (1946). The anatomy of mandibular anesthesia.
J. Am. Dent. Assoc. 33 (23): 1541–1557.
Sicher, H. (1950). Aspects in the applied anatomy of local
anesthesia. Int. Dent. J. 1 (1): 70–82.
Sillanpää, M., Vuori, V., and Lehtinen, R. (1988). The
mylohyoid nerve and mandibular anesthesia. Int. J. Oral
Maxillofac. Surg. 17 (3): 206–207.
Singh, S. (1981). Aberrant buccal nerve encountered at the
third molar surgery. Oral Surg. Oral Med. Oral Pathol.
52(2): 142.
Sloman, E.G. (1939). Anatomy and anesthesia of the
buccinator (long buccal) nerve. J. Am. Dent. Assoc. 26 (3):
428–434.
Stewart, D. (1932). The innervations of the dental tissues and
its importance in regional anaesthesia. Br. Dent. J. 53 (6):
277–284.
Stewart, D. and Wilson, S.L. (1928). Regional anaesthesia and
innervations of the teeth. Lancet 212 (5486): 809–811.
Sutton, R.N. (1974). The practical significance of mandibular
accessory foramina. Aust. Dent. J. 19 (3): 167–173.
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18
Supplementary Techniques inCases ofFailure
Introduction
Supplementary techniques are applied only in the case of
failure of conventional local anesthetic techniques, such as
those mentioned above, therefore they are not firstprimary techniques. All of these techniques have special
characteristics:
1) They are sufficiently powerful to achieve pulpal anesthesia.
2) They are self- limiting in their extension and their effect
is very localized (they cover very few adjacent tissues),
therefore they are not efficacious as primary techniques
in the case of wider procedures that involve both soft
and hard tissue.
3) Their action is independent of anatomical variations, such
as accessory innervations or cortical thickness, which usually affect the efficacy of conventional techniques.
4) Anesthetic solutions enter the bloodstream easily and
quickly, therefore it is important to take into account the
following:
○ The total dose administered is limited. Their advan-
tage is that the dose required is very low.
○ Aspiration is unnecessary since this is very often pos-
itive (almost intravascular).
5) Anesthetics with a long- lasting effect in the soft tissues,
such as bupivacaine, etidocaine, and ropivacaine, are
contraindicated because they do not improve the efficacy of pulpal anesthetic (Johnson etal.1985; McLean
etal.1992; Hull and Rothwell1998; Meechan2002). In
addition, since they enter the systemic bloodstream easily, they increase toxicity.
6) They are usually painful when used as primary techniques.
In this chapter, we shall address four techniques. However,
the intraseptal technique can be considered a hybrid of the
periodontal ligament technique (PDL) and intraosseous
techniques. The techniques are as follows:
● Intrapulpal.
● PDL.
choice,
● Intraseptal.
● Intraosseous.
Intrapulpal Anesthesia
This supplementary technique is applied when traditional
methods fail, therefore the adjacent tissues are usually
anesthetized, even if the dental pulp remains sensitive. The
method consists of the injection of anesthetic solution
directly into the dental pulp when the chamber is open.
This approach is indicated in two situations:
1) In endodontic treatments, where the pulp chamber is
open and remains sensitive to contact with instruments
(the most common situation).
2) In surgical extractions in which the tooth is cut and
remains sensitive (Berini and Gay1997).
Below, we analyze two intrapulpal techniques, as
follows:
● The traditional technique (the most frequent).
● The topical anesthesia technique.
Traditional Technique
Keys toa Successful Approach
1) The pressure of the injection of anesthetic solution on
the pulp (Birchfield and Rosenberg1975; Van Gheluwe
and Walton1997). Experiments have shown that 100%
of injections are unsuccessful if there is no pressure
(Van Gheluwe and Walton1997) and that injection of
saline solution under pressure can be effective in a high
percentage of patients (Birchfield and Rosenberg1975;
Van Gheluwe and Walton1997).
2) An anesthetic solution with vasoconstrictor such as the
standard solution of lidocaine 2% with epinephrine
1:100 000 (10 μg/ml) (L- 100). Experiments have shown
that a 90% success rate is achieved with saline solution,
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
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but that a 100% success rate is achieved with L- 100 (Van
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Gheluwe and Walton1997). Higher concentrations of
anesthetic and/or vasoconstrictor are not recommended
because the anesthetic solution passes easily into the
systemic bloodstream (Lamian and Simard- Savoie1979;
Smith and Smith1983a), although this step is limited by
apical constriction and residual pulp (Smith and
Smith1983a).
These recommendations enable 100% pulpal anesthesia,
even in patients with irreversible, anesthetic-
resistant acute
pulpitis (Dreven et al. 1987; Cohen et al. 1993; Nusstein
etal.1998: Parente etal.1998).
Intrapulpal Technique
● 27G or 30G short needle (20–25 mm). If the needle is to
be inserted into the radicular pulp canal, then the finer
the better. It is usually necessary to bend the needle
along its stem to facilitate insertion. The needle should
not be bent at the hub, which is the weakest part and
where it most commonly breaks.
● A little hole should be made in the pulp chamber to insert
the needle. If the hole is too big, the anesthetic cannot be
inserted under pressure and the solution will leak from
the chamber. This can be avoided by placing a cotton wool
ball in tweezers and pressing it against the needle inserted
into the chamber to prevent reflux and maintain pressure
(Walton1990) (Figure18.1).
● The patient should be warned that he/she will feel
“intense discomfort” at the beginning of the injection,
although this will be very brief (Miles1983).
● The needle should be placed firmly with the fingers in the ori-
fice and a few drops should be injected under pressure into the
pulp chamber. In the case of multirooted teeth, if discomfort
is felt in a canal as result of the instruments, the tip of the
needle is inserted into the entrance of the canal, the needle
is held firmly, and the solution is injected under pressure in
such a way that it reaches the apex (Smith and Smith1983a).
If it is not possible to maintain pressure, place a cotton ball
(see above) to maintain pressure and prevent reflux.
● After the injection, wait 30 seconds before starting to
work. The anesthetic is working if the instruments can
be introduced into the canals without pain. If the patient
continues to experience discomfort, repeat the maneuver
with emphasis on maintaining pressure (Van Gheluwe
and Walton1997).
Topical Anesthetic Technique
This approach involves placing topical anesthetic gel (generally benzocaine 20%) into the root canals with endodontic files (DeNunzio1998). Although this technique can be
used as an alternative to the traditional technique, it is
Intrapulpal Anesthesia 319
Tweezers
Cott
Figure18.1 Traditional intrapulpal technique in which a
cotton wool ball has been placed in the pulp chamber to
prevent reflux and maintain pressure during the injection.
mainly used in cases of sensitive, twisted, and narrow
canals where the needle cannot be appropriately positioned to maintain injection pressure.
Technique
● Cover the tip of a no. 10 or 15 file with benzocaine 20%
gel. It is very important for the gel to be viscous so that it
adheres to the metal, therefore it should be kept at a low
temperature. If the gel is very thin, having a liquid- like
consistency due to high ambient temperatures, it can be
placed in the refrigerator.
● Insert the file into the canal and file for a few seconds.
One or two applications is usually sufficient, except in
extremely sensitive patients, who may require more time
and more applications.
● Any benzocaine gel remaining in the chamber can act as
a reservoir for anesthesia of other canals in multirooted teeth.
● Once anesthesia is achieved, abundant irrigation can be
applied to remove any remaining anesthetic from the
canal. If irrigation is with hypochlorite, the benzocaine
can turn a dark reddish- orange color. This also occurs if
benzocaine mixes with blood. The color has no clinical
relevance.
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Periodontal Ligament Technique (PDL)
This technique is also known as the intra- alveolar, intraperiodontal, intrasulcular, intraperiosteal, transligamentary, intraligamentary, or peridental technique (Nevin and
Puterbaugh1949; Mulkey1976). The method involves trying to inject the anesthetic solution under pressure across
the periodontal ligament and cancellous bone to reach
the apex.
According to Nevin and Puterbaugh, this technique was
first used in 1895 (Nevin and Puterbaugh1949). The oldest
reference we were able to find was by Emilie Sauvez from
Paris in 1905 (Sauvez1905), although it is not referenced as
the original. Cassamani wrote a doctoral thesis on this technique in 1924 (Cassamani1924), but this remained outside
the scientific literature until the 1970s, when it was discussed in the studies of Robert Lafargue and Chenaux
(Lafargue1973; Chenaux et al.1976). In 1981, a study by
Richard Walton and Bernard Abbott made this technique
known in English (Walton and Abbott1981). Since then the
number of his published scientific studies has increased.
Indications andContraindications
Indications
1) When the habitual anesthetic techniques fail (Council on
Dental Materials, Instruments, and Equipment 1983;
Johnson et al. 1985; Cowan 1986; Walton 1990;
Meechan 1992). This is the basic indication since the
duration of pulpal anesthesia is short and postdiscomfort is common, as is the risk of periodontal lesions
(see below).
2) In patients with severe hemophilia- associated coagula-
tion disorders (Sachs etal.1978; Pin1987; Spuller1988)
or patients with high international normalized ratio
(INR) taking anticoagulants (see Chapter 8), truncal
block techniques (such as mandibular block, hightuberosity technique, or transpalatal technique) can be
replaced by the PDL technique.
injection
○ Children with severe coagulation abnormalities
(Spuller1988) (see above).
○ Computer- controlled PDL injections (The Wand)
because pressure is controlled (Table18.2) and there
are no enamel abnormalities (Ashkenazi etal.2010).
2) Teeth with advanced periodontal disease (Rakusin
etal.1986), given that this can compromise periodontal
support. Logically, teeth with periodontal disease that
are to be extracted are an exception.
3) Infection at an injection site with cellulitis or abscess,
given that this can be very painful and it may not be possible to achieve deep anesthesia (Reader et al. 2011;
Council on Clinical Affairs2015).
Diffusion ofthe Solution
With the needle inserted in the gingival sulcus and firmly
placed between the alveolar crest and the neck of the root
of the tooth, the strong pressure exerted on the anesthetic
solutions leads the solution to diffuse through two sites
(Figure18.2):
1) The periodontal ligament (Dreyer et al. 1983; Fuhs
etal.1983). Small quantities pass through to the periodontal ligament. Larger quantities cannot pass in
humans, the width of the ligament is 0.13–0.21
(Coolidge 1937), the interval ranges from 0.06 to
0.35 mm (Kronfeld1931), and the finest 30G needle has
a caliber of 0.3
mm, thus restricting direct passage to the
ligament. However, part of the solution penetrates via
C
mm
Contraindications
1) In primary teeth (Brännström etal.1984). Even though
experimental studies in animals have demonstrated
that solution injected using this procedure is distributed
between the bony crypt and the enamel organ without
penetrating the organ and with minimal apparent risk
(Tagger etal.1994a), experiments in monkeys revealed
increased enamel abnormalities in the permanent teeth
below the primary teeth that are injected using the PDL
technique (Brännström et al. 1984), although these
abnormalities are minimal. The exceptions to this contraindication are as follows:
Capillary
Figure18.2 Diffusion of the anesthetic solution along the
periodontal ligament and along the fenestrations of the alveolar
bone wall and of the subperiosteal orifices.
t.me/Dr_Mouayyad_AlbtousH
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