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370
Foot Control
The foot control serves to control the injection rate and
enable aspiration:
1) Injection flow rate, from very fast to slow.
2) Aspiration, after activation of this function by pressing a
button on the CPU (aspiration button). In the original
devices, aspiration lasted 14
seconds (Goodell etal.2000).
In more modern devices, however, this time has been
reduced to 5
seconds (Saloum et al. 2000; Nicholson
etal.2001).
The injection flow rate also warns us using acoustic and
visual signals:
1) Acoustic. A soft “beep” sounds every time a drop is
injected.
2) Visual. The original devices had lights on the front part
of the CPU. Today’s devices have a screen that tells us
the exact volume of solution administered and the pressure of the injection.
The huge advantage of the foot control is that it leaves the
hands free throughout the injection and aspiration procedure so that the dentist can concentrate on guiding and controlling the needle. Furthermore, during aspiration, traction
on the plunger with the thumb on the ring in the conventional technique meant that, for a second, the needle moved
uncontrollably and almost imperceptibly. An invitro study
performed in 2016 showed how this movement of the tip of
the needle was 2.5 mm with conventional cartridge syringes,
but less than 1
mm with The Wand, precisely because of the
control provided by the foot control (Kämmerer etal.2016).
Handpiece
The handpiece is made of single- use plastic in the form of
an ultralight pencil. It looks like a wand, with a long, fine
shaft that is held in a pen grasp and with a type of head at
the most anterior part, where a needle with a Luer lock fitting is screwed into its nozzle (Figure20.6).
This shape makes for a highly precise, maneuverable,
and flexible device that increases tactile sensitivity
(Hochman et al.1997) and ensures that the needle is in
contact with the fingers, almost an extension of them.
Therefore, it is easier to use than conventional syringes, in
which the fingers are far from the needle in order to support the body of the syringe and retract the plunger
(Krochak and Friedman1998).
A 60-
in. (5 ft or 1.5 m) sterile microtubing enters the posterior part of the head and connects the cartridge, which is
located on the upper part of the CPU, with the nozzle of the
head of the wand, into which the needle is screwed. To prevent cross- contamination, the microtubing, the handpiece,
and the cartridge are single use (Nusstein etal.2004a).
Figure20.6 Method of holding the handpiece in a pen grip.
Fingers close to the head of the handpiece.
The long posterior shaft of the handpiece can be broken
down to only the head with the needle and its connection
to the microtubing in such a way that it is even more manageable, as if the needle was being held with the fingers.
Needles
The handpiece accepts needles that are compatible with a
Luer lock. These are screwed into the nozzle on the head.
While various brands are available, the most widely used
are those from Becton-
Dickinson Co. Table20.5 shows the
different calibers and lengths of needle.
Set- up
The system uses conventional 1.8- ml cartridges, which are
loaded into the plastic cartridge support and adjusted to an
opening in the upper part of the CPU. This houses the piston, which is controlled by the microprocessor so that the
Table20.5 Caliber andlengths ofneedles frombrands used
withThe Wand.
Length
Needle Caliber
Extrashort 30G 12 ½ Becton Dickson Co
32G 12 ½ Misana- Dental
27G 12 ½ Monojet
Short 30G 25 1 Becton Dickson Co
30G 25 1 J. Morita
30G 25 1 Sherwood Medical
Long 27G 30 1
BrandMillimeters Inches
(TycoHealthcare)
1/4
Becton Dickson Co
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head of the piston fits into the plunger of the cartridge
(Krochak and Friedman1998).
The single-
use microtubing that crosses the diaphragm
of the nozzle of the cartridge holder socket is inserted into
the far end of the plastic support. The microtubing reaches
the head of the handpiece (wand) to deliver the anesthetic
solution.
Once the system is set up, it is started by pressing on the
foot control. The system primes the microtubing with local
anesthetic, purging the system from any air. The priming
volume (of the microtubing) is 0.4 ml, leaving only 1.4 ml
in the first cartridge for administration to the patient.
As with conventional systems, the cartridge, needle, and
microtubing are disposed of, since they are contaminated
with blood, plasma, or tissue fluids in each aspiration, even
when the aspiration is negative (Trapp and Davies1980).
Advantages andDisadvantages
● Disadvantages:
1) The device is expensive, and new microtubing and
handpiece must be used for each patient.
2) Lost volume of 0.4 ml of local anesthetic solution
from the first cartridge when priming the microtubing.
3) The injection process takes several minutes.
4) The operator must undergo a learning curve– albeit
short– before mastering the hand-
● Advantages:
foot technique.
1) The injection method is almost painless in most
cases, or at least less so than with conventional methods (Annex 32).
2) The needle moves very little during aspiration
(<1
mm) (Kämmerer etal.2016).
3) As we will see below, new anesthetic techniques can
be used, namely, P-
AMSA and P- ASA. The outcomes
of these techniques are more favorable with The
Wand than with conventional manual syringes (Lee
etal.2004).
P- AMSA
P- AMSA stands for palatal approach to the anterior and
middle superior alveolar nerves. The technique was devised
by Ronald P. Spinello in 1996 during the development of
the prototypes of The Wand, specifically for this device
(Friedman Friedman and Hochman1997,1998). The technique can also be applied using conventional techniques,
although it is not as successful (Lee etal.2004) and is more
painful (Nusstein etal.2004b).
The P- AMSA technique aims to anesthetize the anterior
and middle superior alveolar nerves from the palate, with a
slow and pressurized injection that enables the anesthetic
solution to penetrate through the many small accessory
foramina of the palate (Friedman and Hochman 1999).
The objective is to achieve pulpal anesthesia of the incisors, canines, and premolars, as well as of the palatal fibromucosa on the same side.
Anesthetized Area
● Teeth, pulp, and periodontal ligament of the central and
lateral incisor, canine, and maxillary premolars on one
side (Friedman and Hochman 1998, 2001; Fukayama
etal.2003; Lee etal.2004).
● Palate, including fibromucosa, periosteum, and bone of
the whole palatine hemiarch, up to the midline, from the
central incisor to the area of the molars (Lee etal.2004).
● Vestibule. Fibromucosa of the gingiva and interdental
papillae and periosteum of the teeth where pulpal anesthesia is achieved.
Note: We do not anesthetize the alveolar mucosa, lips,
nose, or the muscles of facial expression. If the solution is
administered bilaterally, anesthesia is, in theory, from the
second maxillary premolar to the contralateral second
maxillary premolar.
Technique
● Use extrashort 30G needles (12 mm) compatible with a
Luer lock (Friedman and Hochman1997,1998,2001) or
short 27G needles (25 mm) (Lee et al. 2004; Nusstein
etal.2004b).
● Position of dentist and patient:
○ The dentist places him/herself at 7:00–8:00 o’clock for
block on the right side and at 11:00 o’clock for block on
the left side.
○ The patient lies back horizontally, with his/her head
back, the neck well extended (hyperextension), and
the mouth open as far as possible so that the dentist
can see the palate clearly. The patient’s head can be
turned right or left depending on the approach.
● Warn the patient about the following (Lee et al. 2004;
Nusstein etal.2004b):
○ Administration of the anesthetic may take 4–5 minutes.
○ He/she will hear sounds during administration; these
are only warnings from the computer.
○ There may be some discomfort in the palate. This
affects only one area, is over quickly (1–2 seconds),
and is followed by a sensation of pressure.
● The handpiece (wand) is held in a pen grasp (Figure20.6),
with the right hand (for right- handed operators), and the
palate is approached from the area of the contralateral
maxillary premolars (Friedman and Hochman2001).
● The needle is inserted at the midpoint between the pala-
tal gingival margin between the first and second premolars and the midline of the palate (Figure20.7).
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Figure20.7 Needle injection site in P- AMSA.
● In the palate, the needle is directed toward the teeth
(premolars) with the bevel parallel to the palate and an
approximately 45° angle between the needle and the palate.
● Insertion of the needle using two similar approaches:
1) After the first contact with the mucosa, the solution is
injected slowly, drop by drop, to ensure that the anesthetic penetrates from the start.
2) Alternatively, a cotton swab can be used to press
firmly down on the palatal mucosa during insertion
to reduce discomfort and absorb the excess anesthetic
that oozes out during the first drops of the injection.
● Advancing the needle. Once the needle is inside the pala-
tal fibromucosa and while the solution is being injected
drop by drop, we can advance it in two ways. However,
the needle should be rotated biaxially with the fingers
(45° clockwise, 45° anticlockwise) (Figure20.8):
1) Advancing with pauses (Lee et al. 2004; Nusstein
et al. 2004b), together with pressure from a cotton swab:
■ Advance 1–2 mm.
■ Short pause and injection of three or four drops in
more or less 4 seconds (four beeps).
■ Advance a further 2–4 mm until the needle is just
touching the bone, then smoothly withdraw the
needle by 1 mm.
■ Short pause and injection of a further four drops in
more or less 4 seconds (four beeps).
■ Withdraw the swab. Palatal blanching can be
observed.
Figure20.8 Biaxial and bidirectional rotation of the needle with
the fingers approximately 45° clockwise and 45° anticlockwise
while advancing the needle.
2) Continuous advance (Friedman and Hochman
1997, 1998):
■ Advance smoothly and slowly while injecting
drop by drop until the bone is reached. Then withdraw the needle slowly by 1 mm (Friedman and
Hochman2001).
■ Palatal blanching will be observed as the anesthetic
solution enters the palate.
● The aspiration cycle is activated with the foot control.
● Slow injection, drop by drop:
○ The amount to be injected can be:
■ Up to 1 ml in children.
■ 0.6–0.9 ml in adults (Friedman and Hochman 1997,
1998) or up to 1.4
ml (Friedman and Hochman1997;
Lee etal.2004; Nusstein etal.2004b). Remember that
the maximum amount in the first cartridge is 1.4 ml.
○ If anesthetic solution leaks out, then the needle should
be repositioned.
○ Monitor excess blanching by periodically pausing the
injection so that the solution can spread and there is
no risk of palatal ulcer due to excessive pressure.
● After the injection, which takes 3–5 minutes, wait 5–10 sec-
onds before withdrawing the needle, since:
○ This reduces reflux of the anesthetic to the exterior.
If the needle is withdrawn quickly, residual pressure in the tissues tends to expel part of the solution
through the opening left by the needle (Nusstein
etal.2004b).
○ Observe how blanching of the palate extends first for-
ward toward the incisive papilla and then backwards
toward the soft palate but without passing the midline
(Lee etal.2004).
● Pulpal anesthesia takes a further 10–20 minutes to
achieve (Corbett etal.2010).
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● Final remarks:
○ This technique must sometimes be reinforced with an
extra 0.9
○ Talk to the patient throughout the process to distract
ml of solution.
him/her and verify how he/she is feeling.
Efficacy of the P- AMSA Technique
The clinical outcomes are similar to those of conventional
techniques (Annex 32). Studies on pulpal anesthesia evaluated using an electrical pulp tester yield more modest
results (Table20.6), with approximately 40% in the central
incisor and around 70% in the lateral incisor, canine, and
first and second premolars.
Another important factor to take into account is that
onset of pulpal anesthesia is slow, i.e. 15–20
minutes
(Fukayama etal.2003; Lee etal.2004; Corbett etal.2010),
possibly because the anesthetic solution has to cover some
distance from the palatine process to the apexes of the tooth.
Specific Complications ofthis Technique
1) The technique causes moderate or severe pain in 20% of
patients during the procedure (Table20.7).
2) Inflammation of the palate at the injection site in less
than 10% of cases, and postoperative pain in less than
10%, which lasts 1–2 days before resolving spontaneously (Nusstein et al.2004b). Palatal ulceration is rare
but may occur.
Table20.6 Percentage of pulpal anesthesia, evaluated using
an electric pulp tester, after injection of standard solution
(L- 100) with the and The Wand.
Fukayama etal.
(2003)
Tooth
Central incisor 45% 35% 43%
Lateral incisor 65% 58% 75%
Canine 85% 52% 77%
First premolar 65% 42% 68%
Second
premolar
L- 100 is lidocaine 2% with epinephrine 1:100 000 (10 μg/ml).
Table20.7 Percentage ofpain caused by P- AMSA
withTheWand.
Reference Pain
Friedman and Hochman (1997) 4%
Fukayama etal. (2003) 15%
Nusstein etal. (2004b) 38%
1.4 ml
75% 55% 86%
Average 20%
Lee etal.
(2004)
1.4 ml
Corbett etal.
(2010)
1 ml
Advantages of the P- AMSA Technique
1) Only 20% of patients complain that the P- AMSA tech-
nique using The Wand was painful or uncomfortable
(Table20.7), even though it was in the palate, the most
painful area for injection in the mouth (Annex 23).
2) There is no soft tissue anesthesia affecting the lips,
face, or muscles of facial expression, therefore it is very
useful in aesthetic evaluations of the teeth and lips
along the smile line (Friedman and Hochman 1998;
Fukayama et al. 2003; Lee et al. 2004). It has been
reported that only 15% of patients experienced soft tissue anesthesia lasting under 2
hours in the upper lip
(Corbett etal.2010).
3) It achieves pulpal anesthesia of five maxillary teeth
(central incisor, lateral incisor, canine, first and second
premolars) with a single injection and a low dose of
anesthetic solution (Friedman and Hochman 1998;
Gibson etal.2000).
P- ASA
P- ASA is the acronym for palatal approach to the anterior
superior alveolar nerve. The technique was developed by
Mark J. Friedman in 1999 specifically for The Wand
(Friedman and Hochman1999) and is a variation of nasopalatine nerve block that is applied to try to anesthetize
the dental pulp of six anterior teeth, from canine to
canine. The P-
ASA technique is used to anesthetize the
nasopalatine nerve and anterior superior alveolar nerves
by means of a slow injection at a constant pressure that
enables the anesthetic to reach the dental pulp painlessly.
Therefore, this technique is different from conventional
injection of the nasopalatine nerve, in that the needle
penetrates more deeply, and a higher quantity of anesthetic is injected to anesthetize the dental pulp (Nusstein
etal.2004a).
Anesthetized Area
● Teeth, pulp, and periodontal ligament of the central
incisor, lateral incisor, maxillary canine on both sides,
that is, the six anterior teeth (Friedman and Hochman
1999, 2001).
● Palate, including the fibromucosa, periosteum, and bone
of the whole anterior third of the palate supplied by
nasopalatine nerve.
● Buccal. Fibromucosa of the gingiva and interdental
papillae, bone, and periosteum of the six anterior and
maxillary teeth.
Note that there is no anesthesia of the alveolar mucosa,
upper lip, nose, or muscles of facial expression (Ram and
Kaissirer2006).
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Technique
● Use Luer Lock–compatible 30G extrashort needles
mm) (Friedman and Hochman1999,2001; Ram and
(12
Kaissirer 2006) or 25-
mm needles (Burns et al. 2004;
Nusstein etal.2004a).
● Position of the dentist and patient:
○ Right- handed dentist at 10:00–12:00 o’clock.
○ Patient reclining horizontally with the head back-
wards, the neck extended (hyperextension), and the
mouth open as wide as possible so that the dentist
has a clear, direct view of the palate (Friedman and
Hochman1999).
● Warn the patient of the following (Nusstein etal.2004a):
○ Administration of the anesthetic solution takes some
time, 4–5
○ The patient will hear sounds during administration.
minutes.
These are warnings from the computer.
○ The palate will be anesthetized but not the upper lip
or face.
○ The patient may initially notice some small and short
discomfort in the palate (1–2
seconds) and then a cer-
tain feeling of pressure.
● The dentist takes the handpiece (The Wand) in a pen
grasp, using the right hand (for right-
handed dentists),
and approaches the incisive papilla between the two central incisors in the on the right side (Figure20.9).
● Insertion of the needle:
○ Press the papilla firmly with a cotton swab from the
left side with the supporting hand (that is, the left
hand in right-
○ Insert the needle into the lateral groove of the incisive
papilla on the right-
handed dentists).
hand side, with the bevel parallel
to the palate just below the point where the cotton
swab is being pressed.
○ Start a slow flow with the foot pedal (drop by drop)
while maintaining pressure with the cotton swab for
6–8
seconds (six to eight beeps).
Note: The cotton swab helps to do the following:
1) Reduce the discomfort from needle insertion and the
injection.
2) Absorb the anesthetic that flows back into the mouth
during the injection.
● Advancing the needle:
○ Rotate the needle biaxially with the fingers (45° clock-
wise, 45° anticlockwise) (Friedman and Hochman
1999; Burns etal.2004). This is also known as bidirectional rotation and helps the needle to penetrate the
tissues (Figure20.8) with minimal resistance and discomfort as it advances slowly:
■ With advance- pause cycles. Thus, advancing
1–2
mm, followed by a pause of 4–5 seconds (four or
five beeps), advancing a further 1–2
by a pause of 4–5
■ Throughout this period, the solution is injected
seconds.
mm followed
steadily and slowly (drop by drop).
○ After this maneuver, withdraw the cotton swab.
Blanching of the papilla is observed.
● Reorientation of the needle to enter the incisive canal.
○ Slightly withdraw the needle and redirect it parallel to
the axes of the maxillary central incisors. Solution is
not injected during this maneuver.
○ Advance in the new direction:
■ By rotating the needle biaxially (see above).
■ By advancing in advance- pause cycles, i.e. advanc-
ing 1–2
seconds followed by a pause of 2–6 seconds.
■ The solution is injected steadily and slowly through-
out this period.
○ If the needle makes contact with the bone (25% of
cases) (Burns etal.2004; Nusstein et al. 2004a), stop
injecting and redirect the needle to ensure that it is in
the canal.
○ During the maneuver, it is useful for the assistant to
have the suction cannula near the needle to aspirate
the drops of anesthetic that flow back, thus stopping
them from entering the patient’s mouth.
● Final injection and position:
○ The needle is advanced with advance- pause cycles
some 6–10 mm in adults (Friedman and Hochman2001;
Nusstein et al. 2004a) or 3–5 mm in small children
(Ram and Kaissirer2006).
Figure20.9 Injection site with P- ASA.
Note: It is not recommended to penetrate further, since
this may perforate the floor of the nose (Friedman and
Hochman1999).
○ Activate the 5- second aspiration cycle with the foot
control before injecting the final amount. Aspiration
is rarely positive with this technique (Friedman
and Hochman 1999; Burns et al. 2004; Nusstein
etal. 2004a).
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○ Slowly inject 0.9–1.4 ml (Friedman and Hochman 1999,
2001; Burns etal.2004; Nusstein etal.2004a; Ram and
Kaissirer2006). Remember, with the first injection, the
maximum amount of anesthetic is 1.4
○ Blanching of the whole anterior palate is observed.
● After the injection, wait 5–10 seconds before withdraw-
ml.
ing the needle so that the pressure of the injected solution can reach all the tissues and does not flow back into
the mouth (Burns etal.2004; Ram and Kaissirer2006).
● Throughout the process, distract the patient by talking
and checking on how he/she feels.
● Dental pulp becomes anesthetized in around 5 minutes
(3–7
minutes) (Friedman and Hochman1999,2001).
Final remark: Slow injection (drop- by- drop) prevents the
transmission of excessive pressure to the tissue and gives
time for the solution to be absorbed.
Efficacy of P- ASA
While the clinical outcomes are similar to those of conventional techniques (Annex 32), studies on pulpal anesthesia
evaluated using an electric pulp tester yield more modest
results (Table 20.8), with approximately 55% in the four
incisors and a third in the canines. Furthermore, pulpal
anesthesia is achieved fairly quickly, in about 5 minutes
(Friedman and Hochman1999,2001; Burns etal.2004), in
contrast with P- AMSA.
Specific Complications withthis Technique
1) The technique is painful despite being slow and careful
since it produces moderate to severe pain in 55% of
patients during the procedure (Nusstein etal.2004a).
2) It leaves the incisive papilla inflamed in 25% of cases
and postoperative pain at the same site in 15% of
patients. This usually resolves spontaneously in 1–3 days
(Nusstein etal.2004a). Rarely (approx. 2%), the incisive
papilla becomes ulcerated at 2–4 days and resolves
spontaneously in 7–10 days (Friedman and Hochman
1999; Nusstein etal.2004a).
Table20.8 Percentage of pulpal anesthesia, evaluated using an
electric pulp meter after injection of standard solution (Lusing the with The Wand.
Tooth Right side Left side
Canine 35% 32%
Lateral incisor 48% 58%
Central incisor 58% 58%
L- 100 is lidocaine 2% with epinephrine 1:100 000 (10 μg/ml).
Source: Data from Burns etal. (2004).
100)
3) Excessive penetration by the needle can accidentally per-
forate the floor of the nose (Friedman and Hochman1999).
4) Pulpal anesthesia of the canines is often unsuccessful
(Table20.8), therefore it may be necessary to inject a
further 0.4
ml with P- ASA or inject buccally using the
conventional technique.
Advantages of P- ASA
1) The technique causes “relatively little discomfort”
when used with The Wand, especially considering that
it is used in the anterior palate, the most painful site for
injection in the mouth (Annex 23).
2) There is no soft tissue anesthesia of the lips, face, or
muscles of facial expression, therefore the technique is
very useful in cosmetic evaluations of the lips and teeth
on the smile line (Friedman and Hochman1999; Ram
and Kaissirer2006).
3) With P- ASA, we can anesthetize six maxillary teeth (inci-
sors and canines) using a single injection and a reduced
dose of anesthetic (Friedman and Hochman1999).
The Wand and Conventional Techniques
The system makes it possible to perform all the conventional techniques with the same results, given that we
inject the same drugs at the same sites; the only variation is
that The Wand enables greater control of the injection rate,
especially for a slow, drop- by- drop injection, which cannot
be achieved with conventional syringes (Tzafalia and
Sixou2011). However, the periodontal ligament technique
and mandibular block present some variations.
Periodontal Ligament Technique
Technique
● Use extrashort 27G needles (12 mm) (Nusstein et al.
2004c) or 30G (Ram and Peretz 2003; Ashkenazi
etal. 2005).
● The needle is inserted into the gingival groove at a mesio-
vestibular or distal- vestibular angle with the bevel
toward the tooth.
● Approximately 0.6 ml is injected slowly (drop by drop) into
each angle of the monoradicular teeth (Ram and Peretz2003)
and 0.7–0.9 ml into each angle of the multirooted teeth
(Nusstein etal.2004c; Ashkenazi etal.2005) at 0.7 ml every
2 minutes and 20 seconds (Nusstein etal.2004c).
● Once the injection is complete, it is advisable to maintain
the needle in place for a further 10 seconds so that the
injected solution can disperse and be distributed through
the tissues and not reflux to the exterior. Nevertheless, it
is thought that around 0.05 ml flows back (Nusstein
etal.2004c).
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Results In children, The Wand has been shown to be less
painful in the periodontal ligament technique (PDL) than
the conventional approach and as effective as maxillary
buccal infiltrations (Ram and Peretz2003). However, when
compared with mandibular block, the discomfort caused
by the injection is worse, and clinical efficacy is poorer
with the PDL using The Wand (Öztas etal.2005).
Specific Complications ofthis Technique Experimental studies
in animals have shown The Wand to produce limited
inflammation of the periodontium that lasts 24
disappears after around 7
days (Froum etal.2000).
hours and
In children, application in primary teeth has not been
proven to increase hypoplasia in permanent teeth, possibly
because slow injection reduces pressure on the tooth buds
of the permanent teeth (Ashkenazi etal.2010).
Mandibular Block
Mandibular block is applied as in the conventional technique, although The Wand makes it possible to insert the
needle using bidirectional or biaxial rotation (Hochman and
Friedman 2000). The method requires the head of the
handpiece to be held in a pen grasp and, as the needle is
inserted into the tissue of the pterygomandibular space, it
is turned with the fingers 45° clockwise and 45° anticlockwise, in the same way as endodontic files are turned during
instrumentation of root canals (Figure 20.8) in such a
way that:
Comfort Control Syringe fromMidwest
This system, designed by Mark Smith from Ontario
(Canada), first appeared in 2001 (Hawkins and Moore2002).
It does not have a foot control and consists of two components (Hawkins and Moore2002; Clark and Yagiela2010):
● The base unit, which is modern in design and makes it
possible to select five injection speeds depending on the
technique: blocks, infiltrations, periodontal ligament
injection, intraosseous injection, and palatal injection
(Figure20.10).
● The hand piece. The cartridge is inserted into the hand
piece in a special sheath and the needle is adjusted. This
component is operated using the hand that holds it by
pressing the button for injection and aspiration
(Figure20.11).
On activation, the system begins to inject the solution at
an extremely low rate, 0.007
Hochman2001), which increases after 10
ml per second (Friedman and
seconds depend-
ing on the program preselected in the base unit (Hawkins
● The needle enters the tissue with minimum resistance
(40–50% less) and therefore with minimum discomfort.
● We avoid deviation of the tip of the needle from the
objective, as is the case with linear insertion (as is usual
with conventional syringes). This maneuver is very effective for preventing deviation independently of the caliber
of the needle or the characteristics of its manufacture.
The maneuver is very difficult to perform with conventional syringes that are held in a thumb- palm grasp, which
are designed for linear insertion.
Other Computer- controlled Injection
Systems
The launch of The Wand onto the market was followed by
other systems like the Calaject controlled- flow system
(Romero- Galvez etal.2016). In the coming years, we expect
to see variations, with improvements, the disappearance of
some systems, and the appearance of new approaches. The
two most important at the moment are the Comfort Control
Syringe system from Midwest and QuickSleeper.
Figure20.10 Base unit of the Midwest Comfort Control
Syringe system.
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Figure20.11 Handpiece of the Midwest Comfort Control
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Syringe system.
and Moore 2002; Clark and Yagiela 2010). This device
presents a series of advantages:
1) The learning curve is smoother, since it is managed in
much the same way as conventional techniques (Clark
and Yagiela2010).
2) As there is no microtubing, there is no need to prime it
for each patient and it is not contaminated by aspiration.
However, it also has some disadvantages:
1) It is expensive, and a new cartridge sheath must be used
for each patient (Clark and Yagiela2010).
2) The handpiece is bulky, and the injection is activated
with the buttons of the hand that holds it, thus rendering it less manageable than The Wand.
Finally, initial clinical studies have provided promising
results (Grace et al. 2000, 2003; Langthasa et al. 2012;
Rogers etal.2014), although more randomized clinical trials are necessary to demonstrate its advantages over conventional systems. Other less popular variants have begun
to appear, like Smartject (Ghaderi and Ahmadbeigi2018).
Quicksleeper
This system, known as transcortical anesthesia, was first
developed by Alain Villette in France in 1984 (Villette1984).
The first study with the modern device was published in
2003 (Villette 2003). QuickSleeper is a special device for
administering computer- controlled intraosseous and infiltrative injections. Version 2, which was available in 2006,
was improved on by Version 5in 2016.
With QuickSleeper, one instrument makes it possible to
administer infiltrative anesthesia, perforate the bone (by
rotating a special needle), and perform a controlled slow
injection that gradually speeds up with a force that can
reach 25 kg. The whole process is regulated using a foot
377
control. The idea is to achieve painless intraosseous anesthesia very quickly by anesthetizing the dental pulp in
under 3 minutes. As the technique is intraosseous, it is contraindicated in primary teeth so as not to affect the tooth
buds of the permanent teeth (Sixou etal.2009).
Equipment
The equipment and device comprise the following elements (Figure20.12):
● Hand piece (QuickSleeper5), where the cartridge is
loaded. The hand piece contains the plunger and nozzle,
into which a special needle is screwed. The needle rotates
in the hand piece to perforate the cortical plate. Currently
there is a new hand piece call SleeperOne5, also bulky
but very light (71
● Foot control, with three functions:
g).
1) Rotation of the special needle for perforation,
although the rotation is discontinuous: 1
rotation, 1
second without so as not to overheat the
second with
bone and thus ensure painless anesthesia.
2) Slow, progressive anesthesia: 61 seconds for half a
cartridge and 93
seconds for the remainder of the car-
tridge. Thus, anesthesia is painless.
3) Rapid injection: 32 seconds for half a cartridge and
64
seconds for the remainder.
Note: These actions emit beeps during functioning, and
lights go on in the base unit.
● Special Transcort- S needles, with asymmetric bevels that
enable not only the injection, but also perforation of the
cortical plate. These are of two types (Sixou etal.2009):
○ 27G extrashort (12 mm).
○ 30G extrashort (9 mm).
Anesthetized Area
● In the maxilla: three teeth mesially and two distally from
the injection site.
● In the mandible: two teeth mesially and one distally
from the injection site.
Transcortical Technique
● If local anesthetic solutions containing epinephrine are
injected, the patient should be warned that he/she may
experience palpitations (tachycardia) but that these will
disappear spontaneously in 2–4 minutes.
● Injection site. Between the teeth, mesially or distally
from the tooth selected, into the attached gingiva
2–10 mm from the neck of the tooth. The injection is
always into the attached gingiva since if it is into the
alveolar mucosa, which is mobile, then this becomes
caught in the drill and can tear.
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378
(a)
Figure20.12 QuickSleeper 5: (a) foot control, (b) handpiece QuickSleeper5, and (c) handpiece SleeperOne5.
● Anesthetize the attached gingiva:
○ Insert the needle over the gingiva with the bevel flat or
parallel to it, that is, with an angle of 15–20° over the
axis of the needle.
○ Advance the needle approximately 1–3 mm.
○ Using the foot control, activate the slow injection to
place some drops of anesthesia in the gingiva.
○ Observe the gradual blanching of the gingiva and
mucosa and wait 30 seconds until the anesthesia
takes effect.
● Perforate the cortical plane:
○ Turn the needle so that it is perpendicular to the bone
plate with a 90° angle.
○ Activate the foot control so that the needle rotates and
perforates the cortical plate. A “click” is felt as the needle penetrates the trabecular bone. At this point the
needle has crossed the cortical plate.
○ It generally takes from 1 to a maximum of 6 seconds to
perforate the cortical plate (Villette2003). In children it
takes around 1 second (Sixou and Barbosa- Rogier2008;
Sixou et al. 2009) and in adults usually 2–3 seconds
(Villette2003).
● Injection of the anesthetic:
○ Withdraw the needle a few millimeters (although
remaining within the trabecular bone) to leave space
so that the anesthetic can spread.
○ Start a slow progressive injection with the foot control.
In general, half a cartridge is injected.
Note: The whole process usually takes 3 minutes.
Efficacy of QuickSleeper
Although clinical trials have been performed in adults
(Villette2003; Benito- Brotons etal.2012) and in children
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(Sixou and Barbosa- Rogier2008; Sixou etal.2009), randomized controlled trials are still required to fully evaluate
the efficacy of this system. Nevertheless, current results do
seem promising. Trials have shown satisfactory results in
75–85% of extractions and 90–95% of endodontic procedures in primary and permanent teeth (Sixou and BarbosaRogier2008), although there is less efficacy in permanent
teeth and mandibular teeth.
Trials comparing QuickSleeper with conventional techniques have shown how anesthesia is very quick (less than a
minute), although its duration is short (a few minutes) and
the injection is usually more painful than with conventional
techniques; however, 70% of patients prefer QuickSleeper
(Benito-
Disadvantages
Brotons etal.2012).
1) The device is expensive.
2) The hand piece is large and bulky, thus making it less
manageable than The Wand.
3) More clinical trials are necessary, since the duration of
anesthesia is short, although the initial results seem
promising.
Intranasal Maxillary Local Anesthesia
(Kovanaze®)
Kovanaze® (intranasal 3% tetracaine and 0.05% oxymetazoline spray) is a needleanesthesia. The first clinical studies began in 2012
(Giannakopoulos etal.2012; Ciancio etal.2013), when the
drug was known as K305 (Ciancio et al. 2016; Hersh
etal.2016b). Kovanaze® was approved by the United States
Food and Drug Administration (US FDA) in June 2016 for
anesthesia of the anterior teeth superior and maxillary premolars. Kovanaze® is a formulation of two wellmedications, tetracaine and oxymetazoline (Saraghi and
Hersh 2017). Local anesthetic and vasoconstrictor for
intranasal administration were combined based on the fact
that these medications have been used for many years to
provide local anesthesia for surgical and diagnostic procedures in the nasal cavity (Hersh etal.2017).
Composition ofthe Solution
1) Tetracaine (hydrochloride) is an ester local anesthetic
(Chapter12). It has been used for many years by ear,
nose, and throat (ENT) surgeons to provide local anesthesia of the nasal mucosa for diagnostic and surgical
procedures (Hersh etal.2016a,2017). The main characteristics of tetracaine are summarized in Table 12.7
(Chapter12).
free means of achieving dental local
known
2) Oxymetazoline (hydrochloride) is a sympathomimetic
drug that was developed in Germany in 1961 (Vardanyan
and Hruby2006). It is a selective adrenergic receptor α
agonist and an α
adrenergic receptor partial agonist
2
that induces vasoconstriction (Ciancio et al. 2016) to
compensate for the marked vasodilatory effect of tetracaine (Chapter 5). Oxymetazoline is a commonly
used nasal decongestant and the active ingredient in
Afrin® nasal spray. It has traditionally been used with
tetracaine for ENT procedures to enhance hemostasis
and lower the risk of bleeding (Ciancio et al. 2013:
Hersh etal.2016a,2017).
3) Benzyl alcohol is the vehicle by which the drug is for-
mulated (Hersh etal.2016b; Saraghi and Hersh2017).
Zone Anesthetized
On entering the maxillary sinus (Hersh etal.2016a: Saraghi
and Hersh2017), intranasal maxillary local anesthesia targets the afferent sensory nerves, namely, the anterior superior and the middle superior alveolar nerve (it is important
to remember that the middle superior alveolar nerve is
only found in 55% of cases (Table2.2, Chapter2). Kovanace®
can be used to anesthetize the following:
● Teeth. All maxillary primary (baby) teeth in children
(who weigh at least 40
kg) and permanent maxillary
teeth from the second premolar to the second premolar
(canines and incisors, from one side to the other) in teenagers and adults, i.e. the smile zone.
● Soft tissues. A unique feature of this delivery system is
that the cheeks, lips (15–20
minutes), and nose retain
their sensation. The anterior palatal mucosa is anesthetized for about 30 minutes (Ciancio etal.2013). Soft tissue anesthesia was sufficient for restoration of
interproximal caries and for the patient to tolerate the
placement of matrix bands and wedges (Hersh
etal.2016a,b; Saraghi and Hersh2017).
Indications andContraindications
Indications
Intranasal tetracaine (Kovanaze®) is indicated for regional
anesthesia when performing a restorative procedure (drilling and filling) on maxillary teeth from the second premolar to the second premolar (from one side to the other) in
adults and children for all maxillary primary (baby) teeth
who weigh 40 kg or more.
Intranasal local anesthetic obviates the need for injection
and is therefore highly desirable in patients who have nee-
dle phobia and experience fear and anxiety associated with
intraoral injections (Hersh et al. 2016a; Saraghi and
Hersh2017).
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