Local infiltration
1.
-
type of injection that anesthetizes a small area (one
or two teeth and asscociated areas)
anesthesia deposited at nerve terminals
Nerve block
2.
-
type of injection that anesthetizes a larger area
anesthesia deposited near larger nerve trunks

Methods:

Reducing temperature.
 Is used only to produce surface anaesthesia e.g. ethyl chloride
spray.

Physical damage to nerve trunk e.g. nerve sectioning.
 Unsafe for therapeutic uses, only in Trigeminal Neuralgia.

Chemical damage to nerve trunk e.g. neurolytic agents.
 Silver nitrate, Phenol - Unsafe for therapeutic use.

Methods: Cont

Anoxia or hypoxia resulting in lack of oxygen to
nerve.
 Unsafe as well.

Stimulation of large nerve fibres, blocking the
perception of smaller diameter fibres.
 includes Acupuncture and TENS (Transcutaneous
Electronic Nerve Stimulation)

Drugs that block transmission at sensory nerve
endings or along nerve fibres.
 There action is fully reversible and without permanent
damage to the tissues.

Classified according to their chemical structures and
the determining factor is the intermediate chain, into
two groups:
Ester
Amide
 They differ in two important respect:
 Their ability to induce hypersensitivity reaction.
 Their pharmacokinetics - fate and metabolism.

Maxillary
A.
B.
C.
D.
E.
F.

posterior superior
alveolar block
middle superior alveolar
block
anterior superior
alveolar block
greater palatine block
infraorbital block
nasopalatine block
Mandibular
A.
B.
C.
D.
E.
inferior alveolar block
buccal block
mental block
incisive block
Gow-Gates mandibular
nerve block





dental procedures can usually commence after
3 – 5 minutes
failure requires re-administration using
another method
never re-administer using the same method
keep in mind the total # of injections and the
dosages
never inject into an area with an abcess, or
other type of abnormality









Chart 9-1
pulpal anesthesia: through anesthesia of each nerve’s dental
branches as they extend into the pulp tissue (via the apical
foramen)
periodontal: through the interdental and interradicular branches
palatal: soft and hard tissues of the palatal periodontium (e.g.
gingiva, periodontal ligaments, alveolar bone)
PSA block: recommended for maxillary molar teeth and
associated buccal tissues in ONE quadrant
MSA block: recommended for maxillary premolars and
associated buccal tissues
ASA block: recommended for maxillary canine and the incisors in
ONE quadrant
greater palatine block: recommended for palatal tissues distal to
the maxillary canine in ONE quadrant
nasopalatine block: recommended for palatal tissues between the
right and left maxillary canines


figures 9-2 through 9-7
pulpal anesthesia of the
maxillary 3rd, 2nd and 1st
molars



required for procedures
involving two or more molars
sometimes anesthesia of the
1st molar also required block
of the MSA nerve
associated buccal
periodonteum overlying
these molars


including the associated
buccal gingiva, periodontal
ligament and alveolar bone
useful for periodontal work
on this area

target: PSA nerve







as it enters the maxillar through
the PSA foramen on the maxilla’s
infratemporal service – Figure 9-2
& 9-3
into the tissues of the mucobuccal
fold at the apex of the 2nd
maxillary molar (figures 9-4 and
9-5)
mandible is extended toward the
side of the injection, pull the
tissues at the injection site until
taut
needle is inserted distal and
medial to the tooth and maxilla
depth varies from 10 to 16 mm
depending on age of patient
no overt symptoms (e.g. no lip or
tongue involvement)
can damage the pterygoid plexus
and maxillary artery







limited clinical usefulness
can be used to extend the infraorbital
block distal to the maxillary canine
can be indicated for work on maxillary
pre-molars and mesiobuccal root of 1st
molar (Figure 9-8)
if the MSA is absent – area is innervated
by the ASA
blocks the pulp tissue of the 1st and 2nd
maxillary premolars and possibly the 1st
molar + associated buccal tissues and
alveolar bone
useful for periodontal work in this area
to block the palatine tissues in this area
– may require a greater palatine block

target area: MSA nerve at the apex of the
maxillary 2nd premolar (figures 9-8 and 9-9)
mandible extended towards injection site
 stretch the upper lip to tighten the injection site
 needle is inserted into the mucobuccal fold
 tip is located well above the apex of the 2nd premolar

 figure 9-11


harmless tingling or numbness of the upper lip
overinsertion is rare





figures 9-12 through 9-14
can be considered a local
infiltration
used in conjunction with an MSA
block
the ASA nerve can cross the
midline of the maxilla onto the
opposite side!
used in procedures involving the
maxillary canines and incisors and
their associated facial tissues


pulpal and facial tissues involved –
restorative and periodontal work
blocks the pulp tissue + the
gingiva, periodontal ligaments
and alveolar bone in that area




target: ASA nerve at the apex of the maxillary
canine – figures 9-12 & 9-13
at the mucobuccal fold at the apex of the
maxillary canine – figure 9-13
harmless tingling or numbness of the upper lip
overinsertion is rare




figures 9-15 through 9-17
anesthetizes both the MSA and
ASA
used for anesthesia of the
maxillary premolars, canine and
incisors
indicated when more than one
premolar or anterior teeth




pulpal tissues – for restorative work
facial tissues – for periodontal work
also numbs the gingiva,
periodontal ligaments and
alveolar bone in that area
the maxillary central incisor may
also be innervated by the
nasopalatine nerve branches



target: union of the ASA and MSA with the IO nerve
after the IO enters the IO foramen – figure 9-15
also anesthesizes the lower eyelid, side of nose and
upper lip
IO foramen is gently palpated along the IO rim


move slightly down about 10mm until you feel the depression
of the IO foramen – figure 9-16
locate the tissues at the mucobuccal fold at the apex of the 1st
premolar
 place one finger at the IO foramen and the other on the injection site
– figure 9-17
 locate the IO foramen, retract the upper lip and pull the tissues taut
 the needle is inserted parallel to the long axis of the tooth to avoid
hitting the bone

harmless tingling or numbness of the upper lip, side of
nose and eyelid






figures 9-19 through 9-21
used in restorative procedures that involve more than
two maxillary posterior teeth or palatal tissues distal to
the canine
also used in periodontal work – since it blocks the
associated lingual tissues
anesthetizes the posterior portion of the hard palate –
from the 1st premolar to the molars and medially to the
palate midline
does NOT provide pulpal anesthesia – may also need
to use ASA, PSA, MSA or IO blocks
may also need to be combined with nasopalatine block

target: GP nerve as it enters the GP
foramen



located at the junction of the maxillary
alveolar process and the hard palate – at
the maxillary 2nd or 3rd molar – figure
9-19
palpate the GP foramen – midway
between the median palatine raphe
and lingual gingival margin of the
molar tooth – figure 9-21
can reduce discomfort by applying
pressure to the site before and during
the injection
produces a dull ache to block pain
impulses
 also slow deposition of anesthesia will
also help


needle is inserted at a 90 degree angle
to the palate – figure 9-22


figure 9-23 through 9-26
useful for anesthesia of the bilateral portion of the hard
palate


for palatal soft tissue anesthesia




from the mesial of the right maxillary 1st premolar to the mesial
of the left 1st premolar
periodontal treatment
required for two or more anterior maxillary teeth
for restorative procedures or extraction of the anterior
maxillary teeth – may need an ASA or MSA block also
blocks both right and left nerves

target: both right and left nerves as they enter the incisive foramen
from the mucosa of the anterior hard palate – figure 9-23 & 9-25





injection site is lateral to the incisive papilla – figure 9-26
head turned to the left or right
inserted at a 45 degree angle about 6-10 mm – gently contact the
maxillary bone and withdraw about 1mm before administering
can reduce discomfort by applying pressure to the site before and
during the injection



posterior to the incisive papilla
produces a dull ache to block pain impulses
also slow deposition of anesthesia will also help
can anesthetize the labial tissues between the central incisors prior
to palatal block

can block some branches of the nasopalatine prior to injection










Chart 9-2
infiltration is not as successful as maxillary anesthesia
substantial variability in the anatomy of landmarks when
compared to the maxilla
pulpal anesthesia: block of each nerve’s dental branches
periodontal: through the interdental and interradicular branches
Inferior Alveolar block: for mandibular teeth + associated lingual
tissues and for the facial tissues anterior to the mandibular 1st
molar
Buccal block: tissues buccal to the mandibular molars
Mental block: facial tissues anterior to the mental foramen
(mandibular premolars and anterior teeth)
Incisive block: for teeth and facial tissue anterior to the mental
foramen
Gow-Gates: most of the mandibular nerve

for quadrant dentistry



also called the mandibular block
most commonly used in dentistry
for restorative, extraction and periodontal
work
pulpal anesthesia for extractions and
restorative
 lingual periodonteal anesthesia
 facial periodonteal anesthesia of anterior
mandibular teeth and premolars






may be combined with the buccal block
can overlap with the incisive block
local infiltrations in the anterior area are
more successful than posterior injections
variability in the location of the
mandibular foramen on the ramus can
lessen the success of this injection
usually avoid bi-lateral injections since
they will completely anesthetize the entire
tongue and can affect swallowing and
speech



target: slightly superior to the mandibular
foramen – figure 9-27

the medial border of the ramus

palpate the coronoid notch – above the 3rd
molar
imagine a horizontal line from the coronoid
notch to the pterygomandibular fold which
covers the pterygomandibular raphe –
figure 9-32
this fold becomes more prominent as the
patient opens their mouth wider
refer to video notes
figure 9-33
will also anesthetize the adjacent anterior
lingual nerve – figure 9-30
injection site is found using hard
landmarks







needle is inserted into the
pterygomandibular space until the
mandible is felt – retract about 1 mm
average depth: 20-25mm
diffusion of anesthesia will affect the
lingual nerve



symptoms: harmless tingling and numbness of the
lower lip due to block of the mental nerve
tingling and numbness of the body of the tongue and
floor of mouth – lingual nerve involvement
complications:



failure to penetrate enough can numb the tongue but not block
sufficiently
lingual shock – involuntary movement as the needle passes the
lingual nerve
transient facial paralysis – facial nerve involvement if inserted
into the deeper parotid gland – figure 9-34
 inability to close the eye and drooping of the lips on the affected
side
 hematoma can occur


some muscle soreness
patient-inflicted trauma – lip biting etc...




figures 9-36 and 9-37
for buccal periodonteum of mandibular molars,
gingiva, periodontal ligament and alveolar
bone
for restorative and periodontal work
buccal nerve is readily located on the surface of
the tissue and not within bone



target: buccal nerve as it passes
over the anterior border of the
ramus through the buccinator
– figure 9-36
injection site is the buccal
tissues distal and buccal to the
most distal molar – on the
anterior border of the ramus as
it meets the body – figure 9-37
pull the buccal tissue tight and
advance the needle until you
feel bone – only about 1 to
2mm
figure 9-38

patient-inflicted trauma – lip
biting etc...



figures 9-39 through 941
for facial periodonteum
of mandibular
premolars and anterior
teeth on one side
for restorative work –
incisive block should be
considered instead


target site: mental nerve before it enters
the mental foramen where it joins with
the incisive nerve to form the IA nerve
– figure 9-39
palpate the foramen between the apices
of the 1st and 2nd premolars
palpate it intraorally – find the
mucobuccal fold between the apices of
the 1st and 2nd premolars – figure 9-42
 in adults, the foramen faces
posterosuperiorly
 may be anterior or posterior
 can be found using radiographs





insertion site is the mucobuccal fold
tissue directly over or slight anterior to
the foramen site
avoid contact with the mandible with
the needle
depth is 5 to 6mm
no need to enter the foramen

for pulp and facial tissues of the teeth anterior
to the mental foramen




same as the mental block except pulpal anesthesia is
provided also
restorative and periodontal work
IA block indicated for extractions – no lingual
anesthesia with an incisive block
target: mental foramen – figure 9-43

injection site: figure 9-44







same as for the mental block
directly over or anterior to the
mental foramen
in the mucobuccal fold at the
apices of the 1st and 2nd premolars
pull the buccal tissues laterally
more anesthesia is used for this
block when compared to the
mental block
pressure is applied during the
injection – forces for anesthetic
solution into the foramen and
block the deeper incisive nerve
the increased injection solution
may balloon the facial tissues





figures 9-45 through 950
blocks the IA, mental,
incisive, lingual,
mylohyoid,
auriculotemporal and
buccal nerves – figure 928 and 9-45
used for quadrant
dentistry
buccal and lingual soft
tissue from most distal
molar to the midline
greater success than an
IA block




target site: anteromedial border of the
mandibular condylar neck – figure 946
just inferior to the insertion of the
lateral pterygoid muscle
injection site is intraoral
locate the intertragic notch and labial
commisure extraorally






draw a line from the tragus/intertragic
notch to the labial commisure – figure
9-47
place your thumb on the condyle (just
in front of the tragus when the mouth is
open)
pull buccal tissue away
place the needle inferior to the
mesiolingual cusp of the MAXILLARY
2nd molar
the needle penetrates distal to the
maxillary 2nd molar
see the video
Indications and contra-indications to
removal of permanent teeth.
Indications to planned tooth removal:
 1.)Unsuccessfulness of endodonthyc treatment
with presence of the chronic inflammation of
periodontium and adjoining tissues of a bone.
This intervention is especially indicated in case
of chronic intoxications of the patient with
odontogenic intoxication centres
(chroniosepsis)
 2.) Impossibility of conservative treatment
through considerable crown destruction or the
technical obstacles connected with anatomic
features, treatment errors, caused by root
perforation.




3.) Total destruction of crown part of the tooth,
impossibility of using the root for tooth
prosthetics.
4.) Mobility of ІІІ degree and tooth promotions as a
result of resorption of bone round a cell with
presence of heavy forms of a periodontosis and
parodontitis.
5.) Atypically placed teeth which injure a
mouth mucous membrane, tongue, and which
can't be treated by ortodonthic treatment.
6.) Unteethed in time or partially teethed teeth
which predetermine inflammatory processes in
adjoining tissues, which cannot be liquidated
some other way.


7.) Placed in crisis cracks, teeth do impossible
reposition of fragments and can't be treated by
conservative treatment.
8.) Outstanding as a result of loss of the
antagonist teeth, teeth which convergence and
divergence, disturb embarrass the process of
manufacturing tooth prosthetics. treatment. For
elimination of anomalies of a bite (occlusion)
during the orthodontic treatment, intact teeth
removal is also indicated.
Contra-indications. A number of inflammatory
and local diseases, and also some physiologic
conditions are contra-indications to this
intervention. Removal of tooth at such patients
can be done after preparation and treatment.
Relative contra-indications to operations of tooth
removal are:
 1.) Cardiovascular diseases (preinfarction
conditions and 3-6 month after the infarction of a
myocardium, hypertonic illness in crisis.
IHD(ischemic heart disease), paroxysm, blinking
arhythmia, paroxysmal tachycardia, acute septic
endocarditis);
 2.) Acute diseases of parenchymatosic organs liver, kidneys, pancreas (an infectious hepatitis,
(glomerunonephritis);
 3.) Haemorragical diseases (a hemophilia, illness of
Verlgof, agranulocytosis, acute leukemia);
 4.) acute infectious diseases (a flu, ARVD(acute
respiratoric virus disease), a pneumonia);




5.) disease of CNS (central neuronic
system), (acute disorder of encephal blood
circulation, a meningitis);
6.) Mental (psychological) diseases in an
aggravation period (a schizophrenia, a
psychosis, an epilepsy);
7.) acute radiation sickness І - ІІІ degrees;
8.) disease of a mucous membrane of a
mouth (a stomatitis, gingivitis, cheilitis).
Preparation of tooth removal:




-Inspection.
-Preparation of the patient.
-Preparation of doctor’s hands.
-Preparation of the operation field.
Technique of tooth removal:

Tooth removal consists in violent rupture of
tissues which connect root with walls of a
cell and gums, and its deducing from a cell.
During removal of the distorted roots from
a cell, its walls are being replaced and the
entrance to it extends. Tooth removal is
being made by special tools, forceps and
elevators. In certain cases tooth extraction
by using this tool is impossible. Then a drill
for bone removal is used. (operation of root
cutting)
Forceps and elevetaors for teeth removal:
 Forceps. Under the process teeth removal a lever
principle is used. Forceps consists of: cheeks,
handles and the lock. In some kind’s of forceps
between cheeks and the lock there is a transitive
part. Cheeks are used to cover the root or a crown.
The handle – a part which is used to hold the
forceps. The lock is placed between the handle and
a cheek.

For the best fixing of tooth or a root, cheeks have
fillets with longitudinal cutting from the inside.
The external surface of handles on significant
length is relief, internal - smooth. The form of
forceps is not the same. Construction depends on
anatomical structure of the tooth and it’s place in
row of teeth.

Forceps for maxilla

Forceps for the root’s of maxillar teeth

Forceps for mandibula

Structure of the forceps, about the surface

Types of correct forceps handling

Luxation and rotation during teeth removal

Correct and incorrect forceps positions
Types of elevators:
Lekljuz elevator

Types of elevators:







Stages of operation of removal of tooth:
Operations of removal of tooth,are being
led by forceps, also consists of several
serial stages:
1.) Superimposing of forceps
2.) Advancement of forceps
3.) Interlocking of forceps (fixing)
4.) A tooth Dislocation (luxation or tooth
rotation)
5.) Deduction of tooth from a cell
(traction)






Complication, that can occur during, and after tooth
exraction.
Root crisis can be prevented by using the method of section
and separation of gums, with the following chisel
debridement of cell wall, to one third of length, and also by
using forceps for root extraction.
Damage of soft tissues, occurs during careless, rough
manipulations of physician, disorder of tooth extraction
technique.
When insufficient gums dislayering, before tooth extraction,
rupture of mucous membrane often occurs during operation;
In case of wrong tooth extraction technique, when a doctor
imposes forceps directly on a mucous membrane, dislayered
it not enough from the cell process, or a part.
In case of careless dislocating of roots, by direct elevator,
tissue damage of the bottom of oral cavity, tongue(when
removing the roots of lower molars) and palate(when
removing the roots of upper molars) occurs.


On a background of the damage of soft
tissues, bleeding occurs, which complicates
the work of a doctor, while tooth extracting;
In postoperative period, inflammatory
complications can occur.
A technique of granting of the urgent help:
a stop of a bleeding and suturing the
wound.









a fragment break of cell parts (more often on the bottom jaw) damage of tisses arises:
- Under condition of an union of a tooth root with cell walls;
- In case of deep imposing cheeks of nippers on cell walls - thus
tooth removes together with a bone tissues.
Technique of granting the urgent medical aid: to smooth down (if
necessary - to remove) sharp, unequal edges of a cell of tooth, to
suture a mucous membrane.
Break of a tuber of the top jaw arises during removal of the third top
molar, as a result of deep imposing forceps cheeks on walls of a cell,
or a rough dislocation of tooth by straight elevator:
In such case, there is a broken off fragment of a tuber of the top jaw
on extracted tooth (roots)
-a considerable bleeding occurs;
-If the maxillar sinus is damaged, vials of air from the extracted
tooth cell occure during attempt to blow air through closed with
fingers nose.
The technique of granting urgent help: smoot keen edges of tooth
cell by bone spoon, mobilize and suture tightly a mucous
membranem so that a bone wound would be completely closed. If
the stomatologist cannot independently stop a bleeding, and suture
a wound, he put iodoform tampon and transport’s the patient
immediately in a surgical stomatologic department.










Perforation of the bottom of maxillar sinus arises during removal of
the first top molar, sometimes - the second and premolar.
It is explained, that tops of the given teeth are closely located to the
bottom of sinus.
Perforation of the bottom of maxillar sinus can occur, when:
- Traumatic removal of the named teeth (if rough manipulation in
a tooth cell is done), and during careless manipulations;
- Owing to anatomic features, when the root is located under a
sinus mucous membrane;
- When inflammatory process on a top of a root has destroyed a
sinus bottom.
Diagnostics:
During careful tubage of a cell, the instrument gets for the length
more than the deepnes of the cell.
On the basis of passage of the air from the oral cavity, into a nasal
cavity, ot contrary. The patient, having clamped fingers on his nose,
should try to blow the air throughout it. Thus air through an
aperture (perforation) of the bottom of maxillar sinus leaves it with a
whistle and goes into oral cavity, or blood vials of air from a cell of
extracted tooth occur;
Radiological research is conducted (an aim picture).




Technique of granting urgent medical aid in case of
perforation of maxillar sinus:
- In the presence of a purulent antritis (pus is goin
out from a tooth cell, through a perforated
aperture) in entrance of cell iodoform tampon and
hospitalization of the patient in maxillofacial
deparment;
- In case of pushing a root through in a sinus, its
removal in the conditions of a hospital is indicated;
- In case of a healthy sinus (when radiological
research does not reveal a root in a sinus) it is
necessary to close a perforated aperture (a cell of
extracted tooth) by a mucosial rag, taken from a
vestibular surface of cell process. If the doctor has
not mastered this technique, he should tightly
suture a cell (to Impose 2-3 seams of polyamides).




The bleeding arises after operation of
removal of tooth. Distinguish early
bleedings and late. Early bleedings, arise
right after removals of tooth (trauma).
Late bleedings can arise:
1) In some hours after tooth removal, for
example in case of adrenaline overdose.
2) For some days after operation which
becomes complicated by an inflammatory
process.