.
Concept of pain. Reaction
of the body to pain,
postoperation injury. Local
anesthetics.Anatomy of jaw
area.
Definition of pain.

One of the most successful definitions of pain is
Academician Anokhin, who described the pain as «a
kind of mental condition, defined set of physiological
processes in the nerv system, which caused a
devastating powerful or irritation». Pain - a
phenomenon that affects different aspects of human
activity and society in general. It is a symptom of many
acute and chronic human diseases, and creates a
number of health problems, social and economic. It’s
very hard find someone who at least once fill a pain in
life. And their own experience and the experience of
many generations of living things makes us avoid the
pain and deal with them. Accordingly the problem of
pain is devoted to a large number of scientific studies,
conflicting theories and hypotheses.

In dental pain identifies two factors physiological and psychological pain. Pain is a
physiological reaction to a number of stages:
contact of receptors, the reaction of the central
brain structures and Afferent mechanisms of
pain as a complex vegetative and motor
reactions, which affect all the vital and support
functions of the body. In this kind of
classification we have some specific. Because
which is that the basis of psychological factors
of pain is psychogenic chemical reaction.
Pain is produced by evolutionary process
that occurs when action on the body
injured factors or by inhibition of nerve
system

. Pain is negative biological necessity, as its formation is
always associated with a change of fundamental
homeostatic constants. The most significant of these is
the integrity of the containment body (skin, mucous
membranes, peritoneum, etc..) And the oxygen level of
tissue. In response to damage in the body activated
reparative processes and is mobilizing function of
organs and systems that support oxygen of tissues. On
the other hand, the damage leads to activation of
neuroendocrine structures that provide an integrativecontrolling activity of the CNS.

According to some authors, there are three types of
(physical) physiological pain, depending on their
causes:
- Pain caused by external influences. while maintaining
the integrity of peripheral organs and functions of the
central mechanisms that modulate pain. Localization :
skin, mucous membrane.
- Pain associated with internal pathological processes.
In the case of such skin pain usually does not
participate, except for direct or indirect damage pain
kept gear that modulate pain and holding on Afferent
fibers;
- Pain that came as a result of damage to the nervous
system and its apparatus Afferent (neuralgia, phantom
pain)

Psychogenic pain reason mainly
psychological or emotional factors (emotional
condition of the individual, the surrounding
situation) and is a phenomenon, formed
integrated anatomical, physiological,
psychological components, each with its own
structure.
The mechanism of formation and
transmission of pain impulse.

Reception, transmission and analysis
nonitseptyvnoyi information, as well as a
pain sensation provided by the central
and peripheral neural entities and
consist of the following processes:
transduction, transmission, modulation
and perception (rice).

Transduction is the process of perception, and
transformation nonitseptyvnoyi information
encoded receptor apparatus of the nervous
system. Specific pain receptors (notsitseptory)
nerve endings, characterized by high touch
threshold. Especially rich in their skin, cornea,
mucous membrane, peritoneum, ham. blood
vessel walls. By nature, the specific pain
receptors are hemotseptyvete They activate
under the influence of chemical agents that are
generated during tissue damage.
Today, we know three types of this
substances.

1. Fabric (serotonin, histamine,
acetylcholine, prostaglandins
leykotriyeny, K + ions and H +).
2. Plasma (kallidyn, bradykinin).
3. Neurogenic (substance P).

Fabric pain mediators directly activate the
terminal branching bezmiyelinovyh fibers in the
skin, muscle and visceral nerve ending.
Prostaglandins themselves do not cause pain,
but enhanced the effect nonitseptyvnoyi
influence. Plasma alloheny causes pain both
directly and by increasing vascular insight that
leads to tissue edema. Substance P released
from nerve endings acting on receptors that are
localized at the membrane, and
depolyaryzuyuchy it help generate momentum
nonitseptyvnoho flow.
Transmission nonitseptyvnoyi lies in transmitting
information across the nerve guide and
integrative centers (CNS)

Fibers involved in transmitting pain impulses are
divided into:
1) thick mielinovi A-β fibers that conduct impulses from
mechanic receptor a speed of 30-70 m / s;
2) miyelynovi A fiber-fiber transmitting pulses of pain
and temperature sensitivity of the speed of 12-30 m / s;
3) somatic and bezmiyelinovi posthahnlionarni C-fibers,
which conduct impulses at a speed of 0.25 - 1 m / sec.
Depending on the activation of a certain diameter fibers
distinguish different types of pain.

Modulation is process of information transfer in
neural system. Following way: horn of the spinal
cord to the reticular formation of the brain . It
ends with ways nerve branch systems. A
contact reticular formation of the hypothalamus,
basal nuclei and limbic brain neuroendocrine
and implemented motivational-emotive
component of pain sensation .Pertseptshion
formation takes place in the brain. (first and
second somatic sensitivity zone, stress reaction)

In accordance with the above drugs for pain relief can
be divided into the following groups:
1. Drugs that affect the transduction :
Anesthesia in surgical dentistry. Historically, visiting the
dentist was associated with unavoidable pain and fear
of their occurrence. This pattern manifests itself today,
despite a long history of anesthesia and modern
features of its implementation, because anesthesia
when their conduct is one of the most pressing
problems of dentistry, and especially in surgery.
Anesthesia - a loss of pain sensitivity, which is achieved
by a complex of activities aimed at the temporary
exclusion of the central or peripheral nervous system.
Depending on this are divided into general anesthesia
(anesthesia) and local.

Anesthesia in surgical dentistry. Despite significant
progress general anesthesia and application of new
narcotic drugs should be noted that the main method of
anesthesia in dental practice are still local anesthesia. It
is very popular and widely are using under a hospital
and clinics. Knowledge of topographic features anatomy
of upper and lower jaws, and innervations blooding and
anesthesia techniques allow possibility achieve full
anesthesia required areas of tissues. Local anesthesia
has several advantages: it does not require a expensive
equipment, ease of implementation, minimal toxicity.
After surgery under local anesthesia patient does not
require special medical supervision and may be
dismissed to home .Na date knowledge of the principles
of local anesthesia, its types and methods of conducting
is absolutely necessary for the dentist of any account,
especially for the dentist-surgeon.
Anatomical considerations:

Trigeminal nerve:
 Sensory divisions:
○ Ophthalmic division V1
○ Maxillary division V2
○ Mandibular division V3
 Motor division:
○ Masticatory- masseter, temporalis, medial and lateral
○
○
○
○
pterygoids
Mylohyoid
Anterior belly of the digastric
Tensor tympani
Tensor veli palatini
Maxillary Division (V2):
Exits the cranium via foramen rotundum of
the greater wing of the sphenoid
 Travels at the superior most aspect of the
pterygopalatine fossa just posterior to the
maxilla
 Branches divided by location:





Inter-cranial
Pterygopalatine
Infraorbital
Facial
Maxillary Division (V2):

Branches:
 Within the cranium- middle meningeal nerve
providing sensory innervation to the dura
mater
 Within the pterygopalatine fossa○ Zygomatic nerve
○ Pterygopalatine nerves
○ Posterior superior alveolar nerve
Maxillary Division (V2):

Within the pterygopalatine fossa Zygomatic nerve:
○ Zygomaticofacial nerve- skin to cheek prominence
○ Zygomaticotemporal nerve- skin to lateral
forehead
 Pterygopalatine nerves:
○ Serves as communication for the pterygopalatine
ganglion and the maxillary nerve
○ Carries postganglionic secretomotor fibers through
the zygomatic branch to the lacrimal gland
Maxillary Division (V2):

Within the pterygopalatine fossa Pterygopalatine nerves:
○ Orbital branches- supplies periosteum of the
orbits
○ Nasal branches- supplies mucous membranes
of superior and middle conchae, lining of
posterior ethmoid sinuses, and posterior nasal
septum.
 Nasopalatine nerve- travels across the roof of nasal
cavity giving branches off to the anterior nasal
septum and floor of nose. Enters incisive foramen
and provides palatal gingival innervation to the
premaxilla
Maxillary Division (V2):

Within the pterygopalatine fossa Pterygopalatine nerves:
○ Palatine branches- greater (anterior) and
lesser (middle or posterior) palatine nerves
 Greater palatine: travels through the pterygopalatine
canal and enters the palate via the greater palatine
foramen. Innervates palatal tissue from premolars to
soft palate. Lies 1cm medial from 2nd molar region
 Lesser palatine: emerges from lesser palatine
foramen and innervates the mucous membranes of
the soft palate and parts of the tonsillar region
Maxillary Division (V2):

Within the pterygopalatine fossa Pterygopalatine nerves:
○ Pharyngeal branch- exits the pterygopalatine
ganglion and travels through the pharyngeal
canal. Innervates mucosa of the portions of
the nasal pharynx
○ Posterior superior alveolar nerve (PSA):
branches from V2 prior to entrance into
infraorbital groove. Innervates posterior
maxillary alveolus, periodontal ligament,
buccal gingiva, and pulpal tissue (only for 1st,
2nd, and 3rd molars)
Maxillary Division (V2):

Infraorbital canal branches:
 Middle superior alveolar (MSA):
○ Provides innervation to the maxillary alveolus,
buccal gingiva, periodontal ligament, and pulpal
tissue for the premolars only
 Anterior superior alveolar (ASA):
○ Provides innervation to the maxillary alveolus,
buccal gingiva, periodontal ligament, and pulpal
tissue for the canines, lateral and central incisors
○ Branches 6-8mm posterior to the infraorbital nerve
exit from infraorbital foramen
Maxillary Division (V2):

Facial branches:
 Emerges from the infraorbital foramen
 Branches consist of:
○ Inferior palpebral- lower eyelid
○ External nasal- lateral skin of nose
○ Superior labial branch- upper lip skin and
mucosa
Mandibular division (V3):
Largest branch of the trigeminal nerve
 Composed of sensory and motor roots
 Sensory root:

 Originates at inferior border of trigeminal
ganglion

Motor root:
 Arises in motor cells located in the pons and
medulla
 Lies medial to the sensory root
Mandibular division (V3):

Branches:
 The sensory and motor roots emerge from the
foramen ovale of the greater wing of the sphenoid
 Initially merge outside of the skull and divide
about 2-3mm inferiorly
 Branches:
○ Branches of the undivided nerve
○ Branches of the anterior division
○ Branches of the posterior division
Mandibular division (V3):

Branches of the undivided nerve:
 Nervus spinosus- innervates mastoids and
dura
 Medial pterygoid- innervates medial
pterygoid muscle
○ Branches into
 Tensor veli palatini
 Tensor tympani
Mandibular division (V3):

Branches of the anterior division:
 Buccal nerve (long buccal and buccinator):
○ Travels anteriorly and lateral to the lateral
pterygoid muscle
○ Gives branches to the deep temporal
(temporalis muscle), masseter, and lateral
pterygoid muscle
Mandibular division (V3):

Branches of the anterior division:
 Buccal nerve (long buccal and buccinator):
○ Continues to travel in antero-lateral direction
○ At level of the mandibular 3rd molar, branches
exit through the buccinator and provide
innervation to the skin of the cheek
○ Branches also stay within the retromandibular
triangle providing sensory innervation to the
buccal gingiva of the mandibular molars and
buccal vestibule
Mandibular division (V3):

Branches of the posterior division:
 Travels inferior and medial to the lateral
pterygoid
○ Divisions:
 Auriculotemporal
 Lingual
 Inferior alveolar
Mandibular division (V3):

Branches of the posterior division:
 Auriculotemporal: all sensory
○ Transverses the upper part of the parotid
gland and posterior portion of the zygomatic
arch
○ Branches:
 Communicates with facial nerve to provide sensory
innervation to the skin over areas of the zygomatic,
buccal, and mandibular
 Communicates with the otic ganglion for sensory,
secretory, and vasomotor fibers to the parotid
Mandibular division (V3):

Branches of the posterior division:
 Auriculotemporal: all sensory
○ Branches:
 Anterior auricular- skin over helix and tragus
 External auditory meatus- skin over meatus and
tympanic membrane
 Articular- posterior TMJ
 Superficial temporal- skin over temporal region
Mandibular division (V3):

Branches of the posterior division:
 Lingual:
○ Lies between ramus and medial pterygoid
within the pterygomandibular raphe
○ Lies inferior and medial to the mandibular 3rd
molar alveolus
○ Provides sensation to anterior 2/3rds of
tongue, lingual gingiva, floor of mouth
mucosa, and gustation (chorda tympani)
Mandibular division (V3):

Branches of the posterior division:
 Inferior alveolar:
○ Travels medial to the lateral pterygoid and lateroposterior to the lingual nerve
○ Enters mandible at the lingula
○ Accompanied by the inferior alveolar artery and vein
(artery anterior to nerve)
○ Travels within the inferior alveolar canal until the
mental foramen
○ Mylohyoid nerve- motor branch prior to entry into
lingula
Mandibular division (V3):

Branches of the posterior division:
 Inferior alveolar:
○ Provides innervation to the mandibular alveolus,
buccal gingiva from premolar teeth anteriorly, and
the pulpal tissue of all mandibular teeth on side
blocked
○ Terminal branches
 Incisive nerve- remains within inferior alveolar canal from
mental foramen to midline
 Mental nerve- exits mental foramen and divides into 3
branches to innervate the skin of the chin, lower lip and
labial mucosa
Local anesthetic instruments:
Anesthetic carpules
 Syringe
 Needle
 Mouth props
 Retractors

Local anesthetic instruments:

Carpules:
 1.7 or 1.8cc
 Pre-made in blister
packs or canisters
 Contains preservatives
for epinephrine and
local anesthetics
Local anesthetic instruments:

Syringe
 Aspirating type
 Non-aspirating type
Local anesthetic instruments:

Needle:
 Multiple gauges used
○ 25g
○ 27g *used at UTMB
○ 30g
 Length:
○ Short- 26mm
○ Long- 36mm *used at
UTMB
 Monobeveled
Local anesthetic instruments:

Topical anesthetic:
 Used prior to local
anesthetic injection to
decrease discomfort in
non-sedated patients
 Generally benzocaine
(20%)
Local anesthetic instruments:
Maxillary anesthesia:

3 major types of injections can be
performed in the maxilla for pain control
 Local infiltration
 Field block
 Nerve block
Maxillary anesthesia:

Infiltration:
 Able to be performed in the maxilla due to
the thin cortical nature of the bone
 Involves injecting to tissue immediately
around surgical site
○ Supraperiosteal injections
○ Intraseptal injections
○ Periodontal ligament injections
Maxillary anesthesia:

Field blocks:
 Local anesthetic deposited near a larger
terminal branch of a nerve
○ Periapical injections-
Maxillary anesthesia:

Nerve blocks:
 Local anesthetic deposited near main nerve trunk
and is usually distant from operative site
○ Posterior superior alveolar -Infraorbital
○ Middle superior alveolar
○ Anterior superior alveolar
-Greater palatine
-Nasopalatine
Maxillary anesthesia:

Posterior superior alveolar nerve block:
 Used to anesthetize the pulpal tissue,
corresponding alveolar bone, and buccal
gingival tissue to the maxillary 1st, 2nd, and
3rd molars.
Maxillary anesthesia:

Posterior superior alveolar nerve block:
 Technique
○ Area of insertion- height of mucobuccal fold
between 1st and 2nd molar
○ Angle at 45° superiorly and medially
○ No resistance should be felt (if bony contact
angle is to medial, reposition laterally)
○ Insert about 15-20mm
○ Aspirate then inject if negative
Maxillary anesthesia:

Middle superior alveolar nerve block:
 Used to anesthetize the maxillary premolars,
corresponding alveolus, and buccal gingival
tissue
 Present in about 28% of the population
 Used if the infraorbital block fails to
anesthetize premolars
Maxillary anesthesia:

Middle superior alveolar nerve block:
 Technique:
○ Area of insertion is height of mucobuccal fold
in area of 1st/2nd premolars
○ Insert around 10-15mm
○ Inject around 0.9-1.2cc
Maxillary anesthesia:

Anterior superior alveolar nerve block:
 Used to anesthetize the maxillary canine,
lateral incisor, central incisor, alveolus, and
buccal gingiva
Maxillary anesthesia:

Anterior superior alveolar nerve block:
 Technique:
○ Area of insertion is height of mucobuccal fold
in area of lateral incisor and canine
○ Insert around 10-15mm
○ Inject around 0.9-1.2cc
Maxillary anesthesia:

Infraorbital nerve block:
 Used to anesthetize the maxillary 1st and 2nd
premolars, canine, lateral incisor, central
incisor, corresponding alveolar bone, and
buccal gingiva
 Combines MSA and ASA blocks
 Will also cause anesthesia to the lower
eyelid, lateral aspect of nasal skin tissue,
and skin of infraorbital region
Maxillary anesthesia:

Infraorbital nerve block:
 Technique:
○ Palpate infraorbital foramen extra-orally and
place thumb or index finger on region
○ Retract the upper lip and buccal mucosa
○ Area of insertion is the mucobuccal fold of the
1st premolar/canine area
○ Contact bone in infraorbital region
○ Inject 0.9-1.2cc of local anesthetic
Maxillary anesthesia:

Greater palatine nerve block:
 Can be used to anesthetize the palatal soft
tissue of the teeth posterior to the maxillary
canine and corresponding alveolus/hard
palate
Maxillary anesthesia:

Greater palatine nerve block:
 Technique:
○ Area of insertion is ~1cm medial from 1st/2nd
maxillary molar on the hard palate
○ Palpate with needle to find greater palatine
foramen
○ Depth is usually less than 10mm
○ Utilize pressure with elevator/mirror handle to
desensitize region at time of injection
○ Inject 0.3-0.5cc of local anesthetic
Maxillary anesthesia:

Nasopalatine nerve block:
 Can be used to anesthetize the soft and
hard tissue of the maxillary anterior palate
from canine to canine
Maxillary anesthesia:

Nasopalatine nerve block:
 Technique:
○ Area of insertion is incisive papilla into incisive
foramen
○ Depth of penetration is less than 10mm
○ Inject 0.3-0.5cc of local anesthetic
○ Can use pressure over area at time of
injection to decrease pain
Maxillary anesthesia:

Maxillary nerve block (V2 block):
 Can be used to anesthetize maxillary teeth,
alveolus, hard and soft tissue on the palate,
gingiva, and skin of the lower eyelid, lateral
aspect of nose, cheek, and upper lip skin
and mucosa on side blocked
Maxillary anesthesia:

Maxillary nerve block (V2 block):
 Two techniques exist for blockade of V2
○ High tuberosity approach
○ Greater palatine canal approach
Maxillary anesthesia:

Maxillary nerve block (V2 block):
 High tuberosity approach technique:
○ Area of injection is height of mucobuccal fold
of maxillary 2nd molar
○ Advance at 45° superior and medial same as
in the PSA block
○ Insert needle ~30mm
○ Inject ~1.8cc of local anesthetic
Maxillary anesthesia:

Maxillary nerve block (V2 block):
 Greater palatine canal technique:
○ Area of insertion is greater palatine canal
○ Target area is the maxillary nerve in the
pterygopalatine fossa
○ Perform a greater palatine block and wait 3-5
mins
○ Then insert needle in previous area and walk
into greater palatine foramen
○ Insert to depth of ~30mm
○ Inject 1.8cc of local anesthetic
Mandibular anesthesia:
Infiltration techniques do not work in the
adult mandible due to the dense cortical
bone
 Nerve blocks are utilized to anesthetize the
inferior alveolar, lingual, and buccal nerves
 Provides anesthesia to the pulpal, alveolar,
lingual and buccal gingival tissue, and skin
of lower lip and medial aspect of chin on
side injected

Mandibular anesthesia:

Inferior alveolar nerve block (IAN):
 Technique involves blocking the inferior alveolar
nerve prior to entry into the mandibular lingula on
the medial aspect of the mandibular ramus
 Multiple techniques can be used for the IAN nerve
block
○ IAN
○ Akinosi
○ Gow-Gates
Mandibular anesthesia:

Inferior alveolar nerve block (IAN):
 Technique:
○ Area of insertion is the mucous membrane on
the medial border of the mandibular ramus at
the intersection of a horizontal line (height of
injection) and vertical line (anteroposterior
plane)
○ Height of injection- 6-10 mm above the
occlusal table of the mandibular teeth
○ Anteroposterior plane- just lateral to the
pterygomandibular raphe
Mandibular anesthesia:
Mandibular anesthesia:
Mandibular
anesthesia:
Mandibular
anesthesia:

Inferior alveolar nerve block (IAN):
 Mouth must be open for this technique, best to
utilize mouth prop
 Depth of injection: 25mm
 Approach area of injection from contralateral
premolar region
 Use the non-dominant hand to retract the buccal
soft tissue (thumb in coronoid notch of mandible;
index finger on posterior border of extraoral
mandible)
Mandibular anesthesia:

Inferior alveolar nerve block (IAN):
 Inject ~0.5-1.0cc of local anesthetic
 Continue to inject ~0.5cc on removal from
injection site to anesthetize the lingual
branch
 Inject remaining anesthetic into coronoid
notch region of the mandible in the mucous
membrane distal and buccal to most distal
molar to perform a long buccal nerve block
Mandibular anesthesia:

Akinosi closed-mouth mandibular block:
 Useful technique for infected patients with
trismus, fractured mandibles, mentally
handicapped individuals, children
 Provides same areas of anesthesia as the
IAN nerve block
Mandibular anesthesia:

Akinosi closed-mouth mandibular block:
 Area of insertion: soft tissue overlying the
medial border of the mandibular ramus
directly adjacent to maxillary tuberosity
 Inject to depth of 25mm
 Inject ~1.0-1.5cc of local anesthetic as in the
IAN
 Inject remaining anesthetic in area of long
buccal nerve
Mandibular anesthesia:

Mental nerve block:
 Mental and incisive nerves are the terminal
branches for the inferior alveolar nerve
 Provides sensory input for the lower lip skin,
mucous membrane, pulpal/alveolar tissue
for the premolars, canine, and incisors on
side blocked
Mandibular anesthesia:

Mental nerve block:
 Technique:
○ Area of injection mucobuccal fold at or
anterior to the mental foramen. This lies
between the mandibular premolars
○ Depth of injection ~5-6mm
○ Inject 0.5-1.0cc of local anesthesia
○ Message local anesthesia into tissue to
manipulate into mental foramen to anesthetize
the incisive branch
Local anesthetics:

Types:
 Esters- plasma pseudocholinesterase
 Amides- liver enzymes

Duration of action:
 Short
 Medium
 Long
Local anesthetics:






Agent:
Lidocaine with epi (1 or 2%)
Lidocaine without epi
Mepivacaine without epi (3%)
Bupivacaine with epi (0.5%)
Articaine with epi (4.0%)
Dose:
7mg/kg
Onset/Duration:
Fast/medium
4.5mg/kg
Fast/short
5.5mg/kg
Fast/short
1.3mg/kg
Long/long
7mg/kg
Fast/medium
*ADULT DOSES IN PATIENTS WITHOUT CARDIAC HISTORY
Local anesthetics:

Dosing considerations:
 Patient with cardiac history:
○ Should limit dose of epinephrine to 0.04mg
○ Most local anesthesia uses 1:100,000 epinephrine
concentration (0.01mg/ml)
 Pediatric dosing:
○ Clark’s rule:
 Maximum dose=(weight child in lbs/150) X max adult dose (mg)
○ Simple method= 1.8cc of 2% lidocaine/20lbs
Local anesthesia
complications:
Needle breakage
 Pain on injection
 Burning on injection
 Persistent anesthesia/parathesia
 Trismus
 Hematoma
 Infection

Local anesthesia
complications:
Edema
 Tissue sloughing
 Facial nerve paralysis
 Post-anesthetic intraoral lesion

 Herpes simplex
 Recurrent aphthous stomatitis
Local anesthesia
complications:

Toxicity
 Clinical manifestations
○ Fear/anxiety
○ Restlessness
○ Throbbing headaches
○ Tremors
○ Weakness
○ Dizziness
○ Pallor
○ Respiratory difficulty/palpitations
○ Tachycardia (PVCs, V-tach, V-fib)
Local anesthesia
complications:

Allergic reaction:
 More common with ester based local
anesthetics
 Most allergies are to preservatives in premade local anesthetic carpules
○ Methylparaben
○ Sodium bisulfite
○ metabisulfite