1. Local infiltration- type of injection that anesthetizes a small

area (one or two teeth and asscociated areas)

- anesthesia deposited at nerve terminals

2. Nerve block- 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.

MaxillaryA. posterior superior

alveolar blockB. middle superior

alveolar blockC. anterior superior

alveolar blockD. greater palatine blockE. infraorbital blockF. nasopalatine block

MandibularA. inferior alveolar blockB. buccal blockC. mental blockD. incisive blockE. 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 from the mesial of the right maxillary 1st premolar to

the mesial of the left 1st premolar for palatal soft tissue anesthesia

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 posterior to the incisive papilla

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 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

will also anesthetize the adjacent anterior lingual nerve – figure 9-30

injection site is found using hard landmarks 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

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 2mmfigure 9-38 patient-inflicted trauma – lip

biting etc...

figures 9-39 through 9-41

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 9-50

blocks the IA, mental, incisive, lingual, mylohyoid, auriculotemporal and buccal nerves – figure 9-28 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 9-46

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.