Local Anaesthetics

What you should Know!

1. Nerve Origins
 Branchial Arches

Why do I need to know this?

• Each of the arches has: specific tissues including muscles and nerves
associated with it.

Therefore, know your arches you will know your gross

nerve supplies!!!!
A

Branchial arch and membrane

anatomy at approximately 5
weeks' gestation. Each arch
contains arch-specific
Branchial arch and membrane cartilage (C), muscle anlage
anatomy at approximately 5 (M), artery (A), and cranial
weeks' gestation. First (I), nerve (CN). Inner branchial
second (II), third (III), fourth pouch (FBP) is lined by
Branchial arches develop in (IV), and sixth (VI) branchial endoderm (EN), and outer
cranio-caudal sequence. First arches are shown. Plane of branchial cleft (groove) (FBC)
branchial arch (I) begins to section through branchial is lined by ectoderm (EC).
form at approximately day 22 arches corresponds to Branchial membrane (FBM)
of gestation; second (II) and interrupted line in Figure A. consists of endodermal cells
third (III) arches, at day 24 of Area outlined by rectangle of branchial pouch,
gestation; and fourth (IV) and illustrates cross-sectional ectodermal cells of branchial
sixth (VI) arches, at day 29 of anatomy of one branchial cleft, and intervening
gestation. arch. mesoderm.
Nerves/Muscles associated with arches 1&2
1ST Arch 2nd Arch
Trigeminal Nerve Facial Nerve
(CN V) (CN VII)

Muscle of first branchial arch gives Muscle of second branchial arch gives rise to muscles
rise to muscles required for of facial expression: orbicular muscle of mouth (OM)
mastication—temporal (T), and of eye (OE), nasal muscle (N), levator muscle of
masseter (M), medial and lateral upper lip, greater and lesser zygomatic muscles,
pterygoids (P)—and to anterior belly buccinator muscle (B), auricular muscles (A), and
of digastric muscle (ABD), tensor occipitofrontal muscle (OF). Other muscles that originate
tympani muscle (TT), mylohyoid from second branchial arch are posterior belly of
muscle (MH), and tensor muscle of digastric muscle (PBD), stapedius muscle (S), and
velum palatinum. stylohyoid muscle (SH).
 Mesenchyme arch derivatives of 1& 2
1ST Arch 2nd Arch
Trigeminal Nerve Facial Nerve
(CN V) (CN VII)

Arch dermal mesenchyme forms Derivatives of second branchial arch. Cartilage

mandible, maxilla, zygomatic derivatives of second branchial arch include stapes (S),
temporal bone, and squamous styloid process (SP), stylohyoid ligament (SL), and
temporal bone (ST) through direct lesser horns and upper rim of hyoid bone (H).
ossification. First-arch cartilage
derivatives include malleus (M);
incus (I); alisphenoid (greater wing
of sphenoid); and small fibrous core
in mandible, which is called
Meckel's cartilage (MC).
 Summary
Mesenchyme

CN V CN VII

Muscle
2. Nerve Distribution and Branches
Bone / Teeth & Gingivae
 Relevant Nerve Supply
• From knowledge of Branchial arches:
Sensory Nerve supply to Gingivae, Bone
and Teeth is mainly Via Cranial Nerve V ~
Trigeminal
• Trigeminal N. comprises 3 major divisions:
– Ophthalmic - sensory
– Maxillary- sensory
– Mandibular - mixed (motor branches to muscles
mastication)
Trigeminal N. - Basic Anatomy
 Trigeminal N. - Basic Anatomy

Gasserian
Ganglion
Maxillary Division ~ 1
Maxillary Division Lateral View

Infraorbital
Foramen

Infraorbital N.

Posterior Superior
Superior
alveolar branches
Dental Plexus
Maxillary Division Palatal view
Infraorbital
Foramen
Infraorbital N.

Posterior superior
alveolar N.
Incisal Foramen

Greater
Palatine N. Nasopalatine N.
Mandibular Division ~ 1
Mandibular Division Lateral View

Lingual N.

Inferior Dental N.
Mental Foramen
Long Buccal N.
Mental N.
 Mandibular Division Sagital View

Inferior Alveolar N.
Lingula
Long Buccal N.

Lingual N.
3. Physiology of Nerve Conduction
 Action Potential
+35 mV

-70 mV -70 mV
-90 mV

See your Plenary notes from Dr. Smith

 extracellular
+35 mV
Generation of an Action
Potential
At -55mV the voltage gated Na+ channels open and the membrane rapidly
depolarises
An action potential is initiated on receipt of stimulus by membrane

Na + depolarisation. -55 mV
Initially movement
Membrane of K+K+
contains and impermeability
and Na+ channelsto Na+-70
some and
of mV
anions
which aregenerates
are The resting
voltage potential
activated

V V Plasma membrane

intracellular
K +
At -35mVInitially
Thethe
the voltage membrane
voltage gated
gated hyperpolarises
Na+ channels
K+ channels to -90mV
close
open and the membrane
before equilibrium
Rapidly is restored
Repolarises.

K+

-90
-70 mV
V V

Na + K+
4. Blockade of Nerve Conduction
As the pH falls (i.e. in an infected/inflamed area) the amount of
TheIn solution
Free baseLA (B)agent
is the+comprises
biologicallyFree base
active (B)
component as
B
The ratio of B to BH is dependent on the tissue pH
theand
lackpositively
of chargecharged
allows itcations (BH+) tissues
to penetrate
falls and thus the LA action is impeded

pH B BH+
 B BH +
LA free base inhibits the action potential by interfering with
Na+ influx

Na+ -70 mV

V V

K+
5. Important Pharmacology of LA
 Pharmacology
AMIDES e.g. Lidocaine

Aromatic Nucleus - NHCO - Amino

ESTERS e.g. Benzocaine

Aromatic Nucleus - COO - Amino

AMIDES are usually Local Anaesthetics

ESTERS are usually Topical Anaesthetics
 Pharmacology
Metabolism

• Amides - Metabolised in the Liver

• Esters - Metabolised by Serum
cholinesterase
 Terms Used in LA
• Paraesthesia - Altered sensation
• Analgesia - Loss of pain sensation only
• Anaesthesia - The loss or abolition of all
modalities of sensation which include pain
and touch

Local Anaesthesia is more correctly

LOCAL ANALGESIA
 Pharmacology
LA Action depends on:

• Time of exposure
• Concentration
• Volume in Vacinity of Nerve
• Size of fibre A Vs. C
– autonomic > temp > Pain > Touch > Pressure
>motor
 Duration of Analgesia
Tissue Conc..

Pulpal Analgesia

Soft Tissue Analgesia

Note soft tissue remain anesthetised

Time

much longer than the pulp

 Relative Contraindications
• Lack of Cooperation
• Acute infection - spread, pain, failure
• Hypersensitivity -patient (eg.Methylparaben) , dentist
• Haemophilia
• Radiotherapy - mandible
• Antidepressant Drugs
• Medical - CVS, Thyrotoxicosis, Liver disease
• Age
• Pregnancy (Citanest)
6. Equipment for LA
 LA Equipment

• LA Cartridge
• Needle
• Syringe
• Safety Glasses
 LA Cartridge ~ Contents

• Sterile water
• Anaesthetic agent
• Vasoconstrictor +/-
• Reducing Agent
• Buffer
 LA Cartridges ~ at LUDH
Volume LA Agent Conc/2.2ml Vasocon Conc.
.
2.2ml /1.8mL 2% Lidocaine 44 mg Epinephrine 1:80000
(max 300mg)

2.2mL 3% Citanest 66mg Octapressin 0.54g/mL

(Prilocaine) (max 400mg)

2.2mL 4% Citanest 88mg -

(Prilocaine) (max 400mg)

2.2mL 3% Scandonest 66mg - -

(Mepivicaine) (max 300mg)

2.2mL 4% Articaine 88mg Epinephrine 1:100000

(Septanest) (max 500mg)

see Mech., 1998 BDJ 184: 7 p.334-335

 LA Cartridges
Aspirating

Standard
Lidocaine

Aspirating

Citanest Standard

N.B. Latex Allergy

(Use Citanest as silicone bung)
 Cartridge Check
• Date ??
• Cloudiness ??
• Partly Used ??
• Large Air bubble ??
• Pierced Seal ??
• Glass or Plastic ?? (not suitable for IL injections)
 Needles
(for metal LA syringes)
Colour Gauge Length Use

White 30G 12mm Intraligamentary

Green 30G 21mm Infiltration

Blue 27G 35mm Block

Safety Plus syringes
Step 1: Tear back the paper seal and remove the
sterile Ultra Safety Plus XL unit from the blister
pack and gripping the barrel firmly, fully insert the
anaesthetic cartridge into the open end of the
syringe

Step 2: Grip the Ultra Safety Plus XL plunger handle,

push the finger holder to the end till it stops and
covers the silicone washer. Support the finger holder
from behind with your thumb, then `pushing forward´
ROLL the 'bull-nose' of the handle in behind the
cartridge. Be sure to see the base of the unit is fully
attached to the handle.

Step 3: Now slide the sheath protecting the needle

backwards towards the handle until it CLICKS on to
the handle. Make sure there is no gap between the
transparent sheath and the black handle (the click is
made as the sheath hits the handle and LOCKS the
unit together).
How does the instrument lock on to the handle?
Inside at the end of the cartridge barrel there are
lips which when the protective sheath are 'clicked'
into place are crimped behind the bull-nose of the
handle in the gutter provided.
Note: Failure to retract the sheath fully until you
hear the CLICK, locking the instrument securely
may result in the system disassembling during
use - leave no gap between the transparent
sheath and the black handle.

Step 4: All movements are now away from the

needle. Remove the needle cap and discard it. The
system is now ready for use.
PASSIVE ASPIRATION: At the base of the Ultra
Safety Plus XL cartridge barrel you will see there
is a small protuberance. It appears as a blob of
glue holding the centered needle, the needle-end
that penetrates the diaphragm of the cartridge
when inserted. At the start of the injection the
diaphragm is pressed against the protuberance, a
depression occurs and when released (injection
stopped) the diaphragm moves back away from
the protuberance. Aspiration occurs.

ACTIVE ASPIRATION: Obtained by the silicone tip of

the plunger handle creating a vacuum when, thumb in
ring, the practitioner pulls back. The bung follows the
plunger tip providing active aspiration, best observed
when a minimum of 0.25ml to 0.35ml of solution
(providing space) has been expelled or used from the
cartridge.
Step 5: When only using one cartridge.

NOTE: During multiple injection procedures using

one cartridge the practitioner may safely retain the
syringe for further use by movement of the sheath
towards the needle until it reaches the holding
position (A). Should you need to insert a second
cartridge follow from Step 7 onwards.

To complete the procedure, now slide the

protective sheath towards the locking position
(B) until it clicks (which is the second notch at
the end of the barrel). This has now locked the
needle safely in the protective sheath.
Step 6: Now that you have finished with the Ultra Safety
Plus XL and have locked it in the (B) position, you will
need to separate the plunger handle. Hold the barrel
with one hand and using the other hand place a finger in
the ring of the plunger handle and pull backwards until
the plunger is fully retracted. Now that you have fully
retracted the plunger, peel off the handle in one
movement. Once the handle is separated from the
syringe, you need to remove the empty cartridge to
dispose in your glass box - see steps 7-8. Now that the
handle has been removed the unit can be disposed of
safely needle down into your sharps box and the handle
autoclaved.

Step 7: Inserting a second cartridge.

NOTE: During procedures that require more than one

cartridge, retract the protective sheath to the holding
position (A) (Fig 5) as a needle stick prevention
device. Now you have finished with the first cartridge
and wish to reload with a second cartridge. Take hold
of the Ultra Safety Plus XL handle and with the other
hand grip the protective sheath and slide it towards
the holding position (A).
NOTE: Should the system be inadvertently fully locked
into position (B), no attempt whatsoever should be made
to unlock it, use a new Ultra Safety Plus XL unit. Hold
the Ultra Safety Plus XL barrel with one hand and using
the other hand place a finger in the ring of the plunger
handle and pull backwards until the plunger is fully
retracted. Now that you have fully retracted the plunger,
peel off the handle in one movement.

Step 8: You are now ready to take out the empty

cartridge. Take hold of the plunger handle and pull the
finger grip handle back towards the ring exposing the
silicone tip. Now insert tip of the plunger into the
empty cartridge, which is inside the Ultra Safety Plus
XL barrel. Pull out the cartridge attached to the
plunger by the silicone tip, remove cartridge from
plunger and dispose of safely in the glass box.
7. Giving the LA
 Making the injection comfortable !
• Calm manner
• Explanation of procedure
• Follow correct syringe set-up
• Topical Anaesthetic
• Keep tissues taut
• Do not scrape needle across periostium
• Advance needle slowly and smoothly
• Aspirate prior to injection
• Inject slowly
• Avoid injecting air bubbles
• Avoid inflamed areas
Topical Anaethesia
• Usually esters eg. 20%
benzocaine gel
• More use in infiltrations
• Need dry mucosa
• Take at least 2 mins to
act
• Gels better than sprays
– difficult to direct
– taste bad
– anaesthatise tongue
– Can induce salivation
• Useful especially in
nervous patients and
kids
LA in the Maxilla - the infiltration

• Tip of needle
needs to lie at root
apex
• Bevel of needle
should face tissues
• Anaesthesia relies
on diffusion
– Bone in maxilla
thinner than
majority of
mandible
• Takes time to work
 LA in the Maxilla

REMEMBER ANATOMY
LA in the Maxilla

• Finger and Thumb

inserted into mouth
– Tenses the tissues
– Allows for visualisation
of injection site
• ?? Apply Topical
LA in the Maxilla

• Needle is placed parallel

to long axis of tooth
• Needle is advance slowly
above periostium
• Needle tip lies at root
apex
• Aspirate
• Slowly inject ~1.0mL
local
• Can be repeated for all
teeth in Maxilla
LA in the Maxilla

• Supplemental palatal
injection for:
– Extractions
– Multirooted endo
– Rubber dam placement
Failed buccal
anaesthesia
• Needle tip at root apex
• Aspirate
• ~ 0.2mL Local
• Tissue may obviously
blanche
• Injection often painful!!
LA in the Maxilla

• Modern anaesthetics
spread through the
tissues rapidly
• Approx. 1 tooth either
side of injection
• Surrounding soft tissue
 LA in the Mandible

• In anterior
mandible bone
Block is thin
• Posterior
mandible bone
thick

Infiltration
LA in the Mandible - infiltration

• The anterior Mandible

can be compared with
the Maxilla
• Modern anaesthetics
spread through the
tissues rapidly
• Approx. 1 tooth either
side of injection
• Surrounding soft tissue
• Cross over of fibres in
lower 1/1 region
LA in the Mandible - infiltration
• Finger and Thumb inserted into
mouth
– Tenses the tissues
– Allows for visualisation of
injection site
• ?? Apply Topical
• For lower 2 -2 buccal infiltration
– Supplement with lingual if
for extraction
• Insert needle- aim for root apex
• Advance slowly
• Aspirate
• Inject ~1.0mL local
LA in the Mandible - mental block

• The Mental Block is a

useful way of
anaesthatising multiple
teeth for restorations.
• Note: lingual tissues are
still live!
• Note: cross over of
nerve fibres 1/1 region
LA in the Mandible - mental block
• Finger and Thumb inserted into
mouth
– Tenses the tissues
– Allows for visualisation of
injection site
• ?? Apply Topical
• Insert needle parallel to roots of
and between 4 and 5.
• Advance slowly
• Avoid penetrating nerve
• Aspirate
• Inject ~ 2.0mL anaesthetic
 LA in the Mandible - ID block

Inferior Alveolar N.

Long buccal N Lingula

not affected by
ID block Block
Lingual N.
 Anatomy of ID Block
Inferior alveolar artery
Medial Pterygoid M.

Inferior alveolar N/

Parotid Lingual N.

Internal oblique Ridge

Ptery
goma
nd
Mandible Raph ibular
e

Masseter
Sagital Section showing
Pterygomandibular fossa
Anatomy of ID Block

Need to introduce LA around

Nerves in fossa
ID Block
• Locate the internal oblique line of
the mandible
• Place Thumb onto Line and wrap
fingers around angle of mandible
– Tenses the tissues
– Allows for visualisation of
injection site
• Apply Topical (not that useful)
• Visualise the diamond shape
formed in the mucosa :
– Medially by the
pterygomandibular raphe
– Laterally by the mandibular
ramus
– Both these lines converge at
the retromolar pad
ID Block
• With the patients mouth fully
open
• Go across the arch from the
contralateral 1st premolar
• 1cm above the occlusal plane
• Insert the needle into the
middle of the target area
• Advance the needle until bone
is felt -1.5 - 2cm
• Withdraw the syringe 1-2mm
• Aspirate - VITAL
• Inject slowly (30secs) 1.5mL
local
• Withdraw the needle 0.5cm
• Inject 0.5mL slowly - Lingual N.
Long Buccal
• Supplemental injection required
for:
– Extraction of teeth
– ?Failed IDB on 678
– ?Rubber dam clamp
– ?matrix band placement
• Infiltration in mucosal fold
buccal to third molar
• Hit bone
• Withdraw
• Aspirate
• Inject 0.5mL slowly.
Possible Injection combinations
TEETH TECHNIQUE FOR TECHNIQUE FOR
CONS EXTRACTIONS ETC.
Upper 8-8 Buccal Infiltration Buccal and Palatal Infiltration

Lower 3-3 Buccal Infiltration (Buccal Infiltration or Mental Block

Or Plus Lingual Infil.)
Mental Block (NB 1/1) Or
IDB
Lower 4-5 Mental block IDB
Or Plus
IDB Long Buccal Infil.
Lower 6-8 IDB IDB
Plus
Long Buccal Infil.
 LA Syringe Safety
• Consider patient suitability - eg. cooperation, medical
conditions and maximum dose
• Always check cartridge
• Assemble equipment in correct sequence
• Always expel some LA after assembling
• Use Safety Plus system appropriately
• Never walk around with an unsheathed needle
• Never leave a needle unsheathed on bracket tray
• Always dispose of Safety Plus in sharps box after
procedure is complete
• Follow latest advice if get a sharps injury
 Failed LA -See Meecham 1999 BDJ 186:1 p15-20
• Misplaced LA
– ? Intravenous injection
– ? Outside pterygomandibular raphe
– ?location of mandibular foramen - OPT
– ?bevel of needle
– ?injected too fast
• Insufficient LA - relies on diffusion
• Local Infection
• Alternative injections:
– Intra-pulpal
– Superior posterior block
– Intra-ligamentary
– Intra-osseous
– Extra infiltrations
– Infra-orbital block -(Only for the very experienced)
– Gow-Gates IDB& Akinosi IDB -(Only for the very
experienced)