Periodontal Ligament Injection Indications Anesthesia for 1-2 teeth Bilateral mandibular treatment needed Isolated treatment in children Nerve blocks contraindicated (hemophiliacs) Aid diagnosis of mandibular pain

Periodontal Ligament Injection Contraindications Primary teeth Infection/inflammation Psychological need for “feeling numb”

Periodontal Ligament Injection Advantages Avoid unecessary areas of anesthesia Minimizes dosage of anesthetic Supplements partially effective block

Periodontal Ligament Injection Disadvantages Administration difficult in some areas May cause post-op discomfort, tooth extrusion, &/or tissue necrosis Excess pressure may break cartridge

Periodontal Ligament Injection Technique Insert needle on long axis of tooth Deposit 0.2 ml slowly (30 secs) Should feel resistance to deposition

Intraosseous Infiltration Indications Local factors preclude adequate anesthesia dense cortical plate infection / inflammation severe pulpal irritation

Intraosseous Infiltration Injection site Lateral - distil to tooth treated avoid mental foramen area Vertical - for edentulous area on alveolar crest, mesial or distil to treatment area

Intraosseous Infiltration Stabident System Technique Apply topical, consider local infiltration Push perforator through tissue to bone Activate in short spurts until resistance is lost ( approx. 2 secs) Hold syringe in pen grip, into perforation Inject “plain” anesthetic (0.6 ml-1-2 teeth)

Mylohyoid Nerve Infiltration Mylohyoid nerve may provide sensation to molar teeth May be used as a supplement to IAN block Supplements lingual anesthesia

Mylohyoid Nerve Infiltration Technique Retract tongue medially Penetrate mucosa of floor of mouth by alveolus Aspirate, deposit 0.5 ml solution

Extraoral Nerve Blocks Maxillary Infraorbital Mandibular

Extraoral Nerve Blocks Indications Infection Inability to open mouth Presence of pathology Trauma Diagnostic or Theraputic reasons

Extraoral Maxillary/Mandibular Nerve Block Target area Foramen Rotundum / Foramen Ovale Penetration Point Skin overlying sigmoid notch Landmarks Pterygoid plates

Extraoral Maxillary/Mandibular Nerve Blocks Armamentarium 20-22 gauge spinal needle (3-5 inch) 3 ml syringe Alcohol skin prep

Extraoral Maxillary/Mandibular Nerve Blocks Technique Prep skin overlying sigmoid notch, Anesthetize skin and masseter muscle Pass spinal needle through sigmoid notch until the pterygoid plate is contacted

Extraoral Maxillary/Mandibular Nerve Blocks Technique Withdraw, then re-direct anterior/superior to 4.5 cm for maxillary block Re-direct posterior/superior toward Foramen Ovale for mandibular block

Extraoral Maxillary/Mandibular Nerve Blocks Technique Remove stylette Place filled syringe on spinal needle Aspirate and deposit 3 ml of anesthetic solution

Extraoral Infraorbital Nerve Block Landmarks Infraorbital rim Infraorbital foramen Pupil

Extraoral Infraorbital Nerve Block Technique Palpate foramen- 6 mm below rim on pupillary line Prep skin Penetrate skin and contact bone Redirect until foramen entered Advance 2-3 mm and deposit solution