Oral Surgery

1. Medical emergencies

Wed, 27 Apr 2022 08:28:55 +0000

MEDICAL EMERGENCIES

SYNCOPE

Most common in dental clinic
Most common complication of LA injection – due to fear
Cause is anxiety
Most frequent cause of fainting in dental office - vasovagal syncope/ shock
Rx is leg end elevation or lie in supine position
Ammonia smell – hypoglycemia precipitates a syncope

ALLERGY

C/F – urticarial – red rashes on skin with itchiness & irritability.
Rx

o Antihistamine
o Steroid
o Patient has penicillin allergy only

DIABETES AND FEBRILE TEMPERATURE ABOVE 102° C

Always under antibiotic coverage for dental procedure
Must be below 120
100 is normal
Morning aapointments
Dry mouth, xerostomia, perio problems, sometimes caries

HYPERTENSION

If BP shows 210/100 – refer to physician & postpond the treatment.
Don’t try LA WITHOUT ADRENALINE
OR DON’T SIMPLY THINK THAT ITS BECAUSE OF FEAR FROM DENTAL SHOW, esp if BP repeatedly shows high ok!

ANAPHYLAXIS

C/F – broncho constriction

o Palpitation

Rx – 1:1000 adrenaline IM/ SubCutaneous MOH**

ANGINA PECTORIS

Rx –

o Glyceryl trinitrate
o Isosorbyl dinitrate } sublingual tabs
o Nitroglycerin

MYOCARDIAL INFARCTION

All elective Rx to be done after 6 months
Even RCT contra – indicated in recent MI

HEART FAILURE

o Treat the patient in upright position or reclined position

ASTHMA

Constriction & inflammation of bronchiolesAvoid NSAIDS
Rx

o Always with inhaler (bronchodialator)
o In upright position.
o ACUTE CASES – administer Epinephrine, subcutaneous 1:1000************

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)

2 – 3 litres of O2 to be given prior to procedure
O2 mask given to patient
Never put mask directly on mouth

HYPERVENTILATION

Low CO2 in body –
Therefore treatment is CO2 administration
How can you do that – ask patient to breathe into paper bag(not plastic)
Caused due to anxiety

RENAL FAILURE

Surgical procedure best done 24 hours after dialysis

2. ME- Infection endocarditis

Wed, 27 Apr 2022 08:28:49 +0000

INFECTIVE ENDOCARDITIS

Subacute infection / bacterial endocarditis — present in already diseased heart patient conditions like

o Ventricular septal defect
o Mitral regurgitation (MR)
o Valve replacement
o Down’s syndrome
o Congenital heart disease

If surgery done - it will lead to mitral stenosis, bacteremia and septicimia
Bacteria responsible – streptococcus viridans group: Sanguis , Mitis
If such patients has to undergo dental procedure that involves gum bleeding – give prophylaxis
I] Procedures requiring prophylaxis

o Extraction
o Banding on molars
o Intraligamentary injection
o Scaling (deep)

II] No prophylaxis needed

o RCT
o Bonding
o Nerve block
o Supragingival scaling

PROPHYLAXIS : [I AND II present in patients]

o Amoxycillin 2grams – most common I E prophylaxis
o For pedo – amox 50mg/kg body weight (either or or options)****
o 1⁄2 to 1 hour before the procedure
o Another choice – cephalosporin prophylaxis
o If allergic to penicillin and cephalosporin
- Azithromycin
o If asthmatic patient under theophylline is allergic to penicillin
- Ciprofloxacin
- Because azithromycin is contra indicated to theophylin
o PROSTHETIC VALVE PATIENT**
- Prophylaxis is must
- Than MI or even recent bypass surgery
o If patient is unconscious and allergic to penicillin
- Clindamycin , ciprofloxacin

PENICILLIN

Mech Of Action – inhibit cell wall synthesis
Complications – urticarial, angioedema, swelling in throat /mouth, wheezing, anaphylaxis
Rx : 1:1000 adrenaline/epinephrine injection

ANTIPLATELET DRUG

Bleeding time
ASPIRIN THERAPY

3. ME - Anticoagulant therapy

Wed, 27 Apr 2022 08:28:43 +0000

ANTICOAGULANT THERAPY

PT (prothrombin time) → tested for Anticoagulant, liver damage (from alcoholism), vit k deficiency patients
PTT (plasma thromboplastin time) → HEPARIN, Renal dialysis, haemophilia pts
INR- INTERNATIONAL NOMINALIZED RATIO (Patient PT/ Control PT) → WARFARIN/COUMIDAN- anticoagulant

PROTHROMBIIN TIME
NORMAL INR IS 1
IF MORE THAN 1 – BLEEEDER
IF LESS THAN 1 - CLOTTER
INR SHOULD BE 2-3 FOR EXTRACTION IS OKAY
IF UNDER WARFARIN, might have more inr, so need to check

4. Extraction

Wed, 27 Apr 2022 08:28:38 +0000

EXTRACTION

ABSOLUTE CONTRA–INDICATION

Central hemangioma
A V fistula

BONE SWAGGING – pushing bone into contact with root surface without # the
bone at its base.

SEQUENCE OF EXTRACTION
a) Maxilla followed by mandible
b) Posterior followed by anterior
c) 8.7.5.4.2.1.6.3

Fibre injure – dentogingival fibre – 1st fibre torn while extracting****
Pure rotation — maxillary CI, PM mandibular
More palatal — maxillary primary molars
Alveoloplasty — after multiple extraction

o To reduce severe labial undercuts

5. Complications of extraction

Wed, 27 Apr 2022 08:28:30 +0000

COMPLICATIONS OF EXTRACTIONS

➣ Most common during extraction — haemorrhage / bleeding

Rx – localized application of pressure

➣ Most common after extraction —

Dry socket (alveolar Osteitis) (3-4 days after extraction)****
Cause is dislodgement or disintegration of clot
Patient comes with pain 3 – 4 days after extraction (because until thes time they are under medication for extraction)
Common sites – mandibular 3rd Molar
Rx

o Sedative dressing ZnO
o Eugenol for every 24 hours

Precipitating factors

o Smoking
o Oral contraceptives

➣ Most common for maxillary posterior

Oro – antral fistula
Maxillary 1st Molar > maxillary 2nd p Molar
Tooth closest to maxillary sinus is maxillary 1st followed by maxillary 2nd PM
Which tooth has root that is mostly pushed into sinus when extraction ➝ PALATAL ROOT of Max first molar !!***
Rx

o Below 2 mm – no Rx req
o 2 - 6 mm — tight suture
o More than 6 mm — flap placement (from buccal to palatal)

➣ Most common with Maxillary 3rd molar

Tuberosity fracture
Rx

o If teeth is not attached to #ed maxillary tuberosity **, remove teeth, replace the tuberosity bone and tight
o Suture in the soft tissue.
o If teeth attached to #ed tuberosity, place tooth back and splint with metal wire to adjacent tooth and remove after 6 months

➣ While removing maxillary tori, nasal cavity is exposed

6. I & D + Space Inflection

Wed, 27 Apr 2022 08:28:21 +0000

INCISION AND DRAINAGE (NO:11 BLADE)

Need not require antibiotic prophylaxis unless the patient is diabetic or febrile 102°C
Other cases — Do I&D — followed by antibiotics
Site — most prominent fluctuant portion of swelling — BEST SITE

NOTE- IF THE SITE IS necrotic, by gravity principle the site of I and D is bottom of
the swelling

SPACE INFECTION

SUBLINGUAL SPACE INFECTION

Shows change in colour in the floor of mouth
Tongue will be elevated
Incision to be done intraorally parallel to wharton’s duct***

SUBMANDIBULAR SPACE INFECTION

o Extraorally at the angle of mandible

I & Dto be done

o The drain to be saturated to muscle

7. Impaction

Wed, 27 Apr 2022 08:28:15 +0000

IMPACTION

W – winter WAR lines
H – height of mandible outline – easy for extraction
A – angulation of tooth – mesio angular – easiest
(most common) - disto – difficult ( least common)
R – root type – convergent root – easy
F – follicle – large follicle – easiest

Mesio - angular, converging roots, large follicle “EASY”
Disto - angular, divergent roots, small follicle, “DIFFICULT”

Horizontal – requires sectioning of tooth**********
QN Palatal root of upper 6 is the most pushed in max. sinus.
QN Factors that make surgery more difficult:- Distoangular, thin follicle, narrow PL, & divergent
curved.

OCCLUSAL XRAY ➝ BEST FOR IMPACTED LOWER CANINE

8. Sutures

Wed, 27 Apr 2022 08:28:10 +0000

SUTURE

Needle – 3/8th curved, reverse cutting edge is commonly used in dentistry for perio, surgical extraction etc.
Needle should be held at 2/3rd from the tip or 1/3rd from the eyelet
In 3rd M surgery, most commonly used needle holder intra orally — curved hemostat or artery forceps

SUTUTRE MATERIALS:-

Most commonly used material intra orally — 3.0 black braided silk

Resorbable
Eg: Catgut – 8 days
o Shouldn’t sterilize in autoclave because cattle protein will get denatured
o Sterilize using 70% isopropyl alcohol
◾ Best % /concentration of alcohol for sterilization purpose
o Normal catgut will completely resorb by 70 days
o Eg: chromium catgut (12-15 days)
◾ Catgut coated with chromium layer
◾ Advantages — increase tensile + increase life span
◾ Main use in oro antral fistula suture

Eg: Vicryl
◾ Made of polyglycolic acid

Non – resorbable
◾ Eg: nylon
◾ Silk (BBS)
◾ Prolene
Blood clot suture to return blood in its place = figure of 8

HEMOSTAT
a) Gelatin sponge
b) Bone wax
c) Oxidized cellulose – MOST EFFICIENT**
d) d-cotton soaked in epinephrine

9. Instruments

Wed, 27 Apr 2022 08:28:05 +0000

INSTRUMENTS

ELEVATORS

Commonly used intra oral periosteal elevator — 9 molt
Commonly used extraction elevator — straight elevator
Commonly used to remove #ed root tip — apexo elevator
Commonly used to remove mandibular # M root tip – crier

PRINCIPLE OF ELEVATORS

Mechanical advantage — wheel and axle principle
Wedge principle – adjacent tooth should be present

o done for bone dialation

Lever principle — interdental bone breakage

o Wedging of socket wall not uses elevator

EXTRACTION FORCEPS

For Mandibular 1st M — NO. 11 (a type of cowhorn)
For Maxillary anterior – No. 150
For Maxillary PMS- NO.1 UNIVERSAL *****
For Mandibular anterior and PM — No. 151

TISSUE FORCEPS

Most commonly used — Addison’s forceps
Most for 3rd M region tissue holding flap — Stills forceps
Epulis fissuratum — Allis forceps
To hold a tooth that is luxated from socket — Russian forceps
To raise flap from inner side of upper lip — Metzehaum forceps
Suture forceps after mandibular 3rd M extraction — curved hemostat
To retract cheek and buccal periosteum – Minnesota Retractor
For dentoalveolar # in maxilla (Lefort I) — Roud disimpaction forceps

o (ENGAGE AT HARD PALATE ALONG NASAL FLOOR)

Nasomaxillary # in maxilla — Arch forceps or walsham forceps

BONE FILE

Used to remove sharp edges after extraction
Used in ALVEOLOPLASY process for smoothening of bony edges!***

SURGICAL BLADES
1) BP No.15 blade – most common intra oral surgery**
2) No.12 blade – most common periodontal surgery
3) No.11 blade – stab incision (I& D)**

Most important sign of fracture of mandible is Malocclusion

1. QN- Walsham's Forceps: for nasal fracture treatment

2. QN Ach’s Forceps For nasal bone straightening
3. QN Allis Forceps: to hold tissues prior to excision
4. QN Addison Forceps: to hold tissue flap during suturing
5. QN Stillis Forceps: It used in the posterior region in mouth where
6. QN Addison Forcep cannot reach due to its long length (7 to 9 Inches)
7. QN Artery Forceps: to ligate ruptured arteries or arteries planned to be removed
8. QN Minnesota retractor: retract flap and cheek together.
9. QN Farabeuf Retractor the retractor which retract the flap and the cheek together when doing surgery.

10. Muscles of mastication

Wed, 27 Apr 2022 08:27:59 +0000

MUSCLE OF MASTICATION

Derived from 1st branchial arch
Nerve supplied — anterior division of mandible nerve

◾ — max trunk – medial pterygoid

Artery supplied — maxillary artery
Accessory muscles of mastication —

o A) geniohyoid
o B) anterior belly of digastric } mouth opening or depression of mandible
o C) mylohyoid (dislodgement of the denture)

Major muscles – masseter , temporalis, medial and lateral pterygoid

A) MASSETER
a. Present on the lateral surface of mandible
b. Closing of mouth / elevates the mandible
c. Strongest muscle of mastication that helps in slight protrusion of mandible
d. Cause for trismus in tetanus (lock jaw) = masseter

B) TEMPORALIS
a. Fan shaped muscle
b. Muscle is originated from the posterior to anterior
c. Elevation of mandible
d. Retrusion of mandible

C) MEDIAL PTERYGOID
a. Muscle present on the medial surface of ramus of mandible
b. Muscle that has to be dissected during maxillary tuberosity surgery
c. Trismus during IANB – due to needle pricking their medial pterygoid muscle
d. Elevation of mandible
e. Protrusion of mandible } actions

D) LATERAL PTERYGOID
a. Muscle of TMJ
b. Depression of mandible
c. Protrusion of mandible } actions

ELEVATION – MASSETER, M.Pterygoid, Temporalis
DEPRESSION – L. Pterygoid, mylohyoid, geniohyoid, anterior digastric.

1. QN Muscles of Mandibular movement :
2. QN Muscles elevation of the mandible: Masseter, temporalis and medial pterygoid
3. QN Muscles depression of the mandible: geniohyoid, mylohyoid, digastric, lateral pterygoid and infrahyoid
4. QN Muscles protrusion of the mandible: Lateral pterygoid, medial pterygoid assists, masseter
5. QN Muscle retraction (retruded) of the mandible: Temporalis
6. QN Muscle do lateral movement of the mandible: Lateral pterygoid, medial pterygoid.
7. QN Glenoid fossa (mandibular) found in temporal bone.

NOTE 1 — muscle involved in protrusion
— bilaterally medial pterygoid
— lateral pterygoid
NOTE 2 — in condylar #, the condyle is displaced — anteromedialy**
NOTE 3 — in TMJ dislocation, condyle is displaced – anteriorly
NOTE 4 — mandible displaces to affected side / same side aka IPSILATERAL
A) Unilateral condylar #
B) Unilateral condylar hypoplasia
C) Unilateral condylar ankylo*****
NOTE 5 — in # of body mandible, the proximal segment is displaced in
UMA — UPWARD, MEDIAL, ANTERIORLY

INTERNAL DERANGEMENT
Problem associated with defect in any of the masticatory muscle, mainly L.Pterygoid

11. Anterior disc displacement

Wed, 27 Apr 2022 08:27:53 +0000

ANTERIOR DISC DISPLACEMENT

Most common
C/F

o Pain, tenderness, deviation, deflection

o A) clicking round present, no restriction in mouth opening
◾ Reason – with reduction
o B) no clicking sound, but restricted mouth opening
◾ Rx – without reduction

12. Biopsy

Wed, 27 Apr 2022 08:27:47 +0000

BIOPSY

A. Excisional biopsy
a. < 1 cm
b. Rx and investigation
i. Most common biopsy done intra orally
ii.
B. Incisional biopsy
a. > 1 cm
b. Only investigation
c. Specimen – periphery of lesion along with normal tissue

Media used for biopsy — 10% formalin
Most common biopsy for cancer — incisional biopsy
Most common biopsy for candidiasis — cytological smear
Most common biopsy for cyst — FNAC/ ASPIRATION
Least common biopsy done intra-orally — punch biopsy

FNAC uses 18 guage needle
Gentotoxicity test comes under * primary tests

13. Fractures

Wed, 27 Apr 2022 08:25:08 +0000

FRACTURES

TYPES OF FRACTURE

Simple # - no wound – no antibiotics regimen required
Compound # — wound present in mandible

◾ — communication with oral cavity
◾ — amoxycillin (drug of choice)

Communited # — multiple fragments of bone

◾ — gunshot injury
◾ Rx
– Closed reduction – Just putting the bones back into position without surgery, followed by internal fixation using a hard wire to hold the bones in place together.
– Now a days open reduction is preferred
◾ The surgeon chose 2mm plate to fix, the size of the drill hole to fix the plate to
alveolar bone 1.5mm
◾ QN- Reduction of fractured bones mean realignment of fracture segment , while
fixation mean holding the fracture segment in place
◾ Rx of #ed segment stages
1. Reduction — approximation of the #ed ends only
2. Fixation and immobilization -
3. Mobilization — physiotherapy
◾ Greenstick # — bending of long bones in children with no actual fracture, Fracture in which only cortical bone is fractured**

MANDIBLE FRACTURE
A. BODY OF MANDIBLE
a. Favourable #
i. Rx – closed reduction with IMF
ii. Commonly used IMF is arch bar
iii. IMF in pedo is cap splint
iv. IMF edentulous is Gunning
b. Unfavourable #
i. Rx – Open reduction with monocortical plates
ii. Posterior to mental foramen – I plate b/w teeth and canal
iii. Anterior to foramen — 2 parallel plates

B. CONDYLAR FRACTURE scenarios
a. Unilateral or bilateral condylar # with no occlusal discrepencies — no Rx
b. Unilateral condylar # with occlusal discrepancy — Rx : IMF for 3-4 weeks
c. Bilateral condylar fracture with occlusal discrepancy
d. (anterior open bite seen) — ORIF(open reduction with internal Fixation) + IMF
(intermaxillary fixation)
e. In pedo, unilateral or bilateral condylar # with occlusal discrepancy
Rx – IMF for 7 to 10 days
Step deformity after fracture in mandible is due to Upward pull of masseter n
temporalis***
NB: complication of condylar # and its management — ankylosis

14. Occlusal splint

Wed, 27 Apr 2022 08:25:02 +0000

OCCLUSAL SPLINT — to protect from excess masticatory force

Hard splint – given also in TMJ disorders

o — performs occlusal correction

BITE PLANES

o To increase VD

Hard/Soft splint — given in bruxism

o (Bruxism that caused by stress then Rx is psychological management – then final
rehabilitation by crowns)

15. Le Forte fractures

Wed, 27 Apr 2022 08:24:55 +0000

MAXILLARY FRACTURE

Le – Fort fracture – I

Also known as dentoalveolar #;Guren #; telescopic #; transalveolar #; transmaxillary #
Gure’s sign seen as palatal ecchymosis

Le – fort fracture – II

Also known as pyramidal #*; floating maxilla*
CSF rhenorrhea — complications – meningitis, encephalitis
Diplopia – due to defect in the eyeball muscle

o — Rx wait and watch - 15
◾ Observe overtime
◾ Then if not subsiding —management

Epiphora – eye tears
Mobility at frontonasal suture
Moon face
Conjunctival bleeding
Parasthesia of upper lip – infra orbital nerve involved
Step deformity in orbital rim at zygomatic suture

Le – fort # - III

Also known as craniofacial disjunction
CSF rhinorrhea = discharge of csf fluid into nose & sinuses. (Its content is GLUCOSE ****)
Epiphora
Conjunctival bleeding
Diplopia
Moon face
PANDA face – block eye – paranasal fluid
Hooding of eye
Midface separation **- cranialfacial dysjunction

ZYGOMATICO MAXILLARY COMPLEX FRACTURE:

Moon face is not seen
Maybe one side
Nerve involved in # - infraorbital nerve – echymosis around orbit
Investigation – submento vertex projection – limited mouth opening
Rx – Gillis temporal approach – for open reduction

o Subjunction bleeding
o —ROWE’S ZYGOMATIC ELEVATOR
o — TEMPORALIS MUSCLE – muscle guiding

16. Cleft lip & palate

Wed, 27 Apr 2022 08:24:39 +0000

CLEFT LIP AND PALATE:

Development in IUL

o Lip development happens at 4-6 weeks intra uterine life
o Palate develops at 6-8 weeks of IUL.

Vander woude syndrome

4 lip pits + cleft palate + cleft lip

Cleft lip – unilateral/bilateral

o Failiure of fusion between median nasal process & maxillary process**

Cleft palate

o Muscle involved is levator veli palatine ie there is an abnormal atachment
o Defect between pre- mxilla and palatal shelves or primary and secondary palatte

Causes : multifactorial (environmental, hereditary, drugs)
Common defect : both cleft lip and palate together**
Males – cleft lip
Females – cleft lip + palate
Missing teeth commonly – lateral incisior
Complication – class III, hypomaxilla, crossbite

Management timings

Lip surgery – 2-3 months
Soft palate repair – 6 months
Cleft palate repair – 18 months / 1 and half years
Graft placement in alveolus – 6-11 years (before eruption of canine)

DEVICES in cleft palate cases :

Obturator – to assist feeding(1st)
Artificial Velum - to assist speech (last) (acrylic substitute for loss of soft tissue of the soft palate)
Maxillary Expansion Device – to prevent collapse of maxilla / palate
Orthodontic approach done, followed by RME and finally rhinoplasty is done
Psychiatrist plays an important role

17. Implants

Wed, 27 Apr 2022 08:24:29 +0000

IMPLANTS

Best material is Titanium, because its biocompatible
Principle of implant — osseointegration
Bone selection : best bone – D2
D1 –

o DENSE CORTICAL BONE

D2 – best

o DENSE TO POROUS CORTICAL BONE SURROUNDING DENSE TRABACULAR BONE
o ANTERIOR MANDIBLE- BEST SITE FOR IMPLANTS

o THIN POROUS CORTICAL BONE SURROUNDING FINE TRABACULAR BONE

D4 – worst (least preferred) [only cancellous bone]

o FINE TRABACULAR BONE
o POSTERIOR MAXILLA – highest failure rate

Best site for implant – mandibular anteriors
Poor site for implant – maxillary posterior
Minimum distance from tooth – 1.5 mm

Minimum distance between 2 implants – 3 mm
Std diameter of implant – 3.5mm(if not given in Q)
Minimum space needed to place implant = 1.5+3.5+1.5 m= 6.5 mm

o (length of edentulous span)

Most commonly used implant = endosteal implant
Space required to place two implants b/w two teeth

SPACE NEEDED= 1.5+3.5+3+3.5+1.5 = 13 mm

Contra indicated in HIV
Recommeded no. of implants for edentulous

o Maxillary — 6
o Mandibular – 4

Minimum implants

o Maxillary – 4
o Mandibular — 2

IMPLANT ABUTMENT
a) Screw retained abutment
a. Indicated in inter occlusal distance less than 7 mm
b) Cement retained abutment
a. Indicated in proclined maxillary anteriors

Complication – most common – Peri implantitis

Most common complication intra operatively – body of implant fracture
Yearly checkup – scaling and examination of implant surface should be done by plastic
tipped instruments
Bone loss around the implant in 1st year is about 1 mm
Bone loss yearly after that is 0.2mm
Success of properly placed implant is 95 %

1. QN Most place of failure in posterior max(27 -best place for sucess implant in anterior
mandible. -min.
2. QN Failure in mandible between mental foramen.
3. QN The best type of implant allowing osteointegration root form endosseous.
4. QN Rarefaction: decreased density of bone such as a decrease in weight per unit of volume.
5. QN-Areas denuded from bone.

18. Local anesthesia

Wed, 27 Apr 2022 08:24:24 +0000

LOCAL ANESTHESIA

LA is painful because it is acidic
Works in weak base only
PH o f blood is 7.4 (ie; basic slightly)
Doesn’t work in injection site because its acidic already
The local anesthesia depend on  strength bond between drug and nerve***

THEORY OF LA action:

Most accepted theory – specific receptor theory
Most accepted mechanism - Closing of Na channel
Pain(1st) ➝ touch(2nd) ➝ temp(3rd) ➝ pressure(last)
Pain - fading ➝ pressure
Pressure – return ➝ pain
1st sensation to loss and last one to regain is Pain
Last sensation to loss and 1st one to regain is pressure

QN The choice of local anesthesia depend on local anesthetic agent chemistry, while technique by bone structure.

CHEMISTRY OF LA

ESTER

o Metabolized by blood lasma
o Eg : Tetracaine, Procaine, Benzocaine ( one I - ester)
o E(s)ter ...pla(s)ma

AMIDES

o Metabolized by liver except articaine
o Eg : Lidocaine/Lignocaine/Xylocaine, Prilocaine, Mepivacaine, Bupivacaine.
o Am(i)de--lidocaine ...l(i)ver.

19. LA- to byheart

Wed, 27 Apr 2022 08:24:17 +0000

Slowest onset of anesthesia by procaine
1st LA discovered — procaine
Most toxic LA — procaine (because its vasodialating thus causes toxicity)
LA that can induce in Meth-hemo-globinemia – prilocaine
Fastest acting LA (because of high diffusion) — Articaine
Best LA for posterior infiltration 8 — Articaine
Longer duration LA — Bupivacaine (ectidocaine)
Best LA for spinal anesthesia in pregnancy — Bupivacaine
1st amide LA introduced — lignocaine
Best anesthetic media for patients allergic to LA — Diphenhydramine is mainly
Safest LA in pregnancy — lignocaine with adrenaline (Because adrenaline reduced, bleeding, pain and toxicity)

LOCAL ANESTHETIC AGENTS IN DENTISTRY
a. The most commonly used local anesthetic is Lidocaine (also called Xylocaine or Lignocaine).
b. LA given during pregnancy - LIDOCAINE

Red catridge – with adrenaline
Blue catridge – without adrenaline

Surface anesthesia most common in children — EMLA – euletic mixture of LA ie. Lignocaine + prilocaine
Only amide mostly metobolized in blood – Articaine (less half life)
Avoiding patients with chronic heart failure — Bupivacaine

20. LA composition

Wed, 27 Apr 2022 08:23:41 +0000

VASOCONSTRICTORS

Adrenaline / Epinephrine

o 200 μg – limit for normal healthy person

PROPERTIES Or ACTIONS

o Increased duration

o Reduces bleeding

o Decreases toxicity****

PRESERVATIVE

Sodium meta bisulphate

o Preserves vasoconstrictor from oxidisation

CARRIER MEDIA

Ringer lactate – best
Saline
Distal water
IF A QN - weakest part of a needle is HUB

COMPLICATIONS OF LA
a) Syncope
b) Allergy/anaphylaxis
c) Hematoma ( if seen after PSA Block – Pterygoid Plexus of Veins is injured)
d) Toxicity/ complication – due to LA agent itself ie; LIGNOCAINE

1st CNS effects

Tonic clonic seizures
Excitation followed by depression
Nervousness
Rx – Diazepam I.V

2nd CVS effects

Cardiac depression

21. LA techniques

Wed, 27 Apr 2022 08:23:29 +0000

LA TECHNIQUES

Type of LA tq depends on the bone(maxillary/mandibular) to be anesthetized
Type of agent depends on the chemical component of LA solution
Duration of action of Surface Anesthesia – 30 seconds

o Best agent – Benzocaine

Infiltration

o Most common tq in pedo
o It’s a supraperiosteal tq

Nerve block

o Indicated in Infective Endocarditis (to avoid bleeding around gums)
o Contra indicated in haemophilia
o Only nerve block in pedo is IANB

Intra ligamentary

o Contra indicated in Infective E ndocarditis (avoid)
o Indicated in heamophilia (prefer)
o On pulpal circulation
o Mainly given for extraction
o Less effective for RCT / LONG pulpal procedure
o Can be used only for short pulpal / DPC, 5 min thermocresol pulpotomy

PAINLESS L A TECHNIQUE
1. Slow infusion – best ( Incisors, C and PMs)
2. Surface anesthesia
3. 27 gauge needle(instead of 25) – causes severe pain
a. ∴ leastest effective
4. Stretch the muscle – least effective
5. location – incisive papilla , Nerve – nasopalatine in max anteriors
6. incisive nerve supplies Mand.

1. QN – After IANB, pain persist at lower Ci while extraction, give infiltration at CI,
because is cross innervation from other side
2. QN – after IANB, pain persist at 1st Molar due to mylohyoid nerve innervation
3. QN- Anterior palatine NB (new) ➝ anesthetics the nerves same as in greater
palatine NB

22. Nerve blocks

Wed, 27 Apr 2022 08:23:14 +0000

NERVE BLOCKS

PSA NERVE BLOCK

Also known as zygomatic block or tuberosity block***
Site of diffusion – infratemporal fossae
No bony anatomical landmark
No subjective symptoms needle amount – half of bony needle
Complications

o Hematoma – injury to pterygoid plexus of veins
◾ Rx – intermittent cold pack
o Mandibular anesthesia

M S A NERVE BLOCK

Middle superior alveolar
MB root of 1st M + 1st PM + 2nd PM

IANB

Space of diffusion — pterygomandibular space
Most commonly pierced muscle – Buccinator muscle (normal)
Trismus in IANB — due to piercing medial pterygoid muscle (abnormal)

o Hematoma in infratemporal fossa

Transient facial nerve palsy — LA deposited in parotid gland
Secondary complication — hematoma
Can extract canine and 1st PM with IANB injection only
IANB and Mandibular foramen wrt occlusal plane

o Above 6 years — above occlusal plane
o At 6 years — at occlusal plane
o Below 6 years — below occlusal plane (ie; 5 mm below)

23. NB Gowgates + Vazirani

Wed, 27 Apr 2022 08:23:08 +0000

GOW GATES

Mandibular nerve block
All nerves get anesthetized [IAN, buccal, mental incisive, mylohyoid]
Open mouth tq
Not indicated for

o Crown prep, intraligamentary is indicated for short pulpal procedure
o Pulpectomy, pulpal procedure like DPC, pulpotomy

Site of injection – condylar neck
Only nerve block that anesthetizes both hard and soft tissues of lower posterior teeth in one injection*******

VAZIRANI AKINOSY

Closed mouth tq
85% success
Mandibular nerve block
Needle penetration – sigmoid notch
Site of injection – muccobuccal fold of maxillary 3rd molar
Angulation of needle – parallel to occlusal plane * 25 mm penetration

* 25 gauge long needle

Indicated in trismus
Buccal periosteum of posterior is not anesthetised

24. LA calculation 1

Wed, 27 Apr 2022 08:23:01 +0000

LA CALCULATIONS

CLARK RULE FOR PEDO DOSAGE
Child dose = Weight of the child in lbs / 150 x adult dose

MAX DOSE OF LA

WITHOUT ADRENALINE = 4.4MG/KG IE. FOR 1 KG (PH=5.5)
WITH ADRENALINE = 7MG/KG (PH= 3.3)
IN PEDO WITH /WITHOUT = 4.4MM/KG

QN. Max dose of LA with adrenaline in 60kg body wt
a)7mg
b)4.4mg
c)360 mg
d) 420 mg
o Ans – d) 420 mg 60kg *7 = 420mg

MAX DOSE OF LA IN ML

(MAX DOSE X WEIGHT) ÷ PERCENTAGE X 10 = DOSE IN ML

25. LA calculation 2

Wed, 27 Apr 2022 08:22:49 +0000

MAX DOSE OF LA IN ML

(MAX DOSE X WEIGHT) ÷ PERCENTAGE X 10 = DOSE IN ML

QN – Max dose of 2% LA WITH adrenaline can be safely injected in 60kg wt pt
a)10ml
b) 21ml
c)36ml
d) 48 ,;
Ans: 7*60/ 2*10 = 420/20 = 21 ml

QN – max no of catridge of 2% LA with adrenaline can be safely given to 60 kg
a)10
b)15
c) 7
d) 21
Ans: 10
Max ml / 2 = 7*60 / 2*10 = 21/2 =10.5

QN – mg of LA in 1 ml = x% *10. How much mg of 2% LA in 1ml
a) 10mg
b) 20 mg
c) 36mg
Ans: 2% *10 = 20mg

QN – How much mg of 2% in 1 catridge /syringe
= x% *10*2 1 catridge – 2ml
= 2*10*2 = 40mg (in 2 ml catridge)

QN – Max dose of 3% LA with adrenaline in 90kg
a) 10 ml
b) 21ml
c) 36ml
d) 48ml
ANS: 21ml
7*90/3*10=630*30 = 21 ml

QN – how much mg of 4% present in 1 catridge
a)0.036g
b) 0.018g
c) 0.072g
d) 0.04g
Ans: 4*10 *2= 80mg in 1 catridge
80M/1000 = 0.080 = 0.072

QN – Adrenaline max dose in N pt — 0.2mg

QN - Max dose in cardiac — 0.04mhg46. Maximim amount of Anesthesia 80kg patient lidocaine 2% + epinephrine, 1:100,000
Answer: 7*80= 560mg
(Adrenaline contra indicated in hyperthyroidism)

Qn. patient needs LA for surgery . weight 80 kg. 1:100000 la max dose hw much
a) 320
b) 400
c) 560**

Qn. Old patient who is 80kg wat s the max LA with xylocaine 2% 1:100000
365
560**********

Qn. How many carpules can you give from lidocaine 2% to a child who weighs 20 kg
a. 2.4********