ANESTHESIOLOGY MIDTERM REVIEWER

MANDIBULAR DIVISION
Gasserian Ganglion/ Semilunar Ganglion Foramen Ovale Infratemporal Fossa (ITF) Mandibular Foramen Mandibular Canal (3rd M to 2nd PM) Inferior Alveolar Nerve (between 1st & 2nd PM on buccal side) LONG BUCCAL NERVE o Innervates mucosa on posterior part on surface of the mandible up to the 2nd PM o

Leads anesthetic agent into the foramen

DIRECT METHOD o The syringe should be straight at the occlusal plane of the bicuspids crossing from the opposite side Deposit of the content of the cartridge slowly (for the inferior alveolar nerve) Withdraw of the needle then deposit of the content slowly (for the lingual nerve)

INCISIVE NERVE o Innervates teeth from 1st PM to Central Incisors Innervates bone on the Labial/Facial side

INDIRECT METHOD o The syringe should be straight at the occlusal plane coming from the same side Insert of the needle and deposit of the cartridge then move lateral (for lingual nerve) Move to the other side then insert of the needle and deposit of the content slowly (for inferior alveolar nerve)

MENTAL NERVE o Innervates lip and mucosa on the facial surface o

LINGUAL NERVE o Innervates the anterior 2/3 of the tongue

DIRECT INDIRECT METHOD o The syringe should be straight at the occlusal plane of the bicuspids crossing from the opposite side Insert of the needle and deposit of the content slowly (for inferior alveolar nerve) Withdraw of the needle and deposit of the content slowly (for lingual nerve) Move to the same side and deposit

INFERIOR ALVEOLAR NERVE BLOCK Anesthetizing lingual nerve, inferior alveolar nerve and occasionally the long buccal nerve Anesthetizes half of the lower jaw o

METHODS OF ANESTHETIZING THE INFERIOR ALVEOLAR NERVE HOW TO PALPATE: o RETROMOLAR FOSSA/RETROMOLAR TRIANGLE Bounded by external oblique ridge, internal oblique ridge and distal side of 3rd molar

INFILTRATION TECHNIQUES: SOFT TISSUE INFILTRATION o o o o o o o supraperiosteal or paraperiosteal periodontal or intraligamentary intrapulpal or pressure subperiosteal submucosal circular topical

Use index finger to palpate starting from the bicuspid area to the deepest curvature at the ascending portion of the mandible and feel the triangular fossa The tip of the index finger should be at the internal oblique ridge inch from the internal oblique ridge is the point of puncture LINGULA

BONY TISSUE INFILTRATION o o Intraosseous Intraseptal

PREPARATION OF SOFT TISSUES Do oral prophylaxis Ask the patient to rinse Apply antiseptic solution Apply topical anesthetic Check for numbness

A very painful technique

SUBMUCOSAL TECHNIQUE Most superficial aside from topical anesthesia Indicated for Frenectomy

CIRCULAR TECHNIQUE Deposit around the area (incisive papilla)

SUPRAPERIOSTEAL TECHNIQUE Landmark: MUCOBUCCAL/MUCOLABIAL Lift the lip, retract the corner of the mouth Insert the needle at the center following the curvature of the bone Insert 1/3 to of the needle cartridge slowly Apply soft pressure on the area to facilitate diffusion of the anesthetic solution Most commonly used technique

INTRAOSSEOUS TECHNIQUE Supplementary technique Open-flap technique to expose the bone Involves the bone

INTRASEPTAL TECHNIQUE Good technique done with children due to the porosity of their bone Deposited in between two incisors

INCISIVE NERVE BLOCK Deposited into the incisive foramen to anesthetize both incisive and mental nerve Anesthetizes first premolar to central incisor

PERIODONTAL TECHNIQUE A.k.a. INTRALIGAMENTARY TECHNIQUE Anesthesia in the periodontal space (thin, minute space) Danger: may destroy the periodontal ligaments Only a supplementary technique Pressure syringe: using ultra thin, ultra fine needle 4 point of puncture for posterior Use only for extraction of the tooth

INFRAORBITAL NERVE BLOCK From central incisor to the first molar (lingual and buccal root) Facial surface and not palatal

PAIN PHYSIOLOGY
PAIN One of the most commonly experienced symptoms in dentistry A major concern to the dentist Protective mechanism usually manifested when an environmental change occurs that causes injury to responsive tissue

INTRAPULPAL TECHNIQUE A.k.a. PRESSURE TECHNIQUE Only indicated for vital teeth Supplementary technique Insert the needle into the root canal then deposit the anesthetic solution slowly Pressure applied contributes to the numbness

NERVE CONDUCTION Self-propagated passage of an electrical current along nerve fibers Nerve Cell Membrane o a thin elastic covering composed of a layer of lipid between two layers of protein

SUBPERIOSTEAL TECHNIQUE Supplementary technique Point of Puncture: Bisect the root of the tooth, insert the needle (bevel facing the bone)

membrane contains many minute pores through which ions can diffuse under the proper circumstances

electrolytic solutions containing an equal concentration, approximately 155 mEq, of anions and cations are present on both sides of the cell membrane

An active mechanism resulting to the maintenance of the resting potential which moves the sodium from the area of lesser concentration inside the nerve to that of greater concentration outside Greater concentration inside: 142 mEq Lesser concentration outside: 10 mEq Sodium tends to diffuse back across the membrane into the nerve as it is being pumped out

o o

RESTING STATE o nerve is at rest: greater number of anions (-) are present inside the cell membrane; equal number of cations (+) are gathered outside the membrane potassium ions concentrated inside sodium and chloride ions concentrated outside membrane potential can develop by the creation of an ionic imbalance and can be accomplished by: o an active diffusion of ions through the membrane a diffusion of ions across the membrane because of a gradient difference

Relative impermeability of the nerve membrane during the resting state o o Prevents a massive influx of this ion Polarization of the membrane will continue as long as the nerve remains undisturbed

DEPOLARIZATION Initiation of changes in membrane permeability to sodium o Occurs as a result of displacement of calcium ions from a phospholipid-binding state

electrochemical gradient approximately -70 to -90 mv o indicates that the inside of the membrane becomes 70 to 90 mv more negative than the outside membrane is polarized with the inside electrically negative relative to the outside

Alteration in the permeability of the cell membrane that is initiated after an adequate stimulus is applied o Acetylcholine a transmitter substance that is liberated at the site of stimulation

polarized membrane is a potential source of energy resting potential of the nerves is assumed to result from and be maintained by o the relative permeability of the cell membrane to potassium the relative permeability to sodium ions

Passage of the impulse/speed of the action potential o Result a continuing stimulation or chain reaction, with each area generating its own potential by the alteration of the permeability of the membrane to the inward passage of sodium followed by the outward passage of potassium

SALTATORY CONDUCTION o Jumping of the impulse from node to node through the surrounding interstitial tissue Explains the greater rate of speed at which impulses are conducted by myelinated nerves

potassium remains within the axioplasm o positively charged potassium ions are retained by the electrostatic attraction of the negatively charged nerve membrane

chloride remains outside the nerve membrane o as a result of the opposing electrostatic influence forcing outward migration no chloride diffuses into the nerve membrane REPOLARIZATION Permeability of the nerve membrane again decreases while high permeability to potassium is restored Potassium moves freely out of the cell

SODIUM PUMP

Restoring the original electrochemical equilibrium and resting potential *NOTE: please read the handouts for the rest of the topics good luck to us! Thanks

Relative refractory period o When the normal ionic distribution pattern begins to return, the nerve can be stimulated but only by a stimulus greater than usual

Membrane is normally polarized and will react to a stimulus of normal intensity o When the pre-impulse concentration gradients of potassium inside the nerve and of sodium outside are reached following a relative refractory period However, certain minimal stimulus is necessary to provoke a sufficient ionic interchange to create an impulse -Rosette Go 013110

ALL OR NONE LAW OF NERVE ACTION o Amplitude of electrical change as well as the speed of nerve conduction remains constant regardless of the quality or intensity of stimulus applied

PAIN THEORIES SPECIFICITY THEORY o DESCARTES (1644) pain system as a straight-through channel from skin to the brain MULLER (1900) theory of information transmission only by way of sensory nerves VON FREY concept of specific cutaneous receptors for touch, heat, cold and pain

PATTERN THEORY o GOLDSHEIDER (1894) stimulus intensity and central stimulation are critical determinants

GATE CONTROL THEORY o MELZACK & WALL regulation of pain along the pathway it travels

Pain is influenced by: o o o Injury signal Other types of afferent impulses Descending control