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Professor Dr. R.

Padmanabhan Adesh University

SUPRAPERIOSTEAL Or DEEP SUBMUCOUS INFILTRATION Supraperiosteal Vs. Subperiosteal Infiltration:-

The effort of modern dentists

and oral surgeons to simplify the

method of infiltration anesthesia to the end that post-injection sequelae, such as pain, edema, and infection, may be minimized, has eventuated in a spirited controversy on the relative merits of the supraperiosteal and the subperiosteal infiltration techniques in the extraction of' teeth. The questions as to (1) whether it is preferable to penetrate the areolar tissue close to the apex of the tooth in a straight line and thus deposit the anesthetic solution directly at the apex of the tooth upon the periosteum (supraperiosteal infiltration as advocated b y Posner, and deep submucous by Fischer), or (2) whether the best results may be, obtained by penetrating beneath the periosteum at a point halfway, up the root of the tooth, and then by propelling" the needle beneath the periosteum to the apical region (subperiosteal infiltration), both have their staunch adherents. It is not the intention of the author to take sides. The advantages and disadvantages of both methods will be set forth impartially for the reader to weigh for himself.

Site of Puncture for the Supraperiosteal Injection:-

Let us examine the so-called "gum" tissue covering the alveolar process, proceeding from the neck of the teeth toward the apex. First is the free margin of the gum, or gingiva. This merges imperceptibly into the dense, firm and fibrous alveolar mucosa, extending about half-way up the roots of the teeth. Here the pink alveolar mucosa changes abruptly to a deep red shade. The latter area stains deeper with iodine. This represents the line at which the mucous membrane begins to separate from the periosteum of the bone. Whereas the alveolar mucosa consists of closely adherent layers of mucous membrane,

Professor Dr. R. Padmanabhan Adesh University

submucosa, and Periosteum, there is gradually an increase in the thickness of the submucosa (areolar tissue) beginning at the line mentioned. The result is that, at the mucobuccal fold (the reflection of the mucous membrane from the gums to the cheek) the submucosa becomes a thick stratum of loose connective tissue interposed between the mucous membrane

and the periosteum. Now, if the lip be grasped between the forefinger and the thumb and drawn downward and outward, the mucobuccal fold becomes sharply defined. In general the apices of the teeth lie approximately 6 to 10 mm. (1/4 to 3/8 inch) beyond the level of the mucobuccal fold. The site of the puncture for the supraperiosteal injection

is always at this fold and to the mesial of the tooth, with the one exception in the case of the maxillary central incisor, where it is made distally.

Technique for Buccal and Labial Aspects of Maxilla:-

Assuming that the mucous membrane has been sterilized and desensitized, the syringe is held in the pen grasp, and the needle (25mm. or 1 inch, No. 23 gauge) introduced mesially to the tooth and at the line of the mucobuccal fold, with the bevel turned toward the bone, not toward the lip or cheek. The exact position of the fold should be determined in each individual case by the simple expedient of drawing the lip downward and outward for the maxilla, and upward and outward for the mandible. This line may also be determined by the difference in iodine stain. A few drops of solution (not more than 5 drops or 0.5 cc.) is released within the fold to render the remaining penetration completely painless.

The needle is then made to lie flat upon the gum and to advance the remaining 6 - 10 mm. (1/4 to3/8 inch) to the apex along and upon the periosteum. If the bevel of the needle is kept facing the periosteum the latter will not be scratched and

Professor Dr. R. Padmanabhan Adesh University

no resistance will be encountered. The remaining 1.5 cc. of anesthetic (2 per cent procaine-epinephrine) are deposited upon the periosteum at the apex without pressure, by bearing down lightly and slowly upon the piston of the syringe. Only for the maxillary incisors does the point of the needle penetrate the mucobuccal fold distally to the tooth. This is to avoid the thick nasal spine at the mid-line.

For Buccal and Labial Aspects of Mandible:-

Mandibular supraperiosteal infiltration, like all other forms of infiltration, is limited to the anterior teeth. The supraperiosteal technique for this region is identical with minute that for the maxillary the teeth. cortical Because plate of of the the fact that are

perforations

through

mandible

most numerous in the right and left incisive fossae (see Anatomy of mandible), a convenient method has been developed for anesthetizing

the mandibular incisors and cuspids by depositing the solution in these fossae..

Supraperiosteal infiltration of Incisive fossa`of Mandible:-

In the same manner as for other supraperiosteal injections, the lip is drawn upward and outward to delineate the mucobuccal fold. The point of the 26 mm. No. 23 gauge needle, bevel boneward, is then introduced from the right side at the fold in the median line and continued downward and in the direction of the left cuspid apex. As soon as bone (the mental tubercle) is encountered, 1 cc. of 2 per cent procaineepinephrine solution is released without pressure. To infiltrate the right incisive fossa, the needle is withdrawn and inserted into the reflection of the mucous membrane in the axis of the right cuspid. In this case, the needle travels almost vertically downward until bone is felt. It will be found that for the anesthetist who operates from the right side, the variation in technique just described is less clumsy: the left incisive fossa

Professor Dr. R. Padmanabhan Adesh University

injection is made with the shaft of the needle held at an oblique angle, while the right incisive fossa infiltration requires a vertical insertion of the needle. Care should be observed to keep the needle free from the periosteum so that the anesthetic solution may be deposited upon it rather than beneath it. Gentle massage of the skin over the chin will expedite absorption of the drugs to the extent that anesthesia will be obtained in one to two minutes. It should be noted that the position of the anesthetist is behind and to the right of the patient.

For Palatal Aspect of Maxilla:-

On the palate as well as externally do we find a gradual change in the gum tissue. The dense, firm, and pink alveolar mucosa gradually becomes softer and more resilient as we approach the mid-line of the palate, due to the increase in thickness of the submucous or areolar layer. Instead of puncturing the fibrous tissue close to the neck of the tooth with the pain and pressure incident to this procedure, advocates of the supraperiosteal method advise insertion of the needle into the loose tissue at about l cm. (About 1/2 inch) from the palatal gingival margin. This is accomplished by slipping in obliquely from the opposite side of the mouth with the 25 mm. No. 23 gauge needle, bevel toward the bone. The injection of 1/4 cc. of 2 per cent procaine-epinephrine may be made with gentle pressure after the bevel has been permitted to slide upon the periosteum for about 10 mm. or 3/8 inch. In this manner, the solution will paralyze the terminal filaments of the nasopalatine or anterior palatine nerve, as the case may be. Where more than one tooth must be anesthetized, it is recommended that the nerve trunks just mentioned be blocked by conduction technique, so as to obviate the necessity of multiple individual punctures.

Professor Dr. R. Padmanabhan Adesh University

For Lingual Aspect of Mandible:-

Supraperiosteal infiltration of the lingual surface should not be employed posterior to the cuspid teeth because of the thickness and compactness of the bone beyond the cuspids, and because of the liability of the sublingual tissue to infection Even in the case of the anterior teeth, the lingual bone is porous for only 2 or 3 mm. ( 1/8 inch) beyond the neck. One-quarter cc. of 2 per cent procaine-epinephrine solution deposited within the area indicated is sufficient to intercept the terminal filaments of the lingual nerve.

Multiple Infiltration by Single Puncture:-

Frequently the dentist and oral surgeon are faced with the problem of anesthetizing several adjacent teeth. When it is desired to accomplish this without resorting to conduction anesthesia, the method of multiple infiltration by single puncture may be utilized. Since this very effect is achieved in the mandible by the incisive fossa injection, we will concern ourselves, at this time, only with the maxilla.

If we assume that an operation must be performed upon the maxillary cuspid and lateral and central incisors, we select the most anterior area for the initial insertion at which the external alveolar plate protrudes most. In our example, this would be the central incisor region. After sterilization of the surface, a supraperiosteal injection of the central incisor is completed with a 42 mm. ( 1 5/8 inch) No. 23 gauge needle attached to a 5 cc. syringe containing a 2 per' cent procaine epinephrine solution. The needle is then withdrawn until only the bevel is buried in the tissues, and rotated until it is parallel to the mucobuccal fold. With the bevel turned toward the bone, it is advanced along the periosteum

Professor Dr. R. Padmanabhan Adesh University

to the lateral incisor apex where 1 cc. of solution is allowed to escape. Its progress is completed with the final injection at the apex of the cuspid.

Where the cuspid and bicuspids require anesthetization, the procedure is identical with that just outlined, except that the direction of the needle is posteriorly from the cuspid. For the three molars, the optimum point of insertion is at the mesiobuccal apex of the first molar. There is no such thing as multiple infiltration by single puncture for the palatal aspect of the maxilla. The choice must be made between individual insertions for each tooth or conduction anesthesia of the inner nerve loop (nasopalatine and anterior palatine nerve injections).