Purpose of Root Canal Obturation and method of root canal obturation Introduction Root canal obturation involves the

three-dimensional filling of the entire root canal system and is a critical step in endodontic therapy. There are two purposes to obturation: the elimination of all avenues of leakage from the oral cavity or the periradicular tissues into the root canal system; and the sealing within the root canal system of any irritants that remain after appropriate shaping and cleaning of the canals, thereby isolating these irritants. Pulpal demise and subse uent periradicular infection result from the presence of microorganisms, microbial to!ins and metabolites, and the products of pulp tissue degradation. "ailure to eliminate these etiologic factors and to prevent further irritation as a result of continued contamination of the root canal system are the prime reasons for failure of nonsurgical and surgical root canal therapy. The importance of three-dimensional obturation of the root canal system cannot be overstated, with the ability to achieve this goal primarily dependent on the uality of canal cleaning and shaping as well as clinical skill. #ther factors that influence the ultimate success or failure of each case include the materials used and how they are used. The ultimate coronal restoration of the tooth following canal obturation may loom as the most important goal, for there is reasonable evidence that coronal leakage through improperly placed restorations after root canal treatment and failure of the restorative treatment or lack of health of the supporting periodontium are the final determinants of success or failure in treatment. Factors influencing complete obturation $uality of the cleaning and shaping of the canal system %kill and e!perience of the clinician

&aterials and their usage Restoration of the tooth 'ealth of the supporting periodontium

Characteristics of an Ideal Root Canal Filling (n ideal root canal filling three-dimensionally fills the entire root canal system as close to the cemento-dentinal )unction as possible. &inimal amounts of root canal sealers, most of which have been shown to be biocompatible or tolerated by the tissues in their set state, are used in con)unction with the core filling material to establish an ade uate seal. Radiographically, the root canal filling should have the appearance of a dense, three-dimensional filling that e!tends as close as possible to the cemento-dentinal )unction. These standards should serve as the benchmark for all clinicians performing root canal therapy, and it is only through a knowledgeable approach to root canal treatment that uality assurance can be continually demonstrated in the obturation of root canal systems. The ideal root canal filling 3-D filling of the entire root canal space as close as possible to the cementodentinal junction

Radiographically dense fill

ith absence of !oids

"hape reflecting a continuously tapered funnel that is appro#imately the same as the e#ternal root morphology

*hile a plethora of materials has been advocated over the last +,- years for root canal obturation, historically, gutta-percha has proven to be the material of choice for successful filling of root canals from their coronal to apical e!tent. (lthough it is not the ideal filling material, gutta-percha has satisfied the ma)ority of criteria for an ideal root filling material. The disadvantages of gutta-percha . specifically, its adhesiveness, lack of rigidity, and ease of displacement under pressure . do not overshadow its advantages. /n light of its shortcomings, a sealer0cement is always used with gutta-percha. 'owever, regardless of the delivery system or techni ue used, neither gutta-percha nor sealer0cement alone enables standard-ofcare canal obturation. /n addition, the available materials and techni ues do not routinely provide for an impervious seal of the canal system; all canals leak to a greater or lesser e!tent. /t is recommended that clinicians master multiple obturation techni ues and become competent with various root canal sealers0cements, to be able to manage the diversity of anatomical scenarios that may be encountered. Contemporary "ealers$Cements The use of a sealer during root canal obturation is essential for success. 1ot only does it enhance the possible attainment of an impervious seal, it also serves as a filler for canal irregularities and minor discrepancies between the root canal wall and core filling material. %ealers are often e!pressed through lateral or accessory canals and can assist in microbial control should there be microorganisms left on the root canal walls or in the tubules.%ealers can also serve as lubricants, enabling thorough seating of the core filling material during compaction. /n canals in which the smear layer has been removed, many sealers demonstrate increased adhesive properties to dentin in addition to flowing into the patent tubules. ( good sealer should be biocompatible and well tolerated by the periradicular tissues, and although all sealers e!hibit to!icity when freshly mi!ed, their to!icity is greatly reduced on setting and all

are absorbable when e!posed to tissues and tissue fluids. %ubse uent tissue healing or repair generally appears unaffected by most sealers, provided there are no adverse breakdown products of the sealer over time. /n particular, the breakdown products may have an adverse action on the proliferative capability of periradicular cell populations. %ome clinicians consider that a small puff of root canal filler e!tending beyond the working length is indicative of a fully obturated canal space with a well-sealed apical constriction. 2!cessive sealer should not be routinely placed in the periradicular tissues as part of an obturation techni ue. %ealers0cements can be grouped based on their prime constituent or structure, such as 3inc o!ide-eugenol, polyketone, epo!y, calcium hydro!ide, silicone, resin, glass ionomer, or resin-modified glass ionomer. 'owever, many of the sealers0 cements are combinations of components, such as 3inc o!ideeugenol and calcium hydro!ide,45 with the addition of calcium hydro!ide claimed to create a therapeutic material that can be inductive of hard tissue formation.2po!y-based and methacrylate-based resin sealers that can be bonded to the root canal dentin 6but not to gutta-percha7 are also now available. %ealers should be mi!ed to a creamy consistency, allowing them to adhere to the master cone and not ball up at the shaft of the cone, leaving the gutta-percha e!posed. The sealer should adhere to the cone evenly along its length and at the end of the cone. 8linicians should read the product insert and material safety data sheet for each product chosen before using it. Contemporary Core Filling %aterials 9utta-percha is the standard material of choice as a solid core filling material for canal obturation. /t demonstrates minimal to!icity and minimal tissue irritability, is the least allergenic material available when retained within the canal system,and in cases of inadvertent gutta-percha cone overe!tension into the periradicular tissues, is well tolerated provided the canal is clean and sealed. 8hemical solvents have been used for almost +-- years to soften gutta-percha, with methods ranging from merely dipping the gutta-percha cones into the solvent for one second for better canal adaptation, to creating a completely softened paste of gutta-percha with the solvent. %olvents used have included chloroform, halothane, rectified white turpentine, and eucalyptol. Periradicular tissues may be irritated if the solvent is e!pressed beyond the canal or significant amounts of softened gutta-percha are inadvertently placed into the periradicular tissues. "ailure to allow for dissipation of chemical solvents, if volatile, or the removal of e!cess solvent with alcohol can result in significant shrinkage and possible loss of the apical seal. The use of chemical solvents has been both praised and uestioned, but with the advent of thermoplastici3ed gutta-percha, the need to consider the use of solvents at any time must be uestioned. The use of solvents, however, may still be considered for a number of challenges the clinician may face in daily practice, such as the custom fitting of master cones in irregular apical preparations or following ape!ification. &utta-percha Cones The composition of gutta-percha cones is appro!imately +:; to <<; =alata and ,:; to >,; 3inc o!ide, with the remainder a combination of various wa!es, coloring agents, antio!idants, and metallic salts.,? The specific percentages for components varies by manufacturer, with resulting variations in the brittleness, stiffness, tensile strength, and radiopacity of the individual cones attributable primarily to the

percentages of gutta-percha and 3inc o!ide. The antimicrobial activity of guttapercha is also primarily due to the 3inc o!ide. The cones are manufactured in both standardi3ed and nonstandardi3ed si3es. The standardi3ed si3es coordinate with the /%# root canal files si3es +, through +4- and are used primarily as the main core material for obturation. They generally have a <; taper, but can have a 4 or @; taper or more. The non-standardi3ed si3es are more tapered from the tip or point to the top. *ith some obturation techni ues these cones have been used primarily as accessory or au!iliary cones during compaction, being matched with the shape of the prepared canal space or the compaction instrument. 1on-standardi3ed cones began to assume a greater role as the primary core material in the more contemporary obturation techni ues, and with the development of more predictable shapes with current nickel titanium 61iTi7 rotary and hand instruments, cones tapered from 4; to +-; have gained use. Tapered gutta-percha cones

/n particular, for techni ues that use vertical compaction of heat-softened guttapercha, both the non-standardi3ed and more tapered cones have become uite acceptable. 8ustom cones can also be developed for canals with irregular or large apical anatomy, #ver time, numerous methods have been advocated for obturating the prepared root canal system, each with their own claims of ease, efficiency, or superiority. &ost contemporary techni ues still rely on gutta-percha and sealer to achieve their goal. "our basic techni ues e!ist for the obturation of the root canal system with gutta-percha and sealer ('( the cold compaction of gutta-percha) *+( the compaction of heat-softened gutta-percha ith cold instruments Cold compaction carrier ,eated compaction Presoftened core

until it has cooled; 657 the compaction of gutta-percha that has been thermoplastici3ed, in)ected into the system, and compacted with cold instruments; and 647 the compaction of gutta-percha that has been placed in the canal and softened through the continuous wave techni ue 68alamus7. ( multitude of variations on these four basic themes e!ists. "or in)ectable thermoplastic obturation techni ues, gutta-percha may come in either pellet forms or in cannulae. Cold compaction carrier ,eated compaction Presoftened core 1o single techni ue has proven to have statistically significant superiority when considering both in vitro and in vivo studies, as the success of all techni ues is highly dependent on the cleaning and shaping of the canals and the clinicianAs e!pertise in the use of a particular techni ue.*hile many have advocated the use of the lateral compaction techni ue or a single cone fill 6monocone7 to achieve a uality apical seal, the techni ue in itself does not necessarily favor the filling of canal irregularities.@5 Recogni3ing this, use of a softened gutta-percha techni ue with heat or chemical softening is re uired to achieve a thorough obturation.

/n addition, while filling the entire root canal system is the ma)or goal of canal obturation, a ma)or controversy e!ists as to what constitutes the apical termination of the root canal filling material. *orking length determination guidelines often cite the cemento-dentinal )unction or apical constriction as the ideal position for terminating canal cleaning and shaping procedures and placing the filling material. 'owever, the cemento-dentinal )unction is a histologic and not a clinical position in the root canal system and, in addition, the cemento-dentinal )unction is not always the most constricted portion of the canal 6yellow arrows7 in the apical portion of the root 8ontemporary practices of obturation favor material softening even this does not guarantee that an impervious seal of the root canal system will be established. (lso, with softened gutta-percha obturation techni ues there has been a greater incidence of material e!trusion beyond the confines of the canal. *hile softening of guttapercha may be viewed as routinely desirable, the selective use of this techni ue solely or in combination with a solid core of gutta-percha must be at the discretion of the competent clinician when anatomy dictates this approach. -pical constriction of root canal

Recent research conducted at 1ova %outheast Bniversity using micro 8T scanning technology has shown the effectiveness of scanning for imagery and the greater precision observed compared to standard radiographs. /n one e!ample, a mesiobuccal canal was filled using 9TC %eries DE obturator and the mesiolingual canal was filled using a single cone techni ue 6(ctiF 9P7. /t appeared from one angle that all canals were e ually filled. Radiograph of filled canals

'owever, closer e!amination subse uent to filling showed voids using the single cone techni ue throughout the length of the root filled using this techni ue. The single cone techni ue did not produce a monoblock obturation. The gutta-percha from the 9T obturator flowed into the canal isthmus and filled it. .oids using single cone techni/ue

Cross-section

ith -cti. &P and &T "eries 0 obturation

-cti! . &P

&T "eries 0 obturator

Canal isthmus filled

ith &T obturator gutta-percha

Gifferences in obturation techni ues and results are also more observable using 8T scanning than using traditional radiographs.8ontemporary techni ues include the use of bonded root canal filling materials. Recent developments in resin-bonding have led to the availability of resin cones and pellets similar in shape and si3e to gutta-percha materials. Resin-based cones containing methacrylate resin, fillers, bioactive glass, and polymers are available that can be handled similarly to gutta-percha and can be used with a lateral or vertical compaction techni ue. Resin-based materials can also be delivered via a heated syringe 6#btura gun, %partan #btura7. %ince resin-based materials re uire a slightly moist environment, it is important to avoid using any dessicating solutions, such as alcohol, during root canal preparation. "urther, if sodium hypochlorite or pero!ide was used during root canal preparation, this must be thoroughly removed prior to using a resin-based material as it would reduce the ability of the resin material to bond. %imilarly, the smear layer must also be thoroughly removed. Prefabricated Obturators 9utta-percha can also be formed on a plastic carrier or corecarrier. Prefabricated obturators were first described in +:>? by *illiam =en Hohnson.>: The prototype for the obturator had been prenotched I-files wrapped in gutta-percha 6hand formed7 that were then heated over a flame until the surface glistened and e!panded. These prenotched JobturatorsK were inserted into the canal and apical pressure applied while the handle was twisted off. Prototype obturator

Prefabricated obturators were introduced in +:?? 6Thermafil7 using first a stainless steel and subse uently a titanium core, coated with gutta-percha. Plastic obturators were first offered in +::<. %ince then, a number of prefabricated obturator systems have been introduced, including one that does not involve thermosoftening of the gutta-percha 6%impli"il, Giscus Gental7 but instead is used cold with only the apical area coated in gutta-percha, and after placement the carrier itself is removed. ( recently developed prefabricated obturator utili3es a resin-based system 6Real%eal #ne, %ybron 2ndo7 and is used with, and bonded to, methacrylate resin-based sealer material and is first held in its custom oven and thermosoftened. #ther systems use thermosoftened gutta-percha, including 8alamusC 6Tulsa Gental, Gentsply7 , %uccessfilC 6'ygienic-8oltene-*haledent, /nc.7, 9utta- "lowC, %ystem = #bturation %ystem, Thermafil, Thermafil Plus, ProTaperC Bniversal and Pro%ystem 9TC #bturators 6Gentsply, Tulsa Gental7, and %oft-8oreC 6%oft-8oreC Te!as, /nc.7.

8urrent plastic obturators are available in a nonvented shape with a taper of around -.-4 6Gensfil7 and a vented shape with the same taper 6Thermafil Plus7. =oth are biologically inert. The carrier is thick with a thinner outer coating of gutta-percha, which helps to reduce material shrinkage as the gutta-percha cools in the canal. ( vented prefabricated obturator helps the flow of gutta-percha during placement and also aids in retrieval of the obturator should retreatment be necessary. "or si3es 4- and below in the Thermafil series, an insoluble li uid crystal plastic is used. "or si3e 4, and above soluble polysulfone polymer is used. (ll of these use a si3e verifier to help select the correct si3e obturator, as do ProTaper Bniversal carriers, which start at a .-4 taper. %ystems that do not use a si3e verifier include the Pro%ystem 9T carriers and 9T %eries D carriers, which are made in a variety of tapers between -.-4 and -.+< Regional -nesthesia %anual1upper e#tremity bloc2s Introduction Peripheral nerve blocks are gaining widespread popularity for perioperative pain management because of their specific advantages over general anesthesia and central neura!ial anesthesia. Pain relief with P1= avoids side effects such as somnolence, nausea and vomiting, hemodynamic instability and voiding difficulty inherent to general and central neura!ial anesthesia. Patients who undergo surgery under P1= can bypass phase / recovery room and fre uently be discharged e!peditiously following ambulatory surgery. Patients with unstable cardiovascular disease can undergo surgery under P1= without significant hemodynamic changes.

Patients who have abnormalities in hemostasis or infection which contraindicate use of central neura!ial block can be candidates for surgery under P1=. ( substantial savings in operating room turnover time can occur if P1= is done outside the operating room. /f the patient has a functioning block preoperatively there is no induction or emergence time. Patients with a P1= can fre uently position themselves. *hen used as part of a combined general regional techni ue, P1= facilitates lighter planes of anesthesia, avoiding the use of opioids and allowing a uick emergence and recovery. /n order to carry out a regional block safely and effectively, the anesthesiologist must be proficient in the following: (natomy 'ave knowledge of the neural elements to be blocked, their relationship to muscular, vascular and other anatomic structures and their ultimate motor and sensory innervation. Inowledge of the innervation will provide guidance to select the most suitable techni ue for a particular surgical procedure. The bony, vascular, muscular and fascial relationships will serve as landmarks to guide the needle to the appropriate site, thus improving the success of the block and minimi3ing side effects and complications. Pharmacology Inowledge of local anesthetic pharmacology will assist in the selection of the most appropriate local anesthetic drug and dosage. The anesthesiologist must also be familiar with the clinical pharmacokinetics i.e. pattern of onset of and recovery of the nerve block. This allows an assessment of the clinical efficacy of the block with respect to operative anesthesia and appro!imate duration of postoperative analgesia after a particular local anesthetic drug has been in)ected. 8omplications and side effects Inowledge of the possible complications and the errors in the techni ue will help in preventing the complication and also in managing them effectively in case they do occur. Inowledge of the possible side effect which could occur from blockade of the other neural elements in the vicinity such as phrenic nerve, recurrent laryngeal nerve and the sympathetic nerves will help in patient education as well as in assessing the contraindication to the techni ue. Local anesthetics: 8linical pharmacology, drug selection and to!icity To select an appropriate local anesthetic drug for a specific clinical situation, one should be familiar with the clinical pharmacology of the local anesthetic drugs and ad)uvants. Local anesthetics e!ert their effect either by inhibiting the e!citatory process in the nerve endings or in the nerve fibers. The following se uence of events is generally accepted as the mechanism of action of local anesthetic agents:

=inding of the local anesthetic moiety to the receptor sites in the nerve membrane. Reduction in sodium permeability Gecrease in the rate of depolari3ation "ailure to achieve threshold potential Lack of development of propagated action potential 8onduction blockade

The pharmacological activity of local anesthetic agents is influenced by their chemical structure, lipid solubility, protein binding, pIa. 8hemical %tructure =ased on their chemical structure local anesthetics can be grouped into:

(minoesters . Procaine, cocaine, tetracaine, choroprocaine. (minoesters have an ester linkage between the ben3ene ring and the intermediate chain. These are hydroly3ed in the plasma by pseudocholinesterase. #ne of the primary metabolites of ester compounds is paraminoben3oic acid. Paba has known allergic potential. (minoamides . Lidocaine, mepivacaine, bupivacaine, ropivacaine. (minoamides have an amide link between the ben3ene ring and intermediate chain. These are degraded in the liver by microsomal en3ymes. The amide drugs are not metaboli3ed to paraaminoben3oic acid and rarely produce allergic reactions. &ultidose vials of amide local anesthetic may contain methylparaben 6&P" should always be used for regional anesthesia7 which is a paraaminoben3oic acid derivative with allergic potential.

Lipid %olubility

Lipid solubility is the primary determinant of intrinsic anesthetic potency. Potency increases as a function of lipid solubility until a blood0lipid partition coefficient of 4 is reached. "urther increases in lipid solubility do not cause a further increase in the local anesthetic potency. =ased on the lipid solubility and potency, local anesthetic drugs can be divided into 5 groups: Low lipid solubility0potency: Lipid partition coefficient M +. These drugs must be administered in high concentrations 6< to 5 ;7 to achieve effective neural blockade. Local anesthetic drugs in this category include procaine and chloroprocaine. /ntermediate lipid solubility0potency: Lipid partition coefficient +-5. These drugs may be in concentrations of + to <;. Local anesthetic drugs in this category include lidocaine, mepivacaine, and prilocaine. 'igh lipid solubility0potency: Lipid partition coefficient N4. These drugs are clinically effective at low concentrations M+;. Local anesthetic drugs in this category include tetracaine, bupivacaine, and ropivacaine. Protein =inding (ddition of larger chemical radicals to the amine or aromatic end of a local anesthetic compound increases its binding to protein, which is a determinant of local anesthetic duration. Protein binding of commonly used local anesthetics is: =upivacaine-------------------------:,; Tetracaine---------------------------:,; Ropivacaine-------------------------:4; &epivacaine------------------------>4; Lidocaine----------------------------@,; Procaine-------------------------------@;

PIa Pka is the p' at which ioni3ed and unioni3ed fractions of a substance are present in an e ual amount. The onset of local anesthetic effect will be determined by the total amount of unioni3ed fraction of the local anesthetic agent because the unioni3ed fraction primarily diffuses across the nerve membrane. The percentage of local anesthetic, which is present in the unioni3ed form 6cation or base7 when in)ected into the tissue at 6p' >.47 is inversely proportional to the pIa of the agent. (s the p' of the local anesthetic solution goes down, the unioni3ed fraction will decrease when the p' increases the unioni3ed fraction increases. There is a correlation between the onset of the block and the pIa of local anesthetic drug. The drugs with pIa of >.@>.? 6 lidocaine, mepivacaine, prilocaine7 have a more rapid onset of action than do bupivacaine and tetracaine which have a pIa of ?.+ and ?.@ respectively. (t the body p' 6>.47, 5, ; of lidocaine e!ists in unioni3ed base form and only , ; of bupivacaine e!ists in unioni3ed base form.

(d)uvant Grugs These drugs can reduce the onset time, prolong the duration, increase the density and reduce dosages of the commonly used local anesthetics.

2pinephrineProlongs duration by vasoconstriction and slowed absorption. Guration can be increased by 5--,-;. Peak plasma concentrations can also be reduced by ,-;. 8an also be a marker for intravascular in)ectionOtachycardia. 8lonidineProlongs duration of local anesthetics by synergistic alpha-< effects. Lesser or no prolongation with =upivacaine and Ropicacaine but can prolong &epivacaine-Lidocaine by 4--4--; with +-micrograms. Larger doses are not additive and cause more side effects.

3pper 4#tremity 5loc2s The ple!us of nerves innervating the upper e!tremity is contained in a fascial sheath, which is surrounded by reliable anatomic landmarks. This allows an in)ection of local anesthetic to reliably block the sensory and motor innervation to the upper e!tremity with two e!ceptionsO (reas of the upper e!tremity with cervical ple!us innervation. The sensation of the skin overlying the shoulder is supplied by the nerve roots 85 and 84 of the cervical ple!us. These nerve roots lie superior to the most cephalad aspect of the brachial ple!us. /nterscalene blocks done with large volume of local anesthetic 65,-4-ml7 may block these nerve roots as well in the vast ma)ority of cases. The surgical procedures where 85 and 84 blocks are beneficial usually involve the clavicle. (rea of the upper e!tremity with intercosto-brachial 6T<7 innervation. The sensory innervation of the a!illa and anterior shoulder is T<, which is also derived from outside the brachial ple!us. ( T< block is re uired for shoulder surgery with anterior incisions 6anterior stabili3ation for shoulder dislocation7 and surgery involving the elbow and upper arm. /nnervation of the upper e!tremity "or convenience the branches of the brachial ple!us which innervate the upper e!tremity can be divided into supraclavicular 6branches from roots and trunks7 and infraclavicular branches from the divisions, cords and nerves.

(ll the supraclavicular branches are motor with the e!ception of the suprascapular nerve, which provides sensation to the shoulder )oint. %uprascapular branches supply the scalene muscles, serratus anterior via the long thoracic nerve, muscles of the upper back and contribute to the phrenic nerve. The infraclavicular branches comprise all of the sensory and motor innervations to the upper e!tremity and are important to the anesthesiologist both from the point of view of techni ue 6distribution of parasthesia, motor response if nerve stimulator is being used to locate the ple!us7 and e!tent of the block and identification of missed nerves.

(natomic relations of the =rachial ple!us Inowledge of the anatomic structures, which surround the brachial ple!us, will help in the location of the ple!us as well as in the prevention of complications. Perivascular compartment This concept has promoted the single in)ection techni ue of the brachial ple!us block. 8linically, pro!imal blocks behave as if there were a sheath surrounding the ple!us. ( single in)ection techni ue lends itself to a short onset and high success rate. 'owever with a more distally placed block like an a!illary block, a single in)ection techni ue is less reliable because of the individual peripheral nerves

begin to diverge. To improve the success of an a!illary block several strategies are used to improve pro!imal spread of local anesthetic- such as in)ecting high in the a!illa, adduction of the arm and application of pressure distal to the in)ection. Fascular relationship There are no ma)or vessels at the level of the roots e!cept for vertebral vessels, which lie far medially and anterior to the ple!us. ( long needle directed hori3ontally in the interscalene space may get into the vertebral artery or vein. The needle can also get into the subarachnoid or epidural space via the intervetebral foramen. The trunks of the ple!us also lie in close pro!imity to the subclavian artery, which separates them from the anterior scalene muscle. . This relationship must be born in mind when doing a subclavian perivascular approach is being used. (nother anatomic fact is the significance that the inferior aspect of the trunk of the ple!us may be trapped behind and under the artery. /n this situation, there is probably a mechanical barrier to the spread of local anesthetic if it is placed high in the interscalene groove. %o the most common elements of the brachial ple!us missed with an interscalene approach are 8? and T+.

=locks above the clavicle Level of the roots . /nterscalene brachial ple!us block Trunks . %ubclavian perivascular brachial ple!us block0 classical supraclavicular brachial ple!us block =locks below the clavicle

Givision08ords . /nfraclavicular brachial ple!us block 8ords0Terminal nerves . (!illary brachial ple!us block (!illary (pproach of the =rachial Ple!us The a!illary block is the most commonly used approach to the brachial ple!us since this approach is free of the risk of pneumothora!.

Position: The patient is placed supine with the arm abducted :- degrees and fle!ion of the forearm with e!ternal rotation so that the forearm lies parallel to the long a!is of the body. 'yperabduction will obliterate the a!illary artery pulse in ?-; of individuals because the artery is compressed between the head of the humerus and the pectoralis minor muscle. 1eedle placement: The arterial pulse should be identified and followed as pro!imal as possible, ideally to the point where the pulse disappears beneath the pectoralis ma)or. The artery is located between the inde! and middle fingers of the nondominant hand. *ith light digital pressure the artery is fi!ed against the humeral head high in the a!illa. ( P<< gauge +., cm = bevel needle is introduced slightly superior to the finger tip and advanced at about a 5- degree angle to the skin, tangential and parallel to the neurovascular bundle until one of the following 5 endpoints are met. %low needle placement until a parasthesia is obtained 6%uccess rate ?,-:-;7. The transarterial approach: The needle is slowly advanced until bright red blood is obtained during continuous advancement. #nce blood return is obtained, the needle should be advanced through the wall of the a!illary artery until no additional blood can be aspirated. #nce it has been verified by the aspiration that the needle tip lies posterior to the arterial wall 6)ust +-mm7, the total anesthetic volume 64--,- ml7 is in)ected in ,-ml increments posterior to the artery. %plitting the local anesthetic volume to deposit posterior and anterior reduces rather than increases the success rate of the block. The success of the block is related to the close pro!imity of the needle tip to the posterior wall of the artery 6clinical sign to ensure this is aspiration of slight blood stained fluid during intermittent aspiration and in)ection7. (fter appro!imately <- ml of local anesthetic in)ection the needle can be withdrawn back though the artery and advances again through the posterior wall. This reconfirms that the needle tip is in close pro!imity to the posterior wall of the artery. (ppropriately performed, the transarterial approach has nearly +--; success rate. ( sharp needle 6not a blunt tipped nerve stimulator needle7 should be used for the transarterial techni ue. (!illary block using a nerve stimulator . Bsing an insulated needle, connect the negative lead to the needle. Bse low output current 6.5-.,ma7 at l sec twitch rate. Look for an appropriate motor response in the hand in the distribution of the ulnar, radial, or median nerves. Please note that motor response at the elbow 6biceps twitch7 indicates that stimulation of the musculocutaneous nerve, which is outside the sheath. The in)ection at the endpoint will result in the block of the musculocutaneous only. 2pinephrine +:<--,--- 6, mcg0ml7 should be used in all perivascular blocks. Girect close attention to the 289 or pulse o!imeter pulse tone to effectively identify intravascular in)ection. (fter in)ecting 4--4,cc, a small volume of local anesthetic should be in)ected subcutaneously over the a!illary artery to block the branches of the intercostobrachial and medial brachial cutaneous nerve. (ssessing the %uccess of the (!illary =lock

/f the onset of pro!imal motor block 6loss of forearm e!tension; i.e. inability to point to the ceiling . radial nerve block7 occurs within minutes of the in)ection, you can e!pect good surgical anesthesia in <- minutes. 8heck the sensory distribution of the individual nerves to identify the unblocked nerves. 6Push, Pull, Pinch, Pinch7

/nterscalene approach to the brachial ple!us This techni ue for brachial ple!us anesthesia is used for surgical procedures of the upper arm and shoulder. This approach is specifically suited for shoulder surgery since it blocks the suprascapular nerve which supplies sensation to the shoulder )oint. Techni ue: The key to success is correct identification of the interscalene groove. The patient should be supine and asked to elevate the head, bringing the sternocleidomastoid muscle into prominence. The inde! and middle fingers are places behind the clavicular head of the sternocleidomastoid muscle and the patient is asked to rela! and turn the head and onto the opposite side with the chin in the midclavicular line. Turning the neck too far laterally will make the scalene muscles difficult to palpate. The palpating fingers are moved medially behind the sternocleidomastoid to lie on the anterior scalene muscle. The palpating fingers are then rolled laterally until the groove between the anterior and middle scalene muscles is identified. Please note that the groove is wider distally, so keep the distal palpating finger in the groove )ust above the clavicle. Ieep the middle finger firmly in the distal part of the groove and the palpating inde! finger at the level of 8@ anterior to the e!ternal )ugular vein. /f there is difficulty in identifying the anterior scalene muscle, ask the patient to ma!imally inhale. This makes the anterior scalene muscle

more prominent and its palpation easier. The needle is inserted in the into the interscalene groove at the level of 8@ which can be identified by drawing a line from the crycoid cartilage to the interscalene groove. (n additional landmark is the e!ternal )ugular vein when visible crosses the interscalene groove at the level of 8@. *ith both the inde! and middle fingers in the groove, a P<< gauge =-bevel needle is inserted at the level of 8@ perpendicular to all planes mostly mesiad, but slightly caudad and posterior. . The appropriate needle placement should be @- degrees from the sagittal plane. The needle is advanced until a parasthesia is elicited in the shoulder or there is a motor evoked response in the forearm at M-., m( or the transverse process is contacted. /f bone is contacted then the needle tip should be withdrawn and redirected caudad until the appropriate motor response or parasthesia is obtained.

Please note that when a large volume of local anesthetic 65,-4- ml7 is in)ected especially in a thin patient, a visible swelling will appear above the clavicle defining the inferior portion of the supraclavicular brachial ple!us. Gue to the distance of the 8? and T+ nerve roots from the sight of in)ection, the ulnar nerve is fre uently missed with the interscalene approach. (lso, the intercostobrachial and brachial cutaneous nerves, which supply the a!illa and medial aspect of the upper arm, will be missed. (ssessing the success of the /nterscalene =lock &otor block precedes sensory block. /nnervation to the shoulder fle!ors are the first blocked. /f the patient cannot lift the shoulder of the table within <-5 minutes of local anesthesia 6even with -.,; =upivacaine7 e!pect good surgical anesthesia for shoulder surgery within <- minutes. . /nfraclavicular brachial ple!us block (natomy: The boundaries of the infraclavicular fossa are pectoralis ma)or and minor muscles anteriorly, ribs medially, clavicle and coracoid process superiorly and humerus laterally. The ple!us is approached in close pro!imity to the coracoid process.

Techni ue: the patient is supine, the ipsilateral arm is abducted to a :--degree angle and the patientAs head is turned to the opposite side. The following landmarks are identified and marked . &edial head of the clavicle (cromion process . The most prominent structure on the superior aspect of the shoulder. (!illary artery . at the highest point in the a!illa place a mark on the pectoralis ma)or, Goppler can be used to mark the a!illary artery along the infraclavicular area &ark the midpoint of the clavicle between the (cromion and the sternal head of the clavicle. 1eedle entry site is . <., cm below the midpoint of the clavicle along the a!illary artery.

The anesthesiologist stands at the patientAs side opposite to the one being blocked. The needle entry site is infiltrated with local anesthesia. ( +- cm insulated block needle is inserted at a @- degree angle to the sagittal plane directed away from the rib cage towards the a!illa. Pectoralis ma)or contractions are observed at a depth of + . 5 cm. The ple!us lies 5 . > cm deep. %ince musculocutaneous and a!illary nerves are outside the sheath, motor response of those two nerves 6i.e. deltoid and biceps contractions7 should not be accepted. /f these two motor responses are obtained redirect the needle in)ection toward the ape! of the a!illa. The ideal motor evoked response is hand movement at 6.5-.47m(. #nce ideal motor evoked response is obtained in)ect 4- . ,- ml of local anesthesia incrementally. /f no motor response is encountered, progressive needle redirection to ?- degrees will yield an appropriate response. %uprascapular 1erve =lock The suprascapular nerve provides sensory innervation to >-; of the shoulder )oint. The suprascapular nerve supplies %uperior and posteriosuperior regions of the shoulder )oint capsule and variable portions of the overlying skin. (nteriorly and inferiorly the skin and )oint capsule are supplied by the a!illary nerve, upper and lower subscapular nerves. %uprascapular nerve blocks can be used for postop analgesia but not for operative anesthesia. Techni ue: The patient should sit up and lean forward with the arms hanging loosely at the side. Graw a line along the length of the spine of the scapula. Palpate the acromion process at the edge of the spine of the scapula. (t the point where the thicker acromion process fuses with the thinner spine of the scapula is marked. The skin is prepped. ( <, or <> gauge needle is used to anestheti3e the needle entry site at the marked point. (n insulated block needle . 6%timuple!7 <<g < inch 6M>- kg7 or 4 inch 6N>- kg7 is introduced through the marked point. The needle should contact bone at a depth of one inch. The needle is walked superiorly and medially until it slides off into the suprascapular notch. The needle should be advanced no more than + cm from the suprascapular notch because of the risk of pneumothora!. %timulation of the suprascapular nerve causes contraction of the supraspinous and infraspinous muscles with abduction and e!ternal rotation of the arm. *ith the appropriate motor evoked response, in)ect +- . +, ml of local anesthesia. /ntravenous Regional (nesthesia 6/FR(, =ier =lock7 /FR( can be used for short surgical procedures on the e!tremities. /FR( involves an /F in)ection of local anesthetic mi!ture into an e!sanguinated e!tremity that is vascularly isolated by a tourni uet. /t is technically simple. 'igh reliability 6:>-+--;7, ease of administration and safety are ma)or advantages of this techni ue. /FR( is suitable for surgical procedures below the elbow in the upper e!tremity and below the knee in the lower e!tremity of less than +-hour duration. The only drug specifically approved by the "G( for /FR( is Lidocaine -.,; preservative-free. "or upper e!tremity blocks, a volume of 4--,- ml is used and for the lower e!tremity blocks, a concentration of -.<,; with a volume of +---+<, ml is used. The purpose of using a high volume is to assure an ade uate distribution of local anesthetic in the entire venous system of the e!sanguinated e!tremity.

Techni ue of /FR( %tart an /F infusion in the uninvolved e!tremity for drug administration and hydration. (pply the appropriate monitors; give supplemental o!ygen and ade uate sedation to make the patient comfortable. 8heck baseline %=P so that the appropriate tourni uet inflation pressure can be used 6+-- mm 'g higher than %=P7. Place a <- or << 9 angiocath near the surgical site preferably in the dorsum of the hand. Go not place the angiocath near the site of the surgical incision. (pply *ebril gau3e to the upper arm from armpit to elbow. This protects the skin and the ulnar nerve in the cubital tunnel. (pply two separate tourni uets of the *ebril. Place a <4-cm tourni uet pro!imally and +?-cm tourni uet distally on the upper arm. /n obese patients with conical shaped upper arm, use a single large 5--cm tourni uet. 2levate the e!tremity and e!sanguinate with an 2smarch bandage from hand to distal tourni uet. *hile wrapping the arm be careful not to wrap the area over the angiocath. 8ompression of the angiocath hub beneath the 2smarch bandage can cause ulceration of the underlying skin. /nflate the distal tourni uet to <,--mm 'g and then inflate the pro!imal tourni uet. #nce the pro!imal tourni uet is inflated, deflate the distal tourni uet. 2nsure that the inflation pressure is at least +-- mm 'g above the systolic pressure. /n a hypertensive patient N <,- mm 'g may be needed. This is very important for maintaining a bloodless surgical field. Remove the 2smarch bandage and check for presence of a radial pulse. Place a tourni uet pro!imal to the angiocath on the forearm and in)ect the local anesthetic solution into the angiocath slowly. Remove the angiocath and compress site for < . 5 minutes. Tourni uet Pain Tourni uet pain manifests itself in many forms: e.g. patient getting restless, vague complaints of aches and pains and pressure in the arm, tourni uet site, or in the shoulder. This may occur <--5- minutes after the inflation of the pro!imal tourni uet. /f you suspect that the patient is having tourni uet pain, inflate the distal cuff then deflate the pro!imal cuff. (lways inform the surgeons before switching the tourni uets as they may be in the middle of a crucial maneuver and any tourni uet mishap may complicate their procedure. %upplemental analgesics and sedatives are also used to prevent and manage tourni uet pain.
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