1. 2. 3. 4. 5. 6. 7. 8. 9.

1.2 Dentoalveolar Surgery Indications and contraindications for extraction Indications for surgical extraction Surgical extraction and impaction Classification of impaction Surgical principles Exposure Alveoplasty Tori removal Soft tissue surgery Reconstructive dentoalveolar surgery Implant

1.

Indications and Contraindications for extractions 1. Nonrestorable tooth. 2. Untreatable pulpal necrosis/ IPP 3. Severe perio: irreversible bone loss 4. Ortho: 1st premolar and 3rd molars 5. Malposed teeth mucosal trauma, unopposed hyperocclusion 6. Cracked teeth 7. Preprosthetic extractions 8. Impafcted teeth and supernumerary 9. Pre-radiation Contraindications 1. Uncontrolled metabolic disease End stage renal, brittle diabetes, unsatlbe angina. Leukemia/lymphoma Hemophilia/platelet disorders 2. Head and neck radiotherapy osteoradionecrosis treat: hyperbaric oxygen chamber 3. Pericoronitis (cellulitis): around partial erupted 3rd clear infection first! 4. Relative: acute infectious stomatitis, malignancy 5. Drugs: intravenous bisphosphonates osteoradionecrosis Indications for surgical extraction Need for excess force. Failed forcep extraction Heavy/dense bone older patients Short clinical crowns (attrition) Hypercementosis/ divergent roots Extensive decay/crown loss Surgical extraction/impactions Impaction causes: inadequate arch space. dense bone and soft tissue, adjacent teeth

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Most common: mandibular 3rd max 3rd max canines Unerupted = impacted and erupting. Embedded = impacted Consider removing impact at diagnosis to prevent: i. Periodontal disease, caries, pericoronitis, root resorption, odontogenic cysts/tumors, pain, jaw fractures, help ortho treatment Contraindications to remove impact: i. Extreme age ( preteen/asymptomatic > 35 yrs) ii. Poor health, poor location: canal (structure damage) Impact classification: Angulation: Mesioangular (least difficult), horizontal, vertical, distoangular (most difficult) Pell and Gregory: anterior ramus i. Class 1: normal position. Class 2: 1/2 in ramus, class 3: entirely in ramus Occlusal plane: i. Class A: same as other molars, Class B: btw occlusal and cervical, Class C: below cervical Easy extraction: i. MA position, class 1A, fused conic root, separate from second molar, soft tissue impact. 1/3-2/3 roots, wide pdl, large follicle, elastic bone, separate from nerve kids Difficult extractions: complete opposite: Bold opposite adults Surgical principles Exposure: adequate visibility. i. Envelop flap w/ release incisions base > apex for blood supply. ii. Mand third molar: bone posterior to 3rd molar thins and diverge laterally easy to damage lingual nerve tongue numbness on same side iii. Prevention of soft tissue injury: pay attention, develop adequate size, do not retract with force Bone removal: for atraumatic extraction. i. Need more for impacted third. Remove down to tooth cervix. ii. Depends on tooth position and morphology iii. Do not injure lingual cortex Tooth sectioning avoid radical bone removal/injury Irrigation: prevent subperiosteal abscess from fragments Complications: i. Mucosal tearing prevent with large incisions ii. Puncture: tongue, palate, soft tissues. Pressure leave open for secondary intent healing. Maybe antibiotics iii. iv. v. vi. vii. viii. Oral-antral communications: figure-8 suture, nasal spray, keep ostium open, sinus precautions Root fracture and alveolar fracture: common in maxillary tuberosity. Tooth displacement: maxillary molars sinus/infratemporal fossa. Mandibular submandibular space or through buccal bone. Tooth lost into oropharynx airway obstruction, call 911 Adjacent teeth injury: fracture/luxation Trauma to IAN or lingual nerve. Avoid lingual. Numbness > 4 weeks refer for evaluation

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Bleeding: uncommon. 3 causes: 1. IAartery: mandibular 3rd molar. Muscular arteriolar bleed: FMF. Poor hemostasis: (warfarin/platelet inhibition, hemophilia, von Willebrands, chronic liver disease) Infection: flaps have potential for subperiosteal abscess irrigate before suture Localized osteitis: 3% of mandibular 3rd, no antibiotics needed. Irrigate + local treatment + pain control

x. xi.

Alveoplasty: pre-prosthetic. i. Preassessment: bone amount and contour, quality of soft tissue of DBA, vestibular depth, muscle attachment location, jaw relationships, soft/bony pathology ii. Minor: remove sharp edge. Major: remove undercuts and mylohyoid ridge Tori removal: remove only for denture construction/trauma. Common: palate/lateral alveolar ridge Soft tissue surgery: Bone is okay, soft tissue too thick: areas: i. Retromolar pad, max tuberosity, excessive alveolar ridge tissue, IFH, labial and lingual frenum Reconstructive surgery. 3-1 i. Implants: Success depends on: primary stability, bone amount, anatomic structures chart ii. Augmentation: 1. Grafting alveolous. 2. Autogenous: obtain cortical bone: lilac crest, rib, antieror chin cortex, lateral cortex of ramus/ external oblique. 3. Allogenic material 4. Distraction osteogenesis

1.3 Trauma Surgery 1. 2. 3. 4. 1. 2. Tooth Fracture Facial Fracture Mandible Fracture Midface Fracture Facial Fracture: symptoms: pain, contour deformity, ecchymosis, laceration, abnormal mobility, numbness, crepitations, hematoma. Rule out in fights, falls, or accidents Mandible fracture: Suspect fracture: confirm with at least 2 radiograph: panoramic, townes, AP, Lateral oblique Most common site condyle, angle and symphysis (Picture) Classification: greenstick, simple, comminuted, and compound (open) Treatment: open reduction and internal fixation with titanium bone plates and screws. Other methods: lingual splinting (pediatrics), IMF (wiring jaws close) Midface fractures: (3-3) Evaluate with CT: 2 orientations axial and coronal needed. Treatment:

3.

i. ii. iii.

Internal rigid fixation: LeFort, orbital fractures and zygomatic fractures. Isolated zygomatic fracture: open reduction, no plates and screws needed Simple nasal fractures: internal and external splints 1.4 Orthognathic Surgery

1. 2. 3. 1. 2. 3.

Imaging Diagnosis Surgery Imaging: Mainly used: lateral cephalograms. Take panoramic, AP cephalograms, periapicals as needed. Diagnosis:Maxilla: hyper/hypoplasia. Anterior open bite: apertognathic, Excess OVD (long maxilla, gummy smile., crossbites, macrogenia/microgenia. Surgery: Maxilla: LeFort 1 osteotomies. Mandibular surgery: BSSO, vertical ramus osteotomy. i. BSSO: Ramus divided by horizontal osteotomy on medial aspect and vertical osteotomy on lateral aspect. Connected by anterior ramus osteotomy. Chin: genioplasty (osteotomy) macrogenia/microgenia Distraction Osteogenesis for cleft/lip palate and hemifacial microsomia. DO: osteotomy to separate bone, appliance to separate gradually. 1.5 Facial Pain and Neuropathology

1. 2. 3. 1.

Overview Classification of orofacial pain Neuropathic pain Overview Pain perception: psychologic + physiologic. i. Physiologic pain: 3 parts: transduction, transmission, modulation. 1. Transduction: A-delta/C to spinal cord/brain stem 2. Transmission: CNS thalamus and cortical centers 3. Modulation: limit rostral pain info from spinal cord to high cortical center ii. Psychologic: if pain > 4-6 months Classification of orofacial pain: Somatic ( stimuls = pain) Musculoskeletal and visceral Neuropathic (stimulus intensity pain) Pain pathway damage: TN, trauma, stroke Psychogenic: intrapsychic disturbance: conversion reaction, psychotic delusion, malingering Atypical: Idiopathic facial pain Neuropathic pain: TN, Odontalgia, PHN, Neuromas, Burning Mouth, chronic headache (3-3), temporal arteritis (giant cell arteritis) TN: > 50. Trigger point pain and electric, shooting, episodic, followed by refractory.

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i. ii. iii. iv.

Treatment: anticonvulsant: carbamazepine, oxcarbazepine, gabapentin) Surgery: microvascular decompression (Janetta Procedure) Gamma knife radiosurgery Percutaneous needle rhizotomy, entry zone ballon root compression

Odontalgia 2ndary to deafferentation i. Endo trauma or extraction trauma. damage afferent pain transmission ii. Pathogenesis: Peripheral hyperactivity at surgical site, CNS hyperactivity secondary to 2nd order nerve changes in trimeginal nucleus PHN: Herpes zoster: burning, aching, electric shock. i. Treat: anticonvulsants, antidepressants, sympathetic blocks ii. Ramsay Hunt: HZV of CN 7 and 8 facial paralysis, vertigo, deafness and EAC cuntaneous eruptions Neuromas proximal transected nerve form sprouts filled with Schwann cells. chronic neuropathic pain. Burning mouth syndrome: 2ndary to modulation defect i. Predisposition: postmenopausal females. ii. iii. Pain, dryness, mouth burning and tongue, altered taste 50% resolve in 2 years. Hormone, anticonvulsants/antidepressants meh results

Table 3.3 1.6 TMD 1. 2. 3. 4. 1. Overview Types: MPD, DDD, systemic arthritic, chornic recurrent dislocation, ankylosis Nonsurgical treatment Surgical treatment Types MPD: Most common masticatory pain/poor function i. Etiology: abnormal muscle fxn and hyperactivity: parafxn habits/DDD/degenerative arthritis ii. Diffuse, poorly localized, preauricular region. Wear facets, Pain worsens in mornings iii. Involves masticatory muscles. Disc displacement disorder: 2 types: reduction/ without reduction. i. Reduction: normal interincisal opening w/o deviation, joint/muscle tenderness, clicking. 1. Opening click: condyle over posterior area of anteriorly displaced disc ii. 2. Closing click: disc trapped Nonreduction: Ipsilateral devation and opening. (3-10)

Systemic arthritis: RA, lupus, gout/pseudogout (calcium pyrophosphate dihydrate CPPD) Chronic recurrent dislocations: condyle translates anterior to eminence i. Pain and muscle spasm. ii. Mechanical manipulation for reduction. Chronic: botulinum toxin A (Botox), lateral pterygoids or surgery

Ankylosis: intracapsular vs extracapsular. Fibrous vs bony i. Causes: Trauma (most common), surgery, radiation therapy, infection ii. Limited translation on affected side. 2. Nonsurgical therapy: used for everything except severe DJD, ankylosis, internal derangement Counseling: for MPD (parafxn/stress) Medical therapy: NSAIDS, steroids, narcotics, non-narcotic analgesics, antidepressants and muscle relaxants PT: Biofeedback, USG, TENS, massage, thermo treatment, exercise, iontophoresis. i. Objective: increase circulation remove by-products deliver therapeutic medication ii. TENS override pain input + endogenous endorphins release Occlusal Splints: autorepositioning / anterior repositioning. i. Auto: muscle and joint pain when no anatomical pathologies reduce intra-articular pressure. No working/balancing interferences ii. AR: protrude mandible recapture normal disc-condyle relationship Arthrocentesis: indication: internal derangement i. 2 needles into superior joint space. Inject saline/lactated ringer. Suggest lavage. 3. ii. Success depends: distension of joint capsule, adhesion release, removing chemical medicators Surgical Treatments: Arthroscopy: 2 cannulas to manipulate superior joint space. i. Techniques: disc manipulating, disc release, posterior band cautery, disc repositioning and stabilizing. ii. Advantage: Less invasive Open arthroscopy: aka disc repositioning surgery. i. Indications: painful, persistent clicking and closed locks. ii. iii. Mobilize disc and remove posterior wedge, suture disc into new position. Initial good results, 10-15%: no benefits/worsens

Discectomy: disc repair or removal i. Indications: severely damaged disc ii. Remove disc, replace with temporalis muscle, fascia fat and auricular cartilage. iii. Results vary WIDELY Condylotomy: performed with intraoral vertical ramus osteotomy (IVRO) i. Indications: internal derangement w/, w/o reduction, DJD, chronic dislocation ii. Proximal condyle not fixated, soft tissue reposition condyle and disc to neutral position. Total Joint replacement i. Indications: severe joint in RA, DJD, ankylosis, neoplasia, posttrauma. ii. Condyle problem: Costochondral bone graft most common. iii. Fossa pathologies: total prosthetic material Odontogenic Infections 1. 2. Pathophysiology Organisms

3. 4. 5. 6. 1.

Progression Fascial Spaces Treatment Principles Microbiology Pathophysiology: Polymicrobial. Most common: aerobic gram-positive cocci, anaerobic gram-positive cocci, anaerobic gram-negative rods. Anaerobic 75%, aerobic 25% Organisms: Streptococcus initiate infection deep tissue cellulitis (aerobic consumes oxygen) anaerobic proliferates. Progression: Origin: periapical abscess/periodontal infection. Path of least resistance. Intramedullary space perforate thin bony cortex anatomic space. Most common space: vestibular space asymptomatic fistula Spread along anatomic planes. Fascial spaces: aka potential spaces Vestibular, buccal, canine, sublingual, submandibular, submental, masticator (pterygomandibular, masseteric, superficial temporal, deep temporal), lateral pterygoid. i. Buccinator space: between buccinator muscle and overlying skin/fascia ii. Space of mandibular ramus: bounded by masseter, medial pterygoid, temporal fascia and skull iii. Submandibular space: between mylohyoid and skin and superficial fascia. 2nd-3rd molar iv. Lateral pharyngeal: medial pterygoid muscle laterally, and lateral aspect of superior pharyngeal constrictor medially. v. Retropharyngeal and prevertebral space: between pharynx and vertebra 1. Retrophryngeal: between superior constrictor and alar of prevertebral fascia 2. Prevertebral: between alar layer and prevertebral fascia.

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Spaces are contiguous pain, trismus, dysphagia, dysphonia. Cavernous sinus thrombosis: canine space infections and deep temporal space infections via ophthalmic veins. Lateral pharyngeal infections retropharyngeal and prevertebral spaces mediastinum. 5. Treatment Principles Determine infection severity: i. Critical systemic symptoms: dysphagia, dysphonia, trismus, fever, chills, malaise and face ii. numbness, headhache, meningeal signs, altered vision. Physical exam: signs of sepsis, airway compromise, anatomic space involvement

Evaluate host defense mechanisms i. Uncontrolled metabolic disease: uremia, alcoholism, malnutrition, severe diabetes ii. Suppressing diseases: leukemia, lymphoma, malignant tumors iii. Suppressing drugs: chemo or immunosuppressive drugs. Referral criterias (3-6)

Surgical treatment vary in spectrum: pulpotomy to transfacial incisions i. Obtain 2 mL exudate for culture and sensitivity. Use 5-10 mL and 18-gauge needle. ii. Cap with rubber stopper, place into anaerobic specimen tube. iii. iv. Gram-stain to determine antibiotic management. Goal: drainage and remove offending agent

Medical support: airway, hydration/electrolytes, antibiotics, nutrition, analgesics Indications for antibiotic use: 3.7 Odontogenic infection i. Predictable bacteria: routine empirical therapy acceptable. ii. Antibiotics: penicillin V preferred. 1. Penicillin allergic: clindamycin/Clarithromycin. 2. Narrow-spectrum > broad dont alter normal flora and develop resistant strains 3. Low toxicity and side effects. 4. 5. Bactericidal > bacteriostatic. Consider cost

Osteomyelitis: medullary bone infection i. Progress: most common initiating cause: odontogenic infection and trauma. 1. Medullary cavity/ cancellous cortical bone periosteum soft tissue. ii. Rare. Common in immunocompromised Mandible > maxilla due to low blood supply. iii. Hematogenous infectious spread to jaw is rare. CARIES ENDO-PERIO RELATIONSHIPS 1. 2. 1. Pulp-perio communication Type of endo and perio lesions Pulp-perio communication: tubules, lateral/accessory canals, furcation, apical foramen Endo causes perio, but perio doesnt usually cause endo (unless perio involves apex) Perio treatment affects pulp health (root planning) bacteria penetrate dentin Types of endo/perio lesions Primary endo: i. Clinical: apical inflammation (maybe), along lateral aspect of root/furcation, or sinus tract ii. iii. along PDL Nonvital tooth Only endo

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Primary perio: i. Clinical: perio is progressive. Sulcus apex (plaque/calculus bone/soft tissue loss) ii. Manifest as perio abscess during acute inflammation iii. Broad-based pocket formation

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Vital teeth Treat: perio therapy

Primary perio with secondary endo involvement: i. Clinical: deep pocket with history of extensive perio True combined i. Clinical: when endo lesion and perio combine indistinguishable ii. Treat: both endo and perio. Prognosis: depends on bone destruction. Endo Microbio 1. 2. 3. 1. Bacteria entry into pulp Nature and dynamic of RC infection Antibiotics in endo Portals of bacterial entry: Caries, permeable tubules (cavity prep, exposed dentin, leaking restorations, necrotic pulps), cracks/trauma, pulp exposure 2. RC infection Polymicrobial. Size of periradicular radiolucency = number of bacteria in canal Primary infection vs infection from unsuccessful endo i. Primary endo: strict anaerobes 1. Gram negative ana: Porphyromonas, bacteroids melaninogenica most common 2. Gram positive ana: Actinomyces (root caries) ii. Unsuccessful RCT: enterococcus + facultative anaerobes. 3. LPS: aka endotoxins in gram-negative cause periradicular inflammation Antibiotics in endo Penicillin VK first choice Most strict anaerobes + gram-positive facultative i. Ana: Prevotella, porhyromonas, Peptostreptococcus, Fusobacterium and actinomyces ii. Gram + fac: strep and enterococcus Clindamycin: gram-negative + positive, include both strict and facultative Metronidazole: effective against strict anaerobes ONLY. Post-treatment Evaluation Restoration of Endodontically Treated Teeth Success and Failure Coronal Leakage Major cause of endo failure restoration failure causes endo failure often. Risk increases with duration of saliva exposure. Use bonded temporary for occlusal protection. Place permanent ASAP Structural considerations Endo teeth do not become brittle.

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Weakened by tooth structure loss: i. reduced marginal ridges lose cuspal strength ii. excessive tooth removal in access prep fractures in RCT teeth > vital iii. No restorative material can replace tooth structure Ferrule (draw pic) i. A band that encircles external dimension of residual tooth ii. Formed by walls and margins of crown iii. Longer ferrule: fracture resistance to cervical tensile strength, lateral forces from posts and leverage from crown. 1. Crown prep with 1mm coronal extension of dentin above restoration margin doubles fracture resistance. 2. Ferrule must encircle vertical wall of tooth, not terminate on core material 3. Crown lengthening/ortho extrusion if insufficient structure for ferrule. iv. Post prep: 1. Purpose: retain core in tooth when extensive loss of cornal structure 2. Post need dictated by amount of reminaing coronal tooth 3. 4. Posts WEAKENS instead of reinforcing tooth Need at least 4-5 mm of remaining GP Success and Failure 1. Endo failure causes: Inadequate seal: coronal seal > apical seal Poor access cavity Inadequate debridement Missed canal Vertical frac. List Factors influencing success rate: PRP: reduce successful endo by 10-20% Bacteria in canal decrease prognosis Quality of endo and coronal seal Factors of successful endo: Triad: sterilization, debridement, obturation. 1.8 Biopsy 1. 2. 3. 4. 5. 6. 1. Overview Oral brush cytology Aspiration Incisional Excisional Hardtissue/intraosseous Overview

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Abesthesia: Use block instead of local prevent distorting architecture. i. If infiltration inject 1 cm away from lesion Tissue stabilization: finger/clamps. Hemostasios: gauze compresses/gauze-wrapped suction tip on low suction. NO HIGH SPEED Incision: use sharp scapel: less damage, better samples Extent to tissue: obtain normal adjacent tissue if possible Laser: CO2 laser in superpulsed mode with small focused beam cause peripheral necrotic zone Handling and tagging: i. Use traction suture to handle tissue specimen. Tissue forceps cause specimen trauma ii. Use tissue tag to identify surgical margin for correct specimen orientation. iii. Place in 10% formalin 20x the size of specimen Wound management: mostly primary closure. Gingival/palatal biopsy: periodontal dressing for secondary healing 2. Records: Biopsy Data Sheet: Oral brush Cytology Indication: screening/monitoring cancerous/precancerous lesion Technique: i. brush rotate 5-10 times on lesion all 3 epithelial layers obtained transfer to slide for fixation. ii. 3 categories: negative, positive (definite cellular atypica/carcinoma), or atypical (abnormal epithelium) iii. Positive + atypical additional scalpel biopsy Aspiration biopsy (FNA) Method: syringe to collect clinical/radiographic mass. Any intraosseous lesion before surgical exploration Uses: low morbidity and high diagnostic accuracy. Other uses: aspirate hard/soft tissue to determine solid, cystic or vascular Incisional biopsy Large > 1 cm, polymorphic, suspicious malignancy, dangerous anatomic area. Avoid necrotic area, need adequate depth Excisional biopsy Smaller lesions < 1 cm, benign, small vascular and pigmented lesions Remove entire lesion and perimeter of surrounding uninvolved tissue margin Hard tissue/intraosseous biopsy techniques When intraosseous lesion is not an odontogenic inflammatory lesion. Method: i. All radiolucency should be aspirated first ii. Flaps: FMP always used, 4-6 mm margins iii. Osseous windows: 1. Depends on lesion size, cortical perforations, proximity to teeth/neuro structure 2. Excisional curette 1mm of adjacent bone in all directions.

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Incisional irrigate and close. 1.9 Surgical Management of Cysts and tumors

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Cysts and cystlike lesions Jaw tumors Cysts and cystlike lesions: chart Jaw tumors Chart Malignant tumors: i. Most common: epidermoid carcinoma (SCC) ii. Salivary glands, blood vessels, lymph, muscle, bone and other CT primary malignancies of head and neck iii. Breast, prostate, lung kidney, thyroid, blood colon metastasize ot head and neck Primary head and neck cancer: clinical staging FIRST to determine treatment. Exams: CT, PET scans, chest radiograph, pan endoscopies

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Reconstruction Must decide prior to resection, depends on: patient expectation, medical comorbidities, prognosis, and fxn/esthetic Treatment options: no treatment/wound management microvascular osteocutaneous reconstruction with implants Local Anesthesia

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Drug review Pharmacodynamics Systemic toxicities Adding vasoconstrictors Pregnancy and Lactation Techniques

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Drug review: 1. Pharmacodynamics: block Na channels. Differential nerve blockade: (critical length) i. Local anesthetic must block a minimum successive nodes of Ranvier to block action potential ii. Sensation disappear and reappear in order: pain, temperature, touch, pressure Redistribution affected by: i. Diffusion away from site ii. Vascularity: flow, decrease duration iii. Protein binding: protein binding, lipid solubility = duration Principles i. Onset: Lower the pKa, faster the onset:

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ii. Duration: related to protein binding and solubility Systemic toxicities Initial signs: i. Mild-to-moderate: talkativeness, apprehension, excitability, slurred speech, dizziness, disoreitentation ii. Severe toxicity: seizures, respiratory depression, coma, death Allergic response i. Esters: high incidence (5%), Amides: low (<1%) ii. Allergy usually due to methylparaben (1985). Use diphenhydramine (Benadryl) for ester AND amides allergy iii. Metabisulfite: antioxidant w/ low allergencity. Protects vasoconstrictor from oxidation iv. Methemoglobinemia: caused by prilocaine: when exceeding 600 mg. but lower dose is also problem in hereditary methemoglobinemia Adding vasoconstrictors i. Primary rationale: increase duration effect ii. Secondar rationale: 1. Reduce systemic toxicity by decreasing absorption. 2. Reduce bleeding: only in local not block Drug interactions 1. Antidepressants: tricyclic/polycyclic (amitriptyline, tradosone) increased sensitivity to epinephrine 2. Nonspecific beta blockers: propanolol, inderal Ehance peripheral alpha1 with beta 2 blockade (unopposed alpha) i. Beta block HR, epi increase BP = increase BP w/o tachycardia 3. 4. Normal, healthy ASA1 patient: maximum of 200g of epi Cardiovascular bad patient: <40g per appointment

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Pregnancy and lactation i. Pregnancy class C drugs: bupivacaine, mepivacaine, articaine, epi ii. Pregnancy B: lidocaine, prilocaine, etidocaine (no longer on market) Local Anesthetic Techniques 1. Needle dimensions Length shrot needle: 20 mm, long needle: 32 mm Outside diameter: i. 30 gauge: 0.3 mm. 27 gauge: 0.4, 25 gauge: 0.5 mm Needle gauge i. Positive aspiration correlated ot needle gauge ii. Larger-gauge needles do not deflect, do not break (30 breaks most frequently). iii. Patient cant tell difference between 30, 27 and 25 PSA Anesthetized area: maxillary 3rd to maxillary first (except MB of first)

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No palatal tissue Technique: distal to malar process. 45 degrees to MD pland BL plane, 15-16 mm penetration True anterior SAN (IO block) Anesthesia: midline of maxilla to MB of maxillary first i. Anestheize ASA, MSA, inferior palpebral, lateral nasal and superior labial No palatal tissue ii. Line from pupil to lip commisure: needle penetrate over maxillary first premolar iii. 15 mm deep and lateral to height of buccal vestibule iv. Needle touches bone as endpoing v. Aspirate, inject 1.0 mL, pressure applied for 2 mintues (timed) Greater Palatine Anesthestic area: distal to canine and from gingival margin to midline Genearlly located halfway between gingival margin and midline of palate, 5 mm anterior to hard and soft palate junction (vibrating line) Technique: topical, pressure anesthesia. Pressure anesthesia: 20 second minimm. Approximatly 5 mm penetration Nasopalatine NP Anesthetic area: palatal soft tissue from canine to canine (premaxilla) Technique: topical pressure anesthesia. Needle tip 45 to palatal soft tissue, penetrate junction of palate and incisive papilla. Local anesthesia: mandnibular technique Mental incisive: i. Soft tissue on buccal of premolars anterior to midline lip, chin, periosteum and bone ii. Topical anesthesia iii. Insert needle in depth of buccal vestibule opposite mandibular premolars iv. v. vi. 5 mm depth of insertion Deposit 1/2 cartridge Pressure 2 minutes

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Mandibular block i. AA: pulps and buccal soft tissue of mandibular teeth, lip, cim, periosteum and bone ii. Traditional (Halstead) block 1. Needle penetration: 1.0 cm above mandibular occlusal plane 2. Approach from contralateral premolars. 1.0 cma bove madnibualr occlusal plane and parallel to it 3. Needle 50% of MD length of ramus iii. iv. Higher block 1. 1.5 cm above mand. Occlusal plane Needle endpoint 60% of MD ramus distally Either block 1. Advance 25 gauge until boen contact (required) 2. Withdraw 1 mm, aspirate, inject 3/4 over 2 minutes. 3. Withdraw halfway (10-15 mm), aspirate 4. Slowly inject lingual, save rest for buccal

Vazirani-Akinosi technique (1977) i. Anestheties: inferior alveolar, lingual and long buccal ii. Useful for: uncooperative children and trismus iii. Technique: 1. Long needle parallel to max occlusal plane at level of maxillary buccal vestibule 2. Peentrate 1/2 MD length of ramus: 25 mm in adults 3. End superior to lingual 4. Blind injection: no bony stop 5. Adult patients: rule of thumb: needle hub should be opposite to mesial aspect of maxillary second molar

Gow-Gates (1973) i. Originally only extraoral landmarks ii. Unique amont intraoral injections: do not need to get as close as possible to nerve iii. iv. Anesthetizes: inferior alveolar, lingual, auriculotemporal, mylohyoid, long buccal (75%) Technique 1. Open mouth widely: rotate and translate condyle 2. 3. 4. 5. 6. Palpate condyle with fingers, thumb retract check Begin from contralateral canine, needle positioends o puncture is at location of DB cusp of maxillary second molar Inserted to 25-30 mm, do not inject until bony contact Withdrawn slightly Neeld etip: approximately 1.0 cm superior to nerve, in superior aspect of pterygomandibular space.