Intraseptal anesthesia in periodontal surgery

A

r t ic l e s

An alternative to conventional local infiltration or regional nerve block injection of anesthesia can be used with efficacy and safety.

Intraseptal anesthesia in periodontal surgery Andre P. Saadoun, DDS, MS Stanley Malamed, DDS, MS

w

ith the introduction in the late 1970s of the two local anesthetic syringes, Peri-Press and Ligmaject, it became pos­ sible to more easily perform the intraligamental injection1 and achieve through this type of injection a profound anes­ thesia of a single tooth without the need for regional nerve block and without anesthetizing the soft tissues of the cheeks, lips, or tongue. Many articles2'15 have reported the clinical and biologic findings on the periodontal ligament in­ jection and the effectiveness of this type of anesthesia to provide consistently reli­ able pain control for a variety of short dental procedures (tooth extraction, re­ storation, crown preparation, and end­ odontic treatment). Malamed6 has reported the use of the periodontal ligament injection for root planing and curettage; however, there has been no report in the literature on the use of this type of injection for surgical peri­

odontal procedures. In 1967, the intraseptal injection was introduced in France by Marthaler (H. W. Marthaler. Intraseptal anesthesia for re­ storative purposes, personal communica­ tion, Toulous 1967). This original tech­ nique, which differs from the Banford in­ traseptal te ch n iq ue 16 and the intraligamental technique,17-18 was able to achieve in short dental procedures the same results obtained by using the intraligamental injection technique. The purpose of this article is to present the rationale, describe the technique, and evaluate clinically the effects of the use of intraseptal anesthesia w ith a syringe (Ligmaject). The purpose is also to monitor the comfort of the patient during and after the injection, evaluate the extent of the soft tissue anesthesia, and the dura­ tion of anesthesia on the teeth and the surrounding periodontal structures and in particular the alveolar bone and-gin-

giva. Is the intraseptal injection able to achieve a level of anesthesia effective enough to perform surgical periodontal procedures such as open flap curettage, flap curettage with or without osseous

Fig 1 ■ Occlusal view of alveolar socket showing multiple perforations in alveolar bone and in par­ ticular tip of interdental septum with thin cortical plates. 0A, V ol. I l l , A ug ust 1985 ■ 249

ART I CL E S

surgery, osseous grafts, or root amputa­ tion?

Rationale To understand the rationale of the intra­ septal technique, it is important to con­ sider the macroscopic structure of the al­ veolar bone surrounding the roots of the teeth. Examination of a lateral portion of the mandibular arch shows, in the inter­ nal surface of the alveolar bone and the interproximal septum, minute perfora­ tions that are the termination of the medu­ lar canals (Fig 1). The alveolar bone portion of the alveo­ lar process or cribriform plate lines the sockets in which the roots of the teeth fit. It is thin and pierced by many small open­ ings through which blood vessels, lym­ phatics, and nerve fibers pass. It also con­

tains the embedded ends of the connec­ tive tissue fibers (Sharpey’s fibers) of the periodontal ligament. The alveolar bone fuses with the cortical plate of the labial and lingual or palatal sides at the crest of the alveolar process. The cancellous or spongious bone occupies the area be­ tween the cortical plates and the alveolar bone. The spongious bone with its mar­ row spaces occupies most of the interden­ tal septum but only a relatively small por­ tion of the lingual or buccal plates. On a transverse section of the mandibu­ lar arch between the first and second mo­ lars, the thickness of the buccal and lin­ gual cortical plate can be seen, as can the tip of the interdental septum as only al­ veolar bone and the thin cortical plates. One or more large arteries, veins, and nerve bundles are longitudinally situated in the interradicular bone process, and their branches enter the periodontal lig­ ament through the many openings in the cribriform plates.19 These important ana­ tomic considerations help to explain the rationale behind the intraseptal tech­ nique.

Precautions and instrumentation To perform this technique, the following guidelines and precautions must be used: use of the intraseptal syringe, use of the 27-gauge short needle, use of a 2% lidocaine solution with 1:50,000 epinephrine, a precise point of puncture, and a correct orientation of the nee­ dle. In the intraseptal injection technique, the needle of the syringe must puncture the tip of

the interdental septum to deposit the anes- 1 thetic solution in the bone marrow space. In- J troduced under pressure, the anesthetic solu- 1 tion flows radially down the established hydrostatic pressure gradient along the path of least resistance until it reaches the arterioles that supply the pulp.14

Use of intraseptal syringe The delivery of this syringe has a greater me­ chanical advantage over conventional syringes; it exerts adequate pressure necessary for the injection smoothly and harmoniously (Fig 2). This syringe is considered safe because the anesthetic cartridge is enclosed in a cali­ brated sleeve (Teflon), and allows the operator to control, through the visual cartridge chamber, the amount of liquid injected and its pressure. This mechanical and visual protec­ tion eliminates the danger of injury to the pa­ tient through a sudden breakage of the glass cartridge.5 This syringe has shown a precise delivery of the anesthetic solution with a uniform and continuous pressure. This, combined with a fine-gauge needle, can produce high fluid pressure in the intraseptal space even with its low distensibility.

Use o f 27-gauge short needle The needle should be thin enough to penetrate the alveolar cribriform bone of the interdental septum and, at the same time, be rigid enough to prevent its bending during the injection. A 28-gauge, 0.38-x 8-mm rigid and short needle has been developed by Marthaler and is avail­ able in Europe, but this needle does not fit the Ligmaject syringe; a 27-gauge (% inch) short needle was used in this study.

papilla.

Fig 4 ■ Correct orientation of needle Fig 3 through ■ Pointinter­ of impact Fig of 5 ■ needle Orientation in interdental of needle in frontal plane. dental papilla to interproximal alveolar bone.

Fig 6 ■ Orientation of needle in sagittal plane.

Fig 7 ■ Orientation of needle in horizontal plane.

250 ■ JA D A , Vol. I l l , A u g u s t 1985

Fig 8 ■ Proper angulation for intraseptal anesthesia in maxillary anterior region.

ART I CL E S

Use o f 2% lidocaine solution with 1:50,000 epinephrine The purpose of using this solution (in a 1.8-cc cartridge) is to prolong the duration of pulpal anesthesia and the extent of the degree of osse­ ous and tissue anesthesia. It will also decrease local bleeding during the surgical procedure through the direct action of epinephrine on alpha-receptors in arterioles.

Precise point o f puncture Whatever tooth is to be anesthetized, the point of insertion of the needle is always located in the center of the papillary triangle, about 2 mm below the tip of the interdental papilla. This point of impact should be at equal distance from the adjacent teeth (Fig 3).17,18

Correct orientation o f needle The orientation of the needle is paramount and affects the success or the failure of the tech­ nique (Fig 4).17,18The orientation of the needle should be considered in the three planes of the space: the frontal, the sagittal, and the horizon­ tal. In the frontal plane, the needle should pen­ etrate and hold to form an angle of 40° to 45° with the long axis of the tooth (Fig 5). In the sagittal plane, the needle should be directed at a right angle to the soft tissue (Fig 6). In the horizontal (coronal) plane, the needle should be directed along the bisecting angle of the buccal or lingual embrasure (Fig 7). By observing these guidelines and using the proper instrumentation, the penetration of the interproximal alveolar septum and direct infil­ tration of the spongious bone is achieved with a minimum dose of anesthetic solution.

Technique

dle oriented toward the apex. After a few drops of anesthetic are slowly injected in the papil­ lary fibromucosa, the needle is advanced until osseous contact occurs (Fig 8). The operator

the syringe. The anesthetic is injected in in­ crements of 0.2 ml with each depression of the lever of the syringe. The insertion of the needle is usually almost painless because of the fine gauge of the needle and the fact that the gingi­ val papilla is not too sensitive at this site. How­ ever, the pressure from the solution could be painful during the injection. There must be resistance to the deposit of the solution in the peak of the septum for this type of anesthesia to be successful. If firm back­ pressure is not encountered and the solution appears to flow easily from the injection site and the soft tissue, the needle did not penetrate the alveolar bone, and the anesthesia will usu­ ally be ineffective. The needle should then be repositioned and the fluid reinjected.3-5,6,8 To withdraw the tip of the needle 1 mm or to rotate the needle before reinjection facilitates the in­ jection in the septal bone. If the injection of the solution seems too difficult, the needle should be removed and the site punctured again im­ mediately above or below the initial point of insertion. The alveolar bone can be contacted directly when the tip of the needle penetrates 2 or 3 mm, or it can be reached indirectly by the hydrostatic movement of the solution in the several canals of the alveolar bone. Blanching of the gingiva overlying the bone (Fig 9) and back-pressure during the injection indicate that the solution has been properly deposited in the septal bone and that the anes-

The im m ediate onset o f anesthesia perm its the procedure to start as soon as the injection is completed.

applies continual pressure on the syringe, pushing the needle deeper into the interdental septum for a few millimeters, according to Marthaler’s technique.17,18 The anesthetic is then injected slowly and under continual pressure, using the trigger of

thesia will be effective and successful.14 Before injection, periodontally involved teeth require a radiographic examination and a sounding with the needle of the level of proxi­ mal bone. Mandibular posterior teeth require bending of the needle from 45° to 90° for proper

Table 1 ■ Number of surgeries on 54 patients. No. of teeth 4 5 6 7 8 10 Total

M axillary

M andibular

Total

2 11 14 3 22 1 53

6 16 10 4 8 3 47

8 27 24 7 30 4 100

Table 2 ■ Dental anxiety of patients. No sedation No. of surgeries 100

Anxious

Relaxed

Sedation

22

59

19

Following the prescribed rules, the operator directs and inserts the tip of the needle into the interdental papilla, with the bevel of the neeS a a d o u n - M ala m e d : IN T R A SE PT A L AN E ST H E SIA IN P E R IO D O N T A L S U R G E R Y ■ 251

ART I CL E S

Table 3 ■ Pain during injection. No. of surgeries

Pressure

No pain Discomfort

100

100

52

Pain

21

27

Table 4 ■ Time to complete injections. No. of teeth 4 5 6 7 8 10 Total

No. of surgeries

Total time (min)

8 27 24 7 30 4 100

37 128 148 50 241 37 641

Average time (min, sec) 5, 5, 6, 7, 8, 9, 7,

Average per tooth (min, sec)

2 14 16 14 3 25 22

1, 1. 1, 1, 1,

15 2 2 2 0 55 1, 2

100

No pain

Discomfort (Cavitron) (after 30 to 45 m inutes)

Pain

78

20

2

directional positioning.13 The onset of anesthesia is usually immediate (within 15 seconds) and the effects are gener­ ally limited to the tooth and its neighboring structures; if anesthesia is not obtained within 30 seconds, a second injection should be at­ tempted.3 The flow reduction by pressure may also be significant in explaining why a rather small volume of anesthetic solution can quickly anesthetize the pulp and the surround­ ing periodontal tissues.7 When surgical periodontal procedures are performed, the intraseptal injection should be started on the buccal side, using the same rec­ ommendations of injection described. The penetration of the needle on the lingual and palatal sites can be painless and easy to per­ form.

Results Pain during injection

Table 5 ■ Pain during surgery. No. of surgeries

other types of anesthesia would be used in case , of failure of the intraseptal injection. During this study, no block injections were performed either before or during the proce­ dure on any patient. None of the patients had any medical contraindications to surgery. Even though some patients were controlled diabetics or were taking medication for high blood pressure, all were still classified as American Anesthesiologist Association Class 1 or 2. All the periodontal procedures (Table 2) were performed on patients under intraseptal anesthesia, with or without oral sedation with diazepam (5 to 10 mg) or butisol sodium (90 to 120 mg).

Materials and methods One hundred periodontal surgeries—open flap curettage with or without osseous surgery, apically positioned flap with osseous recontouring, graft, and root amputation—were per­ formed on 54 adult patients (Table 1) with moderate to advanced periodontal disease (6to 10-mm pocket depth). Initial preparation consisted of oral hygiene instruction, scaling, and root planing. All periodontal surgeries included buccal and palatal flap curettage on the maxillary arch and buccal and lingual flap curettage on the mandibular arch. A solution of lidocaine 2% with 1:50,000 epinephrine was used for all surgical procedures. All patients were aware that it was a clinical experiment, and that the

When patients were asked about pain encoun­ tered during the intraseptal injection (Table 3), the majority (73%) seemed to agree that the puncture from the needle was almost painless, but that they did notice the feeling of pressure during the injection of the anesthetic solution. Some, however, reported no difference in pain of intraseptal injection and the pain of local infiltration experienced before. The main concern was that it was necessary for the practitioner to puncture several times (12 times for sextant, and 18 times per quadrant for a buccal and lingual flap) and that it took a certain length of time to complete the injection (Table 4). These facts may make some patients more apprehensive of this multiple injection technique, even though the lingual or palatal injections were not usually felt when the buc­ cal injection was initially done. Most patients were surprised and satisfied to notice the localized effect of the anesthesia, the lack of swollen feeling of the tongue, the ab­ sence of numbness of the upper and lower parts of the cheeks and lips, and the missing slurred speech normally experienced with local infiltration and regional anesthesia. Some of the patients reported mild palpitation and tremor a few minutes after the injection of lidocaine 2% with epinephrine 1:50,000.

Onset o f anesthesia The onset of the anesthesia was immediate, allowing the surgical procedure to start as soon as the several punctures were completed. In general, an average of 10 seconds (5 to 15 sec­ onds) should be allowed per tooth for the onset of the anesthesia. The time lag from the injec­ tion to the start of the procedure varied with the length of the area anesthetized—an average of 1 minute per tooth for the injection (Table 4). The injection was significantly more effec­ tive and successful in obtaining anesthesia when strong back-pressure was present, The greatest frequency of success was attained when injecting under pressure. However, the rapidity of onset of the anesthesia was not re­ lated to the presence of strong back-pressure.3 Fig 10 ■ Extent of palatal gingival anesthesia checked with periodontal probe. Needle puncture points are shown in interdental papillae mesial and distal to first molar.

252 ■ JA D A , V ol. I l l , A ugust 1985

E xtent and duration of anesthesia o f periodontium The intraseptal injection produced a dramatic anesthesia of the different components of the periodontium: gingiva, alveolar bone, cemen-

A R T IC L E S

Table 6 ■ Duration of the procedures.

No. of teeth 4 5 6 7 8 10 Total

No. of surgeries 8 27 24 7 30 4 100

turn (tooth), and periodontal ligament. EXTENTOF GINGIVAL ANESTHESIA. Analysis of the buccal, lingual, or palatal soft tissue showed that anesthesia reached an average ex­ tent of 21 to 25 mm in c lu d in g a ll the keratinized gingiva (Fig 10) and extending be­ yond the mucogingival junction. The use of lidocaine 2% with 1:50,000 epinephrine also had the advantage of providing more firm and less hemorrhagic tissue during surgery. EXTENT OF ALVEOLAR BONE ANESTHESIA. By the time the marginal incisions were done and the full thickness flaps raised, the buccal and lingual or palatal bone was totally anes­ thetized. Osteotomy, osteoplasty, and osseous grafting were performed without discomfort to the patient and with a minimum of bleeding. The extent and depth of cortical and alveolar bone anesthesia were totally complete during all the procedures and for all the patients. EXTENT OF ANESTHESIA ON PERIODONTAL LIGAMENT. No sensitivity was found in the periodontal ligament in the area of the anes­ thesia during any of the procedures. EXTENT OF ANESTHESIA ON CEMENTUM. The diffusion of the anesthetic solution from the crestal alveolar bone to the periodontal liga­ ment and the apex of the tooth through the multiple canals of the spongeous bone and cribriform plate provided an immediate onset of pulpal anesthesia, and allowed the practi­ tioner to perform root planing without discom­ fort to the patient. There seems, however, to be a significant difference in the duration of anes­ thesia among the different components of the periodontium. The duration of complete pul­ pal anesthesia was 30 to 60 minutes, a finding that confirms previous studies.6,10,12 In some cases, a certain sensitivity was perceived on the teeth by the patient during the use of the ultrasonic scaler, primarily toward the end of the procedure before closure of the flaps. It seemed that the duration of anesthesia for mandibular teeth was longer than for maxillary teeth, which have greater vascularity. It was also found that although pulpal sensation re­ turned (Table 5), the extent of gingival and osseous anesthesia remained much longer on both labial and lingual or palatal sides for an additional 30 to 45 minutes, which was suffi­ cient to permit completion of the procedures (Table 6). The subjective report of duration of soft tissue numbness with the intraseptal injec­ tion was, however, significantly shorter than that for the local infiltration. The overall frequency of success in attaining anesthesia of the periodontium with this type

Total time (minutes) 342 1,375 1,343 2,013 5,851

Average time/procedure (minutes) 43.15 51.33 56.36 65.29 67.10 80.25 60.58

of injection was 98%. This rate included situa­ tions in which another injection was per­ formed during the surgical procedure directly in the intraseptal bone (Table 7). The majority of these patients, when asked about the choice of injection, favored intraseptal anesthesia over the inferior alveolar nerve block. BLEEDING DURING THEPROCEDURE. Blood loss can be considerable during periodontal proce­ dures and should be a concern for the practi­ tioner20,21 because it may exceed that which occurs in major surgery. It is, therefore, neces­ sary to use anesthetic solutions containing vasoconstricting agents that allow minimal hemorrhage during periodontal surgery. The safe maximum dose for the healthy dental pa­ tient is 0.2 mgm of epinephrine, which is 10 ml (or 5.5 cartridges) of a 1:50,000 concentra­ tion.22 The results from the study using an anes­ thetic solution of lidocaine 2% with 1:50,000 epinephrine have shown that a minimum of

Average time/tooth (minutes) 11.18 10.26 9.39 9.32 8.38 8.02 9.42

odontal surgery. In this study, to help patients cope with postsurgical discomfort and prevent postsurgical bleeding,23 analgesics (Empirin no. 3, Tylenol no. 3, or Motrin 600) were pre­ scribed: four tablets a day for 5 days if pain was encountered. The postinjection pain caused by the intra­ septal injection was difficult to evaluate with precision because the periodontal surgery oc­ curred in the area of the injection. However, in evaluating the average doses of pain medica­ tion required by the patients (zero to five tablets a day, an average of 2.5 tablets a day before suture removal), it cannot be concluded that the discomfort was more significant be­ cause of the infiltration itself (Table 10). The healing was, in the majority of the cases, une­ ventful and the gingival tissue appeared healthy 1 week later (Fig 12). In fact, the point of insertion of the needle in the buccal and lingual or palatal crestal septum is no longer present at the end of the procedure because this portion of the alveolar bone is reshaped and

Table 7 ■ Success rate of anesthesia. First Second intraseptal intraseptal No. of surgeries injection injection 100 92 6

Local infiltration 2

Rate 98

Table 8 ■ Number of cartridges. No. of teeth 4 5 6 7 8 10 Total

No. of surgeries Total cartridges 8 7.25 27 32.25 24 28.50 7 9.50 30 36.03 4 5.75 100 119.28

Average cartridge Average cartridge per procedure per tooth 0.90 0.22 1.19 0.23 1.18 0.19 1.35 0.19 1.20 0.15 1.43 0.14 1.19 0.18

Table 9 ■ Bleeding during surgery. No. of surgeries Minimum Moderate Excessive 100 92 5 3

9/10 of a cartridge was used for flap and osse­ ous surgery performed on four teeth and a maximum of two cartridges were used for flap and osseous surgery performed on ten teeth (Table 8). A mean average of 1 1/5 cartridges per procedure were used and were sufficient to achieve pain control and minimize bleeding (Fig 11) during the surgical procedure (Table 9). POSTINJECTION PAIN. Postoperative pain or discomfort is a common symptom after peri­

grooved with a carbide or diamond bur during the ostectomy-osteoplasty phase.

Discussion The results of the present study show that the use of the intraseptal administration of 2% lido cain e w ith epinephrine 1:50,000 can achieve pain and bleeding control during periodontal flap proce­ dure with or without osseous recontour-

Saadoim-Malamed : INTRASEPTAL ANESTHESIA IN PERIODONTAL SURGERY ■ 253

ART I CLE S

ing. This study confirms many of the re­ cent studies using the intraligamental in ­ jection. K aufm an and others12 found that lidocaine with epinephrine 1:50,000 pro­ duced the longest duration of pulpal anesthesia and had the least steep slope in the recovery curve. Kim and others14 found that the intraseptal technique pro­ duced the greatest decrease in pulpal blood flow, which was attributed to the epinephrine. It was also found in this clinical study that immediately after pul­ pal sensation returned, the root became more sensitive to the ultrasonic scaler, but that gingival and osseous anesthesia was still recorded on the buccal and lin ­ gual or palatal side. It seems that the ex­ tent of soft tissue anesthesia is strongly related to the concentration of vasocon­ strictor and the long-acting properties of the anesthetic drug. The greater the epi­ nephrine concentration, the larger the anesthetized area, even when pulpal anesthesia has dim inished or disap­ peared. The long-acting anesthetic, etidocaine HC1, with a low concentration of epinephrine (1:200,000), produced the most profound tissue anesthesia with a short pulpal anesthesia (20 to 25 minutes) and did not offer adequate hemosta­ sis.12,14,24 This limits its use in surgical

0.2 mgm, which is 1 ml or 5.5 cartridges (0.036 mgm per cartridge) of a 1:50,000 concentration or 20 ml or 11.1 cartridges of a 1:100,000 concentration.22 Surgical periodontal procedures using lidocaine 2% with 1:100,000 epinephrine have, through the comparative study pub­ lished recently by Buckley and others25 and through our clinical study on a cer­ tain number of patients (our first study was limited and stopped because of its inconvenience: bleeding loss, early dis­ comfort), had more than twice as much blood loss as those using lidocaine 2% with 1:50,000 epinephrine. By m inim izing bleeding during the procedure and prolonging the duration of the anesthesia,26epinephrine at a concen­ tration of 1:50,000 made the surgical site easier to visualize, reduced working time, was able to provide good hemostasis at the end of the surgery, and decreased total blood volume loss and consequently the level of postsurgical discomfort. Buckley and others26 reported also that as the length of the surgery increased so did the periodontal procedures. Even though the pain experienced dur­ blood loss, as did the quantity of epineph­ ing the intraseptal injection was felt more rine injected. by the patient because of the mechanical In our study, using the intraseptal in­

Table 10 ■ Pain after surgery (day 1 to 7). No. of surgeries 100

No pain (0 to 1 tab/day)

Discomfort (2 to 3 tab/day)

Pain (4 to 5 tab/day)

46

30

24

pressure of the solution and the greater number of punctures from the needle, comparisons of subjective postinjection discomfort between the local infiltration and the intraseptal injection were not significant. Subjective postinjection soft tissue numbness w ithout concurrent anesthesia of the tongue and upper and lower lip was significantly shorter and less extensive with the intraseptal injec­ tion than with the local infiltration: an advantage noted by the majority of pa­ tients. Epinephrine is the most potent and ef­ fective vasoconstrictor used in dental an­ esthetic solutions. The safe maximum dose for the healthy dental outpatient is

jection with lidocaine 2% and 1:50,000 epinephrine, it was possible to obtain anesthesia of the surgical site with an av­ erage 1.19 cartridge (range between 9/10 cartridge and 1.43 cartridges) for four to ten teeth. The duration of the procedure ranged from a m inim um of 43 minutes to a maximum of 80 minutes after the ad­ ministration of the local anesthetic. This small dosage of epinephrine (av­ erage of 0.030 mgm in V-U cartridge), in such a short time (average time after anes­ thesia was 60 minutes, 58 seconds) pre­ sents two m ajor advantages of the technique— the quantity of blood loss during and after the procedure is reduced to a m inim um , and the amount of epi-

Intraseptal injection requires the smallest amount of anesthetic solution, reducing the potential hazard to the patient and minimizing toxicity.

254 ■ JA D A , Vol. I l l , A ugust 1985

ART I CLE S

nephrine injected is kept to a small dose. Two advantages (Table 6, 8)—reduc­ tion of tim e and m in im u m dose of vasoconstricting drug— decrease the risks that a patient may encounter during surgery: excessive blood loss, w hich should be replaced immediately with in­ travenous fluid27,28; adverse reaction or toxicity to the drug such as transient stress syndrome or elevation of blood pressure; tachycardia; arrhythmia; and headache. These advantages enable us to use the intraseptal injection on patients with or­ ganic heart disease, in which case it is prudent to lim it the total dosage of epi­ nephrine to 0.04 mgm.22 In fact, the aver­ age dose of epinephrine used in this study is 100 times less than the effective dose for positive or pressor effect in humans when injected subcutaneously, and 20 times less than the maximum dose rec­ ommended by the American Heart Asso­ ciation. Concern was expressed by several in ­ vestigators7that, through use of the intraligamental injection, sepsis might result from forcing bacteria into the tissue, thus increasing the risk of infectious contami­ nation of the periodontal space and po­ tentially into the bloodstream, inducing a transient bacteremia. This would proba­ bly be of no greater extent than that seen after subgingival root planing.7 This con­ cern was a contraindication to the use of the periodontal ligament injection on pa­ tients with periodontal disease.2,5>17’18 The use of the intraseptal injection avoids

niques. Kaufman and others10 and Garfunkel and others11 reported that gingi­ val papillitis with marginal necrosis oc­ curred once with the intraligamental in­ jection. Dubose13 also reported that more than four injections at the same site dur­ ing one appointment can cause sloughing of the gingival papilla. Malamed6 noted few adverse responses such as consider­ able discomfort during the intraligamen­ tal injection on a patient with highly in­ flamed gingival tissue after the anesthetic effect had resolved. The tooth was de-

The same advantages described fo r intraligam ental injection can be achieved with intraseptal anesthesia.

this complication because injection is made directly in the crestal bone, without involving the periodontal pocket. Com­ plications encountered with local infil­ tration and block anesthesia (intravenous injection, hematomas, trismus, and face and tongue anesthesia) are avoided with intraseptal anesthesia. Other complications of the periodontal ligament injection, reported recently by Brannstrom and others,15 such as enamel hypoplasia, hypomineralization, and al­ tered tooth development, are induced by the penetration of the anesthetic solution into the tooth germ, and could be pre­ vented by use of the intraseptal injection. Some complications in the periodontal ligament and bone, and some side effects in the gingiva, are common to both the intraligam ental and intraseptal tech­

scribed as being sore or “high.” The most significant histologic find­ ings4 of the periodontal ligament injec­ tion in the cervical crestal region of squir­ rel monkeys4 indicate that the injection resulted in slight but reversible damage to the periodontal ligament. This damage was confined to the region at or im ­ mediately adjacent to the injection site, with slight resorption of nonvital bone occurring in the crestal regions forming a wedge-shaped defect. These bony altera­ tions subsequently showed signs of rapid repair, absence of inflammation, and for­ mation of new bone in the region of re­ sorption. This study indicated also that the injection of solution was not in itself damaging and that the procedure resulted in minor reversible changes and is safe for the periodontium.

Brannstrom and others7 also reported that tissue damage after intraperiodontal injection was limited to the area of the injection, and these changes never ex­ tended more than 1.5 mm from the area of needle insertion. The entire bony septum at this level lost all its lacunar osteocytes, and the gingival papilla showed clinical superficial necrosis. This local damage caused by the injection was repaired within 2 weeks. However, when intra­ ligamental injection was made on both sides of a thin alveolar bony septum, a necrotic-like defect was found in the sep­ tum at the top of the crest. This condition is sufficient evidence to negate injection on both sides of the alveolar crest (that is, on the mesial side of one tooth and on the distal side of the adjacent one). Only one point of puncture in the m id­ dle of a papilla is used on the buccal or lingual side with the intraseptal injection and even though some minor damage is expected to occur because of the needle penetration, these changes are reversible. These changes will usually not occur be­ cause the portion of the bony septum in ­ volved in the puncture is removed through bony defect elimination or re­ duction during the actual surgical proce­ dure. The entire periodontium w ill then undergo a normal healing process.

Advantages The same advantages described in the lit­ erature1'15 for intraligamental injection can be achieved with the intraseptal anes­ thesia: — Anesthesia of the quadrant to be op­ erated on can be attained without the tra­ ditional lip or tongue numbness (swollen feeling) encountered with the use of the

S aad o u n - M a la m e d : IN T RASEPT A L ANESTHESLA IN P E R IO D O N T A L S U R G E R Y ■ 255

AR T I C L E S

Anesthesia of the quadrant to be operated on can be attained without the traditional lip or tongue numbness encountered with the use of the block injection.

block injection. —The injection prevents the prolonged postoperative discomfort, such as dis­ orientation of speech and mastication, or trauma to the lip and tongue associated with block anesthesia. —Intraseptal injection requires the smallest amount of anesthetic solution, reducing the potential hazard to the pa­ tient and minimizing toxicity. —Controlled and decreased bleeding from periodontal structures during the surgical procedure can be achieved. —The injection reduces discomfort and lessens the anxiety period, allowing the patient to be more relaxed. —The technique has a high level of ac­ ceptance because it is often less painful than a conventional injection. —The immediate onset of anesthesia permits the procedure to start as soon as the injection is completed. —Patients report no unusual postoper­ ative symptoms of pain or discomfort from the anesthesia. —This injection can be used on periodontally involved teeth because it avoids the usual infected areas of the pocket used with the intraligamental in­ jection. Disadvantages Some disadvantages have also been noted with the use of intraseptal anesthesia: —Use of the special syringe is neces­ sary, which is costly. —The needle may be difficult to orient before the puncture. —The procedure requires multiple punctures and time to complete the anes­ thesia. —The solution often leaks and tastes bad to the patient. Correct use of the suc­ tion tip by the surgical assistant should prevent this inconvenience. —The shorter duration of pulpal anes­ thesia or the limited extent of soft tissue anesthesia, especially beyond the mucogingival junction, may necessitate a second intraseptal injection or a small supplemental local infiltration on the buccal and lingual surfaces. This latter phenomenon did not occur frequently (2%).

—Some clinical experience is required to become proficient in this technique. 256 ■ JA D A , Vol. I l l , A ug ust 1985

Conclusions One hundred flap curettage procedures with or without osseous surgery were per­ formed on patients with moderate to ad­ vanced periodontal disease, using in­ traseptal anesthesia. In this clinical study, the intraseptal injection appears to be a successful alternative to the conven­ tional local infiltration or regional nerve block injection to achieve an effective, safe, and comfortable anesthesia for peri­ odontal surgical procedures on maxillary and mandibular arches. When used in accordance with the guidelines described, the intraseptal in­ jection performed with the Ligmaject syringe can overcome many of the in­ conveniences of the other types of anes­ thesia, and offer many obvious advan­ tages such as immediate onset, minimum risk, lower toxicity, minimum bleeding, mild postoperative sensations, and less discomfort. Further research is presently in prog­ ress to determine the path and extension of diffusion of the solution in the periodontium.

The inform ed consent of all hum an subjects who participated in the experim ental investigation re­ ported or described in this m anuscript was obtained after the nature of the procedure and possible discom ­ forts and risks had been fully explained. T he authors thank Dr. Juan G onzalez and Ms. Laurie Pontrelli, RDA, for surgical assistance, Darla A m ador, RDH, for assistance w ith proofreading, David Beard for the drawings, Martin Fong for photo­ graphing the color cells, and Larry Eisenberg for typ­ ing th e m anuscript. The authors know of no connection to the products used in the study, and do not have any at the present time. Dr. S aad o u n is assista n t professor, sectio n of periodontology, and Dr. M alamed is associate profes­ sor, section of anesthesia and m edicine, University of Southern California, School of Dentistry, University ParkM C-0641, Los Angeles, 90089-0641. A ddress re­ quests for reprints to Dr. Saadoun. 1. Chenaux, G.; Castagnola, L.; and Colombo, A. Intraligam entary anesthesia w ith the “ P erip ress” syringe. SSO 86(11):1165-1173, 1976. 2. Lafargue, R. Intraligam entary anesthesia. Pos­ sib ilities of a new m ethod. Acta O dontol Scand 27(103):551-573, 1973. 3. W alton, R., and Abbott, B. Periodontal ligam ent injection: a clinical evaluation. JADA 103(10):571575,1981.

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