The superiosteal injection and gentle dental anesthesia

DEPARTMENT

OF

ORAL SURGERYAND SURGICAL ORTHODONTIA 2 z

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Under

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Editorial

Supervision

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of

M. N. Federspiel, D.D.S., M.D., F.A.C.S., Milwaukee.-Vilray P. Blair, M.D., F.A.C.S., St.Louis, Mo.-William Carr, A.M., M.D., D.D.S., New York.-Leroy M. S. Miner, M.D., D.M.D., Boston.-mm. L. Shearer, M.D., D.D.S., Omaha.Fredrick F. Molt, D.D.S., Chicago.Robert H. Ivy, M.D., D.D.S., Philadelphia

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It031 lyjng

the time of the eilrliest cslwrimel~ts in local allcsthrsia, the undcridea was to tlrive the aIlcsthcti.zing solution into the tissues under

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down to us unchanged to t!lc present Despite this customary practice, it must ployment of force in infiltration ancsthcsi;i is Jiljection made in a gelltle Mi~iiJJeJ’, cscludinp slIrC, u-i] [ prodUCC: ~iJJCSthCSi~1 01’ greilt depth. different from any heretofore cn1J~loyct1; the

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ducing

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aucsthesia through

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infiltratioli

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da!-. now be recognized that the emunnecesswry, it’ not unscientific. clltirely the idea of higIl I)rcsThe technic is i’undamentaJ1~ drawbacks of previous methods :ll’C 1JlaIly. This new means of inl)c termed the sLL]JeJ.lJcriostra1 in-

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It’ n e will at this tiltre i10lc Ilic \-arious locations heretofore selected for the initial insertion of the ilwdle. \ve shall readily see why snc~h inject ions at these widely divergent points demanded extrellle fowt. fh interesting JJ~caJls of Sewt~iJl~ anesthesia which came into Vogue ;ll>(JLLi thirty years ago begall lvith il cwaine injection alxwe the apes of the ii\\-olyetl tooth. An openill g was tlictl drilled th7 ouph the soft tissues ant1 illto the al\-eolal~ procdess alwvc the aJ)es. Into this opeliing, 2 short closely fitting 11rec1lr

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Prinz. The anesthetic solution was discharged beneath the free margin of the gum, and driven along the peridentnl tllenlbrane to the apex. A third method is that with which we are very familiar. At present it is the most popular. A short needle mounted on a powerful syringe is inserted into the dense g!:mu just above the neck of the tooth. The anesthetizing SOIL:lion is delkered with all the power of the clenched hand, and every effort made to pierce the pcriosteum and bone. Anesthesia is usually evidenced . by the blanchiug of the gmn. Several insertions of the needle are usuall: made on the facial aspect. A variation of this technic consists in the use of a longer needle, and after the injection of some of the anesthetic into the dense g:‘um, the needle is advanced until the apex is reached where the bulk of the solution is deposited. Each of these methods presents at least one serious objection. Drilling into the bone near the apex to provide an avenue of entrance for the liypo-

Fig. l.-Dense

gum and mucobuccal fold.

dcriuic needle causes undue injury to the tissues with resulting afterpain, and enlarged possibilities of infection. Peridental anesthesia with its insertion of the needle beneath the free margin of the gum will cause an injury to the peridental membrane from which the tooth might not readily recover. Its use therefore in purely conservative measures is contraindicated. The euormous pressure exercised while injecting into the dense gum presents one of the disadvantages of infiltration anesthesia which is most frequently advance?I. This objection which is melf taken, lies in the fact that the BIdessure will frequently spread infection into healthy adjacent tissues. THE

root

MTJCOBUCCAL

FOLD

Above the necks of the teeth facially and covering about half of the is a dense band of firm pink tissue cotllmonly called the gum. This

is composed of the III~~US 111e1111~1~11~e 23~1 peiksteuiii, boll: closely united aud joined to the bone beneath. Ikyond the l~~rder of the gum. the IIIII~WUS memhrant: separates from the periostcum, lows its dense t*hal~a~tc~ a11tl wnIts ~OlOV is IlO\\% lllUt~l1 tli~l’k~l’. tinues oIlward to line tllc lips ant1 vll?t?liS. may Iw 11101’tclra~*ly dis;rIld of a purplish 1111~. This lint of dcmarkatioii tinguished if the sol’t tlssucs abovtl Ilit, ll?YliS of tlrtl tertli he I)aiiitrtl \l;itii iodine. The dense gUllI ~‘Ililll~t’S I)llt littlc : tllP IIIII~OIlS lllt~llllll*~ill~. llO\veYC?r, tine to tile iotline, has assrlttrtvl ;I tlark 1)1*0\13 t~olor. If the lil) is takvii lwt\\~c7~11tlrullll) aild iiitltas fiiigr.1,. i111d pullet1 tlown a little \\.a!- frt1111 the treth it \vill lw !Iotitwl tllat an angle 11;:s lwt~11 for~ne~l

is your constant and unfaZng starting point. While maintaining downward tension on the lip or cheek, insert the needle at the line of reflection At once of tlie mucoud membrane, and mesially to the tooth in question. The needle at, this time f0r11is an acute angle deposit one or two drops. Jvith the root. To proceed, you must, 110~ permit the shaft of the needle to lie flat against the gum and from this position advance until its orifice is opposite the apex of the tooth. TTere upon the periosteuill, deposit the balance of the solution. 1’RECAUTIONS

After the first few drops of norocaine have been injected, look closely at the needle. I)raw the lip down firmly. Is the needle really at the apes of the Ilrucobuccdal fold? Tn the he$nninp you will find that it is out on the

Fig. 3.-Mucobuccal

fold in mandible

lip too llluch, and that the line of reflection of the nlucous membrane is the needle, and actually much nearer the dense gum. Therefore withdraw This is of utmost importance, for if injection make a corrected insertion. is not made at the proper point, then it is too far away from the bone. In such cases, the solution \rill be discharged into the soft tissues, and only This will be evinn unsatisfactory submucous anesthesia will be obtained. denced by ballooning of the tissues. This wheal may also be produced if the Whenerer this occurs, pause for a few moments injection is made too rapidly. This will and gently place your finger over the raised ~UCOIIS menlhrane. distribute the solution. Throughout the entire injection, the needle is at no time to be forced beneath the periosteuni ! It should rather slide across the surface of the periosteum until the apes of the tooth is reached. The depth of needle insertion at this time is from a quarter to three eights of an inch. p\‘o cases are ever present where the use of pressure at the mucobuccal fold is warranted

.i l,O(;lC.\l,

1S.J I’C’PIOS

quklrly follows- the superInfiltration. penetration arid anesthetization 1:eriosteal injwtion. 13enieilll)el~ Ihat this is all awomplishecl with an entire and delight tlic il I)seiice of force or pressure, alit! iin ease that will suq)riw

l~c~ginnel*. The shodest clktallcc to the apes of a11y tooth ill the lllasilla is opposite the apex. The l)onc being tliiiinest licw. is iuost r-al)iilly peiieti2tetl. The pulp, to hecome anesthetizecl, lirust wme under the action 0-f the ilovocaine. thing to tlo is to deposit the Then sum!)- the 111ost rrnso~lahle of IloYocaine opposite the apes of thr toot11 \vliere the pull) c~iitci*s. illSteil(l (IGring it to tllc apes under pwsww f1-0m sollie distant point. \-.~IzI.\‘I‘Ioss

Injection for the caentl al incisor o?’ tlic lLiesia1. o\vil1g to tlic fwiiuul

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distal

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hodcr instead This gi\-cs the

This also happens to be the central and lateral the same starting point. start,ing point for the new infraorbitwl injection of Sicher.” When the first molar area is reached, it will be found that the needle cannot be advanced parallel with the long axis of the tooth, owing to the malar process which arches down over the buccal roots. After the mucobuccal fold has been entered and a few drops deposited, the needle is tilted so that it points towards the tuberosity. lt may then be advanced slightly beneath the malar process where the remainder of the solution is injected. E’or the second and third molars, it is for the sake of convenience that we begin our injections a little more to the mesial. The depth of anesthesia for these teeth following the same technic as for any of the others is so profound that this method readily replaces the tuberosity injection. WHERE,

HOW,

AND

\VHY

In all instances of infiltration anesthesia through the superperiosteal injection, the needle enters at the mucobuccal fold. In all cases, the needle advances upon the periosteum ; the bulk of the solution should be deposited at the apex, for here is the shortest distance to the pulp. DOSAGE

AND

DVRATION

For preparing cavities or removing the pulp, the buccal injection alone is needed. One and one half C.C. is sufficient for this purpose and the resulting anesthesia persists for at least a half hour. Where extraction is contemplated, it is necessary tq give in addition, a palatal injection. WAITING

PERIOD

For extractions, you are free to proceed within a minute after you have It is amazing to observe the rapidity with which completed the injections. the ~UCOLIS membrane, periosteum and bone are anesthetized through the superperiosteal injection. It is’just as rapid as the high pressure, subperiosteal injection which it supersedes. When the tooth is to be drilled for cavity preparation, or pulp extirpation, a wait of five to ten minutes is advisable. Even then, as is frequent,ly t,lle case in block anesthesia, it, may also be necessary to apply a pressure pluglet of novocaine to the exposure. Nerve endings are extremely resistent to all forms of local anesthesia, and succumb reluctantly. EXTENT

OF

ANESTHESIA

It will be found that if one tooth is injected. the neighboring n-ill also come under the influence of the established anesthesia. PALATAL

one distally

ANESTHESIA

Looking at the roof of the mouth, it would seem at first glance that the palatal mucosa was equally dense throughout. Upon closer observation, it mos,

*A Consideration August, 1923.

of

the

Improved

Technic

of

Dr.

Guide

Fischer

(Posncr).

Dental

Cos-

van be seen that it is di\-idetl into ii tlense area surrounding the necks of the teeth, and a less resistant area, whic~h reaches to the median line of the palate. If the curve of the tuberosity and its dense nlueosa is followed, as it wiues onto the palate, the liuc 01’dcinai.kation between thwe dissiniilai* tismes m-ill be obtained. ISy gently probing \2.ith the tips of ii pair of pliers out’ (‘ill1 C~UiClily 1ealize the difiewiice iu texture of the palatal IIIucosa. The liiie of the tubwosity cwrrespontls lvitli the aiiterior palatine nerve direc9ly IN>ijeath it. This ntr~e lies in a lollgituclinal poo~~c at the ,jiinction of tlic :~lreolnr and palatal processes. This gi*oo~r is rather aiigwlar, and forms :I sort of recess in its wul’se. It is due to the fact thilt the ltlucous nlelrrl)rane of the palate stretches B~IYMS the nt~me in a wr( of (*anopy, that gives it its cIlastic: ehaizaeter. The ncetlle enters here, alid is at once atlraiivetl lo the roof of the niouth, uutil bone is eiicwuntcred. Thret~ or four drops of tio\ocainc are sufficieiit to anesthetize tliv l)i~lnclics \\-liich iiw iliteiwptetl ,jusi as they are given off from the bo~ly of the nerv(~. T~I cwwequeuw rapid anesthesia of the ~uucous membranr periosteultr aud bone iu the awa behind the tooth ensues. If this injection is lriadc opposite the third 111o1ar. (‘veryihing to the median line of the palntt and as far for\vard as the c.aIIine will lw anesthetixed. The injection has blocked all iillpulses of the autwior Ijalatine uerre, just as it eniei*petl E~oiii the postrl*ior palatine forallren. The needle in palatal anesthesia is inserted at the desiretl point along the litle of the tuberosity, and at an angle to the tooth. Once the IIIUCWSUha% been entered, the ueedlr should be atlranced to the bone in line with the Ion% axis of the tooth. Depth of penetration here is not much over a qn;ii*tciof an inch.

Infiltration in the uiandible is limited to the six anterior terth. The technic is the same as for the teeth in the maxilla. The mucobucval fold, however, is now seen to begin ikllmedintcl~ at the lower border of tire gulii. This ma;\’ be well demonstvated .b?- tlrawing out the lower lip horixontall~.

1t is to be unde~st~ooct that the itljwtions described are to he ulatltl iuto tissues which appear normal. Where infwtiou exists, it is alwa\-s I)erlriissible to inject to either side of the pathologic area. Here we hare the ontst;indin~ feature of the superperiosteal injection, for the absence of pressure ilt owc precludes the danger of driring infection into healthy su~roundinp territory. In the greatest numbel~ of cases of acute mlditions attendant with s\\-rllingsJ ;rntl abscess, nitrous oxitle and osygen ~vould be the anesthetic of clroiw. l~STRl‘ILII’~TARIITI\I >I

One needle alone will ans\vei* the Yequirenlents iii auy case of superperiosteal injection. It should be platinum iridium, one inch long:, 25 gauge. You will not bend the thinnest needle, neither will you blunt the point in this injection. Aud these itl+e the 011lp disadvantages which have ever lv+en ai:-

yanced against platinum needles. The flame affords instant sterilization ! Norocaine suprarenin in ampules provides a sterile, isotonic, safe solution, always ready. The syringe, now that tile idea of force and pressure is dispelled need not be of the heary powerful type. The writer has designecl an all glass syringe, which may be boiled after each use conveniently, for it can be dismantled in an instant; the needle, permanentI>- affixed to a smooth hub, is slipped over the tip of the syringe and locks with a simple twist of the fingers; a sterile needle, a sterile solution, a sterile syringe.

The superperiosteal injection carries with it the advantages of all other types of infiltration, and merely eliminates their inherent disadrantages. For one thing, it shows a remarkable record of freedom from afterpain which is to be expected when delicate tissue cells are spared the injury of high pressure. There are many fields of dentistry in which new ideas and methods often require the lapse of months or even years, before their true value appears. Here the proof is immediate. Just inject.