JMBS2010 (1 8)
JMBS2010 (1 8)
JMBS2010 (1 8)
1*
ABSTRACT Objective: The aim of this study was to assess the immediate complications after injection of inferior alveolar nerve block (IANB) using a modified indirect technique. Patients and Methods: A total of 5000 IANB injections was performed by an oral and maxillofacial surgeon for a total of 3454 adults. Patients with hyperthyroidism were excluded from the study. The following data were collected: name, age, sex, and side of the IANB. Furthermore, the presence of any complication was noted as well as its type, persistence, and severity. All data were analyzed using SPSS (SPSS Inc., Chicago, IL), and descriptive statistics were generated. Results: Failures of IANB and the need for second injections were seen in 48 patients (1%). Positive aspirations were noted in 84 patients (1.7%). Blanching of the cheek was found in four patients (0.08%), which persisted for about 5 minutes. Two patients (0.04%) had electrical pain radiating to the tongue. In addition, facial paralysis was seen in one patient (0.02%), persisting about 4 hours, and there were two cases of blurred vision (0.04%) Conclusion: Based on the results and within the limitations of the study, the following can be concluded: This technique shows lower failure rate, lower positive aspiration rate, and lower incidence of facial paralysis than the standard technique described by Malamed. In addition, aspiration is important before the deposition of the anesthetic solution in IANB. Key words: immediate complications, inferior alveolar nerve block, oral and maxillofacial surgery
INTRODUCTION Probably one of the most common procedures in dentistry is the administration of local anesthetic. The inferior alveolar nerve block (IANB) is the most frequently used mandibular injection technique for achieving local anesthesia 2 for restorative and surgical procedures. In 1884, Halsted and Hall described the first inferior alveolar regional nerve block by injecting an anesthetic 3 solution ( cocaine) into the area of the mandibular foramen. Then, Fischer , described the classic technique which, 4 was modified later by many authors. Nowadays, most of the dentists all-around the world are using a technique 3,5 although, similar to the one described by Jorgensen and Hayden in 1967, which targeting the mandibular nerve. there are some complications associated with this standard IANB technique, it is still considered by many authors as 3,5 the technique with the least complications, safest administration, and least discomfort to the patients. An anesthetic complication can be defined as any deviation from the normally expected pattern during or after 6 the injection of local anesthesia. Complications of local anesthesia can be classified as local or systemic. These complications may include local and/or systemic immediate post-injection, as failure, needle breakage, penetration of a blood vessel, hematoma, nerve damage, facial nerve paresis, blanching, and reactions (eg, overdose, allergy, 15 idiosyncrasy). Different techniques are used in IANB. Therefore, the aim of this study was to assess the incidence, types, and severity of the complication(s) of IANB injection given using a modified, indirect injection technique. This study is 1 similar to research by Joseph et al ; this current study focused only on the inferior alveolar nerve injection with a larger number of injections for more reliable and accurate results. PATIENTS AND METHODS Patients This study period was from March 2001 to November 2008 with 3,454 adults Saudi patients who received a total of 5000 IANB injections. Only patients with hyperthyroidism were excluded. The study involved 1841 females and 1613 males between 17 to 56 years old with a mean age of 36. The reasons for IANB injections were extractions of wisdom teeth (74.7%) and extractions of other mandibular posterior teeth (25.3%) (Table 1). Only patients who are treated at Oral and Maxillofacial surgery clinic are included in this study. All patients are Saudi referred for extraction of the lower Molar teeth.
1
52
Fig. 1. Syringe design and long 27-gauge needle used in the study
Fig. 2. The needle was inserted from the opposite premolar to touch the antero-medial aspect of the ramus 1.5 cm above the occlusion level
Fig. 3. The needle was redirected by moving the syringe to the same side of injection above the occlusion level Fig. 4. The needle was advanced in contact with the bone 75% of the needle length (about 30 to 34 mm)
Fig. 5. Showing the length of the needle that should be inserted before deposition of the anesthetic solution.
53
Male
1613
Female
1841
total
3454
582 1031 (1164 injections) 964 877 (1928 injections) 1546 1908 (3092 injections) 5000 IANB injections
2017
788
3735
1265
74.7 %
25.3%
If there is no bone contact, the needle is withdrawn and redirected until having bone contact, we never inject unless we have a bone contact. Aspiration was performed, and then 1.8 cc of local anesthesia solution (2% lidocaine with 1:100,000 epinephrine 1.8 cc cartridge) was deposited for the anesthesia of inferior alveolar and lingual nerves. Then 0.3 cc of 2% lidocaine with 1:100,000 epinephrine solutions was injected in the buccal sulcus opposing to the affected tooth as an infiltration to the long buccal nerve. We used only one 1.8 cc cartridge of (2% lidocaine with 1:100,000 epinephrine) in all patients as IANB at the start of the procedure, then if patients showed improper anesthetic effect for extraction we injected with a second cartridge and considered as a failure in the first injection trail. Data Collection and Statistical Analysis In all patients, the following data were collected: name, age, sex, and side of the IANB. The presence of any complications was noted, including type, persistence, and severity. All data were analyzed using SPSS, and descriptive statistics were generated. RESULTS A total of 5000 IANB injections were administered during the study period. Failures and the need for a second injection occurred in 48 patients (1%). Positive aspirations were noted in 84 patients (1.7%). Blanching of the cheek was seen in four patients (0.08%), which persisted about 5 minutes. Two cases of blurred vision (0.04%) were recorded in two female patients, both on the right side (IANB), and both patients showed complete improvement after about 7 minutes. Two patients (0.04%) had electrical pain radiating to the tongue. One person had facial paralysis (0.02%), which persisted about 4 hours. Needle breakage, overdose, allergy or idiosyncrasy, and persistent nerve damage were not found in any patient. Table 2 summarizes the incidence of complications and their duration in all patients. Table 2. Number (%) of complications encountered following IANB Complication Failure Positive aspiration Blanching Blurred vision Facial paralysis Electrical pain DISCUSSION According to failure rate, this study showed IANB failure was present in 1% of IANB injections. These results 2,3,7 7 were significantly different from previous studies. Wong and Jacobsen reported a failure rate of 5% to 15%. In 5 addition, Malamed identified the inferior alveolar nerve block as the injection with the highest clinical failure rate (15% to 20%) when properly administered. Furthermore, Malamed attributed failure to a high degree of variation in the morphology of the mandibular ramus and the location of the mandibular foramen; however, improper technique is the 3,5,8 Because of the specialty in which IANB is given, the authors results showed lower most common reason for failure. 9 10 failure rate (1%) when compared with the results of Cohen et al and Nusstein et al who reported that the failure rate of IANB to be between 38% and 75% of the time in their endodontic clinical trails. Incidence number 48 84 4 2 1 2 percentage 1% 1.7 % 0.08 % 0.04 % 0.02% 0.04 % duration
54
1. 2. 3. 4. 5. 6. 7. 8.
Lustig JP, Zusman SP. Immediate complications of local anesthetic administered to 1,007 consecutive patients. J Am Dent Assoc. 1999;130(4):496-499. Hannan L, Reader A, Nist R, et al. The use of ultrasound for guiding needle placement for inferior alveolar nerve blocks. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1999;87(6):658-665. Johnson TM, Badovinac R, Shaefer J. Teaching alternatives to the standard inferior alveolar nerve block in dental education: outcomes in clinical practice. J Dent Educ. 2007;71(9):1145-1152. Waikakul A, Punwutikorn J. A comparative study of the extra-intraoral landmark technique and the direct technique for inferior alveolar nerve block. J Oral Maxillofac Surg. 1991;49(8):804-808. Malamed SF. Handbook of Local Anesthesia.4th ed. St. Louis, MO: C.V. Mosby Co.; 1997. Bennett RC. Monheims Local Anesthesia and Pain Control in Dental Practice.7th ed. St. Louis, MO: C.V. Mosby Publishing; 1984. Wong MK, Jacobsen PL. Reasons for local anesthesia failures. J Am Dent Assoc. 1992;123(1):6973. Madan GA, Madan SG, Madan AD. Failure of inferior alveolar nerve block: exploring the alternatives. J Am Dent Assoc. 2002;133(7):843-846.
55
12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 1. 23. 24.
56