![• Adequacy of reduction was assessed by comparing preoperative with postoperative cone-beam computed
tomography scans of the patient by use of 3-dimensional planning software.
• The fracture gap in each patient in the anterior end (ie, at the sigmoid notch [g1]) and at the posterior
border of the mandible (g2) was measured with the software’s measuring tool. This was used to calculate
the average fracture gap (G) in each patient before and after the intervention: G = (G1 + G2)/2
• All procedures were performed by the same team using lidocaine as the anesthetic agent
• All patients were discharged on the day of the operation; prescribed a muscle relaxant for 3 days
postoperatively;
• Advised to eat a soft diet; and instructed to perform postoperative physiotherapy with opening, protrusive,
and laterotrusive exercises starting the night of the operation. Patients were followed for 4 weeks and
instructed to continue physiotherapy for 8 weeks](https://image.slidesharecdn.com/localanesthesia-250321151435-921c3972/85/LOCAL-ANESTHESIA-i-hate-reevaand-th-pptx-13-320.jpg)
LOCAL ANESTHESIA i hate reevaand th.pptx
- 1. LOCAL ANESTHESIA JOURNAL CLUB Moderator- Dr. Rachana Ravishankar Presented by- Dr. Arun U Nair
- 2. ARTICLE - 1
- 3. INTRODUCTION • The optimal treatment for adult mandibular condylar fractures (MCFS) has largely shifted in favor of open reduction and rigid internal fixation. • However, a sizeable portion of these injuries are still being treated in a closed manner based on old literature, convenience, and lesser associated morbidity. • Most MCFS are appropriately treated under general anesthesia. • However, some selected isolated MCFS or those with minimal associated mandibular condylar fractures can be treated optimally with patients under local anesthesia.
- 4. AIM • . The purpose of this study was to develop a safe, sound, effective protocol for routine surgical management of mandibular Subcondylar fractures under local anesthesia
- 5. INCLUSION CRITERIA • A total of 7 patients with mcfs and other associated facial fractures were included in the study • Age 18 to 60 years • Subcondylar or low subcondylar fractures (condylar neck and condylar base fractures according to the strasbourg osteosynthesis research group classification) without associated high-velocity injuries • Panfacial trauma, and/or cerebrospinal fluid leak, presenting within 7 days of injury; • Malocclusion not corrected by traction or guiding elastics • And patients for whom GA is declared unsuitable
- 6. EXCLUSION CRITERIA • Extremely apprehensive, • Uncooperative, • Nonconsenting patients; • Pediatric patients; • Very high condylar fractures • Medially displaced or dislocated fractures; • Patients taking central nervous system depressants • Malocclusion that was corrected after guiding or traction elastics • Bilateral subcondylar fractures
- 7. PARAMETERS ASSESSED • Intraoperative pain assessed by a visual analog scale, • Fracture reduction assessed by measuring the preoperative and postoperative average fracture gap, • The presence of malocclusion preoperatively and postoperatively, • Deviation on mouth opening • Maximal mouth opening.
- 8. PROPOSED PROTOCOL • The salient steps of the protocol proposed wre: • 1. Careful case selection • 2. Adequate muscle relaxation 3 days preoperatively and postoperatively (after ruling out contraindications) • 3. Condylar traction (in cases with more displacement) • 4. Analgesia with an SCPB and MB • 5. Rigid fixation • 6. Occlusal check by means of functional movements • 7. Meticulous closure • 8. Immediate postoperative physiotherapy • 9. Follow-up
- 9. MATERIALS AND METHODS Centrally acting muscle relaxant (5-10mg Baclofen TID for 3 days pre and post op) Intraoperative mandibular block and superficial cervical plexus block with 2% lidocaine 1:2,00,000 After aseptic preparation midpoint of sigmoid notch palpated
- 10. MANDIBULAR NERVE BLOCK Needle inserted cephalomedially lateral to the pterygoid plate and the needle is “walked off” with multiple reinsertions. When the patient complaints of tingling it means the nerve has been contacted. Needle should be withdrawn 2mm to avoid intraneural injury 5ml of 2%lidocaine 1:2,00,000 epinephrine injected
- 11. SUPERFICIAL CERVICAL PLEXUS BLOCK 5 ml of solution deep to the mid point of posterior border of SCM muscle, also superior and inferior to that point creating a field block. 2ml of same LA solution infilterated subcutaneously for hemostasis. Standard submandibular or retromandibular incision is given
- 12. • To create space for manipulation of the condylar fragment, a small mouth prop was placed in an ipsilateral manner on the posterior-most molars and mild cephalad pressure was applied manually at the chin, causing the ramus to rotate downward. • After plate bending, the prop was removed, and screws were placed first at the anterior border of the condyle while anatomic reduction was being visually confirmed • Drilling of the posterior screws and final tightening of the screws were performed after re- establishment of Imf. • Fixation, the patient was instructed to perform opening, protrusive, and laterotrusive movements, and after confirmation of proper reproducible occlusion, closure was performed meticulously with subcuticular suture applied for the skin
- 13. • Adequacy of reduction was assessed by comparing preoperative with postoperative cone-beam computed tomography scans of the patient by use of 3-dimensional planning software. • The fracture gap in each patient in the anterior end (ie, at the sigmoid notch [g1]) and at the posterior border of the mandible (g2) was measured with the software’s measuring tool. This was used to calculate the average fracture gap (G) in each patient before and after the intervention: G = (G1 + G2)/2 • All procedures were performed by the same team using lidocaine as the anesthetic agent • All patients were discharged on the day of the operation; prescribed a muscle relaxant for 3 days postoperatively; • Advised to eat a soft diet; and instructed to perform postoperative physiotherapy with opening, protrusive, and laterotrusive exercises starting the night of the operation. Patients were followed for 4 weeks and instructed to continue physiotherapy for 8 weeks
- 14. RESULTS • The mean duration of the procedure was 35.14 minutes (from incision till closure), • mean rating of intraoperative pain or discomfort was 0.57 as reported on the visual analog scale by the patients. • Mean mouth opening improved from 17.1 to 40.5 mm, • deviation on opening improved from 4.4 to 0.28 mm. • The average fracture gap was reduced from 6.32 to 0.97 mm. • None of the patients displayed malocclusion
- 15. CONCLUSION • The uncertainty surrounding management of adult MCFS has largely been dispelled; however, most of these are still being sub optimally managed by closed methods based on old literature. • The protocol presented in this pilot study essentially reduces the treatment of MCFS to a minor operating room procedure with minimal morbidity, making it applicable even in a resource-deficient and/or high–patient volume setting. • By extension of this protocol it is a viable alternative for patients in whom GA is deemed unsuitable
- 16. CONCLUSION • The greatest advantage with this protocol is that reduction and fixation can be checked accurately and subsequently revised if the patient to perform functional movements on his or her own intraoperatively and inquiring whether his or her preinjury intercuspation has been restored. • Thus, the patient’s intact proprioception can be harnessed to aid optimal fracture reduction, which is impossible under GA. Moreover, operating time, morbidity, and cost are reduced and duration of hospital stay is shortened, which speeds up recovery and rehabilitation.
- 17. REVIEW ARTICLE
- 18. • Aim -To evaluate the safety and effectiveness of superficial cervical plexus (SCP) block as an alternative to general anesthesia in selective cases of oral and maxillofacial surgical (OMFS) • Total number of patients included in the study was 10, out of which 6 were male and 4 were female. • Out of 10 patients included in the study, • Five required incision drainage of peri mandibular spaces, • Two required cervical lymph node biopsies, • Two required cyst enucleation of mandible, • One patient required open reduction and internal fixation of mandibular angle fracture. • All the patients were given superficial cervical plexus block along with the supplemental nerve blocks.
- 19. • All patients had their surgical procedures under regional anesthesia (SCP block with supplemental nerve blocks) performed by the same surgeon with satisfactory anesthesia without any complication • Results- SCP block with concomitant mandibular nerve and/or long buccal nerve block has a high success rate, low complication rate, and high patient acceptability and can be used as an alternative to general anesthesia in selective OMFS case
- 20. ARTICLE -2
- 21. AIM • . The aim of this study was to assess the effectiveness of endonasal infiltrative anesthesia in the management of nasal bone reduction
- 22. EXCLUSION CRITERIA • Less than 16 years or more than 80 years, • Fracture type III or IV of the murray–maran scale, • Allergies to local anesthesia, • Impaired consciousness (due to dementia or alcohol, toxin, or drug ingestion), • Psychiatric disorders, • Associated facial fractures, • Open nasal fractures.
- 23. METHODS • Between january and july 2016, consecutive patients who presented in the emergency department with mild nasal bone fractures were randomly assigned to two groups. • Group A -patients received 2 ml of 10% topical lidocaine applied in each nostril through gauze plugs wetted with anesthesia solution, which were kept in place for 10 min. Subsequently, all patients were administered 4 ml of 2% mepivacaine with adrenaline (1 in 100,000) through a percutaneous injection in the fracture focus. • Group B- after completing the previous steps, 4 ml of 2% mepivacaine with adrenaline was injected endonasally through each nostril with the help of a Rhinoscope to block mucous sensitivity in the area of the nasal bones and septum.
- 24. • Nasal fracture treatment was accomplished through closed manipulation until a satisfactory reduction was achieved. Afterward, bilateral anterior nasal tamponade with gauze and antibiotic ointment was performed. • After completing the procedure, the pain was assessed through the visual analog scale (vas), which comprised a horizontal line of 10 cm anchored at one end with the words “no pain at all” and at the other end with the words “worst pain imaginable.”
- 25. • Patients were first asked about a known pain (the pain of a paper cut) to compare the sensitivity with the previous pain in both groups. Then they were questioned about the following steps of the procedure: • (1) pain during the endonasal anesthesia process; • (2) pain with percutaneous infiltration anesthesia at the focus of the fracture; • (3) pain with the fracture reduction maneuvers • 4) pain during the nasal packing. • Finally, the patients were inquired if, in the case of nasal bone reduction again in the future, they would opt for the same method of anesthesia.
- 26. RESULTS • There was significant pain reduction with the reduction maneuvers and group that included the endonasal infiltrative anesthesia. • There were also significant differences when comparing pain with the topical endonasal anesthesia and the topical plus infiltrative anesthesia. • As to whether the patient would choose the same anesthetic method, there were no significant differences between the two groups
- 27. CONCLUSION • Endonasal infiltrative anesthesia was effective for reducing pain during the reduction maneuvers. This technique also reduced the pain associated with nasal tamponade
- 28. REVIEW ARTICLE
- 29. • Objective: to determine the most effective local anaesthetic method for manipulation of nasal fractures, and to compare the efficacy of local anaesthesia with that of general anaesthesia. • Method: systematic review and meta-analysis. • Databases: Medline, Embase, Cochrane library, national research register and Metaregister of controlled trials. • Included studies: included randomised, controlled trials comparing general anaesthesia with local anaesthesia or comparing different local anaesthetic techniques. Non-randomised studies were also systematically reviewed and appraised. No language restrictions were applied.
- 30. Results: • Five randomised, controlled trials were included, three comparing general anaesthesia versus local anaesthesia and two comparing different local anaesthetic methods. • No significant differences were found between local anaesthesia and general anaesthesia as regards pain, cosmesis or nasal patency. • The least painful local anaesthetic method was topical tetracaine gel applied to the nasal dorsum together with topical intranasal cocaine solution. • Minimal adverse events were reported with local anesthesia. • Conclusions: local anaesthesia appears to be a safe and effective alternative to general anaesthesia for pain relief during nasal fracture manipulation, with no evidence of inferior outcomes. The least uncomfortable local anaesthetic method included topical tetracaine gel
- 31. ARTICLE- 3
- 32. INTRODUCTION • The surgical removal of impacted third molar involves trauma to soft and bony tissue and can result in considerable pain, swelling, and trismus, and therefore may affect the patient’s quality of life after the surgical procedure. • Anti-inflammatory agents remain the key drugs to limit patient discomfort after such oral surgical procedures. • Steroid being potent anti-inflammatory agents has been widely used to reduce the sequelae that follow removal of third molars. At most instances, oral and maxillofacial surgeons are well-versed with parental routes of administration. • There have been clinical trials evaluating steroids administered via intravenous and intramuscular route following third molar surgery of these drugs, but general dental practitioners involved in such dentoalveolar oral surgery are not. • General dental practitioners are trained and well-versed with administering the drugs via oral tissues
- 33. AIM This study was undertaken to validate the existing data on the use of twin mix in minor oral surgery based on power analysis, statistical sample size estimation and an ultraviolet (UV) spectrometry study for chemical stability of the mixture.
- 34. PATIENTS AND METHODS • A prospective, randomized, double-blind trial was designed to validate the pilot study on the efficacy of twin mix and 2 % lignocaine with 1:200,000 epinephrine in the surgical removal of impacted mandibular third molars. • 23 medically healthy patients (ASA 1) were randomly selected with bilateral impacted mandibular third molars where 7 were female patients and 16 males with a mean age of 26.2 years (±5.20). • Local anaesthetic used for the transalveolar extractions in all 46 surgical procedures utilized either 1.8 ml of 2 % lignocaine with 1:200,000 epinephrine or 2.8 ml twin mix (1.8 ml 2 % lignocaine with 1:200,000 epinephrine+1 ml 4 mg dexamethasone). The anaesthetic selection was done randomly in such a way that each patient receives both the study drug combinations, one on either side.
- 35. • All the cases included in the study had a similar difficulty index with bilateral class II position B Mesioangular impacted mandibular third molars as per the Pell and Gregory’s classification system. Standard surgical procedure was followed for all cases using modified ward’s mucoperiosteal flap for surgical access and bone removal with a 702 surgical carbide fissure bur on straight surgical micro-motor/handpiece with copious normal saline irrigation.
- 37. LABORATORY ANALYSIS • Twin-mix (study solution) admixture was prepared by mixing 1.8 ml of 2 % lignocaine with 1:200,000 epinephrine and 4 mg/1 ml of dexamethasone. • The study solution of twin-mix admixture was stored in an amber colored glass vial. • Physical compatibility of the twin-mix solution was checked for a period of 15 days from the preparation of the admixture. • The prepared twin-mix solution was inspected every day for the appearance of any precipitate against a black background and for any color change against a white background. • The evaluation of the chemical stability of the test solutions of twin mix was done using a spectrophotometric study of the test solutions—2.8 ml twin-mix study solution, 1.8 ml control local anaesthetic solution and 1 ml 4 mg dexamethasone solution diluted 1,000 times (1 to 1,000 ml) with double distilled water. • The dilutions were required to obtain spectrometry graphs in a visible range for evaluation. All the three test solutions were subjected to double beam UV visible Spectrophotometery.
- 39. RESULTS • The results showing better post-operative outcome with administration of dexamethasone and lignocaine as an intra space injection. • The anaesthetic efficacy of the twin-mix admixture was found statistically similar to the control solution of 2 % lignocaine with 1:200,000 epinephrine • The solution of dexamethasone used for this study was found physically compatible with the solution of 2 % lignocaine with 1:200,000 epinephrine showing neither precipitate nor colour change. • The characteristic wavelength (λmax) of 1 in 1,000 dilution of 2 % lignocaine with 1:200,000 epinephrine was recorded at 224 and 291 nm for the dexamethasone solution. • The mixing of the two solutions did not show any significant variations in the individual solution wavelengths with recorded λmax (twin mix) at 291.5 and 223 nm . • The ph of dilutions prepared for the spectrometric study is summarized .
- 41. CONCLUSION • To conclude, clinical anaesthetic efficacy of twin mix is comparable to 1.8 ml 2 % lignocaine with 1:200,000 epinephrine when administered in the pterigomandibular space with the additional advantage of single prick co-administration of dexamethasone with local anaesthetic, lesser sting of local anaesthetic injection, shorter aesthetic latency and prolonged duration of the soft tissue anaesthesia and a decrease in postoperative discomfort after the oral surgical procedure. • A long term stability study is mandated to assess the compatibility of the mixture components for its production, storage and shelf life assessment.
- 42. REVIEW ARTICLE
- 43. AIM The study evaluates the effectiveness of intra-space administration of 4 mg of dexamethasone on postoperative discomfort after third molar
- 44. DISCUSSION • This study utilized 2.8 ml study solutions for pterygomandibular nerve blocks to maintain volume parameter consistent in the study groups 1 ml more than the standard inferior alveolar block. • Adjuvant dexamethasone used with local anesthesia in the study increased the ph of the local anesthetic solution from 4.5 to 6 and clinically demonstrated faster onset of anesthesia and longer duration with reduction in postoperative VAS scores. • Steroid induced shorter onset and prolonged duration, apart from change in ph, which may also be due to the property of vasoconstriction dexamethasone has, or by increase in the activity of the inhibitory potassium channels on nociceptive c-fibers, thus decreasing their activity. • Addition of dexamethasone increases the Ph, thereby increases the amount of free base of the local anesthetic, decreases the time required for onset of the anesthetic, decreases pain on injection, and also improves overall the patients postoperative comfort and quality of life as demonstrated by the postoperative VAS scores, measurements for the facial swelling, and the measurement of the reduction in mouth opening.
- 45. CONCLUSION • The addition of dexamethasone to lignocaine and its administration as an intra-space injection significantly shortens the latency and prolongs the duration of the soft tissue anesthesia, with improved quality of life in the postoperative period after surgical extraction of mandibular third molars
- 46. PRESENTERS TAKE • The protocol presented in the study essentially reduces the treatment of MCFS to a minor operating room procedure with minimal morbidity, making it applicable even in a resource-deficient and/or high–patient volume setting. By extension of this protocol it is a viable alternative for patients in whom GA is deemed unsuitable. • Endonasal infiltrative anesthesia was effective for reducing pain during the reduction maneuvers. This technique also reduced the pain associated with nasal tamponade, and can be used as a viable technique for nasal bone fracture reduction. • Clinical anaesthetic efficacy of twin mix is comparable to 1.8 ml 2 % lignocaine with 1:200,000 epinephrine when administered in the pterigomandibular space with the additional advantage of single prick co-administration of dexamethasone with local anaesthetic, lesser sting of local anaesthetic injection, shorter aesthetic latency and prolonged duration of the soft tissue anaesthesia and a decrease in postoperative discomfort after the oral surgical procedure.