Adequate Anesthesia for Implant Placement?

I'm not quite sure about the line of reasoning behind infiltrating for a mandibular osteotomy. Just give a block and be done. Have good x-rays, a good work-up, good technique, and provide adequate anetshesia. Thousands of oral surgeons can't be wrong. On a more serious note, think about what you are trying to anesthetize before you give an injection. You are deep in the alveolus, you need true inferior alveolar nerve anesthesia. The mandibular block will also get the entire lingual nerve. This should be the easiest part of your procedure and should NEVER compromise your result.

The previous post is good advice.

Well dear Dr. when you want to give an intra osseous anesthesia to the patient then what went wrong in the begining that u dint gave Inferior Alveolar Anesthesia. Think before you work. Dont do simply blunders in your practice.(Nothing Personal ) Regards

Pain probably was due to granulation tissue left deep inside. There likely used to be tooth with endo problem. Normally, infiltration is sufficient to anesthetise soft tissue, whereas, bone does not feel pain. If you checked on X-ray and are absolutely sure you are in the clear nervewise - give IMB and dont worry.

I'm a GP that places and restores. I block mandibles. I have observed my surgeon friend infiltrate often and there is usually some feeling even when osteotomy is in safe zones. I prefer the block to keep the patient comfortable. I make extensive use of intraoperative x-rays while my oral surgoen does not. His experience allows his infiltration to be his x-ray as it were. I am very concerned with angulation and depth so I use x-rays a lot. With digital x-rays you have instant results and should never ever have to be concerned about whether you have invaded the IAC space or mental foramen. Keep your patient comfortable and use careful thoughtful correct technique and all will go well.

There is no reason to infiltrate only for mandibular posterior implants. If infiltration only anesthesia is being taught at a course you attended you should disregard this. I attended an implant surgery lecture where infiltration was advocated a few years ago, but no support for this was given. Thorough pre-operative planning and clinical evaluation will enable you to use comfortable block anesthesia for your patients. Obtaining intra-operative peri-apical films helps sometimes if you need the extra assurance of your working lengths. If you choose to use infiltration anesthesia in the lower jaw (especially in the molar region), you will have some very uncomfortable/unhappy implant patients. It is also less likely that your patient will move or "jump" at a bad time (which could result in nerve injury!).... Good luck with your next implant.... go ahead with block anesthesia

The rationale behind the infiltration is so the patient can "tell" you if you are too close to the IAN. The trouble is it doesn't work as you often get a false positive. You may find a 4% solution (septocaine) works far better. Also press the floor of the mouth inferiorly so you are infiltrating at or below where the apices of the tooth would be. Finally, just take the advice of sboralsurgeon. I have done over 5000 implants and I block every one I can.

I am a practicing perio/prosth and as many of the docs above i have placed and restored thousands of implants. This is not a point of bragging but rather to establish experience. The infiltration is a throwback to that era before CBCT's were commonplace (yes children we placed implants in the time before this technology). We found that the common PA's and PAN had inherent inaccuracies and pressure/transections were not uncommon. The infiltration was utilized such that if the surgeon was encroaching on the IAN the patient would have sensation corresponding to this, could inform the surgeon and the implant could be backed off. Now that EVERYONE is using CBCT's (wink) and Computer Assisted Site Prep (wink wink) the surgeons are better prepared for the exact spatial position of the nerve. Thus IA block is not necessarily a bad proposal. I scan every implant case in my office (OK I have a scanner in my office) and I use multiple third party softwares to plan my surgeries...i do everything possible to know exactly where the nerve is...and i still infiltrate. guess you cannot change the spot on a leopard. btw...without exception every single IAN transection and/or parasthesia case i have had the displeasure of being a professional witness for in the civil court of law has utilized a block technique for the mandibular nerve. this does not mean it will not happen with an infiltration, just the odds are tipped a little more in your favor that you will stop short of giving your patient a 'dribble lip'.

I would never try to anesthetize the mandible by infiltration with anything but Septocaine 4% with 1:100,000 epi. I agree with Dr. Andrey that infiltration is normally sufficient but you do have to think through the case. If it is a graft showing incomplete bone growth on spots that might be granulation tissue then block. I have not had such an occurrence and have done all of my mandibles with infiltration and no complaints of pain. You do need to anesthetize properly and take Dr. Levitt's advice on getting inferiorly enough with your anesthesia.

INFERIOR BLOCK IS MANDATORY FOR IMPLANT PLACEMENT AT LOWER JAW THIS WILL GIVE U BETTER REFLICTION AND INSPECTION OF SURGICAL AREA AND I DO NOT FIND ANY REASON FOR USING INFELTATION

The facts are that more and more general dentists will be doing their own implant surgical procedures.For cases that seem routine, and what appears to be an adequate space between the crest of the ridge and the "ceiling" of the IAN, the majority of practitioners will not be using cone beam technology. In most cases, infiltration of a choice local anaesthetic buccal and lingual will give adequate anaesthesia to allow guide pins to be placed to have a radiograph of the exact relationship of where the initial osteotomy bottoms out. This spatial relationship is extremely helpful and should be a determinating factor if a mandibular block should be done at this stage. If there is sufficient space between the bottom of the initial osteotomy and a 2 mm zone of safety from the "ceiling of the mandibular canal... then by all means go for it. By randomly giving a mandibular block (without the aid of cone beam technology) is like playing Russian Roulette. The anterior loop of the mental foramen, which may not be visible in the radiograph, can cause paraesthesia if impinged upon.... even though the radiograph showed adequate space. As mentioned above, granulomatous lesions that have been left behind are highly sensitive and give the impression that the IAN has been damaged. In my experience, unless 100% sure that I am in a safe zone, I prefer to place a pledget of sterile cotton soaked with topical anaesthetic into the osteotomy, and wait a few minutes before going deeper, as well as allowing local anaesthetic to pool in the osteotomy before continuing..... my personal choice rather than a block! Accidents do happen.... be careful, and remember... its better to have the patient feel a little discomfort during the procedure, than to have no sensation after the surgery. Gerald Rudick dds Montreal

ANON, Dentistry is an art, and none of us can pretend to know your patient and all of his circumstances (APPREHENSION). Thank you for posting this question. 1.) Generally, it is not indicated to replace a second molar with an implant. 90 % of masticatory efficiency occurs from the mid occlusal of the first molar - anteriorly. The mandible and IA arc coronally in the distal second molar region. Maximum bite force is delivered to the second molar. AGAIN, we don't know your patient's circumstances. I HAVE OFTEN DIVERGED FROM GENERAL PRINCIPLES FOR SPECIFIC REASONS. It will work given good occlusion - Class I, no occlusal disease (wear, cracks, multiple restored teeth, little CR-MI slide), and infra-occlusion in normal, latero-,medio-, and pro-trusive mvmts. 2.)Pain is controlled centrally and peripherally. A fraternity bro (DW, Sulphur, LA) likes to say "either you will be sedated or I will be sedated." So, Mobic 24 hrs pre-op and at time of surgery, Cleocin 300/Halcion .25-.5 30-60 mins before, N2O at 50%, and septocaine, no need for post-op meds if flapless (I am not only the HairClub President, I am an Astra client...). Probably need IA in 2nd molar region because the buccal shelf is so damn wide here. Buccal and lingual infiltration EVERYWHERE else for single implants. YOU MAKE US BETTER WITH YOUR QUESTIONS! mjp, new orleans

Thanks Docs. I'm going to print this discussion thread and add it to a journal that I just read about local anesthesia.

Thank you DRP for the "conclusion" of the topic. I am very interested if anyone continues with comments!?

the concept of infeltration anesthesia in implant therapy was tobe in the safe side (as in removing caries without anaesthesia so the patient can tell when u are close to the pulp)to answer the Q? well it works?if it work then why we have to give block anesthesia during extraction?the answer is simple.block anaesthesia is blocking the nerve which is still with connection with the tooth.infeltration anaesthesia will work to the area of bone but not enough to penetrate the canal where the nerve is protected inside even from the infeltration anesthesia you think it is going to penetrate the bucall cortex & then the canal cortex, this is explian why the patient well feel the pain when u get down because the vibration of drilling is enogh to cause that pain in the uncomplete sleeping nerve.most of the cases where infelration anaesthsia was used show that the implant was placed shorte & longer implant must be used. Block inferior alveolar nerve should be given ,with a good treatment plan for selection of implant length is best

INFILTRATION - NOT INFELTRATION

I think that as you are sure to be in safe side above inferior alveolar nerve, you can give block injection and go on

if we use the word "always", we don't have to discuss

I agree with Dr. Ayoob, also look up the "zone of safety" in any of Misch's books.

I place on an average 300 implants a year, and only do local infiltration. IAN Block is good as well, but I actually feel safer with infiltration. Yes, I do scan every case with NewTom VG Flex. Find your own path....

Thanks for your comments guys. It seems there is more than one way to skin a cat. Im the person who asked the initial question and the follow up question about trying an intra osseous injection into the cancellous bone at the base of the osteotomy was only touched upon. Has anyone tried this and what were the results? Again thanks for your help.

Tony, Sounds like it would work.

As many doctors suggested,if you have 3-D scan and proper surgical stent or some other foolproof methods to avoid injury to IAN or abundance of bone,then block is right anesthesia.Otherwise use infilteration to save you from bigger troubles.You may end up little short but shorter implants are better than no (implants+paresthesia).

Anaesthesia via infiltration serves to allow feed back from the patient to indicate when you are perhaps encroaching the IAN. There is no other purpose. It will not help in the matter of perforating the lingual aspect of the cortical plate and possibly causing the lingual artery to hemorrhage. When a mandibular lingual undercut is present it will not be detectable on a 2-D radiograph. Get a CBVT (CT Scan) with any case involving 1st mandibular molar or posterior, sinus surgery, or case with multiple sites. A scan runs the patient $250-$500, and will allow you to operate in a more calm, cool, and aware manner. I am a proponent of general practicioners a performing all phases of implants, but you must be properly and adequatly trained and educated to do so. One or two local courses or time spent with a sales rep is not adequate. I highly recomend Carl Mish's Implant Institute. MIII will give you a great start, and allow you to practice with confidence and a greater level of expertise. Regards, Scott K. Kareth

I always use id blocks. injecting locally could lift the periosteum and cause a local anoxia and reduce blood supplyto bone surrounding the implan potentially and also to a bone augmentation procedure.

Thanks for the comment, guys.. How would you proceed for implants in edenteolous mandible..double inferior nerve blocks? I personally use infiltration but I had troubles with some extractions I had to do...

Use nerve blocks with infiltration. Take careful measurements and use drillstoppers. Then go for it.