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Application of Extra-oral Infraorbital Nerve Block in Implant for Upper Anterior Region by Dr. Shady Negm

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Course of the Nerve

The cranial nerve V (trigeminal nerve) provides sensory innervation to the face. The second division, the maxillary nerve (V2), exits the skull from the foramen rotundum. After giving off numerous branches, the maxillary nerve eventually enters the face through the infra-orbital canal where it ends at the infra-orbital nerve. The infra-orbital nerve supplies sensory branches to the lower eyelid, the side of the nose, and the upper lip including the anterior part of the alveolar ridge at the side of innervation.

Indications include wound closure, pain relief and anes- thesia for debridement. Contraindications include any allergy or sensitivity to the anesthetic agent, evident of infection at the injection site, distortion of anatomical landmarks and uncooperative patients. One disadvantage to the procedure is that the technique is performed by blind palpation of the infra-orbital foramen.

Discussion

The majority of local anesthetic agents share the same basic chemical structure, which consists of an aromatic ring, linked to an intermediate chain. (The intermediate chain between the aromatic and hydrophilic segments is either an ester or an amide.) This is linked to a hydrophilic amine segment as seen in figure 1.

The chemical structure of this intermediate group classifies the agent into the amide group or the ester group. This structural difference determines the pathway by which the agent is metabolized and its allergic potential. The toxicities associated with local anesthetics are cardiovascular and neurologic. Methemoglobinemia can occur with use of these agents, though it is rarely clinically significant.

An infra-orbital nerve block requires 1-3ml of the chosen anesthetic agent. Lidocaine (xylocaine) is the most commonly used agent. The onset of action for lidocaine is approximately four to six minutes. The duration of effect is approximately 75 minutes, which is sufficient enough to complete the implant surgery without needing to give anesthesia again.

Technique
  • During the extra-oral technique, the needle is in very close proximity to the facial artery. Because of this proximity, avoid adding vasoconstrictors to the anesthetic agent.
  • Use the landmarks to locate the infra-orbital foramen.
  • Prepare the skin overlying the infra-orbital foramen with povidone iodine (betadine) and sterile gauze.
  • Using sterile technique, insert the needle through the skin, the subcutaneous tissue, and the muscle.
  • Aspirate to ensure the needle is not within a vessel. The facial artery and vein are very close to the needle in this position.
  • Inject the anesthetic solution. The infiltrated tissue appears swollen.
  • Firmly massage this area for 10-15 seconds.
Complications

Complications for a procedure such as this could include bleeding, hematoma formation, allergic reaction, infection, unintentional injection into an artery or vein, failure to anesthetize, nerve damage and swelling of the eyelid.

Case presentation

Two Egyptian female patients came to my clinic seeking implants to restore the missing teeth in the anterior segments of their alveolar ridges. I decided to use the extra-oral infra-orbital nerve block rather than infiltration intra-orally. The technique is painless and less traumatic. The anesthesia was very effective and I completed the surgery without any problems. Figures 2-6 illustrate the technique.

Conclusion

The extra-oral infra-orbital nerve block often achieves anesthesia with a smaller amount of medication than is required for local infiltration. In addition, unlike local tissue infiltration, blocks can provide anesthesia without causing tissue distortion. A Successful infra-orbital nerve block provides anesthesia for the area between the lower eyelid and the upper lip including the anterior part of the alveolar ridge at the side of innervation.



References
  1. Gray H, Lewis WH. The trigeminal nerve. Gray's Anatomy of the Human Body. Bartleby.com. Accessed May 16, 2008.
  2. Amsterdam JT, Kilgore KP. Regional anesthesia of the head and neck. In: Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: WB Saunders Company; 2004:552-66.
  3. Crystal CS, Blankenship RB. Local anesthetics and peripheral nerve blocks in the emergency department. Emerg Med Clin North Am. May 2005;23(2):477-502.
  4. Trott AT. Wounds and Lacerations: Emergency Care and Closure. 2nd ed. St. Louis, Mo: Mosby; 1997.
Dr. Shady A. M. Negm is an Egyptian dentist and demonstrator at oral medicine and periodontology department at faculty of dentistry at Pharos University. He has experience spanning many years from the dental lab to the dental chair. His passion is to put people at ease, provide the best care, and have patients leave with a smile. Education is an ongoing commitment. He believes strongly that continuing his professional knowledge allows him to exchange ideas and discuss new treatment methods with colleagues, which ultimately benefits not only him, but his patients as well. He is a fellow of the International Congress of Oral Implantologists, as well as Alexandria Oral Implantology Association. He is a diplomate of Clinical Implant from Seville University, Spain, and of Infection Control, Oxford College, UK.
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