Intraoral anesthesia in the practice of a cosmetologist

Yaroslav Lata, dermatovenerologist, leading specialist at Institute Hyalual ^® (Ukraine)

Oleg Evdokimenko, head of the outpatient department of the Kharkov Regional War Veterans Hospital, dentist of the highest category (Ukraine)

Protocols for various injection methods of cosmetic facial correction - mesotherapy, redermalization, contouring, thread lifting ⎼ provide for topical anesthesia with various topical anesthetics. It should be noted, based on personal experience, that this type of anesthesia is usually sufficient in the frontal-frontal region and partially in the buccal-zygomatic region. It is practically difficult to achieve adequate pain relief using topical anesthesia in the area of the nasolabial triangle and nasolabial folds, mental and perioral areas, especially the red border of the lips.

Practical experience in the use of local anesthesia in dental practice and maxillofacial surgery, which allows for both therapeutic and surgical dental treatment, gives us the right to allow the use of intraoral conduction anesthesia techniques in injection aesthetic cosmetology ⎼ with drugs that are used in dental practice.

Considering that our information is intended for readers who have higher medical education, we omit the presentation of well-known general medical concepts regarding contraindications to local anesthesia, methods for performing allergy tests, types of complications during local anesthesia and emergency care for them. All this deserves separate consideration in the context of medication provision in the cosmetologist’s office and his tactics in the event of emergency conditions.

To perform intraoral conduction anesthesia, we used the domestically produced drug “Artifrin-Zdorovya Forte” for use in dental practice (1.7 ml in capsules No. 10). This drug is injected using a cartridge syringe with a 27 G needle (American or European standard) intended for it.

INNERVATION OF THE FACE

To understand the technique of intraoral anesthesia, let us briefly recall the innervation of the face. As is known, the innervation of the skin of the face, its muscles, mucous membranes of the oral cavity, bones of the facial skull and teeth is carried out by the trigeminal nerve. The trigeminal nerve (n. trigeminus) is the fifth pair of cranial nerves, the peripheral processes of which form three branches:

• ophthalmic;
• maxillary;
• mandibular

Optic nerve

The first branch - the optic nerve (n. ophtalmikus) - is a sensory nerve that exits from the cranial cavity into the orbit through the superior palpebral fissure, before dividing into three branches:

• lacrimal nerve (n. lacrimalis);
• frontal (n. frontalis);
• nasociliary (n. nasociliaris).

All of these branches of the optic nerve provide pain, tactile, temperature and proprioceptive sensitivity to the skin of the forehead, the anterior parts of the parietal and temporal regions, the upper eyelid, the root, the back and wings of the nose, the lacrimal gland, the eyeball and its external muscles.

Maxillary nerve

The second branch of the trigeminal nerve - the maxillary nerve (n. maxillaris) - contains, like the first branch, only sensory branches. It exits the cranial cavity through the foramen rotunda, dividing into several branches and passing further along the bony structures of the skull, in particular along the infraorbital canal, which is called the infraorbital nerve (n. infraorbitalis). For cosmetologists, it is important that the infraorbital nerve, emerging from the infraorbital foramen, is divided into terminal branches, which branch and innervate in the corresponding half the skin of the perioral region and the mucous membrane of the lip to the corner of the mouth, the skin in the area of the lower eyelid, the wings of the nose and the skin parts of the nasal septum.

Mandibular nerve

The third branch of the trigeminal nerve is the mandibular nerve (n. mandibularis). It is a mixed nerve containing both sensory and motor fibers. It exits the cranial cavity through the foramen ovale, dividing into branches:

• anterior – smaller, predominantly motor;
• the back is large, extremely sensitive.

Motor fibers go to the group of masticatory muscles, the mylohyoid muscle and the muscle that stretches the soft palate. The sensory branches of the mandibular nerve are:

• buccal nerve (n. buccinatorius), which branches in the skin of the cheek and its mucous membrane, giving branches to the mucous membrane of the lower gingival margin;
• auriculotemporal (n. auriculotemporalis), the secretory branches of which branch in the area of the parotid gland, and the sensitive branches in the skin of the temporal region, external auditory canal and in the skin of the auricle;
• the lower alveolar nerve (n. alveolaris inferior) with its large branch - the mental nerve (n. mentalis), which, leaving the lower jaw through the mental foramen, innervates the skin of the chin and the mucous membrane of the lower lip;
• lingual nerve (n. lingualis) - innervates the anterior two-thirds of the tongue, the mucous membrane of the sublingual region and the lingual surface of the alveolar process of the mandible, giving off thin branches to the pharynx.

TECHNIQUES FOR INTRAORAL ANESTHESIA

Now, after a brief anatomical excursion, let me move directly to the technique of intraoral anesthesia.

In the practice of a cosmetologist, when carrying out various types of invasive techniques, we consider it relevant to perform conduction anesthesia, which has undeniable advantages over infiltration: it is the achievement of adequate pain relief over a larger area of the skin of the face with a smaller amount of anesthetic with a minimum number of needle punctures of the oral mucosa.

We consider it appropriate to carry out the following types of intraoral conduction anesthesia:

• infraorbital and incisive anesthesia - when working with the skin in the area of the wings of the nose, upper lip, upper perioral and infraorbital areas;
• mental anesthesia - when working with the skin in the area of the lower lip, lower perioral area and chin;
• buccal anesthesia - when working in the area of the angle and branches of the lower jaw.

The key to high-quality conduction anesthesia will be the introduction of an anesthetic as close as possible to the nerve trunk, which requires the ability to correctly find the place where the needle will be inserted. A number of anatomical conditions of the oral cavity and jaws contribute to this, since there are certain fixed identification points in the form of tooth crowns, edges of the orbits, relief of the transitional fold and branches of the lower jaws.

ALGORITHM FOR INFRAORBITAL ANESTHESIA

1. We find the position of the infraorbital foramen using some identifying features: if we draw a vertical line through the pupil until it intersects with the lower edge of the orbit, then the infraorbital foramen will be located at a distance of 0.5⎼0.75 mm below the lower edge of the orbit along the drawn vertical line.
2. With the thumb of the left hand we pull the upper lip up and outwards, at the same time with the index finger of the same hand we press the skin covering it to the upper jaw at the location of the infraorbital foramen.
3. We insert the needle, moving anteriorly by 0.5 cm, into the mucous membrane of the transitional fold between the central and lateral incisor, giving the needle direction to the infraorbital foramen, and advance it until it comes into contact with the bone.
4. We introduce a small amount of anesthetic (0.1⎼0.2 ml) to further painlessly advance the needle to the bone area under the index finger and, by slightly moving the needle, we find the infraorbital foramen.
5. Having inserted a needle into the infraorbital canal to a depth of 5⎼7 mm, we inject 0.5⎼0.7 ml of anesthetic there.

The given algorithm is a classical technique that allows for surgical intervention. Considering that a cosmetologist does not require this level of anesthesia, it is permissible not to insert a needle into the infraorbital canal.

Anesthesia occurs in no more than 5 minutes.

ALGORITHM FOR INCISIONAL ANESTHESIA

1. With the patient's mouth wide open, the needle is directed perpendicular to the hard palate and injected into the mucosa at the incisive papilla (Fig. 1).

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2. Advance the needle until it comes into contact with the bone and inject 0.3⎼0.5 ml of anesthetic.
3. To achieve deeper anesthesia, it is recommended to advance the needle into the incisive canal by 0.5 mm, and then inject another 0.3⎼0.5 ml of anesthetic.

Anesthesia occurs within 3⎼5 minutes.

ALGORITHM FOR MENTAL ANESTHESIA

1. The doctor is positioned behind the head of the patient, who closes his jaws.
2. The doctor moves the soft tissues of the cheek aside with his left hand and with his right hand inserts the needle from the outside, from top to bottom and forward into the transitional fold at the level of the middle of the crown of the first lower painter to a depth of 1 cm (Fig. 2).

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3. A small amount of anesthetic is injected and the bone surface is carefully felt with a needle.
4. If you feel the needle “sinking” or pain appears in the lip area, the needle is advanced a few millimeters and 0.5⎼1.5 ml of anesthetic is injected.

Anesthesia sets in within 5 minutes.

ALGORITHM FOR BUCCAL ANESTHESIA

1. The patient opens his mouth wide, and the doctor moves the patient's cheek to the side with his left hand.
2. The needle is inserted into the transitional fold to the bone to a depth of about 1 cm in the area of the distal edge of the crown of the lower third painter and 0.5 ml of anesthetic is injected (Fig. 3).

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Anesthesia sets in within 10 minutes.