Dental Science:
Scientific Information
Intraligamentary anesthesia –
pathway of spread and histological
effects
Pathway of spread – Garfunkel et al.
Intraligamentary-intraosseous anesthesia. A radiographic demonstration.
Histological effects – Galili et al.
Intraligamentary anesthesia – a histological study.
The initial assumption was that anesthetic solution injected via intraligamentary anesthesia would spread
along the periodontal ligament (PDL) space to the apical area. Concern existed about possible damage
resulting from the anesthethic solution being forced down the PDL space. However, animal experimental
studies revealed that intraligamental injected anesthetic solution enters the cancellous bone and spreads
intraosseously to the apical area by avoiding the PDL route(1, 2).
That is the name of the intraligamenatry anesthesia technique refers to the site of needle injection but not to
the direction of the local anesthetics’ spread(2). Furthermore, histological examinations have demonstrated
that any tissue changes caused by needle or anesthetic injection are localized, minor and reversible(3, 4, 5).
The following two studies demonstrate the pathway of spread and the histological effects of intraligamentary
anesthesia.
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Pathway of spread – Garfunkel et al. Histological effects – Galili et al.
Intraligamentary-intraosseous anes- Intraligamentary anesthesia –
thesia. A radiographic demonstration. a histological study.
Objective
Objective
Aim of the study was to investigate the spread of intraligamental
injected anesthetics through the dental tissues.
The study´s purpose was the evaluation of possible damage to
periodontal tissues when administering intraligamentary anesthesia.
Materials and Methods
Materials and Methods
Baboon monkeys received intraligamental injection of radiopaque
material in four different permanent teeth. Increments of 0.4bml
of contrast medium were injected using a pistol type syringe with
an ultra-short 30 gauge needle advanced about 2 – 3bmm into
the periodontal ligament. Serial radiographs were taken during
the injection procedure to visualize the pathway of the injected
radiopaque material spread.
A baboon monkey received intraligamentary anesthesia with
a pistol type syringe at 14 different teeth 22, 15, 8, 3 days as
well as 1 day and 1bh before histological examination. Each
tooth, mesially and distally, received 0.2bml lignocaine 2 % with
1:100,000 epinephrine using an extra-short 30 gauge needle
which was inserted about 2 – 3bmm deep into the periodontal
ligament. Respective contralateral teeth did not receive any
injection and served as control. Longitudinally cuts of the teeth
were histological examined under the microscope.
Results
Results
The radiographs revealed a concentration of the injected radiopaque material adjacent to the needle tip followed by a clouding
of the crestal bone area. The opacitiy advanced through the
alveolar bone crest and bone marrow spaces to the apical area.
The PDL space remained clear of radiopaque material.
Histological examination of the teeth which received intraligamental injection 1bh, 1 day respectively 3 days before, revealed
a defined damage to the gingival tissue but no signs of damage
to the alveolar bone or cementum. In most of the specimens the
histological changes already disappeared within 8 days. After
15 days but at the latest after 22 days the histological picture
returned to normal and complete healing was found.
Conclusion
Conclusion
The intraligamental injected material spread intraosseously to
the apical area under avoidance of the PDL space. The authors
presumed that the solution is redirected into the surrounding
cancellous bone through the fenestrations in the dental socket.
The intraligamentary anesthesia approach was concluded to
exert its effect by spreading intraosseously to the apical area.
The histological effects remained limited to the needle penetration
depth. No damage of the periodontal ligament apical the penetration site was found. Overall, no bone or cementum damage
was detected. All signs of initial detected histological changes
were found to subsequently completely heal. Due to only localized,
minor and reversible histological changes the intraligamentary
anesthesia was considered a safe anesthetic technique.
Source
Source
Garfunkel AA, Kaufman E, Marmary Y, Galili D: Intraligamentaryintraosseous anesthesia. A radiographic demonstration. Int J
Oral Surg 12(5), 1983: 334–9. The study was abbreviated and
summarised by Heraeus Kulzer.
Galili D, Kaufman E, Garfunkel AA, Michaeli Y: Intraligamentary
anesthesia – a histological study. Int J Oral Surg 13(6), 1984:
511–6. The study was abbreviated and summarised by
Heraeus Kulzer.
In the literature described unwanted effects like elongation of teeth or post-injection pain are mainly attributed to a too fast injection(6).
Results of recent clinical studies show that controlled slow intraligamental injection barely induces unwanted side effects(6, 7). Zugal documented 205 cases of intraligamental injection, without any patient reporting tooth elongation or pressure pain after subsidence of anesthesia(6). Also among 202 clinical cases of intraligamental injection documented by Glockmann et al. only 2 cases of elongation feeling
occurred(7). In both investigations controlled slow injection was performed, i.e. at least 20 seconds for 0.2 ml anesthetic solution per
root, to allow sufficient time for the solution to diffuse in the surrounding tissue(6, 7).
As the initially common injection systems of the pistol-type hardly allow a controlled injection procedure(6) and often are associated
with post-injection complications, they are considered as obsolete nowadays(8, 9).
Garfunkel AA, Kaufman E, Marmary Y, Galili D: Intraligamentary – intraosseous anesthesia. A radiographic demonstration. Int J Oral Surg 12(5), 1983: 334-9.
Smith GN, Walton RE: Periodontal ligament injection: distribution of injected solutions. Oral Surg Oral Med Oral Pathol 55(3), 1983: 232-8. (3) Dreyer WP,
van Heerden JD, de V Joubert JJ: The route of periodontal ligament injection of local anesthetic solution. J Endod 9(11), 1983: 471-4. (4) Galili D, Kaufman E,
Garfunkel AA, Michaeli Y: Intraligamentary anesthesia – a histological study. Int J Oral Surg 13(6), 1984: 511-6. (5) Anneroth G, Danielsson KH, Evers H, Hedström
KG, Nordenram A: Periodontal ligament injection. An experimental study in the monkey. Int J Oral Surg (14(6), 1985: 538-43. (6) Zugal W: Die intraligamentäre
Anästhesie in der zahnärztlichen Praxis. Zahnärztl Mitt 91, 2001: 46–52. (7) Glockmann E, Dirnbacher T, Taubenheim L: Die intraligamentäre Anästhesie –
Alternative zur konventionellen Lokalanästhesie? Quintessenz 56(3), 2005: 207-216. (8) Zugal W, Taubenheim L, Schulz D: Triade des Anästhesie-Erfolgs:
Instrumente – Anästhetika – Methoden-Beherrschung. Z Stomatol 102, 2005: 9-14. (9) Endo T1, Gabka J, Taubenheim L: Intraligamentary anesthesia: benefits
and limitations. Quintessence Int 39(1), 2008: 15-25.
(1)
(2)
Heraeus Kulzer GmbH • Grüner Weg 11 • 63450 Hanau • www.heraeus-kulzer.com
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