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Conversation Opener: Predictable, profound local anesthesia without side effects: A proposed novel technique

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Milan with edgesDr. Milan Somborac spoke with Dr. John O’Keefe about a solution he developed to deal with the feeling of numbness consequent to the use of local anesthetics in dental procedures. 

For further information, contact Dr. Somborac at milan@drmilan.com and by phone: 705-441-4566

 

Watch the video interview

 

 

21 Comments

  1. Dr.Fawzia February 9, 2015

    Nice. Please provide more videos how to do effective block anesthesia.

    Reply
    1. Milan Somborac DDS February 10, 2015

      We are planning a follow up to show how CILA can replace the mandibular block for all treatment except wisdom tooth extraction.

      Milan

  2. Cliff Leachman February 9, 2015

    Interesting, never had a problem in 25 years with the Maxilla, but I question the wisdom of drilling a channel interproximally into the bone. Better anaesthesia, but are you inducing bone loss, infections or tissue loss?

    Reply
    1. Milan Somborac DDS February 10, 2015

      To address bone loss concerns, we know that five-walled bony pocket heals nicely in the absence of infection. The CILA channel is, in fact, a very narrow diameter, five-walled bony pocket free of infection.

      Concerning infections, if, as we should, we work in a surgically clean environment (sterile intra-oral environment is not possible) this need not be an issue.

      The tissue loss is minimal. I have been at the receiving end of CILA local anesthesia and would gladly pay the price of small tissue loss for the absence of numbness and the effectiveness of the local anesthesia.

      CILA would benefit from a well designed study using large numbers of patients.

      Milan

  3. Anonymous February 9, 2015

    My concern would be nicking the adjacent roots when drilling through the bone. Your comments?

    Reply
    1. Milan Somborac DDS February 10, 2015

      We accept root loss during orthodontic movement. What sort of problem do you see arising if we nick a root? In our office, we have used CILA on a daily basis for over a year. I am sure that we have nicked some roots. We have not noticed any problems arising from this likelihood.

      A better answer to your objection could come from a well designed animal study.

      Milan

  4. Alan Grant February 9, 2015

    Dr. Somborac,

    Thank you for sharing your anesthesia technique. I think it would work well in experienced dental hands, I would be worried for the new grads inadvertently perforating or damaging the tooth roots.

    I really like the idea of little or no soft tissue anesthesia.

    Alan Grant

    Reply
  5. Reza Nouri February 10, 2015

    A very interesting approach. Thank you for sharing. I believe a large RCT study would be worthy. There is definitely concern for inadvertent trauma to adjacent root anatomy, but this is less invasive than Temporary Anchorage Devices (TADs)placed in orthodontics. Studies on TADs have shown that when the root is nicked the bone heals around it and there are generally no adverse effects.
    Reza Nouri, Vancouver, BC

    Reply
  6. Dr. R.F.Jezdinsky February 10, 2015

    Interesting concept, I would be little concerned about a possibility of damage to the vitality of teeth. I realise that it is an intraosseous and not an intraligamental application but it still makes me slightly nervous. Intraligamental application which I used successfully many times was reserved only for teeth that were non vital already or to be devitalised for the obvious concern of the damage to the vitality of the tooth involved.

    Reply
  7. Milan Somborac DDS February 10, 2015

    Alan,

    I share your concern. I would like to see CILA become a part of undergraduate training.

    Personally, I find mandibular block anesthesia more difficult to administer. Also creating tight contacts for class two posterior composites, finding that fourth canal in a maxillary molar, treating a gingival class five lesion in a maxillary second molar or on the lingual surface of a mandibular molar, removing the small roots of a first maxillary bicuspid – and on and on. The list of clinical challenges is long. CILA is not on that list once the technique is mastered.

    Milan

    Reply
  8. Anonymous February 10, 2015

    I just reviewed my last few upper molar endos and to me it would seem that there is rarely enough room between the premolar and molar for this type osteotomy or injection. I feel nicking the roots would be very common.

    If i were needing this i would use one of the introseous injection products out there for their limited cost and much smaller drill diameter

    Reply
  9. Dr. R. Cormack February 10, 2015

    Thanks for the information. This technique seems a little invasive (removing cortical bone just for L.A.?). I would be concerned about potential increase in post-op pain, future periodontal issues (blunting of papilla, fenestration or dehiscence), patient acceptance, potential root damage, etc.

    Reply
  10. A Witzke February 10, 2015

    There are several systems like this available in Europe and have been used for many years. Look up the Quicksleeper S4, which you cannot get in Canada yet, but is much nice than using a handpiece and bur to remove bone, much less discomfort on healing as well I’d assume.

    Reply
  11. Stephen Bray February 10, 2015

    Dr. Milan Somborac must be complimented on revisiting this technique, there was a time when a kit was available commercially, it came out after the first intra-ligamentory injection techniques and guns; as I’m sure Dr. John O’Keefe remembers too. (We’re all of that vintage now!) It had the appropriate burs, etc. and as I recall had a stopper to prevent leakage too (Dr.Somborac’s idea of the endo. marker is a good one). Does anyone still have a kit out there? I forget the name, I believe they were out of the US?
    Steve

    Reply
  12. Jurgen Vander Velden February 10, 2015

    Seems like an aggressive version of the stabident system (which, by the way works very well). As with the stabident system, case selection is critical- if the roots of adjacent teeth are too proximal, then there will be insufficient cancellous bone in which to introduce the anaesthetic. I’ll stick with the stabident perforator in a slow speed handpiece, because the much smaller aperture is harmonized with the size 30 short needle, and far less likely to cause iatrogenic damage. For over 10 years, stabident has replaced the Mn block in my practice when treatment involves lower 5’s, 6’s or 7’s.

    Reply
    1. Dr M.Maillette February 18, 2015

      I’m totally with you on this statement. I have used Stabident on a daily basis for 10 years. I’ve by ailler experienced some necrosis of the cortical bone (especially in the lower molar region) with stabident. After a few weeks, a small piece of cortical (looking like a white endo stopper with the perforation in the center) was ejected from the gum. This situation has an appearence of a fistule without beeing one. I found that it occured in situations where the cortical bone was thicker and difficult to pierce. At one time, we had to make a small surgical intervention to get the sequestre out of there because the swelling wasn’t healing by itself.
      I think patients should be advised of the possibility of swelling on the injection site and that they should call the office if it persists more than one week. So we can make sure to do the adequate follow-up (antibiotics/curettage of the lesion if necessary).
      Salutations
      Dr Michel Maillette

  13. Mahmoud Ektefaie February 10, 2015

    Feeling of numbness after local anesthesia is being presented as a “major” concern or “side effect” in this video. While not feeling profound numbness immediately after a dental procedure could be desirable, one should weigh the risks and benefits of this approach.

    This technique bears a huge risk of irreversibly damaging roots if one is not careful enough with the orientation of an aggressive bur with a high speed drill. It can also have a limited use in the anterior region (specially in the anterior mandible due to root proximity).

    The major risk here can be minimized by using a similar system such as X-Tip which utilizes a slow-speed drill with a small trephine bur. No irreversible damage can be done by the X-Tip system even if the initial penetration into the cortical bone is directed towards the root. [I have no financial interest in the X-Tip system but as a practicing endodontist I use the X-Tip system safely].

    “Primum non nocere”

    Reply
  14. Kevin Ingham February 11, 2015

    Was his study a double blind controlled trial? In developing the technique trial and error was used. What kind of error was involved? Were there follow-up studies with pre and post radiographs to see if negative consequences to bone developed?

    Stabident and X-Tip have small gauge pilot drills with only end-cutting ability. A surgical length fissure bur does not. Stabident and X-Tip recommend 1/4 carpule of anesthetic due to risks of the intravascular nature of the injection. This technique uses 1/2 to 1 carpule? 4% Prilocaine would be equivalent to double the dose of 2% Lidocaine (though without the epinephrine). Do the risks outweigh the inconvenience of soft tissue anesthesia? Just a few concerns I’m putting out there. Higher success of anesthesia is definitely a plus.

    Reply
  15. N Dickinson February 11, 2015

    Thanks for the video and sharing your experience. This technique seems very similar to the dental col injection technique which works very well without having to drill into the bone with a high speed handpiece. There is lots of information on this technique on Dentaltown. I do routinely anesthetize via infiltration and blocks as I find it simple but have all of these techniques in my back pocket as well. I don’t find that I need the X-tip often but do use it with success on a difficult-to-anesthetize patient. We offer Oraverse for any patient wishing to reverse the effects of local anesthetic but haven’t found many patients interested or needing this.

    I am curious if you’ve assessed the post-operative discomfort with this technique? Also, how much do you administer per tooth and how long do you feel you have profound anesthesia? Do you think that air emphysema could be a possible side effect to your treatment with the use of the high speed handpiece into tissue and bone?

    Reply
  16. Dr Michel Maillette February 18, 2015

    Dr Milan, have you experienced necrosis of the cortical bone with this technique? Because I have used Stabident for many years on a daly basis and it occured that the cortical bone sometimes overeated during the peircing…. Causing occasional swallowing of the injection site and rarely a sequestre (in the mandibular molar vestibular region). I like your technique because it looks fast and the “hole” to inject in is probably easier to find back with the injection needle than with Stabident. But the speed of peircing of the turbine makes me wonder about the necrosis of the cortical bone on the site of injection.
    Salutations Dr M.Maillette

    Reply
  17. Lauren February 24, 2015

    Very interesting information. Thanks for sharing your expertise on this topic!

    Reply

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