Pain sensations associated with dental diseases are among the most intense. Although dental treatment is intended to relieve pain, the process itself is often associated with significant discomfort. Effective pain management serves as the cornerstone determining the quality of any therapeutic or surgical intervention in dentistry.
Modern progress in the dental industry is largely driven by the introduction of innovative tools and techniques that allow for lengthy and invasive manipulations in the oral cavity with minimal patient discomfort. In the early 1990s, a significant leap occurred in the equipment of dental offices: the market was actively developing, saturated with advanced units, instrumentation, as well as high-quality filling and endodontic materials. Simultaneously, complex yet highly effective and aesthetically perfected technologies began to be widely used. The implementation of such methods required impeccable local anesthesia, capable of providing reliable and complete pain relief for all types of dental interventions.
Thus, highly effective and safe pain relief has become an indispensable condition for providing top-quality dental care. The effectiveness of anesthesia directly depends on the choice of anesthetic, the subtleties of its administration technique, the injection instruments used, and the selected routes of administration. Among the variety of local anesthesia methods, the most common are topical, infiltration, and conduction anesthesia. As an alternative to infiltration and conduction anesthesia, intraosseous dental anesthesia (also known as spongiosal) is proposed, in which the anesthetic solution is injected directly into the spongy bone substance or the alveolar process, located between the roots of the teeth.
The origins of intraosseous dental anesthesia date back to 1891, when the Norwegian physician Otte performed the first intraosseous dental injection of a cocaine solution. The procedure involved perforating the cortical plate of the mandible using a bur. Researchers from England and the USA attribute the pioneering work to their compatriots A. S. Parrot (1910) and G. N. Hein (1906). French scientists, in turn, believe that the author of the method in 1907 was their compatriot, Dr. Nogui.
The technique described by Nogui under the name “transcortical anesthesia” turned out to be identical to Otte’s method. The term “transcortical anesthesia,” used by French specialists, fully corresponds to the Russian concept of “intraosseous anesthesia” and accurately reflects the process of the needle penetrating through the cortical plate. Various methods for perforating the cortical plate were proposed to ensure the anesthetic’s access to the spongy bone tissue (illustrated in Fig. 1).
The technological process for performing intraosseous dental anesthesia involves preliminary anesthesia of the bone puncture site using the infiltration method, followed by an incision of the mucous membrane, and then trepanation of the bony cortical plate using a small-diameter bur at low speed. The perforation is performed either above the interdental papilla (on the upper jaw) or below it (on the lower jaw), in the vertical plane, dividing the interdental papilla into two equal parts. The perforation point is located 2 mm below the gum level of the adjacent teeth. The bur is inserted into the spongy substance of the interdental septum at a 45-degree angle to the longitudinal axis of the tooth, to a depth of up to 2 mm.
After creating the channel, the needle is inserted into the spongy bone tissue in the area of the interdental septum. Moderate force is required to advance the needle 1-2 mm deep (which is easier with youthful bone tissue and more difficult with its sclerotic changes). Then, from 0.5 ml of a strong anesthetic solution to 1.5 ml of a weak solution is slowly injected. This process instantly provides pronounced anesthesia of the adjacent teeth.
It is critically important that the diameter of the bur and the needle match to prevent the anesthetic from leaking back into the oral cavity.
A fundamental study of the mechanism of action of intraosseous dental anesthesia was conducted by A. Zh. Petrikas (during the periods of 1974, 1983, 1997). His comprehensive clinical, histological, and radiological research allowed for the formation of a detailed understanding of the process. One direction of the local anesthetic’s spread involves its diffusion through the medullary spaces of the interdental septum and the periapical area. Another pathway involves the penetration of the solution into the vascular bed through the same spaces.
The method of intraosseous dental anesthesia did not gain widespread use previously due to technical difficulties associated with the imperfection of the needles and injectors used. The emergence of new injection systems and computer-controlled injectors has revived interest in this method of anesthesia. Starting in 2006, automated injectors such as the Quick Sleeper, equipped with needles featuring asymmetric sharpening designed for various types of anesthesia, including intraosseous, have been actively used in dental practice. Special needles with an offset center and a cutting lateral surface were developed for this injector, facilitating their penetration into soft tissues and perforation of the cortical plate. The use of computer-controlled syringes, such as the Quick Sleeper, has significantly simplified the technique of intraosseous dental anesthesia.
The use of intraosseous dental methods with computer-controlled injectors requires careful selection of the local anesthetic, its dosage, an understanding of its distribution pathways in the tissues, as well as the onset time and duration of the anesthetic effect. The electronic Quick Sleeper system (developed by Dental Hi Tec, France) significantly facilitates the performance of intraosseous dental anesthesia, thereby simplifying the dentist’s daily work. The exclusive PAR system (Permanent Analysis of Resistance) ensures uniform administration of the anesthetic, regardless of tissue density, and eliminates the risk of cartridge breakage. The use of this technique makes even the most complex clinical situations significantly easier.
The system’s configuration includes a main unit, a pedal for controlling anesthetic delivery and performing the aspiration test, as well as an injector in the shape of a pen with a cartridge for a standard anesthetic carpule and a disposable needle. Penetration of the cortical plate is carried out as part of a single-stage anesthesia procedure. Electronic control of the perforation and injection parameters prevents painful administration. The pen-like shape of the injector eliminates the need for applying additional force during insertion. Unlike other devices, this system does not require special consumables or component replacement, which reduces the overall cost of procedures. Due to the development of this technology, intraosseous dental anesthesia has received a new name – transcortical. The essence of the method lies in penetrating through the cortical plate and administering the anesthetic in close proximity to the tooth requiring treatment. The procedure is simple and takes minimal time, as treatment can begin immediately after the injection. The Quick Sleeper system offers two pre-programmed anesthetic delivery speeds, ensuring an optimal regimen for each clinical case. An additional ‘low’ mode is intended for anesthetizing particularly sensitive areas, such as the lingual frenulum, or for working with children. Injections are performed under continuous control, are easy to execute, painless, and atraumatic, allowing the doctor to focus solely on the injection site.
In one publication, the author, using iCATvision software, investigated the depth of needle insertion during intraosseous dental anesthesia in various areas of the maxillary and mandibular apparatus, establishing the optimal puncture depth for each site. Other researchers studied conduction and intraosseous dental anesthesia using anesthetics containing articaine.
Intraosseous dental anesthesia is characterized by a faster onset of analgesia (30-60 seconds) compared to conduction anesthesia (2-5 minutes), allowing treatment to begin immediately after the injection. Administration of 1.7-2.5 ml of Ultracain D-S anesthetic using the conduction method provides analgesia for 40-60 minutes. At the same time, an intraosseous injection of 0.2-0.4 ml of Ultracain D-S produces an analgesic effect for 25-40 minutes. Direct proof of the anesthetic’s introduction into the vascular bed is the fact that in almost all cases, when performing aspiration, blood was detected in the syringe – either as noticeable traces or (more often) in significant quantities. Negative aspiration also indicates a not entirely successful perforation, meaning the needle did not enter the bony crypt, and sometimes the impossibility of performing the anesthesia. Thus, achieving an analgesic effect with an intraosseous injection requires smaller doses of the anesthetic solution compared to conduction methods, which allows for the recommendation of intraosseous dental anesthesia for patients in the anesthesiological risk category.
During conduction anesthesia, besides blocking the inferior alveolar nerve, simultaneous blockade of the lingual and buccal nerves occurs. Intraosseous anesthesia does not affect the lingual and buccal nerves, which excludes the sensation of soft tissue numbness in the cheek and tongue. Dynamic monitoring of blood pressure indicators during conduction and intraosseous anesthesia did not reveal statistically significant differences.
Intraosseous dental anesthesia can be successfully used both as an additional and as a primary method of anesthesia in outpatient dental practice. The instantaneous speed of onset of the effect allows for the immediate initiation of therapeutic procedures. Effective anesthesia using minimal doses of anesthetic makes this method particularly valuable for patients belonging to the anesthesiological risk group.
Intraosseous dental anesthesia provides a short-term effect without the customary numbness of the cheeks, lips, and tongue. The anesthetic is capable of clinically significant diffusion to the nerves only when blood flow in the venous plexus is severely impaired and/or when it enters the arterial bed. This approach is considered one of the most suitable for performing tooth extractions. The main advantage of intraosseous dental anesthesia is the almost instantaneous onset of analgesia, with cases of ineffectiveness being extremely rare. Nevertheless, it should be remembered that intraosseous dental anesthesia is contraindicated in the presence of periodontal pockets with purulent contents.
In the area where the anesthetic solution is administered, changes in the bone tissue structure are observed, manifested by an expansion of the medullary spaces by 1.5-2 times compared to the initial state, which provides an understanding of the zone of anesthetic spread in the bone tissue. The volume and area of anesthetic spread depend on the density of the bone tissue. If prolonged treatment (more than 40 minutes) is necessary, repeated intraosseous administration of the anesthetic may be required.
Intraosseous methods of anesthesia possess significant potential for achieving highly effective and safe results, which is facilitated by the use of modern computer-controlled injectors.
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