Transcortical anesthesia as a first-line treatment for children: - Rident

Paediatric Odontology
Professional training
E. MOULIS 1 , O. CHABADEL 2 , N. ESCUDERO-PAPOT 2 , M.C. GOLDSMITH 3
Transcortical anesthesia
as a first-line treatment
for children:
Minimal doses for maximum
effectiveness?
Intraosseous anesthesia for a child is an effective
technique, able to be used as first-line treatment or as a
complement for a local or local-regional anesthesia. As a
first-line treatment, intraosseous anesthesia allows an
immediate, painless anesthesia, and by limiting the
anesthesia of the soft tissues it considerably reduces the
risk of post-operative bites, in particular of the lower lip.
However, the use of this technique and in particular
Quick-Sleeper for a child requires carrying out a
preoperative radiographic x-ray, in order to accurately
locate the cortical perforation site, allowing a rigorous
training to optimise the results and to adapt the procedure
to the various clinical situations. Beside these undeniable
clinical advantages for a child, the intradiploic injection of
the anesthetic solution also makes it possible to both
decrease the anesthetic quantity of solution injected, and
to limit the toxicity.
Key words
Anesthesia, children, intradiploic
The improvement of the conditions of local anesthesia for a child
is a permanent research for the pediatric odontologists, and
correctly translates their conception to work in greatest comfort,
without pains and adverse effects. Thus the ideal anesthesia
would be painless, immediate, without failures, without
after-effects (bites, inflammations or necroses) and performed
completely safely. The mastery of the different techniques, the
knowledge of the anatomy and pharmacology on local
anaesthetics and on vasoconstrictors are a prerequisite to the
anesthesia’s success. Moreover, the use of
electronically-controlled injection systems and the realisation of
transcortical or intraosseous injections make it possible today to
still improve the conditions of local anesthesia, avoiding the
failures in more delicate situations of the mandibular molars
and/or in inflammatory stages. In this local anesthesia
optimisation view, the use of Quick-Sleeper represents for the
child or the teenager an undeniable contribution and constitutes
an additional instrument to improve the effectiveness of our
anesthesia, while limiting their toxicity by reducing the quantity of
anesthetic solution injected.
1. University conference lecturer, hospital practitioner, pediatric
odontology, Department of Research and Training in
odontology, Montpellier I, France.
2. Hospital-university assistant, pediatric odontology, Department of
Research and Training in odontology, Montpellier I, France.
3. University Professor, hospital practitioner, pediatric odontology, Department
of Research and Training in odontology, Montpellier I, France.
LE CHIRURGIEN-DENTISTE DE FRANCE I N° 1321 18 OCTOBE R 2007

The pressure allows to the needle to penetrate in the intraseptal
spongy bone. Intraosseous anesthesia in temporary teeth is done
in intraseptal, in mesial or in distal of the tooth to be treated, with
or without needle rotation. Preoperative radiography
examination is imperative in order to visualize the structures
present (Fig. 5 and 6).
In young permanent teeth
The periodontium acquires its maturity and sees its increasing
degree of mineralization, the intradiploic injection then requires
the perforation of cortical by a rotation movement set to the
needle. The choice of injection point meets several criteria, the
first relates to the needle position and orientation. The needle
shall be positioned in order to remain perpendicularly to the
osseous cortical exactly in the tooth middle space, following a
vertical line passing by the papilla (Fig. 7): between 3 and 5 mm
above the collar line at the jawbone and between 2 and 3 mm
under the collar line at the mandible. In order to still improve the
ergonomic conditions, new sites of injection are currently
proposed by the originators of Quick-Sleeper.
Fig. 7: Cortical perforation sites in the upper jaw and mandible. Note the axis
of the needle to the mandible which is rectified into posterior in order to
remain perpendicular to the external oblique line.
The perforation of the cortical bone is performed by a
discontinuous rotation setting of the needle by foot control. The
number of rotations necessary to perforate varies according to
the thickness and osseous mineralization; the number of
rotations at the mandible is higher [22]. Once the perforation is
performed, the operator has the perception, of a low resistance of
the spongy bone. The osseous perforation is atraumatic and
painless, the cortical tissue being non-innervated [7]. The
LE CHIRURGIEN-DENTISTE DE FRANCE I N° 1321 18 OCTOBE R 2007
needle penetration must be from 3 to 4 mm maximum. The
perforation being performed by the needle, it is not possible to
drill a dental root, in the case of a poor evaluation of the injection
point. The recommended needles by the manufacturer are
40/100 th 12 mm and 30/100 th 12 mm needles for temporary teeth,
and the specific Transcort-S needles have an asymmetrical bevel
in order to facilitate the osseous perforation. The installation of a
protective sleeve around the sheath of the needle makes it
possible to avoid the labial or gingival wounds related to the
needle rotation setting.
Intradiploic injection
The intradiploic injection is the last stage, and it is performed
after the perforation of the cortical bone, still by foot control.
The electronically-controlled injection makes it possible to
control the injection speed, and the anesthetic quantity injected.
Particularly in temporary teeth, it is recommended to keep the
speed injection slow in order to avoid any pain. A lighting
indicator and an aural signal make it possible to visualize the
injection of each quarter cartridge.
Finally, a second indicator on the control box gives the
possibility to measure injection resistance, and if resistance is
too great (blocked needle, cortical not perforated or needle in
contact with a dental root), the injection automatically then stops.
Thus, it is appropriate to determine the cause; purge the needle,
repeat the incomplete perforation, or change the perforation site.
The use of Quick-Sleeper, in order to give effective results,
requires training and a regular practice easily making possible to
exceed the few difficulties encountered in its initial uses.
Ergonomics:
The position of the handpiece, in particular in the posterior
sectors is delicate sometimes, because of the need to respect the
perpendicular position of the needle relative to the osseous
cortical. However, the new sites of osseous perforation have a
largely improved accessibility [26].
Perception of the perforation:
The perception of a less osseous resistance associated with the
needle penetration in the spongy bone is sometimes very subtle,
and can go unperceived.
Blocked needle:
During the perforation by the needle rotation, the operator must
imperatively not exert any pressure, with the risk to see the
needle blocked by a cortical stopper and to thereafter prevent the
injection

Table 1: Transcortical anesthesia results obtained with Quick-Sleeper 2 according to the treatment performed.
Teeth Dental care Success Failures Context
Conservative care 8 0
Temporary Pulpotomy 41 3 2 treatments that are too long. 1 fearful child
Avulsion 13 2 2 periodontal impairments (parulis)
Total 61 5
Conservative care 28 3 NAD
Permanent Endodontics 6 1 Extended duration treatment, anesthesia too short
Avulsion 8 2 2 Insufficient lingual anesthesia
Total 41 6
Likewise, after several successive rotations, in the case of thick
cortical bones, the needle can be clogged. In this case, it is
possible to directly purge the needle in the oral cavity of the
patient by a fast speed injection after having retracted the needle
from the bone.
Duration of anesthesia:
The injection of a small quantity of anesthetic (1/2 cartridge) can
limit the duration of the anesthesia. But the injection of a greater
quantity or the use of cartridges containing a 1/100,000 th or
1/80,000 th concentration of vasoconstrictor according to
pathology, make it possible to compensate for this drawback,
and the choice must depend on the supposed duration of the
operational procedure and the local conditions (infection,
inflammation) [15, 22, 23]. The anesthesia obtained by
transcortical injection is immediate, only one injection allowing
the pulpal, vestibular and lingual periodontal anesthesia. The
major advantage for children and in particular the very young, is
the absence of labial mucosa analgesia which sometimes
prevents severe bites. Operational consequences are very few;
however it is necessary to note some episodes of transitory
tachycardia without consequences for the general patient’s state,
because the anesthesia cartridge contains a vasoconstrictor [4, 10,
21, 25].
Lastly, it is necessary to note possible deferred inflammation at
the perforation site, associated with light pains, more frequent at
mandible (3.55% at the mandible against 2.83% at the jawbone)
[22]. The rare contra-indications of the transcortical anesthesia
must be listed: significant alveolus, radicular proximity, or acute
alveolar abscess, infection and inflammation decreasing the
effectiveness of the anesthesia [5, 15].
RETROSPECTIVE STUDY CONDUCTED AT THE
MONTPELLIER UNIVERSITY HOSPITAL
Equipment and methods
The objective of this study was to evaluate the average quantity
of anesthetic solution used to perform transcortical anesthesia by
Quick-Sleeper, for the realization of conventional treatment:
LE CHIRURGIEN-DENTISTE DE FRANCE I N° 1321 18 OCTOBE R 2007
Table 2: Transcortical anesthesia results obtained with Quick-Sleeper 2 according to the treatment
performed presented in the form of percentages.
Teeth Dental care Success Failures
Temporary Conservative care 100% 0%
Pulpotomy 93,2% 6,8%
Avulsion 86,7% 13,3%
Conservative care 90,3% 9,7%
Permanent Endodontics 85,7% 14,3%
Avulsion 80% 20%
conservative care, pulpotomies, pulpectomies or avulsions.
This study involved 97 children, including 54 girls and 43 boys,
ages 4 to 14, treated in the pediatric odontology functional unit
of Montpellier University Hospital, by D3 and Tl students (5th
and 6th years).
113 teeth were concerned, including 66 temporary teeth and 47
permanent teeth. The anesthesia was performed by the same
operator having attended one day of training on transcortical
anesthesia and on the use of Quick-Sleeper. Children affected
with general pathologies or presenting co-operation difficulties
did not participate in the study. The anesthetic solution used was
articaine hydrochloride 4%, with adrenaline at 1/100,000 th . The
average quantities of injected anesthetic solution were 0.67
cartridge for temporary teeth, i.e. about 2/3 of a cartridge, and
0.93 cartridge for permanent teeth. The number of rotations
allowing the perforation of cortical in temporary teeth was 0 or 1,
and in permanent teeth it varied between 1 and 4 according to the
thickness of the cortical bone.
Results
The results are presented in tables 1, 2 and 3. The success rate for
temporary teeth is 92.4%, 87.2% for permanent teeth, i.e., a 90.2%
success rate, and no labial bites were observed.

Table 3: Maximum number of 1.8 ml cartridges with vasoconstrictor for a normal
child [18].
0 to 2 years 1 cartridge
3 to 4 years 2 cartridges
5 to 12 years 3 cartridges
> 12 years 4 cartridges
Two permanent teeth (36, 46) could be extracted in an
inflammatory and/or infectious situation (refractory cellulites
after one week of anti-biotherapy), with the injection of only one
cartridge of anesthetic solution, which confirms the power of
this type of anesthesia.
Finally, the failure analysis highlighted various factors:
- On the one hand the difficulty for certain children to
differentiate feeling and pain, the presence of a symptomatology
(pulpitis or infection, parulis), which would have required a
higher vasoconstrictor concentration (1/80,000 th ).
- On the other hand, certain failures are related to insufficient
duration of the anesthesia correlated with a relatively long
duration of the treatment session, those being performed by
inexperienced student practitioners.
Discussion
To decrease the toxicity of local anesthesias and to limit their
complications remain priorities for pediatric odontologists.
However, the toxicity of the anesthetic solutions is not higher for
a child, because after 2 years, their capacity to eliminate
anesthetic is increased. In contrast, the most current harmful
effect remains the bite associated with the absence of sensitivity
of the soft tissues (lower lip or tongue) [12]. Thus, "small
patient" does not mean "small anesthesia", but there is a
maximum number of 1.8 ml per kilo-weight anesthetic
cartridges that is not to be exceeded [16-18]. The toxicity risks
related to anesthetic overdose can be decreased using
vasoconstrictors. Indeed, they make it possible to decrease the
intravascular passage of the anesthetic solution and ensure the
increase in the duration and depth of the anesthesia by reducing
its systemic effects [14,17].
Thus, the Francophone Society of Oral Medicine and Oral
Surgery recommends the use of vasoconstrictors in children
after 6 months, outside contra-indications, while respecting the
maximum tolerated amounts (table 1). The real
contra-indications of vasoconstrictors: an irradiated bone (40
Gy dose), a pheochromocytoma (adrenal tumour), a cardiac
arrhythmia and an unstable arterial hypertension, are very rare in
children.
LE CHIRURGIEN-DENTISTE DE FRANCE I N° 1321 18 OCTOBE R 2007
The contribution of the cartridges (9 µg of vasoconstrictor in a
cartridge at 1/200,000 th ) is very weak compared to the
endogenous catecholamine release among patients, in the event
of pain, stress or anxiety [14,17]. However, the use of
Quick-Sleeper as a first-line treatment enabled us to perform
care by limiting the maximum number of cartridges of
anesthesia to 0.67 for temporary teeth and 0.93 for permanent
teeth.
These primary results should still be able to be improved by a
broadened clinical practice. In terms of effectiveness, they are
comparable with those of the study undertaken on children from
4 to 16 years old at Rennes University Hospital showing a
transcortical anesthesia success rate higher than 90%, with a
quantity of anesthetic solution injected of 0.45 cartridge on
average (anesthetic solution with adrenaline at 1/200,000 th ) [20].
These are results also comparable with the results obtained by
transcortical anesthesia during previous clinical studies
conducted on adult patients [20].
The results can approach 100% success if we correctly choose
the concentration of vasoconstrictor. However, the practice of
the transcortical anesthesias is still restricted, remaining for
some a complementary technique, used only as a second-line
treatment to improve and reinforce an insufficient mandibular
anesthesia in the posterior sectors [3, 9, 11, 19].
CONCLUSION
Transcortical anesthesia can be used as a first-line treatment for
children and teenagers, for preservation treatment, endodontic
treatment, and for the avulsions, of temporary or permanent
teeth. It can be used for asymptomatic teeth but also for
symptomatic teeth (pulpitis, infections). In the same way,
transcortical anesthesia can be used as a second-line treatment,
in situations where the loco-regional (mandibular nerve block)
anesthesia is insufficient. The use of this technique for a child,
easily accepted and relatively simple, after a training period, is
incontestably a new tool in the pediatric odontology therapeutic
arsenal. It makes it possible to limit the amounts of injected
anesthetic solution and the complications of local and regional
anesthesia, in particular labial self-bites in the youngest children.
Forthcoming studies will make it possible to still improve the
effectiveness, the choice and the management of the quantities
of anesthetic solution injected, based on the different clinical
situations.

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