Data supporting the use of supplemental Local Anaesthetic within Oral and Maxillofacial surgery under General Anaesthetic

1. Supplementary LA to
GA in Oral and
Maxillofacial surgery
inter & post operation
implications
Lau Tung Hin
Muchara Mahachi
Matthew Sin
University of Dundee, Dental Surgery

2. Oral & Maxillofacial Anesthesia
A general concept
– GA is chosen anesthesia for cosmetic and functional maxillofacial surgery in
the United Kingdom (Beck & Johnston, 2014) and also paediatric dental
treatment
– Some countries apply supplemental/infiltrated LA in OMFS surgical
procedures under GA, such as Hong Kong (Fung, 2020)
– Still a highly debated topic
H0 (1): Interoperative use of LA under GA improves interoperative surgical management
H0 (2): Interoperative use of LA under GA reduces postoperative physiological response.
Ha (1): Interoperative use of LA under GA has no effect on interoperative surgical management
Ha (2): Interoperative use of LA under GA has no effect on postoperative physiological response.
Hypothesis
Null hypothesis

3. Strategy of research
bibliographic search on various databases, no date/time limitations
language restrictions to English only
Keywords/MeSH terms: "LA", "GA", "nerve block” … etc
Title/abstract terms "oral surgery, maxillofacial surgery, orthognathic
surgery, Le Fort, osteotomy, dental extraction, glossectomy,
pharyngectomy ... etc"
5 studies
PubMed, Google Scholar

4. Anesthetics, a review
General Anesthetics GA
– Reversable, drug induced suppression
of the central nervous system (Milam,
1984)
– Narcotic analgesic, muscle relaxer,
hypnotic agent (Fung, 2019)
– Post-operative side effects: Prolonged
drowsiness, amnesia, shivering,
breathing difficulty, nausea and
vomiting. (NHS, 2020 )
Local Anesthetics LA
– Common LAs used in dentistry:
– Lidocaine
– Articaine
– Mepivacaine
– Some may contain
vasoconstrictors, such as epinephrine
or levonordefrin (Sisk, 1992)
– Preferred method for dental surgical
procedures, producing nerve blocks

5. GA with supplemental LA
Implications and mechanisms
Intra-operative
– Stabilize vital signs (Townsend et al 2014,)
– ↓sympathetic tone, vasoconstriction,
– ↓ surgical site bleeding, ↑ interoperative
visibility (Espitalier et al, 2011)
– ↑ ease of soft tissue handling in
surgery (De Verbizier et al, 2019)
– Decreased cost of anaesthesia (Goktas et
al, 2011)
Post-operative
– ↓ postoperative pain (Plantevin et al,
2007)(Espitalier et al, 2011)(Nobel et al,
1994)(Sammons et al, 2007) (Atan et al, 2004),
– ↓ nausea (Atan et al, 2004)
– ↓ postoperative anxiety (Nobel et al, 1994)
– ↓ in-patient recovery time, ↓ postoperative
care (Fung, 2019)
Preferred method for OMFS major surgeries (e.g. orthognathic surgery) in HKHA
Add LA intraoperatively, GA narcotic analgesic part trimmed/reduced (Fung, 2019) (Plantevin et al
2007) (Townsend et al 2014,)

6. GA with supplemental LA
Literature dataStudy and surgery type Postoperative
Pain Score
Distress/Anxiety at
discharge
Interoperative
Surgical Field Dryness
Interoperative
Bleeding Score
Espitalier et al 2011
Sagittal split mandibular
osteotomy
(MNB vs
Bilateral cutaneous puncture)
LA GA 0 [0-2], NRS n/a 29% 20 [0–40]
GA 3 [1-5], NRS n/a 5% 55 [20–80]
Atan et al 2004
Restoration, dental extractions,
surgical procedure with muco-
periosteal flap raised
(2% lignocaine with adrenaline vs nil)
LA GA 0 , Odds
Ratio
0, Odds of
pain
n/a n/a n/a
GA 39, Odds
Ratio
15, Odds of
pain
n/a n/a n/a
Noble et al 1994
Dental extraction
(Prilocaine vs nil)
LA GA n/a n/a 18 (8.0), mean VAS n/a n/a
GA n/a n/a 23 (5.6) mean VAS n/a n/a
Sammons et al 2007
Dental extraction
(2% lignocaine with adrenaline vs nil)
LA GA 0 [0-1], TPPPS n/a n/a n/a
GA 0 [0-5], TPPPS n/a n/a n/a
Plantevin et al 2007
Partial glossectomy, Transmandibular
lateral pharyngectomy.
(MNB vs Saline)
LA GA 3 (VAS > 7), VAS n/a n/a n/a
GA 10 (VAS > 7), VAS n/a n/a n/a
NRS: numerical rating scale
VAS: Visual analog scale
TPPPS: Toddler-Preschooler
Postoperative Pain Scale:

7. GA with supplemental LA
Conclusion
– Based on the results of the 5 studies
– Varying levels of statistical and clinical differences between LA+GA and GA
alone
– LA improves interoperative surgical management and reduces postoperative
physiological response
– Generally shows an improved inter/post- operative outcome with supp. LA to
GA
– There is literature that supports the use of supp. LA with GA

8. GA with supplemental LA
Evaluation of research
– Bias in GA&LA clinical trials
– Pain scores: subjective
– Different studies also use different scales for pain scores (i.e. TPPPS, NRS)
– “screw-you-effect”/negative-participant role, patients in pain may give inaccurate results
– Surgeries are case by case
– Insufficient clinical trials
– Larger sample should be tested
– More high quality RCTs needed

9. References
– Atan, S., Ashley, P., Gilthorpe, M., Scheer, B., Mason, C., & Roberts, G. (2004). Morbidity following dental treatment of children under intubation general
anaesthesia in a day-stay unit. International Journal Of Paediatric Dentistry, 14(1), 9-16. doi: 10.1111/j.1365-263x.2004.00520.x
– De Verbizier, C., Denis, F., Moussa-Badran, S., Sébastien, L., & Clara, B. (2019). Pilot study in France about the infiltration of local anaesthetics associated
to oral surgery procedures performed under general anaesthesia. Journal Of Oral Medicine And Oral Surgery, 25(2), 13. doi: 10.1051/mbcb/2018041
– Espitalier, F., Remerand, F., Dubost, A., Laffon, M., Fusciardi, J., & Goga, D. (2011). Mandibular nerve block can improve intraoperative inferior alveolar
nerve visualization during sagittal split mandibular osteotomy. Journal Of Cranio-Maxillofacial Surgery, 39(3), 164-168. doi: 10.1016/j.jcms.2010.04.015
– Fung, SC. (2019, August 16). Personal interview.
– Goktas, U., Isik, D., Kati, I., Atik, B., & Soyoral, L. (2011). Effects of lidocaine infiltration on cost of rhinoplasty made under general anesthesia. The Journal
of craniofacial surgery, 22(6), 2176–2178. https://doi.org/10.1097/SCS.0b013e318232414c
– Milam S. B. (1984). General anesthetics: a comparative review of pharmacodynamics. Anesthesia progress, 31(3), 116–123.
– National Health Service. (2020). General anesthesia. Retrieved from https://www.nhs.uk/conditions/general-anaesthesia/
– Noble, D.W., Raab, G.M., MacLean, D., MacLachlan, D. (1994). Prilocaine Infiltration as Postoperative Analgesia for Children Having Dental Extractions
Under General Anesthesia Regional Anesthesia. The Journal of Neural Blockade in Obstetrics, Surgery, & Pain Control, 19, 126-131.
– Plantevin, F., Pascal, J., Morel, J., Roussier, M., Charier, D., Prades, J.-M., … Molliex, S. (2007). Effect of mandibular nerve block on postoperative
analgesia in patients undergoing oropharyngeal carcinoma surgery under general anaesthesia. British Journal of Anaesthesia, 99(5), 708–712. doi:
10.1093/bja/aem242
– SAMMONS, H., UNSWORTH, V., GRAY, C., CHOONARA, I., CHERRILL, J., & QUIRKE, W. (2007). Randomized controlled trial of the intraligamental use of a
local anaesthetic (lignocaine 2%) versus controls in paediatric tooth extraction. International Journal Of Paediatric Dentistry, 17(4), 297-303. doi:
10.1111/j.1365-263x.2007.00832.x
– Townsend, J., Hagan, J., & Smiley, M. (2014). Use of Local Anesthesia During Dental Rehabilitation With General Anesthesia: A Survey of Dentist
Anesthesiologists. Anesthesia Progress, 61(1), 11-17. doi: 10.2344/0003-3006-61.1.11
– Oral & Maxillofacial Surgery | Smile Stylers Blog. (2020). Retrieved 6 March 2020, from http://smilestylers.net/blog/?p=182