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Introduction
In the clinical stomatological praxis nowadays, two long-acting effect
anesthetics are used - bupivacaine and etidocaine. These long-acting effect
anesthetics usually enable painless stomatological as well as surgical work in
mandibula. However, it is not the case with maxillofacial surgery, since these
anesthetics provide neither painless work nor a long lasting postoperative
efficiency.1 The vasodilatation effect of the above mentioned anesthetics is
familiar, so, due to this fact, vasoconstrictor is added to them in order to
improve their anesthetic characteristics as well as to secure the controllable
hemostasis on the very spot of injection.2 The problem of intensified bleeding
is noticeable in operations demanding the removal of a larger part of the soft
or bony tissue (for example, spongiosus bony tissue). In addition, a larger
residual postoperative space may as well come into being enabling postoperative
hemorrhage out of the remaining part of the tissue (maxillary sinus). When the
certain orally surgical operations are carried out, the pain is usually the most
intensified as the anesthesia loses its effect, so, it is usually alleviated by
non steroidal antiinflammatory medications.3
Ropivacaine is a local anesthetic of amid type with the outstanding long-acting
effect and it is chemically similar to bupivacaine and mepiva-caine.4 It is
introduced into clinical praxis in 1996.5 Furthermore, ropivacaine has a
vasodilatation effect, which makes it a unique local anesthetic suitable for
work, as it lessens both intraoperative and postoperative bleeding
respe-ctively.6
The application of ropivacaine has not been described in orofacial surgery so
far. Therefore, this paper deals with the application of 0,75% of ropivacaine as
a local anesthetic in the maxillary sinus (MS) surgery with oroantral
communication, and a root deeply pressed into the sinus.
Case Report
A female patient, M. S. born in 1950 according to her dentist's referral form,
after the unsuccessful tooth extraction 6/, was admitted at the oral surgery
department of the Clinic of Stomatology in Nis. Anamnesis data revealed that in
the course of the tooth removal the opening of the maxillary sinus took place as
well as the pressure of the root into the sinus.
A positive Luc-Caldwell test was determined by the clinical examination, whereas
a careful probing of the surface wound confirmed oro-antral communication (OAC)
in mesio-buccal tooth socket 6/. Both retroalveolar and ortho-pantomographic
x-ray proved the existence of OAC, as well as the retained root in the maxillary
sinus. The x-ray of certain paranasal cavities showed no inflammatory disease of
mucous membrane. As there weren't any local and medical surgical
contraindications causing the postponement of the operation, a revision surgery
of the maxillary sinus and the extraction of the pressed root were carried out
on the same day. The operation was performed under local anesthesia with 5ml
0,75% of Naropine® (ropivacaine) (Astra Zeneca, Sweden). The anesthetic of 2 ml
was respectively used for both, conduction infraorbital and tuber anesthesia,
whereas only 1 ml of anesthetic was used for the terminal anesthesia of gingivae
on the palatal side. The operation lasted 45 minutes, without any complications.
After the operation, the patient said that she hadn't felt any pain during the
whole process. Bleeding was as expected, that is, there was no bleeding which
would aggravate the operation or endanger the patient. The patient was dismissed
for health care on the same day and some appropriate advice concerning her
further behavior was given as well. The following day, when the patient was
referred for the regular check up and the dressing of the operative wound, she
rendered a piece of information - that the numbness of the operative region had
lasted about 4 hours after the operation itself.
Discussion
Ropivacaine is new and the first amid anesthetic with a long-lasting effect,
which is at the same time a pure S- enantiomer. This kind of “S” configuration
enables less cardiotoxic effect in relation to some similar anesthetics having
“R” configuration as well bupivacaine.7 Ropivacaine has become popular in the
surgery praxis, after the death report of accidental, unconscious intravein
injection of bupivacaine. Since then, bupivacaine had been used as a standard
local anesthetic with a long-lasting effect.8
In stomatology, ropivacaine has started to be used in a recent past, while there
are no data confirming its use in either oral or maxillary surgery. The reasons
for the use of the ropi-vacaine in the surgery of maxillary sinus were manifold.
The first reason was to examine the possibilities of the use of new anesthetic
in the anatomic region which primarily demands working under general anesthesia
(due to pain occurring during the operation). The published data revealed that a
successful infiltration in maxilla was possible2, which is in turn con-firmed by
the painless work in the described case. The successful anesthesia during the
operation performed in the case of MS was expected, since ropivacaine is used as
a local anesthetic in the surgery of skin, for the epidural block as well as for
the peripheral nervous block, for the surgical anesthesia (the operation of
herein, breast reconstruction, orthopedic operations, urological operations),
for epidural block for the post-operative analgesia (after the operations in the
abdominal surgery) and for the epidural block in gynecology.9 In the course of
operation performed on MS as well as after the operation itself, bleeding from
the operative field is possible, which in turn may slower operation and, in some
cases, aggravate the patient. Therefore, the aim of this paper is to establish a
hemostasis using 0,75% of ropivacaine, which enabled normal work during the
operation. Furthermore, the patient was not in danger as far as bleeding was
concerned. This kind of vasoconstrictor effect of ropivacaine has been
described, so, nowadays ropivacaine presents the only local, long-acting effect
anesthetic having vasoconstrictor effect.6 Pain may be present in the standard
surgical praxis, during the post-operative period, due to the massing of
inflammatory mediators.3 In the described case, after the application of
ropivacaine, there was no need for analgetics as the post-operative anesthesia
lasted for 240 minutes, which enabled analgesia and annulated negative
(painful) effect of inflammatory mediators. The lasting effect of this
anesthesia was recorded as well in the previous researches.4
The overall impression is that the use of ropivacaine as a local anesthetic for
infiltration anesthesia in the surgery of maxillary sinus with oroantral
communication and root pressed into sinus showed to have been rather successful.
The achieved anesthesia using ropivacaine enabled painlessness during the
operation and with usual bleeding, whereas post-operative anesthesia lasted long
enough to prevent the co-nsumption of analgetics.
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