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Effective January 1, 2025: ASP+6% reimbursement for EXPAREL when billing with code J0666 across all outpatient surgical settings.

Third-Molar Extractions

This case study represents an individual clinician experience with and methodology for using EXPAREL.

Pacira BioSciences, Inc., recognizes that there are other methodologies for administering local anesthetics, as well as individual patient considerations, when selecting the dose for a specific procedure.

Please see Important Safety Information below and refer to the Full Prescribing Information.

Disclosure: Dr Lieblich is a paid consultant for Pacira BioSciences, Inc.

Background
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CASE INFORMATION
 
Physician Name
Stuart E. Lieblich, DMD
Affiliation
Department of Oral and Maxillofacial Surgery, University of Connecticut
Avon Oral & Maxillofacial Surgery, Avon, CT
Surgical Case Performed
Third-molar extractions
Inpatient or Outpatient Procedure
Outpatient
PATIENT CHARACTERISTICS
 
Gender
Female
Age
19 years
Patient History
and Characteristics
Recurrent lower-right pericoronitis
Pathology
Soft tissue impactions of teeth #1 and #16; partial bony impactions of teeth
#17 and #32
PROCEDURAL DETAILS
 
Incision Size
2-cm sulcular incisions
Preoperative Analgesics Used
Upper Molars
  • 2% lidocaine with 1:100,000 epinephrine for infiltration into the buccal and palatal aspects

Lower Molars
  • 2% lidocaine with 1:100,000 epinephrine for inferior alveolar nerve block and lingual nerve block in the mandible
  • 0.5% bupivacaine HCl with 1:100,000 epinephrine for inferior alveolar nerve block and long buccal nerve block
Intraoperative Analgesics Used
10 mL (133 mg) of EXPAREL (unexpanded)
Dose of EXPAREL and
Total Volume Used
10ml

The recommended dose of EXPAREL for infiltration in adults is based on the size of the surgical site, the volume required to cover the area, and individual patient factors that may impact the safety of an amide local anesthetic. The maximum dose of EXPAREL should not exceed 266 mg. The recommended dose of EXPAREL for patients aged 6 to <17 years old is 4 mg/kg, up to a maximum of 266 mg. The recommended dose of EXPAREL in adults for interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and adductor canal is 133 mg. The recommended dose of EXPAREL in adults for adductor canal block is 133 mg (10 mL) admixed with 50 mg (10 mL) of 0.5% bupivacaine HCl, for a total volume of 20 mL.

EXPAREL can be administered unexpanded (20 mL) or expanded to increase volume up to a total of 300 mL (final concentration of 0.89 mg/mL [ie, 1:14 dilution by volume]) with normal (0.9%) saline or lactated Ringer’s solution.

Bupivacaine HCl (which is approved for use in patients aged 12 and older) may be administered immediately before EXPAREL or admixed in the same syringe, as long as the ratio of the milligram dose of bupivacaine HCl to EXPAREL does not exceed 1:2. Admixing may impact the pharmacokinetic and/or physicochemical properties of EXPAREL, and this effect is concentration dependent. The toxic effects of these drugs are additive and their administration should be used with caution, including monitoring for neurological and cardiovascular effects related to local anesthetic systemic toxicity. Other than with bupivacaine, EXPAREL should not be admixed with other drugs prior to administration.

ASSESSED THE SIZE OF THE SURGICAL SITE AND DEPTH OF TISSUE, THEN PREPARED INJECTION MATERIALS ACCORDINGLY

In this procedure, the panoramic radiograph showed the soft tissue–impacted maxillary third molars and partial bony–impacted mandibular third molars.

Dr Lieblich assessed the surgical sites and determined he would need the following to provide analgesic coverage:

  • 2% lidocaine with 1:100,000 epinephrine for infiltration into the buccal and palatal aspects 2% lidocaine with 1:100,000 epinephrine for inferior alveolar nerve block and lingual nerve block in the mandible 0.5% bupivacaine HCl with 1:100,000 epinephrine for inferior alveolar nerve block and long buccal nerve block
  • 1.7 mL of 2% lidocaine with 1:100,000 epinephrine for infiltration into buccal aspect and 0.2 mL into palatal aspect of each upper third molar
  • 1.7 mL of 2% lidocaine with 1:100,000 epinephrine for each lower inferior alveolar nerve block and lingual nerve block in the mandible
  • 1.5 mL of 0.5% bupivacaine HCl with 1:100,000 epinephrine for each lower inferior alveolar nerve block
  • 0.3 mL of 0.5% bupivacaine HCl with 1:100,000 epinephrine for each long buccal nerve block Dr Lieblich also determined that he would need a total volume of approximately 10 mL of EXPAREL® (bupivacaine liposome injectable suspension) (unexpanded).
panoramic-radiograph

FIGURE 1. Panoramic radiograph

Dr Lieblich also determined that he would need a total volume of approximately 10 mL of EXPAREL® (bupivacaine liposome injectable suspension) (unexpanded).

injection

Dr Lieblich used bupivacaine HCl with epinephrine for the long buccal nerve block because non–bupivacaine-based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. Formulations of bupivacaine other than EXPAREL should not be administered within 96 hours following administration of EXPAREL.

INFILTRATED INTO THE FOLLOWING AREAS USING A 22-GAUGE NEEDLE

Dr Lieblich planned to infiltrate as follows:

mouth

Step #1:

For teeth #1 and #16, Dr Lieblich infiltrated 1.7 mL of 2% lidocaine with 1:100,000 epinephrine into the buccal aspect and 0.2 mL into the palatal aspect.

Step #2:

For teeth #17 and #32, Dr Lieblich administered 1.7 mL of 2% lidocaine with 1:100,000 epinephrine into the inferior alveolar nerve and 1.7 mL into the lingual nerve in the mandible, on each side, to create nerve blocks.

Step #3:

Dr Lieblich infiltrated 1.5 mL of 0.5% bupivacaine HCl with 1:100,000 epinephrine into the inferior alveolar nerve and 0.3 mL into the long buccal nerve, on each side, to create nerve blocks.

injection

Do not administer lidocaine into the soft tissues adjacent to the mandibular third-molar sites where EXPAREL® (bupivacaine liposome injectable suspension) is administered.

Step #4:

After primary closure, Dr Lieblich infiltrated 4 mL of EXPAREL along the lateral aspect of the mandible, on each side, as 4 separate 1-mL injections, for a total of 8 mL. For each injection, the needle was inserted into the base, aspirated, and then 1 mL of EXPAREL was injected as the needle was withdrawn, creating a column effect—ensuring maximum analgesic coverage.

step4-img

FIGURE 4. Lateral aspect of mandible

Step #5:

Dr Lieblich then infiltrated 1 mL of EXPAREL into the buccal aspect of the upper third molars, on each side, for a total of 2 mL.

step5-img

FIGURE 5. Buccal aspect of the upper third molars

PROPER TECHNIQUE IS CRUCIAL FOR ANALGESIC COVERAGE

Dr Lieblich infiltrated EXPAREL® (bupivacaine liposome injectable suspension) into all tissue layers using a moving needle technique. With a moving needle technique, the injections were spread in a fan-like pattern and occurred as the needle was withdrawn to maximize the coverage area. This technique was systematically and meticulously repeated at each injection site, with overlapping diffusion of EXPAREL to ensure there were no gaps in analgesic coverage.

technique
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Important Notice

Indication

EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block. Safety and efficacy have not been established in other nerve blocks.

Important Safety Information

  • EXPAREL is contraindicated in obstetrical paracervical block anesthesia.
  • Adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via nerve block were nausea, pyrexia, headache, and constipation.
  • Adverse reactions with an incidence greater than or equal to 10% following EXPAREL administration via infiltration in pediatric patients six to less than 17 years of age were nausea, vomiting, constipation, hypotension, anemia, muscle twitching, vision blurred, pruritus, and tachycardia.
  • Do not admix lidocaine or other non-bupivacaine local anesthetics with EXPAREL. EXPAREL may be administered at least 20 minutes or more following local administration of lidocaine.
  • EXPAREL is not recommended to be used in the following patient populations: patients <6 years old for infiltration, patients younger than 18 years old for nerve blocks, and/or pregnant patients.
  • Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease.

Warnings and Precautions Specific to EXPAREL

  • Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL.
  • EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and adductor canal block, or intravascular or intra-articular use.
  • The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials.

Warnings and Precautions for Bupivacaine-Containing Products

  • Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression.
  • Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability, which may lead to dysrhythmias, sometimes leading to death.
  • Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients.
  • Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use.
  • Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use.

Please refer to full Prescribing Information.

SEE MORE

EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block. Safety and efficacy have not been established in other nerve blocks.

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