Techniques of local anaesthesia

1/Preparation for injection:

.patient is fully supine. This provides excellent return of blood
from legs to the heart and the brain.
.right -sided operators will deliver most injections from the right
side of the patient.Ex:R-inf alveolar n block/R-greater palatine
NB/R-lingual infiltrations.
. Use anesthetic cartridge and syringe
with temperature as close to room
temperature as possible to avoid sudden injection and enhance
patient comfort.
.scaling/cleaning the site of injection/dried/use of non irritant
antiseptic solution/apply topical anesthesia just to the site of
injection.

.
 Basic procedures during injection
.Communicate with the patient.
. Establish a firm hand rest.
. Make the tissue taut.
. Keep the syringe out of the patients line of sight.Insert the
needle into the mucosa.
.Watch and communicate with the patient.
.Slowly advance the needle toward the target.
. Deposit several drops of local anesthetic before touching
the periosteum.
. Aspirate.
a.Slowly deposit the local anesthetic solution,1.8 requires 2
minutes.
. Slowly withdraw the syringe. Cap the needle and discard.
. Observe the patient after the injection.
 Techniues of local anaethesia
TOPICAL ANAESTHESIA
It is the application of ointments or solution
containing L.A agent to an accessible
structures e.g skin or mucous membrane .
Topical anaesthesia has a limited effect on the
free nerve endings
INFILTRATION ANAESTHESIA:
Infiltration anaesthesia is produced when the terminal nerve endings is flooded by the
L.A solution

Soft tissue infiltration

According to depth of penetration.
submucosal.
paraperiosteal.
subperiosteal. No need as it cause pain.
.Bony infiltration.
intra osseous special needle to drill.
Inter septal needle inserted into interseptal bone.
NERVE BLOCK ANAESTHESIA:
The L.A solution is deposited in
close proximity to the main nerve
trunk supplying the operative field
 Factors affecting choice of local
anaesthetic technique
1.Area to be anesthetized.
depending on density of bone.
2.Extent of surgical procedure.
multiple extractions,nerve block anaesthesia is preferable.
3.Profoundness and duration required.
4.Age of patient (dense bone)
5.Hemostasis local infiltration is recommended.
6.Presence of infection.
7.Skill of the operator.
Maxillary injection technique
 Labial and Buccal infiltration

Indication:
pulpal anesthesia for one or two maxillary teeth
and soft tissue surrounding them
.contraindications:
.infection or acute inflammation.
.dense bone covering a the apices of the tooth.
Procedure:
Needle should be 45 degree with long axis of the
tooth and inserted at the height of mucobuccal fold 3-5 mm. over the tooth/bevel facing bone.
When meet resistance withdraw slightly.
Aspirate then deposit
o.6ml slowly
over 20 sec.
Slowly withdraw the
needle.
Wait for 3-5 min before
starting the
procedure.
 area anesthesised by labial
infiltration:incisor and
canine pulp, as well as the
vestibular fold, the labial
gingiva, the periosteum and
the bone
Signs and Symptoms
1. Subjective: feeling of
numbness in the area of
administration
2. Objective: absence of
pain during treatment
Palatal injection:
Traumatic experience for patient with complains of
extreme pain while performing anesthesia.
This can be reduced by
applying topical anesthesia
pressure anesthesia
slow deposition of anesthetic
The point of insertion of the needle is on the palatal side of the
tooth, midway between the cervical margin of the tooth and
the midline of the palate.
The needle should be at right angel with the palate (it should
be advanced from the opposite side), 0.2 to 0.3 ml. of the
anesthetic solution is injected slowly.
NB. Injection of large amount of the solution may cause
sloughing and ulceration of the palatal mucosa due to
separation of a large area of the dense palatal mucoperiosteum
from the bone with subsequent loss of its blood supply
 maxillary nerve block anesthesia:
Infra Orbital N.B:
Indications:
Treatment procedures involving two or more maxillary anterior teeth
If supraperiosteal is contraindicated
If supraperiosteal is proven ineffective
Contraindications:
Discrete areas
Local hemostasis needed.
Advantages
simple
Minimize number of injections
Minimize volume of local anesthesia used
Disadvantages
Psychological
Difficulty in defining landmarks
Area anesthetized:
Pulp of maxillary central incisors to canine, in 72 % maxillary
premolars and mesiobuccal root of 1st molar, buccal periodontium
of
same teeth
Lateral aspect of nose, lower eyelid, and upper lip
Procedure:
1 Locate infraorbital notch at infraorbital margin.
Move finger downwards>> convex feeling is roof of foramen >>
further downwards concave feeling is Infraorbital foramen
pulpated
on face.
2 index finger held over the foramen/thumb of the sane hand is
placed in the mucobuccal fold/cloed mousth/lip retraction
3 5 mm out from the fold to span the canine fossa.
4 Insert needle at height of mucobuccal fold over 2st premolar with
needle held parallel to long axis of tooth till 16 mm depth and
5 Aspirate.
n. Slowly deposit 0.9 to 1.2 ml (over 30 to 40 seconds).

Signs and Symptoms

1. Subjective: tingling and numbness of the lower eyelid,
side of the nose, and upper lip indicate anesthesia of
the infraorbital nerve
2. Subjective and objective: numbness in the teeth and
soft tissues along the distribution of the ASA and MSA
nerves (developing within 3 to 5 minutes if pressure is
maintained over the injection site)
3. Objective: no pain during dental therapy
Complications:
.Carful steralization/never use when infection present.cavernous sinus thrombosis may occure.
.trauma to the vessels can cause unsightly bruising of the skin which may take as long as 10-14
days to rresolve.
.diplopia due to analgesia entering orbit.
 Posterior-superior alveolar nerve block
Indications
1. When treatment involves two or more maxillary molars
2. When supraperiosteal injection is contraindicated
(e.g., with infection or acute inflammation)
3. When supraperiosteal injection has proved ineffective
Contraindication. When the risk of hemorrhage is too
great (as with a hemophiliac), in which case a
supraperiosteal
or PDL injection is recommended
Area anesthesised:
Pulp of maxillary 3rd, 2nd and 1st molar ( entire tooth in 72%
and
mesiobuccal root not anesthesised in 28 % as it may be supplied
by
MSAN)
Procedure:
Insert needle at height of mucobuccal fold over 2nd Molar .
Advance upward (45 degrees to occlusal plane), Inwards
(medially at
45 degrees to occlusal plane) and backwards ( at 45 degrees to
long
axis of 2nd molar )
long needle is
recommended.
The left index is moved over the
mucobuccal fold in a posterior
direction from the premolar region till
it reaches the zygomatic process till it
rests on a concavity in the mucobuccal
fold. The finger is rotated so that fingernail
faces medially. Then the finger is
moved to be at right angle to the
maxillary occlusal plane and at 45
angle to the sagittal plane.

The needle is inserted into the

height of mucobuccal fold over
the second molar in a line parallel
to the finger
 Middle superior alveolar nerve
Present in 28 % of population
Indication:
When infraorbital block fails
Area anesthesised:
Pulp of maxillary 1st and 2nd premolar and mesiobuccal root
of 1st molar
Procedure:
Insert needle at height of mucobuccal fold over 2nd
premolar .
Advance till tip of needle reach well above the apex of 2nd
Premolar
Aspirate
Slowly deposite 0.9 to 1.2.
Signs and Symptoms
1. Subjective: upper lip numb
2. Objective: no pain during dental therapy
Complications (rare). A hematoma may develop at the
site of injection
 Nasopalatine nerve block
Indications
1. When palatal soft-tissue anesthesia is
necessary for
restorative therapy on more than two teeth
procedures involving palatal soft and hard
tissues
 Areas anesthetized:
The areas palatal gingiva and mucosa from the
maxillary canine on the right to the
maxillary canine on the left side of the maxilla.
Both the right and left nasopalatine nerves
in close proximity
Oral mucosa in this region is tightly adhered to the
hard palate; thus deposition of
anesthetic in the area has less space to diffuse
 Procedure:
Use a cotton swab applicator to apply pressure to the injection
site
Insert the needle into the palatal mucosa lateral to the incisive
papilla parallel to the labial alveolar plate.
Deposit a small amount of anesthetic to help anesthetize the
papilla
Advance the needle in incisive canal between the central
incisors making 45 degree with the palatal mucosa 4 mm
penetration depth.
Withdraw the needle slightly and perform aspiration
After a negative result on aspiration, very slowly inject 0.3
of anaesthesia.
 Contraindications
1. Inflammation or infection at the injection site
2. Smaller area of therapy (one or two teeth)
Advantages
1. Minimizes needle penetrations and volume of solution
2. Minimal patient discomfort from multiple needle penetrations
Disadvantages
1. No hemostasis except in the immediate area of injection
2. Potentially the most traumatic intraoral injection.
Positive Aspiration. Less than 1%
Multiple needle penetration
First injection at labial frenulum ,0.3 ml
Second injection labial aspect of papilla between central incisors
Third injection if second injection has failed then to lateral
aspect of
insicive papilla 45 degree to it deposite 0.3 ml.
 Greater palatine nerve block:

Indication:
Dental procedures involving palatal soft tissues distal to canine.
Area anesthesised:
Posterior part of hard palate and overlying soft tissue till 1st
premolar
anteriorly and medially midline.
Procedure:
Path of insertion from opposite aside of the mouth at a right
procedure:
Locate the greater palatine foramen by using a cotton swab
applicator to press
down on the tissue in the region of the 1st maxillary molar,
moving posteriorly
until the swab dips into the tissue (usually posterior to the 2nd
maxillary molar)
 Locate the greater palatine foramen by using a cotton swab applicator to press
down on the tissue in the region of the 1st maxillary molar, moving posteriorly
until the swab dips into the tissue (usually posterior to the 2nd maxillary
molar)
Use a cotton swab applicator to apply pressure to the injection site
Insert the needle and inject a small amount of anesthetic to lessen patient
discomfort; the tissue of the area will begin to blanch from the effects of the
anesthetic agent
Advance the needle until it contacts the hard palate
Withdraw the needle slightly and perform aspiration
After a negative result on aspiration, slowly inject 0.5 of anasthesia.
Signs and Symptoms
1. Subjective: numbness in the posterior portion of the
palate
2. Objective: no pain during dental

Complications
2. Ischemia and necrosis of soft tissues when highly
concentrated vasoconstricting solution used for hemostasis
over a prolonged period
their soft palate
becomes anesthetized
Mandibular Injections
 INFERIOR ALVEOLAR NERVE BLOCK
Indication: Procedures on multiple mandibular teeth in one
quadrant
Areas anesthetized:
All mandibular teeth (inferior alveolar nerve)
Epithelium of the anterior 2/3rds of the tongue (lingual
nerve)
All lingual gingiva and lingual mucosa (lingual nerve)
All buccal gingiva and mucosa from the premolars to the
midline (mental nerve)
Skin of the lower lip (mental nerve)
 IANB TECHNIQUE
3 IMPORTANT PARAMETERS TO
CONSIDER:

1) Height of the injection

2) Anteroposterior placement of the needle tip

3) Depth of needle penetration

 Height of IANB Injection

Place the index finger in the coronoid notch

Imaginary line should be parallel with the occlusal plane
6-10 mm above the occlusal plane
Finger on the coronoid notch pulls the tissues taut
Needle insertion is 3/4th the distance from the coronoid
notch back to the deepest part of the pterygomandibular
raphe
Needle tip gently touches the most distal aspect of the
pterygomandibular raphe
 Anteroposterior Site of Injection

Needle penetration occurs at intersection of 2

lines:
line1: a horizontal line from the coronoid notch to
the deepest part of the pterygomandibular raphe as
it ascends vertically toward the palate

line 2: a vertical line through line 1 about 3/4ths of

the distance from the anterior border of the ramus
determines the AP site of the injection
 Penetration Depth
Bone must be contacted at this point of the
injection
Slowly advance the needle until you meet
boney resistance
Average depth until boney contact is 20-25
mm; or 2/3rds to 3/4ths the length of the long
dental needle (32 mm)
 After bone is contacted (IANB)

6) Withdraw syringe 1 mm to avoid subperiosteal injection

7) Aspirate; slowly if negative rotate and aspirate again,
inject solution ~ 1.5 1.8 ml
(1 cartridge)
8) Wait 20 seconds and return the patient to the upright

position to allow gravity to move the solution

inferiorly;
begin treatment in 3-5 minutes
 Common Problems
If Bone Contacted Too Soon
1) less than half of the dental needle penetrated until
bone contact means the needle tip is located too far
anteriorly on the ramus

SOLUTION
-withdraw needle slightly; do not remove completely
-bring the syringe barrel around to the front of the mouth
over the canine or lateral incisor on the contralateral side
-needle tip is now located more posteriorly
2) If Bone is not contacted
1) needle tip is located too far posterior (medial)

SOLUTION
-withdraw the needle tip slightly so that 1/4 th of the needle
tip still lies in tissue
-bring the syringe barrel more posterior over the mandibular
molars
-after bone contact, withdraw syringe 1 mm to avoid
subperiosteal injection; results in ballooning of tissue
 Area anesthetized:
Mandibular teeth, body and ramus of
mandible, buccal mucoperiosteum and
anterior two
third of tongue(lingual nerve).
 Bells Palsy
Do not inject solution if bone is not contacted;
more than likely the needle tip will be within
the parotid gland;
 Accessory Innervation
Failure of the IANB is related to accessory
innervation of mandibular molar teeth by
branches of the Mylohyoid Nerve
 Solutions To Inadequate Anesthesia After
IANB
Provide anesthesia on the lingual surface
of the tooth posterior to the tooth in question
(apex of 2nd molar if problem tooth is 1st
molar) penetrate soft tissue until bone is
contacted; aspirate and deposit 1/3rd cartridge
to gain anesthesia of the mylohyoid accessory
nerves
 Errors:
Too high injection:
Numbness of ear by auriclotemporal nerve anaesthesia.
Lateral trygoid muscle injection leads to trismus.
Too low injection:
-Deposited in parotid gland
.temporary facial nerve paralysis
-medial pterygoid muscle
.trismus
-deposited in posterior facial vein
.Toxicity
.Too media injection.
Deposited in constrictor muscle of pharynx :disphagya
 Complications of IANB
Hematoma (rare)
2) Trismus (common)
3) Transient Facial Paralysis (Bells Palsy)
 Buccal Nerve Block Technique
Indication: When buccal soft tissue anesthesia
is required for dental
procedures in the mandibular molar region.
Area anesthetized:
Soft tissues and periosteum buccal to
mandibular molar teeth.
Target is the buccal nerve as it passes over the
anterior border of the ramus

Mouth Mirror, retract the buccal mucosa to

obtain good visualization and pull the tissues
taut
3) Penetrate the mucosa distal and buccal to the last
molar near anterior border of the ramus.

4) Advance the needle slowly until bone is contacted gently

5) Depth of penetration is approximately 2-4 mm

(1-2 mm)

6) Aspirate; inject slowly 0.3 ML

 Gow-Gates Block

Gow-Gates Block is a true complete mandibular

block

Onset is longer than IANB; 5 minutes with GG;

2-5 minutes with IANB
Nerves Blocked (Gow-Gates):
1) Inferior Alveolar Nerve 5) Incisive Nerve
2) Mylohyoid Nerve 6) Auriculotemporal nerve
3) Lingual Nerve 7) Buccal Nerve
4) Mental Nerve
Gow-Gates advantages over IANB

Lower incidence of positive aspiration 2% as

opposed to 15% with IANB

Absence of accessory nerve innervation because

GG is true mandibular block
 Gow-Gates Areas Anesthetized
1) Mandibular teeth to the midline
2) Buccal mucoperiosteum on the side of injection
3) Anterior 2/3rds of the tongue and floor of the mouth
4) Lingual soft tissues and periosteum
5) Body of the mandible; inferior portion of the ramus
6) Skin over the zygoma, posterior portion of the cheek and temporal
region

*Remember, when doing extractions, the buccal nerve block is needed in

addition to the IANB, however, with GG, only one injection is required
 Gow-Gates Technique
1) 25 gauge long needle
2) Insertion point: mucous membrane of the mesial of the
mandibular ramus, on a line from the intertragic notch to
the corner of the mouth, just distal to the maxillary 2 nd
molar
3) Target area: lateral side of the condylar neck, just below
the insertion of the lateral pterygoid muscle
5) Height of injection: place needle tip just below the
mesiolingual cusp of the maxillary 2nd molar
6) Ask patient to open wide to allow the condyle to
assume a frontal position

7) Direct syringe from the corner of the mouth from the opposite
side of mouth

8) Height of insertion is considerably greater than the

IANB by 10-25 mm

9) Average depth of penetration is 25 mm

(same as IANB
10) Do not deposit solution unless bone is contacted

11) Withdraw the needle 1 mm, aspirate, deposit 1.8

ml of solution

12) Request that the patient keep their mouth open for
1-2 minutes to allow diffusion of the anesthetic
solution

13) Return the patient to the upright position; wait 3-5

minutes to start
14) Bone contacted is the head of the condyle

15) Medial deflection is the most common cause of

the needle missing the head of the condyle;
redirect the barrel of the syringe more distally
which will move the needle tip more anteriorly

16) Partial closure of the patients mouth will move

the condyle in a distal direction making boney
contact more difficult
 Vazirani-Akinosi Closed Mouth
Mandibular Block
.Injection for a patient with considerable trismus
.Third division block (V3) will relieve
trismus/muscle spasm
.VA Block is an intraoral approach to providing
anesthesia
in patients with severe trismus (inability to
open the mouth)
Nerves Anesthetized
1) Inferior Alveolar Nerve
2) Incisive Nerve
3) Mental Nerve
4) Lingual Nerve
5) Mylohyoid Nerve
 VA Block Areas Anesthetized
1) Mandibular teeth to the midline

2) Body of the mandible and inferior portion of the

ramus

3) Buccal mucoperiosteum and mucous membrane

in front of the mental foramen

4) Anterior 2/3rds of the tongue and floor of the mouth

5) Lingual soft tissues and periosteum

 Advantages of VA Block
Lower aspiration rate 10 %.
usuful in bifid IAN.
Good for macroglossic patient.
 Disadvantages of VA Block
1) Difficult to visualize the path of the needle and
depth of insertion

2) No boney contact (similar to PSA); depth of

penetration is arbitrary

3) Traumatic

4) Difficult in patients with widely flaring ramus.

 VA Block Technique
1) 25 gauge long needle

2) Area of insertion: soft tissue overlying the medial

(lingual) border of the mandibular ramus directly adjacent
to the maxillary tuberosity at the height of the
mucogingival junction adjacent to the maxillary 3rd molar

3) Target area: soft tissue on the medial (lingual) border of

the ramus as the inferior alveolar, lingual and mylohyoid
nerves run inferiorly from the foramen ovale toward the
mandibular foramen

*Height of injection of the VA is below that of the GG but above that of the IANB
4) Landmarks are the mucogingival junction of the maxillary 3 rd
molar, maxillary tuberosity and the coronoid notch of the ramus

5) Bevel is directed away from the bone of the ramus

(toward midline)

6) Reflect the tissue on the medial aspect of the ramus

laterally with the Minnesota Retractor or mouth mirror

7) Barrel of the syringe is held parallel to the maxillary

occlusal plane with the needle at the level of the
mucogingival junction of the maxillary 3rd molar
8) Direct the needle posterior and slightly laterally

9) Advance the needle 25 mm into tissue (same as GG and IANB)

distance is measured from the maxillary tuberosity

10) Tip of the needle will lie in the midportion of the

pterygomandibular space where the branches of V3 are located

11) Aspirate and deposit 1.8 ml of solution

12) Return patient to the upright position which speeds anesthesia

13) If motor nerve anesthesia is present but not sensory, the patient
should be able to open therefore allowing the IANB or GG
injection
 If the there is tingling or numbness in the
tongue, which is a branch of the posterior
division of the mandibular nerve then you can
feel confident that your injection has reached
its target
 Reasons For Failure of VA Block

1) Most common is failure to appreciate the flaring nature of

the ramus; direct the needle tip parallel with the lateral flare of
the ramus; if the needle is directed medially it rests
medial to the sphenomandibular ligament in the
pterygomandibular space resulting in failure

2) Injection point too low; make sure the needle is inserted at

or slightly above the mucogingival junction of the last
maxillary molar and parallel the occlusal plane as it advances
through the soft tissue

3) No bone is contacted so under/overinsertion possible (25mm)

 Mental Nerve Block
Mental nerve is the terminal branch of the IA nerve

Provides sensory innervation to the buccal soft tissues lying

anterior to the foramen and the soft tissues of the lower lip and
chin

Mental nerve block is the least used of the mandibular blocks

Anesthetizes buccal mucous membranes anterior to the mental

foramen and skin of the lower lip and chin

Used for suturing tissues, biopsies in this area

Procedure:

1) 25 gauge short needle

2) Insertion: mucobuccal fold at or anterior to

the mental foramen

3) Target area: mental nerve as it exits the

mental foramen (usually located between the
apices of the 1st and 2nd premolars)

4) Pull the tissue taut

5) With gentle finger pressure it is possible to
feel the mental nerve as it exits the foramen
(patient will complain of discomfort)

6) Penetrate needle 5-6 mm and inject 1/3rd 0.6 ml

cartridge of anesthetic

7) No need to enter the foramen with the needle tip to

gain anesthesia
 Incisive Nerve Block
Areas Anesthetized
1) Premolars
2) Canine
3) Lateral Incisor
4) Central Incisor
5) Buccal soft tissue and bone

The incisive nerve block is indicated when bilateral anterior

teeth or premolars require restoration; try to avoid
bilateral IANBs because it makes the entire tongue/lower
lip numb
Procedure:

Same technique used for mental nerve block except:

1) Apply pressure to area after injection to facilitate

movement of anesthetic
solution into the foramen

2) Apply pressure for at least 2 minutes