Local Anesthetic Techniques

Maxillary and Infraorbital Branch

Maxillary nerve passes through foramen rotundum to reach the pterygopalatine fossa Major Branches: Zygomatic Orbital Nasal Palatine Pharyngeal Infraorbital Facial

Posterior Superior Alveolar Nerve

PSA descends from the main trunk of the Maxillary nerve in the pterygopalatine fossa just before entering the infraorbital canal Provides sensory innervation to:
mucus membrane of the sinus alveoli periodontal ligaments pulpal tissue of third, second and distobuccal root of first molar (28% mesiobuccal)

Nasopalatine and Greater Palatine Nerves

Greater palatine nerve supplies sensory innervation to the palatal tissue and bone up to the first premolar where it intermingles with the nasopalatine n. Nasopalatine nerve passes across the roof of the nasal cavity between the mucous membrane and periosteum of the septum to exit the incisive canal providing sensory innervation to the mucosa of the premaxilla Greater Palatine Nerve

Infraorbital Nerve / Anterior Superior Alveolar Nerve

Provides nasal branch that innervates anterior part of nasal cavity Sensory innervation to the central and lateral incisors, canines, buccal bone and mucus membranes associated with these teeth If no MSA present (72%), will also provide innervation to the premolars and mesiobuccal root of the first molar as well

Mandibular Nerve
Mandibular nerve carries both motor and sensory fibers Nerve trunk remains undivided for only 2 to 3 mm before splitting into an anterior and posterior division Anterior Division
muscles of mastication long buccal nerve

Posterior Division
auriculotemporal nerve lingual nerve inferior alveolar nerve mylohyoid nerve

Long Buccal Nerve

Long Buccal nerve passes between the two heads of the lateral pterygoid muscle and crosses in front of the anterior border of the ramus Provides sensory innervation to the buccal gingiva of the mandibular molars

Masseter and Auriculotemporal Nerves

Auriculotemporal Nerve The masseter nerve passes in front of the temporomandibular joint and enters the masseter muscle The auriculotemporal nerve passes behind the condylar neck to provide sensory innervation to the skin of the external auditory canal and anterior temple

Inferior Alveolar and Mental Nerves

Inferior Alveolar and Mental Nerves

IAN is the largest branch of the mandibular division Accompanied by the inferior alveolar artery which is branch of the internal maxillary artery Provides pulpal anesthesia to all teeth of the quadrant Exits the mandible via the mental foramina Divides into the mental and incisive branches Incisive branch provides pulpal anesthesia to the mandibular premolars, canines and incisors Mental nerve innervates skin of the chin and mucous membranes of the lower lip

Mylohyoid Branch
Mylohyoid nerve branches from the IAN prior to entry into the mandibular canal Runs forward in the mylohyoid groove to the mylohyoid muscle Motor to the mylohyoid muscle and anterior belly of the digastric Provides some fibers to skin of the mental protuberance May provide some innervation to mandibular incisors and possibly to the molars

Lingual Nerve
Lingual nerve branches off the mandibular nerve before entering the bone to reach the base of the tongue Proceeds anteriorly and loops medial to the Whartons duct of the submandibular gland Sensory to the anterior 2/3 of the tongue as well as taste via the chorda tympani nerve

TECHNIQUE

Local Anesthetic Injection Techniques

Do Not Inject Under the Periosteum PAINFUL!!!

Maxillary Infiltration Technique

Maxillary Infiltration Technique

Supraperiosteal Placement of Local Anesthetic

Posterior Superior Alveolar Nerve Block

Useful block for third, second and distobuccal root of first molar Risk of hematoma No bony landmarks Second injection required for mesiobuccal root of first molar
Target for PSA Injection

Middle Superior Alveolar Nerve

MSA nerve present in about 28% population Anesthetizes the maxillary premolars Used when infraorbital nerve block fails distal to the canine

Infraorbital Nerve Blockade

Not popular due to operator familiarity Highly successful and very safe technique Provides pulpal and buccal soft tissue anesthesia in 72% of patients Also anesthetizes lower eyelid, lateral nose and upper lip

Infraorbital Nerve Blockade

Palpate the inferior orbital rim and move inferiorly until reaching the infraorbital foramina Maintain finger position over the foramina and orient needle into the mucobuccal fold over the first premolar Approximate depth of insertion is 16 mm

Infraorbital Nerve Blockade

Greater Palatine Nerve Block

Nerve block will provide anesthesia to the posterior portion of the hard palate and overlying soft tissues as far as the first premolar Use a cotton swab to find the depression of the foramina Apply pressure to blanch tissue prior to injection Not necessary to deposit local anesthetic within the foramina

Area Anesthetized by Infraorbital Nerve Block

Nasopalatine Nerve Block

Will anesthetize the hard and soft tissues of the premaxilla including the area between the canines Single injection technique places needle directly into the incisive papilla Soft tissue is very adherent to bone and the region of the incisive papilla is very sensitive Multiple needle penetration technique first deposits local anesthetic into the labial frenum Second injection through the labial papilla between the central incisors towards the incisive foramina Third injection adjacent to the incisive foramina only if necessary

Maxillary Division Nerve Block

Also called Second Division Block Effective method of achieving profound anesthesia of hemimaxilla Approached by either the high tuberosity technique or the greater palatine approach Not indicated in children High incidence of hematoma from the high tuberosity approach No true bony landmarks Needle inserted to depth of 30 mm Aim for pterygopalatine fossa

Maxillary Division Nerve Block

Areas anesthetized:
maxillary teeth in quadrant overlying bone periodontium soft tissues of the hard palate and part of soft palate skin of the lower eyelid, side of nose, cheek and upper lip

Maxillary Division Nerve Block

Greater palatine approach can also be used Potential trauma to nerve from needle insertion More difficult to locate the greater palatine foramina Advance needle to depth of 30 mm 5 to 15% of canals will have obstructions that prevent passage of needle

Mandibular Infiltration
Useful predominately for the mandibular incisors and buccal tissues Effective because of thin alveolar bone Not reliable for anesthesia of the canine due to thicker cortical bone

Mandibular Infiltration

Mandibular Infiltration

Mental Nerve Block

Provides mostly sensory innervation to the buccal soft tissues anterior to the foramina of the lip/chin Least frequently used block Unreliable anesthesia of the premolars No need to enter foramina Pull tissue taut and may be able to visualize nerve branches

Mental Nerve Block

Long Buccal Nerve Block

Branch of the anterior division of V3 Required for surgical procedures involving the buccal soft tissues adjacent to the molars Success rate of nearly 100% due to location just below mucosa Low incidence of hematoma formation which can be controlled with direct pressure

Long Buccal Nerve Block

Inferior Alveolar Nerve Block: Direct Technique

Most frequently used nerve block in dentistry 15 to 20% rate of clinical failure Positive aspiration 10 to 15% Anesthetizes:
mandibular teeth to midline anterior 2/3 of tongue (Lingual n.) lingual soft tissues mental n. soft tissue distribution

Average depth of penetration is 20 to 25 mm

Inferior Alveolar Nerve Block: Direct Technique

Inferior Alveolar Nerve Block: Direct Technique

Zone of Injection for IAN Block Deposition of Local Anesthetic in the Pterygomandibular Space

Lingual Nerve Block

Lingual nerve block usually made in conjunction with the inferior alveolar nerve block Deposition of anesthetic upon withdrawal of needle Inject anesthetic when approximately half the needle length has been withdrawn Local from the IAN block will usually diffuse to the lingual nerve as well

Lingual Nerve Block

Akinosi Closed Mouth Mandibular Block

Used primarily in patients with trismus who require mandibular anesthesia Contraindicated in patients with infection or acute inflammation in region of injection Will provide sensory and motor nerve blockade if administered properly

Akinosi Closed Mouth Mandibular Block

Orient bevel away from bone Barrel of syringe held parallel with the maxillary occlusal plane Height of needle above the mucogingival junction of the maxillary third molar Advance needle about 25 mm into tissue measured from the maxillary tuberosity to the mid portion of the pterygomandibular space

Gow-Gates Mandibular Block GowTrue mandibular nerve block since it provides:

inferior alveolar lingual mylohyoid mental incisive auriculotemporal long buccal

Gow-Gates Mandibular Block GowNeedle is inserted at the distal of the maxillary second molar directed towards the tragus Advance the needle until bone is contacted at the neck of the mandibular condyle Average depth of penetration is 25 mm If bone is not contacted, withdraw and re-direct the reneedle Do not deposit local if bone has not been contacted

Higher rate of failure due to operator unfamiliarity Complications include hematoma formation and CN III, IV, and VI temporary paralysis

Extraoral Mandibular Block

Useful in cases of severe trismus when unable to perform a Direct IAN or Gow-Gates block GowCan be administered via the sigmoid notch or inferiorly from the chin

Local Complications of Local Anesthetics

Needle breakage Pain on injection Burning on injection Persistent anesthesia Trismus Hematoma Infection Sloughing of tissues Facial nerve paralysis Post-anesthetic intraoral lesions Post-

Systemic Complications of Local Anesthetics

Allergy Epinephrine effects Overdose (progression of symptoms)
slurred speech disorientation vomiting elevated heart and respiratory rate visual disturbances (blurring) auditory disturbances (tinnitus) loss of consciousness tonic clonic seizure activity depressed blood pressure, heart rate and breathing

The End