TYPE AREA ALTERNATIVES LANDMARKS ORIENTATION ACCIDENTS COMPLICATIO

TERRITORY OF INNERVATION NS
Supraperiosteal Buccal mucosa Superior alveolar nerve Upper vestibulum – M of tooth Needle: bevel parallel with bone Necrosis
Periosteum
Alveolar bone Maxillary nerve block Vestibular mucosa (junction mobile Oblique, towards apex, reorient Postextractional
1-2 teeth in area (MX, MD anterior) mucosa) 60 degrees alveolitis
MX
Infraorbital Dental pulp and periodontium of Supraperiosteal 8-10mm under infraorbital rim EXTRAORAL Artery haemorrhage,
(anterior superior incisors and C Inferior and medial to the puncture/pterygoid hematoma, bruise
alveolar) Maxillary nerve block Junction between external 2/3 and infraorbital foramen venous plexus
Alveolar bone anterior 1st PM internal 1/3 of the infraorbital rim, diplopia, visual
Periodontal ligament under zygomatic-MX suture At the level of ala nasi dysfunction
B mucosa and periosteum anterior teeth injection Enter orbit:
5mm inward to the vertical pupilar line 0.5-1cm outside nasolabial fold
Anterior wall of the MX sinus and
overlying mucosa Vertical line which runs through the Needle: oblique, upward,
axis of the 2nd PM, 2.5cm above apex backward, slightly outward
AREAS: skin of infraorbital area, half
of upper lip, lateral aspect of nose, Same vertical line with the supraorbital Contact bone, enter infraorbital
lower eyelid and mental foramen canal 0.5-1cm
INTRAORAL
PATIENT: slight extension, mouth Puncture in the C fossa, in the
fully closed or partially opened vestibular mucosa, above and D
to C
DENTIST: right side, front, at 10
o’clock, thumb retracts lip and cheek, Needle: upward, backward,
index on infraorbital foramen outward, 45 to the sagittal plane

Keep bone contact, enter foramen

2.5cm

Parallel to long axis of 2nd PM

Middle superior Pulps of MX1st 2nd premolars, MB root Mucobuccal fold above the MX 2nd PM Toward bone
alveolar of 1st M
Height of MB fold above 2nd PM
Buccal periodontal tissue

Bone
Posterior superior Buccal mucosa and periosteum D to the Supraperiosteal (except 1st Maxillary tuberosity Upwards superiorly at 45 angle to Puncture venous plexus Haemorrhage,
alveolar (intraoral) zygomatic process of MX MX molar) occlusal hematoma,
D zygomatic process of maxilla Needle breakage infection, abscess
1st 2nd 3rd molars Maxillary nerve block Inward medially 45 to occlusal
M root of 2nd molar MD anaesthesia
Alveolar bone of 1st 2nd 3rd molars Periodontal ligament Backward posteriorly (IAN, lingual,
injection and hard tissues Vestibular mucosa in the MB fold buccal)
Posterior wall of MX sinus along with Bone contact with tuberosity,
overlying mucosa PATIENT: extension, dental arches in slide 2.5-3cm
partial contact not to block access
DENTIST: in front and right, retract
cheek
Nasopalatine Palatine mucosa and periosteum in Local infiltration of palate On the median line, between CI Puncture at the margin of incisive Few of significance
anterior 1/3 of the palate, bilaterally papilla, laterally
Maxillary nerve block 1cm above and behind column of I, Hematoma rare
Supraperiosteal infiltration or covered by the incisive papilla 1cm behind and above gingival
infraorbital for anterior teeth margin Necrosis of soft
DENTIST: 9 or 10 o’clock, facing same tissue
PATIENT: important head extension, direction Needle: upward, backward,
mouth fully opened outward, parallel to CI’s root
Greater palatine Mucosa, periosteum in the area of Local infiltration of the 0.5cm before posterior margin of hard Puncture at the junction of Puncture of palatine Abundant
molar and premolars, distal to C, palate palate alveolar process with palatine artery haemorrhage and
unilaterally bone, 2nd M hematoma
Maxillary nerve Angle formed by alveolar process with Brutal injection,
Posterior 2/3 of hard palate, up to horizontal blade of palatine bone At the mid distance between pressure can decollate Necrosis
midline palatine median raphe and the palatal muco-
1cm above column of last molar gingival free margin, interdental periosteum Transient oedema,
PATIENT: important head extension, space between 1st and 2nd M discomfort,
rotated same side, mouth completely 1cm before the hook of internal wing of Too far backward: soft dysphagia
opened pterygoid process of MX Needle: upward, backward, palate infiltration
slightly outward
Anterior to the greater palatine foramen
(minimise discomfort if soft palate Bevel oriented towards palatal
numb), D to the 1st M soft tissue, syringe reaches oral
commissure on opposite side
Local infiltration of Palatine mucosa on a restricted 1-2 Greater palatine Puncture: 1cm above the free Few of significance
palate teeth area gingival margin
Nasopalatine Necrosis of soft
Vasoconstrictor of a palatine territory in Needle: perpendicular to bone, tissue
order to decrease haemorrhage during Maxillary bevel toward the palatal soft
interventions tissue
MD
Inferior alveolar nerve Nerves: inferior alveolar, incisive, Mental nerve for B soft 1cm above MD M occlusal plane Puncture: temporal crest and Puncture of inferior Paleness,
(IAN) mental, lingual tissues anterior to 1st M pterygomandibular raphe alveolar vessels palpitations,
Temporal crest, medial and posterior to syncope, lack of
MD teeth to the midline Supraperiosteal the anterior border of the ramus 1cm above occlusal plane Needle: anaesthetic
infiltration for pulpal - too medial
Body of the MD anaesthesia of I Ptergygomandibular raphe Needle: parallel to sagittal plane - too deep (paresis) - dysphagia
when contact with bone, at - too lateral - paralysis
B mucoperiosteum anterior to the 1st M Gow Gates procedure PATIENT: head slight extension, temporal crest, is established - too high (loss - no anaesthetic
up to the midline mouth fully opened taste) - masseter
Vazirani-Akinosi MD DENTIST: While pushed backwards, syringe muscle
Soft tissues of half lower lip and mental Right side: 8 o’clock, facing patient body goes opposite side Needle breakage paralysis
area Periodontal ligament Left side: 10 o’clock (patient moves, bending
infiltration 1cm lingual nerve needle before insertion) Hematoma
Epithelium and anterior 2/3 tongue 1.5-2cm inferior alveolar nerve (swelling, apply
Can start only when lingula is pressure)
reached Trismus
Facial paralysis
DIELAUFE: 1cm above occlusal,
syringe in contact with opposite
oral commissure, MD canine
 MACCARY: 1.5cm above
occlusal, syringe barrel at the
level of contralateral MX LI
SARGENTI: 0.8-1cm above
occlusal, barrel in contact with
contralateral upper C-PM
ALTERNATIVE Inferior alveolar and lingual nerve Mucogingival junction of the MX 2nd or Puncture: B mucosa covering Hematoma
Vazirani-Akinosi 3rd M ascending ramus, at the level of
mucogingival junction of the MX Trismus
(Limited mouth Maxillary tuberosity 2nd or 3rd M
opening)
Coronoid notch Laterally to the MX tuberosity Transient facial
nerve paralysis
Medially to the coronoid notch

Needle: posteriorly and slightly

laterally, parallel to the occlusal
plane of the upper molars
Tangent to the MX tuberosity, as
close to the coronoid process
Lingual nerve block Attached gingiva of the lingual side of Simultaneous anaesthesia Internal angle of the MD Puncture: at the level of 3rd lower
the MD, midline to 3rd M - along with IAN molar
- Gow-Gates Last lower molar
Floor of the mouth - Veisbrem Anterior and medial to the
- Ginestet Mandibulo-lingual sulcus internal angles
Anterior 2/3 of tongue
In the mandibulo-lingual sulcus

½ distance from the gingival free

margin and base of tongue

Needle: backward and slightly

outward, towards bone
Lingual nerve block Anterior 1/3 of the mouth floor and Completion of IAN Lower C or 1st PM Puncture: at the level of C or 1st
alternative tongue PM, in the angle between the
(Theodorescu) Angle between the lingual gingiva of mandible and the floor of the
Gingival on the lingual side of the the MD and the floor of the mouth mouth
frontal teeth
Needle: thin, downward and
slightly outwards, towards bone
Mental and incisive Teeth, alveolar bone, vestibular mucosa Local infiltration Mental foramen – the external side of Puncture: in the lower vestibule,
from midline to 1st and 2nd PM the MD body, ½ distance between in the mobile mucosa, at the level
IAN/Vazirani-Akinosi alveolar process and lower border of M root of 1st M
Soft tissues of the contralateral inferior
alveolar nerve block Gow-Gates or other Between 1st and 2nd PM Needle: oblique, downward,
simultaneous inward and forward, 15-20 angle
Lower lip, mental area, bone, teeth, Edentulous: ½ distance between the with the axis of 2nd PM
periodontium, B mucosa from midline symphysis and anterior border of the
to 1st and 2nd PM masseter muscle (on occlusal, higher) Incisive nerve further 4-5mm
Buccal nerve Gingival and B mucosa corresponding
to lower molars (completion)
Mucosa of cheek
Skin and muscles (buccinator) of cheek
and oral commissure
Completion of IAN Anterior margin of the coronoid process
Upper molars occlusal plane
1cm posterior and inferior from
Stenson’s duct papilla
Puncture: at the junction between
anterior margin of the coronoid
process with occlusal plane of the
upper molars
Needle: horizontal, backward and
outward till bone contact of
coronoid process obtained

Syringe barrel in contact with

contralateral oral commissure
Simultaneous blocks

VEISBREM Simultaneous block of IAN, lingual and Pterygomandibular raphe Puncture: lateral to the
buccal pterygomandibular raphe, medial
Anterior margin of the ascending ramus to the base of the coronoid
process, at 0.5cm under the
Occlusal plane of the upper molars occlusal plane of the upper molars

Needle: perpendicular to the

mucosa, 1.5cm the MD tuberosity
is touched (for lingual and IAN),
retract about 3-4mm to leave
solution for buccal nerve

GOW-GATES IAN, lingual, buccal, auriculotemporal Lateral side of the condylar neck, below
nerve insertion point of the lateral pterygoid
muscle
Extraoral: intertragic notch, oral
commissure
Intraoral: mesiopalatal cusp of 2nd and
3rd upper molar, area distal to the MX
2nd and 3rd molar
Puncture: mucosa on the M side Puncture of IMA Hematoma
of ramus, on a line from
intertragic notch to the corner of Trismus
the mouth, D to the MX 2nd M
Temporary paralysis
Needle: posterior, on the plane of cranial nerves III,
described, insert up the bone IV and VI
contact condylar neck 2.5cm,
barrel over contralateral MD
bicuspids

GINESTET IAN, lingual, buccal, masseter Puncture: 1cm above occlusal

surface of last molar, on the
anterior margin of the ascending
ramus

Needle: at the level of anterior

margin, 1ml for buccal nerve
External side of ramus, 1-1.5cm
depth, 1ml for masseter
Internal side of ramus, 1cm
posterior to temporal crest, 1ml
for lingual
Another 0.5-1cm deeper, for IAN