TECHNIQUES OF LOCAL

ANESTHESIA

• JIMMA UNIVERSITY.
DENTISTRY DEPARTEMNT

1
Precaution to be considered during injection
inside the mouth:

-Do not inject local anesthetic into an area that is

swollen. This can spread the infection to other
areas also the local anesthetic doesn’t work
properly in an acidic pH.

-If the person has heart disease or hypertension

not use an anesthetic with epinephrine
(vasoconstrictor). Use lidocaine without
epinephrine.
2
-Before the needle enter the mucosa, be sure its
bevel is facing the mucosa.

-Before the local anesthetic is injected, aspirate

with the syringe to prevent an intravascular
injection. If this happens pull the needle part
way out and gently move it over to a different
place.

-Use a sharp needle and inject the solution very

slowly.

-Be sure the syringe is clean and sterile.

3
 INFILTRATION ANESTHESIA, MAXILLARY
AND MANDIBULAR REGIONAL ANESTHESIA
Equipment

Administration of regional anesthesia of the

maxilla and mandible is achieved via the use of a:

-Dental syringe.

-Needle.

-Anesthetic cartridge.

4
Dental Syringe.

5
Several types of dental syringes are
available for use, however the most
common is the breech-loading, metallic,
cartridge-type, aspirating syringe.

The syringe is comprised of a thumb ring,

finger grip, barrel containing the piston with
a harpoon, and a needle adaptor

6
• Figure 3: Breech-loading, metallic,
cartridge-type, aspirating syringe

7
A needle is attached to the needle adaptor which
engages the rubber diaphragm of the dental
cartridge

Figure 4: Needle-syringe assembling: A needle is

attached to the needle adaptor.
8
The anesthetic cartridge is placed into the
barrel of the syringe from the side (breech
loading). The barrel contains a piston with
a harpoon that engages the rubber
stopper at the end of the anesthetic
cartridge

9
Figure 5, A: Needle-
syringe assembling : The Figure 5, B: A piston with a harpoon
anesthetic cartridge is engages the rubber stopper at the
placed into the barrel of end of the anesthetic cartridge while
the syringe from the side the needle adaptor engages the
(breech loading). rubber diaphragm of the dental
cartridge 10
After the needle and cartridge have been attached, a
brisk tap is given to the back of the thumb ring to
ensure the harpoon has engaged the rubber stopper
at the end of the anesthetic cartridge (Fig.6, A, B,
and C).

Figure 6, A and B: Needle-syringe assembling: A brisk

tap is given to the back of the thumb ring to ensure the
harpoon has engaged the rubber stopper at the end of the11
anesthetic cartridge.
Dental needles

12
 Dental needles
Dental needles are referred to in terms of their
gauge which corresponds to the diameter of the
lumen of the needle.

Increasing gauge corresponds to smaller lumen

diameter. Twenty-five and twenty-seven gauge
needles are most commonly used for maxillary
and mandibular regional anesthesia and are
available in long and short lengths.

13
The length of the needle is measured from
the tip of the needle to the hub. The
conventional long needle is approximately
40mm in length while the short needle is
approximately 25mm in length. Variations in
needle length do exist depending upon the
manufacturer.

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15
Anesthetic cartridges

16
The contents of an anesthetic cartridge are the local
anesthetic, vasoconstrictor (anesthetic without
vasoconstrictor is also available), preservative for the
vasoconstrictor (sodium bisulfite), sodium chloride, and
distilled water.

The most common anesthetics used in clinical practice

are the amide anesthetics lidocaine and mepivacaine.
Other amide anesthetics available for use are
prilocaine, articaine, bupivacaine, and etidocaine.
Esther anesthetics are not as commonly used however
remain available. Procaine, procaine plus
propoxycaine, chlorprocaine, and tetracaine are some
common esther anesthetics. 17
Anesthetic cartridges are prefilled, 1.8cc glass
cylinders with a rubber stopper at one end and an
aluminum cap with a diaphragm at the other end
(Fig. 7, A and B).

Figure 7, A: Dental cartridges. The rubber stopper is

on the right end of the cartridge while the aluminum cap
with the diaphragm is on the left end of the cartridge. B:
Containers of dental anesthetic 18
Additional armamentarium includes dry gauze,
topical antiseptic and anesthetic.

The site of injection should be made dry with gauze

and a topical antiseptic should be used to clean the
area. Topical anesthetic is applied to the area of
injection to minimize discomfort during insertion of
the needle into the mucous membrane (Fig. 8).
Common topical preparations include benzocaine,
butacaine sulfate, cocaine hydrochloride, dyclonine
hydrochloride, lidocaine, and tetracaine
hydrochloride.
19
Figure 8: Topical anesthesia: Prior to
injection, topical anesthetic can be applied on
the mucosa in the area of an injection to
minimize discomfort to the patient 20
Universal precautions should always be observed
by the clinician which include the use of protective
gloves, mask and eye protection. After withdrawing
the needle once a block has been completed, the
needle should always be carefully recapped to
avoid accidental needle stick injury to the operator.
21
Retraction of the soft tissue for visualization
of the injection site should be performed with
the use of a dental mirror or retraction
instrument. This is recommended for all
maxillary and mandibular regional
techniques discussed below. Use of an
instrument rather than one’s fingers will help
prevent accidental needle stick injury to the
operator.

22
23
 INFILTRATION ANESTHESIA
Clinical pearls
Techniques of Anesthesia for Treatment of a Localized Area or One or
Two Teeth

TECHNIQUE AREA ANESTHETIZED

Individual teeth and buccal

Supraperiosteal Injection
soft tissue Individual teeth
Subperiosteal Injection
and buccal soft tissue
Intraosseous
Individual teeth and buccal
Intraseptal Injection
soft tissue
Periodontal Ligament
Localized soft tissue
Injection
Individual teeth and buccal
Intrapulpal Injection
soft tissue
Individual tooth
24
 INFILTRATION ANESTHESIA

Another method of administering local anesthesia. It

consist in the infiltration of the material directly into
the tissue and alveolus at the site of the dental
procedure.
This technique is most frequently used to
anesthetize the maxillary teeth. It may be useful as a
secondary injection to block gingival tissues
surrounding the mandible teeth.
Infiltration anesthesia is possible in the maxillary
teeth because of the more porous nature of the
alveolus which allows the solution to reach the
apices of the teeth.
25
26
27
 Local infiltration

1.Nerves anesthetized. Free nerve endings in the

infiltrated

2. Areas anesthetized. Mucous membrane and

mucoperiosteou the infiltrated area only.

3. Anatomical landmarks. No anatomical landmarks

used as solution is infiltrated into required areas.

4. Indications
a. Anesthesia of restricted area of the mucous
membrane limited soft tissue surgery.
b. Subsequent insertion of other needles. 28
5. Technique. In the mandibular area a 1 inch 25
gauge needle is inserted beneath the mucous
membrane into the underlying tissues and the area
infiltrated with anesthetic solution. More than one
needle insertion may be necessary, depending upon
the area of anesthesia required. The solution should
be injected slowly and in min volumes.

6. Symptoms of anesthesia. No subjective

symptoms. Instrumentation will determine the
presence of adequate analgesia.

29
 Local Palatal Infiltration

The administration of local anesthetic for the

palatal anesthesia of just one or two teeth is
common in clinical practice. When a block is
undesirable, local infiltration provides
effective palatal anesthesia of the individual
teeth to be treated. Contraindications
include acute inflammation and infection
over the area to be anesthetized. A 25- or
27-gauge short needle is preferred for this
technique.
30
Technique- The patient should be in the supine
position with the chin tilted upward for visibility of the
area to be anesthetized. Identify the area to be
anesthetized. The right handed operator should be
at the ten o’clock position where as the left handed
operator should be at the two o’clock position. The
area of needle penetration is five to ten millimeters
palatal to the center of the crown. Apply pressure
directly behind the injection site with a cotton swab.
Insert the needle at a forty five degree angle to the
injection site with the bevel angled toward the soft
tissue (Fig. 16).
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Figure 16: Local infiltration on the palatal aspect of the
maxillary right 1st premolar. The needle is inserted
approximately 5 to 10mm palatal to the center of the crown.
32
While maintaining pressure behind the injection site,
advance the needle and slowly deposit anesthetic
solution as the soft tissue is penetrated. Advance the
needle until bone is contacted. Depth of penetration is
usually no more than a few millimeters. The tissue is
very firmly adherent to the underlying periosteum in
this region causing resistance to the deposition of local
anesthetic. No more than 0.2 to 0.4cc of anesthetic
solution is necessary to provide adequate palatal
anesthesia. Blanching of the tissue at the injection site
immediately follows deposition of local anesthetic.
Successful administration of anesthetic using this
technique results in hemostasis and anesthesia of the
palatal tissue in the area of injection. 33
 Supraperiosteal (Local) Infiltration
The supraperiosteal or local infiltration is the one of
the simplest and most commonly employed
techniques for achieving anesthesia of the maxillary
dentition. This technique is indicated when any
individual tooth or soft tissue in a localized area is to
be treated. Contraindications to this technique are
the need to anesthetize multiple teeth adjacent to
one another (in which case a nerve block is the
preferred technique), acute inflammation and
infection in the area to be anesthetized, and less
significantly, the density of bone overlying the apices
of the teeth. A 25- or 27-gauge short needle is
preferred for this technique.
34
Technique- Identify the tooth to be anesthetized and
the height of the mucobuccal fold over the tooth. This
will be the injection site. The right handed operator
should stand at the nine o’clock to ten o’clock
position whereas the left handed operator should
stand at the two o’clock to three o’clock position.
Retract the lip and orient the syringe with the bevel
towards bone. This will prevent discomfort from the
needle coming into contact with the bone and will
minimize the risk of tearing the periosteum with the
needle tip. Insert the needle at the height of the
mucobuccal fold above the tooth to a depth of no
more than a few millimeters and aspirate (Fig 9, A
and B). 35
36
Figure 9, A: Locate the height of the mucobuccal fold over
the tooth to be anesthetized. B: Clinical picture depicting a
local infiltration of the maxillary left central incisor tooth.
Note the penetration of the needle at the height of the
37
mucobuccal fold above the maxillary left central incisor
If aspiration is negative, inject one third to
one half (0.6-1.2cc) of a cartridge of
anesthetic solution slowly, over the course of
thirty seconds. Withdraw the syringe and
recap the needle. Successful administration
will provide anesthesia to the tooth and
associated soft tissue within two to four
minutes. If adequate anesthesia has not
been achieved repeat the procedure and
deposit another one third to one half of the
cartridge of anesthetic solution.
38
 Subperiosteal Infiltration

Sub-periosteal Injeclion.—In this technique the

anaesthetic solution is deposited between the
periosteum and the cortical plate. As these
structures are firmly bound together this
injection is painful. Therefore it should only be
used if there is no alternative or when
superficial anaesthesia has been achieved by
a supra-periosteal injection. This technique
can be of value if a supra-periosteal injection
has failed to produce complete anaesthesia.
39
 Intra-osseous Injection

As the name implies, in this technique the solution is

deposited within the medullary bone. The procedure is
most
effectively carried out b’ the use of bone drills and needles
especially designed for the purpose. After giving a supra-
periosteal injection in the ordinary way a very small
incision is made through the muco-periosteum at the
chosen site of injection to provide access for the
introduction of a bur or fine reamer. A small hole is then
made through the outer cortical plate of bone with the
instrument selected. The siting of this hole is critical and is
illustrated in Fig. 28. It must be near the apex of the tooth
concerned but in such a position that damage cannot
40
becaused to the roots of the teeth.
41
A short needle upported by a long hub is inserted
through the hole and advanced into the bone. 025 ml
of anaesthetic solution is then deposited slowly in the
medullar spaces of the bone (Fig. 29). This amount of
solution is usually sufficient for most dental
procedures. The intraosseous technique produces
excellent anaesthesia of the pulp accompanied by
minimal impairment of sensation in the soft tissues.
However, some trauma to the alveolar bone is
inevitable and a potential route for infection is
produced. Strict attention to asepsis at all stages of the
procedure is mandatory. In practice the effectiveness
of the anaesthetic solutions now available has reduced
considerably the need for intra-osseus injections and
the technique is seldom used. 42
 Intraseptal Injection

The intraseptal technique not used as often

in clinical practice, the technique offers the
added advantage of hemostasis in the area
of injection. Terminal nerve endings in the
surrounding hard and soft tissue of individual
teeth are anesthetized with this technique.
Contraindications to the procedure include
acute inflammation and infection over the
site of injection. A 27 gauge short needle is
preferred for this technique.
43
Technique- Place the patient in the supine position. The
target area is the interdental palpillae 2-3mm apical to the
apex of the papillary triangle (Fig. 17). The right handed
operator should be at the ten o’clock position where as
the left handed operator should be at the two o’clock
position. The operator may ask the patient to turn his or
her head for optimum visibility. The syringe is held at a
45 degree angle to the long axis of the tooth with the
bevel facing the apex of the root. The needle is inserted
into the soft tissue and is advanced until bone is
contacted. A few drops of anesthetic should be
administered at this time. The needle is then advanced
into the interdental septum and 0.2cc of anesthetic
solution is deposited. Resistance to the flow of anesthetic
solution is expected and ischemia of the soft tissue
surrounding the injection site will ensue shortly after 44
anesthetic solution is administered.
Figure 17: Note the position of the needle 3mm
apical to the apex of the papillary triangle for the
intraseptal technique.
45
Periodontal Ligament (Intraligamentary Injection)

The periodontal ligament or intraligamentary injection

is a useful adjunct to the supraperiosteal injection or
a nerve block. Often, it is used to supplement these
techniques to achieve profound anesthesia of the
area to be treated. Indications for the use of this
technique are the need to anesthetize an individual
tooth or teeth, need for soft tissue anesthesia in the
immediate vicinity of a tooth, and partial anesthesia
following a field block or nerve block. A 25- or 27-
gauge short needle is preferred for this technique.

46
Technique- Identify the tooth or area of soft tissue to
be anesthetized. The sulcus between the gingiva
and the tooth is the injection site for the periodontal
ligament injection. Position the patient in the supine
position. For the right handed operator, retract the
lip with a retraction instrument held in the left hand
and stand where the tooth and gingiva are clearly
visible. The same applies for the left handed
operator except that the retraction instrument will be
held in the right hand. Hold the syringe parallel to
the long axis of the tooth on the mesial or distal
aspect. Insert the needle (bevel facing the root), to
the depth of the gingival sulcus (Fig. 10).
47
Figure 10: Clinical picture depicting a periodontal ligament
injection. Note the position of the needle between the
gingival sulcus and tooth with the needle parallel to the long
48

axis of the tooth

Advance the needle until resistance is met. A
small amount of anesthetic (0.2cc) is then
administered slowly over the course of twenty
to thirty seconds. It is normal to experience
resistance to the flow of anesthetic.
Successful execution of this technique
provides pulpal and soft tissue anesthesia to
the individual tooth or teeth to be treated.

49
 Intrapulpal Injection

Intrapulpal injection involves anesthesia of the

nerve within the pulp canal of the individual
tooth to be treated. When pain control cannot
be achieved by any of the aforementioned
methods, the intrapulpal method may be used
once the pulp chamber is open. There are no
contraindications to the use of this technique as
it is at times the only effective method of pain
control. A 25- or 27-gauge short needle is
preferred for this technique.

50
Technique- The patient should be in the supine position
with the chin tilted upward for visibility of the area to be
anesthetized. Identify the tooth to be anesthetized. The
right handed operator should be at the ten o’clock
position whereas the left handed operator should be at
the two o’clock position. Assuming that the pulp
chamber has been opened by an experienced dental
professional, place the needle into the pulp chamber
and deposit one drop of anesthetic. Advance the
needle into the pulp canal and deposit another 0.2cc of
local anesthetic solution. It may be necessary to bend
the needle in order to gain access to the chamber
especially with posterior teeth. The patient usually
experiences a brief period of significant pain as the
solution enters the canal followed by immediate pain 51
relief.
52
 Regional Anesthesia
Maxillary
Clinical pearls

Techniques of Anesthesia for Treatment of a Quadrant or Multiple Teeth

TECHNIQUE AREA ANESTHETIZED

Maxillary

Maxillary molars (with exception of mesiobuccal root of

Posterior Superior Alveolar Nerve Block maxillary 1st molar
in some cases), hard and soft tissue on buccal aspect

Mesiobuccal root of maxillary 1st molar (in some cases),

Middle Superior Alveolar Nerve Block premolars and
surrounding hard and soft tissue on buccal aspect

Maxillary central and lateral incisors and canine, surrounding

Anterior Superior Alveolar Nerve Block/Infraorbital Nerve hard and soft tissue
Block on buccal aspect, mesiobuccal root of maxillary 1st molar (in
some cases)

Palatal mucosa and hard palate from 1st premolar anteriorly

Greater Palatine Nerve Block to posterior aspect of
the hard palate, and to midline medially

Hard and soft tissue of lingual aspect of maxillary anterior

teeth from distal of
Nasopalatine Nerve Block
canine on one side to distal of canine on the contralateral
side
53
Techniques of Maxillary Regional Anesthesia

The techniques most commonly employed in

maxillary anesthesia include supraperiosteal (local)
infiltration, periodontal ligament (intraligamentary)
injection, posterior superior alveolar nerve block,
middle superior alveolar nerve block, anterior
superior alveolar nerve block, greater palatine nerve
block, nasopalatine nerve block, local infiltration of
the palate, and intrapulpal injection. Of less clinical
application are the maxillary nerve block and
intraseptal injection.
54
 Posterior Superior Alveolar Nerve Block
1.Nerves anesthetized. Posterior superior
alveolar nerve.
 2. Areas anesthetized. The maxillary molars, with
the exception of the mesiobuccal root of the first
molar; the buccal alveolar process of the maxillary
molars including the overlying structures‑periosteum,
connective tissue, and mucous membrane.
 3.Anatomical landmarks
a. Mucobuccal fold and its concavity
 b. Tuberosity of the maxilla
 4. Indications. For operative procedures of the
molar teeth and supporting structures. This injection
must be combined with palatal injection when
instrumentation extends into this area. 55
 
 5. Needle Pathway during insertion. The needle
penetrates the mucosa and possibly the buccal pad of
fat. It penetrates the posterior fibers of the buccinator
muscle.
Technique- Identify the height of the mucobuccal fold
over the 2nd molar. This will be the injection site. The
right handed operator should stand at the nine o’clock to
ten o’clock position whereas the left handed operator
should stand at the two o’clock to three o’clock position.
Retract the lip with a retraction instrument. Hold the
syringe with the bevel toward the bone. Insert the needle
at the height of the mucobuccal fold above the maxillary
2nd molar at a 45 degree angle directed superiorly,
medially, and posteriorly (one continuous movement).
Advance the needle to a depth of three quarters of 56 its
total length (Fig. 11, A and B).
No resistance should be felt while advancing the
needle through the soft tissue. If bone is contacted,
the medial angulation is too great. Slowly retract the
needle (without removing it) and bring the syringe
barrel toward the occlusal plane. This will allow the
needle to be angulated slightly more lateral to the
posterior aspect of the maxilla. Advance the needle,
aspirate, and inject one cartridge of anesthetic
solution slowly over the course of one minute
aspirating frequently during the administration. Prior
to injecting, one should aspirate in two planes to
avoid accidental injection into the pterygoid plexus.
After the first aspiration, the needle should be
rotated one quarter turn.
57
The operator should then reaspirate. If
positive aspiration occurs, slowly retract the
needle one to two millimeters and reaspirate
in two planes. Successful injection technique
will result in anesthesia of the maxillary
molars (with the exception of the
mesiobuccal root of the first molar in some
cases), and associated soft tissue on the
buccal aspect.

58
 Middle Superior Alveolar Nerve Block
The middle superior alveolar nerve block is useful for
procedures where the maxillary premolar teeth or the
mesiobuccal root of the 1st molar require anesthesia.
Although not always present, it is useful if the
posterior or anterior superior alveolar nerve blocks or
supraperiosteal infiltration fails to achieve adequate
anesthesia. Individuals in whom the MSA nerve is
absent, the PSA and ASA nerves provide innervation
to the maxillary premolar teeth and the mesiobuccal
root of the 1st molar. Contraindications include acute
inflammation and infection in the area of injection or a
procedure involving one tooth where local infiltration
will be sufficient. A 25- or 27-gauge short needle is
preferred for this technique. 59
Technique- Identify the height of the mucobuccal
fold above the maxillary 2nd premolar. This will be
the injection site. The right handed operator should
stand at the nine o’clock to ten o’clock position
whereas the left handed operator should stand at the
two o’clock to three o’clock position. Retract the lip
with a retraction instrument and insert the needle
until the tip is above the apex of the 2nd premolar
tooth (Fig. 12, A and B). Aspirate and inject two
thirds to one cartridge of anesthetic solution slowly
over the course of one minute. Successful execution
of this technique provides anesthesia to the pulp,
surrounding soft tissue and bone of the 1st and 2nd
premolar teeth and mesiobuccal root of the 1st
molar. 60
 Anterior Superior Alveolar Nerve Block/Infraorbital
Nerve Block
The anterior superior alveolar (ASA) nerve block or
infraorbital nerve block is a useful technique for
achieving anesthesia of the maxillary central and
lateral incisors and canine as well as the surrounding
soft tissue on the buccal aspect. In patients that do
not have an MSA nerve, the ASA nerve may also
innervate the premolar teeth and mesiobuccal root of
the 1st molar. Indications for the use of this technique
include procedures involving multiple teeth and
inadequate anesthesia from the supraperiosteal
technique. A 25 gauge long needle is preferred for
this technique.
61
Nerves anesthetized. Intraorbital, anterior,
and middle superior alveolar nerves;
inferior palpebral, lateral nasal, and
superior labial.

2. Areas anesthetized. Incisors, cuspids,

bicuspids, and mesiobuccal root of the
first molar on the side injected, including
bony support and soft tissue; upper lip
and a portion of the nose on the same
side.
62
3. Anatomical landmarks. Infraorbital ridge,
infraorbital depression, supraorbital notch,
infraorbital notch, anterior teeth, and pupils of the
eyes.

4. Indications. When the anterior and middle

superior alveolar nerves are to be blocked, any
procedures, surgical or operative, may be
performed on the five anterior maxillary teeth on
the same side of the median line. Midline or
overlapping innervation should be considered.

63
5. Needle pathway during insertion
a. Bicuspid approach. The needle passes through
the mucosa and areolar tissue and during insertion
should go beneath and lateral to the external
maxillary artery and the anterior facial vein.
b. Central incisor approach. The needle passes
through mucosa and areolar tissue and beneath
the angular bead of the quadratus labii superioris
muscle. It proceeds anterior to the origin of the
Caninus muscle and beneath the external
maxillary artery and the anterior facial vein.

64
7. Symptoms of anesthesia

a. Subjective. Tingling and numbness of the upper

lip on the side affected will always be present but
are not necessarily an indication of good
anesthesia, since the superior labial nerve to the
upper lip may be blocked while the anterior superior
alveolar nerve remains unaffected. Closing the
teeth together may give some indication of the
anesthesia status. The only positive indication is
testing.
b. Objective. Instrumentation will demonstrate
absence of sensation.
65
Technique- Place the patient in the supine position.
Identify the height of the mucobuccal fold above the
maxillary 1st premolar. the This will be the injection site.
The right handed operator should stand at the ten o’clock
position whereas the left handed operator should stand at
the two o’clock position. Identify the infraorbital notch on
the inferior orbital rim (Fig. 13, A). The infraorbital
foramen lies just inferior to the notch usually in line with
the second premolar. Slight discomfort is felt by the
patient when digital pressure is placed on the foramen. It
is helpful but not necessary to mark the position of the
infraorbital foramen. Retract the lip with a retraction
instrument while noting the location of the foramen. Orient
the bevel of the needle toward bone and insert the needle
at the height of the mucobuccal fold above the 1st
66
premolar (Fig. 13, B).
Figure 13, A: Location of the infraorbital
nerve. B: The needle is kept parallel to the
long axis of the maxillary 1st premolar and
inserted at the height of the mucobuccal
fold above the 1st premolar.

67
The syringe should be angled toward the
infraorbital foramen and kept parallel with the long
axis of the 1st premolar to avoid hitting the
maxillary bone prematurely. The needle is
advanced into the soft tissue until the bone over
the roof of the foramen is contacted. This is
approximately half the length of the needle
however, this will vary from individual to individual.
After aspiration, approximately one half to two
thirds (0.9-1.2cc) of the anesthetic cartridge is
deposited slowly over the course of one minute.

68
It is recommended that pressure be kept
over the site of injection to facilitate the
diffusion of anesthetic solution into the
foramen. Successful execution of this
technique results in aesthesia of the lower
eyelid, lateral aspect of the nose, and the
upper lip. Pulpal anesthesia of the maxillary
central and lateral incisors, canine, buccal
soft tissue, and bone is also achieved. In a
certain percentage of people, the premolar
teeth and the mesiobuccal root of the 1st
molar is also anesthetized.
69
Figure 11, A: Location of the PSA nerve. B: Position of the
needle during the PSA nerve block. The needle is inserted at
the height of the mucobuccal fold above the maxillary 2nd
molar at a 45 degree angle aimed superiorly, medially and
posteriorly. 70
Greater Palatine Nerve Block (Anterior palatine nerve
Block)
The greater palatine nerve block is useful when
treatment is necessary on the palatal aspect of the
maxillary premolar and molar dentition. This
technique targets the area just anterior to the greater
palatine canal. The greater palatine nerve exits the
canal and travels forward between the bone and soft
tissue of the palate. Contraindications to this
technique are acute inflammation and infection at the
injection site. A 25- or 27-gauge long needle is
preferred for this technique.

71
1.Nerves anesthetized. Anterior palatine
nerve as it leaves the greater palatine
foramen.

2. Areas anesthetized. Posterior portion of

the hard palate and overlying structures
up to the first bicuspid area on the side
injected. At the first bicuspid area,
branches of the nasopalatine nerve will be
met.

72
3. Anatomical landmarks
a. Second and third maxillary molars
b. Palatal gingival margin of second and third
maxillary molars
c. Midline of the palate
d. A line approximately 1 cm. from the palatal
gingival margin toward the midline of the palate

4. Indications
a. For palatal anesthesia to be used in
conjunction with the posterior superior alveolar
block or middle superior alveolar nerve block.
b. For surgery of the posterior portion of the hard
palate. 73
6. Symptoms of anesthesia
a. Subjective. Feeling of numbness in posterior palate
when contacted with the tongue.
b. Objective. Instrumentation necessary to demonstrate
absence of pain sensation.

Technique- The patient should be in the supine position

with the chin tilted upward for visibility of the area to be
anesthetized. The right handed operator should stand
at the eight o’clock position whereas the left handed
operator should stand at the four o’clock position. Using
a cotton swab, locate the greater palatine foramen by
placing it on the palatal tissue approximately one
centimeter medial to the junction of the 2nd and 3rd
molar (Fig. 14, A and B). 74
Figure 14, A: Location of the greater palatine
nerve. B: Area of insertion for the greater palatine
nerve block is one centimeter medial to the
junction of the maxillary 2nd and 3rd molars

75
While this is the usual position for the foramen, it may
be located slightly anterior or posterior to this location.
Gently press the swab into the tissue until the
depression created by the foramen is felt. Malamed
and Trieger found that the foramen is found medial to
the anterior half of the 3rd molar approximately 50%
of the time, medial to the posterior half of the 2nd
molar approximately 39% of the time and medial to
the posterior half of the 3rd molar approximately 9% of
the time.6 The area approximately one to two
millimeters anterior to the foramen is the target
injection site. Using the cotton swab, apply pressure
to the area of the foramen until the tissue blanches.

76
Aim the syringe perpendicular to the injection site
which is one to two millimeters anterior to the
foramen. While keeping pressure on the foramen,
inject small volumes of anesthetic solution as the
needle is advanced through the tissue until bone is
contacted. The tissue will blanch in the area
surrounding the injection site. Depth of penetration is
usually no more than a few millimeters. Once bone is
contacted, aspirate and inject approximately one
fourth (0.45cc) of anesthetic solution. Resistance to
deposition of anesthetic solution is normally felt by
the operator. This technique provides anesthesia to
the palatal mucosa and hard palate from the 1st
premolar anteriorly to the posterior aspect of the
hard palate and to the midline medially. 77
 Nasopalatine Nerve Block

The nasopalatine nerve block, otherwise known as

the incisive nerve block and sphenopalatine nerve
block, anesthetizes the nasopalatine nerves
bilaterally. In this technique anesthetic solution is
deposited in the area of the incisive foramen. This
technique is indicated when treatment requires
anesthesia of the lingual aspect of multiple anterior
teeth. A 25- or 27-gauge short needle is preferred for
this technique.

78
1. Nerves anesthetized. Nasopalatine nerve as it
emerges from the anterior palatine foramen.

2. Areas anesthetized. The anterior portion of the

hard palate and overlying structures back to the
bicuspid area where branches of the anterior
palatine nerve coursing forward create a dual
innervation.

3. Anatomical landmarks
a. Central incisor teeth
b. Incisive papilla in the midline of the palate

79
 4. Indications. For palatal anesthesia.
a. To supplement the block of the anterior and
middle superior alveolar nerves.
b. To augment anesthesia of the six maxillary
incisors.
c. To complete anesthesia of the nasal septum.

6. Symptoms of anesthesia
a. Subjective. Feeling of numbness in palate
when contacted with the tongue.
b. Objective. Instrumentation necessary to
demonstrate absence of pain sensation.
80
Technique- The patient should be in the supine
position with the chin tilted upward for visibility of the
area to be anesthetized. The right handed operator
should be at the nine o’clock position whereas the
left handed operator should be at the three o’clock
position. Identify the incisive papillae. The area
directly lateral to the incisive papilla is the injection
site. With a cotton swab, hold pressure over the
incisive papilla. Insert the needle just lateral to the
papilla with the bevel against the tissue (Fig. 15, A
and B). Advance the needle slowly toward the
incisive foramen while depositing small volumes of
anesthetic and maintaining pressure on the papilla.
81
Once bone is contacted, retract the needle
approximately one millimeter, aspirate, and inject
one fourth (0.45cc) of a cartridge of anesthetic
solution over the course of thirty seconds.
Blanching of surrounding tissues and resistance
to the deposition of anesthetic solution is normal.
Anesthesia will be provided to the soft and hard
tissue of the lingual aspect of the anterior teeth
from the distal of the canine on one side to the
distal of the canine on the opposite side.
Figure 15 A: Location of the nasopalatine nerve. B:
Insertion of the needle just lateral to the incisive papilla
for the nasopalatine nerve block.
82
 Regional Anesthesia

Mandibular

Clinical pearls

Techniques of Anesthesia for Treatment of a Quadrant or Multiple Teeth

TECHNIQUE AREA ANESTHETIZED

Mandibular

Mandibular teeth on side of injection, buccal and

Inferior Alveolar Nerve Block
lingual hard and soft tissue, lower lip

Buccal Nerve Block Buccal soft tissue of molar region

Buccal soft tissue anterior to mental foramen, lower lip,

Mental  Nerve Block
chin

Premolars, canine and incisors, lower lip, skin over the

Incisive Nerve Block
chin, buccal soft tissue anterior to the mental foramen

83
 Techniques of Mandibular Regional Anesthesia

Techniques used in clinical practice for the anesthesia

of the hard and soft tissues of the mandible include the
supraperiosteal technique, intrapulpal anesthesia,
intraseptal injection, inferior alveolar nerve block, long
buccal nerve block, , mental nerve block, and incisive
nerve block.
The supraperiosteal, intrapulpal, and intraseptal
techniques are executed in the same manner as
described above for maxillary anesthesia. When
anesthetizing the mandible the patient should be in the
semisupine or reclined position. The right handed
operator should stand at the nine o’clock to ten o’clock
position whereas the left handed operator should stand
at the three o’clock to four o’ clock position. 84
 Inferior Alveolar Nerve Block
The inferior alveolar nerve block is one of the most
commonly employed techniques in mandibular
regional anesthesia. It is extremely useful when
multiple teeth in one quadrant require treatment.
While effective, this technique carries a high failure
rate even when strict adherence to protocol is
maintained. The target for this technique is the
mandibular nerve as it travels on the medial aspect
of the ramus, prior to its entry into the mandibular
foramen. The lingual, mental, and incisive nerves
are also anesthetized. A 25 gauge long needle is
preferred for this technique.
85
1. Nerves anesthetized. Inferior alveolar nerve
and its subdivisions, mental nerve, incisive
nerve, and, occasionally, the lingual and the
buccinator nerves, which are branches of the
mandibular nerve.

2. Areas anesthetized
a. Body of the mandible and an inferior portion of
the ramus
b. Mandibular teeth
c. Mucous membrane and underlying tissues
anterior to the first mandibular molar
86
3.Anatomical landmarks
a. Mucobuccal fold
b. Anterior margin of ramus of the mandible,
c. External oblique ridge
d. Retromolar triangle
e. Internal oblique ridge
f. Pterygomandibular ligament
g. Buccal sucking pad
h. Pterygomandibular space
`4. Indications
a. Analgesia for operative dentistry on all the
mandibular teeth.
b. Surgical procedures on mandibular teeth and
supporting structures
c. Diagnostic and therapeutic purposes. 87
Figure 18 A: Location of the inferior alveolar nerve. B: After
contacting bone, the needle is redirected posteriorly by
bringing the barrel of the syringe towards the occlusal plane.
The needle is then advanced to three quarters of its depth.
88
Technique- The patient should be in the semisupine
position. The right handed operator should be in the
eight o’clock position whereas the left handed
operator should be in the four o’clock position. With
the mouth open maximally, identify the coronoid
notch and the pterygomandibular raphae. Three
quarters of the anteroposterior distance between
these two landmarks, and approximately six to ten
millimeters above the occlusal plane is the injection
site. Use a retraction instrument to retract the cheek
and bring the needle to the injection site from the
contralateral premolar region. As the needle passes
through the soft tissue, deposit one or two drops of
anesthetic solution. 89
Advance the needle until bone is contacted. Once bone
is contacted, withdraw the needle one millimeter and
redirect the needle posteriorly by bringing the barrel of
the syringe towards the occlusal plane (Fig. 18, A and
B). Advance the needle to three quarters of its depth,
aspirate, and inject three quarters of a cartridge of
anesthetic solution slowly over the course of one
minute. As the needle is withdrawn, continue to deposit
the remaining one quarter of anesthetic solution so as
to anesthetize the lingual nerve (Fig. 18, C).
Successful execution of this technique results in
anesthesia of the mandibular teeth on the ipsilateral
side to the midline, associated buccal and lingual soft
tissue, lateral aspect of the tongue on the ipsilateral
side, and lower lip on the ipsilateral side. 90
9. Symptoms of anesthesia
a. Subjective. Tingling and numbness of the lower
lip and, when the lingual nerve is affected, the tip
of the tongue.
b. Objective. Instrumentation necessary to
demonstrate absence of pain sensation.

Figure 18 C: Location of the lingual nerve which is

anesthetized during the administration of an
inferior alveolar nerve block.

91
 Lingual nerve block

1. Nerves anesthetized. Lingual nerve, a branch

of the mandibular nerve.

2. Areas anesthetized
a. Anterior third of the tongue and the floor of
the oral cavity.
b. Mucosa and mucoperiosteurn on the
lingual side of the mandible.

3. Anatomical landmarks. Same as for the

inferior alveolar nerve.

92
4. Indications. For surgical procedures of the
anterior third of the tongue, floor of the oral cavity,
and mucous membrane on the lingual side of the
mandible.

5. Technique. Same as for the inferior alveolar

nerve, as previously described.

6.Symptoms of anesthesia
a. Subjective. Tingling and numbness of anterior
third of the tongue.
b. Objective. Instrumentation necessary to
demonstrate absence of pain sensation.
93
 Buccal Nerve Block
The buccal nerve block, otherwise known as the
long buccal or buccinator block, is a useful
adjunct to the inferior alveolar nerve block when
manipulation of the buccal soft tissue in the
mandibular molar region is indicated. The target
for this technique is the buccal nerve as it passes
over the anterior aspect of the ramus.
Contraindications to the procedure include acute
inflammation and infection over the site of
injection. A 25 gauge long needle is preferred for
this technique.

94
1. Nerves anesthetized. Buccinator nerve, a branch of
the mandibular nerve.
2. Areas anesthetized. Buccal mucous membrane
and mucoperiosteum of the mandibular molar area.
3. Anatomical landmarks
a. External oblique ridge
b. Retromolar triangle
4. Indications. Surgery on the mandibular buccal
mucosa and to supplement the inferior alveolar
nerve block.
5. Symptoms of anesthesia. No subjective symptoms;
therefore, area must be tested by instrumentation.

95
Technique- The patient should be in the semisupine
position. The right handed operator should be in the
eight o’clock position whereas the left handed
operator should be in the four o’clock position.
Identify the most distal molar tooth on the side to be
treated. The tissue just distal and buccal to the last
molar tooth is the target area for injection (Fig. 19, A
and B). Use a retraction instrument to retract the
cheek. The bevel of the needle should be toward
bone and the syringe should be held parallel to the
occlusal plane on the side of the injection.

96
The needle is inserted into the soft tissue and
a few drops of anesthetic solution are
administered. The needle is advanced
approximately one or two millimeters until
bone is contacted. Once bone is contacted
and aspiration is negative, 0.2cc of local
anesthetic solution is deposited. The needle
is withdrawn and recapped. Successful
execution of this technique results in
anesthesia of the buccal soft tissue of the
mandibular molar region.
Figure 19 A: Location of the buccal nerve. B: The
tissue just distal and buccal to the last molar tooth is the
target area for injection. 97
 Mental Nerve Block

The mental nerve block is indicated for

procedures where manipulation of buccal
soft tissue anterior to the mental foramen is
necessary. Contraindications to this
technique are acute inflammation and
infection over the injection site. A 25 or 27
gauge short needle is preferred for this
technique.

98
1.Nerves anesthetized. Mental nerve, a
branch of the inferior alveolar nerve.

2.Areas anesthetized
a. Lower lip
b. Mucous membrane in the mucolabial
fold anterior to the mental foramen

99
3. Anatomical landmarks. Mandibular
bicuspids, as the mental foramen usually
lies at the apex and just anterior to the
second bicuspid root.

4. Indications. For surgery on the lower lip

or mucous membrane
Techniques l Regional Anesthesia an
analgesia in the mucolabial fold anterior to
the mental foramen when for some reason
the inferior alveolar block is not indicated.
100
5. Symptoms of anesthesia. Tingling and numbness
of the lower lip on the injected side will result.

6.Technique- The patient should be in the

semisupine position. The right handed operator
should be in the eight o’clock position whereas the
left handed operator should be in the four o’clock
position. The target area is the height of the
mucobuccal fold over the mental foramen (Fig. 21, A
and B). The foramen can be manually palpated by
applying gentle finger pressure to the body of the
mandible in the area of the premolar apicies.
101
The patient will feel slight discomfort upon
palpation of the foramen. Use a retraction
instrument to retract the soft tissue. The needle is
directed toward the mental foramen with the bevel
facing the bone. Penetrate the soft tissue to a
depth of five millimeters, aspirate and inject
approximately 0.6cc of anesthetic solution.
Successful execution of this technique results in
anesthesia of the buccal soft tissue anterior to the
foramen, lower lip and chin on the side of the
injection.
Figure 21, A: Location of the mental and
incisive nerves. 102
Figure 21, B: Block of the mental and incisive
nerves: The needle is inserted at the height of
the mucobuccal fold over the mental foramen for
both the mental nerve block and incisive nerve
block.

103
 Incisive Nerve Block

The incisive nerve block is not as frequently

employed in clinical practice however it proves very
useful when treatment is limited to mandibular
anterior teeth and full quadrant anesthesia is not
necessary. The technique is almost identical to the
mental nerve block with one additional step. Both the
mental and incisive nerves are anesthetized using
this technique. Contraindications to this technique
are acute inflammation and infection at the site of
injection. A 25 or 27 gauge short needle is preferred
for this technique.
104
1. Nerves anesthetized
a. Incisor, branch, or continuation of the inferior
alveolar nerve
b. Mental nerve
2. Areas anesthetized
a. Mandible and overlying labial structures anterior
to the mental foramen
b. Bicuspids, cuspids, and incisors on the affected
side
c. Lower lip on the affected side
3. Anatomical landmarks. Same as for the mental
nerve block.

105
4. Indications. For anesthesia of the mandible
and labial mandibular structures, anterior to the
mental foramen and the lower lip when, for some
reason, the inferior alveolar nerve block is
contraindicated or unnecessary.

6. Symptoms of anesthesia
a. Subjective. Patient will experience numbness
and tingling of the lower lip.
b. Objective. Instrumentation will demonstrate
anesthesia of the anterior teeth and supporting
structures.

106
Technique- The patient should be in the semisupine
position. The right handed operator should be in the
eight o’clock position whereas the left handed
operator should be in the four o’clock position. The
target area is the height of the mucobuccal fold over
the mental foramen (See Fig. 21, B). Identify the
mental foramen as previously described. Give the
patient a mental nerve block as described above and
apply digital pressure at the site of injection during
administration of anesthetic solution. Continue to
apply digital pressure at the site of injection two to
three minutes after the injection is complete to aid
the anesthetic in diffusing into the foramen.
107
Successful implementation of this
technique provides anesthesia to the
premolars, canine, incisor teeth, lower lip,
skin of the chin, and buccal soft tissue
anterior to the mental foramen.1

Figure 21, B: Block of the mental and incisive nerves:

The needle is inserted at the height of the mucobuccal
fold over the mental foramen for both the mental nerve
block and incisive nerve block.

108