Techniques Of Local Anesthesia

Dr. Tahmasub Faraz Tayyab

Assistant Professor
Oral & Maxillofacial Surgery
 Learning Objectives
By the end of this session, student should be able to:
• Enlist nerve supply of maxillary and mandibular teeth,
labial and lingual/palatal mucosa.
• Advice local anesthetic technique for maxillary and
mandibular teeth.
• Describe various local anesthesia techniques in a
stepwise manner used in maxillary and mandibular teeth
extraction.
• Identify and manage complications associated with
various local anesthetic techniques.
 Local Anesthesia

• Local Infiltration

• Field Block

• Nerve block
 Nerve Supply of Maxillary teeth
Pulp and Labial Mucoperiosteum

Anterior teeth (1,2,3) Anterior Superior Alveolar Nerve

Premolars (4,5) and MB root of 1st molar Middle Superior Alveolar Nerve

Molars except MB root of 1st molar Posterior Superior Alveolar Nerve

Palatal Mucoperiosteum

Anterior teeth (1,2,3) Nasopalatine nerve

Posterior teeth, Molars & Premolars Greater palatine nerve

(4,5,6,7, & 8)
 Maxillary Local Anesthesia
• Local Infiltration
• Posterior Superior Alveolar Nerve Block
• Middle Superior Alveolar Nerve Block
• Anterior Superior Alveolar Nerve Block
• Nasopalatine Nerve Block
• Greater Palatine Nerve Block
• Maxillary Nerve Block
 Supra periosteal Injections

• Commonly known as local infiltration.

• Most frequently used technique.
Areas Anesthetized:
• Dental plexus i.e. pulp, root area of tooth.
• Buccal periosteum.
• Connective tissue & mucous membrane.
Indications:
• Pulpal anesthesia of one or two teeth when treatment is
limited to one or two teeth.
• Soft tissue anesthesia when indicated for surgical
procedures in circumscribed areas.

Contraindications:
• Infection or acute inflammation in the area of injection.
• Dense bone covering the apices of teeth.
Advantages:
• High success rate.
• Technically easy injection.
• Usually entirely atraumatic.

Disadvantages:
• Not recommended for large areas, because of multiple
needle insertions, & large volume of anesthetic solution
deposition.
Technique:
• 25 or 27 gauge small needle.
• Needle insertion at height of mucco-buccal fold, above tooth
apex.
• Slow injection over a period of 20sec, do not permit the
tissue to balloon.
 Posterior Superior Alveolar Nerve
Block
Areas Anesthetized:
• Pulps of maxillary 3rd, 2nd & 1st molars.
• Buccal periodontium & bone overlying these teeth.
Indications:
• When two or more maxillary molars have to be treated.
Contraindications:
• Risk of hemorrhage is great
Advantages:
• Atraumatic.
• High success rate.
• Minimum number of pricks.
• Minimizes total volume of anesthetic solution deposition.
Disadvantages:
• Risk of hematoma.
Technique:
• 25 gauge needle recommended.
• Bevel of needle towards bone, partially open mouth.
• Pull mandible to side.
• Insert needle over 2nd molar into height of muccobuccal fold.
• Advance needle in one go upward at 45°, Inward medially at
45° & backward posteriorly at 45° to long axis of tooth.
Middle Superior Alveolar Nerve Block

Areas Anesthetized:
• Pulps of maxillary 1st & 2nd premolars, MB root of 1st molar.
• Buccal periodontal tissue & bone over these same teeth.
Indications:
• procedures involving only premolars.
Contraindications:
• Infection/Inflammation in the area of injection.
Advantages:
• Minimizes no. of injections & vol. of solution.
Disadvantages:
• None
Technique:
• 25 or 27 gauge short needle.
• Needle insertion at height of mucco-buccal fold over premolar
area.
• Advance needle till its end is well above apex of 2nd premolar.
• Slowly deposit 0.9-1.2ml of solution.
Anterior Superior Alveolar Nerve Block:
Nerves Anesthetized:
• ASA nerve
• MSA nerve
• Infra orbital nerve
Indications:
• Procedures involving more than 2 maxillary teeth.
Advantages:
• Comparatively simple technique.
• Comparatively safe.
Disadvantages:
• Psychological fear.
• Difficult anatomic land marks.
Technique:
• 25 gauge long needle.
• Height of MB fold directly
over 1st premolar.
• Feel infraorbital foramen
& notch externally.
• Deposit solution slowly.
 Greater Palatine Nerve Block

Indications
• Palatal soft tissue anesthesia for more that one tooth.
• Pain control during periodontal or oral surgical procedures
involving palatal soft & hard tissue.
Contraindications:
• Inflammation or infection at injection site.
• Smaller areas of therapy.
Advantages:
Minimum needle penetration.
Minimum vol. of solution required.
Minimum patient discomfort.
Disadvantage:
No hemostasis except in the immediate area of injection.
Potentially traumatic.
Technique:
• 27 gauge short needle.
• At soft tissue slightly anterior to greater palatine nerve.
• Advance syringe from opposite side of mouth at right angle
to target area i.e 1-2 mm anterior to greater palatine
foramen.
• Minimum volume of solution 0.45-0.6ml.
 Nasopalatine Nerve Block
Indications:
• Palatal soft tissue anesthesia for more that one tooth.
• Pain control during periodontal or oral surgical procedures
involving palatal soft & hard tissue.
Contraindications:
• Inflammation or infection at injection site.
• Smaller areas of therapy.
Advantages:
• Minimum needle penetration.
• Minimum volume of solution required.
• Minimum patient discomfort.
Disadvantage:
• No hemostasis except in the immediate area of injection.
• Potentially the most traumatic injection of oral cavity.
Technique:
• 27 gauge needle.
• Target area is incisive foramen beneath incisive papilla.
Middle Anterior Superior Alveolar
Nerve Block
 Maxillary Nerve Block
High Tuberosity approach Greater palatine Approcah
 Nerve Supply of Mandibular Teeth
Teeth Pulpal nerve supply Buccal/ Labial Lingual
mucoperiosteum & Mucoperiosteum &
Gingiva Gingiva

Molars (6,7 & 8) Inferior alveolar nerve Long Buccal Nerve Lingual nerve

Premolars (4 & 5) -2nd premolar (5) is Mental nerve Lingual nerve

innervated by Inferior
alveolar nerve
-1st premolar (4) is
innervated by incisive
nerve

Anterior teeth (1,2 & Incisive nerve Mental nerve Lingual nerve
3)
 Mandibular Local Anesthesia

• Local Infiltration
• Inferior Alveolar Nerve Block
• Buccal Nerve Block
• Mental Nerve Block
• Incisive Nerve Block
• Gow Gates Mandibular Nerve Block
• Vazirani Akinosi Mandibular Nerve Block
 Inferior Alveolar Nerve Block
.
Nerves Anesthetised:
• Inferior alveolar Nerve
• Incisive Nerve
• Mental Nerve
• Lingual Nerve
Indications:
• Procedures on multiple mandibular teeth in one quadrant.
• Buccal soft tissue anesthesia anterior to 1st molar.
• Lingual soft tissue anesthesia.
Contraindication:
• Infection or acute inflammation.
• Very young or physically handicapped patient.
Advantages:
• One injection provides wide area of anesthesia.
Disadvantages:
• Intraoral land marks not consistently reliable.
• Lingual & lower lip anesthesia discomfort to many
patients.
Technique:
• 25 gauge long needle
• At mucous membrane on medial side of ramus at slightly
above occlusal level lateral to pterygomandibular raphe.
• 2/3rd of the needle should be inserted.
Causes of Failure
 Buccal Nerve Block
• Commonly called long buccal injection.
• Buccal nerve branch of anterior division of mandibular
nerve is blocked.
Indications:
• When buccal soft tissue anesthesia is required.
Contraindication:
• Infection or inflammation locally.
Advantage:
• High success rate.
• Technically easy.
Technique:
• 25 gauge long needle.
• In mucous membrane distal & buccal to most distal molar
tooth in arch.
• Penetrate the needle at the injection site about 2-4mm.
 Mental Nerve Block
• Mental nerve is anesthetized.
Indications
• Soft tissue biopsies in anterior mandible.
• Suturing of soft tissue
Advantages:
• high success rate.
• Technically easy
• Usually atraumatic
Disadvantages:
• Hematoma
Technique:
• 25 or 27 gauge short needle.
• In muccobuccal fold at or just anterior to mental foramen.
• Clinically foramen can be palpated between apices of
lower premolars.
• Depth of needle penetration is 5-6mm.
Gow Gates Mandibular Nerve Block
• Sensory anesthesia to entire distribution of ipsilateral
mandibular nerve.
• It has higher success rate than IANB.
Landmarks:
- lower border of tragus
-corner of mouth
- at the level of mesiolingual cusp of maxillary 2nd molar
- needle insertion distal to max. 2nd molar.
 Vazirani Akinosi Mandibular Block
Indications:
• Limited mouth opening
• Multiple procedure on mandibular teeth
• Inability to see landmarks of IANB.
Advantages:
• Relatively atraumatic
• Mouth opening not required
Technique:
Landmarks:
• Mucogingival junction of max. 3rd molar
• Max. tuberosity
• Coronoid notch
Periodontal Ligament Injection
THANK YOU
 References

• Hupp, James R., Edward Ellis, and Myron R. Tucker. Contemporary Oral and
Maxillofacial Surgery. St. Louis, Mo: Mosby Elsevier, 2008.
• Malamed S.F, Handbook of Local anesthesia. St. Louis, Mo: Mosby Elsevier, 2004.
• Milam, S & Giovannitti, Joseph. (1984). Local anesthetics in dental practice. Dental
clinics of North America. 28. 493-508.
• Images from google