Local Anesthesia

and
Nerve Block

Bipin Poudel
 Defined as loss of sensation in a
discrete region of the body caused by
disruption of impulse generation or
propagation.
 Classification

1. On the Basis of Source of Occurrence

• Naturally occurring, e.g. cocaine

• Synthetic compound
✔ Nitrogenous compound ; PABA, Lignocaine.
✔ Non-nitrogenous compounds, e.g. benzyl alcohol and propanediol.
 2. Based on chemical structure

Esters:- Esters of benzoic acid, e.g. cocaine, benzocaine

-Esters of PABA, e.g. procaine, chloroprocaine.

Amides, e.g. articaine, bupivacaine, dibucaine, etidocaine, lidocaine,

mepivacaine, prilocaine and ropivacaine
 3. Based on Duration of action

Ultra-short-acting agents (less than 30 minutes)

• Procaine without a vasoconstrictor
• 2% lidocaine without a vasoconstrictor

Short-acting agents (45–75 minutes)

• 2% lidocaine with 1:100,000 epinephrine
• 4% prilocaine when used for nerve block
Medium-acting agents (90–150 minutes)
• 4% prilocaine with 1:200,000 epinephrine

Long-acting agents (180 minutes or longer)

• 0.5% bupivacaine with 1:200,000 epinephrine
• 0.5% or 1.5% etidocaine with 1:200,000
 Ideal Properties of Local Anesthesia

• Non irritant and produce no local reaction to the tissues

• No permanent alteration of nerve structure
• No systemic toxicity or very low systemic toxicity
• Time of onset: short (rapid) onset of action
• Effective for topical, as well as when injected
• Sufficient duration of action
 Composition

• Local anesthetic agent: lignocaine HCL 2%

• Vasoconstrictors: Adrenaline, Nor-adrenaline
• Buffering agent: Nacl
• Anti-oxidant/stabilizer: Sodium metabisulphite
• Fungicide: Thymol
• Vechile: Distilled water
• Preservative: Methyl Paraben
 Vasoconstrictor
• Decrease blood flow to operation site
• Decrease absorption of LA into circulatory system
• Decrease toxic effect of LA by reducing plasma concentration
• Increase duration of local anesthesia
 LIGNOCAINE
• Most commonly used local anesthetic agent in dentistry

• It is amide and an acetanilide(xylidine)derivatives.

• It is a white crystalline powder with a melting point of 69°C and used
as hydrochloride salt.
• It is stable and can be stored for a long time at room temperature,
withstands boiling and autoclaving
• It is compatible with all types of vasoconstrictors
 LIGNOCAINE
• Time of onset of action – 2-3 minutes
• Duration of action – depends on type on injection and amount of
vasoconstrictor
• Effective dental concentration – 2%
• Anesthetic half-life – 1.6 hours
• Metabolism - in liver by microsomal fixed function oxidases
• Also in 2% jelly, 5% ointment; and 10% and 15% aerosol
Maximum recommended dose
• With a vasoconstrictor – 7 mg/kg BW but not to exceed 500 mg
• Without a vasoconstrictor – 4.4 mg/kg BW but not to exceed 300 mg
 COMPLICATIONS

• Generally safe if administered in an appropriate dosage and in the correct

anatomic location
• Toxicity - accidental intravascular or intrathecal injection or administration of
an unwanted excessive dose, allergic reactions to the aminoester drugs and
methemoglobinemia after the use of prilocaine.
 LOCAL COMPLICATIONS
• Complications arising from drugs – soft tissue injury, tissue necrosis

• Complications arising from injection techniques – breakage of needle,

needle-stick injuries, hematoma
• Complications arising from both - pain on injection, burning on injection,
persistent paresthesia or anesthesia, persistent or prolonged pain,
postinjection herpetic lesions or postanesthetic intraoral lesions,
neurological complications: such as facial nerve paresis or paralysis and
visual disturbances: diplopia, amaurosis or temporary blindness.
 SYSTEMIC COMPLICATIONS
CNS CVS RESPIRATORY
Lightheadedness and Prolonged PR interval Depression of
dizziness and QRS complex hypoxic drive and
medullary center in
high doses
Difficulty focusing and Bradycardia Allergic reactions
tinnitus (bronchospasm)
Shivering, muscular Decreased myocardial Methemoglobinemia
twitching, tremors contractility

Generalized convulsion Ventricular arrhythmia

Respiratory depression and Hypotension
Nerve Blocks
Maxillary Anesthesia
Posterior Superior Alveolar Nerve Block (PSA)
 Posterior Superior Alveolar Nerve Block

❖ Landmarks:
– Mucobuccal fold
– Maxillary tuberosity
– Zygomatic process of maxilla

❖ Procedure:
– Advance 45 degrees to occlusal plane, inward, and backward (45 deg. to long
axis of 2nd molar)
– Deposit 1.5 ml of anesthetic solution and wait for 3-5 min before working
Needle inserted at height of mucobuccal fold
over 2nd molar

Areas anesthetized:
• Maxillary molars (except MB root of 1st molar)
• Buccal alveolar bone
• Soft tissues
Anterior Superior Alveolar Nerve Block (ASA)
At the height of the mucobuccal fold over
the 1st premolar

Areas anesthetized:
• Canines
• Lateral incisors
• Buccal alveolar bone
• Soft tissues
Middle Superior Alveolar Nerve Block (MSA)
At the height of mucobuccal
fold above maxillary 2nd
premolar

Areas anesthesized:
• Mesiobuccal root of 1st molar
• Premolars
• Alveolar bone
• Soft tissues
Palatal Anesthesia
Greater Palatine Nerve Block
 Greater Palatine Nerve Block

1cm medial from 1st /2nd maxillary

molar on the hard palate

Areas anesthetized:
• Hard palate
• Overlying mucosa from molars to
1st bicuspids
Nasopalatine Nerve Block
Mandibular Injection Technique
 Inferior Alveolar Nerve Block

❖ Target Area:
• Inferior alveolar nerve, near mandibular foramen

❖ Landmarks:
• Coronoid notch
• Pterygomandibular raphe
• Occlusal plane of mandibular posteriors
 Inferior Alveolar Nerve Block

❖ Nerves anesthetized: ❖ Areas Anesthetized:

▪ Inferior Alveolar ▪ Mandibular teeth to midline
▪ Mental ▪ Body of mandible, inferior ramus
▪ Incisive
▪ Lingual
▪ Buccal mucosa anterior to mental
foramen
▪ Anterior 2/3 tongue & floor of
mouth
 Buccal Nerve Block

• Provides buccal soft tissue anesthesia adjacent to mandibular

molars
❖ Target:
o Long Buccal nerve as it passes anterior border of ramus

❖ Landmarks:
o Mandibular molars
o Mucobuccal fold

❖ Contraindications:
• Infection/inflammation at injection site
 Mental Nerve Block

▪ Terminal branch of IAN as it exits mental foramen

▪ Provides sensory innervation to buccal soft tissue anterior to

mental foramen, lip and chin
❖ Indication:

• Need for anesthesia in innervated area

❖ Contraindication:

• Infection/inflammation at injection site

 Incisive Nerve Block

o Innervates the lower teeth anterior to the mental foramen to the

midline
o Anesthetic solution is deposited in the same area as the mental
block, but the incisive nerve runs inside the mental foramen
References

• Malik NA. Textbook of Oral and Maxillofacial Surgery. 4th ed.

• Berde CB, Strichartz GR. Local Anesthetics. In: Miller RD (eds). Miller’s
Anesthesia. 8th ed: Philadelphia: Elsevier; 2016.