Local Anaesthesia In Dentistry,

Techniques and Complications.

By
Dr. Okechi UC
Department of Oral and Maxillofacial Surgery.
University of Nigeria. Ituku/Ozalla Campus, Enugu.
 Basic Definitions As It Concerns Anaesthesia

• i. Anesthesia: Loss of all forms of sensation: Pain,

temperature, touch, pressure
• ii. Local: with in a given area, near by, within etc.
• iii. General: whole.
• iv. Analgesia: Loss of pain sensation only
• v. Pain: An unpleasant sensory and emotional
experience associated with actual or potential tissue damage
or described in terms of such damage.
 Why Do We Require L.A. in Dentistry?

• With the exception of a few non-invasive procedures, virtually

all procedures carried out in the practice of Dentistry will
result in pain.
• Therefore, to be able to carry out these procedures pain must
be eliminated.
• The oral and perioral structures are richly supplied with nerve
endings (nociceptors) that sub serve pain. These nerve
endings are of 2 types:
• finely myelinated A delta fibres and
• unmyelinated C fibres
 Why use L.A. Cont’d.
• These nociceptors are activated by intense or noxious stimuli.
Some nociceptors are unimodal and respond only to thermal
or mechanical stimuli while others are polymodal and
respond to mechanical, thermal and chemical stimuli.
• Nociceptors encode the intensity, duration, and quality of a
noxious stimulus.
• Stimulation of these nerve endings will result in pain,
irrespective of the agent i.e. mechanical, chemical etc.
 Overview of Pain Pathway
• The fifth cranial nerve (Trigeminal nerve) is
the sensory nerve of the oral region and these
impulses are conveyed along the relevant
branches (mandibular or maxillary) to the
central nervous system.
• (Remember that sensory impulses are
described as passing from the periphery to the
CNS and motor impulses from the CNS to the
periphery).
 Overview of Pain Pathway cont’d

• Information associated with pain is carried in the divisions of the CN V to

the trigeminal (Gasserian) ganglion.
• The central processes of these neurons enter the pons, where they
descend in the brainstem as the spinal trigeminal tract.
• Fibres from the spinal trigeminal tract synapse in the adjacent spinal
nucleus of the CN V at the medulla but extends up to the C2 of the spinal
cord where it merges with the dorsal gray matter.
• The nucleus caudalis which is the most caudal of the spinal nucleus is the
principal site in the brainstem for nociceptive information.
 Overview of Pain pathway cont’d

• Axons from the spinal nucleus of the CN V

cross to the opposite side and ascend to the
ventral posteromedia (VPM) nucleus of the
thalamus.
• At this point there are projections to the
reticular formation and the medial and intra
laminar thalamic nuclei.
• From the thalamus, neurons course and end
at the somatosensory cortex in the post
central gyrus.
 Advantages of L.A.
• It a safe, effective and convenient means of
obtaining anaesthesia for dental treatment
• Simple to carry out.
• Armamentarium is cheap, not bulky and easy
to transport (compare with the machine for
GA)
• Premed (preanaesthetic medication is not
routinely given)
 Advantages cont’d
• In most cases patient can return to his
workplace immediately
 Disadvantages/Contraindications

• Presence of infection at the site of injection.

This can spread the infection and the LA is
unlikely to be effective.
• Haemorrhagic disorders (haemophilia etc).
These patients require treatment in a hospital
setting.
• Pregnancy and cardiovascular disease may
require precaution with the use of certain
vasoconstrictors in local anaesthetics.
 Mechanism of Action
• At rest, the resting membrane potential within a peripheral
nerve is about -50 to -70mV i.e. negative, relative to the
outside.
• When such a nerve is stimulated, there is an initial slow
phase of depolarization during which the internal membrane
potential becomes less negative.
• As the potential difference between the interior and the
exterior of the nerve reaches the threshold potential, the
interior becomes positively charged (may reach 40mV).
 Mechanism of Action cont’d.
• Repolarisation soon sets in, restoring the resting membrane
potential.
• At rest, the negative charge of the peripheral nerve is due
largely to potassium ions and very little Na+ but as the nerve
is stimulated, membrane permeability is increased with
resultant influx of Na+.
• This is responsible for the depolarization. At the point of
maximum depolarization, Na+ passage is arrested and K+ pass
out of the cell.
• This effects a repolarisation of the cell membrane.
 Mechanism of Action cont’d.
• The movement of Na+ and K+ at the depolarization stage is passive as it
depends in a concentration gradient.
• After repolarisation, an ionic imbalance exits – i.e. too many Na+
intracellularly and too many K+ extracellulary.
• To restore the status quo the movement of ions is active as it is against
the ionic concentration gradient.
• Na+ is extruded by the Na pump and the energy for this is provided from
the oxidative metabolism for restoring ATP.
 Mechanism of Action cont’d.
• Other possible mechanisms for restoring the membrane potential may
include active transport of K+ or transport of K+ along the electrostatic
gradient between the resting cell and its environment.
• The chain reaction produced by the change in electric potential results in
the propagation of an impulse along the nerve.
• For myelinated nerves. The depolarization takes place at the nodes of
Renvier and the impulse travels in a sultatory manner while in
unmyelinated nerves, a depolarization segment activated the adjacent
segment.
 Pharmacology of L.As.
• By the application of the proper
pharmacological agent i.e. local anaesthetics,
reversible blockage of nerve conduction can
be obtained. These anaesthetic against are
either
• (a) Amino-esters or
• (b) Amino-amide
(i.e. either ester or amide linkage agents).
 Amino-esters
• Clinically useful amino-esters local
anaesthetics are esters of PABA (Para-amino-
benzoic acid).
• The prototype is procaine (Novocaine R)
which for many years was the standard L.A.
another agents in this category is Benzocaine,
used mainly as a topical anaesthetic
 Amino-amides
• The prototype agents is lignocaine which has been in use
since 1944.
• Due to its superior pharmacological properties it soon
replaced procaine which has been in use for about 40 years
before then.
• It is still the most commonly used L.A. in dentistry.
• Unlike procaine, lignocaine has topical action. Lignocaine is a
xylidide, other amide linkage as carbocaine) and prilocaine
(toludene variant of xylidide, sold as Citanest).
 Local anaesthetic Agents

• Lignocaine
• Uses
• Topical L.A. as 2% gel, 5% ointment or 10%
spray.
• Infiltration L.A.
• Regional L.A.
 Presentation of Lignocaine
• Strength – 2%
• Plain – without adrenaline – do not exceed 200mg
• With adrenaline – do not exceed 350mg
• 1.8ml or 2.2ml cartridge. The former is commoner.
• Each ml of 2% solution contains 20mg lignocaine (6mg NaCl,
0.012mg adrenaline HCl, 1mg methyl paraben 0.5mg sodium
metabisulphite and NaOH to adjust the pH).
 Lignocaine cont’d.
• Toxicity - CNS depression (drowsiness, and
sedation). Although tremors and convulsion
may occur
 Mepivacaine
• Uses- For infiltration and regional anaesthesia
• Lacks topical action
• Mepivacaine has a milder vasodilatory effect
than most other amides and so it may be
useful with patients for whom vasoconstrictor
is contraindicated and cannot receive 4%
prilocaine plain.
 Presentation of Mepivacaine
• As a 2% or 3% solution. The former is usually combined with
1:80,000 adrenaline while the latter is used without
adrenaline.
• In the US 2% mepivacaine, 1:20,000 levonordefrin and 3%
mepivacaine (plain).
• Do not exceed 5mg 1kg body weight (Thus 70kg person will
have a maximum dose of 350mg).
• Clinically, the properties of mepivacaine are similar to
lignocaine (ie onset and duration of action, potency and
toxicity)
• Toxicity
• Effects are those of C N S stimulation
 Contraindications of Mepivacaine

• Allergy to amide type L.A

• Liver disease
 Prilocaine
• Uses- infiltration and regional anaesthesia
• prilocaine is less toxic and less potent than
lidocaine or mepivacaine and provides a slightly
longer duration of action.
• lack topical properties
• It has low systemic toxically, below lignocaine
and this offers it several clinical advantages.
• Maximum dose should not exceed 400mg above
which there is a risk of methaemoglobineania.
 Prilocaine
• This is because it reduces the blood's oxygen-
carrying capacity in higher doses (doses greater
than maximum recommended dose)
• relatively contraindicated for use with patients at
risk for methemoglobinemia, patients with
problems of oxygenation such as sickle cell
anemia, cardiac/respiratory failure, and also for
patients who are receiving acetaminophen or
phenacetin because methemoglobin levels are
increased.
 Prilocaine
• Since prilocaine is also metabolized in the
lungs and kidneys, it is metabolized more
easily by the liver than lidocaine or
mepivacaine. In addition, it clears the kidneys
more rapidly than other amides.
 Prilocaine
• prilocaine plain have a milder vasodilatory
effect than most other amides and is the only
intermediate duration plain local anesthetic.
• It can be a good choice for patients for whom
vasoconstrictor is contraindicated.
 Presentation of Prilocaine
• as a 3% 45 solution with each cartridge
• containing 50mg of prilocaine HCl. Felypressin
or adrenaline can be used as vasoconstrictor.
 Contraindications of Prilocaine

• Infancy
• Hypoxia
• Heart failure
• Liver disease
• The latter is of value in patient with
cardiovascular disease.
 Articaine
• Articaine has been available in Europe since
1976, but was not marketed in the United States
until 2000.
• It is the second most popular local anesthetic in
the U.S., currently holding 35.6% of the U.S.
market share, and is the leading dental
anesthetic in Canada and Europe
• Classified as an amide with amide and ester
characteristics, it is 1.5 times more potent than
lidocaine and has similar toxicity.
 Articaine
• In the U.S., it is compounded with epinephrine
as 4% articaine, 1:100,000 epinephrine and
4% articaine, 1:200,000 epinephrine.
• Biotransformation occurs both in the plasma
and the liver.
• The elimination half-life of articaine is only 44
minutes (> 2x ) as fast as all other amide
agents, resulting in a decreased risk of system
toxicity.
 Articaine
• This is significant, particularly, for patients for
whom a higher rate of biotransformation may
be desired (children, medically compromised,
pregnant, nursing, liver disease, etc.).
• Absolutely contraindicated in patients with a
known history of hypersensitivity to local
anesthetics of the amide type, or in patients
with known bisulfite allergy.
 Mechanism Of Action of L.As.

• Local anaesthetic agent interferes with nerve

conduction by decreasing the rate of rise of
the depolarizing phase of the action potential
– by reducing the influx of Na+.
• The membrane resting potential is not
influenced, the critical threshold potential is
not attained and no action potential is fired
and thus no nerve conduction.
 Mech. Of Action Cont’d.
• The site of action is at the axon membrane where the L.A
interacts with specific receptors.
• These sites are probably wears the Na+ channels on the
external and internal surfaces of the membrane. L a agent
appear to affect only the internal receptor sites
• Form of action of L A agent – The L A Exists as a solution with
a free base as positively charged ions.
• Alkaloid base penetrates biological membranes most easily
and it this taken up by the lipids in the nerve fibre.
 Vasoconstrictors
• Adrenaline (epinephrine) present in a range of
1:50,000-100,000.
• The 1:80.00 solutions is most widely used
• - Felypressin (octapressin) – 0.03mg/ml
(1:2000, 000).
• Their presence in a L A solution confers the
certain advantages
 Advantages of Vasoconstrictors + L.A .
• It increase the depth and duration of action
of the LAA. This duration of action depends
on the concentration of the cationic form
around the axons.
• Reduction in systemic toxicity as it slows the
absorption of the LAA.
• It produces a relatively bloodless field of
operation.
 Precautions
• Adrenaline – use with caution in hypertensive patient. (2) Use
with caution in patients
• Undergoing general anaesthesia with halothane or related
agent as there is a risk of arrhythmias
• Felypressin: Do not exceed 8.8ml in patient is ischemic heart
disease
• risk of tachycardia
• Pregnancy. Felypressin may have an oxytocic effect
 Reducing agent
• An oxidized L. A solution will turn brown.
• Avoid exposure to sunlight. In fact bottles of
lignocaine with adrenaline are colored brown
to reduce the effect of sunlight.
• The reducing agent in use is sodium
metabisulphite
 Preservative
• Inclusion of caprylhydrocuprienotoxin ensures
the stability and shelf life of the L A solution.
 Fungicide
• Thymol is added to L A. as a fungicide.
• Cloudy L A solution means that fungi have
grown in it.
 Vehicle
• Modified ringers lactate.
• This is an isotonic solution that help reduce
the pain of injection.
 Armamentarium for L.A.
1. Dental syringe: This comes in various types
• All metal reuseable, steriliseable)
• Plastic (disposable/single use)
• Breech Loading
• Side loading
• Non-aspirating
• Aspirating
 Armamentarium cont’d.
• The dental syringe has a barrel and a plunger.
• The breech loading type has a spring loaded
hinge mechanism that allows opening and
insertion of the cartridge.
• In practice, the aspirating syringe is preferred
as it prevents intravascular injections.
 Armamentarium cont’d.
2. Cartridges: These are made either of glass or plastic and are
usually of 2.2 ml or 1.8 ml capacity.
• Cartridges are single use items and any remaining solution is
discarded.
• Cartridges may differ in their sealing caps.
• The commonest design is the metal cap with a rubber
centre.
• Others are an all metal cap or an all rubber cap.
 Armamentarium cont’d.
3. The dental needle: This is designed such hat it sticks out of
both ends of the hub (the plastic screw portion).
• One end pierces the cartridge and the other the soft tissues.
• Dental needles are single use items.
• No attempt should be made to reuse them or sterilize them.
• They are available in two sizes – (i) long and (ii) short and
usually, there are colour – codes (yellow for long and blue for
short).
 Armamentarium cont’d.
• Long needles measure about 3.5 cm long are
usually employed for regional techniques.
• Short needles are 2 - 2.5 cm long and are used
for infiltrations.
• Needles are beveled at their tips for easier
penetration of the soft tissues.
 Armamentarium cont’d.
• Notes on use of needle
• Bevel of needle should face bone
• Avoid unnecessary movement of the needle within the tissues to reduce
risk of fracture
• Always ensure a portion of the needle is sticking out of the tissues when
in use. This gives you something to grasp in the event of a needle fracture.
• It is also a good guide when giving the inferior alveolar nerve block.
• By the time your needle disappears and you have not struck bone, your
technique is most likely faulty and the needle should be withdrawn and
technique re-assessed.
 Techniques of L.A.
1. Preparation of the Patient
• Virtually everyone dreads injections.
• The dental clinic is the site of unpleasant memories for many
patients so before administering L.A., the dentist must
reassure the patient.
• Full disclosure is probably the best i.e. “I am going to give an
injection that may hurt a little”.
• In the upper jaw, it is probable better to give the buccal
injection before the palatal as the latter is more painful.
 Preparation of Patient cont’d.
• A good proportion of adult patients will be initially
uncooperative but eventually the dentist will win them over.
• Never lose your patience with a patient.
• For really anxious and unco-operative patients, consider
premedication.
• Diazepam can be given nocte some nights before treatment,
midazolam is also a short acting hypnotic I have found useful
for the overly anxious patient.
 2. Patient position for local anesthesia

• This should be the same as for the procedure the patient is being given
the L.A. for.
• This is best practice as it avoids unnecessary movement of the dental
chair and the dental light.
• Remember that by the time L.A is being given, you are gloved and should
not really touch non-sterile items like the chair light or adjust the dental
chair.
• This is a common reason for loss of marks at the Final BDS – a student
who is operating the dental chair or light with his/her gloved hand. So
position the patient for the procedure proper. L.A is part of the
procedure.
 Patient’s position cont’d.
• Generally, when working on the lower jaw, the occlussal
plane of the lower jaw should be slightly below the operator’s
elbow, and horizontal to the floor – so some reclination of the
dental chair is required.
• For the upper teeth, the occlusal plane should be at about the
height of the operator’s shoulder.
• At this point, the patient should be comfortable on the dental
chair and all tight clothing that my obstruct blood flow to the
head and neck should be loosened e.g. belts, ties and tight
collars.
 Patient’s Preparation cont’d.
• So I do not want to see you treating patients
with their ties especially on.
• There should be adequate visibility.
• Do not give L.A. when you cannot see the
injection site
 Preparation of the Mucosa
1. Just as the skin is prepared before an I.M. or I.V. injection,
the oral mucosa should ideally be prepared before L.A. is
given. Solutions to be used include.
• 0.5% chlorhexidine
• Providine iodine
• These are applied over the injection site for about 15 seconds.
• This step is most often omitted when giving L.A. because
injection abscesses are rare intra orally.
 Mucosal Preparation cont’d.
• 2.Topical Anaesthesia – The site of injection for the L.A can be
anaesthetized prior to the injection by using a topical L.A.
• Pre-injection topical anaesthesia can be accomplished with
sprays or ointment. Sprays are difficult to restrict to the
intended injection site.
• Ointments or gels may be preferred and should be applied on
a cotton roll and placed at the injection site.
• A minimum of 2 minutes is required if effective topical
anaesthesia is to be achieved.
 Preparing the syringe
• This should be done out of the view of the patient.
• The sequence is as follows:
1) Open the needle. This is most efficiently done by locating
the seal and then snapping if off or by twisting. Remember
that at this stage you should appear very professional and
you should not be seen to fumble with your instruments. (I
prefer the former since it is more precise).
 Sequence cont’d.
2)Screw the needle unto the syringe.
• An efficient way is by first pressing the hub firmly unto the
syringe before twisting and maintaining the pressure while
twisting.
3)Load the cartridge –
• either through the breach or through the side depending on
the design of the syringe. Then with the fingers (gloved)
slide the cartridge to ensure that it engages the free end of
the needle inside the syringe.
 Sequence cont’d
4) Press gently on the plunger – to eject a small
amount of L.A solution. This ensures that
– The needle is patent – on occasion the needle is
blocked (or may have bent during insertion of
the cartridge) and it while within the tissues that
the dentist discovers this. Not good practice.
 4b: Gentle pressure on Plunger:
• Frees the rubber bung at the base of the
cartridge as it tends to stick to the glass with
storage, if this is not done prior to the
injection, a too rapid pressure is applied to
inject within the tissues.
• This will lead to a painful injection.
 Sequence cont’d.
4c. Gentle pressure on plunger ensures that.
– Any air bubbles in the cartridge are eliminated.

• Speed of injection – this should be slow even when

topical anaesthesia is present. Too rapid an injection
will elicit pain.
 Some Clinical Properties of L.A.
• Onset of action.

• Spread.

• Duration of anaesthesia.
 Onset of Action
• The onset time of action of infiltration L.A is
faster than for block L.A.
• Infiltrations work within 2 minutes while
blocks work within 3-5 minutes.
• In practice, I have found that a wait of 5
minutes is sensible before testing for
anaesthesia.
 2. Spread
• L.A. solutions have the ability to spread.

• This of advantage when precision with the

needle cannot be guaranteed – as is probably
the case in most inferior alveolar nerve
blocks.
 Duration of Anaesthesia
• Pulpal anaesthesia – about 1 hour.

• Soft tissue – about 1½ - 2 hours.

 Types of Local Anaesthesia
• Topical.

• Infiltration.

• Regional.
 Topical Anaesthesia
• Target – superficial nerve endings underneath
the mucous membrane and skin.
• The various presentations we have already
treated.
 Indications for Topical Anaesthesia

• Surface pre-injection L.A.

• Incision of fluctuant abscesses. (ethyl chloride)
• Extraction of very mobile exfoliating deciduous teeth -these
teeth have no roots and are held at the cervical margin by
soft tissue. (lignocaine spray).
• Deep scaling in cases of gingivitis/ periodontitis. (ointments)
• Full mouth impressions in patients prone to retching.
(emulsion)
• Post Op. following gingivectomy.
 Infiltration Anaesthesia

• Target – terminal nerve fibres

 Types of Infiltration Anaesthesia.
• Submucuous.
• Supraperiosteal.
• Subperiosteal.
• Intraosseous.
• Intraseptal.
• Intraligamentary.
 Submucous infiltration
• Site – Underneath the mucosa
• Uses – Long buccal nerve, greater palatine
nerve.
 Supra-periosteal infiltration.
• In this technique the solution is deposited within the
labiobuccal fold, above the periosteum to target the
apices of the teeth.
• The solution is able to pass through the periosteum, the
underlying cortex and into the cancellous bone to reach
the nerves.
• This is possible because the jaw bones in certain areas are
thin and fenestrated (vascular channels).
• This technique is employed for most procedures in the
upper jaw (except the 1st molar region) and the lower
incisor regions.
 Sub-periosteal infiltration
• Should be employed only when a supra
periosteal infiltration fails.
• As the name suggest, the solution is
deposited underneath the periosteum.
 Intraosseous injection.
• This is an extremely rare injection to give and
the efficacy of the newer LA solutions and
alternative techniques has further rendered
the intraosseous injection unnecessary – but
you should read up the technique.
 Intraseptal injection
• Site – the bone at the alveolar crest.
• The principle is that an injection given at this
site passes through the bone and periodontal
membrane to achieve anaesthesia.
• Indication – for extractions only, when a
supra-periosteal infiltration fails or is
contraindicated (immediate dentures).
Intraligamentary (or intraligamental) infiltration

• in this type of infiltration, the needle is

inserted into the periodontal membrane at
30 degrees to the long axis of the tooth, with
the bevel of the needle facing bone.
 Indications/advantages of Intraligamentary
Infiltrations.
• When supra-periosteal infiltrations fail.
• Procedures can be carried out in different
quadrants of the mouth without the wide
spread feeling of regional anaesthesia.
• It avoids anaesthesia of soft tissue that
accompanies supra-periosteal injections.
• Less pain is experienced during injection.
• Risk of intravascular injection is eliminated.
 Disadvantages
• Due to excessive pressure on the plunger,
the cartridge may break.
• Post injection pain may persist longer than
with conventional procedures.
• Tooth may be extruded or even avulsed from
its socket.
• Gingivitis or periodontitis precludes its use.
 Regional (Block) Anaesthesia
• Target – the nerve trunk – this gives the
widest area of anaesthesia of the forms of L.A.
 Testing for L.A.
• Subjective: Ask the patient how the mouth
feels. Patients will respond in varying term
e.g. “my mouth is swollen” , I can’t feel
anything on that side” e.t.c. Some patients
may not express themselves well so you can
assist by asking ‘‘is there any difference
between the injected side and the other
side?”
 Testing for L.A. cont’d.
• Objective- In the mandible – for extraction of
teeth, 3 sites should be tested (penetrated
with a sharp probe) if an inferior alveolar
nerve block has been administered. They are;
A) The buccal gingival crevice (long buccal
nerve)
 Testing for L.A. cont’d.
B) The lingual gingival crevice (lingual nerve)
C) The alveolar mucosa between the 1st and
second premolars (inferior alveolar nerve) if
you have infiltrated the lower incisor region,
then;
i) Labial gingival crevice (incisive and mental
nerves)
ii) Lingual gingival crevice (lingual nerve)
 Testing for L.A. cont’d.
• In the maxilla, two sites are tested i.e.
A) The labio -buccal gingival crevice for the anterior, middle
and posterior superior alveolar nerves depending on whether
you injected the upper anterior, premolars or molars and
B) The palatal gingival crevice for the naso-palatine nerve for
the anteriors and the greater palatine nerves for the
premolars and molars.
 Testing for L.A. cont’d.
• For operative dentistry, this method of testing
is not appropriate as it creates a false pocket.
• Anaesthesia is ascertained by gentle
stimulation of the dentine with a bur or hand
instrument (e.g. probe or excavator).
Anaesthesia of the Mandible
 ANAESTHESIA OF THE MANDIBLE

Basic concepts
• The mandible consists of dense cortical bone so
infiltration techniques are of limited value except in the lower
incisor region where the bone is thin and fenestrated.
• The main stay of LA in the lower jaw is the inferior alveolar
nerve block which is employed for anaesthesia of the molars
and premolars and the lower anteriors.
• On occasions however, the lower anteriors are extracted by
infiltration.
Neuroanatomy
 Neuroanatomy cont’d.
• The mandibular nerve is a mixed nerve; it
reaches the infratemporal fossa through the
foramen ovale.
• It has a small anterior branch which is mainly
motor (to muscles of mastication) except one
sensory branch (the long buccal nerve) and a
large posterior branch which is mainly sensory
(except one motor branch) -the nerve to
mylohyoid
 These sensory branches are:
1. The auriculotemporal (ATN).

2. The lingual nerve LN.

3. The inferior alveolar nerve (IAN)

The auriculotemporal nerve (ATN)
• supplies the external auditory canal and the
skin of the temple anteriorly.
• There is rarely need to anaesthetize it in
routine dentistry.
 The lingual nerve
• Is closely related to the IAN as they pass downwards. (It lies medial to the
IAN).
• It enters the mouth through the gap between the superior constrictor and
the mylohyoid muscle.
• The trunk of the lingual nerve runs on the mandible in this region and in
cases actually grooves it.
• The LN gives off twigs to the lingual gingivae in the molar region.
• The gingivae of the premolars and as well as the floor of the mouth are
supplied by the sublingual branch of the LN.
• The lingual nerve terminates in the tongue.
 The inferior alveolar nerve (IAN)
• Passes downwards from the infratemporal
fossa to enter the mandibular foramen.
• Within the mandibular canal it innervates the
teeth of the lower jaw.
• Just before the IAN enters the mandibular
foramen, it gives off the nerve to mylohyoid.
 IAN…
• Within the mandibular canal, the IAN gives of the mental
nerve, which exits at the mental foramen.
• This mental nerve is sensory to the labiobuccal gingivae from
the midline of the mandible to the second premolar as well as
the adjacent mucous membrane and skin of the lower lip and
chin.
• The IAN continues as the incisive nerve (after giving of the
mental nerve) to supply the canine and incisors.
 LA in the Mandible Cont’d.
• The long buccal nerve – (The sensory branch
from the anterior division of CN V)
• Passes medial to the ramus of the mandible to
supply the gingivae and oral mucosa buccal to
the lower retromolar region, the lower molars
up to the second premolar tooth.
 The Inferior Alveolar Nerve Block
Several methods exist for blocking the inferior
alveolar nerve, to facilitate procedures in the
mandible. They include:
• The direct method
• Indirect method
• The Akinosi technique
 The Direct Technique
• The success of this technique depends on a mastery of the
local anatomy.
• As earlier observed, infiltration techniques are of little value
in the mandible.
• In this technique, the lingual nerve as well is blocked as
needed.
• The objective is to deposit the solution on the IAN just before
it enters the mandibular foramen.
• A tissue space exists in this region and it is called the
pterygomandibular space.
What are tissue spaces?
 Pterygomandibular Space
• Shape – conical
• Boundaries – anteriorly – pterygomandibular
raphe.
(what’s a raphe)
• posteriorly – deep lobe of parotid gland
• laterally – medial aspect of the ramus of the
mandible.
 Pterygomand. Space
• medially – medial pterygoid muscle.

• floor – medial pterygoid muscle.

• roof – lateral pterygoid muscle.

 Method
• The chair position is as earlier described.
• Ideally, the operator should stand in front of the patient for
the injection of both halves of the mandible.
• That is, for the right handed operator, the right mandibular
injection is given with the right hand and the left mandibular
injection is given with the left hand.
• Otherwise, where this cannot be mastered, give the right
mandibular injection from the front and the left injection
from the back.
 Direct Method Cont’d.
• Two procedures are carried out before lifting
the loaded syringe.
1. Inspection :- Identify the surface marking of
the pterygomandibular raphe – the needle
should penetrate anterior and lateral to the
raphe.
 Direct Method Cont’d.
2. Palpation :– the palpating finger (index) feels for the external
oblique ridge.
• After this ridge, it is no longer possible to feel the mandible.
• The injection should be given after this point.
• Also, note that the injection point is about 1 cm above the
occlusal surface of the molars.
 Direct Method Cont’d.
• A variation at this point is to slide your
index finger along the occlusal surfaces
of the molars until the soft tissues at the
retromolar region prevent further
advancement.
 Direct Method Cont’d.
• Then with the long needle, advance from the
opposite lower premolars and penetrate the
mucosa (bisecting the top of your finger nails).
• The needle is advanced for about 2.5 cm at
which point bone should be contacted.
 Direct Method Cont’d.
• The syringe is withdrawn slightly (About 1-2
mm), aspiration performed, and about 1.5ml
of solution given.
• The needle is then withdrawn for about 2cm
to inject a few drops of solution for the lingual
nerve.
 Methods Cont’d.
• I personally deposit drops of
solution all the way as I withdraw
after hitting bone for the lingual
nerve.
 Direct Method Cont’d.
• For anaesthesia of the long buccal nerve, two
options exist:-
1. In the buccal sulcus adjacent to the tooth
being worked on.
2. In the retromolar sulcus, distobuccal to the
lower 3rd molar.
 Direct Method Cont’d.
• The former produces a limited area of
anaesthesia just adjacent to the molar while
the latter gives anaesthesia of the buccal
gingivae and mucosa up to angle of the
mouth.
 Indirect method
• Mentioned for historical reasons. No longer in
vogue.
• Similar to direct technique
• Needle is initially positioned over the molars of the
same side and advanced 10-15 mm
• Needle swung over to the premolars of the
opposite side
• Needle advanced further until bony contact is
achieved as in the direct technique
 Akinosi Technique
• Developed by Professor Akinosi, formerly of
UNILAG / LUTH.
• The injection is given with the teeth in
occlusion and with one injection targets the
IAN, LN and long buccal nerve.
 Akinosi Technique Cont’d.
• The teeth in occlusion, and horizontal to the floor.
• The long needle of a loaded syringe is advanced parallel to
the buccal gingival margins of the upper teeth until further
advancement is prevented by the hub of the needle coming in
contact with the retromolar tissues
• Aspiration is performed and about 1.5ml of solution is
deposited.
 The lower anterior teeth
• Infiltration can be used alone in this region or
can be given to supplement an inferior
alveolar nerve block, which would not be very
effective alone.
• This is because the bone is fenestrated and
thin and due to overlap at the midline, blocks
are not effective.
• With advancing age, infiltration may not
effectively anaesthetize a canine as the bone
becomes sclerotic.
• The lingual soft tissues are also anaesthetized
by an injection in the adjacent lingual sulcus.
 The mental block
• This is somewhat of limited value when pulpal
anaesthesia is required.
• In principle, solution deposited near the
mental foramen would penetrate the canal to
produce anaesthesia of the premolars, canine
and incisors.
• However, for soft tissue surgery of the lower
lip, the mental block is an excellent means of
achieving anaesthesia.
 Anaesthesia of the Maxilla
Basic concepts
• The maxilla in contrast to the mandible
consists of an outer layer of thin cortical bone
that is in most areas fenestrated.
• Thus a L.A solution deposited labiobuccally
can diffuse through this thin plate, into the
cancellous bone to reach the nerves.
 L.A. in the Maxilla cont’d.
• However, in the upper first molar area, the
zygomatic buttress dips over this area, and
this bone has little fenestrae.
• Some modification of the infiltration
technique is required in this region.
 NEUROANATOMY Cont’d
• The maxillary nerve is a purely sensory nerve
and it exists the skull through the foramen
rotundum.
• At the pterygopalatine fossa, it gives off many
branches. Of interest in dental local
anaesthesia are the following:
 Neuroanatomy Cont’d
• 1. Nasopalatine nerve: It enters the oral cavity
through the incisive foramen to supply the
palatal gingivae and mucous membrane of the
premaxilla.
• 2. Greater palatine nerve: Enters the mouth
through the greater palatine foramen. It
supplies the rest of the gingivae and mucous
membrane of the hard palate.
 Neuroanatomy Cont’d
• These are given off from the sphenopalatine
ganglion.
 Neuroanatomy Cont’d
• 3) Posterior superior alveolar nerve – along
with the zygomatic nerve is given off form the
trunk of the maxillary nerve before it enters
the infra orbital canal.
• 4) Infraorbital nerve. The terminal branch
of the maxillary nerve. It exists the skull at the
infraorbital foramen to supply skin and
mucous membrane, of the anterior part of the
check.
 Neuroanatomy Cont’d
• 5. Anterior superior alveolar nerve. This is
given off just before the nerve exists the
infraorbital foramen.
• 6. Occasionally, a middle superior alveolar
branch may be present.
• The gingivae of the molars and mucous
membrane of the posterior part of the check
are supplied by one of the branches of
posterior alveolar nerve.
 THE MAXILLARY MOLARS

• The upper 3rd, 2nd molars and the

distobuccal and palatal roots of the 1st molar
can be anaesthetized by a supraperiosteal
infiltration.
• A long needle is employed. With the
needle angled at 45 degrees to the mesial
aspect of the 2nd molar the mucosa is
penetrated –just after the attached mucosa.
 Upper Maxillary Molars
• The originally described posterior superior alveolar nerve
block carries the risk of intravascular injection and is no
routinely used.
• Also when giving this injection, the mouth should not be
maximally open.
• A fully opened mouth brings the coronoid processes forwards
and reduces the available space for your syringe.
• This should be borne in mind during extractions. As the
coronoid can impede movement of the extraction forceps and
eventual delivery of the tooth.
 Upper maxillary molars
• About 1-1.5ml of solution should be given.
 The mesiobuccal root of upper 1st molar, 2nd
Premolar and 1St Premolar.
• The maxillary first molar is usually anaesthetized by two
injections. The first is as previously described for the molars
and the other is given along the long axis of the upper 2nd
premolar at its approximate apex.
• The 1st and 2nd premolars are anaesthetized by penetrating
(ideally with a short needle) the alveolar mucosa just after the
attached gingivae; with the needle in line with the long axis of
the tooth.
• The needle is then advanced to the approximate apex of the
tooth and about 1-1.5ml of solution deposited.
 THE CANINES AND INCISORS

• Again, these teeth are anaesthetized by

holding the needle in line with the long axis of
the tooth and penetrating up to the
approximate apex of the tooth.
• For the incisors, care must be taken not to
penetrate the floor of the nose so ideally a
short needle is preferred.
• Usually about 1 ml of solution will suffice for
these teeth.
• NB when giving upper buccolabial infiltrations,
make the tissues taut, either with your fingers
(or with experience, your mirror). This
minimizes the pain of penetration.
• Also the injections so far described will suffice
for operative dentistry. If extractions and
other surgical procedures are indicated then
anaesthesia of the palatal tissues will be
required.
 PALATAL ANAESTHESIA

• The premaxillary region: The mucosa is tightly bound to periosteum to

form a mucoperiosteum. Thus injections in this region are essentially a
subperiosteal infiltration and are usually painful.
• Alert the patient before hand.
• Elsewhere in the hard palate, injections are given at the approximate apex
of the tooth, midway between the midline of the palate and the gingival
margin of the tooth in question.
• In this region a submucosa exists (where the greater palatine
neurovascular bundle passes. Injections here cause less discomfort.
 Palatal anaesthesia cont’d
• Also to minimize discomfort, injections should be given at
right angles to the vault of the palate with the bevel of the
needle facing borne.
• As a rule, palatal injections are not given beyond the 2nd
molar.
• This is to avoid anaesthetizing the lesser palatine nerve which
will lead to difficulty in swallowing and discomfort or distress
to the patient.
 Palatal anaesthesia cont’d
• Very little amount of solution is required to
produce palatal anaesthesia –just a few drops.
• Do not to push in larger amounts as this will
lead to pain or discomfort.
 THE INFRAORBITAL BLOCK

• Indications
1)Multiple extractions in the upper premolar-
incisor region.
2)Extensive surgery in the area of supply.
 Techniques of infraorbital nerve block.

1)Extra oral
2)Intra oral
• The intraoral technique is simpler and more
commonly employed and that will be
described here.
• First the centre of the inferior orbital rim is
palpated with the index finger to locate the
infra orbital notch.
 Technique of infraorbital block cont’d

• Just below this notch (about 1cm) is the infra

orbital foramen.
• The index finger is then placed over the point.
• This finger serving both as a guard to note
movement of the needle and as a feeling
finger – to feel when the L.A solution is being
deposited.
 Infraorbital block cont’d
• The thumb is next used to reflect the upper lip.
• A long needle is employed which is inserted above the
reflection of the mucosa over the apex of the 2nd premolar,
in line with its long axis.
• Alternatively, the needle can be inserted over the canine or
the 1st premolar.
• Aspiration is performed before injection.
• As the L.A solution is injected, it would be felt to raise the
index finger over the foramen.
• About 1m of solution is given.
 COMPLICATIONS FOLLOWING L.A

• Complications arising from local anaesthetic

injections are relatively rare, considering the
several millions of injections that are probably
administered daily world wide.
• This said however, the dentist should acquaint
himself with the prevention, diagnosis, and
management of such complications in the
event they arise.
 Complications of L.A. cont’d.
• An excellent account of the diagnosis and
management of difficulties, complications” is
given in local anaesthesia in Dentistry, 3rd ed
by Howe GF and whitehead F.I.
• You are expected to make up the notes from
there, [that’s an assignment as it’s a usual
exam question.]
• As an over view, the complications are
listed as local and general.
 LOCAL COMPLICATIONS

• Failure to obtain anaesthesia.

• Pain during and after injection.
• Haematoma formation.
• Blanching.
• Trismus.
• Facial paralysis
• Horner’s syndrome
• Temporary blindness
 Local complications cont’d.
• Prolonged impairment of sensation.
• Breakage of needle.
• Infection.
• Lip trauma.
• Visual sensations.
 GENERAL COMPLICATIONS

• Syncope.
• Drug interaction.
• Sensitivity reaction.
• Occupational dermatitis.
• Cardio- respiratory disturbances.
 Horner’s syndrome
• A rare complication following an inferior dental nerve
block.
• This arose due to penetration of the local anesthetic
through the lateral pharyngeal and prevertebral
spaces, causing blockade of the stellate ganglion.
• Signs include: Flushing of the face on the same side,
ptosis of the eyelids, vasodilatation of the
conjunctiva; pupillary constriction and (occasionally)
a rash over the neck, face, shoulder and arm of the
ipsilateral side.
 Temporary blindness
• Temporary blindness has been reported
following posterior alveolar nerve block due
to a large quantity of local anesthetic under
great pressure diffusing through the inferior
orbital fissure and coming into contact with
the optic nerve.
 Failure to obtain anaesthesia
• I have decided to elaborate a little on this as it
is the issue that is most likely to confront you
as dentists in the making.
• It is a situation that improves as you acquire
experience.
• It is more likely to occur with block techniques
than with infiltrations.
 Causes include:
• (a) Faulty technique
• i. Inadequate knowledge of the technique will result in
the LA solution being deposited far from the nerve
especially for blocks.
• ii. Intravascular injection – failure to aspirate may mean
that the LA solution is given intravascularly and no
anaesthesia is obtained.
• (b) Injection into muscle – muscle will create a diffusion
barrier and increase the diffusion distance and thus will cause
failure of anaesthesia.
 Causes cont’d.
• (c) Individual reactions – a dose that is
sufficient for one patient may be inadequate
for another. This is another reason to use up
one cartridge for given injection.
 Causes cont’d.
• (d) Injection at a site of infection – in
addition to the dangers of spreading the
infection into deeper tissues, L.A. solution
deposited into an infected area is unlikely to
be effective.
• This is because the pH of such tissue is low
and L.A solutions are less effective under
such pH.
 Causes cont’d.
• (e) Failure of bone contact with needle. As a
cardinal rule, when using direct technique for
an IANB, ensure contact with bone.
• This is a sure way of avoiding injections into
the muscles, parotid gland or the neck
vessels.
 Causes cont’d.
• (f) Expired solutions – always check out the expiry date.
• (g) Resistance to the local anaesthetic agent – rare. Use
another pharmacological agent.

• CONTINUOUS ASSESSMENT TEST!!!!!!!!!!

 Thank you!

Have a Good Day!