• As a general rule for all injections in both jaws the

patient position should be such that it allows access to

the point of injection while affording the safest and
most comfortable placement for the patient.
• Ideally the patient should be fully supine to aid cranial
blood flow and prevent fainting.
• Some patients may be uncomfortable or feel
vulnerable in this position.
• A compromise is to tilt the chair back at least thirty
degrees to the vertical.
 NEEDLE GAUGE
• Gauge refers to the diameter of the lumen of the needle; the smaller
the number, the greater the diameter of the lumen.
• There is increased resistance to aspiration of blood through a
thinner needle (eg,30-gauge) compared with a larger-diameter
needle (eg,27- or 25-gauge).
• Needle deflection along the axis of the bevel and breakage must
also be examined.
• The smaller the diameter of the needle, the more it deflects.
• Thirty-gauge needles deflect significantly, whereas 25-gauge needles
essentially do not deflect at all. Likewise,25-gauge needles very rarely,
if ever, break during an intraoral injection, and 99% of the needles
that do break are 30-gauge needles.
• Buccal Infiltration Anaesthesia
• Solution deposited at the buccal side of the maxillary
alveolus can infiltrate through to the pulps of the teeth
to produce dental anaesthesia (Fig 4-1).
• This is because the cortical plate on the buccal side of
the maxilla is thin.
The advantages of infiltration anaesthesia are:
• simple technique which is easy to master
• when successful, anaesthetises all nerve endings in the
area of deposition independent of the nerve source.
Before the injection of the local anesthetic, the dentist should recognize the
potential risks.
However, most adverse reactions to local anesthetics are not related to the
drug itself, but to the injection of the drug.
The injection of the local anesthesia is the most reported cause for fear and
discomfort of dental patients.
disadvantage

only effective in obtaining pulpal anaesthesia when diffusion through cortical

bone occurs
localised infection may be spread if an inflamed area is infiltrated
only a limited zone of anaesthesia per injection
Technique
The syringe is fitted with a 27 or 30 gauge needle. Usually a 20–25 mm-long
needle is employed. Unless there is a medical contraindication a
vasoconstrictor-containing anaesthetic such as lidocaine with
epinephrine is used.
The point of needle penetration is in the buccal fold within reflected mucosa
(Fig 4-2). Access to this region is easiest when the patient has the
mouth only partly open. This is especially the case in the more posterior
regions of the buccal sulcus. When the mouth is fully open the buccal
tissues are stretched across the teeth, limiting
In this delivery of an infiltration injection, the lips are retracted by a dental
mirror.

This reduces the chances of a needlestick injury during the injection.

 Pulpal anaesthesia of around 45 minutes should ensue when a
vasoconstrictor-containing solution has been used.
 The efficacy of infiltration anaesthesia is dependent upon the volume
and concentration of the local anaesthetic solution and the presence of
a vasoconstrictor.
 The efficacy of lidocaine as an anaesthetic during infiltration
anaesthesia increases with increasing epinephrine concentration.
 Long-lasting local anaesthetics do not provide prolonged postoperative
pain relief if injected by infiltration although soft tissue anaesthesia is
prolonged.
Problems with buccal infiltration anaesthesia
Buccal infiltrations may fail if there is collateral supply to the pulp from the
greater palatine or nasopalatine nerves. This is overcome by
supplementing the injection with one of the palatal techniques
described below.
Another reason for failure may be due to a thick cortical plate reducing the
spread of solution through bone. This may occur in the region of the
zygomatic buttress causing failure of anaesthesia in upper first molars.
This is overcome by infiltrating mesially and distally to the buttress or
by using the regional block methods described below. It must be
remembered that the upper first molar tooth can receive supply from
both the posterior and the middle superior alveolar nerves, thus two
blocks may be required
If there is localised infection at the site of an infiltration it is unwise to inject
at this zone. Using one of the regional block methods described
Regional block methods in the maxilla
 PSAN (posterior superior
alveolar nerve
block)
• Anesthetize the maxillary molars
except for the mesio buccal
aspect of the first molars.

• Clinically, the PSA injection is

given with the insertion point at
the height of the buccal
vestibule at a point just distal to
the malar process.
• TECHNIQUES –
• Landmarks –
• MUCOBUCCAL FOLD
• MAXILLARY TUBEROSITY
• ZYGOMATIC PROCESS OF MAXILLA
• Prepare the tissues and orient the bevel of the needle towards
the bone.
• Advance the needle slowly in an upward, inward and backward
direction.
• The needle is inserted distally and superiorly at approximately
45 degrees to the mesiodistal and buccolingual planes at the
Height of mucobuccal fold above maxillary second molar is
the area of insertion
• The depth of insertion is approximately 15 mm, and following
careful aspiration, 1.0 mL
of solution is slowly deposited.
 COMPLICATI
ONS:
• HAEMATOMA – needle placed most posteriorly into pterygoid
plexus of veins and
chances of maxillary artery perforation. Short needle use is
recommended.

• Visible intraoral hematoma develops within several

minutes in mandibular buccal region. Bleeding continues
until the pressure of extravascular blood equals the
intravascular blood.

• MANDIBULAR ANESTHESIA – since mandibular division is

located lateral to PSA nerves.

• CONTRAINDICATION – risk of hemorrhage is great in

 MIDDLE SUPERIOR ALVEOLAR
NERVE BLOCK
• MSAN - present in only about 28% of the population.
• The (MSA) injection will anesthetize the mesiobuccal aspect
of the maxillary first molar, both premolars, PDL, buccal
bone, and periosteum, along with the soft tissue lateral to
this area.
• TECHNIQUES – 27 gauge short or long needle is used.
1 ml of anesthetic solution should slowly be
introduced after careful aspiration.
• AREA OF INSERTION – height of the mucobuccal fold
above the maxillary second premolar. The needle tip
should approximate the apex of the tooth, which
usually requires a penetration of about 5 mm.
• TARGET AREA – maxillary bone above the apex of the
maxillary second
premolar.
• LANDMARK – mucobuccal fold above the maxillary
second premolar.
ANTERIOR SUPERIOR ALVEOLAR
NERVE BLOCK
• Also called Infraorbital Nerve Block.

• The ASA injection will anesthetize the PDL, alveolar

bone, periosteum, buccal soft tissue, and teeth from the
canine to the midline.

• The penetration is over the maxillary canine

• A 25 gauge long needle is recommended

• The needle depth will be about 16 mm for an average

sized adult with varying depths proportional to the size
of the patient and the bony structure of the cheek.
• AREA OF INSERTION – height of the mucobuccal
fold directly over the first premolar.
• TARGET AREA – infraorbital foramen (below the
infraorbital notch)
• Landmarks
• - mucobuccal fold
• -Infraorbital notch
• -Infraorbital foramen
• ORIENTATION OF THE BEVEL – Toward bone
• To transform it into Anterior Superior alveolar nerve
block –
• Maintain firm pressure over injection site both
during and after the
injection for 1 min.
• Withdraw the syringe slowly.

• Maintain direct pressure after withdrawal for 2

minute to allow more
diffusion of solution into the foramen.
• Wait for 3 to 5 min before the start of dental procedure.
Infraorbital
nerve block
 Failures of anesthesia –
• When needle contacts bone of lower border of
infraorbital foramen, anesthesia developes in the
desired soft tissue area only. That is why a failed
ASA is supraperiosteal injection over the first
premolar.
• Needle deviation medial or lateral to infraorbital
foramen.
• Complications – hematoma may develop across the
lower eyelid around infraorbital foramen
 Other
• There are two approaches to Infraorbital nerve
techniques..
block, the most commonly being bicuspid and central
incisor approach.
• BICUSPID APPROACH – needle is inserted into the
mucosa and areolar tissue using the maxillary bicuspid as
the guide and the needle should pass beneath and lateral
to the external maxillary artery and the anterior facial
vein.
• CENTRAL INCISOR APPROACH – needle is inserted into
the mucosa and areolar tissue using the central incisor as
guide and it passes beneath the angular head of quadratus
Extra-oral
approach
 NASOPALATINE
NERVE BLOCK
• Also called incisive and sphenopalatine nerve block.
• The nasopalatine (NP)injection will anesthetize the tissues
of the palatal aspect of the premaxilla.
• Two approaches –

• Single penetration

• Multiple penetration
 Single penetration
• A 25 or 27technique…
gauge short or ultra-short needle may be
used.
• The area of insertion is the palatal mucosa just
lateral to the incisive papilla (located in the midline
behind the central incisors).
• The path of insertion is approaching the incisive
papilla at a 45 degree angle with the orientation of
the bevel toward the palatal tissue.
 Technique (multiple
penetration)
• A 25 or 27 gauge short or ultra-short needle is recommended.
• There are 3 points of insertion:
• The labial frenum between the maxillary central incisors.
• The interdental papilla between the maxillary central incisors.
• The palatal soft tissue lateral to the incisive papilla.
• First injection: If labial anesthesia has not been
achieved with labial local infiltration of the area, the
following injection is performed. If the area is
anesthetized, proceed to the second injection.
• The path of insertion is into the labial frenum
with the orientation of the bevel
of the needle toward the bone. Retract the upper
lip to improve visibility.
• Insert the needle into the frenum and deposit 0.3ml
• Second injection:
• Hold the needle at right angles to the papilla. The
orientation of the bevel is not
relevant.
• Insert the needle into the papilla just above the crest of
bone.
• Direct it toward the incisive papilla on the palatal side of
the interdental papilla while slowly injecting anesthetic
solution. Do not penetrate through the palatal tissue.
• When blanching is noted in the incisive papilla, aspirate.
• If negative administer 0.3ml of anesthetic solution over 15
seconds.
• Third injection:
• Proceed as above for the single penetration injection;
however, application of topical anesthetic and pressure
anesthesia is unnecessary.
 Greater Palatine
Nerve Block
• TECHNIQUES – 27 gauge short needle is used
• AREAS OF INSERTION – soft tissues slightly
anterior to the greater palatine foramen.
• TARGET AREA – greater palatine nerve passing
anteriorly between soft
tissues and bone of the hard palate.
• LANDMARKS -
• Greater palatine foramen
• Junction of the maxillary alveolar process and
palatine bone
• PATH OF INSERTION – advance the syringe from the
opposite side of the mouth at a right angle to the
target area.
• Anatomically, this is generally 5 mm anterior to the
junction of the hard and soft palates. Penetration will
occur through the epithelium, and the needle will appear
to ‘‘fall into’’ a space of less resistance. The needle
should be inserted until bone is contacted. The depth of
penetration is variable, but usually less than 5 mm is
sufficient. After aspiration, 0.5mL of anesthetic
solution is very slowly deposited.
• Areas anesthesized : Posterior portion of the hard
palate and overlying soft tissues anteriorly as far as the
first premolar and medially to the midline.
• COMPLICATION –
• Rare hematoma
• Ischemia and necrosis of soft tissues
Greater palatine
nerve block
 Maxillary
Nerve Block
• It is an effective method of achieving profound anesthesia
of a hemi-maxilla.
• Useful in procedures involving quadrant dentistry and
in extensive surgical procedures.
• INDICATIONS –
• Pain control before extensive oral surgical,
periodontal or restorative procedures
requiring anesthesia of entire maxillary division.
• When tissue inflammation or infection exceeds the use of
another regional nerve block.
• Diagnostic or therapeutic procedures for neuralgias.
• TECHNIQUES – HIGH TUBEROSITY APPROACH
• AREA OF INSERTION – height of the mucobuccal
fold above the distal
aspect of the maxillary second molar.
• TARGET AREA – maxillary nerve as it
passes through the pterygopalatine
fossa.
• LANDMARKS –
• Mucobuccal fold at the distal aspect
of the maxillary second molar.
• Maxillary tuberosity.
• Zygomatic process of the maxilla.
• The long 25 gauge needle is
• Subjective signs – pressure behind the upper jaw on the
side being injected; this subsides rapidly, progressing to
tingling and numbness of the lower eyelid, side of the
nose and upper lip.
• Subjective symptoms – sensation of numbness in the
teeth and buccal soft tissues on the side of injection.
• complications –
• Risk of hematoma.
• Arbitrary approach, over insertion is possible because
of absence of bony landmarks if proper technique not
followed.
Maxillary nerve block
Recommended volumes of maxillary techniques
local
anesthetic for
Technique VOLUME, ml

Posterior superior alveolar 0.9-1.8

Middle superior alveolar 0.9-1.2

Anterior superior alveolar 0.9-1.2

Greater palatine 0.45-0.6

Nasopalatine 0.45

Maxillary nerve block 1.8