Local Anesthesia Techniques
Part 1
Dr. Rahaf Al-Habbab BDS. MsD. DABOMS
Diplomat of the American Boards of Oral and Maxillofacial
Surgery
2012
Anatomy Review
The trigeminal nerve
is the largest of the
cranial nerves. It has
both motor and
sensory components
Trigeminal Nerve
carries sensory
information from the:
Scalp and forehead,
The upper eyelid,
The conjunctiva and
Cornea of the eye,
The nose (including the
tip of the nose),
The nasal mucosa, and
The frontal sinuses.
The ophthalmic
nerve
The maxillary nerve
carries sensory
information from the:
Lower eyelid and cheek,
Nares and upper lip,
The upper teeth and gums,
The nasal mucosa,
The palate and roof of the
pharynx,
The maxillary, ethmoid and
sphenoidsinuses, and
parts of the meninges
The Maxillary
Nerve
The Maxillary Nerve
 The maxillary nerve continues into the infraorbital canal as the
infraorbital nerve.

The zygomatic nerve emerges and branches into its two major terminal
branches, the zygomaticofacial and zygomaticotemporal nerves, which
innervate the lateral cheek and side of the forehead, respectively.
 As it projects anteriorly, the infraorbital nerve gives off the anterior and
middle superior alveolar nerves, innervating the upper teeth.
 It then exits the canal through the infraorbital foramen to innervate the
upper lip, cheek and side of the nose.
Mandibular nerve
The mandibular nerve
carries sensory information
from the:
lower lip,
The lower teeth and gums,
The chin and jaw (except
the angle of the jaw, which
is supplied by C2-C3),
Parts of the external ear,
and parts of the meninges.
Mandibular Nerve
 The Buccal Nerve innervates the mucosa of the mouth and gums.
 The Auriculotemporal Nerve innervates the external auditory
meatus and portions of the external surface of the tympanic
membrane.
 The lingual Nerve provides general sensation to the anterior 2/3 of
the tongue.
 The Inferior Alveolar Nerve enters the mandibular canal through
the mandibular foramen to innervate the lower teeth and gums.
 Its Terminal branch exits the mental foramen as the mental nerve,
innervating the chin and lower lip.
 Other several Branchial motor nerves .
L.A Tools
Dental Syringe
Dental Needles
L.A Tools
Local Anesthetic
Cartridge
L.A Tools
Local Anesthetic
Cartridges Color
Codes
L.A Indications
 Parenteral local anesthetics are used for infiltration and nerve
block anesthesia.
 Because of variation in systemic absorption and toxicity, the
ideal choice of local anesthetic and concentration depends on
the intended procedure.
 Infiltration anesthesia is often used for minor surgical and
dental procedures.
 Nerve block anesthesia is used for surgical, dental, and
diagnostic procedures and for pain management
Nerve Block Anesthesia
Mandible
Inferior Alveolar
Block
Technique of choice for
mandibular molars also
effective for premolars,
canines, and incisors.
 Aim is to deposit solution
around the inferior alveolar
nerve as it enters the
mandibular foramen
 The patient's mouth must be widely
open.
 Palpate the landmarks of external
and internal oblique ridges and note
the line of the ptyerygomandibular
raphe.
 With the palpating thumb lying in the
retromolar fossa, the needle
should be inserted at the mid point
of the tip of the thumb slightly
above the occlusal plane lateral to
the ptyerygomandibular raphe.
 The needle is inserted ~0.5cm and if
a lingual nerve block is required
0.5ml of LA is injected at this point.
Inferior Alveolar Block
Technique
Inferior Alveolar
Nerve Block
Inferior Alveolar Block Technique
 The syringe is then moved horizontally across the dorsum of
the tongue and advanced to make contact with the lingula.
 Once bony contact is made the needle is withdrawn slightly
and the remainder of the LA injected.
 It should never be necessary to insert the needle up to the
hub.
 Note that the mandibular foramen varies in position with age.
 In the edentulous, the foramen, and hence the point of
needle insertion, is relatively higher than in the dentate.
Additional Block (higher injection)
Why?
 The standard block often fails to anesthetize branches of
cranial nerve V3 that originate proximal to the injection
site and provide accessory innervations to the
mandibular teeth.
 The relatively distal location of the injection also leads to
lack of anesthesia of soft tissues posterior to the mental
foramen.
 That why a higher injection site technique are proposed.
Gow-Gates Technique
 Blocks sensation by depositing LA at head of condyle
 Landmarks:–
 Corner of the mouth (contralateral side)
 Tragus of the ear
 Disto palatal cusp of the maxillary second molar
 AIMING FOR THE NECK OF THE CONDYLE
Akinosi Technique
 LA deposited above lingula
 Closed-mouth technique
 Does not rely on a hard-tissue landmark
 Parallel to occlusal plane, height of the mucogingival
junction
 Advanced until hub is level with distal surface of
maxillary second molar
 Delayed onset of anaesthesia
Akinosi Technique
Gow Gates and Akinosi
Pain to
puncture more
than Akinosi
More Effective
Onset is more
rapid
Less effective
More accepted
by patients
The mental nerve emerges
from the mental foramen lying
apical to and between the first
and second mandibular
premolars.

 LA injected in this region will
diffuse in through the mental
foramen and provide limited
analgesia of premolars and
canine, and to a lesser degree
incisors on that side.
 It will provide effective softtissue analgesia.
Mental Nerve
Block
Place the lip on tension and insert
the needle parallel to the long
axis of the premolars angling
towards bone, and deposit the
LA.
Do not attempt to inject into the
mental foramen as this may
traumatize the nerve
LA can be encouraged in by
massage.
Mental Nerve
Block
Buccal Nerve Block
 The buccal nerve is not anesthetized by an inferior
alveolar nerve block.
 This nerve innervates the tissues and periosteum buccal
to the molars, so if these soft tissues are involved in
treatment, the buccal nerve should be injected as well.
 The additional injection is unnecessary when treating
only the teeth.
 A 25 gauge long needle is recommended
The needle is inserted in
the mucous membrane
distal and buccal to the
last molar.

 Insert the needle to 2 to
4 mm to gently contact
bone, and aspirate.
 If negative, slowly
deposit about 1/8 of the
solution in the cartridge.
Buccal Nerve
Block (Continue)
Sublingual Nerve Block
An anterior extension of the lingual nerve can be blocked by
placing the needle just submucosally lingual to the
premolars, use 0.5ml of LA.
Nerve block anesthesia
Maxilla
Naso-palatine Block Anesthesia
Profound anesthesia can be achieved by passing the needle
through the incisive papilla and injecting a small amount of
solution. This is extremely painful
Infra-Orbital Block
 Rarely indicated.
 A 25 gauge long needle is recommended and inserted with the
bevel toward the bone in the muco-buccal fold over the first
premolar.
 Palpate the inferior margin of the orbit as the infra-orbital
foramen lies ~1cm below the deepest point of the orbital
margin.
 Hold the index finger at this point while the upper lip is lifted
with the thumb.
 Inject in the depth of the buccal sulcus towards your finger,
avoid your finger, and deposit LA around the infra-orbital nerve
Anterior Middle Superior Alveolar Block
The infra-orbital nerve block does not provide adequate
anesthesia to the teeth distal of the canine or if the PSA
injection does not provide anesthesia for the
mesiobuccal root of the first molar, an MSA block
injection should be administered.
A 25 gauge short needle is recommended with insertion in
the muco-buccal fold by the maxillary second premolar.
About ½ to 2/3 of a cartridge of anesthetic is slowly
deposited at the height of the apex of the second
premolar after negative aspiration
Anterior Middle Superior Alveolar Block
(continue)
One injection Central to
second premolar, palatal
and buccal soft tissue
Is used to anesthetize pulp
tissue and facial
periodontium of the
maxillary premolars and the
mesio-buccal root of the first
molar in some cases.
Posterior Superior Alveolar Block
 The posterior superior alveolar (PSA) nerve block is a
commonly used technique for achieving anesthesia for the
maxillary molars.
 Posterior superior alveolar block A rarely indicated technique.
 The short 25 or 27 gauge needle is recommended to decrease
the risk of a hematoma.
 Needle is inserted distal to the upper second molar and
advanced in wards, backwards, and upwards close to bone for
~2cm.
 LA is deposited high above the tuberosity after aspirating to
avoid the ptyerygoid plexus
Greater Palatine Nerve Block
 The greater palatine nerve innervates the palatal tissues
and bone distal of the canine on the side anesthetized.
 Use a 27 gauge short needle with the bevel toward the
palate.
 Palpate the palate until the depression of the foramen is felt
(usually some where medial to the second molar).
 Dry the tissue, and apply antiseptic and topical anesthetic
for 2 minutes.
 Apply pressure with the swab for 30 seconds. Continue
pressure with the swab until the injection is completed.
Greater Palatine Nerve Block (Continue)
 Place the bevel against the tissue and apply pressure
enough to slightly bow the needle.
 Inject a few drops of anesthetic.
 Release the pressure of the needle and advance the tip
of the needle in to the tissues lightly.
 Continue with this procedure of applying pressure to the
bevel and depositing a few drops of anesthetic, then
advancing, until the needle is in contact with the palatal
bone.
 Deposit less than a fourth to a third of a cartridge of
anesthetic after negative aspiration is proven
Maxillary Nerve Block
 Maxillary (V2) nerve innervates half of the maxilla,
including the buccal and palatal aspects.
 This injection technique issued especially in quadrant
surgery or when extensive treatment is indicated for a
single appointment.
 It is also used when another site of injection has failed
or if there is an infection in the area his technique is used
more with adult patients.
 It is not for the inexperienced.
MaxillaryNerveBlock(continue)
 Administration through the buccal aspect involves the possibility
for hematoma.
 The long 25 gauge needle is recommended with the bevel of the
needle facing the bone.
 The needle is inserted at the mucobuccal fold near the distal of
the second molar after the usual protocol of tissue preparation.
 The path of the needle is similar to that of the PSA nerve block,
but is inserted approximately 30mm to the pterygopalatine fossa.
 Aspirate, then rotate the needle bevel ¼ turn, reaspirate. If both
aspirations are negative, slowly deposit one cartridge of
anesthetic (deposit ¼ then aspirate, then deposit ¼ until the
entire cartridge has been administered).
Local Infiltration
Infiltrations
• The aim is to deposit LA supra periosteally in as close
proximity as possible to the apex of the tooth to be
anaesthetized.
• The LA will diffuse through periosteum and bone to bathe the
nerves entering the apex. Lower concentrations of local
anesthetics are typically used for infiltration anesthesia.
• Variation in local anesthetic dose depends on the procedure,
the degree of anesthesia required, and the individual patient's
circumstances.
•
Reduced dosage is indicated in patients who are disabled or
acutely ill, very young or very old, and in patients with liver
disease, arteriosclerosis, or arterial disease.
Infiltrations
Administrative techniques
 The aim is to deposit LA supra periosteally in as close proximity as
possible to the apex of the tooth to be anaesthetized.
 Patient comfort is essential during administration of local anesthetic
agents. Warming the local anesthetic solution prior to
administration to 25-40° C has been recommended.
 Reflect the lip or cheek to place mucosa on tension and insert the
needle along the long axis of the tooth aiming towards bone
Infiltrations Administrative techniques (Continue)
At approximate apex of tooth, withdraw slightly to avoid sub
periosteal injection, LA Is slowly deposited.
For palatal infiltrations, achieve topical analgesia first and
infiltrate interdental papillae; then penetrate palatal mucosa and
deposit small amount of LA under force.
Infiltration in Mandible
 Buccal infiltration anesthesia in the mandible can be
effective in some areas.
 Indeed in children this may the preferred technique
when treating the deciduous dentition.
 In adult patients buccal infiltrations maybe effective in
mandibular incisor region.
Thank You
Local Anesthesia Techniques
Part 2
Dr. Rahaf Al-Habbab BDS. MsD. DABOMS
Diplomate of the American Boards of Oral and
Maxillofacial Surgery
2012
Adjunctive Strategies for Infiltration
Adjunctive Strategies
•
•
•
•
•
•
PDL Injection
Sub-periosteal injection
Intraosseous Injection
Intrapulpal Injection
Intraseptal Injection
Different anaesthetic
PDL Injection
Technique:
 Needle inserted into the gingival sulcus
at a 30 degree angle towards the tooth.
 Bevel placed towards bone.
 Advanced until resistance felt.
 Anaesthetic injected with continuous force for about 15 seconds.
 Approx. 0.2mL of solution
 25 vs. 30 gauge needle
Adjunctive Strategies
•
•
•
•
•
•
PDL Injection
Sub-periosteal injection
Intraosseous Injection
Intrapulpal Injection
Intraseptal Injection
Different anaesthetic
Sub-periosteal injection
 Faster onset than normal infiltration.
 Anesthesia Duration is less.
 Other possible negative effects include ischemia and
necrosis of the periosteum tissue.
 Rarely used.
Adjunctive Strategies
•
•
•
•
•
•
PDL Injection
Sub-periosteal injection
Intraosseous Injection
Intrapulpal Injection
Intraseptal Injection
Different anaesthetic
Intraosseous Injection
 Technique for mandibular infiltration
 Perforate the cortical plate to introduce LA in medullary
bone.
 Two commertial systems available:
• Stabident (patterson)
• X-Tip (Tulsa Dentsply)
Adjunctive Strategies
•
•
•
•
•
•
PDL Injection
Sub-periosteal injection
Intraosseous Injection
Intrapulpal Injection
Intraseptal Injection
Different anaesthetic
Intra-Pulpal Injection
 When a small access cavity is available to the pulp.
 A fitting size needle into the pulp should be used.
 A small amount of LA is injected under pressure (about
0.1ml)
 Usually associated with initial discomfor feeling.
 Followed by rapid onset of anesthetic.
Intra-Pulpal Injection
• When exposure is too large to allow snug needle fit.
• Bathing of the exposed pulp with local anesthetic
solution should be done for a minute.
• Followed by introducing the needle as far apically as
possible into the pulp chamber injecting the local
anesthetic solution under pressure
Adjunctive Strategies
•
•
•
•
•
•
PDL Injection
Sub-periosteal injection
Intraosseous Injection
Intrapulpal Injection
Intraseptal Injection
Different anaesthetic
Intra-Septal Injection
 Intraseptal injection is used for hemostasis, soft tissue
anesthesia, and osseous anesthesia.
 Prepare the tissue with topical anesthetic.
 Use a 27 gauge short needle and insert it into the papilla
of the area to be anesthetized at a 90° angle to the
tissue.
 Slowly deposit 0.2ml of solution
Adjunctive Strategies
Topical Anesthetic
• Benzocaine
• Lidocaine
Effectiveness:
• Gill and Orr 1979 : 15 second application no more
effective than placebo.
• Stern and Giddon 1975: 2-3minutes profound soft tissue
anesthesia
Topical Anesthetic
Recommendations:
 Dry mucous membrane first 2-3minutes
 But concern with tissue sloughing
Topical Anesthetic
Benzocaine Spray
Advice to Dentists:
Benzocaine Sprays and Methemoglobinemia (MHb)
Recommendations:
 Avoid in patients with a history of MHb
 Consider lidocaine as an alternative
 Broken/inflamed tissue may promote uptake
 Use only amount deemed necessary
 If suspicious, send patient to hospital for methylene blue tx
 O2 won’t help, but give it anyways