Technique

Supraperiosteal infiltrations
A supraperiosteal infiltration anesthetizes individual teeth (see image
below). Use this technique only with the maxillary incisors, canines, and
premolars.[2, 3, 1]

Supraperiosteal infiltration.
1.Landmarks: Locate the mucobuccal fold above the tooth to be
anesthetized by grasping the membrane with gauze and pulling
out and down for maxillary locations and out and up for
mandibular locations.
2.Apply topical anesthetic as described in the Anesthesia section.
3.Approach: Insert needle into the mucobuccal fold with the bevel facing
bone, aligned with the center of the tooth to be anesthetized,
aimed toward the maxilla. Contact the maxilla, then withdraw the
needle 1 mm.
4.Aspirate.
5.Slowly inject 1-2 mL of local anesthetic at the apex of the root tip.
Anterior superior alveolar nerve block
The anterior superior alveolar (ASA) nerve block anesthetizes the
maxillary canine, the central and lateral incisors, and the mucosa above
these teeth, with occasional crossover to the contralateral maxillary
incisors (see image below).[2, 4]

Anterior superior alveolar (ASA) nerve block.

1.Landmarks: Locate the mucobuccal fold where it intersects with the
apex of the canine (cuspid) tooth by retracting the membrane with
gauze and pulling out and down.
2.Apply topical anesthetic as described in the Anesthesia section.
3.Approach: While retracting the lip, insert the needle into the
intersection of the mucobuccal fold and the apex/center of the
canine at a 45-degree angle, advancing the needle approximately
1-1.5 cm.
4.Aspirate.
5.Slowly inject 2 mL of local anesthetic and massage for 10-20
seconds.
Middle superior alveolar nerve block
The middle superior alveolar (MSA) nerve block anesthetizes the
maxillary premolars with occasional overlap to the canine and first molar
(see image below).[2, 1, 4]

Middle superior alveolar nerve (MSA) block.

1.Landmarks: Locate the mucobuccal fold where it intersects with the
junction of maxillary premolar 2 and molar 1.
2.Apply topical anesthetic as described in the Anesthesia section.
3.Approach: While retracting the cheek, insert the needle into the
aforementioned intersection point at a 45-degree angle, and
advance 1-1.5 cm.
4.Aspirate.
5.Slowly inject 2-3 mL of local anesthetic and massage for 10-20
seconds.
Posterior superior alveolar nerve block
The posterior superior alveolar (PSA) nerve block anesthetizes
maxillary molar teeth (see image below). With the PSA nerve block, the
first molar may not be completely anesthetized; in this case, the PSA
nerve block can be used in conjunction with an MSA/supraperiosteal
block.[2, 3, 1, 4]

Posterior superior alveolar (PSA) nerve block.

1.Landmarks: Start with the jaw half open and swung toward the
operator. Retract the cheek laterally and locate the intersection of
the mucobuccal fold and the junction of molars 1 and 2.
2.Apply topical anesthetic as described in the Anesthesia section.
3.Approach: Insert the needle into the intersection and direct it toward
the posterolateral maxillary tuberosity (up, back, and inward)
along the curvature or the maxilla and to a depth of approximately
2-2.5 cm. If the needle contacts bone, withdraw and redirect more
laterally.
4.Aspirate.
5.Slowly inject 2-3 mL of local anesthetic.
Infraorbital nerve block
An infraorbital nerve block, which branches from the maxillary nerve,
anesthetizes the lower eyelid, upper cheek, part of the nose, and upper
lip (see image below). The ASA nerve, which innervates the maxillary
canine, the central and lateral incisors, and the mucosa above these
teeth, with occasional crossover to the contralateral maxillary incisors,
also branches from the maxillary nerve, proximal to the infraorbital
nerve.[2, 3, 1, 4] Because of this anatomy, anesthetizing the infraorbital
nerve can result in some overlapping anesthesia of the ASA nerve or
vice versa. However, anesthetizing one of these nerves does not
guarantee anesthesia of the other.

Infraorbital nerve block.

1.Landmarks: Externally, the intraorbital foramen is just medial to the
intersection of a vertical line from the pupil (when midline) to the
inferior border of the infraorbital ridge. Internally, the intraorbital
foramen is approached at the intersection of the mucobuccal fold
and the junction of premolars 1 and 2.
2.Apply topical anesthetic as described in the Anesthesia section.
3.Approach: Place the index finger of the nondominant hand over the
above the intersection mentioned above (ie, the infraorbital
foramen) and retract the cheek with the thumb. Insert the needle
into the mucobuccal fold at junction of premolars 1 and 2. Direct
the needle parallel to the long axis of premolar 2, palpating its
location as the needle is advanced until it is adjacent to the
infraorbital foramen (approximately 1.5-2 cm). If the needle is
directed at an angle that is too acute, it will hit the maxillary
eminence; if directed at an angle that is too superior, the needle
will enter the orbit.
4.Aspirate.
5.Inject 2-3 mL of local anesthetic while holding firm pressure with the
index finger over infraorbital ridge to prevent ballooning of lower
eyelid. Massage for 10-20 seconds.
Nasopalatine nerve block
The nasopalatine nerve block anesthetizes the anterior hard palate and
associated soft tissues (see image below).[3, 4]

Nasopalatine nerve block.

1.Landmarks: The location for this injection is 0.5 cm posterior to the
central incisors at the midline. Look for a slight soft tissue
elevation; this is the incisive papilla, which overlies the incisive
foramen.
2.Apply topical anesthetic as described in the Anesthesia section.
3.Approach: Insert needle with the bevel facing the hard palate just
lateral to incisive papilla. Advance 3-4 mm medially or until the
needle contacts bone.
4.Aspirate.
5.Inject 0.25-0.4 mL of local anesthetic. Do not inject more than this
because it can cause separation of the mucosa from the palate
and subsequent tissue necrosis.
Greater palatine nerve block
Blocking the greater palatine nerve anesthetizes the posterior two thirds
of the hard palate (see image below).[3, 4]

Greater palatine nerve block.

1.Landmarks: The greater palatine foramen can be identified by finding
the junction of molars 2 and 3 and then moving the needle 1 cm
medially.
2.Apply topical anesthetic as described in the Anesthesia section.
3.Approach: Insert the needle adjacent to the greater palatine foramen,
at a 90-degree angle to the curvature of the hard palate. Do not
advance further.
4.Aspirate.
5.Inject 0.3-0.5 mL of anesthetic. Do not inject more than this because it
can cause separation of the mucosa from the palate and
subsequent tissue necrosis.
Inferior alveolar nerve block
An inferior alveolar nerve block anesthetizes all teeth on the ipsilateral
side of mandible, as well as the ipsilateral lip and chin via the mental
nerve (see image below).[2, 3, 1, 4]

Inferior alveolar nerve block.

1.Landmarks: Start by standing contralateral to the side to be
anesthetized. Place the thumb in the mouth, and place the index
finger externally and posterior to the ramus (angle of the jaw).
Retract cheek laterally and palpate the retromolar fossa to find
the greatest depth of the anterior border of the ramus; this is the
coronoid notch.
2.Apply topical anesthetic as described in the Anesthesia section.
3.Approach: With the patient’s jaw open, align the barrel of the syringe
with occlusive surfaces of the teeth, angled between the first and
second premolars on contralateral side (the syringe must be thus
aligned for a successful nerve block). Insert the needle 1 cm
above the occlusive surface of the teeth in the triangle at the
lingula. The lingula is a bony projection on the medial surface of
the ramus 1 cm above the occlusive plain. The goal is to insert
the needle just superior and posterior to the lingula; if the needle
is inserted too low, anesthesia does not occur. Stop insertion
when the needle strikes the bone but not before. Withdraw the
needle 1-2 mm.
4.Aspirate.
5.Inject 2-4 mL of local anesthetic. Because of its close proximity to the
inferior alveolar nerve, the lingual nerve is usually also
anesthetized with this technique.
Mental nerve block
A mental nerve block anesthetizes the ipsilateral lower lip and skin of
the chin (not the teeth; see image below).[2, 3, 1, 4]

Mental nerve block.

1.Landmarks: To locate the mental foramen, retract the cheek and lip
and locate the junction of mandibular premolars 1 and 2 and
down 1 cm inferior to the gum line (just medial to the midline
pupil). Note that this is in the same line as the infraorbital
foramen.
2.Apply topical anesthetic as described in the Anesthesia section.
3.Approach: Insert the needle 1 cm inferior to the second premolar at a
45-degree angle. Advance until the needle contacts the mandible.
Withdraw the needle slightly.
4.Aspirate.
5.Inject 1-2 mL of anesthetic adjacent to the foramen and massage for
10-20 seconds.
Lingual nerve block
The lingual nerve block anesthetizes the anterior two thirds of tongue
(see image below). The lingual nerve also conveys chorda tympani from
the facial nerve to provide taste to the anterior two thirds of the tongue
and preganglionic fibers from chorda tympani to the submandibular
ganglion and, in turn, the submandibular and sublingual glands.[3, 4]

Lingual nerve block.

1.Landmarks: The lingual nerve is located on the lingual side of the
second mandibular molar.
2.Apply topical anesthetic as described in the Anesthesia section.
3.Approach: Stand on the contralateral side. Lift the tongue with a
tongue blade and insert the needle 1 cm below the gumline of the
second mandibular molar. Advance posteriorly 1 cm.
4.Aspirate.
5.Inject 1-1.5 mL of local anesthetic.
Buccal nerve block
The buccal nerve block anesthetizes the mucous membrane of the
cheek and vestibule and, to a lesser extent, a small patch of skin on the
face (see image below).[3, 4]

Buccal nerve block.

1.Landmarks: Locate the buccal nerve 1 mm lateral to mandibular molar
3 at the anterior border of the ramus in the occlusive plane.
2.Apply topical anesthetic as described in the Anesthesia section.
3.Approach: With the thumb of the nondominant hand, pull the cheek
laterally. Insert the needle into the anterior border of the ramus 1
mm lateral to the third mandibular molar and in line with the
occlusive plane. Advance the needle 3-4 mm.
4.Aspirate.
Slowly inject 2 mL of local anesthetic.