TECHNIQUES OF LOCAL

ANESTHESIA
Dr Amna Muzaffar
BDS
ASSISTANT PROFESSOR,OMFS
LOCAL INFILTRATION

 Small terminal nerve endings are

anaesthetized
 0.6 – 1.0ml
FIELD BLOCK

 Deposited in the proximity to the large nerve

branches
 Injection administered
above the apex of the
tooth to be treated is
called field block
NERVE BLOCK

 Depositing the L.A within close proximity to

the main nerve trunk
 1.8- 2.0 ml
INTRALIGAMENTARY INJECTION

 Depositing the L.A solution within PDL

through gingival sulcus
 Provide 30-35 min of anesthesia
INTRAOSSEOUS INJECTION

 L.A solution is deposited directly into

cancellous bone adjacent
to the tooth to be anesthetized
 Recommended for
single teeth (when
other techniques
failed )
INTRAPULPAL ANESTHESIA

 Indicated for obtaining anesthesia for

procedures requiring direct instrumentation
of the pulpal tissue like RCT
 Needle is inserted
directly into pulp
Chamber or root canal
And L.A is injected
INTRASEPTAL INJECTION

 Variation of intraosseous
anesthesia
 Needle is forced into
porous intraseptal bone
on either side of tooth
to be anesthetised.
L.A is then deposited
TECHNIQUES OF MAXILLARY
ANESTHESIA
SUPRAPERIOSTEAL INJECTION

 Also called local infiltration

 Nerve anesthetized – terminal branches of
dental plexus
 Area Anesthetized- tooth (pulp), buccal
periosteum, connective tissue and mucous
membrane
Indications
a. Circumscribed soft tissue anesthesia
b. Pulpal anesthesia of 1 or2 maxillary teeth

Contraindications
c. Infection or acute inflammation
d. Dense bone covering the teeth apices
 Advantages – Technically easy ,high success
rate
 Disadvantages –not recommended for large
areas(multiple pricks, large vol.)
 Technique :
 target area -Height of mucobuccal fold above
the apex of tooth being anesthetized
Orientation of bevel –towards bone
Syringe parallel to long axis of the tooth
 Landmarks – mucobuccal fold
- crown of the tooth
- root contour of the tooth
POSTERIOR SUPERIOR ALVEOLAR
NERVE BLOCK
 Tuberosity block , zygomatic block
 Nerve anesthetized –posterior superior
alveolar and branches
 Area anesthetized – 2nd ,3rd molars ,1st molar
except mesiobuccal root(28%), buccal
periosteum and bone
 Indications : when treatment involves two or
more molars, when supraperiosteal is
contraindicated(infection) or ineffective
 Contraindication : if inc. risk of hemorrhage
like hemophiliac patients )
 Advantages : atraumatic, high success rate ,
minimum anesthesia and pricks
 Disadvantages – risk of hematoma ,
technique arbitrary (no bony landmarks ) ,
2nd injection for mesiobuccal root of 1st molar

 TECHNIQUE :
 Area of insertion :height of mucobuccal fold
above 2nd maxillary molar
 Target area :PSA nerve
 Landmarks : mucobuccal fold,maxillary
tuberosity, zygomatic process of maxilla
MIDDLE SUPERIOR ALVEOLAR NERVE

 Present in only 28% of patients

 Nerve anesthetized – middle superior
alveolar and its terminal branches
 Area anesthetized – pulps, buccal
periodontium and bone of 1st and 2nd
premolar and mesiobuccal root of first molar
 Indications : when ASA block fails distal to
maxillary canine , for procedures involving
premolars
 Contraindications : infection or inflamation,
when MSA nerve absent
 Advantages : minimize no of injections and
vol. of solution
 Disadvantages : none
TECHNIQUE

 Area of insertion : height of mucobuccal fold

above 2nd premolar
 Target area : bone above apex of maxillary
2nd premolar
 Landmark : mucobuccal fold above 2nd
premolar
ANTERIOR SUPERIOR ALVEOLAR
NERVE BLOCK
 Also called infraorbital nerve block
 Nerve anesthetized :anterior superior
middle superior,
infraorbital nerve
(a. inferior palpebral , lateral nasal , superior
labial )
 Area anesthetized :
 Indications : procedure involving more than
two teeth ,localized infection or inflamation,if
supraperiosteal injection ineffective (dense
bone )
 Contraindications : hemostasis of localized
area cannot be achieved , discrete treatment
areas
 Advantages : comparatively simple
technique ,safe technique
 Disadvantages :psychological : fear of injury
to pts eye,difficulty defining landmarks

 Technique :
 Area of insertion :height of mucobuccal fold
over 1st premolar
 Target area : infraorbital foramen
 Landmarks : mucobuccal fold. Infraorbital
notch ,infraorbital foramen
PALATAL ANESTHESIA

 Types
 Greater palatine nerve block
 Nasopalatine nerve block
 local infiltration of the palate
 Anterior middle superior alveolar nerve block
 Palatal approach – Anterior Superior alveolar

 others
 Maxillary nerve block
GREATER PALATINE NERVE BLOCK

 0.45-0.6 ml required
 Also called anterior palatine nerve block
 Nerve anesthetized : greater palatine nerve
 Indications :when palatal soft tissue
anesthesia is necessary (matrix band ), for
pain control during procedures involving
palatal tissue
 Contraindication : infection or
inflammation ,smaller area of therapy
 Advantages :minimize no of needle
penetration and vol of solution , minimize
patient discomfort
 Disadvantages :no hemostasis except
immidiate area of injection

 Area anesthetized :
TECHNIQUE

 Area of insertion : soft tissue anterior to

greater palatine foramen
 Target area : greater palatine nerve
 Landmarks : greater palatine foramen and
junction of maxillary alveolar process and
palatine bone
TECHNIQUES OF MAXILLARY
ANESTHESIA
MAXILLARY TECHNIQUES

 Supraperiosteal injection
 Posterior Superior Alveolar nerve block
 Middle Superior Alveolar nerve block
 Anterior Superior Alveolar nerve block
 Palatal Anesthesia
 Greater palatine nerve block
 Nasopalatine nerve block
 Local infiltration of palate
 Anterior Middle Superior Alveolar nerve block
 Palatal approach –Anterior Superior alveolar
 Maxillary block
NASOPALATINE NERVE BLOCK

 Also called incisive nerve block ,

sphenopalatine nerve block
 Nerve anesthetized : nasopalatine nerves
bilaterally
 Areas anesthetized : anterior portion of the
hard palate (hard and soft tissues) bilaterally
from mesial of right 1st premolar to the mesial
of left 1st premolar
 Indications : when palatal soft tissue
anesthesia is required (subgingival
restoration, matrix band ) . Pain control
during periodontal or surgical procedures

 Contraindications : infection,inflammation
at injection site . Smaller area of therapy
 Advantages : minimize needle penetration
and vol of solution . Minimal patient
discomfort from multiple needle penetration

 Disadvantages : no hemostasis except in the

immediate area of injection , potentially the
most traumatic intraoral injection
 TECHNIQUES

 2 techniques
 Single needle penetration of the palate
 Multiple needles penetration

 Single needle penetration of the palate:

Area of insertion: palatal mucosa lateral to the
incisive papilla
Target area: incisive foramen
Landmarks : central incisors and incisive papilla
 Multiple needle penetration :
- Areas of insertion: a. Labial frenum b.
interdental papilla b/w central incisor c.palatal
soft tissue lateral to incisive papilla
- Target area : incisive foramen
- Landmarks : central incisior and incisive papilla
- Path of insertion :
1st injection: infiltration into labial frenum.
2nd injection: needle held at right angle to
interdental papilla
3rd injection : needle at 45 degree angle to the
incisive papilla
LOCAL INFILTRATION OF THE PALATE

 Nerves anesthetized :terminal branches of

the nasopalatine and greater palatine

 Areas anesthetized : soft tissue in the

immediate vicinity of injection
 Indications : for achieving hemostasis during
surgical procedure . For palatogingival
control (application of rubber dam clamp)

 Contraindications :inflammation or infection

, pain control for more than two teeth
 Advantages : provide acceptable
hemostasis , provides minimum area of
numbness

 Disadvantages : potentially traumatic

injection

 Technique :
- area of insertion : attached gingiva 5-
10mm from free gingival margin.
- Landmark : gingival tissue in the estimated
center of the treatment area
- pathway of insertion : approaching the
injection site at 45 degree angle
ANTERIOR MIDDLE SUPERIOR
ALVEOLAR NERVE
 Nerve anesthetized : ASA nerve , MSA nerve
if present , subneural dental nerve plexus of
the anterior and middle superior alveolar
nerves
 Areas anesthetized : pulpal anesthesia of
maxillary incisiors,canines and premolars,
buccal attached gingiva of these teeth ,
attached palatal tissue from midline to free
gingival margin
 Indications : when scaling and root planning
to be performed , anesthesia to multiple
teeth from single site injection ,
supraperiosteal injection ineffective

 Contraindication : procedures requiring

longer than 90 min , patients unable to
tolerate 3 -4 min administration time ,
 Advantages : provide anesthesia of multiple
teeth with single injection , simple
technique , comparatively simple , minimize
vol of anesthesia and no of punctures
,eliminate postoperative convenience of
numbness to upperlip and muscles of facial
expression

 Disadvantages : slow administration time ,

may be uncomfortable for patient
PALATAL APPROACH – ANTERIOR
SUPERIOR ALVEOLAR
 Point of needle entry is same as nasopalatine
block but differs in final target – needle
positioned within incisive canal.
 Nerve anesthetized : Nasopalatine , Anterior
branches of ASA
 Areas anesthetized : Pulps , facial
periodontial tissue , palatal periodontal tissue
associated with maxillary central,lateral and
to a lesser degree the canines
 Indications : when dental procedures
involving maxillary teeth and tissues are to be
performed,bilateral anesthesia of maxillary
teeth desired from single injection, scaling
and root planning , cosmetic procedures and
smile line assesment is necessary , when
supraperiosteal injection is ineffective
 Contraindications : patients with extremely
long canine root ,who cannot tolerate 3-4 min
administration time, procedures requiring
longer than 90 min
 Advantages : provide bilateral maxillary
anesthesia ,comparatively simple and safe
technique ,accurate smile line assesment ,
eliminate postop numbness of upper lip ,
minimize vol. of anesthesia and no of pricks
 Disadvantages : require slow administration,
operator fatigue , uncomfortable for the
patient , may require supplemental
anesthesia for canine teeth, may cause
excessive ischemia if administered rapidly
 TECHNIQUE :
Area of insertion: just lateral to incisive
papilla in papillary groove
 Target area : nasopalatine foramen
 Landmark : nasopalatine papilla
MAXILLARY NERVE BLOCK

 Nerve anesthesized :
maxillary division of trigeminal nerve

 Areas anesthetized : pulpal anesthesia ,

buccal periosteum and bone of maxillary
teeth on side of block , soft tissue and bone of
hard palate and part of soft palate ,skin of the
lower eyelid ,side of nose, cheek and upper
lip
 Indications :pain control before procedures
requiring anesthesia of entire maxillary
division , when other regional nerve block
ineffective , diagnostic or therapeutic
procedures for neuralgia for neuralgia

 Contraindications : pediatric patients ,

uncooperative patients, infection or
inflammation
 Advantages : atraumatic injection , high
success rate , minimizes number of
penetrations , minimizes vol. of L.A.

 Disadvantages : risk of hematoma

 TECHNIQUES

 Two techniques
 High tuberosity approach
 Greater palatine canal approach

 High tuberosity approach :

Area of insertion : height of mucobuccal fold
above the distal aspect of maxillary second
molar
 Target area : maxillary nerve as it passes
through the pteryfopalatine fossa , superior
and medial to the target of PSA nerve block

 Landmarks : mucobuccal fold (distal aspect

of 2nd molar ) , maxillary tuberosity ,
zygomatic process of maxilla
 GREATER PALATINE CANAL APPROACH :
 Area of insertion : palatal soft tissue directly
over greater palatine foramen
 Target area : maxillary nerve as it passes
through pterygopalatine fossa
 Landmarks : greater palatine foramen ,
junction of maxillary alveolar process and
palatine bone
TECHNIQUES OF
MANDIBULAR ANESTHESIA
MENTAL NERVE BLOCK

 Nerve anesthetized : mental nerve

 Areas anesthetized : buccal mucous
membrane anterior to mental foramen , to
the midline and skin of lower lip

 Indications : when buccal soft tissue

anesthesia is required (biopsy,suturing )
 Contraindications : infection, inflammation
 Advantages : technically easy, high success
rate and entirely atraumatic
 Disadvantages : hematoma

 TECHNIQUE : Area of insertion : mucobuccal

fold at or anterior to mental foramen
 Target area : mental nerve
 landmarks : mandibular premolars and
mucobuccal fold
INFERIOR ALVEOLAR NERVE BLOCK

 Nerve Anesthetized : inferior alveolar , incisive ,

Mental, lingual.
 Areas Anesthetized : Mandibular teeth to the
midline , Body of the mandible ,inferior portion
of of the ramus , buccal mucoperiosteum ,
mucous membrane anterior to mental foramen
(mental nerve), Anterior two thirds of the
tongue and floor of the oral cavity, lingual soft
tissues and periosteum (lingual nerve)
 Indications : procedures on multiple
mandibular teeth in one quadrant , for buccal
and lingual soft tissue anesthesia

 Contraindications : infection and

inflammation , young child or physically or
mentally handicapped adult or child
 Advantages : one injection provides a wide
area of anesthesia

 Disadvantages : not indicated for localized

procedures , intraoral landmark not reliable ,
self – inflicted soft tissue trauma, partial
anesthesia if bifid canal and bifid nerve
present
TECHNIQUE

 Area of insertion : mucous membrane on the

medial (lingual ) side of mandibular ramus ,at the
intersection of two lines – one horizontal
representing the height of needle insertion,the
other vertical ,representing the anteroposterior
plane of injection

 Target area : inferior alveolar nerve as it passes

downward toward mandibular foramen but
before it enters into foramen
 Landmarks : coronoid notch ,
pterygomandibular raphe , occlusal plane of
the mandibular posterior teeth
MANDIBULAR NERVE BLOCK –THE
GOW-GATE TECHNIQUE
 Nerves Anesthesized : inferior alveolar
,mental incisive ,lingual ,mylohyoid,
auriculotemporal ,buccal
 Areas Anesthetized : mandibular teeth to
midline, buccal and lingual soft tissue and
periosteum ,anterior 2/3rd and floor ,body and
ramus of mandible,skin over
zygoma,temporal area and posterior portion
of cheek
 Indications : for buccal and lingual soft tissue
anesthesia , , multiple procedures on
mandibular teeth , when IAN block
unsuccessful

 Contraindications : infection or
inflammation, physically or mentally
handicapped patient , patient with trismus or
limited mouth opening
 Advantages : usually require only one
injection , high success rate, few post op
complications , provide anesthesia in case of
bifid canal or bifid nerve

 Disadvantages :time to onset of anesthesia

is longer :5 min , technique sensitive , lip
anesthesia uncomfortable for patients
TECHNIQUE

 Areas of Insertion : mucous membrane on

mesial of mandibular ramus,on a line from
the intertragic notch to corner of mouth just
distal to maxillary 2nd molar

 Target Area : lateral side of condylar neck

,just below insertion of lateral pterygoid
muscles
 Landmarks :
- Extraoral : lower border of the tragus
corner of the mouth

- Intraoral : height of injection established by

placement of needle tip below mesiopalatal cusp
of maxillary2nd molar
penetration of soft tissues distal to max. 2nd molar
VAZIRANI – AKINOSI CLOSED MOUTH
MANDIBULAR BLOCK
 Nerves anesthetized : inferior
alveolar,incisive , mental , lingual , mylohyoid

 Areas Anesthetized : : mandibular teeth to

midline, buccal and lingual soft tissue and
periosteum ,anterior 2/3rd and floor ,body and
ramus of mandible, lingual soft tissue and
periosteum
 Indications : limited mandibular opening,
multiple procedures on mandibular teeth ,
inability to visualize landmarks for IANB

 Contraindications :Infection or acute

inflammation, mentally or physically
handicapped patient inability to gain access
to the lingual aspect of ramus
 Advantages : usually require only one
injection , high success rate, few post op
complications , provide anesthesia in case of
bifid canal or bifid nerve , atraumatic , patient
need not be able to open the mouth

 Disadvantages : no bony contact , difficult to

visualize path of needle and dept of insertion
potentially traumatic (if near periosteum )
TECHNIQUE

 Areas of Insertion : soft tissue overlying the

medial border of ramus directly adjacent to
maxillary tuberosity at height of
mucogingival junction adjacent to maxillary
3rd molar
 Target Area : soft tissue on medial border of
ramus in region of Inferior alveolar , lingual
and mylohyoid nerve as they run inferiorly
 From ovale to mandibular foramen
 Landmarks : mucogingival junction of
maxillary third molar , maxillary tuberosity ,
coronoid notch
BUCCAL NERVE BLOCK

 Nerve Anesthetized : buccal nerve

 Areas Anesthetized : soft tissue and periosteum

buccal to mandibular molar teeth

 Indication: for buccal soft tissue anesthesia

 Contraindications : infection or inflammation

 Advantages : high success rate , easy
technique

 Disadvantages : painful if needle contact

periosteum
TECHNIQUE

 Areas of insertion : mucous membrane distal

and buccal to most distal molar tooth

 Target area : buccal nerve ( at anterior border

of ramus )

 Landmarks : mandibular molars, mucobuccal

fold
INCISIVE NERVE BLOCK

 Nerve anesthetized : mental and incisive

 Areas anesthetized : buccal mucous
membrane , lower lip and skin of the chin ,
pulpal nerve fibers to the premolars , canine
and incisors
 Indications : when IANB is not indicated
,procedures requiring pulpal anesthesia on
mandibular teeth anterior to mental foramen
 Contraindications : infection or
inflammation

 Advantages : provide pulpal anesthesia

without lingual anesthesia ,high success rate

 Disadvantages : does not provide pulpal

anesthesia , partial anesthesia may develop
at midline bcoz of fibers overlap
 Technique :
 Area of insertion :mucobuccal fold at or just
anterior to mental foramen
 Target area : mental foramen
 Landmarks : mandibular premolars and
mucobuccal fold
 THANKYOU….