This document discusses various techniques for local anesthesia in the maxillary and mandibular regions. It provides detailed descriptions of nerve blocks including the posterior superior alveolar nerve block, middle superior alveolar nerve block, anterior superior alveolar nerve block, greater palatine nerve block, nasopalatine nerve block, and maxillary nerve block. It also briefly mentions techniques used for mandibular anesthesia such as the inferior alveolar nerve block. The goal of these techniques is to anesthetize specific teeth, gums, lips, and other tissues by blocking select nerves that innervate the target areas. Precise needle placement and aspiration are important to minimize risks like hematoma formation.

1. TECHNIQUES OF LOCAL
ANESTHESIA

2. LOCAL ANESTHESIA IN
MAXILLARY REGION RELATED
TO MAXILLARY DIVISION OF
TRIGEMINAL NERVE

3. POSTERIOR SUPERIOR
ALVEOLAR NERVE BLOCK
• One of the frequently used nerve blocks in
dentistry.
• The anesthetic solution is deposited
behind the tuberosity , near the posterior
superior alveolar nerve before it enters the
maxillary sinus.

4. Posterior Superior Alveolar Nerve
Block
• The posterior superior alveolar (PSA) nerve block, otherwise known
as the tuberosity block or the zygomatic block, is used to achieve
anesthesia of the maxillary molar teeth up to the 1st molar with the
exception of its mesiobuccal root in some cases.
• One of the potential complications of this technique is the risk of
hematoma formation from injection of anesthetic into the pterygoid
plexus of veins or accidental puncture of the maxillary artery.
Aspiration prior to injection is indicated when the PSA block is given.
• The indications for this technique are the need to anesthetize
multiple molar teeth.
• In individuals with coagulation disorders, care must be taken to
avoid injection into the pterygoid plexus or puncture of the maxillary
artery. 25- or 27-gauge short needle is preferred for this technique.

5. Technique
• Identify the height of the
mucobuccal fold over the
2nd molar. This will be
the injection site.
• The right handed
operator should stand at
the nine o’clock to ten
o’clock position whereas
the left handed operator
should stand at the two
o’clock to three o’clock
position. Retract the lip
with a retraction
instrument.

6. • Hold the syringe with the
bevel toward the bone.
• Insert the needle at the
height of the mucobuccal
fold above the maxillary
2nd molar at a 45 degree
angle directed superiorly,
medially, and posteriorly
(one continuous
movement). Advance the
needle to a depth of three
quarters of its total length

7. • No resistance should be felt while advancing the
needle through the soft tissue.
• If bone is contacted, the medial angulation is too
great. Slowly retract the needle (without removing it)
and bring the syringe barrel toward the occlusal
plane. This will allow the needle to be angulated
slightly more lateral to the posterior aspect of the
maxilla.
• Prior to injecting, one should aspirate in two planes
to avoid accidental injection into the pterygoid plexus.
After the first aspiration, the needle should be rotated
one quarter turn. The operator should then
reaspirate.
• If positive aspiration occurs, slowly retract the needle
one to two millimeters and reaspirate in two planes.
• Successful injection technique will result in
anesthesia of the maxillary molars (with the exception
of the mesiobuccal root of the first molar in some
cases), and associated soft tissue on the buccal
aspect.

8. Complications
HEMATOMA
• This is commonly produced by inserting the
needle too for posteriorly into the pterygoid
plexus of veins .
• In addition maxillary artery may be perforated.
• Use of short needle minimises the risk of
pterygoid plexus puncture

9. Middle Superior Alveolar Nerve
Block
• The middle superior alveolar nerve block is useful for
procedures where the maxillary premolar teeth or the
mesiobuccal root of the 1st molar require anesthesia.
• Although not always present, it is useful if the posterior
or anterior superior alveolar nerve blocks or
supraperiosteal infiltration fails to achieve adequate
anesthesia.
• Individuals in whom the MSA nerve is absent, the PSA
and ASA nerves provide innervation to the maxillary
premolar teeth and the mesiobuccal root of the 1st
molar.
• Contraindications include acute inflammation and
infection in the area of injection or a procedure involving
one tooth where local infiltration will be sufficient. A 25-
or 27-gauge short needle is preferred for this technique.

10. Technique
•
Identify the height of the
mucobuccal fold above the maxillary
2nd premolar. This will be the
injection site.
• The right handed operator should
stand at the nine o’clock to ten
o’clock position whereas the left
handed operator should stand at the
two o’clock to three o’clock position.
• Retract the lip with a retraction
instrument and insert the needle
until the tip is above the apex of the
2nd premolar tooth .
• Aspirate and inject anesthetic
solution slowly over the course of
one minute. Successful execution of
this technique provides anesthesia
to the pulp, surrounding soft tissue
and bone of the 1st and 2nd
premolar teeth and mesiobuccal
root of the 1st molar.1

11. Contraindications
• Infection or inflammation in the area of
injection or needle insertion or drug
deposition.

12. Anterior Superior Alveolar Nerve Block/ Infraorbital
Nerve Block
• The anterior superior alveolar (ASA) nerve block or
infraorbital nerve block is a useful technique for
achieving anesthesia of the maxillary central and lateral
incisors and canine as well as the surrounding soft tissue
on the buccal aspect.
• In patients that do not have an MSA nerve, the ASA
nerve may also innervate the premolar teeth and
mesiobuccal root of the 1st molar. Indications for the use
of this technique include procedures involving multiple
teeth and inadequate anesthesia from the
supraperiosteal technique. A 25 gauge long needle is
preferred for this technique.

13. Technique
• Place the patient in the supine
position. Identify the height of
the mucobuccal fold above the
maxillary 1st premolar.
• This will be the injection site.
• The right handed operator
should stand at the ten o’clock
position whereas the left
handed operator should stand
at the two o’clock position.
• Identify the infraorbital notch on
the inferior orbital rim.
• The infraorbital foramen lies just
inferior to the notch usually in
line with the second premolar.
• Slight discomfort is felt by the
patient when digital pressure is
placed on the foramen. It is
helpful but not necessary to
mark the position of the
infraorbital foramen.

14. • Retract the lip with a retraction
instrument while noting the location
of the foramen.
• Orient the bevel of the needle
toward bone and insert the needle
at the height of the mucobuccal fold
above the 1st premolar .
• The syringe should be angled
toward the infraorbital foramen and
kept parallel with the long axis of the
1st premolar to avoid hitting the
maxillary bone prematurely.
• The needle is advanced into the soft
tissue until the bone over the roof of
the foramen is contacted. After
aspiration, anesthetic cartridge is
deposited slowly over the course of
one minute.
• It is recommended that pressure be
kept over the site of injection to
facilitate the diffusion of anesthetic
solution into the foramen.
• Successful execution of this
technique results in aesthesia of the
lower eyelid, lateral aspect of the
nose, and the upper lip.
• Pulpal anesthesia of the maxillary
central and lateral incisors, canine,
buccal soft tissue, and bone is also
achieved. In a certain percentage of
people, the premolar teeth and the
mesiobuccal root of the 1st molar is

15. Greater Palatine Nerve Block
• The greater palatine nerve block is useful when
treatment is necessary on the palatal aspect of
the maxillary premolar and molar dentition.
• This technique targets the area just anterior to
the greater palatine canal. The greater palatine
nerve exits the canal and travels forward
between the bone and soft tissue of the palate.
• Contraindications to this technique are acute
inflammation and infection at the injection site. A
25- or 27-gauge long needle is preferred for this
technique

16. Technique
• The patient should be in the supine position with
the chin tilted upward for visibility of the area to
be anesthetized. The right handed operator
should stand at the eight o’clock position
whereas the left handed operator should stand
at the four o’clock position.
• Using a cotton swab, locate the greater palatine
foramen by placing it on the palatal tissue
approximately one centimeter medial to the
junction of the 2nd and 3rd molar

17. • While this is the usual position for the foramen,
it may be located slightly anterior or posterior to
this location.
• Gently press the swab into the tissue until the
depression created by the foramen is felt. The
area approximately one to two millimeters
anterior to the foramen is the target injection
site.
• Using the cotton swab, apply pressure to the
area of the foramen until the tissue blanches.
• Aim the syringe perpendicular to the injection
site which is one to two millimeters anterior to
the foramen.
•

18. • While keeping pressure on the foramen, inject small
volumes of anesthetic solution as the needle is
advanced through the tissue until bone is contacted.
• The tissue will blanch in the area surrounding the
injection site.
• Depth of penetration is usually few millimeters.
• Once bone is contacted, aspirate and inject
anesthetic solution.
• Resistance to deposition of anesthetic solution is
normally felt by the operator.
• This technique provides anesthesia to the palatal
mucosa and hard palate from the 1st premolar
anteriorly to the posterior aspect of the hard palate
and to the midline medially.

19. Nasopalatine Nerve Block
• The nasopalatine nerve
block, otherwise known as
the incisive nerve block and
sphenopalatine nerve block,
anesthetizes the
nasopalatine nerves
bilaterally.
• In this technique anesthetic
solution is deposited in the
area of the incisive foramen.
• This technique is indicated
when treatment requires
anesthesia of the lingual
aspect of multiple anterior
teeth. A 25- or 27-gauge
short needle is preferred for
this technique.

20. Technique
• The patient should be in the supine position with
the chin tilted upward for visibility of the area to
be anesthetized.
• The right handed operator should be at the nine
o’clock position whereas the left handed
operator should be at the three o’clock position.
• Identify the incisive papillae.
• The area directly lateral to the incisive papilla is
the injection site.

21. • With a cotton swab,
hold pressure over the
incisive papilla.
• Insert the needle just
lateral to the papilla with
the bevel against the
tissue
• Advance the needle
slowly toward the
incisive foramen while
depositing small
volumes of anesthetic
and maintaining
pressure on the papilla.
• Once bone is
contacted, retract the
needle approximately
one millimeter, aspirate,
and inject anesthetic
solution over the course
of thirty seconds.

22. • Blanching of surrounding tissues and
resistance to the deposition of
anesthetic solution is normal.
• Anesthesia will be provided to the soft
and hard tissue of the lingual aspect of
the anterior teeth from the distal of the
canine on one side to the distal of the
canine on the opposite side.

23. Maxillary Nerve Block
• Less often used in clinical practice, the maxillary nerve block
(second division block) provides anesthesia of a hemi-maxilla.
• This technique is useful for procedures that require anesthesia
of multiple teeth and surrounding buccal and palatal soft tissue
in one quadrant or when acute inflammation and infection
preclude successful administration of anesthesia by the
aforementioned methods.
• There are two techniques one can use to achieve the maxillary
nerve block:
• High tuberosity approach and the greater palatine canal
approach.
• The high tuberosity approach carries with it the risk of
hematoma formation and is therefore contraindicated in patients
with coagulation disorders.
• The maxillary artery is the vessel of primary concern with the
high tuberosity approach.
• Both techniques are contraindicated when acute inflammation
and infection is present over the injection site.

24. High Tuberosity Approach
• A 25 gauge long needle is preferred for this technique.
• TECHNIQUE-
• The patient should be in the supine position with the chin tilted
upward for visibility of the area to be anesthetized.
• Identify the area to be anesthetized.
• The right handed operator should be at the ten o’clock position
whereas the left handed operator should be at the two o’clock
position.
• This technique anesthetizes the maxillary nerve as it travels through
the pterygopalatine fossa.
• Identify the height of the mucobuccal fold just distal to the maxillary
2nd molar. This is the injection site.
• The needle should enter the tissue at a forty five degree angle
aimed posteriorly, superiorly and medially as in the PSA nerve block

25. • The bevel should be oriented toward the bone.
• The needle is advanced to a depth of approximately
30mm or a few millimeters shy of the hub.
• At this depth, the needle lies within the
pterygopalatine fossa.
• The operator should then aspirate, rotate the needle
one quarter turn, and aspirate again.
• After negative aspiration in two planes has been
established, slowly inject anesthetic solution over the
course of one minute.
• Successful administration of anesthetic using this
technique provides anesthesia to the entire
hemimaxilla on the ipsilateral side of the block.
• This includes pulpal anesthesia to the maxillary teeth,
buccal and palatal soft tissue as far medially as the
midline, as well as the skin of the upper lip, lateral
aspect of the nose and lower eyelid.

26. Greater Palatine Canal Approach
• A 25 gauge long needle is preferred for this technique.
TECHNIQUE
• Place the patient in the supine position.
• The right handed operator should be at the ten o’clock position
whereas the left handed operator should be at the two o’clock
position.
• Identify the greater palatine foramen as described in the
technique for the greater palatine nerve block.
• The tissue directly over the greater palatine foramen is the
target for injection.
• This technique anesthetizes the maxillary nerve as it travels
through the pterygopalatine fossa via the greater palatine canal.
• Apply pressure to the area over the greater palatine foramen
with a cotton tipped applicator.
• Administer a greater palatine nerve block using the
aforementioned technique

27. • Once adequate palatal anesthesia is achieved, gently probe for
the greater palatine foramen with the tip of the needle.
• For this technique, the syringe should be held so that the needle
is aimed posteriorly.
• It may be necessary to change the angulation of the needle in
order to locate the foramen.
• the majority of canals were angled 45-50 degrees.
• Once the foramen has been located, advance the needle to a
depth of 30mm.
• If resistance is met, withdraw the needle a few millimeters and
reenter at a different angle.
• If resistance is met early on and the operator is unable to
advance the needle into the canal more than a few millimeters,
the procedure should be aborted and the high tuberosity
approach should be considered.
• If no resistance is met and penetration of the canal is
successful, aspirate in two planes as described in previous
sections and slowly deposit local anesthetic solution.
• As with the high tuberosity approach, the hemimaxilla on the
ipsilateral side as the injection becomes anesthetized with
successful execution of this technique.

28. TECHNIQUES OF MANDIBULAR
REGIONAL ANESTHESIA
• Techniques used in clinical practice for the anesthesia of
the hard and soft tissues of the mandible include the
supraperiosteal technique, PDL injection, intrapulpal
anesthesia, intraseptal injection, inferior alveolar nerve
block, long buccal nerve block, Gow -Gates technique,
Vazirani-Akinosi closed mouth mandibular block, mental
nerve block, and incisive nerve block.
• When anesthetizing the mandible the patient should be
in the semisupine or reclined position. The right handed
operator should stand at the nine o’clock to ten o’clock
position whereas the left handed operator should stand
at the three o’clock to four o’ clock position.

39. Inferior Alveolar Nerve Block
• The inferior alveolar nerve block is one of the most
commonly employed techniques in mandibular regional
anesthesia.
• It is used when multiple teeth in one quadrant require
treatment.
• While effective, this technique carries a high failure rate
even when strict adherence to protocol is maintained.
• The target for this technique is the mandibular nerve as
it travels on the medial aspect of the ramus, prior to its
entry into the mandibular foramen. The lingual, mental,
and incisive nerves are also anesthetized. A 25 gauge
long needle is preferred for this technique.

40. Technique
• The patient should be in the
semisupine position.
• The right handed operator should
be in the eight o’clock position
whereas the left handed operator
should be in the four o’clock
position.
• With the mouth open maximally,
identify the coronoid notch and the
pterygomandibular raphae.
• Three quarters of the
anteroposterior distance between
these two landmarks, and
approximately six to ten
millimeters above the occlusal
plane is the injection site

41. • Bring the needle to the injection
site from the contralateral
premolar region.
• As the needle passes through
the soft tissue, deposit one or
two drops of anesthetic solution.
• Advance the needle until bone
is contacted.
• Once bone is contacted,
withdraw the needle one
millimeter and redirect the
needle posteriorly by bringing
the barrel of the syringe towards
the occlusal plane
• Advance the needle to three
quarters of its depth, aspirate,
and inject three quarters of a
cartridge of anesthetic solution
slowly over the course of one
minute.
•

45. • As the needle is
withdrawn, continue
to deposit the
remaining one quarter
of anesthetic solution
so as to anesthetize
the lingual nerve

46. • Successful execution of this technique
results in anesthesia of the mandibular
teeth on the ipsilateral side to the midline,
associated buccal and lingual soft tissue,
lateral aspect of the tongue on the
ipsilateral side, and lower lip on the
ipsilateral side

47. INFERIOR ALVEOLAR NERVE BLOCK IN PEDIATRIC
PATIENTS
• Below 3 years – Below the occlusal plane.
• Upto 6 years- At the occlusal plane
• Upto 12 years – Above the occlusal plane

48. Buccal Nerve Block
• The buccal nerve block, otherwise known as the
long buccal or buccinator block, is a useful
adjunct to the inferior alveolar nerve block when
manipulation of the buccal soft tissue in the
mandibular molar region is indicated.
• The target for this technique is the buccal nerve
as it passes over the anterior aspect of the
ramus.
• Contraindications to the procedure include acute
inflammation and infection over the site of
injection. A 25 gauge long needle is preferred for
this technique.

50. Technique
• The patient should be in the
semisupine position. The right
handed operator should be in
the eight o’clock position
whereas the left handed
operator should be in the four
o’clock position.
• Identify the most distal molar
tooth on the side to be treated.
The tissue just distal and
buccal to the last molar tooth is
the target area for injection

51. • The bevel of the needle
should be toward bone and
the syringe should be held
parallel to the occlusal plane
on the side of the injection.
• The needle is inserted into
the soft tissue and a few
drops of anesthetic solution
are administered.
• The needle is advanced
approximately one or two
millimeters until bone is
contacted.
• Once bone is contacted and
aspiration is negative, 0.2cc
of local anesthetic solution is
deposited.
• Successful execution of this
technique results in
anesthesia of the buccal soft
tissue of the mandibular
molar region.

52. Gow -Gates Technique
• The Gow -Gates technique or third division nerve
block is useful alternative to the inferior alveolar
nerve block and is often used when the latter fails to
provide adequate anesthesia.
• Advantages of this technique versus the inferior
alveolar technique are its low failure rate and low
incidence of positive aspiration.
• The Gow-Gates technique anesthetizes the
auriculotemporal, inferior alveolar, buccal, mental,
incisive, mylohyoid and lingual nerves.
• Contraindications to this procedure include acute
inflammation and infection over the site of injection
and trismatic patients.
• A 25 gauge long needle is preferred for this
technique.

53. Technique
• The patient should be in the
semisupine position.
• The right handed operator
should be in the eight o’clock
position whereas the left
handed operator should be in
the four o’clock position.
• The target area for this
technique is the neck of the
condyle below the area of
insertion of the lateral pterygoid
muscle.
• A retraction instrument is used
to retract the cheek.
• The patient is asked to open
maximally and the mesiolingual
cusp of the maxillary 2nd molar
on the side of desired
anesthesia is identified.
• The insertion site of the needle
will be just distal to the maxillary
2nd molar at the level of the
mesiolingual cusp.

55. • Bring the needle to the
insertion site in a plane that
is parallel to an imaginary
line drawn from the
intertragic notch to the
corner of the mouth on the
same side as the injection.
• Advance the needle through
soft tissue approximately
25mm until bone is
contacted at the neck of the
condyle.
• Once bone is contacted,
withdraw the needle one
millimeter and aspirate.
• Redirect the needle
superiorly and reaspirate.
• If aspiration in two planes is
negative, slowly inject one
cartridge of local anesthetic
solution over the course of
one minute.

56. • Successful execution of this technique provides
anesthesia to the ipsilateral mandibular teeth up
to the midline, and associated buccal and lingual
hard and soft tissue.
• The anterior two thirds of the tongue, floor of the
mouth, skin over the zygoma, posterior aspect of
the cheek and temporal region on the ipsilateral
side of injection are also anesthetized.

57. Vazirani -Akinosi Closed Mouth Mandibular
Block
• The Vazirani -Akinosi closed mouth mandibular block is a useful
technique for patients with limited opening due trismus or ankylosis
of the temporomandibular joint.
• Limited mandibular opening precludes the administration of the
inferior alveolar nerve block or use of the Gow-Gates technique both
of which require the patient to be open maximally.
• Other advantages to this technique are the minimal risk of trauma to
the inferior alveolar nerve, artery, vein, and pterygoid muscle, low
complication rate and minimal discomfort upon injection.
• Contraindications to this technique are acute inflammation and
infection in the pterygomandibular space, deformity or tumor in the
maxillary tuberosity region or an inability to visualize the medial
aspect of the ramus. A 25 gauge long needle is preferred for this
technique.

58. Technique
• The patient should be in the semisupine position.
• The right handed operator should be in the eight
o’clock position whereas the left handed operator
should be in the four o’clock position.
• The gingival margin above the maxillary 2nd and 3rd
molars and the pterygomandibular raphae are the
landmarks for this technique.
• A retraction instrument is used to stretch the cheek
laterally.
• The patient should occlude gently on the posterior
teeth.
• The needle is held parallel to the occlusal plane at
the level of the gingival margin of the maxillary 2nd
and 3rd molars.
• The bevel is directed away from the bone facing the
midline.

60. • The needle is advanced through the mucous
membrane and buccinator muscle to enter the
pterygomandibular space.
• The needle is inserted to approximately one half to
three quarters of its length
• At this point the needle will be in the midsection of
the ptyerygomandibular space.
• Aspirate and if negative, anesthetic solution is
deposited over the course of one minute.
• Diffusion and gravitation of the local anesthetic
solution will anesthetize the lingual and long buccal
nerves in addition to the inferior alveolar nerve.
• Successful execution of this technique provides
anesthesia of the ipsilateral mandibular teeth up to
the midline, and associated buccal and lingual hard
and soft tissue. The anterior two thirds of the tongue
and floor of the mouth are also anesthetized.

61. Mental Nerve Block
• The mental nerve block is indicated for
procedures where manipulation of buccal soft
tissue anterior to the mental foramen is
necessary.
• Contraindications to this technique are acute
inflammation and infection over the injection site.
A 25 or 27 gauge short needle is preferred for
this technique.

63. Technique
• The patient should be in the
semisupine position.
• The right handed operator
should be in the eight o’clock
position whereas the left
handed operator should be
in the four o’clock position.
• The target area is the height
of the mucobuccal fold over
the mental foramen
• The foramen can be
manually palpated by
applying gentle finger
pressure to the body of the
mandible in the area of the
premolar apicies.
• The patient will feel slight
discomfort upon palpation of
the foramen

64. • Use a retraction
instrument to retract the
soft tissue.
• The needle is directed
toward the mental
foramen with the bevel
facing the bone.
• Penetrate the soft
tissue to a depth of five
millimeters, aspirate
and inject
approximately 0.6cc of
anesthetic solution.
• Successful execution
of this technique results
in anesthesia of the
buccal soft tissue
anterior to the foramen,
lower lip and chin on
the side of the injection.

65. Incisive Nerve Block
• The incisive nerve block is not as frequently
employed in clinical practice
• However it proves very useful when treatment is
limited to mandibular anterior teeth and full quadrant
anesthesia is not necessary.
• The technique is almost identical to the mental nerve
block.
• Both the mental and incisive nerves are anesthetized
using this technique.
• Contraindications to this technique are acute
inflammation and infection at the site of injection.
• A 25 or 27 gauge short needle is preferred for this
technique.

66. Technique
• The patient should be in the semisupine position.
• The right handed operator should be in the eight
o’clock position whereas the left handed operator
should be in the four o’clock position
• The target area is the height of the mucobuccal fold
over the mental foramen
• Identify the mental foramen as previously described.
• Give the patient a mental nerve block as described
above and apply digital pressure at the site of
injection during administration of anesthetic solution.
• Continue to apply digital pressure at the site of
injection two to three minutes after the injection is
complete to aid the anesthetic in diffusing into the
foramen.
• Successful implementation of this technique
provides anesthesia to the premolars, canine, incisor
teeth, lower lip, skin of the chin, and buccal soft
tissue anterior to the mental foramen.

67. Techniques of Anesthesia for Treatment of a Quadrant or Multiple Teeth
TECHNIQUE AREA ANESTHETIZED
Maxillary
Posterior Superior Alveolar Nerve Block
Maxillary molars (with exception of mesiobuccal root of
maxillary 1st molar
in some cases), hard and soft tissue on buccal aspect
Middle Superior Alveolar Nerve Block
Mesiobuccal root of maxillary 1st molar (in some cases),
premolars and
surrounding hard and soft tissue on buccal aspect
Anterior Superior Alveolar Nerve Block/Infraorbital
Nerve Block
Maxillary central and lateral incisors and canine, surrounding
hard and soft tissue
on buccal aspect, mesiobuccal root of maxillary 1st molar (in
some cases)
Greater Palatine Nerve Block
Palatal mucosa and hard palate from 1st premolar anteriorly
to posterior aspect of
the hard palate, and to midline medially
Nasopalatine Nerve Block
Hard and soft tissue of lingual aspect of maxillary anterior
teeth from distal of
canine on one side to distal of canine on the contralateral side
Maxillary Nerve Block
Hemimaxilla on side of injection (teeth, hard and soft, buccal
and lingual tissue)

68. Mandibular
Inferior Alveolar Nerve Block
Mandibular teeth on side of injection, buccal and lingual
hard and soft tissue, lower lip
Buccal Nerve Block Buccal soft tissue of molar region
Gow-Gates Mandibular Nerve Block
Mandibular teeth to midline, hard and soft tissue of buccal
and lingual aspect, anterior 2/3 of tongue, FOM, skin over
zygoma, posterior aspect of cheek, and temporal region on
side of injection
Vazirani-Akinosi Closed Mouth
Mandibular teeth to midline, hard and soft tissue of buccal
aspect, anterior 2/3 of tongue, FOM
Mental Nerve Block
Buccal soft tissue anterior to mental foramen, lower lip,
chin
Incisive Nerve Block
Premolars, canine and incisors, lower lip, skin over the
chin, buccal soft tissue anterior to the mental foramen

69. . Maximum recommended doses of selected local anesthetics for dental nerve blocks
Patient weight 2% lidocaine with 1:100,000
epinephrine*
0.5% bupivacaine with 1:200,000
epinephrine**
10 kg (22 lb) 44 mg (2.2 mL) 13 mg (2.6 mL)
20 kg (44 lb) 88 mg (4.4 mL) 26 mg (5.2 mL)
30 kg (66 lb) 132 mg (6.6 mL) 39 mg (7.8 mL)
40 kg (88 lb) 76 mg (8.8 mL) 52 mg (10.4 mL)
50 kg (110 lb) 220 mg (11 mL) 65 mg (13 mL)
60 kg (132 lb) 264 mg (13.2 mL) 78 mg (15.6 mL)
>70 kg (154 lb) 300 mg (15 mL) 90 mg (18 mL)

70. Recommended Maximum Doses of Local Anaesthetic
Drug Maximum dose
Articaine 4% with epinephrine 7 mg/kg in adults
(up to 500 mg)
5 mg/kg in children
Bupivacaine 0.5% with epinephrine 2 mg/kg (up to 200 mg)
Lidocaine 2% with epinephrine 7 mg/kg (up to 500 mg)
Mepivacaine 2% with levonordefrin 6.6 mg/kg (up to 400 mg)
Mepivacaine 3% plain 6.6 mg/kg (up to 400 mg)
Prilocaine 4% plain or with epinephrine 8 mg/kg (up to 500 mg)

71. Local anesthetic dose
calculation
• Doses are even more critical in the paediatric
patient, and it is important to note how little one
should give to a child..
• High-concentration solutions, namely prilocaine
and articaine, reach toxic levels with fewer
cartridges.
• Calculations of Doses Percent solutions
represent grams per 100 mL (i.e. lidocaine 2% =
20 mg/mL) Most cartridges = 1.8 mL. Therefore,
one cartridge of 2% lidocaine contains 1.8 mL x
20 mg/mL = 36 mg.

72. • Examples of calculations of maximum local anaesthetic doses
for a 20-kg (44-lb) child
• (assuming that each cartridge holds 1.8 mL)
• ARTICAINE
• 5 mg/kg x 20 kg = 100 mg
• 4% articaine = 40 mg/mL
• 100 mg / (40 mg/mL) = 2.5 mL
• Each cartridge = 1.8 mL, therefore maximum dose = 2.5 mL /
1.8 mL
• Therefore maximum dose = 1.4 cartridges
LIDOCAINE
• 7 mg/kg x 20 kg = 140 mg
• 2% lidocaine = 20 mg/mL
• 140 mg / (20 mg/mL) = 7.0 mL
• Each cartridge = 1.8 mL, therefore maximum dose = 7.0 mL /
1.8 mL
• Therefore maximum dose = 3.9 cartridges

73. MEPIVACAINE
• 6.6 mg/kg x 20 kg = 132 mg
• 3% mepivacaine = 30 mg/mL
• 132 mg / (30 mg/mL) = 4.4 mL
• Each cartridge = 1.8 mL, therefore maximum dose = 4.4 mL /
1.8 mL
• Therefore maximum dose = 2.4 cartridges
PRILOCAINE
• 8 mg/kg x 20 kg = 160 mg
• 4% prilocaine = 40 mg/mL
• 160 mg / (40 mg/mL) = 4 mL
• Each cartridge = 1.8 mL, therefore maximum dose = 4 mL / 1.8
mL
• Therefore maximum dose = 2.2 cartridges

74. Thank You