it helps in identifying anatomical landmarks and nerve blocks

1. Nerve blocks and anatomical
landmarks
presented by :- shubham ingle , sakshi gore
Ronak varyani ,Pratik kore

2.  Pain
pain is unpleasant emotional experience usually initiated by noxious stimulus and
transmitted over a specialised neural network to the cns where it is interpreted as such.
 Local anesthesia
Reversible loss of sensation in a circumscribed area of the body caused by a
depression of excitation in nerve ending or an inhibition of the conduction process in
peripheral nerves.

3. Types of injection procedures
 1) nerve block : depositing the la solution within close proximity to main
nerve trunk.
 2) field block: deposing la in proximity to the larger nerve branches.
 3) local infiltration; small terminal nerve endings are anaesthetised.

5. Anaesthesia for the mandibular tissue
 Inferior alveolar nerve block
 Lingual nerve block
 Long buccal nerve block
 Mental nerve block

6. Rule of 10
 A method of providing a guide as to whether an infiltration or a block injection of
local analgesic is appropriate for a child requiring treatment to a mandibular tooth
 The primary tooth to be anesthetize is assigned a number from 1 to 5 according to
its location in the dental arch (central incisor -1 , second molar -5)
 This nu,ber is added to the age of the child and if number is 10 or less then an
infiltration analgesic I most appropriate if greater than 10 then inferior dental
nerve block is likely to be more effective.
 Example - age of pt =5yr , 1st molar =4 ,
 Then 5 +4= 9 (infiltration)
 Age of pt = 8 , 1st molar = 4
 Then 8+4 = 12 ( block or infiltration)

7. Anesthesia of mandibular teeth and soft tissue
1) Inferior alveolar nerve block + lingual nerve block
 the mandibular foramen is situated at the level of lower than the occlusal plane of
primary teeth of the patient
 the injection must made slightly lower and more posteriorly than for an adult
patient.
 Recommended
Volume of LA =1.5 to 1.8 ml

8. Landmarks
 1) coronoid notch
 2) pteryogomandibular raphe
 3) occlusal plane of mandibular posterior teeth.
 4) anterior border of ramus.
 5) external oblique ridge
 6) internal oblique ridge
 7)mucobuccal fold
 8) pterigomadibular ligament

9. Nerve and Area anesthetized
 Mental nerve
 Incisive nerve
 Lingual nerve
 mandibular teeth of the injected side.
 Body of mandible , inferior portion of ramus
 Buccal mucoperiosteum , mucous membrane anterior to the
mandibular 1st molar
 Anterior 2/3 rd tongue and floor of the mouth
 Lingual soft tissue and periosteum.
 Used for more than1 tooth filling extraction , pulp therapy and
if cant apply mental block due to infection.

10. technique
 25 gauge needle is used
 Area of insertion – mucous membrane on toward the
mandible side of of mandibular ramus near the
mandibular foramen but before it enters the foramen
 Target area –inferior alveolar nerve it passes
downward toward mandibular foramen but before it
enter the foramen
 Patient position –supine or semi supine
 Operator position
 1 . Right ianb -8 o’clock
 2. left ianb -10 o’clock position

11. Procedure
 With the left thumb,palpate the coronoid notch
 With the same finger ,pull the soft tissue laterally to gain visibility and make
the tissue taunt
 The needle insertion point lies three fourth the anterioposterior distance from
the coronoid notch to the deepest portion of pterigomandibular raphe.

12.  The mandibular foramen is situated lower than the occlusal plane of
the primary teeth of pediatric patient
 The injection must be made slightly lower and more posteriorly than
for an adult patient
 Prepare the tissue of injection site
 Place the barrel of syringe in the corner of mouth on the
contralateral side
 Penetrate the tissue with the needle and slowly advance till bony
resistance is felt

13.  Average depth of penetration is 15 mm but it depend upon age and
size of mandible
 When bone is contacted withdraw 1mm to prevent subperiosteal
injection
 Aspirate
 If negative slowly deposit 1.5 to 1.8 ml of anesthetic over of 1 minute
 Slight withdraw the needle and take to the same side
 Reaspirate
 If negative, deposit a portion of remaining anesthetic 0.3 -0.5 ml to
anesthetize lingual nerve
 Withdraw the syringe slowly and make the needle safe
 Wait for 3to 5 min before commencing the dental procedure.

14. Mental nerve block
 Anatomical landmarks
 mandibular premolar
 Mucobuccal fold
 recommended volume
0.6 to 1 ml

15. Mental nerve block
 Nerve anesthetized : mental , terminal
branch of inferior alveolar nerve
 Area anesthetized: soft tissue of lower lip,
chin
Buccal soft tissue anterior to mental foramen are
anesthetized.
 Landmarks:
1. Mandibular premolar
2. Muccobuccal fold

16. technique
 Area of insertion ; - mucobuccal fold at or just anterior to mental
foramen.
 Target area ; -mental nerve as it exist mental foramen
1. locate the mental foramen
2. Place the index finger in the muccobuccal fold and pressed
against body of mandible in the first molar area.
3. Move the finger slowly anteriorly until the bone beneath your
finger feels irregular and somewhat concave.
4. Orient the syringe with bevel directed toward bone
5. Penetrate the mucuos membrane at injection site at the canine or
first premolar,directing the syringe toward mental foramen.
6. Depth of penetration is 5-6 mm deposit 0.6 ml.

17. buccal nerve block
 Site of injection
Mucous membrane distal and buccal to the most distal molar tooth in the arch.
 Area anesthetized
Soft tissue and buccal nerve (branch of anterior divison of mandibular nerve)
 Needle used -25 gauge
 Amount of la required – 0.3 to 0.5 ml
 Indication
when buccal soft tissue anesthesia is necessary for dental procedure in the
mandibular molar region

18. Technique
 Area of insertion – mucous membrane distal and
buccal to the most distal molar tooth in the arch
 Target area –buccal nerve as it passes over the
anterior border of the ramus
 Land marks – mandibular molar and mucobuccal fold
 Orientation of bevel – toward the bone

19. Procedure
 Operator position
 Right buccal nerve block – 8 oclock postion
 Left bnb – 10 o clock position
 Patient position – supine or semisupine
 Prepare the tissue for needle penetration
 With left index finger pull the buccal soft tissue in the area of injection laterally to
improve visibility and mouth tissue taut

20.  Align the needle parallel to the occlusal
plane and buccal to the teeth and direct it
toward injection site
 Penetrate the mucous membrane at the
injection site distal and buccal to the last
molar

21.  Advance the needle until mucoperiosteum is gentaly contacted
 Depth of penetration 1 to 2 mm
 Aspirate
 Slowly deposit 0.3 to 0.5 ml of la over 10 sec
 Withdraw the syringe slowly and immediately make the needle safe
 Wait for approximately 1min before commencing the dental procedure

22. Infiltration for mandibular incisor
 The terminal end of the inferior alveolar
nerve cross over the mandibular midline
slighthtly and provide conjoined innervtion
of mandibular incisor
 The labial bone overlying the mandibular
incisor is usually thin enough for
supraperiosteal anesthesia technique to be
effective.

23. Anaesthesia for maxillary tissue
 Anterior superior alveolar nerve block
 Posterior superior alveolar nerve block
 Middle superior alveolar nerve block
 Nasoplalatine nerve block
 Greater palatine nerve block
 Infiltration

24.  Area anesthetized
1) Pulp and root area of the tooth
2) Buccal periosteum
3) Connective tissue
4) Mucous membrane
 Maxillary nerve branches
1. Anterior superior alveolar nerve
2. Middle superior alveolar nerve
3. Posterior superior alveolar nerve

25. Anterior superior alveolar nerve block
 Anatomical landmarks
1. supraorbital and infraorbital notch
2. Pupil of eye
3. infraorbital ridge
4. Infraorbital depression
5. Anterior teeth

26. procedure
 25 guage needle and 0.9 to 1.2 ml LA use
 Bicuspid approach;- it passes through the mucosa and
alveolar tissue and during insertion should pass beneath and
lateral to the external maxillary artery and anterior facial vein
 Central incisor approach ;-it passes through mucosa and
areolar tissue beneath the angular head of the levator labii
superioris muscle proceed anteriorly to the origin of levator
anguli oris muscle and beneath external maxillary artery and
anterior facial vein
 When in final position at the orifice of infraorbital canal it
should be
1.Beneath infraorbital head levator levator labii superioris muscle
2.Above the origin of levator anguli oris muscle

27.  nerve anesthesized
infraorbital ,anterior and middla superior alveolar
nerve , inferior plpebral, lateral nasal , superior labial
nrves.
Area anesthetized
incisor, cuspids ,bicuspids,and mesiobuccal root of
first molar on th eside injected , including bone and soft
tissue , upper lip and portion of nose on same side

28. Middle superior alveolar nerve block
 Landmark ; muccobuccal fold above maxiilary second
premolar
 Procedure‘;
 A 27 guage short needle is recommended
 Strech the patient upper lip make the tissue taut and to gain
the visibility
 Insert needle in to the height of muccobuccal fold above
second molar with the bevel direct toward bone
 Penetrate the mucous memebrane slowly advanace needle tip
is located above the apex of second premolar
 Aspirate into place
 Deposit 0.9 to 1.2 ml

29. Posterior superior alveolar nerve block
 Anatomical landmarks
1. muccobuccal fold and its concavity
2. Zygomatic process of maxilla
3. Infratemporal surface of maxilla
4. Anterior border and coronid process of ramus of mandible
5. Maxillary tuberosity

30.  Nerve anesthetized
Posterior superior alveolar nad its branches
 Area anesthetized
pulp of maxillary 3rd 2nd and 1st molar (except
mesiobuccal cusp )

31. procedure
 Instruct the child partially close the mouth to allow cheek and lips to be
stretch laterally
 The tip of the dentists forefinger will rest in the concavity in the
mucobuccalfold
 Ball of the finger id in contact with the posterior surface of zygomatic
surface
 Bennett suggest that the finger to be on plane at right angle to the
occlusal surface of the maxillary teeth and 45* to the patient occlusal
surface of the maxillary teeth and 45* to the patients saggital plane
 The index finger should point the direction of the needle during the
injection

32. Palatal anesthesia
 Nasopalatine nerve block
 Greater palatine nerve block

33. 1)nasopalatine nerve block
 Anatomical landmarks
central incisor teeth and incisive papilla
 Nerve anesthetized : nasoplalatine
 Area anesthetized
anterior portion of hard palate , hard and soft tissue
from the mesial of right 1st premolar to mesial of left 1st
premolar

34. Technique
 Two types of technique 1.single penetration
2.multiple penetration
1) Single penetration :
 Area of insertion – palatal mucosa just lateral to the incisive papilla
 Target area –incisive foramen beneath the papilla
 Path =approach the injection site at 45* angle toward insive papilla. chair position 9 o clock facing in the same
direction as the patient
 Slowly advance the needle toward the foramen until bone is gently contacted (depth aprox 5mm)
 Slowly deposit 0.45 ml in 15 -30 sec minimum

35. 2)Greater palatine nerve block
 Anatomical landmarks
1. greater palatine foramen
2. Maxillary alveolar process
3. Palatine bone
 Nerve anesthesize
greater palatine nerve
 Area anesthetized
Posterior portion of hard palate and its overlying tissue
Anteriorly as far as the 1st premolar and medially to the midline

36. technique
 Locate the greater palatine foramen
 Place the cotton swab at the junction of maxillary alveolar
process and hard palate
 Start in the region of maxillary first molar by pressing firmly
into tissue with the swab
 Swab fall in to depression greater than palatine foramen
 Foramen is most frequently located distal to the maxillary
second molar
 Slowly advance the needle until palatine bone is gently
contacted
 If the penetration is 5mm deposit 0.45 to 0.6 ml

38. Infiltration
 Supraperiosteal technique (local infiltration)
most frequently used for obtaining pulpal anesthesia in
maxillary teeth.
Indicated whenever dental procedure are confined to
only one or two teeth
 Anatomical Landmarks : insertion 45* to long access
of the tooth
Muccobuccal fold
Crown of the tooth
Root contour of the tooth

39. Labial or buccal infiltration
 in local infiltration the nerve endings in the area of surgery
are flooded with local anesthetic solution
 Landmark ; mucobuccal fold
 Needle use 1 inch ,25 guage
 Amount =0.45 to 0.6 ml

40. Palatal infiltration anesthesia
 Indication
- palatogingival pain control for rubber dam clamp
retraction cord placement and small surgical procedure
-target area is the palatal tissue 5 t0 10 mm from the
free gingival margin
-masticatory mucosa of the hard palate 3 to 5 mm thick
-palatal infiltration are safe areas anatomically to
deposit anesthetic

41. Supplementary technique
 Intraligamentary (periodontal ligament)anaesthesia
 Intrapulpal anaesthesia
 Intraosseos anaesthesia
 Intraseptal anaesthsia

42. Intraligamentary anesthesia
 Needle 25 guage
 The solution is injected along periodontal membrane of
teeth usually 0.2 ml delivered via a specially designed
system which copramise of high pressure syringe and
ultrafine needles
 The technique can anesthetize only single individual
tooth

43. Intrapulpal anaesthesia
 Indication ; for obtaining anaesia which require direct
instrumentation of pulp tissue
 25 or 27 guage needle is inserted directly into the pulp
chamber . The needle should be held firmly or wedge into
the pulp chmber or root canal

44. Intraosseous injection
 The total anaesthetic solution deposited directly into the
cancellous bone adjacent to be anaesthsized between the
two cortical plate of bone
 Intraosseous injection is usually an adjacent and Is used
when cconventional method have been tried and failed.

45. Intraseptal anesthesia
 A needle is force gently into the porous interseptal bone on either side of the tooth under pressure into
the cancellous bone
 More effective in childrens and young adults
 Indiication
where the Intraligamentary enesthsia is no quite effective
 Technique
The injection is given in the septu,m of two adjoining teeth in between the two cortical plate

46. Reference book
 Stanley f. malamed
 Nikhil marwah
 Neelima malik