LOCAL ANESTEHSIA

PRESENTED BY
Somya Jain
PG 1st year
RCDS & RC,Bhopal
1

Contents :
1 ) Armamentarium
a. Syringe
b. Needle
c. Catridge
2 ) Difference b/w the child and adult patient
3 ) Techniques of regional anesthesia
4 ) Basic injection technique
5 )Techniques for maxillary anesthesia
2

Armamentarium
 Includes 3 essential components –
1. Syringe
2. Needle
3. Cartridge
3
Handbook of local anesthesia - Stanley F Malamed
6th edition

The Syringe
 It is the vehicle whereby the contents of the anesthetic
cartridge are delivered through the needle to the
patient.
4
Handbook of local anesthesia - Stanley F Malamed 6th edition

 Syringe types available in dentistry –
1. Non-disposable syringe :
a. breech-loading , metallic, cartridge-type, aspirating
b. breech-loading, plastic , cartridge-type, aspirating
c. breech-loading , metallic, cartridge-type, self
aspirating
d. Pressure syringe for periodontal ligament injection
e. Jet injector ( “needless” syringe )
2. Disposable syringes
3. “safety” syringes
4. Computer controlled local anesthetic delivery systems
5

American Dental Association criteria for
acceptance of local anesthetic syringes
 They must be durable and able to withstand repeated
sterilization without damage.(If the unit is disposable,
it should be packed in a sterile container.)
 They should be capable of accepting a wide variety of
cartridges and needles of different manufacture, and
permit repeated use.
6

They should be inexpensive, self- contained,
light weighted and simple to use with one hand.
They should provide for effective aspiration and
be constructed so that blood may be easily
observed in the cartridge.
7

Breech-loading , metallic, cartridge-type syringe
8

 It is most commonly used in dentistry.
 Breech loading implies that the cartridge is inserted into
the syringe from the side.
 The needle is attached to the barrel of the syringe at the
needle adaptor.
 The needle passes into the barrel and penetrates the
diaphragm of the local anesthetic cartridge.
 The needle adaptor is removable and can be discarded
9

 The aspirating syringe has a device such as a sharp tip,
harpoon that is attached to the piston and is used to
penetrate the thick silicone rubber stopper (bung) at the
opposite end of the cartridge (from the needle) .
 These are constructed of chrome plated brass and stainless
steel.
10

Self aspirating syringe
Pressure on the thumb disk ( arrow )
increases the pressure within the
cartridge . Release of pressure on
thumb disk produces self aspiration
test.
11
These syringes utilise the elasticity of
rubber diaphragm in the anesthetic
cartridge.

Pressure syringes
 They were introduced in late 1970
 Used for PDL injections/ intraligamentary injection.
12
Pressure syringe (1905) designed
for a periodontal injection
6th edition

13
 The second generation devices – pen grip- they have
ease of being used and adds to mechanical advantage
6th edition

JET INJECTORS
14
 In 1947 Figge and Scherer - introduced a new approach to
parenteral injection
 The first report of the use of jet injections in dentistry was
in 1958 by Margetis and associates
 Jet injections are based on the principle that liquids forced
via. very small openings called jets, at very high pressure
can penetrate intact skin or mucous membrane.

 The primary use of the jet injector is to obtain topical
anesthesia before needle insertion.
 Mucosal anesthesia of the palate.
 Jet injectors is not an adequate substitute for needle and
syringe
15
6th edition

Disposable syringes
 Plastic disposable syringes are available in variety of sizes.
 Most often they are used for intramuscular or intravenous
drug administration but may be used for intraoral
injections.
 These syringes contain a Luer–lock screw-lock on needle
attachment but no aspirating tip.
 Aspiration can be done by pulling back on the plunger of
the syringe before or during injection.
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6th edition

 These syringes do not accept dental cartridge.
 The needle, attached to the syringe, must be inserted into a
vial or cartridge of local anesthetic drug for withdrawing
the drug.
 2 or 3 mm syringes with 23 or 25 gauge needles are
recommended for use in intraoral local anesthesia
administration.
17
6th edition

Safety syringes
 It minimizes the risk of the accident needle stick injury
occurring to the dental health provider with a
contaminated needle after the administration of local
anesthesia.
18
6th edition

 These syringes possess a sheath that locks over the needle
when it is removed from the patient’s tissues thus
preventing accidental needle stick injury.
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6th edition

COMPUTER- CONTROLLED LOCAL
ANESTHETIC DELIVERY SYSTEMS
 It was patented by Charles Pravaz in the year 1853.
 In 1997, first computer controlled local anesthetic
(CCLAD) system was introduced into dentistry.
 The wand (recently renamed: Tbe Wand/CompuDent;
Milestone Scientific, Inc., Livingston, NJ) was designed
to improve the ergonomics and precision of the
dentist.
20
6th edition

 The system enables a dentist to accurately manipulate
needle placement with fingertip accuracy and deliver
the local anesthetic with a foot activated control.
 The lightweight handpiece is held in a penlike grasp
provides increased tactile sensation and control
compared with the traditional syringe.
 The operator focuses attention on needle insertion and
positioning, allowing the motor in the device to
administer the drug at a pre programmed rate of flow.
21
6th edition

22
Computer-controlled local
anesthetic delivery system—The
Wand
Foot-activated control of The Wand.
6th edition

23
The Wand has a lightweight handpiece that
provides improved tactile sensation and control.
6th edition

 The Wand/CompuDent. system utilizes a single-use
disposable "safety" handpiece.
 The penlike grasp has the additional advantage allowing the
operator to rotate the handpiece during penetration and
insertion.
 The system administers local anesthetic at two specific
rates.
 The slow rate is 0.5 ml/min and the fast rate is 1.8ml/min
 An aspiration can be activated anytime by releasing the
pressure on the foot-rheostat starting a 4.5 sec. Aspiration
cycle. 24

The Needle
 The needle is the vehicle that permits local anesthetic
solution to travel from the dental cartridge into the
tissues surrounding the needle tip.
 Most needles used in dentistry are stainless steel and
disposable.
 Needles manufactured for dental intraoral injections
are presterilized and disposable.
25
6th edition

 Parts of A Needle –
26
6th edition

Gauge
27
• Gauge refers to the diameter of the lumen of the needle:
the smaller the number, the greater the diameter of the
lumen.
• A 30-gauge needle has a smaller internal diameter than a
25-gauge needle.
• In the United States, needles are color-coded by gauge.
6th edition

 Larger-gauge needles (e.g., 25-gauge) have distinct
advantages over smaller ones :
1. Less deflection occurs as the needle passes through
tissues.
2. This leads to greater accuracy in needle insertion,
especially in techniques which requires greater needle
penetration in soft tissue.
28
6th edition

Aspiration of blood is easier and more reliable
through a larger lumen.
 25 gauge is the prefered needle for all injections
presenting a high risk of positive aspiration.
 27 gauge can be used for all other injection techniques
, provided the aspiration percentage is low and tissue
penetration depth is not greater (increased
deflection).
 30 gauge needles is not recommended for any
injection, it may be used for infiltration for obtaining
hemostasis. 29
6th edition

30
25-gauge, red; 27-gauge, yellow; 30-gauge, blue.
6th edition

LENGTH
Dental needles are available in two lengths:
 long and short.
 Ultrashort needles are also available with 30-gauge
needles.
The average length of a short needle is 20 mm (mea-
sured hub to tip) and 32 mm for the long dental
needle.
31
6th edition

32
A)Long dental needle: length approximately 32 mm.
B) Short dental needle: length approximately 20 mm.
6th edition

 Needles should not be inserted into tissues to their
hubs.
 One of reasons for this precaution is needle
breakage, which, although rare, does occur.
 The weakest (most rigid part, receiving the greatest
stress) portion of the needle is at the hub, which is
where needle breakage happens.
 When a needle is inserted into the soft tissues to its
hub breaks, the elastic properties of the tissues
permit them to rebound and cover (bury) the needle
entirely. 33

34

 The dental cartridge is a glass cylinder containing local
anesthetic drug, among other ingredients.
 Dental cartridge is, by common usage, referred to as
carpule" by dental professionals.
 The term carpule is registered trade name for the
dental cartridge prepared by Cook-Waite Laboratories,
who introduced it to dentistry in 1920.
THE CARTRIDGE
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6th edition

COMPONENTS
The prefilled 1.8ml cartridge consists of four parts :
 cylindrical glass tube
 Stopper (plunger, bung)
 aluminium cap
 diaphragm
36
6th edition

37

 The stopper (plunger) is located at the end of the
cartridge that receives the harpoon of the
aspirating syringe.
 The harpoon is embedded into the silicone (non-
latexcontaining) rubber plunger with gentle finger
pressure applied to the thumb ring of the syringe.
 The plunger occupies a little less than 0.2 ml of the
volume of the entire cartridge.
38

 An aluminium cap is located at the opposite end of the
cartridge from the rubber plunger.
 It fits snugly around the neck of the glass cartridge,
holding the thin diaphragm in position.
 It is silver colored on all cartridges.
 The diaphragm is a semipermeable membrane, usually
latex rubber, through which the needle penetrates into
the cartridge.
 When properly prepared, the perforation of the needle
is centrically located and round, forming a tight seal
around the needle.. 39

 Improper preparation of the needle and cartridge can
produce an eccentric puncture with ovoid holes leading to
leakage of the anesthetic solution during injection.
 A thin Mylar plastic label is applied to all cartridges
 It protects the patient and administrator in event the glass
cracks and also provides specifications about the enclosed
drug.
 In addition, some manufacturers include a volume
indicator on their label, making it easier for the
administrator to deposit precise volume of anesthetic.
40

41

42

POINTS TO BE KEPT IN MIND REGARDING THE
DIFFERENCE B/W THE CHILD AND ADULT PATIENT
1. Density and calcification of maxillary
and mandibular bone
2. Anatomic structures
3. Penetration of the needle
4. Depth of needle penetration
5. Emotional aspect
43

Introduction
 The most widely used method of pain control in
dental practice is to block the pathway of painful
impulses .
 For a maximum effect the injected LA’s must come in
contact with at least 8-10 mm of the nerve to block 2 or
3 adjacent nodes of Ranvier .
 The size of fiber is also imp. – larger fibers diificult to
block
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Monheim ‘s Local Anesthesia and pain control in dental practice – 7th edition

Definitions
 Analgesia – the loss of pain sensation without loss of
consciousness .
 Regional analgesia – loss of pain sensation over
portion of the anatomy without loss of consciousness.
 Regional anesthesia –applies not only to loss of pain
sensation over portion of the anatomy without loss of
consciousness but also to the interruption of all other
sensations, including temperature , pressure & motor
function.
46

Types of regional anesthesia
techniques
47

Nerve block
48

Field block
49

Local infiltration
50

Supraperiosteal / paraperiosteal
technique
 The needle is inserted into the close proximity of the
periosteum , and the solution is deposited so that it
will diffuse through the periosteum and the
underlying cortical bone .
51

Intraligamentary
52
4. Intraligamentary (0.2 ml)
- depositing the LA solution within PDL
through gingival sulcus.
- Provides 30-35 min of anesthesia.
- Indicated in patient with bleeding disorder
& young handicapped patients .

53
5. Intraseptal (0.1 ml)
It is used to avoid IANB to work
in mandibular primary molars.

54
Intrapapillary
For palatal & lingual anesthesia.
Intrapulpal
In case of pulp therapy when other
techniques have failed.

55
Intraosseous
Injection into the osseous structures
Submucosal
Injection into the mucosal layers

Basic injection technique
56
Atraumatic Injection Technique
1. Use a sterilized sharp needle.
2. Check the flow of local anesthetic solution.
3. Determine whether to warm the anesthetic cartridge
or syringe.
4. Position the patient.
5 .Dry the tissue.
6 .Apply topical antiseptic (optional).
7a. Apply topical anesthetic.
7b .Communicate with the patient.

8. Establish a firm hand rest.
9 .Make the tissue taut.
10 .Keep the syringe out of the patient's line of sight.
11a .Insert the needle into the mucosa.
11b .Watch and communicate with the patient.
12 .Inject several drops of local anesthetic solution
(optional).
13 .Slowly advance the needle toward the target.
14 .Deposit several drops of local anesthetic before
touching the periosteum.
15 .Aspirate ×2.
6th edition 57

16a Slowly deposit the local anesthetic solution.
16b .Communicate with the patient.
17 .Slowly withdraw the syringe. Cap the needle and
discard.
18 .Observe the patient after the injection.
19 .Record the injection on the patient's chart.
6th edition 58

Techniques for maxillary anesthesia
59

MAXILLARY ARCH
INTRA ORAL EXTRA ORAL
1. Post. Superior Alveolar N. Block
2. Mid. Superior Alveolar N. Block
3. Ant. Sup. Alveolar N. Block
4. Greater Palatine N. Block
5. Naso Palatine N. Block
6. Maxillary N. Block
1.Ant. and Middle Superior
Alveolar N. Blocks
2. Maxillary N. Block
60

Anesthetization of maxillary
primary incisors & canines
 Local infiltration ( supraperiosteal technique ) is used.
 Injection should be made closer to the gingival margin
than in the permanent teeth and the solution should
be deposited close to the bone.
 After the needle tip has penetrated the soft tissue at
the mucobuccal fold , it needs little advancement
before the solution is deposited (2mm at most ).
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Dentistry for the child and adolescent – Mcdonald and Avery’s , 9th edition

62

63

 In anesthetizing of the permanent central incisor teeth
the puncture site is at the mucobuccal fold, so that the
solution may be deposited slowly and slightly above
and close to the apex of the tooth.
 Because nerve fibers may be extending from the
opposite side, it may be necessary to deposit a small
amount of the anesthetic solution adjacent to the apex
of the other central incisor to obtain adequate
anesthesia in either primary or permanent teeth.
permanent incisors & canines
64

 If a rubber dam is to be applied, it is advisable to inject
a drop or two of anesthetic solution into the lingual
free marginal tissue to prevent the discomfort
associated with the placement of the rubber dam
clamp and ligatures.
65

Anterior superior alveolar nerve
block ( Infraorbital Nerve block )
66

 Nerves Anesthetized
1. Anterior superior alveolar
2. Middle superior alveolar
3. Infraorbital nerve
a. Inferior palpebral
b. Lateral nasal
c. Superior labial
67

 Areas Anesthetized
1. Pulps of the maxillary central
incisor through the canine on
the injected side
2. In about 72% of patients,
pulps of the maxillary
premolars and mesiobuccal
root of the first molar
3. Buccal (labial) periodontium
and bone of these same teeth
4. Lower eyelid, lateral aspect of
the nose, upper lip
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69
Indications:
- Surgical procedures involving
more that 2 maxillary anterior teeth.
- When supraperiosteal Injection have
been infective.
- Inflammation or infection
Contraindications:
- Hemostasis.
- Discrete treatment
areas(1or 2 teeth only)
Advantages:
-- Simple technique
-- Comparatively safe
- Minimizes the volume of
solution used
Disadvantages:
- Psychological - The
administrator may be at a
initial fear of injuring the
patients eye.
- Anatomical - difficulty
defining landmarks
6th edition

2 methods:
 Bicuspid approach
 Incisal approach
70
6th edition

Anatomical landmarks:
 Bicuspid approach:
Supra orbital notch,
pupil of the ipsilateral eye,
Infraorbital margin, depression, foramen,
First bicuspid,
mucobuccal fold in the region of this tooth.
 Incisal approach:
Other additional landmarks-
central incisor & canine on the ipsilateral side,
mucobuccal fold in the region of canine.
71
6th edition

 Technique for bicuspid approach –
 A 25- or 27-gauge long needle is recommended,
although the 27-gauge short also may be used,
especially for children and smaller adults.
 Area of insertion: height of the mucobuccal fold
directly over the first premolar.
Target area : infraorbital foramen (below the
infraorbital notch).
Orientation of the bevel: toward bone
72
6th edition

73
Procedure -
Position of the administrator
for a right or left anterior
superior alveolar (ASA) nerve
block – 10’o clock position .
The patient's head should be
turned slightly to improve
visibility.

74
Palpate the infraorbital notch
Location of the infraorbital
foramen in relation to the
infraorbital notch.
6th edition

75
Insert the needle for anterior
superior alveolar (ASA) nerve
block in the mucobuccal fold over
the maxillary first premolar
Using a finger over the
foramen, lift the lip, and
hold the tissues in the
mucobuccal fold taut
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76
Advance the needle parallel
to the long axis of the tooth
to preclude prematurely
contacting bone.
Slowly deposit 0.9 to 1.2 mL
(over 30 to 40 seconds).
6th edition

 If the needle tip is properly inserted at the opening of
the foramen, solution is directed toward the foramen.
 The administrator is able to “feel” the anesthetic
solution as it is deposited beneath the finger on the
foramen if the needle tip is in the correct position. At
the conclusion of the injection, the foramen should no
longer be palpable (because of the volume of
anesthetic in this position).
77
6th edition

CENTRAL INCISOR APPROACH:
 The needle passes through the mucosa & areolar tissue &
beneath the levator labii superioris ( angular head of the
quadratus labii superioris) muscle.
 It then passes anterior to the origin of levator angulii oris (
caninus) muscle & beneath the facial artery & vein.
 Area of insertion:
the direction of the needle is such that it bisects the crown
of the ipsilateral central incisor from the mesioincisal angle
to the distogingival angle.
78
6th edition

 The area of insertion is at height of mucobuccal fold, or 4-
5 mms away from the labial cortex of maxilla in the region
of ipsilateral canine.
79
6th edition

 Signs and Symptoms
 Subjective: Tingling and numbness of the lower
eyelid, side of the nose, and upper lip.
 Subjective and objective: numbness in the teeth and
soft tissues along the distribution of the ASA and MSA
nerves (developing within 3 to 5 minutes if pressure is
maintained over the injection site).
 Objective: use of electrical pulp testing with no
response from tooth with maximal EPT output
(80/80).
 Absence of pain during treatment
80
6th edition

Complications
Positive aspiration – 0.7 %
 Hematoma (rare) may develop across the lower eyelid
and the tissues between it and the infraorbital
foramen.
 To manage, apply pressure on the soft tissue over the
foramen for 2 to 3 minutes.
 Hematoma is extremely rare because pressure is
routinely applied to the injection site both during and
after administration of the ASA nerve block.
81
6th edition

primary molars
 Traditionally, dentists have been taught that the
middle superior alveolar nerve supplies the maxillary
primary molars, the premolars, and the mesiobuccal
root of the first permanent molar.
 However, Jorgensen and Hayden have demonstrated
plexus formation of the middle and posterior superior
alveolar nerves in the primary molar area on child
cadaver dissections.
82

 The bone overlying the
first primary molar is
thin, and this tooth can
be adequately
anesthetized by injection
of anesthetic solution
opposite the apices of
the roots.
83

84
 However, the thick zygomatic process overlies the
buccal roots of the second primary and first
permanent molars in the primary and early mixed
dentition.
 This thickness of bone renders the supraperiosteal
injection at the apices of the roots of the second
primary molar much less effective; the injection
should be supplemented with a second injection
superior to the maxillary tuberosity area to block the
posterior superior alveolar nerve as has been
traditionally taught for permanent molars.

85
Posterior superior alveolar injection for maxillary permanent molars and second
primary molar

premolars
86
Middle superior alveolar nerve block

Nerves Anesthetized
 Middle superior alveolar
and terminal branches.
Areas Anesthetized
 Pulps of the maxillary first and
second premolars, mesiobuccal
root of the first molar
 Buccal periodontal tissues and
bone over these same teeth
87
6th edition

88
Indications:
- Treatment involving two
maxillary premolars.
- When infraorbital nerve block
fails to provide pulpal
anesthesia distal to maxillary
canine.
Contraindications:
- Infection or inflammation
in the area of injection.
Advantages:
- Atraumatic.
- Minimizes the no. of injection.
and volume of solution.
Disadvantage:
- None
6th edition

Technique –
 A 27-gauge short or long needle is recommended.
 Area of insertion: height of the mucobuccal fold above
the maxillary second premolar
 Target area: maxillary bone above the apex of the
maxillary second premolar.
 Landmark: mucobuccal fold above the maxillary
second premolar.
 Orientation of the bevel: toward bone
89
6th edition

90
Position of needle
between maxillary
premolars for a middle
superior alveolar
(MSA) nerve block.
6th edition

 Procedure -
91
Position of the administrator for
a (A) right MSA – 10’o clock
position
a (A)left MSA – 8 or 9’o clock
position
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92
Insert the needle into the height of the mucobuccal fold above the second
premolar with the bevel directed toward bone.
Penetrate the mucous membrane and slowly advance the needle until its tip
is located well above the apex of the second premolar.
Slowly deposit 0.9 to 1.2 mL (one half to two thirds cartridge) of solution
(approximately 30 to 40 seconds).
6th edition

Subjective: upper lip numb
Objective: use of electrical pulp testing with no
response from tooth with maximal EPT output (80/80)
Absence of pain during treatment
93
6th edition

Complications (rare)
Positive aspiration – negligible (<3%)
 A hematoma may develop at the site of injection.
 Apply pressure with sterile gauze over the site of
swelling and discoloration for a minimum of 60
seconds.
94
6th edition

95
permanent molars
Posterior superior alveolar nerve block
/ tuberosity block / zygomatic block

Nerves Anesthetized
 Posterior superior alveolar and
branches.
Areas Anesthetized
 Pulps of the maxillary third,
second, and first molars (entire
tooth = 72%; mesiobuccal root
of the maxillary first molar not
anesthetized = 28%)
 Buccal periodontium and bone
overlying these teeth
96
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97
Indications:
- Treatment involving two or
more maxillary molars.
- When supraperiosteal inj. is
contraindicated (infections).
Contraindications:
- high risk of hemorrhage.
Advantages:
- Atraumatic
- minimum no. of necessary
injections
- High success rate
Disadvantages:
- Risk of hematoma
- Technique somewhat
arbitrary
no bony landmarks during
insertion
- 2nd injection necessary for
treatment of 1st molar in 28%
patients.
6th edition

 Anatomical landmarks
 Mucobuccal fold and its concavity
 Zygomatic process of maxilla.
 Infratemporal fossa of maxilla.
 Anterior border and coronoid process of the ramus of the
mandible.
 Maxillary tuberosity
98
6th edition

TECHNIQUE–
 A 27-gauge short needle recommended.
 Area of insertion: height of the mucobuccal
fold above the maxillary second molar.
 Target area: PSA nerve—posterior, superior,
and medial to the posterior border of the
maxilla
99
6th edition

100
Needle at the target area for a posterior superior alveolar (PSA) nerve block
6th edition

101
for (A) right PSA – 10’o clock
position
for (B) left PSA – 8’o clock
position
PROCEDURE
6th edition

 Orient the bevel of the needle toward bone.
 Insert the needle into the height of the mucobuccal
fold over the second molar.
102
6th edition

 Advance the needle slowly in an upward, inward, and
backward direction.
103
(1) Upward:
superiorly at a 45-
degree angle to the
occlusal plane
(2) Inward:
medially toward
the midline at a 45-
degree angle to the
occlusal plane
(3) Backward:
posteriorly at a 45-
degree angle to the
long axis of the
second molar
6th edition

104
In an adult of normal size, penetration to a depth of 16 mm, places
the needle tip in the immediate vicinity of the foramina through
which the PSA nerves enter.
With a “long” dental needle (>32 mm in
length) in an average-sized adult, the depth
of penetration is half its length. Use of
“long” needle on posterior superior alveolar
(PSA) nerve block increases risks of
overinsertion and
hematoma.
PSA nerve block using a “short”
dental needle (≈20 mm in length).
Overinsertion is less likely.
6th edition

 For smaller adults and children, it is prudent to halt
the advance of the needle short of its usual depth of
penetration to avoid a possible hematoma caused by
over penetration.
 Penetrating to a depth of 10 to 14 mm places the needle
tip in the target area in most smaller-skulled patients.
105
6th edition

 Aspirate in two planes :
Rotate the syringe barrel (needle bevel) one fourth turn
and re- aspirate.
 If both aspirations are negative:
(1) Slowly, over 30 to 60 seconds, deposit 0.9 to 1.8 mL of
anesthetic solution.
(2) Aspirate several additional times (in one plane)
during drug administration.
106
6th edition

1. Subjective: usually none; the patient has difficulty
reaching this region to determine the extent of
anesthesia.
2. Objective: use of electrical pulp testing with no
response from tooth with maximal EPT
output(80/80).
3. Absence of pain during treatment.
107
6th edition

Complications –
POSITIVE ASPIRATION – 3.1%
 1 ) Hematoma - This is commonly produced by
inserting the needle too far posteriorly into the
pterygoid plexus of veins.
 A visible intraoral hematoma develops within several
minutes, usually noted in the buccal tissues of the
mandibular region.
108
6th edition

 2) Mandibular anesthesia- The mandibular division of
the fifth cranial nerve (V3) is located lateral to the PSA
nerves.
 Deposition of local anesthetic lateral to the desired
location may produce varying degrees of mandibular
anesthesia
109
6th edition

110
ANESTHETIZATION OF PALATAL
TISSUE

 Nerve Anesthetized-
Greater palatine nerve
 Areas Anesthetized-
The posterior portion of the hard palate and its overlying
soft tissues, anteriorly as far as the first premolar and
medially to the midline
111
6th edition

Indications:
- Surgical of periodontal
procedures involving
palatal soft & hard tissue.
- For restoration therapy on
more that two teeth
(subgingival restorations).
Contraindications:
- Infections at the site of
Injection
Advantages:
- Minimal needle penetration &
Solution
- Minimal patient discomfort.
Disadvantages:
- Potentially traumatic.
112
6th edition

 Landmarks-
1. First & second maxillary molar
2. Palatal gingival margin of first & second maxillary
molar
3. A line approximately 1 cm below the palatal gingival
margin & midline of palate
4. Greater palatine foramen
113
6th edition

 Technique-
- A 27-gauge short needle is recommended.
- Area of insertion: soft tissue slightly anterior to the greater
palatine foramen
- Target area: greater (anterior) palatine nerve as it passes
anteriorly between soft tissues and bone of the hard palate
114
6th edition

- Path of insertion: advance the syringe from the
opposite side of the mouth at a right angle to the
target area
- Orientation of the bevel: toward the palatal soft tissues
115
6th edition

Procedure-
(A) right- 7 or 8 o'clock position.
(A) left- 11 o'clock position
116
6th edition

A. Patient position for a
greater palatine nerve block.
B. Administrator's view of
hard palate when patient is
properly positioned.
117
6th edition

A cotton swab is pressed against the hard palate at the
junction of the maxillary alveolar process and palatal bone.
The swab is slowly moved distally until a depression in the
tissue is felt. This is the greater (anterior) palatine
foramen.
118
6th edition

Note the angle of needle entry into the mouth. The
insertion is into ischemic tissues slightly anterior to
the applicator stick. The barrel of the syringe is
stabilized by the corner of the mouth and the
teeth.
119
6th edition

Prepuncture technique: bevel of needle placed on soft tissue;
pressure exerted by cotton applicator stick. Local anesthetic
solution deposited before needle enters tissues.
120
6th edition

Spread of ischemia as the anesthetic is deposited
(0.45 to 0.6 mL)
121
6th edition

 Subjective: numbness in the posterior portion of the
palate
 Objective: no pain during dental therapy
 Positive Aspiration
Less than 1%.
122
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Complications
1. Few of significance
2. Ischemia and necrosis of soft tissues when highly
concentrated vasoconstricting solution used for hemostasis
over a prolonged period
a Norepinephrine should never be used for hemostasis on
the palatal soft tissues (norepinephrine is not available
in dental local anesthetics in the United States or
Canada).
3. Hematoma is possible but rare because of the density and
firm adherence of palatal tissues to underlying bone.
4. Some patients may be uncomfortable if their soft palate
becomes anesthetized; this is a distinct possibility when
the middle palatine nerve exits near the injection site.
123
6th edition

NASOPALATINE NERVE BLOCK
 Other Common Names
- Incisive nerve block
- sphenopalatine nerve block.
124
6th edition

 Nerves Anesthetized
- Nasopalatine nerves bilaterally.
 Areas Anesthetized
- Anterior portion of the hard palate (soft and hard tissues)
bilaterally from the mesial of the right first premolar to the
mesial of the left first premolar
125
6th edition

Indications:
- Oral surgical /Periodontal
procedure involving soft and
hard tissue.
Contraindications:
- Infection at the site of
injection
- Small area of therapy.
Advantages:
- Minimal needle procedures
and volume of Solution
- Minimal patient discomfort
Disadvantages:
- Potentially the most
traumatic Injection
126
6th edition

 Landmarks-
1. Central incisor teeth
2. Incisive papilla in the midline of the palate
127
6th edition

 Technique-
- A 27-gauge short needle is recommended.
- Area of insertion: palatal mucosa just lateral to the incisive
papilla (located in the midline behind the central incisors); the
tissue here is more sensitive than other palatal mucosa
- Target area: incisive foramen, beneath the incisive papilla
128
6th edition

- Path of insertion: Approach the injection site at a 45-
degree angle toward the incisive papilla.
- Orientation of the bevel: toward the palatal soft tissues
(review procedure for the basic palatal injection)
129
6th edition

Position of the administrator for a nasopalatine
nerve block (9 or 10 o'clock position)
Procedure-
130
6th edition

Palate when the patient is positioned
properly
131
6th edition

Topical anesthetic is applied lateral to the incisive
papilla for 2 minutes, and then pressure is applied
directly to the incisive papilla.
132
6th edition

Pressure is maintained until the deposition of
Solution (0.45 mL) is completed. Needle penetration is
just
lateral to the incisive papilla
133
6th edition

 Subjective: numbness in the anterior portion of the palate
 Objective: no pain during dental therapy
134
6th edition

 Complications
2. Hematoma is possible but extremely rare because of the density and
firm adherence of palatal soft tissues to bone.
3. Necrosis of soft tissues is possible when highly concentrated
vasoconstricting solution (e.g. norepinephrine) is used for hemostasis
over a prolonged period (norepinephrine is not available in dental
local anesthetics in the United States or Canada).
4. Because of the density of soft tissues, anesthetic solution may
“squirt” back out the needle puncture site during administration or
after needle withdrawal. (This is of no clinical significance.
However, do not let it surprise you into uttering a statement such as
“Whoops!” that might frighten the patient.
135
6th edition

Technique (Multiple Needle Penetrations)
 A 27-gauge short needle is recommended.
 Areas of insertion:
A. Topical anesthetic is applied to the mucosa of the frenum. B. First injection,
into the labial frenum. C. Second injection, into the interdental papilla between
the central incisors. D. Third injection, when anesthesia of the nasopalatine area is
inadequate after the first two injections.
136
6th edition

 Target area: incisive foramen, beneath the incisive papilla
 Landmarks: central incisors and incisive papilla
 Path of insertion:
a. First injection: infiltration into the labial frenum
b. Second injection: needle held at a right angle to the
interdental papilla
c. Third injection: needle held at a 45-degree angle to the
incisive papilla
137
6th edition

 Orientation of the bevel:
First injection: bevel toward bone
Second injection: not relevant
Third injection: not relevant
138
6th edition

Area anesthetized
139
6th edition

 Advantage
- Entirely or relatively atraumatic
 Disadvantages
- Requires multiple injections (three)
- Difficult to stabilize the syringe during the second
injection
- Syringe barrel usually within the patient's line of sight
during the second injection
140
6th edition

- Subjective: numbness of the upper lip (in the midline)
and the anterior portion of the palate
- Objective: no pain during dental therapy
141
6th edition

 Complications
2. Necrosis of soft tissues is possible when a highly concentrated
vasoconstrictor solution, such as norepinephrine, is used for
hemostasis over a prolonged period (norepinephrine is not
available in dental local anesthetics in the United States or
Canada).
3. Interdental papillae between the maxillary incisors sometimes
are tender for several days after injection.
142
6th edition

MAXILLARY NERVE BLOCK
 Also known as - Second division block, V2
nerve block
143
6th edition

 The maxillary (second division or V2) nerve block is an
effective method of achieving profound anesthesia of a
hemi-maxilla.
 It is useful in procedures involving quadrant dentistry
and in extensive surgical procedures.
144
6th edition

Nerve Anesthetized
 Maxillary division of the trigeminal
nerve.
Areas Anesthetized
 Pulpal anesthesia of the maxillary
teeth on the side of the block
 Buccal periodontium and bone
overlying these teeth
 Soft tissues and bone of the hard
palate and part of the soft palate,
medial to midline
 Skin of the lower eyelid, side of the
nose, cheek, and upper lip
145
6th edition

146
Indications:
- Oral Surgical procedure requiring
anesthesia of the entire maxillary
division.
- When tissue inflammation or
infection precludes the use of other
regional nerve blocks.
- Diagnostic and therapeutic
procedures.
Contraindications:
- Inexperienced administrator.
- Pediatric patients
- When hemorrhage is risky
(hemophiliac)
Advantages:
- Atraumatic injection
- High success rate
- Minimal amount of LA solu.
- Minimal “pricks”
Disadvantages:
- Risk of hematoma
- Overinsertion, because of
no bony resistance
- Pain
6th edition

2 approaches –
High tuberosity approach
Landmarks
 Mucobuccal fold at the distal aspect of 2nd
molar
 Maxillary tuberosity
 Zygomatic process of maxilla
147
6th edition

Greater palatine canal approach
Landmarks
 Greater palatine foramen
 Junction of maxillary alveolar process and
palatine bone
148
6th edition

 Technique - High tuberosity approach
 A 25-gauge long needle is recommended. A 27-gauge
long is acceptable.
 Area of insertion: height of the mucobuccal fold
above the distal aspect of the maxillary second
molar
 Target area:
a. Maxillary nerve as it passes through the
pterygopalatine fossa.
b. Superior and medial to the target area of the PSA
nerve block
149
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150
6th edition

 Procedure:
151
for (A) right PSA – 10’o clock
position
for (B) left PSA – 8’o clock
position
6th edition

 Partially open the patient's mouth; pull the mandible toward the
side of injection.
 Retract the cheek in the injection area with your index finger to
increase visibility.
 Place the needle into the height of the mucobuccal fold over the
maxillary second molar.
 Advance the needle slowly in an upward, inward, and backward
direction as described for the PSA nerve block.
 Advance the needle to a depth of 30 mm.
 Aspirate in two planes.
 If negative: Slowly (more than 60 seconds) deposit 1.8 mL.
152
6th edition

 Technique (Greater Palatine Canal Approach)
 A 25-gauge long needle is recommended. A 27-gauge long
needle is also acceptable.
 Area of insertion: palatal soft tissue directly over the
greater palatine foramen.
 Target area: the maxillary nerve as it passes through the
pterygopalatine fossa; the needle passes through the
greater palatine canal to reach the pterygopalatine fossa.
 Orientation of the bevel: toward palatal soft tissues
153
6th edition

154
A, Maxillary nerve
block, greater palatine
canal
approach. Note the
direction of the needle
and the syringe barrel
into the canal.
B. Second division nerve
block (V2), greater
palatine canal
approach. Note the
location of the needle tip
in the pterygopalatine
fossa (circle).
6th edition

Procedure:
 Measure the length of a long needle from the tip to the
hub .
 Assume the correct position.
 Ask the patient - (1) Open wide.
 (2) Extend the neck.
 (3) Turn the head to the left or right (to improve
visibility).
 Locate the greater palatine foramen.
155
6th edition

 Direct the syringe into the mouth from the opposite
side with the needle approaching the injection site at a
right angle.
 Place the bevel against the ischemic soft tissue at the
injection site.
 Straighten the needle and permit the bevel to
penetrate the mucosa.
 The needle usually must be held at a 45-degree angle
to facilitate entry into the greater palatine foramen.
156
6th edition

 After locating the foramen, very slowly advance the
needle into the greater palatine canal to a depth of 30
mm.
 Aspirate in two planes - If negative, slowly deposit 1.8
mL of solution over a minimum of 1 minute .
157
6th edition

158
Signs and Symptoms
 Subjective: Pressure behind the upper jaw on the side
being injected; this usually subsides rapidly,
progressing to tingling and numbness of the lower
eyelid, side of the nose, and upper lip.
 Subjective: Sensation of numbness in the teeth and
buccal and palatal soft tissues on the side of injection.
 Objective: Use of electrical pulp testing with no
response from teeth with maximal EPT output (80/80)
 Objective: Absence of pain during treatment
6th edition

Complications –
Positive aspiration - <1 % ( greater palatine
approach
 Hematoma develops rapidly if the maxillary artery is
punctured during maxillary nerve block via the high-
tuberosity approach.
 Penetration of the orbit may occur during a greater palatine
foramen approach if the needle goes in too far; more likely
to occur in the smaller-than-average skull
159
6th edition

160
Maxillary Teeth and Available Local Anesthetic Techniques
6th edition

161
Recommended Volumes of Local Anesthetic for Maxillary
Techniques
6th edition

Contents
1. Topical anesthetics
2. Patient preparation
3. Mandibular nerve
4. Techniques for mandibular anesthesia
5. Complications of LA
6. Reversal of LA
7. Conclusion
162

 Topical anesthetics are substances that can cause
surface anesthesia of skin or mucosa.
 In dentistry these agents are used to temporarily
anesthetize the tiny nerve endings located on the
surfaces of the oral mucosa , with the aim of reducing
the discomfort of dental injections and minimally
invasive procedures.
Local anesthesia : agents , techniques and complications ; Ogle O. , Mahjoubi G ; Dent Clin N Am 2012 ;133-148
164

 Supplied in various forms –
1. Gels
2. Liquid
3. Ointments
4. Pressurized sprays
Different flavors –
1. Strawberry
2. Mint
3. Cherry
4. Banana
5. Bubble gum
165
Local anesthesia : agents , techniques and complications ; Ogle O. , Mahjoubi G ; Dent Clin N Am 2012 ;133-148

 Anesthetic agents used in topical anesthetic
preparations are –
1. Ethyl aminobenzoate ( Benzocaine )
2. Butacaine sulfate
3. Dyclonine
4. Lidocaine
5. Tetracaine
166

 Benzocaine –
Best suited for topical anesthesia
Available in all forms
Rapid onset and longer duration of action
Not known to produce systemic toxicity
Few localized allergic reactions have been repeated
from prolonged and repeated use
Commercially available as : Hurricaine
Topicale
Gingicaine
167

 Technique for application –
Tissue is reflected to expose the injection site
Soft tissue is dried using 2 * 2 gauze pad
Topical gel is applied with cotton tipped applicator
Maintain the applicator at the site for about 30
seconds to 5 mins
Remove the applicator and proceed with the
injection
Pediatric Dentistry infancy through adolescence – Pinkham 4th edition 168

Lidocaine transoral delivery system
 Relatively new delivery system involving “ lidocaine
patches” .
 These are small flat applicator similar in shape to a
miniature adhesive strips impregnated with relatively
high concentration of lidocaine .
 This system seems to be designed primarily for
situations in which superficial oral tissue anesthesia is
desired for several minutes rather than the shorter
time required for local anesthetic injections.
170
Pediatric Dentistry infancy through adolescence – Pinkham 4th edition

 An example of this type of patch is Dentipatch ( Noven
Pharmaceuticals , Miami , Fla. )- 46.1 mg of lidocaine
171
It is extremely important to use the patch according to the
manufacturer’s instructions for maximal benefit i.e placement of
the patch for minimum of 10 mins on a very dry mucosa prior to
needle insertion.

 These patches are extremely effective in pediatric
dentistry for analgesic conditioning of the surface
mucosa of the maxillary anterior segment or the hard
palate prior to LA infiltration .
172

EMLA ( Eutectic Mixture of Local Anesthetics)
 EMLA cream composed of lidocaine 2.5 % & prilocaine
2.5 %.
 It is an emulsion in which the oil phase is a eutectic
mixture of lidocaine & prilocaine in a ratio of 1:1 by
weight.
 Designed as a topical anesthetic able to provide surface
anesthesia for intact skin.
 Originally marketed for use in pediatrics, EMLA has
gained popularity among needle-phobic adults and
persons having other superficial, but painful, procedures
performed (e.g., hair removal).
Handbook of local anesthesia - Stanley F Malamed 6th edition 173

 EMLA is supplied in a 5-g or 30-g tube or as an EMLA
anesthetic disc.
 Because intact skin is a barrier to drug diffusion,
EMLA must be applied 1 hour before the procedure.
 Satisfactory numbing of the skin occurs 1 hour after
application, reaches a maximum at 2 to 3 hours, and
lasts for 1 to 2 hours after removal.

 EMLA is contraindicated in –
1. patients with congenital or idiopathic
methemoglobinemia
2. infants younger than 12 months who are receiving
treatment with methemoglobin-inducing agents
3. patients with known sensitivity to amide-type local
anesthetics or any other component of the product

 Munshi and associates reported on the use of EMLA
cream in 30 pediatric patients undergoing a variety of
clinical procedures, including extraction of mobile
primary teeth and root stumps and pulpal therapy
procedures in the primary teeth, in which EMLA is
used as the sole anesthetic agent.
 Results showed that use of EMLA could eliminate to
some extent use of the needle in procedures
performed in pediatric dentistry.
Munshi, AK, Hegde, AM, Latha, R: Use of EMLA: is it an injection free alternative?. J Clin Pediatr Dent. 25, 2001, 215–219
176

 The preparation of the pediatric patient for the LA
procedure must be carefully considered .
 Throughout all dental care , patient cooperation is
essential, and as such , the administration of
behaviorally successful anesthetic procedure becomes
paramount .
 Patient preparation in the dental environment is
dependent on well – trained team of dental auxillary
personnel.
Fundamentals of Pediatric Dentistry , Mathewson , 3rd edition
178

Operator’s technique for patient preparation
 Communication in language the child can understand
is necessary in pediatric dentistry practice.
 The language level must be appropiate to the age and
understanding of the child .
 A liberal use of euphemistic terms should be used to
soften what otherwise could be disturbing phases.
 Eg : the child may be told that tooth will be “going to
sleep” after a “pinch” is felt near the tooth.
179

 The discomfort of the injection can be lessened by –
1. Counter-irritation
2. Distraction
3. Slow rate of administration
180

 Counter irritation –
It is the application of vibratory stimuli ( e.g. rapid
displacement of loose areolar tissue ) or of
moderate pressure ( e.g. with a cotton tipped
applicator ) to the area adjacent to the site of
injection.
These stimuli have a physical or psychological
basis for modifying noxious stimuli .
181

 Distraction
It can be defined as – “ a state of mind that draws
the attention away from painful or unpleasant
stimuli”.*
It can be accomplished by continuing a constant
monologue with the child and by maintaining his /
her attention away from the syringe.
182
* - Sharkawi et al ; Effectiveness of new distraction technique on pain associated with injection of Local
anesthesia for children;AAPD V34/No 2 ; 2012:142-145

 In a study conducted by Sharkawi et al to evaluate the
effect of a distraction technique using audiovisual
(A/V) glasses on pain perception during
administration of LA in children –
 It was concluded that distraction induced by A/V
glasses significantly reduces pain associated with
injection of local anesthetics.
183
Sharkawi et al ; Effectiveness of new distraction technique on pain associated with injection of Local anesthesia
for children;AAPD V34/No 2 ; 2012:142-145

 Slow rate of administration
The operator should always aspirate and alter the
depth of needle if necessary prior to injecting the
anesthetic solution.
The deposition of single carpule should take atleast 1
min.
Rapid injections tend to be more painful because of
rapid tissue expansion.
They also potentiate the possibility of a toxic rxn if the
solution is inadverently deposited in a blood vessel.
184

Role of dental assistant
 The role of dental assistant is important during the
transfer of the syringe to the dentist and in
anticipation of patient movement .
185

 During the transfer of the syringe from
assistant to the dentist –
The hand of the dentist that is to receive the syringe is
extended close to the head or body of the child.
The body of the syringe is placed between the index &
middle finger , with the ring of the plunger slipped
over the dentist’s thumb by the assistant.
Plastic sheath protecting the needle is then removed
by the assistant .
The dentist peripheral vision guides the syringe to the
mouth in a slow , smooth movement .
186

 During patient movements –
The head can be stabilized by being held firmly but
gently between the body and the arm of the dentist.
The assistant passively extends his or her arm across
the child’s chest so that potential arm and body
movement can be intercepted.
The free hand of the dentist is used to retract the
tissue that is to receive the injection.
This hand can also be used to block the vision of the
child as the syringe approaches the mouth.
187

The mandibular division is the largest branch of the
trigeminal nerve.
 It is a mixed nerve with two roots -
a large sensory root and a smaller motor root.
The two roots emerge from the cranium separately
through the foramen ovale, the motor root lying
medial to the sensory.
They unite just outside the skull and form the main
trunk of the third division.
This trunk remains undivided for only 2 to 3 mm
before it splits into a small anterior and a large
posterior division.
189

BRANCHES
1. Undivided nerve
a Nervus spinosus
b Nerve to the medial pterygoid muscle
2 Anterior division
Nerve to the lateral pterygoid muscle
Nerve to the masseter muscle
Nerve to the temporal muscle
Buccal nerve

3. Posterior division
Auriculotemporal nerve
Lingual nerve
Mylohyoid nerve
Inferior alveolar nerve : dental branches
Incisive nerve : dental branches
Mental nerve

Inferior alveolar nerve block
 It is the most widely accepted LA procedure and is the
only block required for pediatric dental pain control.
193

 The inferior alveolar nerve blocked by this technique
enters the mandibular foramen on the lingual aspect
of the mandible .
 The position of foramen changes by remodeling more
superiorly from the occlusal plane as the child matures
into adulthood.
194

 Olsen reported that the mandibular foramen is
situated at a level lower than the occlusal plane of the
primary teeth of the pediatric patient .
 Therefore the injection must be made slightly lower
and more posteriorly than for an adult patient.
195

 In adults , the foramen is situated approximately 7
mm above the occlusal plane .
 The foramen is approximately midway between the
anterior and posterior borders of the ramus of the
mandible.
196

 Nerves anesthetized –
1. Inferior alveolar
2. Incisive
3. Mental
4. Lingual (commonly)

 Areas Anesthetized

 Anatomical landmarks –
1. Muccobuccal fold
2. Anterior border of the ramus of the mandible
3. Coronoid notch
4. External oblique ridge
5. Retromolar triangle
6. Internal oblique ridge
7. Pterygomandibular ligament
8. Buccal sucking pad
9. Pterygomandibular space
199
Monheim’s Local anesthesia and pain control in dental practice – 7th edition

200
Indications –
1.Procedures on multiple mandibular
teeth in one quadrant
2 When buccal soft tissue anesthesia
(anterior to the mental foramen) is
necessary
3 When lingual soft tissue anesthesia
is necessary
Contraindications
Infection or acute inflammation
in the area of injection
Advantage
One injection provides a wide area of
anesthesia (useful for quadrant
dentistry).
Disadvantages
1. Rate of inadequate anesthesia
(31% to 81%)
2. Positive aspiration (10% to 15%,
highest of all intraoral injection
techniques)
3. Lingual and lower lip anesthesia,
discomfiting to many patients and
possibly dangerous (self-inflicted
soft tissue trauma)
4. Partial anesthesia possible where
a bifid inferior alveolar nerve and
bifid mandibular canals are
present.

Technique –
 A 25 –gauge or 27 gauge needle is recommended
The child is asked to open his or her mouth as far as
possible
The ball of thumb is then positioned on the coronoid
notch of the anterior border of the ramus of the
mandible
The index and the middle fingers are then positioned on
the external posterior border of the mandible
201

The needle is then inserted with bevel oriented parallel
to the bone , at the level of occlusal plane between the
internal oblique ridge and pterygomandibular raphe .
The barrel of the syringe overlies the 2 primary molars
on the opposite side of the arch and parallels the
occlusal plane .
The needle is advanced until it contacts the bone
Aspiration done
202

Then , slowly inject about 1 ml of solution .
Remove the needle
Apply pressure on the area with 2 * 2 gauze for
hemostasis .
 The depth of insertion averages about 15 mm but
varies with the size of the mandible and its changing
proportions depending on the age of the patient.
203

Lingual nerve block
 Nerve anesthetized – lingual nerve
 Area anesthetized –
1 . Anterior 2/3rd of the tongue and floor of the oral
cavity.
2 . Mucosa and mucoperiosteum on the lingual side of
the mandible .
Monheim’s Local anesthesia and pain control in dental practice – 7th edition 205

 It can be achieved by three means –
1. By inferior alveolar nerve block
2. By supraperiosteal injection into the juncture of the
lingual surface of the mandible and the floor of the
mouth adjacent to the area being attended
3. Injection just lingual to the tooth being operated in
which the solution is deposited into the gingival
mucosa of that area .
206

Long buccal nerve block
 Nerve anesthetised – Buccal nerve
 Area anesthetised – Buccal mucosa membrane and
mucoperiosteum of mandibular molar area.
 Anatomical landmarks – 1. external oblique ridge
2. retromolar triangle
207
Monheim’s Local anesthesia and pain control in
dental practice – 7th edition

 It can be accomplished by – field block or submucosal
infiltration .
 Field block –it is achieved by depositing a small
amount of solution into the buccal soft tissues of the
vestibule distal to the most posterior tooth in
mandibular arch .
 Submucosal infiltration – injection given into the
buccal tissues adjacent to the tooth that has to be
anesthetised .
 Deposition of 0.25ml of solution is sufficient .
208

Mental nerve block
 Indicated on occasion in pediatric dentistry .
 Nerve anesthetized – Mental nerve
 Area anesthetized – 1. lower lip
2. mucous membrane in the
mucobuccal fold anterior to the mental foramen
• Anatomical landmarks – mandibular cuspids
210

 It is achieved by first palpating the mental foramen
(usually located between the apices of primary molars
or premolars).
 The injection is targeted at the mucobuccal fold area &
apical to primary 1st and 2nd molars or inter radicularly
of the first and second premolars.
 The needle penetration site is just anterior to mental
foramen , and the syringe is directed posteriorly to the
area.
 With negative aspiration , 0.5-1.0 ml of solution is
slowly expressed.
211

Incisive nerve block
 Used only minimally in pediatric dentistry .
 Nerves anesthetized – incisive & mental
 Area anesthetized – 1. mandible and overlying labial
structures anterior to the mental foramen.
2. bicuspids , cuspids and incisors
3. lower lip on affected side
• Anatomical landmarks – mandibular cuspids
212

 It is achieved by first palpating the mental foramen.
 After the mental foramen is located, needle
penetration is made distal to it, entering the orifice in
a downward , posterio-anterior direction.
 Once in the foramen , aspiration is done .
 If aspiration is negative , 0.5 ml – 1 ml solution is
deposited slowly.
213

 The supraperiosteal incisive nerve procedure is
accomplished through the deposition of a small
amount of the anesthetic agent apically to the incisor
or canine tooth being attended .
215

MANDIBULAR CONDUCTION ANESTHESIA
(GOWGATES MANDIBULAR BLOCK TECHNIQUE)
 In 1973 Gow-Gates introduced a new method of
obtaining mandibular anesthesia, which he referred to
as mandibular conduction anesthesia."
 This approach uses external anatomic landmarks to
align the needle so that anesthetic solution is
deposited at the base of the neck of the mandibular
condyle.
 This technique is a nerve block procedure that
anesthetizes virtually the entire distribution of the
fifth cranial nerve in the mandibular area.
216

Technique –
 External landmarks -tragus of the ear
the corner of the mouth.
 The needle is inserted just medial to the tendon of
the temporal muscle and considerably superior to
the insertion point for conventional mandibular
block anesthesia.
 The needle is also inclined upward and parallel to
a line from the corner of the patient's mouth to the
lower border of the tragus (intertragic notch).
217

 The needle and the barrel of the syringe should be directed
toward the injection site from the corner of the mouth on
the opposite side.
218

PDL Injection
 The PDL injection has been well accepted in pediatric
dentistry and can be used as an alternative to
supraperiosteal injection.
 It provides the doctor with the means to achieve
anesthesia of proper depth and duration on one tooth,
without unwanted residual soft tissue anesthesia.
 The PDL is also useful when a child has discrete carious
lesions in multiple quadrants.

 The PDL injection is not recommended for use on
primary teeth because of the possibility of enamel
hypoplasia occurring in the developing permanent
tooth.

Complications
222
Generalized Localized
Early Late
Paediatric dentistry by Richard R.Welbury , Monty S. Duggal, M.T.Hosey 5th edition

1. Psychogenic –
 most common psychogenic complication is fainting.
Managed by giving LA in semi supine position.
2. Allergy –
Very rare occurrence
Occurs usually with ester linked LA’s like benzocaine
and tetracaine which are used as topical preparations.
If there is any suggestion of child being allergic ,
allergy testing should be done.
223
Generalized complications

3. Toxicity –
Over dosage of LA leading to toxicity is rarely a
problem in adults but common in children.
Children above 6 months of age absorb LA at a faster
rate than the adults ; however this is balanced by the
fact that children have larger volume of distribution
and faster excretion rate .
Thus , the drug dosage should be given related to body
weight .
224

Maximum recommended dosage
of LA for children
225

Maximum recommended dosage
Dose Proprietary
name
% LA Vasoconstri-
ctor
Duration of
anesthesia
MRD
lidocaine xylocaine 2 Epinephrine
1:100,000
Pulpal : 60
min
Soft tissue :
3-5 hr
4.4
mg/kg
Mepivacaine Carbocaine 3 - Pulpal : 20-
40 min
Soft tissue :
2-3hr
4.4
mg/kg
Prilocaine Citanest
forte
4 Epinephrine
1:200,000
Pulpal : 60 -
90 min
Soft tissue :
3-8 hr
6.0
mg/kg
Articaine septocaine 4 Epinephrine
1:100,000
Pulpal : 60 -
75 min
Soft tissue
:180-360
min
7 mg/kg
226

 Local anesthetic toxicity develops when the blood level
of the drug in the brain or myocardium becomes too
high.
 Once the blood level of a drug reaches toxic levels, the
drug exerts unwanted and possibly deleterious
systemic actions.
 Local anesthetic toxicity produces central nervous
system (CNS) and cardiovascular system (CVS)
depression, with reactions ranging from mild tremor
to tonic–clonic convulsions (CNS), or from a slight
decrease in blood pressure and cardiac output to
cardiac arrest (CVS).

 Many treatment appointments in pediatric dentistry
do not exceed 30 minutes in duration; therefore use of
a local anesthetic containing a vasopressor is
considered to be unnecessary and unwarranted.
 It is thought that increased duration of soft tissue
anesthesia, especially after inferior alveolar nerve
block, increases the risk of self-inflicted soft tissue
injury.
 A non–vasopressor-containing local anesthetic is
frequently used (most often, mepivacaine 3%).
 Providing 20 to 40 minutes of pulpal anesthesia,
mepivacaine 3% is considered the appropriate drug for
this group of patients; provided that treatment is
limited to one quadrant per visit.
228

Early localized complications
1. Pain – occurs at the time of injection due to :
a. needle penetrating into mucosa
b. too rapid an injection
c. injection in inappropriate site
The site at which injection may be painful –
i. intraepithelial
ii. subperiosteal
iii. intravascular
iv. Into nerve trunk
229

2. Intravascular injection –
Accidental intravascular injections can occur in
children if aspiration is not done.
Intravenous injections can produce systemic side
effects like tachycardia and palpitations.
Intra arterial injections are rare than intravenous
injections.
How ever if intra arterial injection is made effects
ranges from local pain and cutaneous blanching to
intracranial problems.
230

3. Failure of anesthesia –
Can be due to –
a. Anatomical reasons – bony anatomy or accessory
innervations
b. Pathological reasons – acute infections
c. Operator’s technique fault
231

4. Facial nerve paralysis –
 Can occur due to deposition of LA solution into the
substance of parotid gland due to malpositing of
needle during IANB.
 The most dramatic of this complication is the loss of
ability to close the eyelids in affected side.
232

5. Hematoma formation
Due to penetration of blood vessel during LA
injection.
It is rarely a problem, unless it occurs in a muscle after
IANB which may lead to trismus .
233

Late localized complications
1. Soft tissue injury
 Self-inflicted trauma to the lips and tongue is
frequently caused by the patient inadvertently biting
or chewing these tissues while still anesthetized.
 Trauma to anesthetized tissues can lead to swelling
and significant pain when the anesthetic effects
resolve.

 Cause -
Trauma occurs most frequently in younger children, in
mentally or physically disabled children or adults, and
in older-old patients; however, it can and does occur in
patients of all ages.
The primary reason is the fact that soft tissue
anesthesia lasts significantly longer than does pulpal
anesthesia.
Dental patients receiving local anesthetic during their
treatment usually are dismissed from the dental office
with residual soft tissue numbness

Prevention –
a. A local anesthetic of appropriate duration should be
selected if dental appointments are brief.
b. A cotton roll can be placed between the lips and the
teeth if they are still anesthetized at the time of
discharge. The cotton roll is secured with dental floss
wrapped around the teeth.
237

c. Warn the patient and the guardian against eating,
drinking hot fluids, and biting on the lips or tongue
to test for anesthesia.
d. A self-adherent warning sticker may be used on
children
238

 Management- symptomatic :
1. Analgesics for pain, as necessary
2. Antibiotics, as necessary, in the unlikely situation
that infection results.
3. Lukewarm saline rinses to aid in decreasing any
swelling that may be present.
4. Petroleum jelly or other lubricant to cover a lip lesion
and minimize irritation.

2. Oral ulcerations –
Occurs occasionally
Due to trauma initiating an apthous ulcer .
3. Trismus –
Occurs following IANB and is due to bleeding within
the muscle due to penetration of blood vessel by
needle.
Self resolving condition .
240

4. Infection -
Due to introduction of bacteria at the injection site .
Rarely encountered
5. Developmental defects –
LA agents are cytotoxic to the cells of enamel organ.
It is possible that incorporation of LA agents into
developing tooth germs can lead to developmental
defects.
Experimental evidences for such defects arising after
intraligamentary injection in primary teeth of animal
models have been reported.
Occurrence in humans have not yet been reported.
241

 In patients of minimally invasive procedures , as well
as pediatric patients , residual soft tissue anesthesia is
very inconvinent and annoying.
 Thus these patients can be benefited from the reversal
of the local anesthetics.
Ogle .O , Mahjoubi G ; advances in local anesthesia in dentistry; Dent Clin N Am55 ; 481-499
243

 In May 2009 , The FDA approved OraVerse for the
reversal of soft tissue anesthesia & the associated
functional deficits resulting from LAs.
 OraVerse is approved for use in both adults and
children.
 It is not recommended to be used in children below 6
years of age or weighing less than 15kg(33lbs).
244

 OraVerse is a formulation of Phentolamine , an alpha
– adrenergic antagonist.
 Mechanism of action – it acts as a vasodialator , thus
results in faster diffusion of LA into vascular system &
away from the site .
It thus reduces the unwanted side effects of lingering
lips and tongue numbness.
 It must be injected in the same volume and at the same
site as LA is injected.
245

 Tavares and colleagues evaluated the safety & efficacy
of a formulation of OraVerse for pediatric patients .
 These investigators found that –
drug was well tolerated and safe in children 4- 11 years
old.
The drug accelerated reversal of soft tissue anesthesia
in children of 6 – 11 years of age .
The median recovery time to normal lip sensation was
60 mins in the study group versus 135 mins for subjects
in control group.
246

Conclusion
 The control of pain while performing dental
procedures for the child is one of the most
fundamental and important components supporting
sound principles of behavior management.
 Pain control for the child is provided in most instances
by means of a skilled and sensible local anesthetic
delivery technique.
 The successful administration of the anesthetic agent
is based on both the concept of psychological
preparation and skillful administration of the agent.
247

References
1. Local anesthesia : agents , techniques and
complications ; Ogle O. , Mahjoubi G ; Dent Clin N
Am 2012 ;133-148
2. Dentistry for the child and adolescent – Mcdonald
and Avery’s , 9th edition
3. Pediatric Dentistry infancy through adolescence –
Pinkham 4th edition
4. Handbook of local anesthesia - Stanley F Malamed
6th edition
5. Munshi, AK, Hegde, AM, Latha, R: Use of EMLA: is it
an injection free alternative?. J Clin Pediatr Dent. 25,
2001, 215–219
248

6. Fundamentals of Pediatric Dentistry , Mathewson , 3rd
edition
7. Sharkawi et al ; Effectiveness of new distraction
technique on pain associated with injection of Local
anesthesia for children;AAPD V34/No 2 ; 2012:142-145
8. Monheim’s Local anesthesia and pain control in dental
practice – 7th edition
9. Paediatric dentistry by Richard R.Welbury , Monty S.
Duggal, M.T.Hosey 5th edition
10. Ogle .O , Mahjoubi G ; advances in local anesthesia in
dentistry; Dent Clin N Am55 ; 481-499
249

LOCAL ANESTEHSIA

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