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1. Techniques of local
anesthesia
Meryem Hilal
Mustafa Bahaa
Supervised by: Dr. Sahar AbdulQader

2. • Practicing correct anesthetic techniques require good
knowledge of the anatomy of the oral region and the
nerves relating to it.
• Two branches of the trigeminal nerve are mainly involved
in supplying the region, which are maxillary and
mandibular divisions, they are illustrated alongside their
branches concerning the oral cavity in the following
figures.

3. Maxillary division of trigeminal
nerve

4. Mandibular division of trigeminal
nerve

5. Techniques for Maxillary Anaesthesia
• The maxillary teeth may be anaesthetised by infiltration, regional
and field block, intraligamentary, intra-osseous and intrapulpal
anaesthesia.
• The primary method is infiltration anaesthesia.
• Patient’s position has a significant role in delivering safe and
effective anesthesia while affording comfortable placement for
the patient. Ideally the patient should be in supine position.
• The type of injection administered for a given treatment is
determined by the extent of the operative area.
• For management of small, localized areas, as in providing
hemostasis for soft tissue procedures, infiltration anesthesia may
suffice.
• When two or three teeth are being restored, field block is
indicated.
• for pain control in quadrant dentistry, regional block anesthesia is
recommended.

6. • Local infiltration:
• Small terminal nerve endings in the area of the dental treatment are flooded
with local anesthetic solution.
• incision is then made (or treatment is performed) in the same area in which
the local anesthetic has been deposited.
• A common misusage in dentistry is the use of the term “Infiltration” to
describe a field block type in which the local anesthetic solution is deposited
at or above the apex of the tooth to be treated.
• administration of a local anesthetic into an interproximal papilla before root
planing is an example of local infiltration.

7. • Field block:
• Local anesthetic is deposited near the larger terminal nerve branches so the
anesthetized area will be circumscribed, preventing the passage of impulses
from the tooth to the central nervous system.
• An incision is then made (or treatment is performed) in an area away from the
site of injection.
• Maxillary injections administered above the apex of the tooth to be treated
are properly termed field blocks (although common usage identifies them as
infiltration or supraperiosteal injections).
• It is the most frequently used technique for obtaining pulpal anesthesia in
maxillary teeth.
• When several teeth are involved in the treatment, it is not preferable for the
following reasons:
1. Multiple injections require multiple needle penetrations increasing
the likelihood of producing pain.
2. Permanent or transient damage to the nerves and blood vessels,
3. requires administration of a larger volume of local anesthetic.

8. • Technique:
• A 27-gauge short needle is recommended .
• Area of insertion: height of the mucobuccal fold above the apex of
the tooth being anesthetized.
• The bevel facing towards the bone.
• deposit approximately 0.6 mL (one-third of a cartridge) slowly over
20 seconds.

9. • Regional block:
• Local anesthetic is deposited close to a main
nerve trunk, usually at a distance from the site
of operative intervention.
• Posterior superior alveolar, infraorbital, and
nasopalatine injections are examples of
maxillary nerve blocks.

10. • PSA block:
• A commonly used dental block when two or more maxillary molars are involved or when
supraperiosteal injection is contraindicated due to infection.
• despite its high success rate several issues should be weighed when its use is considered including:
1. the extent of anesthesia produced;the mesiobuccal root of the maxillary first molar is not
consistently innervated by the PSA nerve ( in 28% of the pateints innervated by MSA) and therefor a
second injection maybe needed after PSA block when effective anesthesia has not developed.
2. Insertion of the needle too far distally may lead to a temporarily (10 to 14 days) unesthetic
hematoma.
• The technique is somehow arbitrary as there are no bony landmarks during insertion.

11. • Technique:
• A 27-gauge short needle is recommended.
• Area of insertion: height of the mucobuccal fold above
• the maxillary second molar.
• The bevel facing towards the bone so if it is touched accidently ,
the sensation is less unpleasant.
• The patient’s mouth should be partially opened with the mandible
pulled to side of injection.
• Deposit 0.9 to 1.8 mL of anesthetic solution Slowly, over 30 to 60
seconds.

12. • MSA block:
• It is present in 28% of the patients making the MSA block
usefulness limited.
• Indicated when:
1. ASA nerve block fails to provide pulpal anesthesia distal to the
maxillary canine.
2. For premolars and mesiobuccal root of first molar.
• When MSA is absent, innervation of the premolars is provided by
branches of ASA and the mesiobuccal root of first molar is
anesthetized by means of the MSA technique.

13. • Technique:
• A 27-gauge short needle is recommended.
• Area of insertion: height of the mucobuccal fold above the maxillary
second premolar.
• The bevel facing towards the bone.
• deposit 0.9 to 1.2 mL of the anesthetic solution Slowly, over 30-40
seconds.

14. • ASA block:
• It not as popular as PSA block as there is a general lack of experience
with this technique however, its success rate when performed is high.
• Anesthetizes maxillary incisors, canines and in 72% of the patients,
premolars.
• One major factor inhibiting the use of ASA block is the fear of causing
injury to the patients eye.
• Commonly called “infraorbital nerve block” , which is not very presice as
the infraorbital nerve supplies the extraoral soft tissues not the teeth
and intraoral tissues.
• Indicated mainly when dental procedures are involving more than two
maxillary anterior teeth or supraperiosteal injection is contraindicated
due to infection.
• Rarely hematoma may develop across the lower eyelid and tissues
betwwen it and the infraorbital foramen and is managed by apllying
pressure for 2-3 minutes.

15. • Technique:
• A 25- or 27-gauge long needle is recommended.
• Area of insertion: height of the mucobuccal fold directly over the
first premolar to reach the infraorbital foramen.
• Bevel facing towards the bone.
• Deposit 0.9 to 1.2 mL of the anesthetic solution Slowly, over 30-40
seconds.

16. • Palatal anesthesia:
• Anesthesia of the hard palate is necessary for dental procedures involving
manipulation of palatal soft or hard tissues.
• For many patients it is one of the most traumatic experiences.
• The dentist could perform atraumatic palatal anesthesia by:
1. Provide adequate topical anesthesia at the site of needle
penetration.
2. Use pressure anesthesia at the site both before and during needle
insertion and the deposition of solution.
3. Maintain control over the needle.
4. Deposit the anesthetic solution slowly.

17. • Greater Palatine Nerve Block:
• The greater palatine nerve block is useful for dental procedures involving the
palatal soft tissues distal to the canine unilaterally.
• Less potentially traumatic than nasopalatine nerve block because tissues
surrounding the greater palatine foramen are not as firmly adherent to bone
so they are better in accommodating the recommended volume of anesthesia.
• Contraindicated in the presence of infection or when the operative area is
relatively small (one or two teeth).
• Anesthesia on the palate in the area of the maxillary first premolar may prove
inadequate because of overlapping fibers from the nasopalatine nerve and can
easily be corrected by local infiltration when needed.

18. • Technique:
• A 27-gauge short needle is recommended.
• Area of insertion: soft tissue slightly anterior to the greater palatine
foramen.
• deposit not more than one-fourth to one-third of a cartridge (0.45 to
0.6 mL) slowly over minimum of 30 seconds.
• Bevel facing towards the palatal soft tissues.

19. • Nasopalatine nerve block:
• Nasopalatine nerve block is an invaluable technique for palatal pain control
in which Anterior portion of the hard palate (soft and hard tissues)
bilaterally is anesthetized.
• The most traumatic intraoral injection.
• Largely replaced by intranasal local anesthetic mist.
• Contraindicated in the presence of infection or when the operative area is
relatively small (one or two teeth).

20. • Technique:
• There are two approaches for nasopalatine nerve block:
A. Single-Needle Penetration :
 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) targeting the
incisive foramen just beneath the papilla.
 Bevel facing towards the palatal soft tissues.
 deposit not more than one-fourth to one-third of a cartridge (0.45 to
0.6 mL) slowly over minimum of 30 seconds.

21. B. Multiple Needle Penetrations:
 A 27-gauge short needle is recommended.
 Areas of insertion:
I. Labial frenum in the midline between the maxillary central
incisors with bevel toward bone.
II. Interdental papilla between the maxillary central incisors.
III. If needed, palatal soft tissues lateral to the incisive papilla.
 First injection: infiltration of 0.3 mL into the labial frenum.
 Second injection: penetration through the labial aspect of the papilla
between the maxillary central incisors and slowly depositing 0.3 mL
of the anesthesia over 15 seconds.
 Third injection: aiming toward the most distal portion of the papilla
palatally deposit 0.3 mL of the anesthesia over 15 seconds.
 The main disadvantage is that it requires multiple injections.

23. • Maxillary Nerve Block:
• Effective method of achieving profound anesthesia of a hemimaxilla mainly
indicated in extensive surgical procedures, infection precluding the use of
other regional nerve blocks or for therapeutic procedures for neuralgias.
• Two approaches available:
A. High-Tuberosity Approach:
 A 25-gauge long needle is recommended.
 Area of insertion: height of the mucobuccal fold above the distal
aspect of the maxillary second molar Superior and medial to the
target area of the PSA nerve block.
 Bevel facing towards the bone.
 Deposit 1.8 mL of the anesthetic solution Slowly over more than 60
seconds.

24. B. Greater Palatine Canal Approach:
 A 25-gauge long needle is recommended.
 Area of insertion: palatal soft tissue directly over the greater
palatine foramen.
 The needle passes through the greater palatine canal to reach
the pterygopalatine fossa.
 Bevel facing toward palatal soft tissues.
 deposit 1.8 mL of solution slowly over a minimum of 1
minute.

25. Techniques for mandibular anesthesia
• Performing profound correct anesthesia in the mandibular teeth is
quiet harder than the maxilla and this is mainly attributed to the fact
that the cortical plate of bone overlying maxillary teeth is normally
thin allowing diffusion of anesthetic solution.
• The thickness of the cortical plate of bone in the adult mandible
makes the infiltration technique invaluable except when is patient has
a full primary dentition.
• The primary technique used to achieve adequate anesthesia is
regional block.

26. • Inferior Alveolar Nerve Block:
• The second most frequently used after infiltration) and possibly the most
important injection technique in dentistry.
• Has highest percentage of clinical failures (31% to 81%) even when administered
properly.
• Supplemental block (buccal nerve) is needed when soft tissue anesthesia in the
buccal posterior region is necessary.
• Nerves anesthetized:
1. Inferior alveolar nerve.
2. Incisive nerve.
3. Mental nerve.
4. Lingual nerve.
• Indicated mainly when multiple teeth in the same quadrant are under operation.
• Contraindicated in patients who will more likely bite their tongue and lips
(children and mentally retarded patients).

27. • Technique:
• A 25-gauge long needle is preferred.
• Area of insertion: mucous membrane on the medial (lingual) side of the
mandibular ramus at the intersection of two lines—one, representing the height
of needle insertion, the other one, representing the anteroposterior plane of
injection.
• The bevel orientation is less critical than other nerve blocks as the needle
approaches the IAN at right angle.
• Deposit 1.5 mL of anesthetic solution slowly over a minimum of 60 seconds.
• On withdrawal of the syringe, and when approximately half its length remains
within tissues, deposit a portion of the remaining solution 0.2 mL)to anesthetize
the lingual nerve.
• Care must be taken not to deposit the anesthetic solution if there is no bone
contact as the needle maybe have penetrated the parotid gland near the facial
nerve. Injection of anesthesia will lead to a transient blockade (paralysis) of the
facial nerve.
• Complications involve hematoma, trismus and transient facial paralysis.

29. • Buccal Nerve Block:
• The buccal nerve provides sensory innervation to the buccal soft tissues
adjacent to the mandibular molars only.
• The sole indication for administration of a buccal nerve block therefore is
when manipulation of these tissues is contemplated.

30. • Technique:
• A 25- or 27-gauge long needle is recommended.
• Area of insertion: mucous membrane distal and buccal to the most distal
molar tooth in the arch.
• Bevel facing towards the bone.
• deposit 0.3 mL of the anesthetic solution slowly over 10 seconds.

31. • Mandibular Nerve Block: The Gow-Gates Technique:
• Has a significant advantage over the IAN block as it has a higher success rate.
• Provides sensory anesthesia of virtually the entire distribution of mandibular
nerve.
• Nerves anesthetized:
1. Inferior alveolar nerve.
2. Mental nerve.
3. Incisive nerve.
4. Lingual nerve.
5. Mylohyoid nerve.
6. Auriculotemporal nerve.
7. Buccal nerve (in 75% of patients).
• Indicated when Multiple procedures on mandibular teeth are being performed.
• Contraindicated mainly in patients who can not open their mouth widely.

32. • Technique:
• A 25- or 27-gauge long needle recommended.
• Area of insertion: mucous membrane on the mesial aspect of the mandibular
ramus, on a line from the intertragic notch to the corner of the mouth, just
distal to the maxillary second molar.
• Orientation of the bevel is not critical.
• Patient should be instructed to open his mouth widely during the injection
and for 1-2 minutes after the injection to aid diffusion of the anesthesia.
• Deposit 1.8 mL of solution slowly over 60 to 90 seconds.

34. • Vazirani-Akinosi Closed-Mouth Mandibular Block:
• a closed-mouth approach to mandibular anesthesia.
• Its primary indication remains those situations where limited mandibular
opening precludes the use of other mandibular injection techniques shuch
as trismus on one side of the mandible after sever IANB failed attempts or
in acute irreversible pulpitis.
• Nerves anesthetized:
1. Inferior alveolar nerve
2. Incisive nerve
3. Mental nerve
4. Lingual nerve
5. Mylohyoid nerve

35. • Technique:
• A 25-gauge long needle is recommended.
• Area of insertion: soft tissue overlying the medial (lingual) border of the
mandibular ramus directly adjacent to the maxillary tuberosity at the height of the
mucogingival junction adjacent to the maxillary third molar.
• Bevel orientation in the closed mouth mandibular block is very important it must
be oriented away from the bone of the mandibular ramus (bevel faces toward the
midline).
• Deposit 1.5 to 1.8 mL of anesthetic solution slowly over 60 second.

36. • Mental Nerve Block:
• The mental nerve is a terminal branch of the inferior alveolar nerve. It exits
the mental foramen near the apices of the mandibular premolars.
• provides sensory innervation to the buccal soft tissues lying anterior to the
foramen and the soft tissues of the lower lip and chin on the side of injection.
• Least frequently used nerve block nerve block because of its very little
indication.
• Indicated primarily for buccal soft tissue procedures, such as suturing of
lacerations or biopsies.

37. • Technique:
• A 25- or 27-gauge short needle is recommended.
• Area of insertion: mucobuccal fold between first and second premolars at or
just anterior to the mental foramen.
• Bevel facing towards the bone.
• Deposit 0.6 mL of the anesthetic solution slowly over 20 seconds.
• Hematoma ,bluish discoloration and tissue swelling at the injection site,
may develop and is treated by applying pressure for 2 minutes.
• Contact of the needle with the mental nerve as it exits the mental foramen
may lead to the sensation of an “electric shock” or to various degrees of
paresthesia of the chin and lower lip.

38. • Incisive Nerve Block:
• The incisive nerve is a terminal branch of the inferior alveolar nerve.
Originating as a direct continuation of the IAN at the mental foramen.
• travels anteriorly in the incisive canal, providing sensory innervation to those
teeth located anterior to the mental foramen.
• The nerve is always anesthetized when an inferior alveolar or mandibular nerve
block is successful so ,the incisive nerve block is not necessary when these
blocks are administered.
• The premolars, canine, and lateral and central incisors, including their pulp,
buccal soft tissues and bone, are anesthetized when the incisive nerve block is
administered.
• Mainly indicated when:
1. requiring pulpal anesthesia of mandibular teeth anterior to the mental foramen.
2. When IANB is not indicated (canine to canine or premolar to premolar) are
treated, the incisive nerve block is recommended in place of bilateral IANBs.

39. • Technique:
• Identical to mental nerve block except for one additional step that is
applying pressure on the site of injection during and after the injection
for 2 minutes to assure more volume of solution is entering the mental
foramen.
• The pressure can be intraorally or extraorally.

40. • References:
• Handbook of local anesthesia, Stanley F. Malamed,
DDS, 7th Edition, 2020.
• Practical Dental Local Anaesthesia, John G Meechan,
2002.