This document discusses various techniques for local anesthesia in dentistry. It describes different nerve blocks for anesthetizing specific regions of the maxilla and mandible, including the posterior superior alveolar nerve block, middle superior alveolar nerve block, and anterior superior alveolar (infraorbital) nerve block. It also covers maxillary injection techniques such as supraperiosteal injections and palatal anesthesia techniques like the greater palatine nerve block.

1. Techniques of local
anesthesia

2. Techniques
• Maxilla –
.Maxillary nerve block
Buccal side
• Infraorbital nerve block
• Posterior superor alveolar nerve block
Palatal side
• Nasopalatine nerve
• Greater palatine or anterior palatine nerve block
• Mandible -
• Intraoral entire mandibular nerve block-
• 1. Vazirani –Akinosi closed mouth technique
• 2. Gow gates technique open mouth technique.
• Extraoral entire mandibular nerve block- the needle is inserted posterior to the lateral
pterygoid below the zygomatic arch.
• Other intraoral techniques- Inferior alveolar nerve block ,mental nerve block, lingual nerve
block, incisive nerve block.

3. Maxillary injection techniques
• 1. Supraperiosteal (infiltration), recommended for limited treatment protocols.
• 2. Periodontal ligament (PDL, intraligamentary)injection, recommended as an
adjunct to other techniques or for limited treatment protocols.
• 3. Intraseptal injection , recommended primarily for periodontal surgical
techniques.
• 4. Intracrestal injection, recommended for single teeth (primarily mandibular
molars) when other techniques have failed.
• 5. Intraosseous (IO) injection, recommended for single teeth (primarily
mandibular molars) when other techniques have failed.
• 6. Posterior Superior Alveolar (PSA)nerve block, recommended for management
of several molar teeth in one quadrant.
• 7. Middle Superior alveolar (ASA) nerve block, recommended for management of
premolars in one quadrant .

4. • 8. Anterior Superior Alveolar (ASA) nerve block, recommended for management of anerior
teeth in one quadrant .
• 9. Maxillary (V2, second division) nerve block , recommended for extensive buccal, palatal
and pulpal management in one quadrant.
• 10. Greater (anterior) palatine nerve block, recommended for palatal soft and osseous
tissue treatment distal to the canine in one quadrant .
• 11. Nasopalatine nerve block, recommended for palatal soft and osseous tissue
management from canine to canine bilaterally.
• 12. Anterior middle superior alveolar (AMSA) nerve block , recommended for extensive
management of anterior teeth , palatal and buccal soft and hard tissues.
• 13. Palatal approach – anterior superior alveolar nerve (P-ASA) nerve block ,
recommended for treatment of maxillary anterior teeth and their palatal and facial soft
and hard tissues.

6. Supraperiosteal injection
• The supraperiosteal injection, more commonly (but incorrectly) called local infiltration.
• indications.:-
• 1. pulpal anesthesia of the maxillary teeth when treatment is limited to one or two teeth.
2. soft tissue anesthesia when indicated for surgical procedures in a circumscribed.
Contraindications :-
1. Infections or acute inflammation in the area of injection.
2. Dense bone covering the apices of teeth (can be determined only trial and error; most likely over the
permanent maxillary first molar in children, as its apex may be located beneath the zygomatic bone, which is
relatively dense). The apex of an adult’s central incisor may aso be located beneath denser bone(e.g., of the
nose), thereby increasing the failure rate (although not significantly).
Advantages:-
High success rate (>95%)
Technically easy injection.
Usually entirely atraumatic
Disadvantages:-
Not for large areas due to multiple needle insertions and necessity to administer larer total volumes of LA.

7. Positive aspiration- Negligible, but possible (1%)
Alternative – PDL, IO, regional nerve block
• A 27 gauge short needle is recommended.
• Area of insertion : height of the mucobuccal fold above the apex of the tooth being anesthetized
• Landmarks:-
• A. mucobuccal fold
• B. crown of the tooth
• C. root contour of the tooth.
• Orientation of the bevel – toward bone.
• Signs and symptoms
• 1. subjective :- feeling of numbness in the area of administration.
• 2. objective : use of electrical pulp testing (EPT) with n response from tooth with maximal EPT output (80/80)
• 3. absence of pain during treatment.
• Safety features –
• 1. minimal risk of intravascular administration.
• 2. slow injection of anesthetic ; aspiration.
• Complication – pain on needle insertion with the needle tip against the periosteum. To correct: withdraw and
reisnsert it farther from the periosteum.

8. Posterior Superior Alveolar Nerve Block
• The posterior superior alveolar (PSA) nerve block is a commonly used dental nerve block.
Although it is a highly successful technique (>95%).
• Other common names :- Tuberosity block, zygomatic block
• Nerves anesthetized :- posterior superior alveolar and branches.
• Area anesthetized.
1. Pulps of the maxillary third, second and first molars (entire tooth =72%; mesiobuccal root
of the mesiobuccal root of the maxillary first molar not anesthetized = 28%).
2. Buccal periodontium and bone overlying these teeth .
Indications
1. When treatment involves 2 or more maxillary molars.
2. When supraperiosteal injection is contraindicated (e.g., with infection or acute
inflammation ).
3. When supraperiosteal injection has proved ineffective.

9. • Advantage :-
1. atraumatic ; when administered properly , no pain is experienced by the patient receiving the
PSA because of the relatively large area soft tissue into which the local anesthetic is deposited
and the fact that bone is no contacted .
2. high success rate (>95%).
3. minimum number of necessary injections
• A. one injection compared with opinion of three infiltrations.
4. minimizes the total volume of local anesthetic solution administered
• A. equivalent volume of anesthetic solution necessary for three supraperiosteal injections.=1.8
mL.
• Disadvantages
• 1. Risk of hematoma,usully diffuse , discomforting and visually embarrassing to patient.
• 2. technique somewhat arbitrary: no bony landmarks during insertion.
• 3. second injection necessary for 1st molar (mesiobuccal root) in 28% of patients.
• Alternatives
• 1. supraperiosteal or PDL injections for pulpal and root anesthesia.
• 2. infiltration for the buccal periodontium and hard tissues.
• 3. maxillary nerve block.

10. Technique-
• A 27 gauge short needle recommended.
• Area of insertion: height of the mucobuccal old above the maxillary second molar.
• Target area: PSA nerve – posterior , superior and medial to the posterior border of the
maxilla.
Landmarks:
• A. mucobuccal fold
• B. maxillarytuberosity
• C. zygomatic process of the maxilla.
Orientation of the bevel : toward bone during the injection. If bone is accidentally touched
sensation is less unpleasant .
Procedure:- left PSA – right handed administrator should sit at 10 o’clock position facing the
patient
Right PSA – a right PSA – right handed administrator should sit at the 8 o’clock position
facing the patient.
• Insert the needle into the height of the mucobuccal fold over the second molar . Advance the
needle slowly in an upward, inward and backard direction in one movement not three.

12. • A. aspirate in two planes .
• 1. rotate the syringe barrel (needle bevel) one fourth turn and reaspirate.
• 2. if both aspirations are negative :-
• A. slowly over 30-60 seconds , deposit 0.9 to 1.8mL of anesthetic solution.
• B. aspirate sveral additional times(in one plane )during drug administration.
• C. the PSA injection is normally atraumatic because of large tissue space available.
• Signs and symptoms
• 1. subjective : usually none.
• 2. objective :use of electrical pulptesting with no response form tooth with maximal EPT output (80/80)
• Absence of pain during treatment.
• Safety features.
• 1. slow injection, repeated aspirations.
• No anatomic safety features to prevent overinsertion of the needle; therefore careful observation is
necessary.
• Precaution – depth of needle penetration should be checked: due to hematoma.
• Failures:- needle too lateral, needle not high enough, needle too far posterior.
• Complications- hematoma , mandibular anesthesia ( the mandibular division of the fifth cranial nerve (V3 )
is located lateral to the PSA.

13. Middle Superior Alveolar Nerve
• The MSA block is indicated for procedures on premolars and on the mesiobuccal root of the
maxillary first molar. The success rate of MSA nerve block is high.
Nerves anesthetized – middle superior alveolar and terminal branches.
Areas anesthetized –
• 1. pulps of the maxillary first and second premolars.
• 2. buccal periodontal tissues and bone over these same teeth.
Indications-
• Where ASA fails.
• Dental procedures involving both maxillary premolars only.
Contraindications-
• Infection or inflammation
• Where MSA absent .
Advantages – minimizes number of injections and volume of solution.
Disadvantages-
• None.

14. • Positive aspiration- negligible (>3%).
• Alternative-
• 1. local infiltration (supraperiosteal), PDL, IO injections
• 2. ASA nerve block for 1st and 2nd premolar and the mesiobuccal root of the 1st molar.
• Technique
• 1. 27 gauge short or long needle is recommended.
• 2. area of insertion : height of mucobuccal fold above maxillary second premolar.
• 3. 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 bevel.
• Procedure:-
• For right MSA nerve block , a right –handed administrator – 10 o’clock position.
• For left MSA nerve block, a right- handed administrator – 8 or 9 o’clock position.
• Slowly deposit 0.9 to 1.2 mL (1/2 to 2/3rd catridge) of solution( approximately 30-40 seconds).
• Signs and Symptoms-
• 1. Subjective – upper lip numb.
• 2. objective- use of electrical pulp testing with no response from tooth with maximal EPT output (80/80).
• 3. absence of pain during treatment.

15. • Safety Feature- relative avascular area, anatomically safe.
• Precautions- to prevent pain, do not insert too close to the periosteum and do not inject too
close to the periosteum and do not inject too rapidly;the MSA should be an atraumatic
injection.
• Failures of anesthesia-
• 1. anesthetic solution not deposited high above the apex of the second premolar , to correct-
check radiographs and increase the depth of penetration .
• 2.deposition of solution too far from maxillary bone with the needle placed in tissues lateral
to the height of mucobucal fold , to correct: reinsert at the height of the mucobuccal fold.
• 3. Bone of zygomatic arch at the site of injection preventing the diffusion of anesthetic , to
correct : superiosteal,ASA or PSA injection in place of the MSA.
• Complications – hematoma (rare).

16. Anterior Superior Alveolar Nerve Block
(infraorbital nerve block)
• There is a general lack of experience with this highly successful and extremely safe technique.
Dentists fear from using this block due to injury to the patient’s eye.
• Nerve anesthetized-
1. anterior superior alveolar.
2. middle superior alveolar .
3. infraorbital nerve
• A. inferior palpebral
• B. lateral nasal
• C. Superior labial.
• Areas anesthetized-
• 1. pulps of maxillary central incisor through the canine on the injected side.
• 2. in about 72% of pateints, pulps of the maxillary premolars and mesiobuccal root of the first
molar .
• 3. lower eyelid, lateral aspect of the nose, upper lip.

17. • Indications :-
• Dental procedures involving more than two maxillary teeth and their overlying buccal tissues.
• Inflammation or infection which contraindicates supraperiosteal injection .
• When superaperiosteal injections have been ineffective because of dense cortical bone.
• Contraindicates:-
• 1. discrete treatment areas (one or two teeth only ; supraperiosteal)
• 2. hemostasis of localized areas, when desirable, cannot be achieved with injection; local infiltration into the
treatment area is indicated.
• Advantages –
• 1. comparatively simple technique.
• 2. comparatively safe; minimizes the volume of solution used and no of needle punctures also.
• Disadvantages :-
• 1. psychological :-
• A. administer – initial fear of injury to the patient’s eye (experience with the technique leads to confidence.
• B. patient – extraoral approach t infraorbital nerve may prove disturbing; however, intraoral techniques are
rarely a problem.
• C. anatomic : difficulty defining landmarks.
• Positive aspiration – 0.7%
• Alternatives – 1. superaperiosteal, PDL or IO injection for each tooth., 2. infiltration 3. maxillary nerve block.

18. • Technique :-
• A 25 or 27 gauge long needle is recommended.
• Area of insertion : height of the mucobuccal fold directly over the first premolar (shortest route)
• Target area- infraorbital foramen (below the infraorbital notch).
• Landmarks – a. mucobuccal fold, b. infraorbital notch , c. infraorbital foramen.
• Orientation of the bevel – toward bone.
• Slowly deposit 0.9 to 1.2 mL over 30-40 seconds.
• Signs and symptoms
• 1. Subjective : tingling and numbness of lower eyelid, side of the nose and upper lip indicate
anesthesia of the infraorbital nerve , not the ASA or MSA nerve.(soft tissue anesthesia develops
almost instantly as the anesthetic is being administered).
• 2. 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).
• 3. objective – use of electrical pulp testing with no response from tooth with maximal EPT
output (80/80).
• 4. absence of pain during treatment.

19. • Safety Features. 1. needle contact with bone at the roof of the infraorbital foramen prevents
inadvertent overisertion and possible puncture of the orbit.
• 2. a finger positioned over the infraorbital foramen helps direct the needle toward the
foramen.
• A. the needle should not be palpable . If it is felt , then its path is too superficial (away from
the bone). If this occurs , withdraw the needle slightly and redirect it towards the target
area.
• B. in most patients its not palpable unless its superficial, however with less well-developed
,its palpable.
• Precaution- pain on insertion, tearing of periosteum, to prevent overinsertion exert finger
pressure over the infraorbital foramen.
• Failures of anesthesia- needle contacting bone below (inferior to) the infraorbital foramen.
• Needle deviation medial or lateral to the infraorbital foramen.
• Complications.-
hematoma rarely , to manage apply pressure on soft tissue foramen for 2-3 minutes.

20. Palatal Anesthesia
• Anesthesia of the hard palate is necessary for dental procedures involving manipulation of
palatal soft or hard tissues but it proves to be a very traumatic experience.
• 1. Greater Palatine Nerve Block/ Anterior palatine nerve block - useful for procedures
involving the palatal soft tissues distal to the canine.
• Nerve anesthetized- Greater palatine
• Areas Anesthetized- the posterior position portion of the hard palate and its overlying soft
tissues, anteriorly as far as the first premolar and medially to the midline.
• Indications – 1. palatal soft tissue anesthesia, subgingival restoration.
• 2. for pain control during periodontal or oral surgical procedures involving palatal soft and
hard tissues.
• Contraindications- inflammation or infection , smaller areas of therapy .
• Advantages- minimize needle penetrations and volume of solution.
• Minimizes patient discomfort.
• Disadvantages- 1. no hemostasis except in immediate area of injections.
• 2. potentially traumatic.

21. • Positive aspiration- less than 1%.
• Alternatives- local infiltration into specific regions, maxillary nerve block.
• 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.
• Landmarks- greater palatine foramen and junction of the maxillary alveolar process and
palatine bone.
• Path of insertion: advance the syringe from the opposite side of mouth at a right angle to target
area.
• Orientation of the bevel- toward the palatal soft tissues
• Technique- 1) for right greater palatine nerve block, a right handed administrator – 7 or 8
o’clock. 2) left greater palatine nerve block, a right handed administrator – 11 0’clock.
• Slowly deposit not more than 1/4th to 1/3rd of catridge. (0.45 to 0.6 mL )
• Signs and symptoms – 1. subjective : numbness in the posterior portion of the palate.
• 2. objective: no pain during dental therapy.

22. • Safety Features – 1. contact with bone . 2. aspiration.
• Precautions- do nt enter the greater palatine canal. Although this is not hazardous, there is
no reason to enter the canal for this technique to be successful.
• Failures of anesthesia – 1) the greater palatine nerve block is not a technically difficult
injection to administer , incidence of success is well above 95%.
• 2) if local anesthetic is deposited too far anterior to the foramen, adequate soft tissue
anesthesia may not occur in the palatal tissues posterior to the site of injection (partial
success).
• 3) anesthesia on the palate in the area of the maxillary first premolar may prove inadequate
because of overlapping fibres from the nasopalatine nerve (partial success).
• A. to correct :- local infiltration may be necessary as a supplement in the area of inadequate
anesthesia.
• Complications- few of significance , ischemia and necrosis of soft tissues when highly
concentrated vasoconstricting solution used for hemostasis over a prolonged period bcoz
Norepinephrine should never be used for hemostasis on the palatal soft tissues.
• Hematoma is possible but rare due to firm adherence of palatal tissues to underlying bone.
• Uncomfortable to patients.

24. Nasopalatine Nerve Block
• Potentially highly traumatic injections. 2 techniques- 1. single tissue penetration 2. multiple
needle penetration.
• Other common names- Incisive nerve block, sphenopalatine nerve block.
• Nerves 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.
• Indications- palatal soft tissue anesthesia – for restorative treatment ,subgingival
restorations, insertion of matrix bands subgingivally).
• For pain control during periodontal or oral surgical procedures involving palatal soft and
hard tissues.
• Contraindications- inflammations or infection, smaller area of therapy .
• Advantages- minimizes needle penetrations and volume of solution.
• Minimal patient discomfort from multiple needle penetration.
• Disadvantages –no hemostasis except in the immediate area of injection.
• Potentially most traumatic intraoral injection.

25. Positive aspiration- less than 1%.
Alternatives- 1. local infiltration into specific regions. 2. maxillary nerve block, 3. anterior
middle superior alveolar (AMSA) nerve block (unilateral only).
Technique- 27 gauge short needle is recommended.
Area of insertion – palatal mucosa just lateral to 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 .
Landmarks- central incisors and incisive papilla.
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 ).
Procedure – sit at the 9 or 10 o’clock position , slowly deposit not more than 1/4th of a
catridge (0.45 mL ).
Signs and symptoms – subjective – numbness in the anterior portion of the palate , Objective
– no pain during dental therapy.
Safety features- contact with bone , aspiration.

27. • Precautions – 1) against pain- don’t insert directly into the incisive papilla (quite painful), don’t
deposit solution too rapidly , don’t deposit too much solution.
• 2) against infection – if needle advanced more than 5mm into the incisive canal and the floor of
the nose is entered accidentally , infection may result. There is no reason for the needle to enter
the incisive canal during nasopalatine.
• Failures of anesthesia – highly successful injection (>95% incidence of success) , unilateral
anesthesia , inadequate palatal soft tissue anesthesia in the area of the maxillary canine and
first premolar.
• Complications - few of significance , hematoma is possible but extremely rare , necrosis of soft
tissues is possible when highly concentrated vasoconstricting solution, because of density of soft
tissues , anesthetic solution may squirt back out the needle puncture site during administration
or after needle withdrawal.
• Technique (Multiple needle penetration) – 27 gauge short needle used.
• Areas of insertion :- labial frenum in the midline between the maxillary central incisors,
interdental papilla between the maxillary central incisors, if needed, palatal soft tissues lateral
to the incisive papilla .
• Landmarks- central incisors and incisive papilla .
• Path of insertion –a. 1st injection – infiltration 0.3 mL into the labial frenum.
• B. 2nd injection – needle held at right angle to the interdental papilla .
• C. 3rd injection – needle held at 45 degree angle to the incisive papilla.

28. • Signs and symptoms – 1. subjective – numbness of the upper lip and the anterior portion of
the palate. 2. objective – no pain during dental therapy.
• Safety features- aspiration , contact with bone.
• Advantages – entirely or relatively atraumatic.
• Disadvantages- 1. requires multiple injections(three). 2. difficult to stabilize the syringe
during the second injection .3. syringe barrel usually within the patient’s line of sight
during the second injection.
• Precautions – 1. against pain – entire technique is atraumatic if performed as above. 2.
against infection – on 3rd injection don’t advance the needle into incisive canal due to risk of
nasal floor penetration.
• Failures of anesthesia- highly successful (>95%) injection , inadequate anesthesia of soft
tissues around canine and first premolar due to overlapping of fibres from greater palatine
nerves.
• Complications – few of significance , necrosis of soft tissues is possible when a highly
concentrated vasoconstrictor solution used. , interdental papilla between maxillary incisors
sometimes are tender for several days after injection.

30. Local infiltration of the palate
• Nerves anesthetized – terminal branches of nasopalatine and greater
palatine .
• Areas anesthetized – soft tissues in the immediate vicinity of
injection.