Techniques of Local

Anaesthesia in Dentistry

DR. Rehab Elsharkawy

PhD. Medical College of Georgia, Augusta. Georgia. USA
Assoc. Prof. of Oral & Maxillofacial Surgery
Faculty of Oral & Dental Medicine -Cairo University
• Anesthesia: means the complete loss of all
sensations including that of pain.
• Local anesthesia: loss of sensation, including pain,
in a circumscribed area of the body by a depression
of excitation in nerve endings or an inhebition of
the conduction process in peripheral nerves,
(without inducing loss of consciousness)
• General anesthesia: it is a condition in which the
patient does not react to any stimulus and does not
have any memory of what has happened
(unconscious).
 Methods of inducing Local Anesthesia
1.Application of cold in any form (ice) or application
of volatile liquid to the area (Ethyle chloride spray).
2.Application of pressure: by direct pressure on the
main nerve trunk supplying the area and by
depriving the part from it’s blood supply (ischemia)
to block the nerve conduction.
3.Mechanical trauma.
4.Chemical agents: such as Neurolytic agents (acohol).
5.Chemical agents: such as LA drugs. These can
suppress the function of the nerve without affecting
surrounding tissues.
 Ideal properties of local anesthetics
1. Provide profound anesthesia.
2. Rapid onset of anesthesia.
3. Reasonable duration.
4. Reversible action.
5. Soluble in water.
6. Compatible with the salt used to form isotonic soln.
7. Should not be irritating to the tissues and should
have no effect on its normal healing process.
8. Should not have permanent alteration on nerve
structure.
 Ideal properties of local anesthetics
9. Should have a stable chemical composition that is
able to be stored for considerable time.
10.Sterilizable without deterioration or loss of
function.
11.Should have no or minimal systemic toxicity.
12.Should not produce allergic reaction.
13. VC action if possible or at least compatible with
VC.
14. Should be effective in both topical and injectable
forms.
15. Not expensive.
 Indications of local anesthesia
• Elimination of pain during treatment.

• Diagnostic purposes for vague pain.

• Control of pain in the post operative period.

• To reduce hemorrhage.
METHODS TO PRODUCE REGIONAL
ANAESTHESIA
 Topical anesthesia
• provides a temporary loss of sensation effect
on nerve endings that are located on the
surface of the oral mucosa or skin.

• Supplied as:
•Gel
•Patch
–Spray
–Ointment
–Liquid
 Infiltration Anesthesia

In local infiltration small

terminal nerve endings in the
area of the surgery are
flooded with local anesthetic
solution, rendering them
insensible to pain.
 Field block
The field block method of securing
regional anesthesia consists of
depositing a solution in proximity to
the larger terminal nerve branches so
that the area to be anaesthetized is
walled off or circumscribed to prevent
the central passage of afferent
impulses.
 Nerve block
• The term nerve block applies to
that method of securing regional
anesthesia by depositing a
suitable local anesthetic solution
within close proximity to a main
nerve trunk, and thus preventing
afferent impulses from traveling
centrally beyond that point.
 The methods of accomplishing field block
and local infiltration are:
1. Submucosal injections
2. Paraperiosteal injections (infiltration)
3. Intraosseous injections
4. Intraseptal injections
5. Intraligamentary injections (periodontal
ligament, PDL)
 Advantages of nerve block anesthesia

1.More profound anesthesia

2.Longer duration.
3.Large field of operation by the use of low volume of
anesthetic solutions, thus decrease the chance for
development of drug toxicity.
4.No local ischemic effect from the vasoconstrictor agent
is present (Good blood supply helps quicker healing).
5.Fewer needle punctures.
6.If infection is present, the possibility of infection
dissemination by the infiltration needle is prevented.
 Factors affecting selection of LA technique

1. Area to be anaesthetized
2. Profoundness required
3. Duration of anesthesia
4. Presence of infection
5. Age of the patient
6. Condition of the patient
7. Hemostasis, if needed
8. Skill of the operator.
• LA administration should not be painful.

• There are two components to an atraumatic injection: a

communicative and a technical aspect.

• An injection may be routine for the dentist, but it is

often an unpleasant experience for the patient.
Psychological support, is essential, and will increase the
patient`s confidence in his dentist.
BASIC INJECTION TECHNIQUE
 Basic injection technique
1.Use a sterilized sharp needle.
The needle gauge:
• Refers to the internal diameter of the lumen of the needle.
• The smaller the number, the greater the internal diameter
of the needle lumen.
• Larger diameter needles are used in techniques injecting in
highly vascular area or when needle deflection through soft
tissue would be a factor.
• The most commonly used needles in dentistry are the 27-
gauge long and 30-gauge short.
• Color-coding by needle gauge.
 Advantages of greater diameter
1.Greater accuracy and increased success rate due
to less deflection .
2.They are less likely to penetrate smaller blood
vessels.
3.Aspiration is much easier and more reliable.
4.It is safer because breakage is less likely to occur.
The only disadvantage is that it may be more
traumatic to the patients, but actually patients
cannot differentiate among 23, 25, 27 or 30-
gauge needles.
 The length
• Dental needle are available in three lengths
measured from hub to tip:
1. Long (32 mm).
2. Short (20 mm).
3.Ultrashort (only in 30-gauge).
Long needles are preferred for injection tech.
where the penetration of significant thickness of
soft tissue is required.
 Basic injection technique
2. Use anesthetic cartridge and syringe with
temperature as close to room temperature as
possible.
Not too cold and not too hot.
3. Check the flow of the local anesthetic solution.
4. Proper positioning of the patient.
5. Dry the site of injection and remove any debris
to obtain adequate visibility.
6. Apply topical antiseptic. (Betadine not Alcohol)
7. Apply the topical anesthetic agent (ointment or
spray). Ointment is better as spray tend to taste
badly and it is difficult to be restricted.
 Jet injector
(needleless syringe)

Needleless injectors use pressure to deliver local

anesthesia to soft tissues 2 to 3 mm in depth.
The effect is similar to topical anesthesia. Further
injections are required for profound soft and hard tissue
anesthesia.
 Basic injection technique
8. Keep the syringe out of the patient’s sight as
much as possible.
9. Stretch the tissue at the site of needle
penetration in areas with loose soft tissue. This
allows the needle to penetrate with less
resistance.
10. Always establish a firm hand rest during the
injection procedure.
 Basic injection technique
11. Slowly advance the needle through the mucosa
to desired target.
12. Always aspirate prior to deposition of the drug.
13.Slowly deposit the local anesthetic solution.(e.g.
1ml/minute at least). Observe the patient during
injection.
 Basic injection technique

14. Slowly withdraw the syringe. Cap the needle and

discard.
15. Always communicate with the patient using
reassuring words and praise. Never leave the
patient alone after an injection. Allergic or other
reactions may occur instantaneously at any time.
16. Never leave patients unattended following
administration of local anesthetic.
17. Record the injection in the patients chart.
 Pain during needle Pain during needle
insertion withdrawal
• Sharpness • Fishhook-barbs leading to
• Gauge postoperative trismus
• Speed of insertion and may cause nerve
injury
• Topical
• Bevel Pain during soln
deposition
 PH of the soln.
 Rapid injection
 Contamination of Soln.
 Hot soln.
 Techniques of Maxillary Anesthesia
1.Supraperiosteal (Infiltration) technique.
2.Infraorbital nerve block.
3. Posterior Superior Alveolar (PSA) nerve block.
4. Greater (anterior) palatine nerve.
5. Nasopalatine nerve block.
6. Maxillary nerve block.
Local infiltration
 Maxillary labial and buccal infiltration
• Other names: Supraperiosteal injection
• Nerves anesthetized: small nerve endings in the region
• Areas anesthetized: pulps, bone and soft tissues supplied
by these terminal nerve endings.
• Indications: Dental or surgical procedure in the area of
injection
• Contraindications: Inflammation or infection in area of
injection
• Advantages:
High success rate.
Technically easy injection.
Atraumatic.
 Buccal Infiltration
•A 25-gauge (short) needle is used.
• The point of insertion of the needle is located by the
point of intersection of two imaginary lines.
First is a vertical line parallel to the long axis of the
tooth and dividing it into two equal halves.
Second is a horizontal line made by the mucobuccal
fold just above the apex of the root.
• The needle should be directed at 45 degree angle to
the plane of the outer cortical plate.
The needle is inserted through the mucous
membrane until it gently come in contact with the
periosteum with the bevel facing the bone.
Technique of labial infiltration
• 25-27 gauge short needle.
• Lift the lip pulling the tissues taut.
• Hold the syringe parallel to the long axis of the tooth.
• Orient needle so bevel faces bone.
• Insert the needle in the area at the height of mucobuccal
fold.
• Advance the needle until the bevel is at the apex. .(Target
area)
• Deposit o.6ml slowly. (don’t permit the tissues to
balloon).
• Slowly withdraw the needle.
• Wait for 3-5 min before starting the procedure.
PALATAL INFILTRATION
 Palatal infiltration
• Other names:
• Nerves anesthetized:
• Areas anesthetized:
• Indications:
• Contraindications:
• Advantages:
• Disadvantages:
• Positive aspiration:
• Signs and symptoms:
 Technique of palatal
infiltration
•The patient should be in the supine position with
the chin tilted upward.
•A 25- or 27-gauge short needle.
•The point of insertion of the needle is midway
between the cervical margin of the tooth and the
midline of the palate.
•Insert the needle at a 90 degree angle to the
injection site (it should be advanced from the
opposite side).
•Advance the needle until bone is contacted and
slowly deposit anesthetic solution.
 Technique of palatal infiltration
•The tissue is very firmly adherent to the underlying
periosteum in this region causing resistance to the
deposition of local anesthetic.
•No more than 0.2 to 0.4cc of anesthetic solution is
necessary to provide adequate palatal anesthesia.
• Blanching of the tissue at the injection site
immediately follows deposition of local anesthetic.
• NB. Injection of large amount of the solution may
cause sloughing and ulceration of the palatal
mucosa due to separation of a large area of the
dense palatal mucoperiosteum from the bone with
subsequent loss of its blood supply.
MANDIBULAR INFILTRATION
 Mandibular Anterior teeth

• Incisive nerve
• Lingual nerve
 The Infraorbital Nerve Block
• Other names:
• Nerves anesthetized:
• Areas anesthetized:
• Indications:
• Contraindications:
• Advantages:
• Disadvantages: Hematoma
• Positive aspiration:
• Alternatives:
• Signs and symptoms:
Target:
Point of insertion:
Depth of penetration:
The center of the inferior margin of the orbit is palpated
with the index finger, then gently passed 1cm below the
margin.
• The upper lip is lifted with the index.
• The needle is introduced into the buccal fold
directly over the first premolar.
• The needle is gently pushed forward near to the
bone towards the tip of the index finger.
• Aspiration is performed.
• About 1ml of solution is slowly injected.
PSA NB
 Posterior Superior Alveolar Nerve Block (PSA)
• Other names: Tuberosity, zygomatic
• Nerves anesthetized: PSA
• Areas anesthetized:
Pulps, bone and soft tissue
• Advantages:
Min injection and volume.
High success.
Atraumatic.
• Disadvantages:
Hematoma
No bony landmark.
Need for infiltration for first molar.
 Posterior Superior Alveolar Nerve
Block (PSA)
• Positive aspiration: 3%
• Signs and symptoms:
• Indications:
infiltration is contraindicated or ineffective
• Contraindications: great risk of hge.
• Target
Posterior Superior Alveolar Nerve Block (PSA)
Technique:
• A 25-gauge long needle is
recommended.
• The left index is moved over the
mucobuccal fold in a posterior direction
from the premolar region till it reaches
the zygomatic process till it rests on a
concavity in the mucobuccal fold.
• The finger is rotated so that fingernail
faces medially. Then the finger is moved
to be at right angle to the maxillary
occlusal plane and at 45° angle to the
sagittal plane.
 Posterior Superior Alveolar Nerve Block
(PSA)
• The needle is inserted into the height
of mucobuccal fold over the second
molar in a line parallel to the finger.
• The needle is slowly advanced for
about 16 mm, to come close to the
posterior alveolar foramen.
• Aspiration should be done carefully to
avoid the pterygoid venous plexus.
• Slowly inject 0.9 to 1.8 ml of solution
over one minute.
 Posterior Superior Alveolar Nerve Block
(PSA)
Complications:
1. Hematoma formation.
2. Intravenous injection
Prevention:
1. The needle should never be inserted more than
2.5cm to avoid penetration and/or injection of
the pterygoid venous plexus.
2. Aspiration before injection.
 Nasopalatine nerve block
• Other names: Incisive, Sphenopalatine NB
• Nerves anesthetized:
NP bilaterally
• Areas anesthetized:
ant 2/3 of hard palat
• Advantages: less Insertion and volume
• Disadvantages: most traumatic
• Positive aspiration: less than 1%
• Signs and symptoms:
• Indications: palatal soft tissue anesthesia
• Contraindications: inflammation, smaller area of
therapy.
 Greater palatine nerve block
• Other names:
• Nerves anesthetized:
• Areas anesthetized:
• Advantages:
• Disadvantages:
• Positive aspiration:
• Signs and symptoms:
• Indications:
• Contraindications:
 Technique
To anaesthetize the palatal gingiva
and mucosa in the premolar/molar
region, insert the needle 0.5-1 cm
above the gingival margin between
second and third molars and at
right angles to the mucosa.
When the needle reaches bone
withdraw it 1mm and inject about
o.1 ml. slowly.
 Maxillary nerve Block V2
• Other names: Second division block, high tuberosity
• Nerves anesthetized: Maxillary nerve with all its branches
• Areas anesthetized: Pulps, bone, soft tissue, skin
• Advantages: Atraumatic, high success, less number of
insertion and volume of LA.
• Disadvantages: Risk of hematoma, no bony landmarks.
• Positive aspiration:
• Signs and symptoms:
• Indications:
Pain control before extensive surgery.
Diagnostic or theraputic.
When infection prevent other techs.
• Contraindications: risk of hge. Infection, inexperienced
operator, children.
 The mandibular nerve
• Injections can be used to block the following nerves:
• Inferior alveolar nerve.
• Lingual nerve.
• Mental and incisive nerves.
• Long buccal nerve
• Mylohyoid nerve.
• Other techniques:
• Gow-Gates Tech.
• Vazirani-Akinosi Tech.
 Mental Nerve Block
The mental foramen lies at the
level of and just anterior to the
apex of the second premolar.
The opening of the foramen is
directed posteriorly.
 Mental Nerve Block
• Nerves anesthetized: Mental and incisive nerves.
• Areas anesthetized: Buccal mm. anterior to the mental
foramen to the midline, lower lip, skin of the chin,
mandibular anterior and premolar teeth pulps and
investing structures.
• Indications:
1. When buccal soft tissue anesthesia is required for
surgery in the area.
2. Dental procedures requiring pulpal anesthesia on
mandibular teeth anterior to the foramen.
3. Extraction of anterior or premolar mandibular teeth.
• Contraindications: Infection or acute inflammation in
the site of injection.
 Mental Nerve Block
• Advantages:
1. High success rate.
2. Technically easy.
3. Provide pulpal and buccal soft tissue anesth. Without
lingual anesth( which is uncomfortable to the patients,
particularly when bilateral anesthesia is required.)
• Disadvantages:
1. Hematoma.
2. Partial anesth at the mid line.
3. Need for more injections for the lingual nerve.
• Positive aspiration: 5 %
• Alternatives:
 Technique
• Assume the correct position.
• Locate the mental foramen.
• 27 gauge short needle.
• Target area: Mental foramen where the
mental nerve exits and the incisive
nerve is located.
• Land marks: Mandibular premolar and
mucobuccal fold
• Area of insertion: mucobuccal fold at or
just anterior to the mental foramen.
 Technique
• The cheek is retracted and the
patient is asked to half close his
mouth.
• -The needle is then directed in 45°
angle to the buccal cortical plate.
• Penetrate the mm canine or first
premolar directing the syringe
toward the mental foramen.
• Advance the needle slowly untill the
foramen is reached (depth 5-6mm).
Slowly deposit 0.6ml.
 Mental Nerve Block
• Signs and symptoms:
• Sub: Tingling or numbness of the lower lip.
• Obj: No pain during dental therapy.
• Safety features: Safe region.
• Failure:
1. Inadequate volume of soln leads to lack of
pulpal anesthesia.
2. Inadequate duration of pressure after injection
leads to inadequate anesthesia of the second
premolar.
INFERIOR ALVEOLAR NERVE BLOCK

IANB
 IANB
• Other common names: Mandibular Nerve Block
• Nerves anesthetized: IAN, incisive, mental,
commonly lingual.
• Areas anesthetized:
1. All mandibular teeth to the midline.
2. Body of the mandible and inferior part of the
ramus.
3. Buccal mucoperiosteum and underlying tissues
anterior to the mandibular first molar.
4. Anterior two thirds of the tongue and floor of the
oral cavity.
5. Lingual soft tissue and periosteum.
 IANB
• Indications:
1.Procedures on multiple mandibular teeth in one side.
2.Surgery in all mandibular teeth and its supporting
structures anterior to the lower first molar.
3.Surgery in all mandibular teeth and its supporting
structures post, to the lower second premolar when
supplemented with lingual and long buccal nerve
blocks.
• Contraindications:
1. Infection in the area of injection.
2. Patient who might bite either the lip or tongue.
 IANB
• Advantages: One injection provides a wide area of
anesthesia.
• Disadvantages:
1. Wide area of anesthesia. Lingual and lower lip
anesthesia, discomforting to many patients.
2. Rate of inadequate anesthesia is 15-20%.
3. Intraoral landmarks not consistently reliable and it
may be difficult to see in some patients (e.g.,
macroglossia)
4. Area of injection is vascular (10 -15% chance of
positive aspiration).
5. Partial anesthesia caused by bifid canal.
 Technique
• A 25- gauge long needle.
• Target area: Inferior alveolar
nerve as it passes from the
mandibular foramen.
• Area of insertion: Mucous
membrane on the medial side
of the mandibular ramus, at
the intersection of 2 lines:
horizontal line (Height of
injection)
Vertical line (Antero posterior
plane)
• Land marks:
1. Coronoid notch.
2. Pterygomandibular raphe.
3. Occlusal plane of mandibular teeth.
• Height of injection.
• Anteroposterior site of injection.
• Penetration depth (20-25mm) 3/4 needle.
• Aspirate then Deposite 1.5cc slowly.
• Withdraw ½ the needle length and inject lingual
nerve.
 IANB
• Signs and symptoms:
Subjective:
Numbness of the lower lip.
Numbness of the tongue.
Objective: no pain during therapy.
• Safety features:
Do not deposit LA if bone is not contacted.
Do not contact bone too forcefully.
• Alternatives:
 IANB
Failures of anesthesia
1. Deposition of anesthesia too low (below the
foramen).
2. Deposition of anesthesia too far anteriorly on
the ramus.
3. Accessory innervations to the mandibular teeth
(mylohyoid n.).
4. Incomplete anesthesia of the central or lateral
incisors (cross (overlapping) or accessory
innervations).
 IANB
• Too high:
Errors
• Numbness of the ear.
• Deposition at the insertion of the lateral pterygoid
m. with soreness and trismus.
• Too low:
• Deposition at the insertion of the medial pterygoid
m. with soreness and trismus.
• Deposition at the parotid gland with possible
parotitis.
• Deposition in the posterior facial v. with possible
toxicity.
 IANB
Errors
• Too medial: pain during swallowing due to the
needle insertion in superior constrictor m. of the
pharynx.

• Too deep posterior:

• Deposition at the parotid gland with possible
temporary facial paralysis.
 IANB

1. Hematoma:
Complications
Swelling on the medial side of the ramus.
Pressure and cold application to the area.
2. Trismus:
Muscle soreness and limited movement.
Irritation of tissues by alcohol in soln, injection
intramuscular, Hemorrhage, Infection, multiple
penetrations.
3. Transient facial paralysis:
 Long buccal nerve block
• Other common names: Buccal, buccinator NB.
• Nerves anesthetized: Long buccal nerve.
• Areas anesthetized: Soft tissues and periosteum
buccal to the mandibular molar teeth.
• Indications: When buccal soft tissue anesth. Is
necessary for dental procedure in the mandibular
molar region.
• Contraindications: Acute inflammation or
infection in the area of injection.
 Long buccal nerve block
• Advantages: High success rate (100%).
• Disadvantages: Potential for pain.
• Positive aspiration: 0.7%
• Alternatives:
1. Buccal infiltration.
2. Gow-Gates NB.
3. Vazirani-Akinosi NB.
4. PDL injection.
 Technique
1.Correct position
2.25 gauge long needle.
3.Area of insertion: mm distal and buccal to the
most distal molar in the arch.
4.Target area: Buccal nerve as it passes over the
anterior border of the ramus.
5.Bevel should be oriented toward bone.
 Technique
• Prepare the tissues.
• The syringe should be aligned
parallel with the occlusal plane on
the side of injection but buccal to
the teeth.
• Penetrate the mm buccal and
distal to the last molar.
• Advance the needle until bone is
contacted (2-4mm).
 Technique
• Slowly deposit 0.3ml over 10
sec.
• If tissue at the injection site
balloons or if soln runs out the
injection site:
1.Stop the injection.
2.Advance the needle deeper.
3.Deposit slowly.
• Signs and symptoms: No pain on
probing
 Gow-Gates Mandibular Block
• Other common names: 3rd division nerve block, V3
NB.
• Nerves anesthetized: IAN, mental, incisive, lingual,
mylohyoid, auriculotemporal and long buccal
nerves
• Areas anesthetized:
1.Mandibular teeth with buccal and lingual
mucoperiosteum and body of the mandible till
midline.
2.Anterior 2/3 of the tongue.
3.Skin over the zygoma, cheek and temporal region
 Gow-Gates Mandibular Block
• Indications:
1. Multiple procedures on mandibular teeth.
2. When buccal or lingual soft tissue anesthesia, from
the 3rd molar till midline, is necessary.
3. When conventional IANB is unsuccessful.
• Contraindications:
1. Infection in the area of injection.
2. Patient who might bite either the lip or tongue.
3. Patients who are unable to open their mouth wide.
 Gow-Gates Mandibular Block
• Advantages:
1.Requires only one injection (Long buccal nerve
injection is not necessary and accessory
innervations is blocked).
2.High success rate with experience.
3.Few post injection complications (e.g., Trismus)
4.Fewer blood vessels at this level, therefore less
chance of positive aspiration (2% vs. 10%-15% for
IAN)
5.Provides successful anesthesia in case of bifid
mandibular canal.
 Gow-Gates Mandibular Block
• Disadvantages:
1.Wide area of anesthesia, discomforting to many
patients.
2.Longer time for onset of anesthesia (5min) due
to the size of the nerve trunk and the distance of
the nerve trunk from the deposition site.
3.Clinical experience is necessary for the success.
• Signs and symptoms:
• Subjective: Numbness of the lower lip and tongue.
• Objective: No pain during dental therapy.
• Safety features: Needle contacting bone.
• Failures:
• Too little volume
• Anatomical difficulties.
• Complications
1.Hematoma:
2.Trismus
3.Temporary paralysis of cranial nerves III, IV, and VI.
 Akinosi mandibular block
• Indications:
1. Limited mandibular opening due to trauma,
infection, postinjection trismus.
2. Multiple procedures on mandibular teeth.
3. Inability to visualize landmarks for IANB.
• Advantages
1. Not necessary to open widely.
2. Successful in case of bifid mandibular canal.
3. Relatively atraumatic.
4. Few complications.
5. Low positive aspiration rate.
 Akinosi Mandibular Block
Disadvantages
• Difficult to visualize the path of the needle and
the depth of insertion.
• No bony contact.
• Traumatic if needle hits periosteum.
Alternatives:
• No intraoral alternative in case of trismus.
• Extra oral technique.
 Akinosi Mandibular
Block
Target Area
Soft tissue medial to ramus.
Above foramen, below the condyle.
Failures of anesthesia
Lateral flaring of mandible
Insertion too low
Penetration too deep or shallow (adjust for
patient size)
Complications
Hematoma (<10%)
Facial nerve paralysis.
Trismus (rare)