Tec. regional anesth vijay

Techniques
of
Regional
anaesthesia
Presented by
Dr.R.VIJAYAKUMAR

Contents
 Introduction
 Evaluation of the patient
 Basic injection technique
 Infiltration techniques
 Field block and nerve block
 Nerve blocks for maxillary nerve subdivision
and its branches
 Nerve blocks for mandibular nerve
subdivision and its branches

Introduction
Anaesthesia :-
“an” means “with out;”
“aisthetos” means “sensation”
Local anaesthesia:-
 Loss of sensation in a circumscribed area of the body by a
depression of excitation of nerve endings or an inhibition of
conduction process in peripheral nerves without loss of
consciousness
Regional anaesthesia:-
 Loss of pain sensation as well as interruption of all other forms
of sensation including temperature, pressure and motor
functions over a specific area of the body.

Basic 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.
b. 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
11 a. Insert the needle into the mucosa.
b. 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.

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.

Classification of techniques of
regional anaesthesia

Surface or topical anaesthesia
 Indications
 Forms of surface anesthesia
1. Spray – 10% - 20% lignocaine HCl in water
base, ethyl chloride
2. Ointment – 5% lignocaine HCl
3. Emulsion – 2% lignocaine HCl
4. Jet injection – with hypodermic needle.

Infiltration techniques
 Nerves and areas anaesthetized
 Indications
 Contraindications
 Advantages
 Disadvantages
 Applications

Technique of Infiltration

 Needle: gauge 25, 27 or 30
 Length: 1" or 25 mm.
 Bevel of the needle: facing towards the
bone.
 Point of insertion: In the middle of the area
to be operated.
 Depth of penetration: Beneath the mucous
membrane into the connective tissue.

Types of Infiltration Anaesthesia
Conventional
1. Submucosal or subcutaneous anaesthesia
2. Paraperiosteal or supraperiosteal anaesthesia
3. Subperiosteal anaesthesia
4. Palatal infiltration

Supplementary
1. Intraligamentary (Periodontal ligament)
anaesthesia
2. Intrapulpal anaesthesia
3. Intraosseous anaesthesia
4. Intraseptal anaesthesia

Submucosal or subcutaneous
anaesthesia
Technique
 The solution is deposited in the immediate
submucosal tissue layers
 The solution diffuses through the interstitial
tissues and reaches the terminal fibres of the nerve
.
Procedure
 The needle is inserted beneath the mucosal layers.

 Excessive amounts injected superficially may lead
to sloughing of the overlying tissues.
 0.25-0.5 ml of the local anaesthetic solution is
deposited.

Paraperiosteal or supraperiosteal
anaesthesia

 Commonly used injection technique
for obtaining anesthesia in the region of all
maxillary teeth and mandibular anterior teeth.
 By this method the local anaesthetic solution is
deposited just above and besides the
periosteum.

anaesthesia

Dr. Nevin’s Technique

All maxillary incisors can be anaesthetized by
making the initial puncture over canine on
each side and passing the needle horizontally
towards central incisors infiltrating the apices
of individual teeth.

anaesthesia
 Advantages
 Disadvantages
 Nerves anaesthetized
 Areas Anaesthetised
 Indications

anaesthesia
Technique
Needle: 25 or 27 G short needle .
Point of insertion:
At the height of the mucobuccal fold .
Target area:
The apical region or above the apex of the
tooth to be anaesthetized.
Depth of insertion: Few millimeters.
Bevel: Should be facing towards the bone.

anaesthesia
Landmarks:
1. Mucobuccal fold in the region of the tooth to
be anaesthetized
2. Crown of the tooth
3. Root contour of the tooth

Procedure
 Position of the patient
 Position of the operator
 Preparation of the tissues

Subperiosteal anaesthesia
Technique
 Needle
Length is 1" and the gauge is 25.
 The needle is inserted midway between gingival
margin and the approximate apex of the tooth and at
right angle to the buccal alveolar plate.
 As the needle progresses, about 0.3-0.5 ml of local
anaesthetic solution is injected slowly.
 The periosteum will force the solution through the
cortical plate and into the cancellous bone.

Subperiosteal anaesthesia
 Advantages
1. More appropriate, more specific.
2. No great trauma
3. Safe
4. Less solution is required [0.3-0.5 ml]
5. The onset of action is rapid.

 Disadvantages

Supplementary Techniques
 Intraligamentary (Periodontal ligament)
anaesthesia
 Intrapulpal anaesthesia
 Intraosseous anaesthesia
 Intraseptal anaesthesia

Intraligamentary (Periodontal ligament)
anesthesia

 The name suggests, the local anaesthetic
solution is deposited into the periodontal
ligament or membrane.

 Advantages
 Disadvantages

Intraligamentary (Periodontal ligament)
anaesthesia
Technique
Needle: 25 gauge.
 The solution is injected along periodontal

membrane of teeth, usually 0.2 ml, delivered via a
specifically designed system which comprises of
high pressure syringes and ultrafine needles.
 This technique can anaesthetise only single

individual tooth

Intraligamentary (Periodontal
ligament) anaesthesia

Intrapulpal Anaesthesia
 Indication : for obtaining anaesthesia
which require direct instrumentation of the
pulp tissue.
 25 or 27G needle is inserted directly into
the pulp chamber. The needle should be
held firmly or wedged into the pulp
chamber or the root canal.

Intraosseous Injection Technique
 The local anaesthetic solution is deposited
directly into the cancellous bone adjacent to
the tooth to be anaesthetised, between the two
cortical plates of bone .
 Intraosseous injection is usually an adjunct,
and is used when conventional methods have
been Tried and failed.


Advantage:
It produces profound single tooth
anaesthesia.
Disadvantage:
Specialized equipment and technique is
needed.

Technique
 The soft tissues overlying the apex of the tooth are
first anaesthetised with Paraperiosteal injections.
 A small opening or perforation is made in the outer
cortical layer of bone with the help of round bur. The
drill is similar to 25 G needle.
 The solution is placed through outer cortical plate
into cancellous bone with the help of a needle, which
is inserted through the perforation.

Procedure
 Preliminary infiltration: In order to prevent
trauma, a few drops of infiltration is made
before making a perforation.
 Incision is made and mucoperiosteum is

elevated and buccal alveolar plate is
perforated with a round bur at an angle of 45°
to the long axis of the teeth directing palatally
or lingually.

 Drill the external plate until it reaches
cancellous bone. The drill should not enter
more than 2 or 3 mm.
 The needle is inserted into the opening
created; and 0.5-1 ml of solution is slowly
injected under pressure.
 Anaesthesia by this method will be of short
duration.

Precautions to be taken
 Deposition of too much solution rapidly may
produce signs and symptoms of toxic reactions
 it is easy to find the drill hole, and inject a small
amount of solution, if operation to be postponed to a
later date .
 Never attempt to anaesthetise more than one tooth on
each side of the drill opening. This requires too
much of local anaesthetic solution which may
produce toxic symptoms.
 In Mandible: make drill opening in the retromolar
triangle

Intra septal Anaesthesia
 A needle is forced gently into the porous
interseptal bone on either side of the tooth
under pressure into the cancellous bone.
 More effective in children and young adults.

 Indication
where the intraligamentary anaesthesia is not
quite effective.
 Technique (1)
The injection is given in the septum of two
adjoining teeth, in between the two cortical
plates..

 Technique (2)
 The needle is inserted into the opening made
and few drops of local anaesthetic solution are
injected slowly, under pressure.

Local Infiltration of the Palate
 Palatal injections are potentially painful.
 Informing the patient prior to injection about the pain
during the injection helps in preparing the patient
psychologically.

Precautions to be Taken
 Deposition of excessive solution causes blanching of
overlying soft tissues and results in necrosis.
 Highly concentrated vasoconstrictors in local
anaesthetic agents can lead to ischaemic necrosis and
sloughing of the soft tissues.

Measures to Reduce Discomfort
1. Provide adequate topical anaesthesia at the
site of injection.
2. Use pressure anaesthesia at the site before and
during needle insertion and the deposition of
the solution.
3. Maintain control over the needle
4. Deposit the local anaesthetic solution slowly.

 Nerves Anaesthetised
Terminal branches of greater palatine and
naso palatine nerves.
 Areas Anaesthetised

Soft tissues and bony hard palate in the vicinity of the
injection.
 Indications

Anaesthesia in a small area of injection
Haemostasis in the area of surgery.

Presence of acute inflammation or infection
Provides a small area of anaesthesia.

 Advantages
1. It provides good haemostasis if
vasoconstrictor is used along with the local
anaesthetic agent.
2. As it involves a small area of anaesthesia, it
gives minimum discomfort to the patient.
 Disadvantage
Potentially painful injection

Technique
 Needle: Usually 27 or 30 G needle, 25 G needle can
also be used.
 Point of insertion: In the mucoperiosteum on a line
1 cm from the gingival margin,
 Target area: Mucogingival tissues in the area of
injection
 Path of insertion: From the opposite side at an angle
of 45° to the palate.
 Bevel: Facing towards the palatal soft tissues and
bone

Procedure
 Position of the operator:
right-sided injections - in front of the patient
left-sided injection - side of the patient.
 Position of the patient: The occlusal plane of the
maxillary teeth is at 45° to the floor. The patient is
requested to keep his mouth wide open and the neck
extended.
 Preparation of the tissues: antiseptic and topical
anaesthetic solutions.


 Take a preloaded syringe, and insert the
needle at the point of insertion from the
opposite side at an angle of 45° to the bony
surface.
 Deposit about 0.25-0.5 ml of the solution in
the vicinity of the area to be anaesthetised.
Withdraw the needle slowly.
 Wait for a few minutes before the surgical or
the dental procedure.

Signs and Symptoms
 Numbness .

 Lack of pain with instrumentation.

 Absence of pain during the procedure.

Complications
 Sloughing and ischaemic necrosis

FIELD BLOCK
Anaesthetic solution is deposited in proximity to
the larger terminal nerve branches
Anaesthetic solution is deposited at or above the
apex of the tooth to be treated

FIELD BLOCK
Nerves anaesthetised:-
 Terminal nerve branches in the vicinity of the

area
Areas anaesthetised:
 The areas anaesthetised by the field block will

be larger and circumscribed.
 These areas include the pulps of the teeth and

the tissues distal to the site of injection

FIELD BLOCK
Indications
1. All maxillary teeth
2. Mandibular anterior teeth
Contraindications
1. Presence of infection or acute
inflammation
2. Mandibular posterior teeth due to thick and
dense bone

FIELD BLOCK
Technique
 The local anaesthetic solution is deposited near

the larger terminal nerve branches.

NERVE BLOCK OR
CONDUCTION ANAESTHESIA
 By this method, a nerve trunk is
blocked at some point between the
periphery and the brain, thereby
depriving the area of sensation
distal to the point where the nerve
is blocked.
 The local anaesthetic agent is
deposited close to a main nerve
trunk usually at a distance from
the site of surgical procedure.

NERVE BLOCK
 Methods:
(1) Intraoral
(2) Extraoral
 Nerve blocks for maxillary subdivision and its

branches
 Nerve blocks for mandibular subdivision and

its branches

Nerve blocks for maxillary
subdivision and its branches
a. Intraoral nerve blocks:
(i) Infraorbital nerve block,
(ii) Posterior superior alveolar nerve block,
(iii) Greater palatine nerve block.
(iv) Nasopalatine nerve block, and
(v) Maxillary nerve block,
b. Extraoral nerve blocks:
(i) Infraorbital nerve block, and
(ii) Maxillary nerve block.

Nerve blocks for mandibular
subdivision
a. Intraoral nerve blocks:
(i) Pterygomandibular nerve block- Direct and Indirect
techniques,
(ii) Lingual nerve block,
(iii) Long buccal nerve block,
(iv) Mental nerve block,
(v) Gow-Gates nerve block
(vi) Vazirani-Akinosi nerve block
b. Extraoral nerve blocks:
Mandibular nerve block.

NERVE BLOCK
Indications
1. Extensive oral and periodontal surgical
procedures.
2. Restorative procedures.
3. Extensive maxillofacial soft and hard tissue
procedures.
Contraindications
 Presence of acute inflammation or infection

NERVE BLOCK
Advantages
 1. Avoids multiple penetration of the needle.

 2. Avoids deposition of large volume of local

anaesthetic agent.
Disadvantages
 1. Larger area than required is anaesthetised.

 2. Additional local infiltration is required if

haemostasis is required at the site of surgery.

INJECTION TECHNIQUES FOR
MAXILLARY NERVE AND ITS
BRANCHES

 INFILTRATIONS
 NERVE BLOCKS

a. Intraoral blocks and
b. Extraoral blocks.

Infra orbital nerve block

Two approaches :
 the bicuspid and the central incisior.

Other names:
 Anterior superior alveolar nerve block.

Nerves anaesthetised
 Anterior superior alveolar nerve.

 Middle superior alveolar nerve.

 Infraorbital nerve

Areas anaesthetised
1. Maxillary central and lateral incisors, and canine
2. Maxillary premolars and mesiobuccal root of
first molar
3. Supporting alveolar bone and the labial or buccal
periodontium
4. Overlying labial or buccal mucoperiosteum.
5. Skin of lower eyelid and both surfaces of
conjunctiva, skin of lateral aspect of the nose,
and skin and mucosa of upper lip

Indications
1. Apicoectomies, alveolectomies of maxillary anterior regions,
impacted canines, and cysts.
2. Restorative and endodontic procedures involving more than
two maxillary teeth.
3. Presence of acute inflammation or infection
4. Presence of dense cortical bone that makes any infiltration
technique ineffective.

Contraindications
1. Discrete treatment areas (one or two teeth only).
2. When haemostasis in the area of surgery is desirable.

Advantages
1. Simple, easy and safe.
2. Minimise the volume of solution to be injected
and number of needle punctures
3. The incisor approach lessens possibility of
inadvertently entering orbit.
4. Permits deeper penetration into the
infraorbital canal.

Disadvantages
Bicuspid approach
Psychological : Fear of injury to the patient’s eye.
Anatomical : Difficulty in defining landmarks
Incisor approach
Higher chances of injuring the infraorbital
neurovascular bundle with deeper penetration into the
infraorbital canal.

Anatomical landmarks
Bicuspid approach:
(1) infraorbital margin,
(2) infraorbital depression,
(3) infraorbital foramen,
(4) first bicuspid,
(5) mucobuccal fold in the region of this tooth,
(6) pupil of the ipsilateral eye in the forward gaze,
(7) angle of the nose and
(8) mental foramen.


 Two approaches
cuspid and the central incisor.
 Nerves and areas anaesthetised, indications,
contraindications, advantages are same for
both the approaches.
 Other names: Anterior superior alveolar nerve
block.

Approaches:
 Bicuspid approach: This technique is

comparatively easy .
 The needle passes through the mucosa and

areolar tissue and during insertion should pass
beneath and lateral the facial artery and facial
vein.

Technique:
 Position of the patient: Maxillary occlusal plane is at an
angle of 45° to the floor.
 Position of the operator: For right-sided block- right side of
patient
For the left-sided block- in front of the patient
 Preparation of the tissues: with an antiseptic.

 Needle: Long and 25 gauge
 Bevel: facing the bone.
 Depth of penetration: ¾ th of an inch of the
needle penetrates the soft tissues
 Area of insertion: At the height of
mucobuccal fold in the region of first bicuspid.
 Target area: Infraorbital nerve as it comes
out of infraorbital foramen

Procedure
Palpation of the anatomical landmarks:
 Locate the infraorbital margin..

 Take a preloaded syringe, and insert the needle into the height

of the mucobuccal fold over the first bicuspid with the bevel
facing bone.
 Orient the syringe towards the infraorbital foramen.
 The needle should be held parallel to the long axis of the tooth

 Advance the needle until bone is gently contacted.

 Care should be taken to protect the eye with thumb/finger to

limit the Passage of the needle towards the eye

Central incisor approach:
 The needle passes through mucosa and areolar

tissue and beneath the levator labii superioris
(angular head of the quadratus labii superioris)
muscle. It then passes anterior to the origin of
levator anguli oris (caninus) muscle and
beneath the facial artery and facial vein.

 Technique
 • There are certain steps which are common to
both the approaches. such as position of the
patient, position of the operator, preparatior. of
the tissues, configuration of the needle, and
palpation of the anatomical landmarks; and are
mentioned with the bicuspid approach.

 • Area of insertion: In the central incisor approach, the
direction of the needle is such that it bisects the crown of
the ipsilateral cenfra incisor from the mesioincisal angle to
the distogingival angle. The area of insertion is at the height
of mucobuccal fold, or 4-5 mms away froir the labial cortex
of maxilla in the region of ipsilateral canine. The needle is
inserted about 5 mms from the mucobuccal fold in the
regior. of ipsilateral canine.
 • Target area: Infraorbital nerve as it comes out of
infraorbital foramen. between levator labii superioris muscle
above and levator anguli oils muscle below.

 Procedure
 Palpation of the anatomical landmarks. This is
done in the same way as for the bicuspid approach.
 In either approach the needle should not penetrate
more than 3/4th of an inch. Approximately, 1 ml of
solution is slowly deposited in the area and the thumb
is held in position until the injection is completed
 Wait for 3-5 minutes after completion of the injection
before commencing the dental procedure.

Signs and symptoms
a. Subjective: Tingling and numbness of the
lower eyelid, side of the nose and upper lip.
b. Objective:
1. Comparing the sensation produced with
tapping of anaesthetised and adjacent un
anaesthetised teeth with an instrument.
2. No pain during oral surgical or periodontal
surgical procedures or dental therapy.

Complications:
 1. Haematoma: May rarely develop.

 2. Paresis of face: It occurs when the injection

is given superficially, when the needle lies in
the vicinity of muscles of facial expression or
the nerves innervating them.

Failure to obtain anaesthesia
 Poor surgical technique :

i. Needle contacting bone below the infraorbital
foramen..
ii. Needle deviation medial or lateral to the
infraorbital foramen.
 Intravascular administration : Deposition of

the local anaesthetic solution into a vessel.

Anterior middle superior alveolar
nerve block
 This technique performed by the use of
CCLAD system
 This technique provides pulpal anesthesia on
multiple maxillary teeth (incisors, canine &
premolars ) from a single injection site.
Other common names:-
 Palatal approach AMSA nerve block

nerve block
Nerves anesthetized:-
 ASA
 MSA
 Sub mental dental plexus of the anterior middle
superior alveolar nerves.
Areas anesthetized:-
1. Pulpal anesthesia of maxillary incisors, canines &
premolars.
2. Buccal gingiva.
3. Attached palatal tissues from midline to free
gingival margin on the associated teeth.

nerve block
Indications:-
 Is easier to perform with a CCLAD system

 Procedures involving the maxillary teeth

 When a facial approach supra periosteal

injection has been ineffective .
Contraindications:-
 Patients with unusually thin palatal tissues.

 Procedures requiring more than 90 min.

nerve block
Advantages:-
1. Provides anesthesia of multiple maxillary
teeth with a single injection.
2. Minimize volume of anesthetic.
3. Eliminates the post operative inconvenience
of numbness to the upper lip & muscles of
facial expression.

nerve block
Disadvantages:-
 Requires a sloe administration time (0.5 ml/ min).

 Uncomfortable to patient & operator because of long

administration time.
 Need supplemental anesthetic for central & lateral incisors.

 Causes ischemia if administer too rapidly.

 Caution should be taken when performing this injection with

4% L.A.( prilocaine HCl, articaine HCl.).
 Use of local anesthesia containing with a concentration of

1:50000 is contraindicated.
 Positive aspiration is less than 5%.

nerve block
Technique:-
 27 G; Short needle or 30 G, extra short needle.

 Area of insertion is on the hard palate about half way

along an imaginary line connecting the mid palatal
suture to the free gingival margin.
 Location of line is at the contact point between the 1st

& 2nd premolars.
 Target area  palatal bone at injection site.

 Bevel  needle placed against the epithelium held at

45 degrees to the palate.

nerve block

nerve block
 Procedures:-
a. Position of the operator 9 or 10’o clock position.
b. Position of the patient  supine with slight hyper
extension of head & neck.
 Pre puncture technique:-
 Apply the bevel of needle towards palatal tissue,
place sterile cotton applicator on top of the needle
tip, apply light pressure on the cotton applicator to
create a ‘seal’ of the needle bevel.
 By using CCLAD system a slow rate of delivery of
the local anesthetic maintained.

nerve block
 An anesthetic pathway technique can be
utilized.
 Slowly advance the needle into the tissues.
 Rotating the needle allows the needle to
penetrate into the tissues more efficiently.
 Advance the needle slowly into the palatal
tissue until it contacts with bone. Then aspirate
and deliver anesthetic solution at a rate of 0.5
ml/min to the final dosage of 1.4 – 1.8 ml.

nerve block
Subjective symptoms:-
 Numbness of teeth & palatal tissues from the

central incisor to 2nd premolar.
Objective signs:-
 Blanching of the soft tissues extending from

central incisor to the premolar regoin.
 No pain during dental therapy.

nerve block
Failures of anesthesia:-
 May need supplemental anesthesia for
incisors
a. Adequate volume of L.A may not reach
dental branches
b. To correct, add more L.A or supplement in
proximity to these teeth from the palatal
approach.

nerve block
Complications:-
1. Palatal ulcer at injection site developing 1 –
2 days post operative.
2. Unexpected contact with the nasopalatine
nerve.
3. Density of injection site causing squirt back
of anesthetic & bitter taste.

Posterior Superior Alveolar Nerve
Block
Other names:
(i) Tuberosity block, (ii) Zygomatic
block.
 Nerves anaesthetised:

Posterior superior alveolar nerve
and ii branches.
 Areas anaesthetised

1. Pulps of maxillary third, second
and first molar (except the
mesiobuccal root).
2. Adjoining alveolar bone of these
teeth, buccal periodontium, and
buccal mucoperiosteum.

Block
Indications:
1. Oral surgical or periodontal surgical procedures in the area of
maxillary molars.
2. Restorative procedures involving two or more maxillary
molars.
3. When paraperiosteal injection is contraindicated as in the
presence of acute inflammation or infection.
4. When paraperiosteal injection has failed for any reason.
Contraindication:
When the risk of haemorrhage is high as in a Case of
haemophilic. In such cases, a paraperiosteal or intraligament
injection is recommended.

Block
Advantages
(1) Atraumatic
(2) High success rate
(3) Minimises the number penetrations required.
(4) Minimises the total volume of anaesthetic solution injected.
Disadvantages
(1) Risk of haematoma.
(2) Technique is somewhat arbitrary
(3) Second injection is required for anaesthetising the first molar.

Block
Technique:
 Needle :25 G short needle of 25 mm length.

 Bevel: should be facing the bone

 Point of Insertion: at the height of mucobuccal fold

in the region of the distal surface of maxillary second
molar.
 Depth of insertion: approximately 16 mms.

 Target area: The posterior superior alveolar nerve,

located posterosuperior and medial to maxillary
tuberosity.

Block
Anatomical landmarks:
 Mucobuccal fold in the region of maxillary
second molar
 Maxillary tuberosity

 Zygomatic process of maxilla or the buttress

of zygoma
 Infratemporal surface of maxilla

 Anterior border and coronoid process of the

ramus of the mandible

Block
Procedure
 Position of the patient: semi-supine position with
maxillary teeth occlusal plane at 45° to the floor
 Position of the operator
i. For right-sided injection - the side of the patient.
ii. For left-sided injection - in front of the patient.
 Preparation of the tissues: antiseptic,topical
anaesthetic.
 Partially open the patient’s mouth, pulling the
mandible to the side of injection and maxillary
occlusal plane at 45° to the floor.
 Retract the cheek, pulling the tissue taut.
 Palpation of the landmarks.

Block
 Technique I
 The prominence of the buttress of the zygoma is located
above the first molar. Pass the finger over the prominence and
it will dip superiorly in the sulcus posterior to the buttress..
 The point of the needle in this position should be located in the
depth of the sulcus, above the roots of the third molar, and
anterior to the maxillary tuberosity close to the lateral surface
of the maxilla.
 The needle is inserted into the tissue in a line parallel to the
index finger and bisecting the fingernail with the bevel of the
needle facing the bone.

Block
Technique II

 Insert the needle at the height of the mucobuccal fold, in the
region of maxillary second molar.
 Advance the needle slowly
Superiorly: At an angle of 45° to the occiusal plane.
Medially: At an angle of 45° to the sagittal plane.
Posteriorly: At an angle of 45° to the coronal plane.
 In an adult of normal size, penetration to a depth of 16 mms
will place the needle tip in the target area,
 Aspirate & deposit 0.5-1 ml of solution slowly.
 Withdraw Wait for 3-5 minutes and start the procedure..

Block
 Signs and symptoms:
 Subjective: It is difficult to determine the
extent of anaesthesia subjectively. Feeling of
numbness in the area of distribution of PSA
nerve.
 Objective: Absence of pain with
instrumentation and during procedure.

Block
Failure to achieve anaesthesia
Poor surgical technique
Intravascular administration:
Deposition of the local anaesthetic solution in
pterygoid plexus of veins.
Complications
 Haematoma: It is due to insertion of the needle too
far posteriorly into the pterygoid plexus of veins.
 Mandibular anaesthesia: Deposition of local
anaesthetic agent lateral to the desired location can
produce varying degrees of mandibular anaesthesia.

Nasopalatine Nerve Block
Incisive nerve block,
sphenopalatine nerve
block.
 It is a potentially painful
injection.
 Nerves anaesthetised:
Nasopalatine nerves bilaterally..
 Areas anaesthetised: Anterior
portion of the hard palate
(palatal mucosa) from the
mesial of the right canine/first
premolar to the mesial of the left
canine/first premolar

Indications
1 During oral surgical or periodontal procedures
involving palatal soft and hard tissues.
2. For any restorative procedure on more than
two teeth.
Contraindications
1. Presence of acute inflammation or infection .
2. Whenever there are smaller areas of dental or
surgical procedures (one or two teeth).

Advantages
 minimise mutiple needle penetrations &
reduces the volume of solution.
 minimises patient discomfort.
Disadvantages
 no haemostasis except in the immediate area
of injection.
 most painful intraoral injection.

• Maxillary central incisor teeth
• Incisive papilla in the midline of the palate
• Incisive foramen.
Technique
• Needle: 25 or 27G, length 1” or 25 cm.
• Area of penetration: The palatal mucosa or surrounding the
incisive papilla.
• Target area: The nasopalatine nerve as it comes out of incisive
foramen, beneath the incisive papilla.
• Path of insertion: Making an angle of 45° to the incisive
papilla, approaching from the side.
• Bevel: It is facing the palatal soft tissues or facing the palatal
bone.

Procedure
Preparatory injections: These make the entrance into
papilla less painful.
 a. Labial approach: The preparatory injection is
made by inserting the needle into the labial
intraseptal tissues in between the maxillary central
incisors. The needle is inserted at a right angle to the
labial plate and passed into the tissues until resistance
is felt. Then 0.25 ml of solution is deposited

 b. Palatal approach: The tip of the needle
should be placed in the halo or the depression
surrounding incisive papilla and a small
amount or a few drops of solution is injected
until papilla blanches

Signs and symptoms
(1) Numbness in the anterior portion of the palate.
(2) No pain during surgical procedures or dental
therapy.
Complications
1. Necrosis of soft tissues is possible when highly
concentrated vasoconstrictor solution is used for
haemostasis.
2. The solution may “squirt” back out of the needle,
because of the density of soft tissues

Greater Palatine Nerve Block
Other common names:
Anterior palatine nerve block.
Nerves anaesthetised: Greater
palatine nerve (anterior palatine
nerve)
Areas anaesthetised: The
posterior part of the hard palate
and its overlying soft tissues,
anteriorly as far as the
canine/first premolar and
medially upto the midline or the
median palatine raphe.

Indications
1. During oral surgical or periodontal procedures
involving the palatal soft and hard tissues.
2. For restorative therapy on more than two teeth.
Contraindications
1. Presence of acute inflammation or infection.
2. Smaller areas of surgical procedures or restorative
therapy (one or two teeth )

Advantages
 Minimises the volume of solution and the

number of needle penetrations.
 Simple & easy technique

 High success rate

Disadvantages
1. It is a potentially painful injection.
2. No haemostasis.


• Greater palatine foramen
• Maxillary second and third molars
• Palatal gingival margin of second
and third maxillary molars
• Median palatine raphe
• An area, approximately at a
distance of 1 cm from the palatal
gingival margin towards the
median palatine raphe.

Technique
• Needle: 25 or 27 G and 25 mm length.
• Point of insertion: Palatal soft tissues slightly anterior to the
greater palatine foramen.
• Target area: The greater palatine nerve as it comes out from
the greater palatine foramen, and passes anteriorly between the
palatal mucoperiosteum and the bone of the hard palate.
• Bevel of the needle: Facing the palatal soft tissues.
• Location of anatomical landmarks: Most frequently located
distal to the maxillary second molar about 1 cm from the
palatal gingival margin towards the midline.
• Path of insertion: The greater palatine foramen is approached
from the opposite side at right angle to the curvature of the
palatal bone.

Procedure
• The needle is inserted slowly until the palatal bone is
contacted.
• Aspirate & Deposit 0.25-0.5 m solution.
• The nerve may be blocked at any point along its
anterior course after emergence from the foramen.
Signs and symptoms
1. Numbness in the posterior portion of the palate.
2. No pain during surgical procedure.

Complications
1. Ischaemia and necrosis of soft tissues
2. Discomfort: If the soft palate becomes anaesthetised.
3. Haematoma: Is rare, as the palatal mucoperiosteum is
firmly adherent to the bone of the hard palate.
4. Failures to obtain anaesthesia
 Poor surgical technique:
 In the area of the maxillary first premolar there is
overlapping of fibres from the nasopalatine nerve.

Nerve Blocks for Maxillary Nerve

A. Intraoral maxillary nerve block
B. Extra oral maxillary nerve block.
Indications
 Extensive oral and periodontal surgical

procedures.
 Restorative procedures involving a quadrant

of maxilla.

lntraoral Nerve Blocks for Maxillary
Nerve

Approaches
 High tuberosity approach

 Greater palatine canal approach.

Intraoral Nerve Blocks for
Maxillary Nerve

Major difficulties
 The difficulty in locating the canal

 Higher incidence of haematoma in high

tuberosity approach

Maxillary Nerve
Nerves anaesthetised: Maxillary
division of trigeminal
nerve
 The pulps of all maxillary
teeth
 The bone of the hard palate,
and part of the soft palate,
maxillary sinus, and the
lateral wall of nasal cavity.
 Skin of the lower eyelid, side
of the nose, cheek and the
upper lip

Maxillary Nerve
Indications
 Control of pain
 When other nerve nerve blocks are contraindicated in presence
of infection
 Diagnostic and therapeutic procedures for trigeminal neuralgia
Contraindications.
 Child patients,uncooperative patients.
 Presence of acute inflammation or infection at the site of
injection
 Increased possibility of hemorrhage, especially in a
hemophilic.

Maxillary Nerve
 Advantages
 The high tuberosity approach is less painful.
 Success rate is high.
 It minimises the number of needle penetrations.
 It minimises the total volume of local anaesthetic
solution
 Disadvantages
 Increased risk of haematoma
 The high tuberosity approach is arbitrary
 Lack of haemostasis.
 The greater palatine approach is painful.

Intraoral nerve Blocks for Maxillary
Nerve
TECHNIQUE
High tuberosity approach
 Needle: 25 G, length 1 5/8 of an inch or 40-42 mms.

 Bevel : facing the bone.

 Point of insertion: at the height of mucobuccal fold

above the distal aspect of maxillary second molar
tooth
 Depth of insertion: 1 ¼” of an inch

 Target area: It is the maxillary nerve as it passes

through the pterygopalatine fossa.

Intraoral nerve Blocks for Maxillary
Nerve
 Maxillary second molar

tooth.
 Height of mucobuccal

fold above the distal
aspect of the crown of
maxillary second molar
tooth.
 Maxillary tuberosity.

 Zygomatic process of

maxilla or buttress of the
zygoma

Maxillary Nerve
Procedure
• Marking the length of the needle: To be inserted in
the soft tissues (about 30 mm).
• Position of the patient: Supine or semisupine
• Position of the operator:
For the right-sided block- side of the patient
For the left-sided block- in front of the patient.
• Preparation of the tissues: by application of topical
antiseptic and topical anaesthetic agents.

Maxillary Nerve
 Retract the cheek & needle is placed in the soft
tissues at the height of mucobuccal fold above the
distal aspect of maxillary second molar tooth.
 Advance the needle slowly in a superior, medial, and
posterior direction to a depth of 30 mm.
 At this depth the tip of the needle lies in
pterygopalatine fossa in the proximity to the
maxillary division of trigeminal nerve.

Maxillary Nerve
Greater palatine canal approach
• Location of greater palatine foramen.
• Needle: 25 G ,length is 1 5/8” or 40-42 mms.
• Bevel of the needle: facing the palatal soft tissues
• Point of insertion: The palatal soft tissues directly over the
greater palatine foramen.
• Palpation of the area of insertion: Needle is inserted into
palatal mucosa in a posterolateral direction at a level of distal
half of maxillary I molar.
• Target area: The maxillary nerve as it passes through the
pterygopalatine fossa. The needle passes through the greater
palatine canal to reach pterygopalatine fossa.

Maxillary Nerve
Anatomical landmarks:
 Greater palatine

foramen
 Maxillary second

molar tooth
 Palatal gingival

margin in the area of
this tooth
 Median palatine

raphe.

Maxillary Nerve
Procedure
 Length : mark the length of the needle (30-35 mm)

 Position of the patient : the occlusal plane of
maxilary teeth should be at an angle of 45° to the
floor.
 Position of the operator :

For right sided block – in front of the patient
For left sided block – side of the patient
 Mouth : wide open & neck extended

 Location of the foramen : at the distal aspect of
palatal root of maxillary 2 nd molar

Maxillary Nerve
 Preparation of the tissues : By application of topical
antiseptic and topical anaesthetic agents
 Insertion of the needle : From the opposite side at an
angle of 45° to the palatal bone posteriorly, and enter
the greater palatine foramen.
 Bevel: Against the soft tissues over the foramen.
 Penetrate the needle into the mucosa. Deposit a small
volume of solution.

Maxillary Nerve
 Advance the needle slowly into the greater palatine
canal to a depth of 30-35 mm.. If resistance is felt,
withdraw the needle slightly and change the angle
slightly and advance it further into the canal.
 Aspirate and deposit about 1 ml of solution slowly..
 Withdraw the needle slowly
 Wait for 3-5 minutes and commence with the surgical
or the dental procedure.

Maxillary Nerve
Signs and symptoms
1. Numbness of lower eyelid, side of the nose, and
upper lip.
2. Numbness in the teeth, buccal and palatal soft tissues
3. Absence of pain during the procedure.
Precautions
1. Overinsertion of the needle: It is less likely with
greater palatine canal approach and more likely with
high tuberosity approach.
2. Resistance to insertion of the needle: It is found in
the greater palatine canal approach.

Maxillary Nerve
Failures of anaesthesia
1. Partial anaesthesia:
due to under penetration of the needle..
2. Inability to negotiate the greater palatine canal.
In the presence of obstruction in the canal, it is
advisable to try with tuberosity approach.
The greater palatine canal approach is successful
if the needle is penetrated atleast 2/3rd of its length
into the canal.

Maxillary Nerve
Complications
1. Haematoma: It occurs due to the injury to the
maxillary artery & injury to the pterygoid plexus of
veins, via the tuberosity approach
2. Penetration of orbit: Rare. It may occur in patients
with small sized skulls.
3. Penetration of the nasal cavity: The needle may
penetrate the thin medial wall of the pterygopalatine
fossa and thus the needle enters the nasal cavity

Extraoral Nerve Blocks for
Maxillary Nerve
Indications
1. Wounds sustained due to accidents
2. Swellings of head and neck etc
3. Presence of trismus due to various reasons
Extraoral injections
i. Are not difficult than intraoral injections
ii. The technique can be mastered easily
iii. Have easier accessibility
iv. Have easier achievement of asepsis
v. Larger areas can be anaesthetised.

Extraoral Nerve Blocks for
Maxillary Nerve
Infraorbital Nerve Block
 The nerves and the areas anaesthetised are the
same as that for the intra oral technique.
Indications
 1. When the anterior and middle posterior

superior alveolar nerve are to be anaesthetised;
and the intraoral approach is not possible n
 2. When the intraoral methods are ineffective

(1) Infraorbital margin
(2) Infraorbital depression
(3) Infraorbital foramen
(4) Pupil of the ipsilateral eye.

Technique
• Preparation of skin: with an antiseptic.
• Location of the infraorbital foramen: With the help
of the anatomical landmarks
• Anaesthesia of the skin and the subcutaneous
tissue: achieved by deposition of a few drops of
solution below the skin.
• Needle: Long or short 25 G.

Procedure
 Skin and subcutaneous tissues are anaesthetised by local
infiltration
 The needle is inserted at an angle of about 45° through the
skin medially and inferiorly to the foramen
 The opening of the foramen is located and the needle is
directed slightly upward and laterally to facilitate its entry into
the foramen.
 Incisors and canine are most easily anaesthetised, as solution
is injected close to anterior superior alveolar nerves.
 Carefully aspirate and slowly deposit 1 ml of solution.
 Withdraw the needle slowly, wait for about 10 minutes, and
begin with the procedure.

Advantages:
More precise
Relations
 The needle passes through the following structures -
Skin, subcutaneous tissue, and quadratus labii superioris
muscle.
 When the needle is in final position the important structures in
the vicinity of the tip of the needle are -
Facial artery and facial vein.
 When the tip of the needle is in the canal, it is very close to
the infraorbital nerve and vessels.

Care should be taken
(1) to advance slowly,
(2) to aspirate as needle is advanced,
(3) t ensure that needle remains in the confines
of the canal,
(4) aspiration and deposit 1-2 ml of the
solution.

Signs and symptoms
a. Subjective:
Tingling and numbness of the lower eyelid, side
of the nose and upper lip.
b. Objective:
(1) Demonstration of absence of pain with
instrumentation
(2) No pain during the surgical procedure or
the dental therapy

Maxillary Nerve Block
 Anterior temporal and  hard palate,
zygomatic regions,  part of soft palate
 lower eyelid,  tonsils,
 side of the nose,  part of the pharynx,
 upper lip,  nasal septum ,
 maxillary teeth,  floor of the nose and
 maxillary alveolar mucosa of the posterior
bone, lateral part of the lateral
wall of the nose

Anatomical
landmarks
• Midpoint of
zygomatic arch
• Zygomatic notch
• Coronoid process of
the ramus of the
mandible
• Lateral pterygoid
plate

Indications
1. Where anaesthesia of the entire distribution of the
maxillary nerve is required for extensive surgery.
2. When it is desirable to block all the subdivisions of
the maxillary nerve with only one needle insertion;
and with a minimum of solution.
3. When local infection, trauma, etc make nerve blocks
of terminal branches ineffective

Technique.
• Palpation of the landmarks: The midpoint of the zygomatic
arch is located and the depression in its inferior surface is
marked. The coronoid process of the ramus of the mandible is
located by opening and closing the lower jaw.
• Needle: 25G, a skin wheal is raised just below this mark in the
depression.
• Mark the needle: 4” (8.8 cm), 22 G needle attached to a
leuerlock type of syringe, the operator measures 4.5 cm and
marks with a rubber marker
Insertion of the needle: through the skin wheal, perpendicular
to the skin surface and to the median sagittal plane.
Withdraw & aspirate, 1-2 ml of solution is slowly injected.

Relations
 The needle passes through the following structures:
skin, subcutaneous tissue,masseter muscle,
sigmoid notch, and lateral pterygoid muscle.
 When the needle is in contact with the lateral
pterygoid plate the structures in its vicinity:
Superiorly - the base of the skull.
Inferiorly – crosses internal maxillary artery
Superficially – transverse facial artery
Posteriorly – mandibular nerve & middle
meningeal artery
Anteriorly – pterygomaxillary fissure

Signs and symptoms
1. Subjective symptoms: Tingling and
numbness of upper lip, side of the nose, lower
eyelid, and in some instances anaesthesia of
soft palate and pharynx, with gagging
sensation.
2. Objective symptoms: Absence of pain
sensation with instrumentation

Injection Techniques for
Mandibular Nerve and its Branches

Injection Techniques for
Mandibular Nerve and its branches
1. Infiltration techniques.
2. Nerve blocks:
Intra oral  Inferior alveolar nerve block
Gow-gates mandibular nerve block
Akinosi mandibular nerve block
Extra oral nerve blocks.

INTRAORAL NERVE BLOCKS

Inferior alveolar nerve block
 Mandibular nerve block /

 Pterygomandibular Block/

 Fischer 1,2,3 technique/

 3 positional technique

Nerves Anaesthetised
a. Inferior alveolar nerve, along with its terminal
branches such as incisive nerve and mental
nerve
b. Lingual nerve ( commonly ).

Areas anaesthetised
1. Inferior alveolar nerve:-

 Pulps of all mandibular teeth till the
midline
 Body of the mandible
 Inferior portion of the ramus of the
mandible
 Buccal muco periosteum, in the region
of mandibular anteriors, anterior to
mandibular second premolar or anterior
to the mental foramen
 Skin of the chin, skin of lower lip, and
mucosa of lower lip

2. Lingual nerve:-
 Mucosa of anterior 2/3 of tongue.

 Mucosa of floor of the oral cavity.

 Lingual muco periosteum from the last molar tooth to
central incisor in the midline.
 Sub lingual salivary gland.

Indications:-
 Surgical procedures in the mandibular teeth in one

quadrant
 when buccal anesthesia in the region posterior to

mandibular 2nd premolar is required.
 When lingual soft tissue anesthesia is required.

 Restorative procedures in mandibular 2nd premolar&

molars.
Contra indications:-
 Presence of acute inflammation or infection (rarely).

 In young children or mentally challenged patients as

they may bite their lip or tongue.

Anatomical land marks:-
 Muco buccal fold in the region of premolars and molars

 Anterior border of ramus of the mandible

 External oblique ridge

 Coronoid process

 Coronoid notch

 Retro molar triangle or fossa

 Internal oblique ridge

 Pterygo mandibular raphae

 Pterygo mandibular space

 Occulasal plane of mandibular molars

 Contralateral premolars

 Buccal pad of fat

Approximating structures when needle is in the final position:-
Superior to the following
 Inferior alveolar vessels

 Inferior alveolar nerve

 Insertion of Medial pterygoid muscle

 Mylohyoid vessels, nerve

Anterior to the deeper lobe of parotid gland
Medial to the inner surface of the ramus of the mandible.
Lateral to the following:
 Lingual nerve

 Medial pterygoid muscle,

 Sphenomandibular ligament

Classical Inferior alveolar nerve
block
Technique:-
 Body of the mandible should be parallel to the ground.
Operator stands at 7 o’ clock position.
 With left index finger or thumb palpate the mucobuccal
fold.
 Then finger passed posteriorly to palpate external
oblique ridge & anterior border of the ramus.
 Identify the greatest depth of ramus of the mandible by
moving finger up & down i.e coronoid notch, it is in a
direct line with mandibular sulcus.
 Then finger is moved lingually across the
Retromandibular triangle & on to the internal oblique
ridge.

block
 The finger is moved to the buccal side taking with it the
buccal pad of fat. This gives better exposure to the
pterygomandibular raphae & pterygomandibular
depression.
 When palpating the intra oral land marks the operator
may place the index finger extra orally behind the
ramus of the mandible to asses the width of ramus of
mandible.
 With 25 G & 1 5/8 inch needle if inserted parallel to
Occlusal plane of mandibular teeth from opposite of
mouth at a level of bisecting the finger penetrating the
tissues of the pterygotemporal depression, & entering
the pterymandibular space.

block
 During insertion of the needle patient is asked to kept
his mouth wide open. The needle is penetrated into the
tissues until gently contacting bone on the internal
surface of ramus.
 This should be in the area of mandibular sulcus which
funnels into the mandibular foramen.
 The needle is then withdrawn about 1 mm & 1 – 1.8 ml
of solution deposited slowly ( 1 ½ – 2 min).
 The needle is now withdrawn slowly about one half of
its inserted depth, reminder of the solution is injected in
this area to anaesthetize lingual nerve.

block

Ianb.mov

Modified Inferior alveolar nerve
block

modification of ianb.mov

Fischer 1,2,3 positoinal Technique:-
1. Direct technique
2. Indirect technique
Direct technique:-
 Carried in 3 positions
 1st position—the direction is from the opposite side
—for inferior alveolar nerve
 2nd position—the direction is from the same side—
for lingual nerve.
 3rd position—the direction is from the opposite
side—to inject between the external and internal
oblique ridges—for long buccal nerve.


DIRECT TECHNIQUE

Indirect technique:
 1st position—the direction is from the opposite

side—to inject between the external and
internal oblique ridges—for long buccal nerve.
 2nd position—the direction is from the same

side—for lingual nerve.
 3rd position—the direction is from the

opposite side—for inferior alveolar nerve


INDIRECT TECHNIQUE

Signs & symptoms:-
 Tingling & numbness of the lower lip

 Tingling & numbness of half of the tongue

 Abscence of pain during surgical procedures.

FAILURES OF ANESTHESIA
 Deposition of solution

below the level of mandibular foramen
too far anteriorly on the ramus.
 Accessory innervation in the mandibular teeth

 Cross innervation of mandibular central

incisors due to contra lateral inferior alveolar
nerve innervation.

 COMPLICATIONS:-
 (i) Haematoma
 (ii) Trismus
 (iii) Transient facial paresis

Advantages:-
 One injection provides a wide area of

anaesthesia
Disadvantages:-
 Wide area of anaesthesia

 Positive aspiration( 10%-15%)

 Lingual & Lower lip anaesthesia

Long buccal nerve block
 The long buccal nerve is usually anesthetised
as a part of pterygomandibular nerve block in
indirect technique.
 Other Common Names

 Buccinator nerve block, Buccal nerve block.

 Long buccal branch of the mandibular nerve.

Areas Anaesthetised
 Mucoperiosteum buccal to the mandibular

molar teeth, vestibular mucosa and adjacent
part of buccal mucosa.

Indications
 When anaesthesia of buccal soft tissues in the
mandibular molar region is required
Contraindications:-
 Presence of inflammation or infection
 Advantages:-
 High success rate, and Technically easy.

Disadvantages:-
 It is a potentially painful injection.
 Positive aspiration rate is 0.5%

 Ascending ramus of the mandible

 External oblique ridge

 Retromolar triangle

 Internal oblique ridge

 Last molar tooth.

Technique:-
• Area of insertion: It is the area of mucous membrane
distal and buccal to the most distal tooth or the last
molar tooth.
 Target area: The long buccal nerve as it crosses the

anterior border of the ramus.
 Needle: A 1 inch 25 gauge needle is inserted into the

mucosa just distal and buccal to the last molar tooth
between the external and internal oblique ridges, and
0.25 to 0.5 ml of solution is deposited in this area.

Alternative techniques:-
 1. Insert the needle and deposit the solution directly into the
retrornolar triangle.
 2. Insert the needle in the mucoperiosteum just buccal to the
last molar tooth.
Signs and Symptoms
 i. The patient rarely experiences any subjective symptoms:
 ii. Lack of demonstration of pain with instrumentation in the
anaesthetised area
Complications:-
 Haematoma

Mental Nerve Block and Incisive
Nerve Block
Nerve Anaesthetised
 The terminal branches of inferior
alveolar nerve:
 (i) mental nene and incisive nerve.
Areas Anaesthetised
 1. Labial mucous membrane anterior to
the mental foramen, usually from the
first premolar up to the midline.
 2. Skin of the lower lip and chin.
 3. Pulpal nerve fibres of the first
premolars, canines and incisors.
 4. The periodontium and the supporting
alveolar bone of these teeth.

Nerve Block
Indications
 1. Dental restorative procedures requiring pulpal
anaesthesia of mandibular anterior teeth.
 2. When inferior alveolar nerve block is not indicated
 3. When buccal soft tissue anaesthesia is required for
procedures in the mandible anterior to the mental
foramen (i) soft tissue biopsies. and
(ii) suturing of soft tissues.
Contraindications
 Presence of acute inflammation or infection in the
area of injection.

Nerve Block
Advantages
 i. High success rate.
 ii. Technically easy.
 iii. Usually entirely a traumatic.
 iv. Produces pulpal anaesthesia, as well as soft and hard tissue
anaesthesia without lingual anaesthesia. It is useful in stead of
bilateral inferior alveolar nerve blocks.
Disadvantages
 1. It does not produce lingual anaesthesia
 2. Partial anaesthesia may develop at the midline because the
nerve fibres overlap with those of the opposite side.
 Positive aspiration 5.7%

Nerve Block
Anatomical Landmarks
 Mandibular bicuspids; since the mental foramen usually lies
below the apex of the second bicuspid or below and between
the apices of first and second bicuspids.
Technique
 The apices of the bicuspid teeth should be estimated.
 A 1 inch, 25 gauge needle is inserted into the mucobuccal fold
after the cheek has been pulled laterally.
 The tissue is penetrated until the periosteum of the mandible
is gently contacted slightly anterior to the apex of the second
bicuspid.
 About 0.5 to 1 ml of local anaesthetic solution is deposited in
the area

Nerve Block

Nerve Block
Signs and Symptoms
 i. Tingling or numbness of the lower lip.
 ii. Lack of pain during the surgical or dental restorative
procedure.
Failure of Anaesthesia
 1. Inadequate volume of anaesthetic solution in the mental
foramen, with subsequent lack of pulpal anaesthesia.
 2. Inadequate diffusion of the solution into the mental
foramen. To correct this, apply firm pressure over the injection
site for 2 minutes in order to force anaesthetic solution into the
mental foramen.
 Complications
 Complications are rare, with rare occurrence of haematoma.

Nerves anaesthetised:
The entire mandibular branch of trigeminal nerve is
anaesthetised
(i) inferior alveolar nerve along with its terminal
branches; mental and incisive nerves
(ii) lingual
(iii) mylohyoid
(iv) auriculotemporal, and
(v) long buccal nerves

Areas anaesthetised
 (1) All mandibular teeth up to the midline on the side of
injection
 (2) Buccal mucoperiosteum on the side of injection
 (3) Mucosa of the anterior 2/3rds of the tongue and floor of
the mouth
 (4) Lingual mucoperiosteum from the last standing molar
tooth up to the central incisor in the midline
 (5) Body of the mandible, and inferior portion of the ramus,
 (6) Skin over the zygoma, posterior portion of the cheek and
temporal regions

Indications
 1. Surgical procedures on mandibular body and the ramus.
 2. When buccal soft tissue anaesthesia from the third molar up
to the midline is required.
 3. Surgical procedures in the tongue and the floor of the
mouth.
 4. When conventional inferior alveolar nerve blocks are
unsuccessful.
 5. Restorative procedures on multiple teeth.
Contraindications
 1. Presence of infection or acute inflammation in the area of
injection,
 2. Patients who might bite either their lip or the tongue, such
as young children and mentally challenged adults.

a. Extraoral landmarks
• External ear
• Intertragic notch of the ear
• Corner of the mouth
b. Intraoral landmarks
• Anterior border of the ramus of the mandible
• Tendon of temporalis muscle
• Mesiopalatal cusp of maxillary second molar

Technique
 Target area: Lateral side of the condylar neck,
just below the insertion of the lateral pterygoid
muscle.
Procedure
 • Position of the patient: semi-supine position
 • Position of the operator:
in front of the patient- for right-sided block
by the side of the patient for left-sided
block

Identification of the
land marks:-
an imaginary line
drawn from the corner
of mouth to the inter
tragic notch of the ear

Needle  25 G ;Length
40 mm

gow gate.mov

gow gates-conti.mov


• Signs and Symptoms
 1. Numbness or tingling sensation of the lower
lip.
 2. Numbness or tingling sensation of the
tongue.
 3. No pain felt during surgical procedure.

Complications:-
 Haematoma
 Trismus
 Temporary paralysis of cranial nerves II, IV, VI.
Failure of anaesthesia:
a. Too little volume of local anaesthetic solution is
deposited.
b. Anatomical difficulties.

Akinosi (Closed Mouth) Mandibular
Nerve Block
Described by Joseph Akinosi in 1977.
The entire mandibular branch of trigeminal nerve is
anaesthetised, except the long buccal nerve.
Areas Anaesthetised
• All mandibular teeth on the side of injection up to the midline.
• Body of the mandible and inferior portion of the ramus.
• Buccal mucoperiosteum and mucous membrane in front of the
mental foramen.
• Mucous membrane of the anterior 2/3rds of the tongue and floor
of the oral cavity.
• Lingual soft tissues and periosteum.

Akinosi Mandibular Nerve Block
Indications
1. Limited mandibular opening.
2. Multiple procedures on mandibular teeth.
3. Inability to visualise the landmarks for inferior
alveolar nerve block
Contraindications
1. Presence of acute inflammation or infection in the
area of injection
2. Patients who might bite their lip or tongue, such as
young children an I mentally challenged adults.
3. Inability to visualise or gain access to the lingual
aspect of the ramus

Advantages
1. Relatively atraumatic.
2. Patient need not be able to open mouth.
3. Minimal post operative complications.
4.Lower aspiration rate than with IAN block
5. Provides successful anaesthesia where a bifid inferior alveolar
nerve and bifid mandibular canals are present.
Disadvantages
1. Difficult to visualise the path of the needle and the depth of
insertion.
2. No bony contact, so the depth of penetration is somewhat
arbitrary.
3. Potentially painful if the needle is too close to periosteum

 1. Occlusal plane of teeth in occlusion.

 2. Mucogingival junction of maxillary molar

teeth.
 3. Anterior border of ramus of the mandible.

 4. Maxillary tuberosity.

Technique
 • Needle: 25G, length 1 5/8” or 40-42 mm
 • Bevel: facing away from the bone of mandibular
ramus and towards the midline.
 • Height of injection: With Akinosi’s technique it is
below that of Gow-Gates’ technique but above that of
inferior alveolar nerve block.
 • Target area: The soft tissues on the medial border of
ramus of the mandible in the region of inferior
alveolar nerve, lingual nerve, and mylohyoid nerves
and vessels.

Procedure
 • Position of the patient: The patient is seated in semi
reclining position with head, neck and shoulder
adequately supported.
 • Position of the operator: The operator stands in front
of the patient for both right-sided as well as left-sided
block.
 • Preparation of the tissues: The site of penetration is
prepared by topical application of antiseptic and
anaesthetic solutions.
 • The patient is asked to bring teeth in occlusion


Akhinosi.mov

Signs and Symptoms
1. Numbness or tingling sensation of the lower lip.
2. Numbness or tingling sensation of the tongue.
3. No pain felt during surgical procedure.
Complicatlons:-
I. Haematoma
2. Trismus,
3. Transient facial nerve paresis due to over insertion of
the needle and deposition of the solution into the
body of the parotid gland.

Failure of Anaesthesia
 1. Failure to appreciate the flaring nature of the ramus
which deflects the needle more medially if internal
oblique ridge is not negotiated by keeping the syringe
nearly at an angle of 90° (perpendicular) to fur medial
surface of ascending ramus. This can be easily
achieved by retracting the angle of the mouth
posteriorly with the barrel of the syringe.
 2. Needle insertion point too low.
 3. Under insertion or overinsertion of the needle as no
bone is contacted in this technique, the depth of soft
tissue penetration is somewhat arbitrary.

Extra Oral Technique For
Mandibular Nerve
 Mandibular nerve and its subdivisions;
Areas Anaesthetised
 The entire region innervated by mandibular
nerve and its subdivisions,
 Temporal region,
 auricle of the ear,
 external auditory meatus,

Mandibular Nerve
 temporomandibular joint,
 salivary glands,
 anterior 2/3rds of the tongue,
 floor the mouth,
 mandibular teeth, gingiva, buccal mucosa,
lower portion of the face (except the angle of
the jaw).

Mandibular Nerve
Indications
 1. Presence of acute inflammation or infection at the site of
injection for the subdivisions of mandibular nerve.
 2. Presence of trauma that would contraindicate or make it
difficult or impossible to anaesthetize the subdivisions of
mandibular nerve.
 3. Whenever there is need to anaesthetize the entire
mandibular m and its subdivisions, with one single penetration
and minimum ot local anesthetic solution for extensive
surgical procedures.
 4. For diagnostic and therapeutic purposes.

Mandibular Nerve
 These are common to those for extraoral
maxillary nerve block; and are as follows:
 • Midpoint of zygomatic arch.
 • Coronoid process of the ramus of the
mandible; and prominence of the lateral pole
of the condyle; which is located by having the
patient open and close his mouth.
 • Lateral pterygoid plate.

Mandibular Nerve
Technique
 The technique for mandibular nerve block is
essentially the same as that for maxillary nerve block.
The difference is that the marker is placed i the
needle at a distance of 5 cm.
 The needle contacts the lateral pterygoid plate, then it
is with drawn exactly in the same way as in the
maxillary nerve block.
 It is reinserted, the needle is directed upward and
slightly posteriorly in order for the needle to pass
posterior to lateral pterygoid plate. The needle should
not be introduced to a depth greater than measured 5
cm.

Mandibular Nerve
Approximating Structures:-
a. Structures through which the needle passes:
Skin, subcutaneous tissue, masseter muscle,
sigmoid notch, lateral pterygoid muscle.
b. Structures in the vicinity of the needle when the
needle is in contact with lateral pterygoid plate.
• Superiorly: Base of the skull.
• Internal maxillary artery; as it crosses interiorly
and curves upwards anterior to it, entering the
lower part of pterygomaxillary fissure.
• Temporal vessels for internal maxillary artery that
may lie on either side of it.

Mandibular Nerve
Superficially: The transverse facial artery which
may lie above or
below it.
• Posteriorly: Foramen ovale and posterior to it
foramen spinosum.
• Anteriorly: Pterygomaxillary fissure through
which the needle may
pass into pterygopalatine fossa.

Mandibular Nerve
Signs and Symptoms
a. Subjective: Tingling sensation and numbness of lower lip
and anterior 2/3rd of the tongue.
b. Objective:
i. Demonstration of difference in feeling of lower teeth while
opening and closing the jaws.
ii. Lack of demonstration of pain with instrumentation.
iii. Absence of pain during surgical procedure.
Complications
1. Failure of anaesthesia, and
2. Trismus.

Computer controlled local
anaesthetic delivery
 Also called as CCLAD.
 Introduced in 1997.
 Wand designed to improve on the ergonomics &
precession of the dental syringe.
 The system enables a dentist to accurately
manipulate needle placement with finger tip
accuracy & deliver the L.A solution with a foot
activated control.
 Light weight hand piece provides increased tactile
sensation & control.
 L.A solution delivery is computer control.

Available CCLAD systems:-
 The wand/ compudent system

 Comfort control syringe.

The wand/ compudent system:-
~ utilizes a single use safety hand piece
~ Luer - Lok needle is attached to the handle
~ The handle attaches to a catridge holder via a 60
inch micro tube which can hold a volume of less
than 0.2 ml of fluid.

~ The system administers local
anesthetics at 2 specific rates of
delivery.
~ The slow rate is 0.5 ml /min.
~ The fast rate is 1.8 ml/min.
~ An aspiration test can be activated
at any time by releasing the
pressure on the foot rheostat
starting a 4.5 sec aspiration cycle.

Advantages:-
 Precise control of flow rate & pressure produces a
more comfortable injection even in tissues with
low elasticity eg. palate, attached gingiva & PDL.
 Increased tactile feel & ergonomics from the light
weight hand piece.
 Non threatening
 Automatic aspiration
 Rotational insertion technique minimizes needle
deflection

Disadvantages:-
 Requires additional armamentarium.
 Cost.

Comfort –Control syringe:-
 This is an electronic pre programmed delivery
device that provides the operator with the control
needed to make the patients local anesthetic
injection experience as pleasant as possible.
 It has 2 stage delivery system.

 The injection begins at an extremely slow rate to
prevent pain associated with quick delivery.
 After 10 sec the CCS automatically increases
speed to the preprogrammed rate.


Comfort – control syringe

Advantages:-
 Familiar ‘syringe’ type of delivery system.
 Inexpensive disposables.
 Allows selection of various rates of delivery.
 Disadvantages:-
 Requires additional armamentarium
 More bulky than other CCLADs.
 Vibrations may bother some users and
 Cost.

Electronic dental anesthesia
History:-
 46 AD Scribonius Largus, physician
to the emperor Claudius, used
tarpedo fish to releave the pains of
gout.
 DESENSOR hand piece (1970) – a
high speed device that carried low
voltage current through a bur
directly on to the tooth.
 Trance cutanious electric nerve
stimulation (TENS) & Electronic
dental anesthesia developed since
the mid 1960’s into techniques.

Mechanism of action of TENS :-
 Low frequency electricity (2 Hz)

 Produces measurable changes in the blood

levels of L tryptophan, cerotonin, & beta
endorphins which possesses analgesic actions,
elevating the pain reaction threshold.

Medical uses of TENS:-
 Causalgia  Peripheral nerve injury
 Phantom limb pain  Bursitis
 post herpetic neuralgia  Parturition
 intractable cancer pain  Polycythemia vera
 Lower back pain  Cervical back pain
 Spinal cord injury  Postoperative pain
 Ileus  Diabetic ulceration

TENS in dentistry:-
1. Temporomandibular joint (TMJ) or
myofacial pain dysfunction  By low
frequency extra oral stimulation of the area.
2. Acute dental pain  By high frequency
electronic stimulation.

Indications:-
 Used as a technique in pain control ( needle
phobia )
 Ineffective local anesthesia
 Instances where local anesthetics cannot be
administered.

Indications of EDA in dentistry:-
1. TMJ / MPDS.
2. Administration of local anesthesia.
3. Non surgical periodontal procedures.
4. Restorative dentistry.
5. FPD procedures.
6. Endodontics.

Contraindications:-
 Cardiac pace makers
 Neurological disorders
a. Status post cerebrovascular accident ( stroke)
b. H/o transient ischemic attacks.
c. H/o epilepsy.
 Pregnancy
 Immaturity
 Very young patients & old patients with senile
dementia.

Advantages:-
 No need for needle.
 No need for injection of drugs.
 Patient is in control of the anesthesia.
 No residual anesthetic effect at the end of the
procedure.
 Residual analgesic effect remains for several hours.
 Post surgical pain & swelling can be minimized
through the use of EDA after surgical procedures ( a
low frequency setting for 30 – 60min ).

REFERENCES
 HANDBOOK OF LOCAL ANAESTHESIA –
S.F.MALAMED
 LOCAL ANAESTHESIA AND PAIN CONTROL
IN DENTAL PRACTICE – MONHEIMS
 MANUAL OF LOCAL ANESTHESIA IN
DENTISTRY – A.P. CHITRE
 ORAL & MAXILLOFACIAL SURGERY -
SRINIVASAN
 LOCAL ANAESTHESIA IN DENTAL PRACTICE-
MEECHAM

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