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Anatomical correlation
of
Local anesthesia
in
Dentistry
Pre-Lecture Quiz
1 Identify technique of local
anesthesia
2 Identify technique of local
anesthesia
3
Identify technique of
local anesthesia
4
Identify technique of
local anesthesia
5 Identify technique of local
anesthesia
6 Identify technique of local
anesthesia
7
Identify technique of local
anesthesia
Techniques of Maxillary Anesthesia
 Supraperisoteal infiltration : for limited treatment protocol
 Periodontal ligament injection as adjunct to other techniques
 Intraseptal injection: for periodontal surgical techniques
 Intraosseous injection: for single teeth
 Posterior superior alveolar nerve block: for several molar teeth in one
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quadrant
Middle superior alveolar nerve block: for premolar in one quadrant
Anterior superior alveolar(Infraorbital ) nerve block: for anterior teeth
in one quadrant
Maxillary (Second division) nerve block: for extensive buccal, palatal
and pulpal management in one quadrant
Greater (Anterior ) palatine nerve block: for palatal soft and osseous
tissue treatment distal to canine in one quadrant
Nasopalatine nerve block:for palatal soft and osseous tissue treatment
from canine to canine bilaterally
Supraperiosteal injection
 Indication:
 pulpal
amesthesia for one or two maxillary teeth
and soft tissue surrounding them
 Procedure:
 syringe should be parallel with long axis of the
tooth and inserted at the height of mucobuccal
fold over the tooth
Area anesthetized
Supraperiosteal injection
Posterior superior alveolar nerve block
 Indication:
Treatment involving two or more maxillary molars
Area anesthesised:
Pulp of maxillary 3rd, 2nd and 1st molar ( entire tooth in 72% and
mesiobuccal root not anesthesised in 28 % as it may be supplied by
MSAN)
Procedure:
 Insert needle at height of mucobuccal fold over 2nd Molar .
 Advance upward (45 degrees to occlusal plane), Inwards (medially at
45 degrees to occlusal plane) and backwards ( at 45 degrees to long
axis of 2nd molar )
 Advance depth of 16 mm to reach Alveolar foramina. For smaller
adult and children depth of 14 mm.
Complication:
 Hematoma
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Posterior superior alveolar nerve block
Area anesthetized
Posterior superior alveolar nerve block
Insert needle at height of mucobuccal
fold over 2nd Molar
Advance upward (45 degrees to
occlusal plane), Inwards
(medially at 45 degrees to
occlusal plane) and backwards (
at 45 degrees to long axis of 2nd
molar )
Middle superior alveolar nerve block
 Present in 28 % of population
 Indication:
When infraorbital block fails
 Area anesthesised:
 Pulp of maxillary 1st and 2nd premolar and mesiobuccal
root of 1st molar
 Procedure:
 Insert needle at height of mucobuccal fold over 2nd
premolar .
 Advance till tip of needle reach well above the apex of 2nd
premolar
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Middle superior alveolar nerve block
Area anesthetized
Needle reach well above the apex of 2nd
premolar
Anterior superior alveolar nerve block
(Infraorbital nerve block)
 Indication:
Treatment involving two or more maxillary teeth
 Area anesthetized:
 Pulp of maxillary central incisors to canine, in 72 % maxillary
premolars and mesiobuccal root of 1st molar, buccal periodontium of
same teeth
 Procedure:
 Locate infraorbital notch at infraorbital margin.
 Move finger downwards>> convex feeling is roof of foramen >>
further downwards concave feeling is Infraorbital foramen pulpated
on face.
 Insert needle at height of mucobuccal fold over 1st premolar with
needle held parallel to long axis of tooth till 16 mm depth and
correlated with external landmark.
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Anterior superior alveolar nerve block
(Infraorbital nerve block)
Area anesthetized
Locate infraorbital notch at infraorbital
margin and palpate downwards to located
foramen
Mucobuccal fold over 1st premolar with
needle held parallel to long axis of tooth
Palatal anesthesia
 Traumatic experience for patient with complains of extreme
pain while performing anesthesia.
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 This can be reduced by
 applying topical anesthesia
 pressure anesthesia
 control over needle
 slow deposition of anesthetic
Greater palatine nerve block
 Indication:
Dental procedures involving palatal soft tissues distal to canine.
Area anesthesised:
Posterior part of hard palate and overlying soft tissue till 1st premolar
anteriorly and medially midline.
Procedure:
 Path of insertion from opposite aside of the mouth at a right angle to
target area.
 Locate greater palatine foramen by placing cotton swab at junction of
maxillary alveolar process and hard palate in the groove. Press firmly
posteriorly from first maxillary molar. Swab will fall in the
“Depression” created by greater palatine foramen which is located
usually distal to maxillary 2nd Molar .
Complication:
 Ischemia and necrosis due to concentrated vasocontrictor solution
used for hemostasis.
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Greater palatine nerve block
Locate greater palatine foramen by
placing cotton swab at junction of
maxillary alveolar process and hard
palate in the groove. Press firmly
posteriorly from first maxillary molar.
Swab will fall in the “Depression”
created by greater palatine foramen
which is located usually distal to
maxillary 2nd Molar .
Nasopalatine nerve block
 Indication:
Restorative therapy for more than two teeth.
Area anesthetized:
Anterior portion of the hard palate and overlying soft tissue from
mesial of right 1st premolar to mesial of left 1st premolar.
Procedure:
Single needle penetration
 Insert needle at incisive papilla and advance towards incisive
foramen till the depth of 6-10 mm.
Multiple needle penetration
 First injection at labial frenulum
 Second injection labial aspect of papilla between central incisors
 Third injection if second injection has failed then to lateral aspect of
insicive papilla.
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Nasopalatine nerve block
Nasopalatine nerve block
Area anesthetized
Single needle penetration at incisive papilla
Nasopalatine nerve block
Multiple Needle Penetration
First injection at labial frenulum
Nasopalatine nerve block
Multiple Needle Penetration
Second injection labial aspect of
papilla between central incisors
Third injection if second injection
has failed then to lateral aspect of
insicive papilla.
Maxillary nerve block
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Indication:
 Extensive oral surgical, periodontal or restorative procedures requiring anesthesia of
whole maxillary division.
Area anesthetized:
Hemimaxilla including soft and hard tissues.
Procedure:
High tuberosity approach:
 Insert needle at height of mucobuccal fold over maxillary 2nd molar tooth.
 Advance needle like PSAN block but depth should be 30 mm. At this depth needle tip
is in proximity to maxillary nerve in pterygopalatine fossa.
Greater palatine approach:
 Locate greater palatine foramen
 Advance needle into canal to a depth of 30 mm.
Complication:
 Maxillary artery injury with hematoma
 Penetration into the orbit with ophthalmoplegia.
 Due to septa in greater palatine canal procedure may not be successful.
Maxillary nerve block
Area anesthetized
Needle at height of mucobuccal fold over
maxillary 2nd molar tooth
Inferior alveolar nerve block
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Also known as Mandibular block
Indication:
 Procedures on multiple mandibular teeth in one quadrant.
Area anesthetized:
Mandibular teeth, body and ramus of mandible, buccal mucoperiosteum and anterior
two third of tongue(lingual nerve).
Procedure:
 Height of injection determined by imaginary line extend posteriorly from coronoid
notch to pterygomandibular raphe as it turns upwards towards maxilla.
 Anteroposterior site on injection: about three fourths the distance from anterior
border of ramus
 Penetration depth: till bone is touched usually 20-25 mm.
Complication:
 Trismus
 Transient facial palsy.
 Hematoma.
Mandibular landmarks
1.
2.
3.
4.
5.
6.
Lingula
Posterior border of ramus
Coronoid notch
Coronoid process
Masseteric notch
Condylar process
Inferior alveolar nerve block
Area anesthetized
Inferior alveolar nerve block
Height of injection determined by imaginary line
extend posteriorly from coronoid notch to
pterygomandibular raphe as it turns upwards
towards maxilla.
Buccal nerve block
 Indication:
When buccal soft tissue anesthesia is required for dental
procedures in the mandibular molar region.
Area anesthetized:
Soft tissues and periosteum buccal to mandibular molar
teeth.
Procedure:
 Injection at distal and buccal to last molar near anterior
border of ramus of mandible.
 Depth usually 1-2 mm rarely above 2-4 mm.
Complication:
 Hematoma - bluish discolouration at the injection site..
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Buccal nerve block
Area anesthetized
Buccal nerve block
Injection at distal and buccal to last molar near anterior border of ramus of mandible
Mental nerve block
 Indication:
Dental procedures requiring pulpal anesthesia on
mandibular teeth anterior to mental foramen.
 Area anesthetized:
 Pulpal nerve fibres supplying premolars, canine and
incisors.
 Buccal mucous membrane anterior to mental foramen to
the midline and skin of lower lip and chin.
 Procedure:
 Injection at mucobuccal fold at mental foramen located
between apices of two premolars or canine and deposit
the content at the foramen.
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Mental nerve block
Area anesthetized
Incisive nerve block
 Indication:
When buccal soft tissue anesthesia is required for
procedures in the mandible anterior to the mental
foramen like biopsy and suturing of tissue.
Area anesthetized:
Buccal mucous membrane anterior to mental foramen to
the midline and skin of lower lip and chin.
Procedure:
 Injection at mucobuccal fold at mental foramen located
between apices of two premolars.
Complication:
 Hematoma - bluish discolouration at the injection site..
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Incisive nerve block
Area anesthetized
between apices of two premolars
Mandibular nerve block:
The Gow-Gates Technique
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Higher success rate
Indication:
 Procedures on multiple mandibular teeth in one quadrant and inferior alveolar nerve
block fails.
Area anesthetized:
Mandibular teeth to midline, body and ramus of mandible, buccal mucoperiosteum and
anterior two third of tongue(lingual nerve).
Landmarks and procedure:
 Extraoral: lower border of tragus and corner of mouth (Imaginary line joining these
two points)
 Intraoral: Height of injection determined by tip of needle just below the mesiolingual
(mesiopalatal) cusp of maxillary second molar.
 Penetration just distal to maxillary second molar tooth aligning needle to line
mentioned in Extraoral landmark with average depth about 25 mm.
Complication:
 Trismus
 Temporary paralysis of III, IV and VI.
 Hematoma.
Mandibular nerve block:
The Gow-Gates Technique
Area anesthetized
Mandibular nerve block:
The Gow-Gates Technique
Extraoral landmark: lower border of
tragus and corner of mouth
(Imaginary line joining these two points)
Direction of needle in Gow-Gates Technique
Vazirani-Akinosi Mouth Mandibular nerve block:
 Indication:
Limited mandibular opening.
Area anesthetized:
Mandibular teeth to midline, body and ramus of mandible, buccal
mucoperiosteum and anterior two third of tongue(lingual nerve).
Landmarks and procedure:
 Insert needle at mucogingival junction of maxillary third molar.
 Advance needle slightly laterally and posteriorly with average depth
about 25 mm.
Complication:
 Temporary paralysis of VII.
 Trismus (rare)
 Hematoma.
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Vazirani-Akinosi Mouth Mandibular nerve block:
Area anesthetized
Vazirani-Akinosi Mouth Mandibular nerve block:
Vazirani-Akinosi Mouth Mandibular nerve block:
Post-lecture QUIZ!!!!!
1 Identify technique of local
anesthesia
2 Identify technique of local
anesthesia
3
Identify technique of
local anesthesia
4
Identify technique of local
anesthesia
5: Identify technique of local
anesthesia
6: Identify technique of local
anesthesia
7
Identify technique of
local anesthesia
8
Identify technique of local
anesthesia
9
Identify landmarks at 1
and 3
10 Identify technique of local
anesthesia
11 Identify technique of local
anesthesia
12 Identify technique of local
anesthesia
13 Identify technique of local
anesthesia
…..Thanks…..