Injection Techniques For Regional Anesthesia: Contents of Cartridge

Chapter 9  Local Anesthesia for Orofacial Region 183
Box 9.10: Assembling the syringe (Figs. 9.8A and B). INJECTION TECHNIQUES FOR
REGIONAL ANESTHESIA
Sterilize the syringe
Check the needle container seal In order to make various dental procedures painless, one
Break the seal to use the needle has to plan the desired steps of blocking the pathway of
Screw the needle to syringe hub
painful stimuli and the impulses created by them. This
Double check the needle adaptor to syringe
Check the Cartridge LA content
objective can be achieved by depositing an anesthetic
Expiry date solution in the vicinity of a particular main nerve trunk
Cloudiness of solution or its branches, or terminal nerve endings, so that the
Cracking of glass injected solution can be easily diffused at the target area to
Air bubbles accomplish painless dentistry.
Load the cartridge in the syringe
There are several general methods of achieving pain
Engage the harpoon
control for carrying out various dental/surgical procedures
Examine free flow of LA
using local anesthetic agent.
Three different types of local anesthetic injection
Contents of Cartridge techniques are commonly utilized in dentistry, depending
Anesthetic agent, vasoconstrictor, preservative for vaso- on the type of procedure to be carried out. To learn these
constrictor, sodium chloride, distilled water. techniques, proper knowledge of anatomical landmarks as
A small bubble of approximately 1–2 mm is frequently well as regional neuroanatomy is a must.
seen in the cartridge. It is composed of nitrogen gas, which y Local infiltration
is bubbled into the local anesthetic solution during its
y Field block and
manufacture to prevent oxygen from being trapped in the
cartridge and potentially destroying the vasopressor.
y Nerve block
Topical anesthesia/surface anesthesia is achieved
Instructions regarding assembling the syringe and
prior to any of these three techniques to eliminate dis-
loading the syringe with the cartridge is given in Box 9.10
comfort of a needle puncture and have painfree injection
and Figures 9.8A and B.
(Fig. 9.10).
Multidose Vials
Local Infiltration
LA solution is also available in 30 mL/50 mL multidose
vial form, from where it can be drawn using 18 gauge Many small, less invasive procedures can be carried out by
disposable sterile needle in plastic disposable syringe. instilling local anesthetic at or near the site of surgery. The
The vial should be capped after the withdrawal of the aim of local infiltration is to anesthetize a definite area by
solution. Amber color bottle for prevention of oxidation of this type of injection.
adrenaline from sunlight. Clear bottle for lignocaine plain Small terminal nerve endings in the area of dental
without adrenaline (Fig. 9.9). treatment are flooded with local anesthetic solution.
The technique is easy to perform, quick, safe and mini
Ampoules mum post injection care is needed. However, basic
Certain LA solutions, such as ropivacaine or bupivacaine pharmacology about anesthetic dosing and toxicity, skill
are available in ampoules of 10–20 mL. This can be filled in is needed. Examples: Administration of local anesthetic
4–5 syringes and used. solution into an interdental papilla prior to root planning.
A B
Figs. 9.8A and B: (A) Needle capping or removal of the cap; (B) Holding of the loaded syringe with thumb grip.
184 Section 2  Local Anesthesia in Oral and Maxillofacial Surgery
Fig. 9.9: LA solution is also available in 30 mL/50 mL multidose Fig. 9.10: Different local anesthetic techniques used in dentistry.
vial form from where it can be drawn in plastic disposable syringe.
Amber color bottle for prevention of oxidation of adrenaline from
Nerve Block
sunlight. Clear bottle for lignocaine plain.
The local anesthetic agent is deposited close to a main
Extraoral Local Infiltration nerve trunk, supplying the surgical field, before the nerve
trunk divides into terminal branches, usually at a distance
In the practice of oral and maxillofacial surgery, especially
from the site of operative intervention. Usually indicated
in trauma cases for soft tissue wound suturing or for drain-
for the extensive surgical procedure in the quadrant of
ing of an abscess, one needs to infiltrate extraorally subcu-
jaw. Examples: (1) posterior superior alveolar nerve block,
taneously. Two types of infiltration methods can be used. (2) inferior alveolar nerve block, (3) infraorbital nerve
1. Static infiltration: A needle is inserted in subcutaneous block, and (4) nasopalatine nerve block.
tissue and aspiration is done to acertain that entry in
the blood vessel is avoided and then local anesthetic Position of the Dental Chair, Operator and the
agent is injected. Patient Prior to Injection
2. Continuous infiltration: Inject continuously in the
target surrounding area after initial needle penetration Prior to the administration of the local anesthesia to the
desired target area, the position of the patient, dental
and if required rotate the angle of the needle to infiltrate
chair and operator is adjusted as described in detail in the
the maximum area through one puncture site.
chapter “Exodontia” (see Fig. 18.13A and B) (Figs. 9.11
and 9.12).
Field Block The occlusal plane of the teeth is kept at about 45°
The local anesthetic solution is deposited near the larger angle to the floor. The occlusal plane of the teeth should
terminal nerve branches so that the anesthetized area be above the level of operators elbow. Note that the fingers
will be circumscribed. Examples: maxillary injections of the nondominant hand are used to support the alveolus
administered above the apex of the tooth. and retract cheek/lip.
Fig. 9.11: Chair position for injection and extraction of maxillary teeth. The operator stands on the right side and front of the patient.
Fig. 9.12: Chair position for injection and extraction of mandibular teeth, the occlusal plane of the teeth is horizontal/parallel to the
floor,when mouth is open. The occlusal plane of the teeth should be below the level of operators elbow. The operator stands on right
side and in front of the patient. Note that the fingers of the non-dominant hand are used to support the alveolus and the mandible. It
also help in retracting the cheek and lip.
(sprays and related to increased dosage), broken skin,

Box 9.11: Role of topical anesthetic agents.
inflamed/ulcerative mucosa, infected periodontal pockets,
Minimizing fear and apprehension multidrug combinations without FDA permission.
Minimizing injection pain and discomfort Common adverse reactions seen are dermatitis,
Sometimes eliminate the need for injection erythema, pruritus, vesiculation with oozing. Many
patients have habit of prolonged self-medication, which
Topical Anesthesia/Surface Anesthesia should be discouraged.
Topical anesthesia is the application of ointment, cream
Forms of Topical Anesthetics in the Market (Table 9.7)
or solution containing LA agent to easily accessible tissues,
e.g., mucous membrane or skin. Within few seconds to Different types include gels, sprays, liquids, viscous,
1 minute profound surface soft tissue anesthesia is ointments and patches. They may be applied by using
achieved, to a depth of 2–3 mm. cotton bud, patches, blunt cannula/syringe or aerosol can
with cannula.
Use of topical anesthetics is done routinely in dentistry,
Various products are available either in multidose and/
however, to ensure patient safety, one must be well
or single dose applicator form.
versed with safe application methods, contraindications
and possible adverse reactions. Because many topical y Gel (for skin or mucosa)—usually used for site specific
anesthetics preparations available are vasodilators and preinjection insertion point area. Typically applied
are formulated at higher concentrations to facilitate with cotton tip applicator. 20% benzocaine with water
diffusion through mucous membrane than the injectable soluble polyethylene glycol base is available in different
counterparts, so its misuse will lead to increase the flavors, such as cherry, banana, strawberry, pineapple,
possibility of toxic reactions. Higher the concentration— etc., are liked by children. It has quick topical action
the higher the rate of penetration, so it is important to within 20 seconds.
use small dosages, as most of the topical anesthetics Duration: 12–15 minutes. No systemic absorption and
do not have a MRD. These agents also do not contain easy to use.
vasoconstrictors, so cardiovascular system absorption y Ointment/cream for skin and mucosa—usually 5%
may be rapid and increase the risk of toxicity/overdose, lignocaine or 2.5% prilocaine ointments are available.
so it is the operator’s responsibility to select the safest y Liquids good for periodontal pocket surface anesthe-
agent and it is administration technique for each patient sia, applied with a cotton pellet or with blunt cannula
carefully. Always read the product insert before it is use subgingivally. Sometimes, some liquids are used as a
in children, pregnant women, medically compromised rinse by patients for a more generalized application to
and elderly patients are at higher risks for adverse events gingival tissues or to prevent the gag reflex.
(Box 9.11). y Spray cans are available with disposable extension
tubes or autoclavable cannula. Metered sprays are
Factors Affecting Topical Anesthetic Toxicity recommended and mostly used during intraoral
Concentration of the LA agent, ability to diffuse through radiographs or impression making. Whenever the
tissues, speed of systemic absorption, total area of coverage spray is used, the can is held straight with cannula
Table 9.7: Common topical anesthetic preparations used in dentistry.

Drug name Dosage for adults Onset time Duration Possible adverse reactions FDA approval status
20% benzocaine Small amounts 30 seconds 5–15 minutes Allergies to ester or PABA, Approved
methemoglobinemia
2% lignocaine 600 mg—adults 3–5 minutes 15 minutes Allergies to amides or drug Approved
300 mg—children components
Cetacaine (Cetylite) 2% Unknown 30 seconds 30–60 minutes Allergies to ester or PABA, Not approved
tetracaine, 14% benzocaine, methemoglobinemia
2% butamben
Oraquix (Densply) EMLA 2.5% 5 cartridges 30 seconds 30–60 minutes Allergies to amides or drug Approved
lidocaine and 2.5% prilocaine components
Best topical anesthetic Unknown Unknown Unknown Allergies to amides, esters or Not approved
drug—OTC 12.5% lidocaine, PABA, methemoglobinemia
12.5% tetracaine, 3%
prilocaine
Kovanaze 6 mg tetracaine Two sprays, 4–5 10 minutes 11 minutes Allergies to ester or PABA, Approved
HCL, 0.1 mg oxymetazoline minutes apart methemoglobinemia
HCL in each 0.2 mL spray
pointing towards the area of application. Judicious y Topical patches: Small bioadhesive matrix containing
amount of solution is sprayed protecting the eyes. topical LA agent can be applied to oral mucosa in sore
Spays are flammable. To avoid over delivery, now areas via transoral delivery system.
metered spray cans are also available, which deliver It is not commonly used now. Only one product is
only 50 mg/spray.
available. Topacale GelPatch. The flexible 18% benzocaine
Care should be taken avoid patient inhaling the
spray. Ethyl chloride spray causes snow/refrigeration GelPatch dissolves slowly when applied on the oral
effect. Mainly used externally. Emulsion/viscous- mucosa anesthetic effect lasting for 20 minutes. It may be
flavored form. For deep throat or oral gargles (Coolora/ used prior to injection, needle can be inserted through it
Tantum gargles). (Fig. 9.13).
Fig. 9.13: Topical anesthesia can be achieved by using ointment, cream or spray.
Commonly used Topical Anesthetic Agents y Cetacaine is a combination of 3 ester topical
Both amide and ester agents can be applied topically and anesthetics—2% tetracaine, 14% benzocaine and 2%
these can be incorporated into many different prepara butamben and available in gel, spray and liquid forms.
tions to enhance the efficacy (1) lignocaine/lidocaine, (2) However, it is not FDA approved, but still used widely.
benocaine, (3) tetracaine, (4) dyclonine hydrochloride— The onset time is rapid—30 seconds and has duration
nonester, nonamide, ketone topical anesthetizing agent of 30–60 minutes. Dose recommended is not >0.40 mL.
found in some sore throat lozenges and sprays, (5) Available in spray, liquid and gel form. Contraindicated
benzydamine hydrochloride—0.15% W/V is a locally in cholinesterase deficiencies.
acting nonsteroidal anti-inflammatory drug with local y Oraqix is FDA approved an amide topical anesthetic
available, with a eutectic mixture of LA in flavored
anesthetic and analgesic properties for pain relief. It
aqueous base. Eutectic mixture of local anesthetic
causes numbness—pain relief at the site of application
(EMLA) with 2.5% lidocaine plus 2.5% prilocaine.
stomatitis, mucositis Gargle or rinse with 15 mL every 2–3
Maximum concentration of lignocaine that can be
hours.
obtained in oil droplets is 20% but combination of
Different Topical Preparations Available lidocaine and prilocaine can achieve a concentration
of 80%.
Water based salts dissolved in organic solvents, as It is not recommended for patients under 18 years of
oil-water emlusions, as eutectic mixtures, incorporated age. The onset is 30 seconds with duration 20 minutes
in patches and controlled release devices using and it is a liquid to gel system.
iontophoresis and phonophoresis and incorporated in
liposomes. These mixtures have low melting point than
y Recently, an intranasal needleless anesthetic spray:
Kovanaze of 3% tetracaine HCL plus 0.5% oxymeta
the individual ingredients, and after application in the zoline (vasoconstrictor) with mucoadhesive properties
oral cavity, it changes into liquid form to facilitate rapid is available. This is a prefilled, single use nasal spray.
transmucosal absorption of the bases. This is sprayed into ipsilateral nostril to get diffused
y Benzocaine gel in 20% concentration is the most to spread inferiorly. With this pulpal anesthesia is
commonly used as topical anesthetic agent with the achieved from the premolar to incisors, as anterior and
rapid onset time of 30 seconds and reaches its peak middle superior alveolar nerves are anesthetized. The
effect in 2 minutes and duration of 5–15 minutes. It US Food and Drug Administration has approved this
is poorly soluble in water, so slowly absorbed into intranasal agent for the use in individuals weighing
cardiovascular system (CVS), with low potential for 40 kg or more. Maximum recommended dose of
overdose. Forms include gel, liquid, ointment and gel- 18 mg tetracaine with 0.3 mg oxymetazoline. The
patch, and is available in both multiuse or single unit recommended dose is not more than two sprays—12
doses. mg at 4 to 5 minutes apart. Third spray can be used
Benzocaine is also available in aerosol form—20% after 10 minutes (18 mg) adverse effects reported
spray. are nasal congestion and rhinitis. Contraindications
Spray cans are available with disposable extension include known hypersensitivity to esters, tetracaine,
tubes or autoclavable tips and used for severe gag PABA, oxymetazoline, patients with uncontrolled
reflex. hypertension, active thyroid disease and on b-blockers,
Contraindications: It should not be used in preganant tricyclic antidepressants.
women, known ester or para-aminobenoic acid (PABA) y Dyclonine hydrochloride (0.5–1%) patients who have
allergies and methemoglobinemia. hypersensitivity to amide or ester topical anesthetic
y Lidocaine is available with water soluble form in agents can be prescribed this as it falls into ketone
various concentrations 2–5%. The time of onset for group. It onset is slow with long duration of 30–60
2% topical lidocaine is 3–5 minutes,with duration of minutes of good anesthesia and used as a mouth rinse
15 minutes, the MRD for 2% lidocaine is 600 mg in by swishing for one minute. It should not be swallowed.
adults and 300 mg in children. 10–15% water soluble It has poor water solubility, hence overdose tendency
lignocaine spray is also available. is low. It is also available as anesthetic lozenges.
Contraindication: Pregnancy and known allergy to
amides. It is important to note that the risk of overdose Key Points while using Topical Anesthesia
with amide topical agent is more than with esters and (Topical Gels/Ointment/Cream, Spray, etc.)
increases with the area of application.
The base forms (insoluble in water) of benzocaine Patient Preparation
and lidocaine are preferred as they are more slowly Proper medical history to select the best and safest agent
absorbed into the CVS and are less likely to produce an and previous experience with anesthetics and self use of
overdose when used properly. any topical agent must be asked.
Direction for use of Topical Agents Relative Contraindications for using Local
Check the expiry date of the agent and follow the Anesthesia Techniques
directions for its use. Dry the site with cotton bud for y Extremely apprehensive or having trypanophobia
better efficacy and better penetration and less dilution. (extreme fear of medical procedures involving
Remove excess saliva during application by suction, injections and needles) patients
for minimizing the dilution. If using multiuse tube, use y Presence of local infection
cotton tip applicator. Only small amount is used. Allow y Known allergy to LA agent
it to remain at the site for designated period. Use of y Extremely uncooperative patient—mentally chal-
refrigerated topical agent decreases application time, lenged, senile, epileptic or pediatric unruly patients
provides faster onset. Not more than 28 g per patient y Extensive major surgery
during a 24 hour period should be used. Keep out of y Patients with renal or liver diseases, acutely ill and
reach of children. Do not swallow. debilitated
Documentation Advantages of Local Verses General Anesthesia

Note the location and total dose of topical agent used.
y Intraoperative/postoperative safety
Consider MRD with regards to injectable local anesthetics
plus topical agent for the total dose calculations.
y Ease of administration
y Cost effective
Benefits y Operative time can be prolonged as per the patient
comfort
y Minimizing fear and apprehension y Due to hemostasis, reduced intraoperative bleeding
y Avoiding injection for potentially painful dental y Old age or patient’s general health not fit for general
procedure discomfort (periodontal probing-arch bar anesthesia administration.
removal)
y Avoiding or minimizing injection prick Factors Responsible for the Desired Effect of
y Relieving the pain due to oral ulcers and stomatitis, Local Anesthesia
denture sores, etc. and other mucosal lesions
y Distance of the nerve in contact with LA agent—at least
y Eliminate gag reflex during various dental procedures, 8–10 mm length of the nerve must be in contact with
such as intraoral radiography, impressions, abscess the anesthetic agent—2–3 nodes of Ranvier
drainage, suture removal, and small sharp bony spic- y Size of the nerve fiber—the larger the fiber, relatively
ules, etc. difficult to anesthetize.
y Skin anesthesia prior to abscess drainage, venepunc- y Local anesthetic agent right concentration is important.
ture, abrasion wound care, etc.
y Deciduous teeth extractions without LA injection Key Points/Clinical Pearls to Lessen the
Pain on Injection
Factors Affecting Selection of the y The use of small gauge needle—25 to 30 gauge
Anesthetic Technique y Slow administration of local anesthetic solution
y Area to be anesthetized—depending on the density of y Buffering the LA with sodium bicarbonate—1 mEq/mL
of NaHCO3 to 10 mL of lignocaine (not for bupivacaine
the bone
and ropivacaine).
y Extent of surgical procedure. Multiple extractions
should be done with nerve block technique to avoid Other Key Points to be Followed
multiple needle pricks
y Duration and profoundness of anesthesia required- y Sterile cartridge by 70% alcohol, it should be used at
room temperature
nerve block will give profound depth of anesthesia for
longer duration
y The syringe or cartridge should contain no air.
y In the vicinity of blood vessels, use aspiration syringe
y Age of the patient—older patients have dense bone. In
y The site of injection must be disinfected.
children blocks should be avoided as far as possible. y Stretch the tissues for injection
y Hemostasis—if required additional infiltration in the y Follow shortest way inside the tissues
area of surgery should be considered y The bevel of the needle should be towards bone.
y Presence of infection—infiltration should be avoided y Never bend the needle to change the direction.
to prevent spread of infection y While giving the mandibular block warn the patient
y Skill of the operator not to close the mouth.
A B
Figs. 9.14A and B: In local infiltration technique: (A) The anesthetic solution is deposited over terminal nerve endings where the
procedure is to be carried out. Whereas in field block; (B) Local anesthetic is deposited near the larger terminal nerve branches and the
procedure is done away from site of injection.
Infiltration and Field Block periosteum, lingual/palatal region, connective tissue, and
Maxillary anterior region and mandibular anterior region mucous membrane.
till premolars have thin cortical labial or buccal plate and
Indications
lingual/palatal plate, where the bone is cancellous/porous
in nature. Infiltration or field block in these areas will allow y Pulpal anesthesia of the maxillary/mandibular teeth,
diffusion of LA solution through the periosteum and the except mandibular molars, when treatment is limited
minute foramina in the cortical bone to the nerve filaments to one or two teeth.
entering the apex of a tooth, inside the cancellous bone. y Soft tissue anesthesia when indicated for surgical
In the olden days, the terminologies used for procedures in a circumscribed area.
infiltration techniques were subdivided into submucosal, y In pediatric patients infiltration gives comparable
supraperiosteal, subperiosteal infiltration. But since this anesthesia effectiveness to mandibular nerve block.
method is a blind technique, it is difficult to differentiate
these layers clinically. Contraindications
y Infection or acute inflammation or in the area of
Paraperiosteal Infiltration injection.
Paraperiosteal infiltration method is the acceptable y Dense bone covering the apices of teeth.
term now in dentistry, as the local anesthetic solution is
Advantages
deposited along the periosteum and it is most commonly
used technique for achieving local anesthesia for y High success rate.
individual tooth pulpal tissue in the maxilla or mandible, y Technically easy injection.
except mandibular molar teeth (Figs. 9.14A and B). y Usually atraumatic
Paraperiosteal Infiltration Injection Disadvantages

It is commonly called the local infiltration and is the most Not recommended for large areas because of need for
frequently used local anesthetic technique for obtaining multiple needle pricks and the necessity to administer
pulpal and investing soft tissue anesthesia in maxillary/ larger total volumes of anesthetic solution.
mandibular anterior teeth, till premolars.
Technique (Figs. 9.15 and 9.16)
Nerves Anesthetized A 25 or 27 or 30 gauge 0.30 × 25 mm short needle is
Large terminal branches of nerves in the apical region recommended. Nonaspirating syringe can be used. The
of the teeth to be anesthetized buccally/labially and area of insertion is at the height of mucobuccal fold above
lingually/palatally. the apex of the tooth to be anesthetized. The target area
is the apical region of the tooth to be anesthetized. The
Areas Anesthetized anatomical landmarks include: mucobuccal fold, crown of
The entire region innervated by large terminal branches, the tooth, root contour of the tooth. The orientation of the
such as for the pulp and root area of the teeth, buccal/labial bevel is towards the bone. First imaginary line is vertical
A B
Figs. 9.15A and B: Anatomical landmarks for paraperiosteal labial infiltration: (A) For maxillary teeth; (B) For mandibular teeth.
A B
Figs. 9.16A and B: Penetration of needle for paraperiosteal labial infiltration: (A) For maxillary teeth; (B) For mandibular teeth.
line parallel to the long axis of the tooth and second line is Insert the needle at the height of mucobuccal fold over
a horizontal line along the mucobuccal fold on the buccal/ the target area. Advance the needle at or above the apical
labial side and for lingual infiltration in mandibular teeth region of the tooth and advance until it touches the bone
the second imaginary line should be drawn above the floor and then withdraw a little. Aspirate, if negative, deposit
of the mouth at mucolingual sulcus. approximately 0.5 mL slowly over 20 seconds (at the
Point of needle insertion—the point of intersection of rate of 30 s/mL). Withdraw the syringe slowly. Recap the
these two imaginary lines 2 mm away from the mucobuccal needle. Wait for 2–3 minutes, and commence the dental
fold. procedure.
Direction of needle 45° with the labial or buccal cortical For lingual infiltration for mandibular teeth: The point
plate of bone. of needle insertion is 3–5 mm cervical to the free gingival
margin along the long axis of the tooth and just above the
Procedure mucolingual fold to avoid diffusion of LA solution into
Prepare the tissues at the site of injection. Clean with the floor of the mouth. Direction of the needle insertion—
sterile dry gauze. Apply topical antiseptic. Apply topical the syringe is directed from the corner of the mouth of
anesthetic agent. Lift the lip, pulling the tissues taut. the left side for the right side injection and reverse for
Hold the syringe parallel to the long axis of the tooth. the other side. 0.2–0.3 mL of the solution should be
A B
Figs. 9.17A and B: Diagrammatic representation of palatal infiltration technique.
A B
Fig. 9.18: Clinical picture of palatal infiltration.
injected. Terminal branches of the long buccal nerve also

can be blocked by the infiltration method. C D
Figs. 9.19A to D: (A) Different supplementary infiltration techniques;
Palatal Infiltration (Figs. 9.17 and 9.18) (B) Intrapulpal injection; (C and D) Intraosseous infiltration.
Point of needle insertion on the palatal side of the tooth—
midway between the gingival margin of the tooth and the y Objective-on probing: Absence of pain during treat
median palatal raphe, along the long axis of the tooth. ment
Direction of needle insertion—perpendicular or 90° to Modified Dr Mendel Nevin’s method: All maxillary
the palatine vault. 2 mm depth of needle is inserted from anterior teeth can be anesthetized by inserting the needle
the opposite side. 0.3 mL solution is deposited slowly to over canine tooth on right side and then passing the
avoid pain and ulceration. Palatal injections are most needle horizontal towards other side canine (long needle).
painful; therefore, warn the patient before. Do not deposit The infiltration of LA then starts from left side canine,
excess solution as it may cause blanching, sloughing/ gradually withdrawing the needle over each tooth apices
necrosis of the palatal mucosa.Do not inject while the and depositing the solution slowly. This is a excellent
needle touches the bone as the solution will be deposited method for multiple extractions, alveolectomy, etc.
subperiosteally, which is more painful and can cause
postinjection discomfort. Supplementary Infiltration Techniques
(Figs. 9.19A to D)
Signs and Symptoms Many a times, especially in endodontics, paraperiosteal
y Subjective: Feeling of numbness in the area of adminis infiltration is supplemented by various other methods
tration depending on patient’s response.
y Periodontal ligament injection (intraligamentary) Techniques of Maxillary Anesthesia

y Intraosseous (intrabony) infiltration injection The following techniques are used to achieve clinically
y Intraseptal injection/intrapapillary/intradental injec adequate anesthesia of the teeth and soft/hard tissues in
tion the maxilla.
y Intrapulpal injection.
y Paraperiosteal (infiltration)
Intraligamentary Injection y Periodontal ligament injection (intraligamentary)
y Intraosseous injection
PDL injection: Delivery of LA through the periodontal y Intraseptal injection
ligament to reach the periapical region. Pressure syringe y Posterior superior alveolar nerve block
is preferable, if available over conventional syringe, as y Infraorbital nerve block
there is lot of resistant encountered. The 25–27 gauge, y Nasopalatine nerve block
short needle is inserted mesial or distal to the tooth in y Greater palatine nerve block
the interproximal area at the depth of gingival sulcus y Maxillary nerve block.
at 30° angle. Advance needle apically until resistance is
encountered 0.2 mL solution is injected with continuous Posterior Superior Alveolar Nerve Block/
force over 15–20 seconds. Tuberosity Block/Zygomatic Block
Intraosseous Injection The posterior superior alveolar nerve (PSAN) block is
effective for the anesthesia of maxillary third, second and
Intraosseous injection is rarely used, where the bur hole first molar.
is drilled below the apical area without damaging the However, the mesiobuccal root of the maxillary first
root apex to penetrate the cortical plate and then needle molar is not consistently innervated by the posterior
is introduced through it in the spongy bone to deposit the superior alveolar nerve.
solution. Mainly used for mandibular region. Therefore, a second injection, usually a paraperiosteal,
is indicated following the PSAN block, when effective
Intraseptal Injection anesthesia of the first molar is not achieved.
Intraseptal injection used for hemostasis and additional Nerves anesthetized: Posterior superior alveolar nerve,
anesthesia. At the center of the base of the interdental before it enters the posterior surface of the maxilla, while it
papillae, the 27 gauge needle is inserted at 45–90° with is in the infratemporal fossa and its branches.
the buccal plate, with bevel towards bone. The needle is
Areas anesthetized: Pulps of maxillary third, second
forced gently in the thin interseptal bone on either side of
and first molars, and buccal periodontium and muco
the tooth 0.2–0.4 mL solution is deposited under pressure
periosteum along with investing alveolar bone of these
into the cancellous bone.
teeth, maxillary sinus lining.
Very quick onset and it causes blanching of the gingiva.
Resistance is felt during injection. Indications
Intrapulpal Injection y Treatment involving two or more maxillary molars.
y When paraperiosteal injection is contraindicated as in
Intrapulpal injection useful in acute pulpitis and acute inflammation or infection.
endodontic treatment. Needle is inserted into the pulp
y When paraperiosteal injection has proved ineffective.
chamber, after small access cavity is made or directly in
the root canals. LA is deposited under pressure, if required Contraindications
the needle is bent to gain access. 0.2–0.3 mL is deposited
When the risk of hemorrhage is too great as with a
under pressure to get profound and fast anesthesia.
hemophilic.
When the pulp exposure is too large, then allow a snug fit
needle into root canals to flood with LA solution. Advantages
Nerve Blocks or Conduction Anesthesia

y Atraumatic
y High success rate
A nerve trunk supplying maxillary or mandibular area y Minimum number of injections required
is blocked by LA at some point between the periphery y Minimizes total volume of anesthetic solution injected
and brain, thereby abolishing the sensation distal to the
point where nerve is blocked. It provides larger anesthetic Disadvantages
field, as the area of distribution of that particular nerve is y Risk of hematoma—as needle lies close to the pterygoid
anesthetized. plexus of veins. Aspirate and inject and use short
Techniques can be: (1) Intraoral method, (2) Extraoral 25 mm needle.
A B
Figs. 9.20A and B: (A) Needle in position for posterior superior alveolar nerve block. Maxillary tuberosity (Yellow arrow) and white arrow
(infratemporal surface of maxilla); (B) Clinical picture of Posterior superior alveolar nerve block; the cheek is retracted and the needle is
advanced in inward, upward and backward direction.
y Technique is somewhat arbitrary: No bony landmarks posterosuperior and medial to maxillary tuberosity
during insertion (Figs. 9.20A and B).
y Second injection required for treatment of the first Wait for 3–5 minutes to start the procedure.
molar in 28% of patients
Procedure
Technique A 25 gauge short needle is recommended. For left PSAN
Injection site: Distal aspect of maxillary tuberosity, behind block and right handed operator, stand at 10 o’clock
and above maxillary third molar. position facing the patient. For the right PSAN block
stand at 8 o’clock position. Prepare the tissues. Orient
The patient is in semisupine position with the occlusal
the needle towards the bone. Partially open the patient’s
plane of the maxillary teeth at an angle of 4° to the floor.
mouth, pulling the mandible to the side of injection and
Operator stands on the right side of the patient for right maxillary occlusal plane at 45° to the floor. Retract patient’s
block and in front of the patient for the left side block. cheek, and move the forefinger over the mucobuccal fold
The anatomical landmarks include: Mucobuccal fold and in a posterior direction from the bicuspid area until the
its concavity, zygomatic process of maxilla, infratemporal zygomatic process of the maxilla is reached. At this point
surface of maxilla, anterior border and coronoid process of the left forefinger is rotated so that the fingernail is adjacent
the ramus of the mandible, and tuberosity of maxilla. The to the mucosa and its bulbous portion is still in contact
with the posterior surface of the zygomatic process.
mouth is partly closed.
Now the hand is lowered with the finger keeping the
A 25 gauge needle with 25 mm length is inserted at the bulbous portion still in contact with the zygomatic process
depth of the mucobuccal fold, above the maxillary second so that the finger is in a plane at right angles to the occlusal
molar. surfaces of the maxillary teeth and at 45° angle to the
The needle is advanced slowly, around the curvature patient’s sagittal plane. The previously loaded syringe/
of the posterior part of the maxillary tuberosity upwards, needle is inserted into the tissue in a line parallel to the
backwards, and inwards at an angle of 45° to the occlusal index finger and bisecting the fingernail. The direction of
plane. insertion is in an upward, inward and backward direction
Approximately around 16 mm length of the needle in one movement.
should be inserted to reach the target area, in the vicinity In an adult of normal size, penetration to a depth of
16 mm will place the needle tip in the immediate vicinity
of the foramen through which posterior superior alveolar
of the foramina through which the PSA nerves enter the
nerve enters the posterior surface of the maxilla. posterior maxilla.
It should not touch the bone, to avoid entering the After aspirating in two planes, the operator slowly
pterygoid venous plexus. Aspiration, if negative, then only injects the contents of the cartridge over a period of 30–60
0.5–1.0 mL LA solution injected into the target area of the seconds. Wait for 3–5 minutes before commencing the
posterior superior alveolar nerve. This nerve is located dental procedure.
Infraorbital Nerve Block/Anterior Superior Technique

Alveolar Nerve Block The patient is placed comfortably in the chair and tilted
Nerves Anesthetized so that the maxillary occlusal plane is at an angle of 45° to
the floor.
y Anterior superior alveolar nerve
The operator stands on right side and front of the
y Middle superior alveolar nerve
patient for right side and facing the patient for left side
y Infraorbital nerve along with its branches—inferior
injection. Prepare the tissues at the injection site.
palpebral, lateral nasal and superior labial branches
Locate the infraorbital margin by moving the palpating
Target Area finger downward from the margin, applying gentle
pressure to the tissues. As the finger continues to move
Infraorbital nerve, as it exits from infraorbital foramen. It inferiorly, a concavity will be felt. This is the infraorbital
is situated between levator labii superioris muscle above notch or depression and its deepest part is the infraorbital
and levator anguli oris muscle below. foramen.
Maintain the finger on the foramen or mark the skin
Areas Anesthetized
at that site.
y Pulps of maxillary central incisors up to the second Retract the lip, pulling the tissues in the mucobuccal
premolar on the on the side of injection fold taut to increase the visibility.
y Pulp of mesiobuccal root of maxillary first molar on the
side of injection Needle Pathway During Insertion
y Labial or buccal periodontium, mucoperiosteum and
Bicuspid Approach
supporting alveolar bone of these teeth
y Skin of lower eyelid, skin of lateral aspect of the nose, The needle passes through the mucosa and areolar tissue
and skin and mucosa of upper lip and during insertion should pass beneath and lateral to
the facial artery and facial vein. Orient the syringe towards
Indications the infraorbital foramen.
The needle should be held parallel to the long axis of
y Dental procedures involving more than two maxillary
teeth, and their overlying buccal tissues. the first bicuspid.
y Inflammation or infection which contraindicates Insert the needle into the depth of the mucobuccal fold
paraperiosteal injection. over the first premolar with the bevel facing towards bone.
As it is advanced, care should be taken to avoid
Contraindications premature contact with the bone initially.
Due precaution is taken to protect the eye to restrict the
y Discrete treatment areas (one or two teeth only).
passage of needle towards the eyeball.
y Hemostasis of localized areas, when desirable, an
Advance the needle until bone is gently contacted at
additional local infiltration into the area is indicated.
the deepest part of infraorbital foramen (Figs. 9.21A to C).
Advantages
Central Incisor Approach (Figs. 9.22A and B)
y Comparatively simple technique.
The needle passes through the mucosa and areolar tissue
y Comparatively safe, minimizes the volume of solution
and beneath the angular muscle during insertion should
used and the number of needle punctures required to
pass beneath and lateral to the facial artery and facial vein.
achieve anesthesia.
The syringe is directed obliquely from the mesioincisal
Disadvantages angle of the central incisor to the distogingival/cervical
angle. The area of insertion is about 5 mm away from the
y Anatomical: Difficulty in defining landmarks. mucobuccal fold of ipsilateral canine, and guided into
y Psychological: Initial fear of injury to the patient’s eye. the position by the thumb marking the location of the
infraorbital foramen.
Anatomical Landmarks In either of the approaches the needle should not
Solution is deposited at the orifice of the infraorbital penetrate more than 3/4th of an inch.
foramen and it will diffuse along the canal to anesthetize Approximately, 2 mL of solution is slowly deposited
both the anterior and middle superior alveolar nerve. in this area and the thumb is held in position until the
The landmarks include: Supraorbital notch/foramen, injection is completed.
infraorbital margin, infraorbital depression, infraorbital The operator will be able to feel the anesthetic solution
foramen, anterior teeth, pupil of the ipsilateral eye, mental as it is deposited beneath the finger on the foramen, if the
foramen. needle tip is in the correct position.
A B C
Figs. 9.21A to C: (A) Infraorbital nerve block by bicuspid approach. The needle is advanced parallel to the premolar teeth. The final
position of the needle is in vicinity of the infraorbital foramen. Clinical pictures of infraorbital nerve block; (B) Extraoral landmarks;
(C) Intraoral landmarks.
A B
Figs. 9.22A and B: (A) Infraorbital nerve block by central incisor approach. The syringe is directed obliquely from the mesioincisal angle
of the central incisor to the distogingival/cervical angle. The needle is advanced slowly. The final position of the needle is in vicinity of the
infraorbital foramen; Clinical pictures—(B) Infraorbital nerve block.
Maintain firm pressure with the finger over the injections. To reduce the discomfort to the patient during
injection site both during and for at least 1 minute after palatal anesthesia:
the injection. Diffusion of the solution to the entry of the y Provide adequate topical anesthesia at the site of
foramen can be obtained by lightly massaging the tissue injection.
posterosuperiorly.
y Use pressure anesthesia at the site before and during
Wait for 3–5 minutes after completion of the injection needle insertion and the deposition of the solution
and commence the dental procedure
y Maintain control over the needle
y Subjective symptoms: Patient will experience tingling y Deposit the anesthetic solution slowly
and numbness of the upper lip, side of the nose and
lower eyelid. Greater Palatine Nerve Block
y Objective symptoms: No pain on tapping or instru-
mentation on anesthetized teeth and soft tissue. Nerves anesthetized: Greater palatine nerve.
Figures 9.23A and B show extraoral clinical picture of Areas anesthetized: The posterior portion of the hard
infraorbital block technique, which is rarely used in case of palate and its overlying soft tissues/mucoperiosteum,
local intraoral infection. from maxillary third molar to anteriorly as far as the first
premolar and medially up to the midline of the palate.
Palatal Anesthesia
The anesthesia of the hard palate is necessary for dental Indications
procedures involving procedures of palatal soft and hard y When palatal soft tissue anesthesia is required for
tissues. The palatal anesthesia is one of the most painful restorative therapy on more than two teeth
A B
Figs. 9.23A and B: (A) Traget area in extraoral infraorbital nerve block;
(B) Extraoral approach for infraorbital nerve block—clinical picture.
A B
Figs. 9.24A and B: (A) Target area for greater palatine nerve block; (B) Clinical picture of greater palatine nerve block.
y For pain control during oral surgical or periodontal gingival margin of second and third maxillary molars,
surgical procedures involving the palatal soft and hard midline of the hard palate, and a line approximately 1 cm
tissues from the palatal gingival margin towards the midline of
the palate (Figs. 9.24A and B).
Contraindications
Procedure
y Inflammation or infection at the site of injection
A 25 or 27 gauge needle of 25 mm length is recommended.
y Smaller areas of therapy
The area of insertion is in the soft tissues slightly
Advantages anterior to the greater palatine foramen. The target area is
the greater palatine nerve as it passes anteriorly between
y It minimizes needle penetrations and volume of the soft tissues and the bone of the hard palate.
solution The bevel of the needle is oriented towards the palatal
y Minimal patient discomfort soft tissues.
Locate the greater palatine foramen with a cotton swab
Disadvantages which is most frequently located distal to the maxillary
y It is a potentially traumatic second molar about 1 cm from the palatal gingival margin
y No hemostasis except in the immediate area of towards the midline.
injection The greater palatine foramen is approached from the
The anatomical landmarks include greater palatine opposite side at right angle to the curvature of the palatal
foramen, maxillary second and third molars, palatal bone.
The needle is inserted slowly until the palatal bone Technique
is contacted. Approximately 0.25–0.5 mL of solution is The anatomical landmarks include—maxillary central
injected very slowly after negative aspiration. incisor teeth, incisive papilla in the midline of the palate,
Withdraw the needle slowly and cover it with its sheath. and incisive foramen.
The nerve may be blocked at any point along its anterior
course after emergence from the foramen. Procedure
The nasopalatine nerve block is an extremely painful
Nasopalatine Nerve Block injection unless a preparatory injection is made.
Other common names: Incisive nerve block, sphenopala-
Labial Approach
tine nerve block.
The preparatory injection is made by inserting 1” 25–
Nerves anesthetized: Nasopalatine nerves bilaterally
27 gauge needle into the labial intraseptal tissues in
emerging from incisive foramen beneath the incisive
between the maxillary central incisors. The needle is
papilla and 1 cm in the midline, palatally to the maxillary
inserted at a right angle to the labial cortical plate and
central incisors.
passed into the tissues until resistance is felt. Then 0.25
Areas anesthetized: Anterior portion of the hard palate mL of anesthetic solution is deposited. The needle is
from the mesial of the right premolar to the mesial of the then withdrawn and reinserted slowly into the crest
left first premolar (palatal area of six anterior teeth). of the papilla. The needle is advanced slowly into the
incisive foramen about 0.5 cm into the canal, and about
Indications 0.25–0.5 mL of solution is injected.
y When palatal soft tissues anesthesia is required for
restorative therapy on more than two teeth Palatal Approach
y For pain control during oral surgical or periodontal Direction of the needle is parallel to the long axis of upper
surgical procedures involving palatal soft and hard central incisor.
tissues The tip of the needle is placed in the depression
surrounding incisive papilla and small amount of solution
Contraindications
is injected until the blanching of the papilla is seen. The
y Acute inflammation or infection at the site of injection needle is then advanced into the incisive foramen for
y Smaller areas of therapy (one or two teeth). about 0.5 cm into the canal and about 0.25–0.5 mL of
solution is injected (Figs. 9.25A and B).
Advantages
Signs and Symptoms
y Minimizes needle penetrations and volume of solution
y Minimal patient discomfort from multiple needle y Numbness in the anterior portion of the palate
penetrations y No pain during dental procedure.
Disadvantages Extraoral Maxillary Nerve Block

y No hemostasis except in the immediate area of injection Whenever intraoral anesthesia is not possible, due to
y Potentially the most painful intraoral injection extensive accident wounds, or trismus or limited oral
A B
Figs. 9.25A and B: (A) Target area nasopalatine nerve block; (B) Clinical picture of nasopalatine nerve block.
opening, operator may have to resort to extraoral injection LA solution is injected slowly. Aspirate after each 0.5 mL of
technique. the injection.
Nerves anesthetized: Main trunk of maxillary nerve and all Signs and symptoms: Tingling and numbness of upper lip,
its branches p eripheral to the site of injection. side of the nose, lower eyelid, soft palate and pharynx may
Areas anesthetized: Anterior temporal and zygomatic have gagging sensation.
region, lower eyelid, side of the nose, upper lip, maxillary
teeth along with the investing structures—buccal and Mandibular Anesthesia
palatal mucoperiosteum, hard palate, part of the soft
palate, tonsils, nasal septum, floor of the nose, turbinates, Conventionally achieving anesthesia in the mandibular
lateral wall of the nose, part of pharynx. area is more complicated than in the maxilla. William
Anatomical landmarks: Midpoint of zygomatic arch, Halsted and Richard Hall achieved first regional
zygomatic notch, coronoid process, lateral pterygoid plate. anesthesia of mandible by cocaine solution injection in
1984. Many techniques were introduced since then along
Indications with different modifications.
When anesthesia of the entire distribution of the maxillary
nerve is required for extensive surgery, with only one Anatomical Factors Responsible for Difficulties
needle insertion and with minimum anesthetic agent. For Faced During Mandibular Anesthesia
diagnostic purpose in case of neuralgia.
Mandibular bone has thick bony cortical plate, the
Technique (Figs. 9.26A and B) thickness of the soft tissue for the passage of needle is
often variable. Possibility of accessory nerve innervations
The midpoint of the zygomatic arch is located and the
may be encountered.
depression in its inferior surface is marked. Coronoid
process is located by opening and closing of the mouth.
The center of the depression which is marked with ink Techniques of Mandibular Anesthesia
extraorally is located and that becomes the point of needle y Infiltration: Anterior labial infiltration and anterior
insertion. lingual infiltration and long buccal nerve infiltration.
Needle used: 4 inch/8.8 cm long, 22 gauge needle is chosen y Nerve block anesthesia: (a) Inferior alveolar nerve
and a marking from the tip of 4.5 cm is done on the needle, block, (b) Mental nerve block, (c) Long
by inserting a rubber marker. y Lingual nerve block
Insertion of the needle: The needle is inserted perpen
dicular to the skin and midsagittal plane in the center of Pterygomandibular Block
depression marked earlier. Keep on injecting few drops as
Other common names: Inferior alveolar nerve block,
the needle is advanced, till it touches the lateral pterygoid
mandibular nerve block
plate. The needle should never be inserted beyond the
rubber marker. The needle is slightly withdrawn and Target point: Deposit the LA solution at/above the entry of
redirected in a slight forward and upward direction till the inferior alveolar nerve before it enters into the mandibular
rubber marker depth. After aspiration, if negative, 1–2 mL. foramen.
A B
Figs. 9.26A and B: (A) Bony landmarks of extraoral maxillary nerve block, showing needle tip at target area;
(B) Clinical picture of extraoral maxillary nerve block with markings.
Nerves Anesthetized y When buccal soft tissue anesthesia is required (anterior
to mandibular first molar)
y Inferior alveolar nerve, along with its terminal branches:
y When lingual soft tissue anesthesia is required
■ Incisive nerve
■ Mental nerve.
y Diagnostic and therapeutic purpose.
y Lingual nerve. Contraindications

y Long buccal nerve (Fig. 9.27A)
y Acute inflammation or infection in the area of injection
Areas Anesthetized y Patients who might bite either the lip or the tongue
(young children or mentally handicapped adults).
y Inferior alveolar nerve: It supplies:
■ Mandibular teeth up to the midline Anatomical Landmarks
■ Body of the mandible
Soft Tissue Landmarks
■ Inferior portion of the ramus of the mandible
■ Buccal mucoperiosteum, mucous membrane, y Sulcus mandibularis, mucobuccal fold in the region of
anterior to mandibular first molar mandibular premolars and molars
■ Skin of the chin, skin of lower lip, and mucosa of y Buccal pad of fat
lower lip y Retromolar triangle area
y Lingual nerve: It supplies: y Pterygomandibular raphe/ligament
■ Mucosa of anterior 2/3rds of the tongue y Pterygomandibular space (Fig. 9.28A)
■ Mucosa of floor of the oral cavity
■ Lingual soft tissues and periosteum from the last Bony Landmarks (Fig. 9.27B)
molar to central incisor
■ Sublingual and submandibular salivary gland
y External oblique ridge.
y Internal oblique ridge
y Long buccal nerve: It supplies: y Anterior border of ramus of the mandible
■ Buccal mucoperiosteum in the region of mandibular
molars or buccal mucoperiosteum posterior to y Coronoid process
mental foramen, y Coronoid notch
■ Adjacent part of vestibular mucosa y Occlusal plane of mandibular molars
■ Adjacent part of buccal mucosa y Contralateral premolars.
■ Mucosa of retromolar fossa
Pterygomandibular Space is Bounded
Indications Anteriorly: Pterygomandibular raphe
y Surgical or operative dentistry: Procedures of multiple Posteriorly: Parotid gland
mandibular teeth and supporting structures in one Laterally: Ascending ramus of the mandible
quadrant Medially: Medial pterygoid muscle
A B
Figs. 9.27A and B: (A) Nerves anesthetized by pterygomandibular block—inferior alveolar, lingual, long buccal,
mental and incisive nerves; (B) Palpating the bony landmarks for the same.
Superiorly: Two heads of lateral pterygoid muscle The Height of Needle Insertion/Injection
Inferiorly: Attachment of medial pterygoid muscle.
y Place the index finger or thumb of the left hand on the
external oblique ridge or the anterior border of the
Approximating Structures when Needle is in Final
ramus of the mandible.
Position in Pterygomandibular Space
y When the finger contacts the anterior border of the
y Superior to the following: Inferior alveolar vessels ramus, it is moved up and down until the greatest
and nerve, insertion of the medial pterygoid muscle, depth of the anterior border of the ramus is identified.
mylohyoid vessels and nerve. This area is called the coronoid notch.
y Anterior to the deeper lobe of the parotid gland. y An imaginary horizontal line extends from the coronoid
y Medial to the medial surface of ramus of the mandible. notch posteriorly to the pterygomandibular raphe and
y Lateral to the following: Lingual nerve, medial determines the height of injection and is parallel to
pterygoid muscle, sphenomandibular ligament and 6–10 mm above the occlusal plane of mandibular
molars.
Types of Techniques The palpating finger is then moved lingually across
the retromolar triangle and onto the internal oblique
There are two techniques
ridge. The finger, still in line with the coronoid notch
1. Direct technique: In this technique the inferior alveolar
and in contact with the internal oblique ridge, is moved
nerve is anesthetized first, hence it is known as “direct
to the buccal side, taking with it the buccal pad of fat.
technique”. Most commonly used and is also known as
This gives better exposure to the internal oblique ridge,
Halsted approach.
the pterygomandibular raphe and the pterygotemporal
2. Indirect technique: In this technique the inferior depression.
alveolar is anesthetized in the third position. It is also When palpating the intraoral landmarks with the
known as three positional block technique. thumb/finger, the operator may place the index finger/
thumb extraorally behind the ramus of the mandible, thus
Technique for Locating the Landmarks holding the mandible between the thumb and the index
A 25 gauge 0.40 × 35–40 mm long needle is recommended. finger. In this manner the anteroposterior width of the
The target area is the inferior alveolar nerve as it passes ramus may be assessed.
downward towards the mandibular foramen, but before it
enters the foramen (Fig. 9.28B) Direct Technique
Patient is in semisupine or supine position, with mouth The syringe and the needle is then inserted at the
wide open. Occlusal plane of mandibular teeth must be previously described height of insertion from the opposite
parallel to the floor. side the mouth, at a level bisecting the finger, 6–8 mm
For the right sided block, the operator sits/stands at 8 above the midpoint of the coronoid notch and penetrating
o’clock position facing the patient. For the left sided block, the tissues of the pterygomandibular space.
the operator sits/stands at 10 o’clock position by the side The depth of the needle penetration can be deter
and slightly behind of the patient. mined by estimating when the tip of the needle has
A B
Figs. 9.28A and B: (A) Pterygomandibular raphe (arrow) is an important landmark in inferior alveolar nerve block;
(B) Various anatomical landmarks and their relation to the needle position for giving pterygomandibular block.
been advanced half the distance between the palpating
thumb and index finger. During insertion, the patient
is asked to keep the mouth wide open. The needle
is penetrated into the tissues to a depth 20–25 mm
until gently contacting bone on the medial surface
of the ramus of the mandible (the distance between
mandibular foramen and anterior border of ramus is
around 20–24 mm in adults).
The needle is then withdrawn about 1 mm, and
aspiration done, to avoid intravascular administration of
the solution (as this approach has more rate of positive
aspiration, some clinicians opt for the use of modified
Halsted method with a slightly inferior height at the
level of occlusal plane) and 0.8–1 mL of the solution is A
deposited slowly (in 60 seconds) (positive aspiration
is encountered in 10–15% of cases). The needle is then
withdrawn slowly and when about one-half of its inserted
depth has been withdrawn, the syringe is taken on the
ipsilateral side, without withdrawing the needle outside
the mucosa, 0.5 mL of the solution is injected in this area
to anesthetize the lingual nerve (Figs. 9.29A to C).
Long Buccal Nerve Block

The long buccal nerve is anesthetized with a separate
insertion.
Long buccal nerve injection: Hold the syringe with a
25-gauge and 1” needle, ready to inject at an angle of
45° to the body of the mandible keeping the bevel of the
B
needle facing the bone. The tissue in the mucobuccal
fold is entered just distal to the most posterior tooth or
the area to be subjected to surgery. About 0.25–0.5 mL of
local anesthetic solution is deposited in the midpoint of
the retromolar triangle between the external and internal
obliue ridges. The anesthesia is obtained within 2–3
minutes (Figs. 9.30 and 9.31).
Evaluation of Efficacy of the Anesthesia

y Subjective symptoms: Feedback from patient—tingling
and numbness of the lower lip on the side of injection
indicates anesthesia of the mental nerve, a terminal
branch of inferior alveolar nerve.
y Tingling or numbness of one-half of the tongue on the
side of injection indicates anesthesia of the lingual
C
nerve.
Figs. 9.29A to C: (A) Position of needle at the target area (above
y Objective symptom: Absence of pain during sharp
lingulae, at the opening of the mandibular foramen) during
probe instrumentation in between lower two premolars
inferior alveolar nerve block; (B) The syringe is directed from
on buccal side and probing half of the tongue and the contralateral side from the bicuspid region to block the
lingual gingiva (for IAN and LN). For buccal nerve inferior alveolar nerve first in direct technique; (C) The needle
probing is done on the buccal gingiva behind first is shifted to ipsilateral side to anesthetize lingual nerve in direct
lower molar. technique.
Errors During Injection

Too High Injection
y Anesthesia of the auriculotemporal nerve—numbness
of ear.
y Injection into lateral ptetygoid muscle—soreness,
trismus.
y Injection into the pterygoid plexus of veins
Too Low/Posterior Injection
y Local anesthesia (LA) deposited into parotid gland—
temporary facial nerve paralysis, parotitis.
y LA deposited in medial pterygoid muscle—pain,
trismus.
y LA deposited into the posterior facial vein—toxicity.
Fig. 9.30: Target area in long buccal nerve block. Too Medial Injection
LA deposited into the constrictor muscle of pharynx—
dysphagia.
Variables in Position of the Mandibular Foramen

The shape and size of the mandible and location of the
mandibular foramen differs among different individual
patients.
It can be due to:
y Actual width of ascending ramus
y Width of the mandibular arch
y Oblique angle of the mandible.
y Age of the patient: The position of the foramen
changes with the child’s age in 4 years old or younger,
the foramen is located often below the occlusal plane.
A
As the child grows, it moves to a higher position
(Fig. 9.32).
B
Figs. 9.31A and B: (A) Anatomical landmarks for long buccal nerve
block (occlusal plane and mucosa distobucal to last molar; (B)
The needle is aligned parallel to the occlusal plane on the side of
injection and the solution is deposited below the mucosa distal Fig. 9.32: Factors affecting the relative position of mandibular
and buccal to the last molar. foramen.
Various Reasons for Failure of Desired Anesthesia
Pterygomandibular block has a relatively high rate of
failure reported around 15–20%.
y Deposition of LA solution too low—below the mandi
bular foramen.
y Deposition of LA solution too far anteriorly on the
ramus.
y Accessory innervation to the mandibular teeth from:
■ Cervical plexus nerve C2, C3 branches (cutaneous
coli)
■ Buccal nerve
■ Mylohyoid nerve.
y The mandibular anterior teeth may have cross inner
vations from incisive nerve on the other side or from
mylohoid nerve. The lower premolars—20% of cases
have additional nerve supply from the cutaneous coli
nerve.
y Bifid inferior alveolar nerve, with second mandibular Fig. 9.33: Diagram showing indirect pterygomandibular block:
foramen located more inferiorly also is responsible for 1st position: The needle is in the first position for anesthetizing
incomplete anesthesia. long buccal nerve of the right side, syringe going from the
To overcome this additional paraperiosteal injec opposite side, after depositing LA solution, the needle is slightly
tion is given by holding syringe from the other side withdrawn backwards shown in diagram by short straight arrow
of mouth directing the needle tip to the apical area as shown in No. 2.
of the tooth/teeth to be treated or intraligamental or 2nd position: The syringe is shifted on the other side as shown
intraseptal injection can be given. with the long curved arrow mark towards No. 3 and needle is
slightly advanced, as shown by short straight arrow going towards
No. 4 in the diagram. The needle is inserted to deposit LA from the
Complications
same side, for anesthetizing lingual nerve.
Self-inflicted injuries like lip bite, cheek bite, tongue bite- 3rd position: The syringe is then swung on the opposite side
most common. Occurs usually in children or those with again as shown with short curved arrow. The needle is then further
learning disability. advanced and inserted from the opposite side for anesthetizing
y Inadequate anesthesia/Readministration of injection inferior alveolar nerve as shown in No. 5. In this technique, only
(Dose): Common one prick of the needle is used and it is withdrawn within the space
in three different positions.
y Trismus: Common—too medial injection in medial
pterygoid muscle
y Hematoma: Entry in the blood vessel. ridges—distobuccal to last molar—for long buccal
y Pain at injection site: Occasional nerve deposit 0.5 mL by directing the needle parallel to
y Needle breakage: Avoid inserting complete needle till the occlusal plane.
the hub and use correct gauge of the needle y 2nd position: The direction is from the same side—for
y Prolonged anesthesia: Paresthesia is persistent lingual nerve deposit 0.5 mL.
anesthesia beyond the expected normal duration. May y 3rd position: The direction is from the opposite side—
be because of the injury for inferior alveolar nerve
y Undesired nerve block Rest of 1 mL solution is deposited.
y Transient facial paralysis: Too posterior injection in All the steps of palpating the landmarks will be same
as mentioned in direct technique. At least 2 minutes
parotid gland affecting branches of facial nerve
should be taken to deposit 2 mL of solution.
y Bleeding related to injection Wait for subjective symptoms. These are:
y Rarely needle tract infection ■ A feeling of warmth or tingling sensation in the lip,
which starts at the corner of the mouth and spreads
Indirect Technique until it reaches the midline of the lip. The tingling
This technique of anesthetizing the branches of mandi changes into a gradually increased feeling of
bular nerve is also known as “three positional nerve block profound numbness; the lip may also feel swollen.
technique” (Fig. 9.33) ■ The tip and side of the tongue tingle and then
y 1st position: The direction is from the opposite side— become numb. For profound anesthesia, the
to inject between the external and internal oblique operator must wait for 5–10 minutes.
Mental Nerve Block Areas Anesthetized

Nerves anesthetized: Mental nerve, incisive nerve, part of y All mandibular teeth up to the midline on the side of
inferior alveolar nerve. injection
Target area: Vicinity of mental nerve between lower first y Buccal mucoperiosteum on the side of injection
and second premolars. y Mucosa of the anterior 2/3rds of the tongue
Areas anesthetized: Labial mucous membrane and y Mucosa of the floor of the mouth
pulpal tissue from the first premolar to the midline, plus y Lingual mucoperiosteum from the last standing molar
periodontium and supporting alveolar bone, skin of the tooth up to the central incisor in the midline
lower lip and chin. y Body of the mandible, and inferior portion of the
ramus, etc.
Technique (Figs. 9.34A and B) y Skin over the zygoma, posterior portion of the cheek
and temporal regions, etc.
y 25–30 gauge, 25 mm short needle with aspirating
syringe is loaded. Indications
y Palpate the mental foramen, between the apices of first
y Surgical procedures on mandibular body and the
and second premolar with index finger.
ramus
y Bone around it is rough and the opening is directed
y When buccal soft tissue anesthesia from the third
posteriorly molar up to the midline is required
y Insert the needle in the mucobuccal fold between
y Surgical procedures in the tongue and the floor of the
the two premolars directing the syringe towards the mouth
mental foramen.
y When conventional inferior alveolar nerve blocks fail
y Advance the needle till foramen is reached. to act
y Depth of penetration is 5–6 mm. y Restorative procedures on multiple teeth
y Aspirate—if negative, then inject LA 0.5–1.5 mL. Wait
for 3 minutes for anesthesia to set in. Contraindications
Gow–Gates’ Mandibular Nerve Block y Presence of infection or acute inflammation at the site
of injection.
Technically more difficult than the traditional and closed y Young children and mentally challenged adults, who
mouth method and requires skill and experience. might bite either their lip or the tongue.
y Patients with restricted oral opening.
Nerves Anesthetized
The entire mandibular branch of trigeminal nerve is Advantages
anesthetized. It includes the following: (1) inferior y Good success rate
alveolar nerve along with its terminal branches; mental y Decreased rate of aspiration of blood
and incisive nerves, (2) lingual, (3) mylohyoid, (4) y Decreased incidence of trismus
auriculotemporal, and (5) long buccal nerve. y Single injection technique
A B
Figs. 9.34A and B: (A) Target area in mental nerve block. The solution is deposited in the vicinity of the mental foramen.
(B) Mental nerve block clinical picture.
Fig. 9.36: Extraoral landmarks in Gow–Gates mandibular nerve

Fig. 9.35: Target area for Gow–Gates technique. block (corner of mouth and tragus of ear).
Anatomical landmarks y Identification of the landmarks (Figs. 9.36 and 9.37):

■ The operator visualizes the landmarks and an
y Extraoral landmarks imaginary line is drawn from the corner of the
■ External ear mouth to the intertragic notch of the ear.
■ Intertragic notch of the ear ■ The anterior border of the ramus and the coronoid
■ Corner of the mouth process is palpated with the help of the thumb of
y Intraoral landmarks the left hand. This helps in retraction of tissues and
■ Anterior border of the ramus of the mandible determination of the site of nerve penetration.
■ Tendon of temporalis muscle
■ Mesiopalatal cusp of maxillary second molar
y Configuration of the needle: The recommended
gauge and length of the needle are 25 and 40 mm
respectively.
Technique
y Site and height of penetration:
Target area: Lateral side of the condylar neck, just below ■ The patient is advised to keep mouth widely open
the insertion of the lateral pterygoid muscle (Fig. 9.35). and to remain in that position until the injection
is completed. This position moves the condyle
Procedure anteriorly, thus facilitating the injection.
y Position of the patient: The patient is placed in semi- ■ The operator takes a preloaded syringe and aligns
supine position. the barrel of the syringe with the plane extending
y Position of the operator: The operator stands in front from the corner of the mouth to the intertragic
of the patient for right-sided block; and by the side of notch directing the syringe from the corner of the
the patient for left-sided block. mouth on the opposite side.
A B
Figs. 9.37A and B: (A) Traget are in Gow–Gates mandibular nerve block is neck of condyle;
(B) Intraoral landmarks for Gow–Gates mandibular nerve block.
■ The needle is gently inserted into the mucous Akinosi (Closed Mouth) Mandibular Nerve Block/
membrane just distal to the last maxillary molar Vazirani–Akinosi Block
tooth present, at the height of the mesiopalatal cusp Initially described in 1960, by Vazirani and later described
of maxillary second molar. When the third molar is by Joseph Akinosi in 1977. In 1992, Wolfe suggested a
present, the site of penetration is distal to the third modification of 45° angulation of the needle.
molar, lateral to pterygotemporal depression and
medial to the tendon of temporalis muscle. Nerves Anesthetized
y Depth of penetration: The needle is advanced slowly The entire mandibular branch of trigeminal nerve,
until bone is contacted at the neck of the condyle. The comprising of inferior alveolar nerve along with its
average depth of soft tissue penetration is 25 mm. terminal branches; mental and incisive nerves, lingual,
y If bone contact is not established, the needle should and mylohyoid nerves, except the long buccal nerve.
be withdrawn slightly and redirected until the bone
contact is made, at the neck of the condyle. The average Areas Anesthetized
depth of soft tissue penetration is 25 mm. y All mandibular teeth on the side of injection up to the
y If aspiration is negative, then 2 mL of local anesthetic midline.
solution is deposited slowly over 60–90 seconds. y Body of the mandible and inferior portion of the ramus.
y Withdraw the syringe and keep the needle covered. y Buccal mucoperiosteum and mucous membrane
anterior to the mental foramen.
y Ask the patient to keep the mouth open for 2–3 minutes
y Mucous membrane of the anterior 2/3rds of the tongue
to allow adequate diffusion of local anesthetic solution, and of the floor of the oral cavity.
and bathing of the nerve trunk with the solution.
y Lingual soft tissues and periosteum.
y The onset of anesthesia with this technique is
somewhat slower, requiring 5–7 minutes. Indications
Signs and Symptoms

y Limited mandibular opening—trismus
y Multiple procedures on mandibular teeth
y Subjective: y Inability to visualise the landmarks for inferior alveolar
■ Numbness or tingling sensation of the lower lip nerve block
■ Numbness or tingling sensation of the tongue
Contraindications
y Objective: On probing and during surgical procedure—
absence of pain y Presence of acute inflammation or infection at the site
of injection.
Advantages y Young children and mentally challenged adults, who
might bite either their lip or the tongue.
y Requires only one injection
y Minimum aspiration rate y Inability to visualize or gain access to the lingual aspect
of the ramus.
y Minimum postinjection complications
y Successful anesthesia even in cases of bifid inferior Advantages
alveolar nerve canal
y Relatively atraumatic
Disadvantages y Patient need not open their mouth
y Fewer postoperative complications (i.e., trismus)
y Onset is longer
y Lower aspiration rate than with inferior alveolar nerve
y Learning curve to master the technique is mor block, as there is a minimum chance of over insertion
y Lingual and lower lip anesthesia can be uncomfortable. of the needle and entry into the vessels of pterygoid
plexus.
Complications
y Provides successful anesthesia where a bifid inferior
y Hematoma alveolar nerve and bifid mandibular canals are present.
y Trismus
y Temporary paralysis of cranial nerves II, IV and VI. Disadvantages
y Failure of anesthesia: y Difficult to visualize the path of the needle and the
■ Too little volume of local anesthetic solution depth of insertion.
deposited. y No bony landmarks available, so no bony contact, so
■ Anatomical difficulties. the depth of penetration is somewhat arbitrary.
It must be facing away from the bone of mandibular
ramus and towards the midline.
y Height of injection: With Akinosi’s technique it is
below that of Gow–Gates’ technique but above that of
inferior alveolar nerve block.
y Target area: The soft tissues on the medial border of
ramus of the mandible in the region of inferior alveolar
nerve as it travels towards the mandibular foramen,
lingual nerve, and mylohyoid nerves and vessels.
Procedure
y Position of the patient: The patient is seated in
semireclining position with head, neck and shoulder
adequately supported.
y Position of the operator: The operator stands in front
of the patient for both right-sided as well as left-sided
Fig. 9.38: Various landmarks and target area for block.
Vazirani–Akinosi block.
y Preparation of the tissues: The site of penetration
is prepared by topical application of antiseptic and
y Potentially painful/traumatic if the needle is too close
anesthetic solutions.
to periosteum.
y Closed mouth technique has higher failure rate than y The patient is asked to bring teeth in occlusion. This
aids in relaxation of cheek musculature and helps in
conventional IANB.
good visualization of the landmarks. The operator
Anatomical Landmarks retracts the patient’s lips and cheek exposing the
maxillary and the mandibular teeth on the ipsilateral
y Occlusal plane of teeth in occlusion side.
y Mucogingival junction of maxillary molar teeth y The preloaded syringe with the recommended needle
y Anterior border of ramus of the mandible is taken and the barrel of the syringe is aligned parallel
y Maxillary tuberosity (Fig. 9.38). to the occlusal and sagittal plane but positioned at the
level of the mucogingival junction of the maxillary
Technique (Figs. 9.39A and B) molars.
y Needle: The recommended length is 1 and 1/2 or 38–40 y The needle penetrates the mucosa in the embrasure
mm, and the gauge is 25. just medial to the ramus lateral to maxillary tuberosity
y Bevel: The position of the bevel of the needle in the and is inserted approximately 1½" or 25–30 mm. The
closed mouth mandibular block is very significant. tip of the needle lies in the target area in the midportion
A B
Figs. 9.39A and B: Vazirani–Akinosi closed mouth mandibular nerve block technique: (A) The target area for deposition of the anesthetic
solution is medial side of ramus of mandible (near midpoint of pterygomandibular space); (B) Clinical picture—the syring is held parallel
to the maxillary occlusal plane with the needle at the level of mucogingival junction of second and third maxillary molars.
of pterygomandibular space, close to the branches of y Transient facial nerve paralysis due to overinsertion of
mandibular nerve. the needle and deposition of the solution into the body
y Following negative aspiration, about 2 mL of local of the parotid gland, near the posterior border of the
anesthetic solution is slowly deposited approximately ramus of the mandible.
1 minute.
y Motor nerves paralysis will develop as quickly or more Complications due to the Use of LA
quickly than sensory anesthesia. The patient with The complications arising from the use of local anesthetic
trismus will begin to notice increased ability to open agents are classified as: (1) Local complications and
the jaws shortly after the deposition of local anesthetic (2) Systemic complications.
solution.
y Anesthesia of the lips and tongue will be noticed in 40– Local Complications
90 seconds and the surgical procedures can be usually Local complications are again considered in three
started within 5 minutes. categories:
1. Complications arising from drugs or chemicals used
Signs and Symptoms
■ Soft tissue injury
Tingling or numbness of the lower lip and tongue (Fig. 9.40). ■ Sloughing of tissues (tissue necrosis)
2. Complications arising from injection techniques
Failure of Anesthesia ■ Breakage of anesthetic cartridge
y Failure to appreciate the flaring nature of the ramus ■ Breakage of needle
which deflects the needle more medially, if internal ■ Needle-stick injuries
oblique ridge is not negotiated by keeping the syringe ■ Hematoma
nearly at an angle of 90º (perpendicular) to the medial ■ Failure to obtain local anesthesia
surface of ascending ramus. This can be easily achieved 3. Complications arising from both
by retracting the angle of the mouth posteriorly with ■ Pain on injection.
the barrel of the syringe. ■ Burning on injection.
y Point of needle insertion is too low. ■ Infection.
y Underinsertion or overinsertion of the needle as no
■ Trismus.
bone is contacted in this technique, the depth of soft
■ Edema.
tissue penetration is somewhat arbitrary. Akinosi
■ Persistent paresthesia or anesthesia.
recommended a penetration depth of 25 mm in the
■ Persistent or prolonged pain
average sized adult measuring from the maxillary
■ Post-injection herpetic lesions or post-anesthetic
tuberosity.
intraoral lesions.
Complications ■ Neurological complications, such as:
Facial nerve paresis or paralysis, and
y Hematoma, rarely.
Visual disturbances:
y Trismus, rarely.
− Diplopia
− Amaurosis or temporary blindness
− Permanent blindness.
These are discussed in detail along with management
in Apendix II printed at the end of the book.
Systemic Complications
The systemic complications that occur due to the local
anesthetic agents fall into following categories:
y Vasodepressor syncope
y Adverse drug reactions, such as:
■ Allergic reactions
■ Anaphylactic reactions
■ Toxic reactions (overdose)
■ Idiosyncratic reactions.
Fig. 9.40: Sloughing of the tissues of the lower lip, following Management of adverse drug reactions due to LA is
inadvertent lip biting injury after the numbness of lower lip discussed in the Chapter 51—Management of Medical
following pterygomandibular block. Emergencies in Dental Clinic.
Prevention of Needle Breakage 5. Chitre AP, Parkar MI. A clinical comparative study of
anesthetic effects of marcaine and xylocaine in minor oral
y Avoid using smaller gauge needle (30 and higher)
surgery. Dent Dialog 1 and 2. 1981;11-5.
y Do not use short needle for IANB.
6. Council on Dental therapeutics of the American Dental
y Do not advance the needle to a point of hub touching Association: Accepted Dental Therapeutics, 40th edition.
the mucosa. Chicago: American Dental Association; 1984.
y Do not bend the needle. 7. Derrikson E, Granberg PO. Studies on the renal
y Do not give excessive lateral force while injecting. excretion of Citanest and Xylocaine. Acta Anesth Scand.
y Use caution while injecting children, special needs, 1985(Suppl);16:79-85.
and dental phobic patients. 8. Donaldson D, James-Perdok L, et al. A comparison of
Ultracaine DS (Articaine HCl) and Citanest forte (Prilocaine
CONCLUSION HCl) in maxillary infiltration and mandibular nerve block. J
Can Dent Assoc. 1987;53:1:38-42.
Local anesthetic agents are relatively safe and free of side
9. Dunsky JL, Moore PA. Long-acting local anesthetics: a
effects provided they are administered in an appropriate
comparison of bupivacaine and etidocaine in endodontics.
dosage and in an appropriate anatomical location.
J Endodont. 1984;10:457-60.
10. Ernberg M, Kopp S. Ropivacaine for dental anesthesia; a
Points to Remember dose finding study. J Oral Maxillofac Surg. 60:9:9004-1010,
Definition of pain discussion 1010-1011, 2002.
Propagation of electrical impulses across the nerve: 11. Giovannitti JA, Bennett CR. The effectiveness of 1.5%
Physiology of nerve conduction etidcaine HCl with epinephrine 1:200 000 and 2%
Definition of local anesthesia lidocaine HCl with epinephrine 1:100 000 in oral surgery:
Theories for mechanism of action of local anesthetic a clinical comparison. JADA. 1983;107:616-8.
agents
12. Gupta PP, Tangri AN, Saxena RC, et al. Clinical pharmacology
Details of mechanism of action of local anesthetic
agent
studies on 4-N-butylamino-1,2,3,4,-tetrahydroacrydine
Classification of local anesthetic agents
hydrochloride (Centbucridine)—a new local anaesthetic
Properties of an ideal local anesthetic drug/agent agent. Indian J Exp Biol. 1982;20:344-6.
Lignocaine: Chemistry and pharmacology 13. Haas DA, Lennon D. A 21 year retrospective study of reports
Commercially prepared local anesthetic solution for of paresthesia following local anesthetic administration. J
clinical use in dentistry Can Dent Assoc. 1995;61:4:319-30.
Pharmacology of specific vasoconstrictor agents 14. Hawkins JM, Moore PA. Local Anesthesia: advances in
Armamentarium
agents and techniques. Dent Clinic N Am. 2002;46:719-32.
Injection techniques for regional anesthesia
Complications
15. Hersh EV. Local Anesthetics in Oral and Maxillofacial
Surgery. In Oral and Maxillofacial Surgery by Fonseca
RJ. Vol I: Anesthesia/Dentoalveolar Surgery/Office
Management. Saunders; 2000;58-78.
BIBLIOGRAPHY
16. Howe GL. Minor Oral Surgery, 3rd edition. Mumbai:
1. Arthur GR, Covino BG. Whats new in local anesthetics? Butterworth-Heinemann Ltd. Varghese Publishing House,
Anesthesiol Clin North Am. 1988;6:357-70. Reprint; 1985.
2. Arthur GR, Feldman HS, Covino BG. Comparative 17. Jakobs W. Actual aspect of dental anesthesia in Germany,
pharmacokinetics of bupivacaine and ropivacaine, a new presented at the 10th International Dental Congress on
amide local anesthetic. Anesth Analog. 1988;67:1053-8. Modern Pain Control, IFDAS, Edinburgh, Scotland, UK; 2003.
3. Beri S, Biswas NR, Shende D, et al. Injectable centbucridine 18. Malamed SF, Gagnon S, Leblanc D. Efficacy of Articaine:
and lidocaine hydrochloride for intraocular surgery. a new Amide Local Anesthetic. JADA. 2000;31(5):635-42.
Ophthalmol Surg Lasers. 1997;28:12:1027-9. 19. Malamed SF. Handbook of Local Anesthesia, 4th edition.
4. Brown DL, Carpenter RL, Thompson GE. Comparison New Delhi: Harcourt India Private Limited (Mosby) Indian
of 0.5% ropivacaine and 0.5% bupivacaine for epidural Reprint; 2001.
anesthesia in patients undergoing lower-extremity 20. Malamed SF. Handbook of Local Anesthesia, 5th edition.
surgery. Anesthesiology. 1990;72:633-6. Mosby; 2004.

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Chapter 9  Local Anesthesia for Orofacial Region 183

(sprays and related to increased dosage), broken skin,

Table 9.7: Common topical anesthetic preparations used in dentistry.

Documentation Advantages of Local Verses General Anesthesia

Paraperiosteal Infiltration Injection Disadvantages

Figs. 9.17A and B: Diagrammatic representation of palatal infiltration technique.

Fig. 9.18: Clinical picture of palatal infiltration.

injected. Terminal branches of the long buccal nerve also

y Periodontal ligament injection (intraligamentary) Techniques of Maxillary Anesthesia

Nerve Blocks or Conduction Anesthesia

Infraorbital Nerve Block/Anterior Superior Technique

Disadvantages Extraoral Maxillary Nerve Block

y Lingual nerve. Contraindications

Long Buccal Nerve Block

Evaluation of Efficacy of the Anesthesia

Errors During Injection

Variables in Position of the Mandibular Foramen

Mental Nerve Block Areas Anesthetized

Fig. 9.36: Extraoral landmarks in Gow–Gates mandibular nerve

Anatomical landmarks y Identification of the landmarks (Figs. 9.36 and 9.37):

Signs and Symptoms

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