Dental Anesthesiology Advantages of Local Anesthesia

Midterms ● The patient remains awake and

cooperative
Techniques of Regional Anesthesia
● There is little distortion of the normal
1.Nerve Block physiology of the patient
● There is low incidence of morbidity
-Local anesthetic is deposited close to main
nerve trunk, usually at a distance from the site of ● The patient may leave the office
operative intervention. unescorted
● No additional trained personnel
2.Field Block needed.
-Local anesthetic is deposited near the larger ● The techniques are not difficult to
terminal nerve branches so the anesthetized area master.
will be circumscribed, preventing the passage of ● The percentage of failure is small.
impulses from the tooth to the central nervous ● There is no additional expense for the
system (CNS) patient.
● The patient need not omit the previous
-Incision (or treatment) is then made into an area
meal.
away from the site of injection of the anesthetic
Contraindications of Regional Anesthesia
3. Local Infiltration
-Small terminal nerve endings in the area of the ● Infection at the site of injection
dental treatment are flooded with local ● Major oral surgery
anesthetic solution. Incision (or treatment) is ● Allergy to LA
then made into the same area in which the local ● Other conditions/anomalies that
anesthetic has been deposited preclude the use of LA i.e.,
methemoglobinemia; sulfonamide use
● The patient refuses regional anesthesia
because of fear or apprehension.
● The patient is below the age of reason
● The patient, because of mental
deficiencies, is unable to cooperate.

Pre-Anesthetic Evaluation

● The patient’s general and physical

condition.
● The need for medical consultation.
● Any history of an unpleasant anesthetic
experience,
● Specific drug sensitivity of the patient.
● The need for pre-medication or intra-
operative sedation.
● The time required for the procedure.
● Technique to be used.
● The choice of the anesthetic solution.
 ● The need and quantity of a *stabilization may be increased by drawing the
vasoconstrictor. administrators arm in against his/her chest

Precautionary measure to prevent untoward * index finger used to stabilize the needle
reactions during local anesthesia during nasopalatine block.

● Obtain a detailed medical history *keep the syringe out of the patient’s line of
● Always aspirate prior to injecting the sight by passing it behind the patient’s head/a
solution few inches above the patient’s chest.
● Use sharp needles.
Aspiration
● Inject LA slowly
● Use smallest possible quantity of LA ● Minimizes the possibility of an
● Use lowest possible concentration of intravascular injection.
LA ● The goal is to determine where the tip
● Use the least toxic LA which will of the needle is situated
produce satisfactory anesthesia. ● To aspirate, one must create a negative
● Observe patient during and after pressure inside the cartridge
injection. ● During aspiration, adequate
stabilization is mandatory
Atraumatic Injection technique (Basic injection
● With a harpoon aspirating syringe, the
Technique)
thumb ring should be pulled back gently
● Use a sterilized sharp needle. (1-2mm)
● Check the flow of local anesthetic ● POSITIVE aspiration- any sign of blood,
solution. Determine whether to warm local anesthetic solution should not be
the anesthetic cartridge or syringe. deposited at the site
● Position the patient. ● NEGATIVE aspiration- no return of
● Dry the tissue with sterile gauze blood or small amount air bubble.
● Apply topical antiseptic
Hand position for injection (hand grasp)
● Apply topical antiseptic
● Communicate with the patient. ● Palm down
● Establish a firm hand rest ● Palm up
● Make the tissue taut. ● Palm up and finger rest.
● Keep the syringe out of the patient’s
line of sight Intraoral Techniques
● A. insert the needle into the mucosa. ● Submucosal
● B. watch and communicate with the ● Para/supraparaperiosteal
patient ● Infraorbital NB (ASAN BLOCK)
● Inject several drops of local anesthetic ● PSAN BLOCK
solution ● Naso palatine nerve block (incisive canal
● Slowly advance the needle toward the injection)
target. ● Anterior nerve block (greater palatine
*use the chin as a finger rest, with the syringe NB)
barrel stabilized by the patient’s lip ● Maxillary nerve block-high tuberosity
technique and greater palatine canal
technique
 Techniques of Maxillary Anesthesia Other Common Names. Local infiltration,
paraperiosteal
Submucosal Injection
injection.
-local infiltration
Nerves Anesthetized. Large terminal branches
-most superficial technique except for topical
of the dental plexus.
anesthetic
Areas Anesthetized. The entire region
Nerves anesthetized: Terminal branches of free
innervated by the large terminal branches of
nerve endings
this plexus: pulp and root area of the tooth,
Areas anesthetized; the area into which the buccal periosteum, connective tissue, and
local anesthetic solution is infiltrated. mucous membrane

Indication :when on the mucous membrane and Indications

underlying connective tissue are to be
1. Pulpal anesthesia of the maxillary teeth when
anesthetized.
treatment is limited to one or two teeth
-used for incisions in the mucous membrane or
2. Soft tissue anesthesia when indicated for
before insertion of the other needle.
surgical procedures in a circumscribed area
Anatomical landmarks: no anatomical land
Contraindications
marks are used because the solution is
infiltrated over the required area, 1. Infection or acute inflammation in the area of
injection.
Techniques:
2. Dense bone covering the apices of teeth (can
1.Prepare tissue at the site of injection
be determined only by trial and error; most
2.insert 27 gauge short needle beneath the likely over the permanent maxillary first molar
mucous membrane into the connective tissue I in children, as its apex may be located beneath
the area to be anes the zygomatic bone, which is relatively dense).
The apex of an adult’s central incisor may also
3.aspirate be located beneath denser bone (e.g., of the
4.deposit the anesthetic solution slowly. nose), thereby increasing the failure rate
Solution should not be injected too rapidly or (although not significantly).
into large volume Advantages
5.withdraw the syringe slowly 1. High success rate (>95%)
6. Make the needle safe 2. Technically easy injection
Symptoms of anesthesia: 3. Usually entirely atraumatic
1.subjective: not valid Disadvantages. Not recommended for large
2.objective: instrumentation is necessary to areas because of the need for multiple needle
demonstrate absence of pain sensation insertions and the necessity to administer larger
total volumes of local anesthetic.
Supraperiosteal Injection
Positive Aspiration. Negligible, but possible there be any patient discomfort with this
(<1%). injection.

Alternatives. PDL, IO, regional nerve block. g. Aspirate ×2.

Technique (1) If negative, deposit approximately 0.6 mL

(one third of a cartridge) slowly over 20
1. A 27-gauge short needle is recommended.
seconds. (Do not allow the tissues to balloon.)
2. Area of insertion: height of the mucobuccal
h. Slowly withdraw the syringe
fold above the apex of the tooth being
anesthetized i. Make the needle safe.

3. Target area: apical region of the tooth to be j. Wait 3 to 5 minutes before commencing the
anesthetized dental procedure.

4. Landmarks: Signs and Symptoms

a. Mucobuccal fold 1. Subjective: feeling of numbness in the area of

b. Crown of the tooth administration

c. Root contour of the tooth 2. Objective: use of electrical pulp testing (EPT)
with no response from tooth with maximal EPT
5. Orientation of the bevel*: toward bone
output (80/80)
6. Procedure:
3. Absence of pain during treatment
a. Prepare tissue at the injection site.
Complications. Pain on needle insertion with
(1) Clean with sterile dry gauze. the needle tip against the periosteum. To
correct: Withdraw the needle and reinsert it
(2) Apply topical antiseptic (optional). farther from the periosteum.
(3) Apply topical anesthetic for minimum of

1 minute.

b. Orient needle so bevel faces bone.

c. Lift the lip, pulling the tissue taut.

d. Hold the syringe parallel with the long axis of

the tooth

e. Insert the needle into the height of the

mucobuccal fold over the target tooth.

f. Advance the needle until its bevel is at or

above the apical region of the tooth (Table 13-
1). In most instances, the depth of penetration
is only a few millimeters. Because the needle is
in soft tissue (not touching bone), there should
be no resistance to its advancement, nor should
 Positive Aspiration. Negligible.

Alternatives

1. For hemostasis: none

2. For pain control: nasopalatine or greater

palatine nerve block, AMSA, maxillary nerve
block

Technique

1. A 27-gauge short needle is recommended.

2. Area of insertion: the attached gingiva 5 to 10

Local Infiltration of the Palate
mm from the free gingival margin

3. Target area: gingival tissues 5 to 10 mm from

Other Common Names. None. the free gingival margin

Nerves Anesthetized. Terminal branches of the 4. Landmark: gingival tissue in the estimated
nasopalatine and greater palatine. center of the treatment area

Areas Anesthetized. Soft tissues in the 5. Pathway of insertion: approaching the

immediate vicinity injection site at a 45-degree angle

Indications 6. Orientation of the bevel: toward palatal soft

tissues
1. Primarily for achieving hemostasis during
surgical procedures 7. Procedure:

2. Palatogingival pain control when limited a. If a right-handed administrator, sit at the 10

areas of anesthesia are necessary for o’clock position.
application of a rubber dam clamp, packing of
(1) Face toward the patient for palatal
retraction cord in the gingival sulcus, or
infiltration
operative procedures on not more than two
teeth on the right side.
Contraindications (2) Face in the same direction as the patient for
1. Inflammation or infection at the injection site palatal infiltration on the left side.
2. Pain control in soft tissue areas involving b. Ask the patient to do the following:
more than two teeth
(1) Open wide.
Advantages
(2) Extend the neck.
1. Provides acceptable hemostasis when a
vasoconstrictor is used (3) Turn the head to the left or right for
improved
2. Provides a minimum area of numbness
visibility.
Disadvantage. Potentially traumatic injection.
c. Prepare the tissue at the site of injection. 1 :50,000 concentration). (Norepinephrine is
not available in dental local anesthetics in the
(1) Clean and dry with sterile gauze.
United States or Canada.)
(2) Apply topical antiseptic (optional).

(3) Apply topical anesthetic for 2 minutes.

d. Deposit a small volume of local anesthetic.

e. continue to advance needle and deposit

anesthetic until bone is gently contacted. Tissue
thichness is only 3-5mm in most patients.

f. Withdraw the syringe.

g. Make the needle safe.

h. Commence the dental procedure

immediately.

Signs and Symptoms

1. Subjective: numbness, ischemia of the palatal

soft tissues

2. Objective: no pain during dental therapy

Safety Features. Anatomically safe area for

injection. Nasopalatine Nerve Block

Precaution. Highly traumatic procedure if Other Common Names. Incisive nerve block,
performed sphenopalatine nerve block.

improperly. Nerves Anesthetized. Nasopalatine nerves

bilaterally.
Failure of Hemostasis
Areas Anesthetized. Anterior portion of the
1. The percentage of success is higher if hard palate (soft and hard tissues) bilaterally
vasoconstrictor is included in the anesthetic from the mesial of the right first premolar to
solution; however, inflamed tissues may the mesial of the left first premolar
continue to hemorrhage despite the use of
vasoconstrictor. Indications

Complications 1. When palatal soft tissue anesthesia is

necessary for restorative treatment on more
1. Few of significance than two teeth (e.g., subgingival restorations,
2. Necrosis of soft tissues may be observed insertion of matrix bands subgingivally)
when a highly concentrated vasoconstricting 2. For pain control during periodontal or oral
solution is used for hemostasis over a surgical procedures involving palatal soft and
prolonged period (e.g., norepinephrine, hard tissues
repeated injections of epinephrine in a
Contraindications 5. Path of insertion: Approach the injection site
at a 45-degree angle toward the incisive papilla.
1. Inflammation or infection at the injection site
6. Orientation of the bevel: toward the palatal
2. Smaller area of therapy (one or two teeth)
soft tissues (review procedure for the basic
Advantages palatal injection)

1. Minimizes needle penetrations and volume Procedure:

of solution
a. Sit at the 9 or 10 o’clock position facing
2. Minimal patient discomfort from multiple in the same direction as the patient
needle penetrations b. prepare the tissue
c. Do prepuncture technique
Disadvantages d. Slowly insert a 27g short needle toerd
1. No hemostasis except in the immediate area the incisive formen (5mm into the
of injection canal) until bone is gently contacted
e. Aspirate
2. Potentially the most traumatic intraoral f. If,negative, slowly deposit not more
injection; however, the protocol for an than ¼ of a cartridge(0.45ml)
atraumatic injection or use of a C-CLAD system g. Slowly withdraw the syringe
or a buffered local anesthetic solution can h. Make the needle safe
minimize or entirely eliminate discomfort i. Wait for 2-3 minutes before
Positive Aspiration. Less than 1%. commencing the dental procedure.

Alternatives Complications

1. Local infiltration into specific regions 1. Few of significance

2. Maxillary nerve block (unilateral only) 2. Hematoma is possible but extremely rare
because of the density and firm adherence of
3. Anterior middle superior alveolar (AMSA) palatal soft tissues to bone.
nerve block (unilateral only)
3. Necrosis of soft tissues is possible when
Technique (Single-Needle Penetration of the highly
Palate) concentrated vasoconstricting solution (e.g.,
norepinephrine) is used for hemostasis over a
1. A 27-gauge short needle is recommended. prolonged period
2. Area of insertion: palatal mucosa just lateral
to the incisive papilla (located in the midline
behind the central incisors); the tissue here is
more sensitive than other palatal mucosa

3. Target area: incisive foramen, beneath the

incisive papilla

4. Landmarks: central incisors and incisive

papilla
 1. Pulps of the maxillary central incisor through
the canine on the injected side
2. In about 72% of patients, pulps of the
maxillary
premolars and mesiobuccal root of the first
molar
3. Buccal (labial) periodontium and bone of
these same teeth
4. Lower eyelid, lateral aspect of the nose, upper
lip

1. A 25- or 27-gauge long needle is

recommended, although the 27-gauge short also
may be used, especially for children and smaller
adults.
2. Area of insertion: height of the mucobuccal
fold directly
over the first premolar
3. Target area: infraorbital foramen (below the
infraorbital notch).
4. Landmarks:
a. Mucobuccal fold
b. Infraorbital notch
c. Infraorbital foramen
5. Orientation of the bevel: toward bone
Procedure
1. Assume correct position, sit at 10
o’clock position, directly facing the
patient or facing the same direction as
the patient.
2. Position the patient supine with neck
extended slightly.
3. Prepare the tissue at the injection site
4. Locate the infraorbital foramen
(1) Feel the infraorbital notch.
(2) Move your finger downward from the notch,
applying gentle pressure to the tissues.
(3) The bone immediately inferior to the notch
is convex
Infraorbital Nerve block (ASA NB) (4) As your finger continues inferiorly, a
concavity is felt; this is the infraorbital foramen.
Nerves Anesthetized 5. maintain your finger on the foramen 6.
1. Anterior superior alveolar Retract the lip, pulling the tissue in the
2. Middle superior alveolar mucobuccal fold taut.
3. Infraorbital nerve
7.insert the 25 or 27 long needle into the
a. Inferior palpebral
height of mucobuccal fold
b. Lateral nasal
c. Superior labial A) BICUSOID APPROACH: over the 1st premolar
Areas Anesthetized B) CENTRAL INCISOR Approach: in the direction
when you bisect the crown of the central incisor
from the mesioincisal angle to the distogingival
angle.
8.advence the needle slowly until bone is
gently contacted. Point of contact should be the
upper rim of the infraorbital foramen.(general
depth of needle penetration 16mm for an
average height adult
9. orient the bevel facing the infraorbital
foramen
10.aspirate
11.slowly deposite 0.9 to 1.2 ml or ½ tp 2/3 of
the cartridge over 30 to 40 seconds
12.withdraw the syringe slowly
13.Maintain direct pressure over the injection
site for 1 minute
14.wait for 3 to 5 minutes before starting dental
procedure.
Signs and Symptoms
1. Subjective: Tingling and numbness of the
lower eyelid, side of the nose, and upper lip
indicate anesthesia of the infraorbital nerve,
not the ASA or MSA nerve (soft tissue
anesthesia develops almost instantly as the
anesthetic is being administered).
2. Subjective and objective: numbness in the
teeth and soft tissues along the distribution of
the ASA and MSA nerves (developing within 3 to
5 minutes if pressure is maintained over the
injection site)
Greater Palatine Nerve Block
3. Objective: use of electrical pulp testing with
no
Other Common Name. Anterior palatine nerve
response from tooth with maximal EPT output
block.
(80/80)
Nerve Anesthetized. Greater palatine.
4. Absence of pain during treatment
Areas Anesthetized. The posterior portion of
the hard palate and its overlying soft tissues,
anteriorly as far as the first premolar and
medially to the midline
A 27-gauge short needle is recommended.
2. Area of insertion: soft tissue slightly anterior
to the greater palatine foramen
3. Target area: greater (anterior) palatine nerve
as it passes anteriorly between soft tissues and
bone of the hard palate
4. Landmarks: greater palatine foramen and
junction of the maxillary alveolar process and
palatine bone
5. Path of insertion: advance the syringe from
the opposite side of the mouth at a right angle
to the target area
6. Orientation of the bevel: toward the palatal
soft tissues

Procedure:
1.Assume the correct position
(1) For a right greater palatine nerve block, a
right-handed administrator should sit facing the
patient at the 7 or 8 o’clock position.
(2) For a left greater palatine nerve block, a
righthanded administrator should sit facing in
the same direction as the patient at the 11
o’clock position
2. prepare the tissue
3.Locate the greater palatine foramen,
frequently located distal to the maxillary 2 nd
molar
4. Direct the syringe into the mouth from the
opposite side with the needle approaching the
injection site at a right angle
5.Do the prepuncture technique
6.insert and slowly advance a 27g short needle
anterior to the greater palatine foramen until
palatine bone is contacted.(depth of
Safety Features
penetration 5mm)
1. Contact with bone
7.aspirate
2. Aspiration
8.if negative, slowly deposit not more than ¼ to
Precautions. Do not enter the greater palatine
1/3 of the cartridge (0.45 to 0.60ml)
canal. Although this is not hazardous, there is
9.withdraw the syringe .make the needle safe.
no reason to enter the canal for this technique
10.wait 2-3 minutes.
to be successful.
Posterior Superior alveolar Nerve block

Other Common Names. Tuberosity block,

zygomatic block.
Nerves Anesthetized. Posterior superior
alveolar and branches.
Areas Anesthetized
1. Pulps of the maxillary third, second, and first
molars (entire tooth = 72%; mesiobuccal root of
the maxillary first molar not anesthetized =
28%)
2. Buccal periodontium and bone overlying
these teeth
Technique
1. A 27-gauge short needle recommended
2. Area of insertion: height of the mucobuccal
fold above the maxillary second molar
3. Target area: PSA nerve—posterior, superior,
and medial to the posterior border of the
maxilla
4. Landmarks:
a. Mucobuccal fold
b. Maxillary tuberosity
c. Zygomatic process of the maxilla
5. Orientation of the bevel: toward bone during
the injection. If bone is accidentally touched,
the sensation is less unpleasant.

Procedure:
1. Righthanded administrator,assume 10
o’clock position facing the patient
2. Prepsre the tissue
3. Do prepuncture
4. Insert a 27g short needle into the height
of the mucobuccal fold over the second
molar.
5. Advance the needle slowly in an
upward,inward and backward direction.
6. Advance needle to a depth of 16mm
7. Aspirate
8. Slowly deposit 0.9 to 1.8 (1/2 to 1 Maxillary Nerve Block
cartridge) 30 to 60 seconds Other Common Names. Second division block,
V2 nerve block.
9. Slowly withdraw the syringe
Nerve Anesthetized. Maxillary division of the
10. Make the needle safe
trigeminal nerve.
11. Wait 3-5 min.
Areas Anesthetized.
Precaution. The depth of needle penetration 1. Pulpal anesthesia of the maxillary teeth on
should be checked: overinsertion (too deep) the side of the block
increases the risk of hematoma; too shallow 2. Buccal periodontium and bone overlying
might still provide adequate these teeth
3. Soft tissues and bone of the hard palate and
part of the soft palate, medial to midline
4. Skin of the lower eyelid, side of the nose,
cheek, and upper lip
Technique (High-Tuberosity Approach).
1. A 25-gauge long needle is recommended. A
27-gauge long is acceptable.
2. Area of insertion: height of the mucobuccal
fold above the distal aspect of the maxillary
second molar
3. Target area:
a. Maxillary nerve as it passes through the
pterygopalatine fossa
b. Superior and medial to the target area of the
PSA nerve block
4. Landmarks:
a. Mucobuccal fold at the distal aspect of the
maxillary second molar
b. Maxillary tuberosity
c. Zygomatic process of the maxilla
5. Orientation of the bevel: toward bone
Procedure:
-advance the needle to a depth of 30 mm
-deposite 1.8ml for more than 60 seconds
-3-5 minutes.

Techniques of Mandibular Anesthesia

Inferior Alveolar Nerve Block

Other Common Names. Mandibular block.

Nerves Anesthetized
1. Inferior alveolar, a branch of the posterior
division of the mandibular division of the
Technique (Greater Palatine Canal Approach).
trigeminal nerve (V3)
1. A 25-gauge long needle is recommended. A
2. Incisive
27-gauge long needle is also acceptable.
3. Mental
2. Area of insertion: palatal soft tissue directly
4. Lingual (commonly)
over the greater palatine foramen
Areas Anesthetized.
3. Target area: the maxillary nerve as it passes
1. Mandibular teeth to the midline
through the pterygopalatine fossa; the needle
2. Body of the mandible, inferior portion of the
passes through the greater palatine canal to
ramus
reach the pterygopalatine fossa
3. Buccal mucoperiosteum, mucous membrane
4. Landmark: greater palatine foramen, junction
anterior to the mental foramen (mental nerve)
of the maxillary alveolar process and the
4. Anterior two thirds of the tongue and floor of
palatine bone
the oral cavity (lingual nerve)
5. Orientation of the bevel: toward palatal soft
5.Lingual soft tissues and periosteum (lingual
tissues
nerve)
Procedure:
-1.8ml over 1 minute
Technique
-3 to 5 minutes
1. A long dental needle is recommended for the
adult patient. A 25-gauge long needle is
preferred; a 27-gauge long is acceptable.
2. Area of insertion: Mucous membrane on the
medial (lingual) side of the mandibular ramus,
at the intersection of two lines—one horizontal,
representing the height of needle insertion, the
other vertical, representing the anteroposterior Other Common Names. Gow-Gates technique,
plane of injection third division nerve block, V3 nerve block.
3. Target area: Inferior alveolar nerve as it Nerves Anesthetized
passes 1. Inferior alveolar
downward toward the mandibular foramen but 2. Mental
before it enters into the foramen 3. Incisive
4. Landmarks 4. Lingual
a. Coronoid notch (greatest concavity on the 5. Mylohyoid
anterior border of the ramus) 6. Auriculotemporal
b. Pterygomandibular raphe (vertical portion) 7. Buccal (in 75% of patients)
c. Occlusal plane of the mandibular posterior Areas Anesthetized.
teeth 1. Mandibular teeth to the midline
5. Orientation of the needle bevel: Less critical 2. Buccal mucoperiosteum and mucous
than with other nerve blocks, because the membranes on
needle approaches the inferior alveolar nerve at the side of injection
roughly a right angle 3. Anterior two thirds of the tongue and floor of
Procedure the oral cavity
a. Assume the correct position. 4. Lingual soft tissues and periosteum
(1) For a right IANB, a right-handed 5. Body of the mandible, inferior portion of the
administrator ramus
should sit at the 8 o’clock position facing the 6. Skin over the zygoma, posterior portion of
patient (Fig. 14-4, A). the cheek, and temporal regions
(2) For a left IANB, a right-handed administrator Technique
should sit at the 10 o’clock position facing in the 1. 25- or 27-gauge long needle recommended
same direction as the patient. 2. Area of insertion: Mucous membrane on the
-mouth open wide ,mandible parallel to the mesial of the mandibular ramus, on a line from
floor the intertragic notch to the corner of the
-depth of penetration 20-25mm or 2/4-3/4 mouth, just distal to the maxillary second molar
length 3. Target area: Lateral side of the condylar neck,
-height of insertion 6to 10mm above occlusal just below the insertion of the lateral pterygoid
plane muscle
-deposit 1.5ml over 60 secs 4. Landmarks
-wait 3-5 minutes a. Extraoral
(1) Lower border of the tragus (intertragic
notch). The correct landmark is the center of
the
external auditory meatus, which is concealed by
the tragus; therefore its lower border is
adopted
as a visual aid
(2) Corner of the mouth
b. Intraoral
(1) Height of injection established by placement
of the needle tip just below the mesiolingual
(mesiopalatal) cusp of the maxillary second
molar
(2) Penetration of soft tissues just distal to the
THE GOW-GATES TECHNIQUE
maxillary second molar at the height
established
in the preceding step
5. Orientation of the bevel: Not critical
6. Procedure
a. Assume the correct position.
(1) For a right GGMNB, a right-handed
administrator should sit in the 8 o’clock position
facing the patient.
(2) For a left GGMNB, a right-handed
administrator
should sit in the 10 o’clock position facing the
same direction as the patient.
(3) These are the same positions used for a right
and a left IANB
-locate extraoral langmarks
-place index finger on coronoid notch.retract
soft tissue
=height of insertion is above the mandibular
occlusal plane around 10 to 25mm
-average depth 25mm
-withdarw 1mm VAZIRANI-AKINOSI CLOSED-MOUTH
1.8ml over 60-90 seconds MANDIBULAR BLOCK
-request to open mouth for 1 to 2 minutes Other Common Names. Akinosi technique,
-3-5 mins closed-mouth mandibular nerve block,
tuberosity technique.
Nerves Anesthetized
1. Inferior alveolar
2. Incisive
3. Mental
4. Lingual
5. Mylohyoid
Areas Anesthetized.
1. Mandibular teeth to the midline
2. Body of the mandible and inferior portion of
the ramus
3. Buccal mucoperiosteum and mucous
membrane anterior to the mental foramen
4. Anterior two thirds of the tongue and floor of
the oral cavity (lingual nerve)
5. Lingual soft tissues and periosteum (lingual
nerve)
Indications
1. Limited mandibular opening
2. Multiple procedures on mandibular teeth
3. Inability to visualize landmarks for IANB (e.g.,
because of large tongue)
Technique
1. A 25-gauge long needle is recommended Other Common Names. Long buccal nerve
(although a 27-gauge long may be preferred in block, buccinator nerve block.
patients whose ramus flares laterally more than Nerve Anesthetized. Buccal (a branch of the
usual). anterior division of the V3).
2. Area of insertion: Soft tissue overlying the Area Anesthetized. Soft tissues and periosteum
medial (lingual) border of the mandibular ramus buccal to the mandibular molar teeth
directly adjacent to the maxillary tuberosity at Technique
the height of the mucogingival junction 1. A 25- or 27-gauge long needle is
adjacent to the maxillary third molar recommended. This is most often used because
3. Target area: Soft tissue on the medial the buccal nerve block is usually administered
(lingual) border of the ramus in the region of immediately after an IANB. A long needle is
the inferior alveolar, lingual, and mylohyoid recommended because of the posterior
nerves as they run inferiorly deposition site, not the depth of tissue insertion
from the foramen ovale toward the mandibular (which is minimal).
foramen 2. Area of insertion: Mucous membrane distal
(the height of injection with the Vazirani-Akinosi and buccal
being to the most distal molar tooth in the arch
below that of the GGMNB but above that of the 3. Target area: Buccal nerve as it passes over
IANB) the anterior border of the ramus
4. Landmarks: 4. Landmarks: Mandibular molars, mucobuccal
a. Mucogingival junction of the maxillary third fold
(or second) molar 5. Orientation of the bevel: Toward bone during
b. Maxillary tuberosity the Injection
c. Coronoid notch on the mandibular ramus Procedure:
5. Orientation of the bevel (bevel orientation in -3-5mm
the closed-mouth mandibular block is very -0.3 or 1/8 over 10secs
important): The bevel must be oriented away -3-5mins
from the bone of the mandibular ramus (e.g.,
bevel faces toward the midline)
Procedure:
- 8 o’clock position
- 1.5 to 1.8ml over 60 secs
- -5mins

Buccal Nerve Block

 Mental Nerve Block
Other Common Names. None.
Nerve Anesthetized. Mental, a terminal branch
of the inferior alveolar.
Areas Anesthetized. Buccal mucous membranes Incisive Nerve Block
anterior to the mental foramen (around the
second premolar) to the midline and skin of the Other Common Name. Mental nerve block
lower lip (inappropriate).
Technique Nerves Anesthetized. Mental and incisive.
1. A 25- or 27-gauge short needle is Areas Anesthetized.
recommended. 1. Buccal mucous membrane anterior to the
2. Area of insertion: Mucobuccal fold at or just mental foramen, usually from the second
anterior to the mental foramen premolar to the midline
3. Target area: Mental nerve as it exits the 2. Lower lip and skin of the chin
mental foramen (usually located between the 3. Pulpal nerve fibers to the premolars, canine,
apices of the first and second premolars) and Incisors
4. Landmarks: Mandibular premolars and Technique
mucobuccal fold 1. A 27-gauge short needle is recommended.
5. Orientation of the bevel: Toward bone during 2. Area of insertion: Mucobuccal fold at or just
the Injection anterior to the mental foramen
Procedure: 3. Target area: Mental foramen, through which
-6 to 6mm the mental
-0.6ml over 20 secs nerve exits and inside of which the incisive
-2-3 minutes. nerve is located
4. Landmarks: Mandibular premolars and
mucobuccal fold
5. Orientation of the bevel: Toward bone during
the injection
5. Procedure
-0.6ml over 20 secs
-2-3 minutes.

Lingual Nerve block

Local Infiltration of the Mandible
Nerves Anes:
-free nerve endings in the infiltrated area
Areas Anes:
-mucous periosteum membrane and
mucoperiosteum in the infiltrated area only
Landmark: depends on the tooth
Procedure:
-27g short
-3 to 5 minutes