Local anesthesia techniques are discussed in this presentation

1. MAXILLARYANESTHESIA
Reza Tabrizi DM D
Associate professor of OMFS
Shahid Beheshti University of Medical Aciences

5. Supraperiosteal Injection
Most common in maxilla
Indication:
Pulpal anesthesia of one or two
maxillary teeth
Soft tissue anesthesia when
indicated
Hemostasis

6. Contraindications
Infection or acute inflammation in the area
Dense bone covering apices of teeth

7. Areas Anesthetized
Entire area innervated by the large terminal nerve branches:
Tooth pulp and root area
Buccal periosteum
Mucous membrane and connective tissue

8. Percent Positive Aspiration:
Negligible, but possible (<1%)

9. Alternatives
Periodontal ligament injection
Regional nerve block

24. Signs and Symptoms
Numbness
Absence of pain during dental therapy

25. Safety Feature
Minimum opportunity for intravascular
administration

26. Failures of Anesthesia
Inadequate needle penetration
- not adjacent to tooth apex
Needle too far from bone

27. Posterior Superior Alveolar Nerve Block
Nerve Anesthetized:
Posterior Superior Alveolar Nerve (PSA)
- for maxillary molars and buccal tissue

29. Advantages
Atraumatic; when administered properly, no pain is experienced by the patient
receiving the PSA because of the relatively large area of soft tissue into which
the local anesthetic is deposited and the fact that bone is not contacted
2. High success rate (>95%)
3. Minimum number of necessary injections
a. One injection compared with option of three infiltrations
4. Minimizes the total volume of local anesthetic solution administered
a. Equivalent volume of anesthetic solution necessary for three supraperiosteal
injections = 1.8 mL

30. Disadvantages
Risk of hematoma, which is usually diffuse; also discomfiting and visually
embarrassing to the patient
2. Technique somewhat arbitrary: no bony landmarks during insertion
3. Second injection necessary for treatment of the first molar (mesiobuccal
root) in 28% of patients

31. Positive aspiration
Approximately 3.1 %.

32. Alternatives
Supraperiosteal or PDL injections for pulpal and root anesthesia
2. Infiltrations for the buccal periodontium and hard tissues
3. Maxillary nerve block

33. 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

34. 5. Orientation of the bevel: toward bone during the injection. If bone is
accidentally touched, the sensation is less unpleasant.
6. Procedure:
a. Assume the correct position .
(1) For a left PSA nerve block, a right-handed
administrator should sit at the 10 o'clock position facing the patient.
(2) For a right PSA block, a right-handed administrator should sit at the 8
o'clock position facing the patient.

42. Failures of Anesthesia
Needle too lateral
Needle not deep enough
Needle too far superior

43. Complications
Hematoma
Mandibular anesthesia

44. Middle Superior Alveolar Nerve Block
The middle superior alveolar (MSA) nerve is present in only about 28% of the population

45. Areas Anesthetized
1. Pulps of the maxillary first and second premolars, mesiobuccal root of the first molar
2. Buccal periodontal tissues and bone over these same teeth

46. Indications
1. Where the ASA nerve block fails to provide pulpal anesthesia distal to the maxillary
canine
2. Dental procedures involving both maxillary premolars only

47. Contraindications
1. Infection or inflammation in the area of injection or needle insertion or drug
deposition
2. Where the MSA nerve is absent, innervation is through the anterior superior
alveolar (ASA) nerve; branches of the ASA innervating the premolars and the
mesiobuccal root of the first molar can be anesthetized by means of the MSA
technique.

48. Advantages.
Minimizes the number of injections and the
volume of solution.
Positive Aspiration. Negligible ( <3%).

49. Alternative
Local infiltration (supraperiosteal), PDL, IO injections
2. ASA nerve block for the first and second premolar and the mesiobuccal root of the first
molar

50. Technique
1. A 27-gauge short or long needle is recommended.
2. Area of insertion: height of the mucobuccal fold above the maxillary second
premolar
3. Target area: maxillary bone above the apex of the maxillary second
premolar
4. Landmark: mucobuccal fold above the maxillary second premolar

51. Orientation of the bevel: toward bone
6. Procedure:
a. Assume the correct position.
(1) For a right MSA nerve block, night-handed administrator should face the
patient from the 10 o'clock position.
(2) For a left MSA nerve block, a right-handed administrator should face the
patient directly from the 8 or 9 o'clock position.
b. Prepare the tissues at the site of injection.

52. Precautions.
To prevent pain, do not insert too close to the periosteum and do not inject too rapidly; the
MSA should be an atraumatic injection.

53. Failures of Anesthesia
1. Anesthetic solution not deposited high above the apex of the second
premolar
a. To correct: Check radiographs and increase the depth of penetration.
2. Deposition of solution too far from the maxillary bone with the needle
placed in tissues lateral to the height of the mucobuccal fold
a. To correct: Reinsert at the height of the mucobuccal fold.
3. Bone of the zygomatic arch at the site of injection preventing the diffusion
of anesthetic
a. To correct: Use the supraperiosteal, ASA, or PSA injection in place of the
MSA.

57. Anterior Superior Alveolar Nerve Block
(lnfraorbital Nerve Block)
The ASA nerve block does not enjoy the popularity of the PSA block,
primarily because there is a general lack of experience with this highly
successful and extremely safe technique.
It provides profound pulpal and buccal soft tissue anesthesia from the
maxillary central incisor through the premolars in about 72% of patients.

58. Nerves Anesthetized
1. Anterior superior alveolar
2. Middle superior alveolar
3. Infraorbital nerve
a. Inferior palpebral
b. Lateral nasal
c. Superior labial

59. Areas Anesthetized
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

61. Indications
Dental procedures involving more than two maxillary teeth and their
overlying buccal tissues
2. Inflammation or infection (which contraindicates supraperiosteal injection):
If a cellulitis is present, the maxillary nerve block may be indicated in lieu of
the ASA nerve block.
3. When supraperiosteal injections have been ineffective because of dense
cortical bone

62. Contraindications
1. Discrete treatment areas (one or two teeth only; supraperiosteal preferred)
2. Hemostasis of localized areas, when desirable, cannot be adequately achieved with this
injection; local infiltration into the treatment area is indicated

63. Advantages
1. Comparatively simple technique
2. Comparatively safe; minimizes the volume of solution used and the number of needle
punctures necessary to achieve anesthesia

64. Disadvantages
Psychological:
a. Administrator: There may be an initial fear of injury to the patient's eye
(experience with the technique leads to confidence).
b. Patient: An extraoral approach to the infraorbital nerve may prove
disturbing; however, intraoral techniques are rarely a problem.
2. Anatomic: difficulty defining landmarks (rare)

65. Positive Aspiration. 0.7%.

66. Alternatives
1. Supraperiosteal, PDL, or IO injection for each tooth
2. Infiltration for the periodontium and hard tissues
3. Maxillary nerve block

67. Technique
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

68. 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

69. 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 (felt as an outward
bulge). This represents the lower border of the orbit and the
roof of the infraorbital foramen .
( 4) As your finger continues inferiorly, a concavity is felt; this is the infraorbital
foramen.
(5) While applying pressure, feel the outlines of the infraorbital foramen at this
site. The patient senses a mild soreness when the foramen is
palpated as the infraorbital nerve is pressed against bone.

70. Slowly deposit 0.9 to 1.2 mL (over 30 to 40 seconds) . Little or no swelling
should be visible as the solution is deposited. If the needle tip is properly
inserted at the opening of the foramen, solution is directed toward the foramen

76. PALATALANESTHESIA
For many dental patients, palatal injections prove to be a very traumatic experience

77. The steps in the atraumatic administration of palatal anesthesia are as follows:
1. Provide adequate topical anesthesia at the site of needle
penetration.
2. Use pressure anesthesia at the site both before and during needle insertion and the
deposition of solution.
3. Maintain control over the needle.
4. Deposit the anesthetic solution slowly.
5. Trust yourself ... that you can complete the procedure atraumatically.

78. Indications
1. When palatal soft tissue anesthesia is necessary for restorative therapy on more than
two teeth (e.g., with subgingival restorations, with insertion of matrix bands
subgingivally)
2. For pain control during periodontal or oral surgical procedures involving the palatal
soft and hard tissues

79. Contraindications
1. Inflammation or infection at the injection site
2. Smaller areas of therapy (one or two teeth)

80. Advantages
1. Minimizes needle penetrations and volume of solution
2. Minimizes patient discomfort

81. Disadvantages
1. No hemostasis except in the immediate area of injection
2. Potentially traumatic

82. Positive Aspiration. Less than 1 %.

84. Technique
1. 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

85. 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 right handed administrator should sit
facing in the same direction as the patient at the 11 o'clock position.

92. Nasopalatine Nerve Block
Nasopalatine nerve block is an invaluable technique for palatal pain control in
that, with administration of a minimum volume of anesthetic solution
(maximally, one quarter of a cartridge), a wide area of palatal soft tissue
anesthesia is achieved, thereby minimizing the need for multiple palatal
injections.

93. Two approaches to this injection are presented:
The first approach involves only one tissue penetration, lateral to the incisive papilla
on the palatal aspect of the maxillary central incisors.
2.It involves three needle punctures but, when carried out properly, is significantly less
traumatic than the more direct one puncture technique.
In it, the labial soft tissues between maxillary central incisors are anesthetized
(injection #1), then the needle is directed from the labial aspect through the
interproximal papilla between the central incisors toward the incisive papilla on the
palate to anesthetize the superficial tissues in this area (injection #2). A third injection,
directly into the now partially anesthetized palatal soft tissues overlying the
nasopalatine nerve, is necessary

94. Areas Anesthetized
Anterior portion of the hard palate (soft and hard tissues) bilaterally from the mesial of the
right first premolar to the mesial of the left first premolar

96. Indications
When palatal soft tissue anesthesia is necessary for restorative treatment on
more than two teeth (e.g., subgingival restorations, insertion of matrix bands
subgingivally)
2. For pain control during periodontal or oral surgical procedures involving
palatal soft and hard tissues

97. Contraindications
1. Inflammation or infection at the injection site
2. Smaller area of therapy (one or two teeth)

98. Advantages
1. Minimizes needle penetrations and volume of solution
2. Minimal patient discomfort from multiple needle penetrations

99. Disadvantages
1. No hemostasis except in the immediate area of injection
2. Potentially the most traumatic intraoral injection; however, the protocol for an atraumatic
injection or use of a C-CLAD system or a buffered local anesthetic
solution can minimize or entirely eliminate discomfort

100. Positive Aspiration. Less than 1 %.

101. Technique (Single-Needle Penetration of the
Palate)
1. A 27-gauge short needle is recommended.
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
5. Path of insertion: Approach the injection site at a
45-degree angle toward the incisive papilla.
6. Orientation of the bevel: toward the palatal soft tissues (review procedure for the
basic palatal injection)
7. Procedure: a. Sit at the 9 or 10 o'clock position facing in the same

102. Aspirate in two planes.
1. If negative, slowly deposit (15- to 30-second minimum) not more than one
fourth of a cartridge (0.45 mL).
(1) In some patients, it is difficult to deposit 0.45 mL of anesthetic solution in
this injection.
Injection of anesthetic can cease when the area of ischemia noted at the injection
site has expanded from that produced by the application
of pressure alone.

105. Local Infiltration of the Palate
Indications
1. Primarily for achieving hemostasis during surgical procedures
2. Palatogingival pain control when limited areas of anesthesia are necessary
for application of a rubber dam clamp, packing of retraction cord in the
gingival sulcus, or operative procedures on not more than two teeth

106. Technique
1. A 27-gauge short needle is recommended.
2. Area of insertion: the attached gingiva 5 to 10 mm from the free gingival margin
3. Target area: gingival tissues 5 to 10 mm from the free gingival margin
4. Landmark: gingival tissue in the estimated center of the treatment area
5. Pathway of insertion: approaching the injection site at a 45-degree angle
6. Orientation of the bevel: toward palatal soft tissues

108. Maxillary Nerve Block
The maxillary (second division or V2 ) nerve block is an effective method of achieving
profound anesthesia of a hemimaxilla.

109. Indications
1. Pain control before extensive oral surgical, periodontal, or restorative
procedures requiring anesthesia of the entire maxillary division
2. When tissue inflammation or infection precludes the use of other regional
nerve blocks (e.g., PSA, ASA, AMSA, P-ASA) or supraperiosteal injection
3. Diagnostic or therapeutic procedures for neuralgias or tics of the second
division of the trigeminal nerve

110. Contraindications
1. Inexperienced administrator
2. Pediatric patients
a. More difficult because of smaller anatomic dimensions
b. A cooperative patient is needed.
c. Usually unnecessary in children because of the high success rate of other regional
block techniques Uncooperative patients
4. Inflammation or infection of tissues overlying the
injection site
5. When hemorrhage is risky (e.g., in a hemophiliac)
6. In the greater palatine canal approach: inability to gain access to the canal; bony
obstructions may be present in 5% to 15% of canals

111. Technique (High-Tuberosity Approach).
Technique (Greater Palatine Canal Approach).