This document provides information on local anesthesia techniques. It begins with definitions of local anesthesia and contraindications. It then describes the basic injection technique in 19 steps, including using a sharp sterile needle, checking solution flow, warming cartridges if needed, positioning the patient, drying tissue, applying topical anesthetic, establishing a firm hand rest, making tissue taut, keeping the syringe out of view, slowly inserting and advancing the needle, slowly depositing solution, observing the patient, and documenting the injection. Finally, it discusses various regional anesthesia techniques for the maxilla and mandible, including infiltration, nerve blocks, and intraseptal injections.

1. PRESENTED BY –
DR. SHEETAL KAPSE

2. 1. Definition of LA
1. Basic injection techniques
2. Techniques of regional anesthesia
- for maxillary teeth
- for mandibular teeth
4. Conclusion
5. Recourses

3. Reversible loss of sensation in a
circumscribed area of the body
caused by a depression of excitation
in nerve ending or an inhibition of the
conduction process in peripheral
nerves.
MALAMED (1980)

4. Hemophilia is the absolute
contraindications of local
anesthesia.
Thyrotoxicosis is the
contraindication of local
anesthesia with adrenaline.

5. BASIC
INJECTION
TECHNIQUE

6. • Nothing that is done by a dentist for a patient is of
greater importance than the administration of the drug
which prevents pain during dental treatment.
• Most of the emergency situations - vasodepressor
syncope
(common faint)
• Local anesthetic can & should be administered in a non-
painful or atraumatic manner .

7. The atraumatic injection technique was developed over many years by
Dr. NathanFriedman & the department of human behavior at the
University of Southern California School of Dentistry.
There are 2 components to an atraumatic
injections –
1. Technical aspect
2. Communication aspect

8. STEP 1 : USE A STERILIZED SHARP
NEEDLE
• Stainless steel disposable needles.
• use of needle not wider than 25 gauge.
• patient can not differentiate among 25, 27
& 30 gauge needles.
• 23 gauge & larger needles are associated
with increased pain

9. STEP 2 : Check the flow of
local anesthetic solution
• A few drops of local anesthetic solution
should be expelled from the syringe to
ensure the free flow of the solution.

10. STEP 3 : DETERMINE WHETHER OR NOT
TO WARM THE ANESTHETIC CARTRIDGE
OR SYRINGE
 This is for the cartridges stored in refrigerators or any
cool areas, which should be brought to room
temperature before use.
 Holding the metal syringe in the palm for half a minute
is sufficient.

11. STEP 4 : POSITION THE PATIENT
 Physiologically sound position before & during the injection.
 Vasodepressor syncope (common faint)
- Anxiety
 The sign & symptoms will be –
light headedness,
dizziness,
tachycardia & palpitation
unconsciousness
 Medical condition of the patient
is considered.

12. STEP 5 : DRY THE TISSUE
2 x 2 inch gauze –
• remove any debris .
• Retracting the lip .

13. STEP 6 : APPLY TOPICAL
ANTISEPTIC (OPTIONAL)
 At the site of injection .
 Betadine (povidene iodine), Merthiolate
(thimerosal)
 Alcohol containing antiseptics - burning of soft
tissue .

14. STEP 7A : APPLY TOPICAL
ANESTHETIC
• Directly at the site of needle penetration with the cotton
applicator.
• Excessive amount – large area of soft tissue anesthesia,
- unpleasant taste
• Remain in contact with mucosa for 2 minutes (minimum 1
minute).
• Anesthesia of the outermost
2-3 mm .

15. STEP 7B : COMMUNICATE
WITH PATIENT
• Communicate with the patient in a positive way.
• Injection , shot, pain, hurt

16. STEP 8 : ESTABLISH A FIRM
HAND REST
 Tissue penetration may be accomplished
readily, accurately & without inadvertent nicking of
tissue.
Palm down Palm up Palm up & finger
support

17. • 2 techniques should be
avoided –
 No syringe stabilization of any
kind
 Placing the arm holding the
syringe directly on patient’s arm
or shoulder.

18. STEP 9 : MAKE THE TISSUE TAUT
 This permits the sharp stainless
steel needle to cut through the
mucous membrane with
minimum resistance.
 Loose tissue are pushed & torn
by the needle as it is inserted
producing more discomfort on
injection & more postoperative
soreness.

19. STEP 10 : KEEP THE SYRINGE OUT
OF THE PATIENT’S LINE OF VISION
 Assistant should pass the syringe to the administrator
behind the patient’s line of vision.

20. STEP 11A : INSERT THE NEEDLE
INTO THE MUCOSA
 The bevel of needle should be oriented towards the
bone.
 Gently insert.
 With firm hand rest & adequate tissue penetration
Atraumatic procedure

21. STEP 11 B : WATCH &
COMMUNICATE WITH THE PATIENT
• Patient’s face should be observed for
evidence of any discomfort.
• Signs of discomfort – furrowing of brow or
forehead & blinking of eyes.
• Communicate in a positive
manner.

22. STEP 12 : INJECT SEVERAL
DROPS OF SOLUTION
(OPTIONAL)
The soft tissue in front of the needle may be
anesthetized to with a few drops of local
anesthetic solution.

23.  Step 12 & 13 are carried out together.
 Wait for 2-3 seconds for anesthesia to develop
advance the needle within tissue
 Aspiration is not required .
 Only 1 or 2 drop (<1 mg) .
STEP 13 : SLOWLY ADVANCETRE NEEDLE
TOWARDSTHETARGET

24. STEP 14 : DEPOSITE SEVERAL DROPS OF
LOCAL ANESTHETIC BEFORE TOUCHING
THE PERIOSTEUM
 The periosteum is richly innervated.
 Regional block techniques that requires
this are –
1. Gow-Gates mandibular nerve block
2. Infraorbital nerve block

25. STEP 15 : ASPIRATE
 Minimizes the possibility of an intravascular
injections.
 Care should be taken to remain the needle
unmoved.
 Any sign of blood is a positive aspiration.
 Aspiration should be performed twice
(rotate barrel of syringe 45 degree
for second aspiration test ).

26. STEP 16 A : SLOWLY DEPOSITE THE LOCAL
ANESTHETIC SOLUTION
• Reason -
Preventing the solution from tearing the tissue into which it is
deposited
• Ideal rate of deposition of solution – 1ml/60 sec.
• 1.8 ml cartridge takes approximately 2 min.
• A more realistic time span in a clinical situation is 60 sec. for a full
1.8 ml cartridge.
• There is evidence in the surgical literature that the success of some
techniques is increased with slower injection speeds.
Rucci F S, Pippa P, Boccaccini A, Barbagli R. Effect of injection speed on anaesthetic
spread during axillary block using the orthogonal two-needle technique. Eur J Anaesth
1995; 12: 505-511.

27. STEP 17 : SLOWLY WITHDRAW
THE SYRINGE
 Cap it immediately by Scoop technique .
 Needles should not be reused.
 The acrylic needle holder can be used.

28. STEP 18 : OBSERVE THE PATIENT
 Most adverse drug reactions - during injection or
within 5-10 min.
 Patient should never be left unattended after
administration of a local anesthetic.

29. STEP 19: RECORD THE INJECTION ON
PATIENT RECORD
 Local anesthetic agent
 Vasoconstrictor used (if any)
 Dose
 Needle used
 Injections given
 Patient’s reaction

31. 1. Local infiltration (0.6 – 1.0 ml)
small terminal nerve endings are
anaesthetized.

32. 2. Field block
deposited in proximity to the
larger nerve branches

33. 3. Nerve block(1.8 – 2.0 ml)
depositing the LA solution within
close proximity to a main nerve
trunk

34. 4. Intraligamentary (0.2 ml)
- depositing the LA solution within PDL
through gingival sulcus.
- Provides 30-35 min of anesthesia.
- Indicated in patient with bleeding disorder
& young handicapped patients .
5. Intraseptal (0.1 ml)
It is used to avoid IANB to work in
mandibular primary molars.

35. 6. Intrapapillary
For palatal & lingual anesthesia.
7. Intrapulpal
In case of pulp therapy when
other techniques have failed.

36. 8. Intraosseous
For 1 tooth when other technique
fails.
Perforate within attach gingiva about 2 mm below the
gingival margin of the adjacent teeth in the vertical plane
bisecting the interdental papilla .

37. 1. Supraperiosteal /Infiltration
2. Posterior superior alveolar nerve block
3. Middle superior alveolar nerve block
4. Anterior superior alveolar nerve block
5. Nasopalatine nerve block
6. Greater palatine nerve block
7. Infiltration of palatal tissue
8. AMSA
9. P-ASA

38. SUPRAPERIOSTEAL /
PARAPERIOSTEAL / INFILTRATION
ADVANTAGES
1. High success rate (>95 %)
2. Technically easy
3. Usually atraumatic
DISADVANTAGES
1. Anesthesia for larger area
requires multiple penetrations
– pain.
2. Larger volume of local
anesthetic.
INDICATIONS
1. Maxillary teeth
2. 1-2 teeth
3. Soft tissue anesthesia
CONTRAINDICATIONS
1. > 2 teeth
2. Infection & inflammation
3. Dense bone

39. • Area of insertion
• Target area
• Landmarks –
mucobuccal fold
crown of tooth
root contour of tooth
Wait for 3-5 min.
0.6 ml / 20
sec.

40. SUBJECTIVE
Numbness over area of
injection.
OBJECTIVE
No pain during
procedure
FAILURE OF
ANESTHESIA
Needle tip is too low
Needle tip is too far
COMPLICATION
Pain while needle touches
the periosteum.

41.  Highly successful technique > 95%
 Potential for hematoma formation
 Short needle is recommended
 Depth of needle insertion- 16-20 mm
10-14 m for children
 Aspirate several times

43. ADVANTAGES
1. Atraumatic
2. High success rate (>95 %)
3. Less no. of penetration
4. Equivalent volume
0.6 x 3 = 1.8 ml
DISADVANTAGES
1. Hematoma formation
2. No bony landmark
3. Mesiobuccal root of 1M is not
anesthetized in 28% cases
INDICATIONS
1. 2 or more Maxillary molars
2. When supraperiosteal
injection are contraindicated
or failed
CONTRAINDICATION
Hemophilic patients

44. • Area of insertion
• Target area
• Landmarks –
mucobuccal fold
maxillary tuberosity
infratemporal surface of maxilla
Anterior border & coronoid process
of mandible
zygomatic process of maxilla
Deepth of needle penetration – 16 mm
Wait for 3-5 min.
0.9-1.8 ml / 30-20
sec.

45. SUBJECTIVE
Numbness over area of
injection.
OBJECTIVE
No pain during
procedure
FAILURE OF
ANESTHESIA
1. Needle tip is too low
2. Needle tip is too lateral
3. Needle tip is too posterior
4. Accessory innervation from
greater palatine nerve.
COMPLICATIONS
Hematoma formation
Mandibular anesthesia

46. 1. Limited use
cause – absent in 30-54%
cases

48. ADVANTAGE
Less volume
DISADVANTAGE
none
INDICATIONS
1. Maxillary premolars
2. MB root of 1M
3. When infraorbital injection is
failed
CONTRAINDICATIONS
1. Infection & inflammation
2. Absence of MSA

49. 0.9 – 1.2 /30-40 sec.
• Area of insertion
• Target area
• Landmarks –
mucobuccal fold above maxillary
2 PM
Wait for 3-5 min.

50. SUBJECTIVE
Numbness of upper lip.
OBJECTIVE
No pain during
procedure
FAILURE OF
ANESTHESIA
Needle tip is too high
Needle tip is too lateral
Thick zygomatic bone
COMPLICATIONS
Hematoma formation
(rare)

51. 1. Highly successful & extremely safe
2. Limited use
cause – lack of experience
3. Requires less solution than that of
supraperiosteal technique

52. 0.9 – 1.2 ml solution is required.

53. ADVANTAGES
1. Simple technique
2. Safe
3. Less no. of penetration
4. Less volume
DISADVANTAGES
1. Psychological
Operator & patient
2. Anatomical
INDICATIONS
1. >2 Maxillary teeth
2. Soft tissue anesthesia
3. When supraperiosteal
injection is contraindicated
CONTRAINDICATIONS
1. < 2 teeth
2. To achieve hemostasis

54. • Area of insertion
• Target area

55. • Landmarks –
Infraorbital notch
Infraorbital ridge
Infraorbital depression
pupil
mucobuccal fold
crown of tooth
root contour of tooth
penetration depth – 16 mm
Wait for 3-5 min.
0.69-1.2 ml / 30-40 sec.

57. SUBJECTIVE
Numbness over area
supplied by ASA, MSA
& IO nerve
OBJECTIVE
No pain during
procedure
FAILURE OF
ANESTHESIA
1. Needle tip is too low
2. Needle tip is too medial
3. Needle tip is too lateral
4. Accessory innervation from
nasopalatine nerve.
COMPLICATION
Hematoma over lower
eyelid
(rare)

58.  Generally painful
 Prepare the patient psychologically
 CCLAD – better results
 Adequate topical anesthesia
 Pressure anesthesia – ischemia , blanching
 Control over the needle
 27 guage short needle
 Rapid injection should be avoided

59. 1. Greater palatine nerve block
2. Nasopalatine nerve block
3. Infiltration
4. AMSA
5. P-ASA

60.  Technically difficult but high success rate
>95%
 0.45 – 0.6 ml solution
 Profound palatal hard & soft tissue anesthesia
 Potentially traumatic but less than Nasopalatine
nerve block.

61. 0.45 – 0.6 ml solution is required.

62. ADVANTAGES
1. Less no. of penetration
2. Less volume - 0.45 – 0.6 ml
DISADVANTAGES
1. No homeostasis except in the
area of injection
2. Potentially traumatic
INDICATIONS
1. >2 Maxillary molars
2. Soft & hard tissue
anesthesia for surgical
procedure
CONTRAINDICATIONS
1. 1 - 2 teeth
2. Infection & inflammation

63. 0.45-0.6 /30 sec.
• Area of insertion
• Target area
• Landmarks –
• 2nd & 3rd maxillary molars
• palatal gingival margine of 2M & 3M
• Midline of palate
• A line approximately 1cm towards
midline from free gingival margine
• Approach
• Depth = <10 mm
Wait for 2-3 min.

64. SUBJECTIVE
Numbness over
posterior portion of
palate
OBJECTIVE
No pain during
procedure
FAILURE OF
ANESTHESIA
Technically difficult
Needle tip is too anterior
Inadequate anesthesia of PM
COMPLICATION
1. Ischemia & necrosis with strong
vasoconstrictor
2. Hematoma (rare)
3. Occasionally soft palate
anesthesia
4. Solution ma squirt back - bitter

65. Other common names -
– incisive nerve block

66. 0.3 ml solution is required.

67. ADVANTAGES
1. Less no. of penetration
2. Less volume
DISADVANTAGES
1. No hemostasis
2. Most traumatic intraoral
injection
INDICATIONS
1. >2 Maxillary teeth
2. Soft tissue anesthesia
CONTRAINDICATIONS
1. 1- 2 teeth
2. Infection & inflammation

68. 1. Single puncture
2. Multiple puncture –
labial frenum
labial interdental papilla
incisive papilla (if neded)

69. 0.45 ml / 15-30 sec.
• Area of insertion
• Target area
• Landmarks –
maxillary central incisors
incisive papilla in midline of palate
• Wait for 2-3 min.

70. Advantage –
Relative atraumatic
Amount of solution –
1. 0.3 ml / 30 sec in labial frenum
2. 0.3 ml / 30 sec in labial
interdental papilla
3. 0.3 ml / 30 sec lateral to incisive
papilla
Disadvantage –
1. Multiple penetration
2. Stablization of needle becomes
difficult
3. Syringe comes in line of patient’s
vision
• Wait for 2-3 min.
• Landmarks –
labial frenum
labial interdental papilla
incisive papilla

71. • Area of insertion
• Target area

72. SUBJECTIVE
Numbness over area of
anterior palate
OBJECTIVE
No pain during
procedure
Precautions –
1. Against pain – don’t inject solution
direct in papilla
too rapidly
too much volume
2. Against infection – depth of penetration not more than 5 mm

73. FAILURE OF ANESTHESIA
1. Unilateral anesthesia
2. Inadequate anesthesia to canine
COMPLICATION
1. Ischemia & necrosis with strong
vasoconstrictor
2. Solution may squirt back - bitter

76. ADVANTAGES
1. Acceptable hemostasis
2. Less area of numbness
DISADVANTAGES
1. Traumatic
2. Anesthesia for larger area
requires multiple penetrations
INDICATIONS
1. Hemostasis
2. Palatogingival pain control
CONTRAINDICATIONS
1. Infection & inflammation
2. > 2 teeth

77. 0.2-0.3 ml
• Area of insertion
• Target area
• Landmarks –
attached gingiva , 5-10 mm from
free gingival margine
• Penetration depth = 3-5 mm

78. SUBJECTIVE
Numbness over area of
anterior palate
OBJECTIVE
No pain during
procedure
FAILURE OF ANESTHESIA
However high success rate if
vasoconstrictor is used but
Inflamed tissue continue to
bleed
COMPLICATION
1. Ischemia & necrosis with strong
vasoconstrictor
2. Solution may squirt back - bitter

79.  Other common name – palatal approach anterior
middle superior alveolar nerve anesthesia.
 Newly described technique
 Reported by FRIEDMAN & HOCHMAN IN
1997, along with development of CCLAD system.
 Real field block
 Dental pluxes near the apices of premolars are of
chief concern

81. INDICATIONS
1. With CCLAD system
2. Anesthesia of multiple maxillary teeth & soft
tissue
3. anterior asthetic restorative
procedures, priodontal scaling & root
planning
4. When facial approach for supraperiosteal
injection have failed.
CONTRAINDICATIONS
1. Infection & inflammation
2. Thin palate
3. Patient can not tolerate 3-4
min of administration time
4. Procedure of > 90 min.

82. 1. pulpal anesthesia to multiple maxillary teeth with
single site of injection
2. less no. of penetration
3. Less volume of solution
4. Muscles of facial expression are not anesthetized
5. Less postoperative inconvenience
6. Atraumatic with CCLAD system

83. 1. Requires experience & skill
2. Slow administration (0.5 ml/min)
3. Operator fatigue
4. May require supplemental anesthesia for incisors
5. Too rapid administration – excessive ischemia

84. 0.5 ml/min. & 1.4-1.8 ml
• Area of insertion
• Target area
• Landmarks –
between 1PM & 2PM
between midpalatine line & free
gingival margine

85. SUBJECTIVE
Numbness of teeth & soft
tissue extends from
central incisor to distal
part of 2PM on the side
of injection.
OBJECTIVE
• Blanching
• No pain during
procedure
FAILURE OF
ANESTHESIA
1. Additional anesthesia for
incisors
2. Inadequate solution reaches to
pluxes.
COMPLICATION
1. Palatal ulcer
2. Unexpected contact with
nasopalatine nerve
3. Solution may squirt back

86.  Other common name – palatal approach maxillary
anterior field block.
 Newly described technique
 Reported by FRIEDMAN & HOCHMAN IN 1997, along
with development of CCLAD system.
 1st dental injection providing bilateral pulpal and labial
& palatal mucoperiostel anesthesia
 Dental pluxes near the apices of anteriors &
Nasopalatine nerve are of chief concern
 Along with CCLAD system – atraumatic

88. INDICATIONS
1. With CCLAD system
2. Anesthesia of multiple maxillary anterior
teeth & soft tissue
3. Bilateral anesthesia with single injection.
4. Anterior aesthetic restorative
procedures, periodontal scaling & root
planning
5. When facial approach for supraperiosteal
injection have failed.

89. CONTRAINDICATIONS
1. Canines with large root
2. Infection & inflammation
3. Thin palate
4. Patient can not tolerate 3-4 min of
administration time
5. Procedure of > 90 min.

90. 1. pulpal anesthesia to bilateral maxillary teeth with
single site of injection
2. less no. of penetration
3. Less volume of solution
4. Muscles of facial expression are not anesthetized
5. Less postoperative inconvenience
6. Atraumatic with CCLAD system

91. 1. Requires experience & skill
2. Slow administration (0.5 ml/min)
3. Operator fatigue
4. May require supplemental anesthesia for incisors
5. Too rapid administration – excessive ischemia

92. 0.5 ml/min. & 1.4-1.8 ml
• Area of insertion
• Target area
• Landmarks –
Incisive papilla

93. SUBJECTIVE
Numbness of teeth & soft
tissue extends from
central incisor to distal
part of canine bilaterally
OBJECTIVE
• Blanching
• No pain during
procedure
FAILURE OF
ANESTHESIA
1. Additional anesthesia for
canine
2. Inadequate solution reaches to
pluxes.
COMPLICATION
1. Palatal ulcer
2. Unexpected contact with
Nasopalatine nerve
3. Solution may squirt back

94.  Other common name – maxillary nerve
block,
2nd division block.
 An effective method of achieving profound
anesthesia of hemimaxilla.
 2 approaches – greater palatine canal
approach
- high tuberosity approach

96. INDICATIONS
1. Pain control in surgical procedures.
2. When anesthesia through supraperiosteal
injection & nerve block have failed.
3. Diagnostic & therapeutic purpose.

97. CONTRAINDICATIONS
1. Inexperienced administrator
2. Pediatric patient
3. Unco-operative patients
4. Infection & inflammation
5. Increased risk of hemorrhage – hemophilia
6. Greater palatine approach – inability to
achieve access to canal

98. 1. Usually atraumatic.
2. less no. of penetration
3. Less volume of solution
4. High success rate

99. 1. Requires experience & skill
2. Hematoma
3. Absence of bony landmark
4. Lack of hemostasis
5. Pain & Positive aspiration in <1%
– greater palatine canal approach

100. 1. High tuberosity approach
2. Greater palatine approach
3. Extraoral approach

101. 1.8 ml / min.
• Area of insertion
• Target area
• Landmarks –
mucouccal fold distal to 2M
maxillary tuberosity
zygomatic proccess of maxilla
• wait for 3-5 min.

102. 1.8 ml / min.
• Area of insertion
• Target area
• Landmarks –
- greater palatine foramen
- junction of alveolar process of
maxilla & palatine bone, distal to
2M
wait for 3-5 min.

103. • Landmarks –
- Midppoint of zygomatic arch 2-3 ml
- zygomatic notch DEPTH – 4.5 cm
- coronoid process of ramus
- lateral pterygoid plate

105. SUBJECTIVE
1. pressure behind upper jaw
2. tingling & numbness
OBJECTIVE
• No pain during
procedure
FAILURE OF
ANESTHESIA
1. Partial anesthesia due to
underpenetration
2. Inability to negotiate greater
palatine canal.

106. 1. Hematoma
2. If solution reaches to orbit – periorbital swelling &
proptosis
3. VI cranial nerve block – diplopia
4. Retrobulbar block – mydriasis, corneal anesthesia &
opthalmoplagia
5. Rarely –optic nerve block (blindness) & retrobulbar
hemorrhage
6. Solution may go into nasal cavity

108. 1. Inferior alveolar nerve block
a) classical/ direct technique
b) indirect technique
c) method of CLARKE & HOLMES
d) method of ANGELO SARGENTI
e) method of SUNDER J. VAZIRANI
f) method of KURT THOMA (extraoral technique)
2. Buccal nerve block
3. Mental nerve block
4. Incisive nerve block
5. Mandibular nerve block
Gow-Gate technique
Vazirani-Akinosi technique
Extraoral technique

109.  Most frequently used injection technique
 Highly percentage of clinical failure 15%-20%
 Commonly but inaccurately known as –
MANDIBULAR NERVE BLOCK

110. Mental nerve
Incisive nerve
NERVES
ANAESTHETIZED

111. • Body of mandible
• Mandibular teeth
• Mucous membrane and underlying tissue anterior
to molar

112. ADVANTAGES
1. Wider area of anesthesia
with a single site of injection
INDICATIONS
1. Multiple teeth in 1 qurdrant
CONTRAINDICATION
1. Infection & inflammation
2. Children
3. Physically & mentally
handicapped patients
4. Hemophilic patients
DISADVANTAGES
1. Inadequate anesthesia in 15-20 %
2. Positive aspiration in 10-15% (heighest)
3. Intraoral landmarks are not consistently reliable.
4. Younger patient – soft tissue injury

113. Anatomic Variations
• Mandible
- Mandibular foramen in children 4 years old and less is
below the plane of occlusion. The foramen moves
superiorly in the ramus with the eruption of 6’s
Adults
Children

114. • Position of the patient-body of
the mandible is parallel to the
floor.

115. Depth of penetration – 20-25 mm
1.5ml / 60 sec.
Wait for 3-5 min.

123. SUBJECTIVE
Numbness over area of
supply of inferior alveolar
nerve & lingual nerve
OBJECTIVE
No pain during
procedure
FAILURE OF
ANESTHESIA
1. Needle tip is too low
2. Needle tip is too medial
3. Needle tip is too anterior
4. Accessory innervations from long
buccal, lingual &
mylohyoid, occasionally
auriculotemporal
5. Anatomical variations
COMPLICATIONS
Hematoma formation
Trismus
Transient facial nerve paralysis

124. IANB SUCCESS
IANB
GOW GATE
OR
VAZIRANI-AKINOSI
APPROACH
SUCCESS
SUCCESS
BUCCAL & LINGUAL
INFILTRATION
INTRALIGAMENTARY

125. is anterior and
medial to inferior alveolar nerve
So withdraw the needle about 1mm
and deposite the 0.5 ml of LA

126. Mental nerve
Icisive nerve

127. infiltration in the buccal
sulcus distal to permanent
molar tooth
Amount deposited-0.2-0.5 ml

128. Areas anaesthetized

129. • Technique - intraoral
• Site of insertion of needle
is mucobuccal fold at or
just anterior to MENTAL
FORAMEN (between
roots of two premolar).
• 0.6 ml of solution is
required.

132. • Site of insertion of needle is mucobuccal fold at or just
anterior to MENTAL FORAMEN (between roots of two
premolar).
• 0.6 ml of solution is required.

135. INDICATIONS
1. Multiple teeth anesthesia
2. Buccal soft tissue anesthesia from third molar to
midline along with lingual soft tissue anesthesia.
3. When conventional inferior alveolar nerve block
is unsuccessful.

136. CONTRAINDICATIONS
1. Infection & inflammation
2. Inexperienced administrator
3. Pediatric patient
4. Unco-operative patients
5. Trismus

137. 1. High success rate (95%) – GOW-GATE TECHNIQUE
2. Less positive aspiration
3. Overcomes case of bifid inferior alveolar
nerve & canal
4. less no. of penetration
1. Requires experience & skill
2. Late onset of anesthesia

138. Mental nerve
Icisive nerve
Mandibular nerve
1. GEORGE ALBERT EDWARDS GOW-GATES (1973)
2. VAZIRANI -AKINOSI CLOSED MOUTH MANDIBULAR
BLOCK (1960-1977)
3. EXTRAORAL APPROACH

139. 1.8 ml+1.2ml / min.
• Area of insertion
• Target area
• Landmarks –
soft tissue distal to 2M
mesiopalatal cusp of maillary 2M
intertragic notch
corner of mouth

141. Area of insertion: soft tissue overlying
the medial border of the mandibular
ramus directly adjacent to maxillary
Tuberosity.
Inject to depth of 25mm
1.5-1.8ml
• Landmarks –
- mucogingival junction of maxillary last molar
- maxillary tuberosity
- coronoid notch

143. • Landmarks –
- Midppoint of zygomatic arch
- zygomatic notch
- coronoid process of ramus
- lateral pterygoid plate
DEPTH – 4.5 cm

145. SUBJECTIVE
1. tingling & numbness over
lower lip & tongue
OBJECTIVE
• No pain during
procedure
FAILURE OF
ANESTHESIA
1. Flaring nature of ramus
2. Needle is too low
3. Overinsertion or underinsertion

146. 1. Hematoma <2% in GOW-GATE technique
<10% in VAZIRANI- AKINOSI technique
2. Trismus (rare)
3. Transient facial nerve paralysis.

148. 1. 10% LIGNOCAINE
HYDROCHLORIDE
2. ETHYL CHLORIDE
Onset of anesthesia = 1 min.
Duration Of Action = 10 min.

150. • Mixture of lignocaine 2.5% &
prilocaine 2.5%.
• anesthesia for intact skin.
• Mild skin blanching & edema may
occur
• Contraindicated in infants under age
of 6 months
- because the metabolites of
prilocaine can cause
methemoglobinemia.

151. 2 x 1 x 2

152. • Liposomes are
comprised of lipid layers
surrounded by aqueous
layers.
• Penetrate the stratum
corneum because they
resemble the lipid
bilayers of the cell
membrane.
• available as an ELA-
Max.
• Is used for the
temporary relief of pain
resulting from minor cuts
4% Lidocaine cream in a liposomal
matrix

153. • 0.5% tetracaine,
• 0.05% epinephrine,
• 1.8% cocaine,
• was the first topical anesthetic mixture found to
be effective for nonmucosal skin lacerations.
• Not used now a days.

154. • (Electromotive Drug Administration (EMDA)) is a
technique using a small electric charge to deliver
a medicine or other chemical through the skin.

155. • This is a technique in which a
small amount of local
anesthetic solution is
propelled as a jet into
submucosa without the use
of hypodermic needle.

156. • The wand local anesthesia
system is a computer controlled
injection device. The
wand/compuDent system
administers local anesthetic at
two specific rates of delivery.
• The slow rate is 0.5ml/min and
• fast rate is 1.8ml/min .
• There is a 4.5 seconds of
aspiration cycle.

157. • electronic , preprogrammed delivery device that
provides the control needed to make the patient’s local
anesthetic injection experience as pleasant as
possible
• Standard dental local anesthetic cartridges & dental
needles may be used.

159. • This method of
achieving local
anesthesia involves the
use of the principle of
TRANSCUTANEOUS
ELECTRICAL NERVE
STIMULATION (TENS)
which causes relief of
pain.

160. 1. IMPLANTS
2. NEUROLOGICAL DISORDERS
- POST CEREBRAL STROKE
- STATUS EPILEPTICUS
- H/O TRANSIENT ISCHEMIC
ATTACK
3. PREGNANCY
4. IMMATURITY
1. NO NEED FOR NEEDLE
2. NO RESIDUAL ANESTHETIC EFFECT
3. ANELGESIC EFFECT OVER SEVERAL
HOURS.

161. • 5 to 8 times more potent than
Lidocaine.
• Available as 0.5 % solution form
• It is used for topical & infiltration
anesthesia.
• In therapeutic dose there is no
CNS & CVS adverse effect.

162. • Addition of SODIUM
BICARBONATE
Causes increase in pH to the 7.2
which provides early onset of
anesthesia.
• Too high pH causes rapid
precipitation of drug base &
decrease in shelf life of LA.

163. • Enzyme that breaks down the
intracellular cements, so helps in
easy diffusion of LA.
• Added just before the
administration of LA solution.
• Added as 1/8 th part of LA
cartridge.

164. CONCLUSION
• The administrator of local anesthetics who adheres to
these basic steps develops a reputation among
patients as a PAINLESS DOCTOR.
• It is not possible to guarantee that every injection will
be absolutely atraumatic because the reaction of both
patient & doctor are far too variable.

165. • BOOKS – MALAMAD 5TH EDITION
- TEXTBOOK OF PEDODONICS -BY SHOBHA
TONDON
- LOCAL ANALGESIA IN DENTISTRY – BY D H
ROBERTS
& J H
SOWRAY
- MONHEIM’S LOCAL ANESTHESIA & PAIN
CONTROL IN DENTAL PRACTICE – BY
RICHARD BENNET
7TH EDITION.

166. • Other sources –
1. Rucci F S, Pippa P, Boccaccini A, Barbagli R. Effect of
injection speed on anaesthetic spread during axillary block
using the orthogonal two-needle technique. Eur J Anaesth
1995; 12: 505-511
2. How to overcome failed local anaesthesia J. G.
Meechan Senior Lecturer/Honorary
Consultant, Department of Oral and Maxillofacial
Surgery, The Dental School, Framlington Place, Newcastle
upon Tyne NE2 4BW REFEREED PAPER Received
31.03.98; accepted 17.08.98 © British Dental Journal 1999;
186: 15–20