Techniques of Regional Anesthesia
in Dentistry
Prof. Abeer Kamal
Intended Learning outcome’s ILO’S
By the end of this subject the candidate will be
able to:
1. State different techniques used in LA.
2. Apply infection control guidelines for LA procedures.
3. Perform different clinical techniques used in LA.
4. Communicate in a professional manner with patients,
colleagues & professors.
Techniques of Regional Anesthesia in
Dentistry
IV- Techniques of Maxillary
Anesthesia
Posterior
Superior Alveolar
Nerve Block
Posterior Superior Alveolar Nerve Block
Area anesthetized:
1. Pulps of the maxillary third,
second, and first molars (entire
1st molar = 72% success rate;
mesiobuccal root of the
maxillary first molar not
anesthetized = 28% of PSA
nerve blocks)
2. Buccal periodontium and bone
overlying these teeth
Posterior Superior Alveolar Nerve Block
Complication:
1- Insertion of the needle too far distally
may lead to a temporarily (10 to 14 days)
unesthetic hematoma.
Use of a “short” dental needle is
recommended (depth of penetration is
16 mm)
2- Mandibular ansthesia: mandibular
nerve is located lateral to the PSA nerves
Posterior Superior Alveolar Nerve Block
Indications
1. When treatment involves two or more maxillary molars
2. When supraperiosteal injection is contraindicated (e.g., with
infection or acute inflammation)
3. When supraperiosteal injection has proved ineffective
Contraindication: When the risk of hemorrhage is too great (as
with a hemophiliac; patients taking drugs that can increase
bleeding such as coumadin or Plavix.
Posterior Superior Alveolar Nerve Block
Advantages
1. Atraumatic.
2. High success rate (>95%).
3. Minimum number of necessary injections.
4. Minimizes the total volume of local anesthetic solution.
Disadvantages
1. Risk of hematoma, which is usually diffuse and discomfiting to the
patient
2. Technique somewhat arbitrary: no bony landmarks during insertion
3. Second injection necessary for treatment of the first molar BM root in
28% of patients
Posterior Superior Alveolar Nerve Block
Technique
1. 27-gauge short needle.
2. Area of insertion: height of the mucobuccal
fold above the maxillary second molar.
3. Target area: 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.
Posterior Superior Alveolar N.B.
❖Patient position.
❖Operator position.
❖Point of needle insertion. 16mm
❖Amount of deposited sol. (0.9cc).
❖Area to be anesthetized
Posterior Superior Alveolar Nerve Block
Posterior Superior Alveolar Nerve Block
Procedure:
1- Preparation
2- Insert the needle into the height of the mucobuccal fold over
the second molar
3- Advance the needle slowly in an upward, inward, and
backward direction to the desired depth (16 mm)
4-Aspirate
5- Deposition of the solution
Posterior Superior Alveolar Nerve Block
Signs and Symptoms
1. Subjective: usually none; the patient has difficulty
reaching this region to determine the extent of
anesthesia.
2. Objective: use of a freezing spray (e.g., Endo-Ice) or
an EPT with no response from the tooth with maximal
EPT output (80/80).
3. Absence of pain during treatment.
(Infraorbital Nerve Block)
Inferaorbital Nerve
Block
Infraorbital Nerve Block
Localization of Infraorbital F.
1. Incisor approach.
2. 2nd premolar approach.
Amount of deposited sol. (2cc).
Area to be anaesthetized
3-Extra oral approach.
20mm
2 2 1
Inferaorbital Nerve Block
Nerves Anesthetized
1. ASA nerve
2. MSA nerve
3. Infraorbital nerve
a. Inferior palpebral
b. Lateral nasal
c. Superior labial
Areas Anesthetized
1. Pulps of maxillary central incisor through canine on the injected side
2. Pulps of maxillary premolars and mesiobuccal root of first molar
3. Buccal (labial) periodontium and bone of these same teeth
4. Lower eyelid, lateral aspect of the nose, upper lip
Inferaorbital Nerve Block
Indications
1. Dental procedures involving more than two teeth (incisors to
premolars) and their overlying buccal tissues.
2. Inflammation or infection.
3. When supraperiosteal injections have been ineffective because
of dense cortical bone.
Contraindications
1. Discrete treatment areas (one or two teeth only)
2. Hemostasis of localized areas, when desirable.
Inferaorbital Nerve Block
Advantages
1. Simple technique
2. Minimizes volume of solution used and the number of needle
punctures necessary to achieve anesthesia
Disadvantages
1. Psychological:
a.Administrator: There may be an initial fear of injury to the
patient’s eye
b.Patient: An extraoral approach to the infraorbital nerve may
prove disturbing
1. Anatomic: difficulty defining landmarks (rare).
Inferaorbital Nerve Block
Technique
1. 25- or 27-gauge long needle
2. Area of insertion: height of the mucobuccal fold directly over the
first or 2nd premolar. Or central incisor (MI and DG angle)
3. Target area: infraorbital foramen (below the infraorbital notch).
4. Landmarks:
a. Mucobuccal fold.
b. Infraorbital notch.
c. Intraorbital foramen.
5. Orientation of the bevel: toward bone.
Inferaorbital Nerve Block
20mm
2 2 1
Inferaorbital Nerve Block
Inferaorbital Nerve Block
Inferaorbital Nerve Block
Signs and Symptoms
1. Subjective: tingling and numbness of the lower eyelid, side of the
nose, and upper lip
2. Subjective and objective: numbness in the teeth and soft tissues
along the distribution of the ASA and MSA nerves
3. Objective: use of a freezing spray (e.g., Endo-Ice) or an EPT with no
response from the tooth with maximal EPT output (80/80).
4. Absence of pain during treatment.
Inferaorbital Nerve Block
Precautions
1. For pain on insertion of the needle and tearing of the
periosteum, reinsert the needle in a more lateral (away from
bone) position, or deposit solution as the needle advances
through soft tissue.
2. To prevent overinsertion of the needle, estimate the depth of
penetration before injection (review the procedure), and exert
finger pressure over the infraorbital foramen. a.
Inferaorbital Nerve Block
Failures of Anesthesia
1. Needle contacting bone below the infraorbital foramen.
To correct this:
a. Keep the needle in line with the infraorbital foramen during
penetration. Do not direct the needle toward bone.
b. Estimate the depth of penetration before injecting anesthetic.
2- Needle deviation medial or lateral
To correct this:
a. Direct the needle toward the foramen immediately after
inserting.
b. Recheck needle placement before aspirating and depositing the
anesthetic solution.
Inferaorbital Nerve Block
Complications
Hematoma (rare) may develop across the lower eyelid
and the tissues between it and the infraorbital foramen.
To manage : apply pressure on the soft tissue over the
foramen for 2 to 3 minutes.
Maxillary
Nerve
Block
Maxillary Nerve Block
Nerve block is an effective method
of achieving profound anesthesia of
a hemimaxilla extensive surgical
procedures.
Major difficulties:
-Greater palatine canal approach
involve locating the canal
-High-tuberosity approach is a
higher incidence of hematoma.
Nerve Anesthetized : Maxillary division of the trigeminal
nerve.
Areas Anesthetized:
1. Pulpal anesthesia of the maxillary teeth on the side of the
block
2. Buccal periodontium and bone overlying 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
Indications
1. Pain control before extensive procedures.
2. Infection prevent the use of other technique.
3. Diagnostic or therapeutic procedures for neuralgias
Contraindications
1. Inexperienced administrator.
2. Pediatric patients.
3. Uncooperative patients.
4. Infection of tissues overlying the injection site.
5. When hemorrhage is risky (in a person with hemophilia or patient on
anticoagulant drugs).
6. In the greater palatine canal approach: inability to gain access to the
canal; bony obstructions may be present.
Advantages
1. Atraumatic injection via the high-tuberosity approach.
2. High success rate (>95%)
3. Minimizes the number of needle penetrations necessary
for successful anesthesia of the hemimaxilla
5. Minimizes total volume of local anesthetic solution
injected to 1.8 mL versus 2.7 mL.
6. Neither the high-tuberosity approach nor the greater
palatine canal approach is usually traumatic.
Disadvantages
1.Risk of hematoma, primarily with the high-tuberosity
approach.
2.The high-tuberosity approach is relatively arbitrary.
Overinsertion is possible because of the absence of
bony landmarks if proper technique is not followed.
3.Lack of hemostasis. If necessary, this necessitates
infiltration of small volumes of vasoconstrictor-
containing local anesthetic at the surgical site.
4.Pain: the greater palatine canal approach is potentially
(although not usually) traumatic
Alternatives for Maxillary block
1. PSA nerve block
2. ASA nerve block
3. Greater palatine nerve block
4. Nasopalatine nerve block
Technique for Maxillary block :
I- Intraoral Approach
a- High Tuberosity Approach
B- Greater Palatine Canal Approach
II- Extraoral Approach
a- Sigmoid notch
Intra oral approach: High-Tuberosity Approach
1. A 25–27-gauge long needle.
2. Area of insertion: height of the mucobuccal fold
above the distal aspect of the maxillary second molar.
3. Target area:
a. Maxillary nerve in 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.
- Orientation of the bevel: toward
bone.
- Place the needle into the height of
the mucobuccal fold over the
maxillary second molar.
- Advance the needle slowly in an
upward, inward, and backward
direction as described for the PSA
nerve block
- Advance the needle to a depth of
30 mm
- Aspirate
Intra oral approach:Greater Palatine Canal
Approach
1. A 25-27-gauge long needle.
2. Area of insertion: soft tissue directly over greater
palatine foramen
3. Target area: the maxillary nerve as it passes through
the pterygopalatine fossa; the needle passes through the
greater palatine canal to reach the pterygopalatine fossa.
4. Landmark:
a- Greater palatine foramen,
b- Junction of the maxillary alveolar process and the
palatine bone.
5. Orientation of the bevel: toward palatal soft tissues.
Extraoral Approach for Maxillary Nerve Block :Sigmoid
Notch
A needle inserted
perpendicular to the
sagittal plane should
pass through the
mandibular notch just
inferior to the
midpoint of the
zygomatic arch and
advance it slowly until
it strikes the lateral
pterygoid plate.
Signs and Symptoms
1. Subjective: numbness of the lower eyelid, side of the
nose, and upper lip.
2. Subjective: sensation of numbness in the teeth and buccal
and palatal soft tissues on the side of injection.
3. . Objective: use of a freezing spray (e.g., Endo-Ice) or an
EFT with no response from teeth with maximal EPT
output (80/80).
4. Objective: absence of pain during treatment.
Palatal Block
Greater
Nasopalatine
palatine
nerve block
nerve block
Nasopalatine Nerve Block
• Maximally one-quarter of a cartridge
• Highly traumatic painful
• Two approaches
Areas Anesthetized:
Anterior portion of the hard
palate (soft and hard tissues)
bilaterally from the mesial
aspect of the right first
premolar to the mesial aspect
of the left first premolar
Indications
1. 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
Contraindications
1. Inflammation or infection at the injection site
2. Smaller area of therapy (one or two teeth)
The first approach: involves only one tissue penetration,
lateral to the incisive papilla on the palatal aspect of the
maxillary central incisors
Second approach: involves three needle punctures
1- Labial soft tissues between maxillary central incisors are
anesthetized.
2- 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.
3- Directly into the partially anesthetized palatal soft tissues
overlying the nasopalatine nerve.
1. A 27-gauge short needle
2. Area of insertion: Palatal mucosa just lateral
to the incisive papilla
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.
Greater palatine nerve block
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
Greater palatine nerve block
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
Contraindications
1. Inflammation or infection at the injection site
2. Smaller areas of therapy (one or two teeth)
Signs and Symptoms
1. Subjective: numbness in the posterior portion of
the palate
2. Objective: no pain during dental therapy
Technique
1. A 27-gauge short needle.
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.
Volumes of solutions recommended for maxillary injections.
