MANDIBULAR TECHNIQUES
PRDM169 A.Y. 2024-2025 : 2ND SEMESTER
CONTRAINDICATIONS
MIDDLE SUPERIOR ALVEOLAR
★ MSA nerve is absent (consider
NERVE BLOCK (MSAN)
ASAN + PSAN blocks instead)
★ Presence of infection/
NERVES ANESTHETIZED inflammation at injection site
★ Middle superior alveolar nerve
CLINICAL TIPS
AREAS ANESTHETIZED ★ Slow injection minimizes tissue
distension pain.
★ Maxillary premolars
★ If ineffective, consider
★ Mesiobuccal root of first molar
infraorbital or individual
(if MSA is present)
infiltrations.
★ Buccal gingiva and mucosa
★ Maxillary sinus (portion)
ALTERNATIVES
PROCEDURE ★ Local infiltration (above each
premolar)
★ Position patient in a supine or ★ Infraorbital nerve block (covers
semi-supine position. anterior and middle superior
★ Retract the lip and locate the alveolar nerves
height of the mucobuccal fold
above the maxillary second COMPLICATIONS
premolar. ★ Painful injection (inject slowly)
★ Insert needle parallel to long ★ Hematoma (rare)
axis of the second premolar. ★ Failed anesthesia (if MSA nerve
★ Advance 5-10 mm (do not is absent)
contact bone).
★ Aspirate → If negative, inject
0.9-1.2 mL slowly over 30-60 sec.
★ Wait 3-5 minutes for onset.
INDICATIONS
★ Anesthesia for premolars and
mesiobuccal root of 1st molar
★ Alternative to multiple
infiltrations
1
MANDIBULAR TECHNIQUES
PRDM169 A.Y. 2024-2025 : 2ND SEMESTER
CLINICAL TIPS
ANTERIOR SUPERIOR ALVEOLAR
★ If bicuspids need anesthesia,
NERVE BLOCK (ASAN)
consider an infraorbital
approach.
★ Effective for esthetic dentistry
NERVES ANESTHETIZED
procedures.
★ Anterior superior alveolar nerve
ALTERNATIVES
AREAS ANESTHETIZED
★ Local infiltration (above each
★ Central, lateral, and canine premolar)
★ Buccal mucosa & gingiva ★ Infraorbital nerve block (covers
★ Portion of maxillary sinus anterior and middle superior
alveolar nerves
PROCEDURE
COMPLICATIONS
★ Position patient supine or
★ Painful injection (inject slowly)
reclined. ★ Inadequate anesthesia
★ Locate mucobuccal fold above
the canine.
★ Insert needle toward apical
region of the canine.
★ Advance 5-12 mm.
★ Aspirate → If negative, inject
0.9-1.2 mL slowly.
★ Wait 3-5 min for onset.
INDICATIONS
★ Procedures on incisors &
canines
CONTRAINDICATIONS
★ Infection at injection site
★ Need for anesthesia beyond
canine region (use infraorbital
block instead)
2
MANDIBULAR TECHNIQUES
PRDM169 A.Y. 2024-2025 : 2ND SEMESTER
★ Patients with bleeding
POSTERIOR SUPERIOR ALVEOLAR disorders (risk of hematoma)
NERVE BLOCK (PSAN) ★ Infection at the injection site
NERVES ANESTHETIZED CLINICAL TIPS
★ Posterior superior alveolar ★ Apply pressure and ice
nerve immediately if hematoma
occurs.
★ Avoid over-insertion into
AREAS ANESTHETIZED pterygoid venous plexus.
★ Maxillary molars (except MB
root of 1st molar in ~28%) ALTERNATIVES
★ Buccal gingiva/mucosa
★ Portion of maxillary sinus ★ Infiltration above each molar
★ Maxillary nerve block (V2 block)
PROCEDURE
COMPLICATIONS
★ Position patient supine. ★ Hematoma (risk of puncturing
★ Locate mucobuccal fold above pterygoid venous plexus)
the 2nd molar. ★ Mandibular anesthesia (if
★ Insert needle upward, inward, anesthetic spreads)
and backward at a 45° angle. ★ Trismus (if pterygoid muscle is
affected)
★ Advance 10-16 mm, avoiding
bone contact.
★ Aspirate → If negative, inject 1.5
mL slowly.
★ Wait 3-5 min for onset.
INDICATIONS
★ Extensive restorative or surgical
procedures in molar region
★ Alternative to multiple
infiltrations
CONTRAINDICATIONS
3
MANDIBULAR TECHNIQUES
PRDM169 A.Y. 2024-2025 : 2ND SEMESTER
CONTRAINDICATIONS
INFRAORBITAL NERVE BLOCK
★ Infection at injection site
NERVES ANESTHETIZED CLINICAL TIPS
★ Anterior superior alveolar ★ Provides anesthesia for
★ Middle superior alveolar cosmetic procedures on lips
★ Inferior palpebral, lateral nasal, and face.
superior labial
ALTERNATIVES
AREAS ANESTHETIZED
★ Infiltration above each molar
★ Maxillary incisors, canine, ★ Maxillary nerve block (V2 block)
premolars
★ Buccal gingiva of affected teeth
★ Lower eyelid, lateral nose, COMPLICATIONS
upper lip ★ Ecchymosis or hematoma
★ Temporary numbness of lower
PROCEDURE eyelid
★ Position patient supine.
★ Locate infraorbital foramen
(palpate under the lower orbital
rim).
★ Insert at the mucobuccal fold
above the 1st premolar.
★ Advance 15-20 mm until near
foramen.
★ Aspirate → If negative, inject
0.9-1.5 mL.
★ Apply external pressure over
foramen for 1-2 min.
INDICATIONS
★ Trauma or surgical procedures
of upper lip, nose, or lower
eyelid
4
MANDIBULAR TECHNIQUES
PRDM169 A.Y. 2024-2025 : 2ND SEMESTER
GREATER PALATINE NERVE BLOCK CLINICAL TIPS
★ Use pressure anesthesia to
NERVES ANESTHETIZED minimize pain.
★ Greater palatine nerve
ALTERNATIVES
AREAS ANESTHETIZED ★ Local palatal infiltration
★ Posterior hard palate
★ Soft tissues from premolars to COMPLICATIONS
molars ★ Painful injection (use pressure
anesthesia)
PROCEDURE
★ Position patient supine.
★ Locate greater palatine
foramen (near 2nd molar).
★ Apply pressure anesthesia with
a cotton swab.
★ Insert needle just anterior to
foramen.
★ Advance 3-6 mm until bone
contact.
★ Aspirate → If negative, inject
0.4-0.6 mL.
INDICATIONS
★ Surgical procedures involving
posterior palatal tissue
★ Pre-prosthetic procedures
(denture fittings, extractions)
CONTRAINDICATIONS
★ Infection at injection site
★ Patient intolerance to palatal
injections
5
MANDIBULAR TECHNIQUES
PRDM169 A.Y. 2024-2025 : 2ND SEMESTER
CLINICAL TIPS
NASOPALATINE NERVE BLOCK
★ One of the most painful
injections — use pressure
NERVES ANESTHETIZED anesthesia.
★ Nasopalatine nerve
ALTERNATIVES
AREAS ANESTHETIZED ★ Local palatal infiltration
★ Palatal mucosa from canine to
COMPLICATIONS
canine
★ Most painful maxillary injection
PROCEDURE (use pressure anesthesia)
★ Risk of inadequate anesthesia
★ Position patient supine. (may need reinforcement)
★ Identify incisive papilla.
★ Apply pressure anesthesia with
cotton swab.
★ Insert needle lateral to incisive
papilla.
★ Advance 3-5 mm until bone
contact.
★ Aspirate → If negative, inject
0.3-0.5 mL.
INDICATIONS
★ Periodontal & surgical
procedures on anterior palate
★ Palatal anesthesia for esthetic
dentistry
CONTRAINDICATIONS
★ Highly sensitive patients (very
painful injection)
