OPEN AND CLOSED MOUTH

TECHNIQUES OF LOCAL
ANESTHESIA
ATIKA IFTIKHAR
FINAL YEAR BDS
 INTRODUCTION
• ANESTHESIA

o AN-loss

o ESTHESIA-sensation

“Anesthesia is loss of sensation”

 INTRODUCTION
• TYPES

o General: Anesthesia affecting the entire body

and accompanied by loss of consciousness.

o Local: Anesthesia affecting specific part of the

body.
METHODS OF LOCAL ANESTHESIA
BRANCHES OF TRIGERMINAL
NERVE
 TECHNIQUES OF LA
• OPEN MOUTH TECHNIQUES
• CLOSED MOUTH TECHNIQUES
OPEN MOUTH TECHNIQUES
MAXILLA
 NERVE SUPPLY TO MAXILLARY
TEETH
PULP, INVESTING SRUCTURES AND BUCCAL
MUCOPERIOSTEUM
Anterior teeth (1,2,3) Anterior superior alveolar nerve

Premolars (4,5) and MB root of Middle superior alveolar nerve

first molar (6)

Molars except MB root of first Posterior superior alveolar nerve

molar (6)
 NERVE SUPPLY TO MAXILLARY
TEETH
PALATAL MUCOPERIOSTEUM

Anterior (1,2,3) Nasopalatine nerve

Premolars (4,5) and molars Greater palatine nerve

(6,7,8)
 Maxillary
anesthesia

Injection Block

Supraperiosteal Poterior superior

Injection alveolar NB

Intraligamentary Anterior superior

(PDL) Injection alveolar NB

Intrapulpal middle superior

anesthesia alveolar NB

Intraosseous
Maxillary NB
anesthesia

Intraseptal Greater Palataine

anesthesia NB

Incisive NB
 SUPRAPERIOSTEAL INJECTION
(BUCCAL INFILTRATION)
• NERVES AND AREAS ANESTHETIZED
• INDICATIONS
o One or two teeth procedure
o Soft tissue procedure of circumscribed area

• CONTRAINDICATIONS
o Inflammation of the area
o Dense bone covering the apex of teeth

• ADVANTAGES
o High success rate
o Easy method
o Atraumatic

• DISADVANTAGES
o Not recommended for large area
• STEPS FOR BUCCAL INFILTRATION
1. Retract lip/cheek with mirror or finger
2. Point of insertion of needle

3. Needle is inserted into apex of tooth into height

of mucobuccal fold of target tooth , making an
angle of 45° with the buccal aspect
4. Needle is pushed through soft tissue (within 2mm)

5. Needle is held firmly and anesthetic solution is slowly

deposited

6. Needle is withdrawn and recapped

7. Wait 2-3min , then start dental procedure

• CONFIRMING ANESTHESIA

o Subjective – numbness of area

o Objective – no pain on probing

 INTRALIGAMENTARY INJECTION
• Local anesthetic solution is deposited into the
periodontal ligament space
• comprises of high pressure syringes and
ultrafine needles
 INTRAPULPAL INJECTION
• INDICATION
procedures requiring direct instrumentation of
the pulpal tissue like RCT.

• AREA
Needle is inserted directly
into the pulp chamber or
the root canal and LA is injected.
 INTRAOSSEOUS INJECTION
• AREA
LA solution is deposited directly into the cancellous bone
adjacent to the tooth to be anesthetised.
• INDICATION
single teeth (primarily mandibular molars) when other
techniques have failed.
• DISADVANTAGE:
Specialised equipment and technique.
 INTRASEPTAL ANESTHESIA
• A variation of intraosseous anesthesia.
• TECHNIQUE
1. Needle is forced gently into the porous interseptal bone on
either side of the tooth to be anesthetised.
2. The local anesthetic solution is then forced under pressure
into the cancellous bone.
• INDICATION
periodontal surgical techniques.
 ANTERIOR SUPERIOR ALVEOLAR
NERVE BLOCK
• NERVES AND AREAS ANESTHETIZED
• INDICATIONS
o Multiple teeth procedures
o If infiltration is contraindicated
o Others ineffective

• CONTRAINDICATIONS
o One or two teeth procedure

• ADVANTAGES
o Safe process
o Minimizes volume of solution used

• DISADVANTAGES
o Psychological( operator's fear, patient's anxiety)
o Difficulty determining landmarks
• TECHNIQUE OF ASA NB
Target area: infraorbiltal foramen
2 approaches:

BICUSID APPROACH INCISAL APPROACH

Height of mucobuccal fold over 1st Height of mucobuccal fold over canine
bicuspid region region
1. Locate foramen

2. lip or cheek retracted

3. needle inserted height of mucobuccal fold directly

over first premolar or canine region.

4. landmarks: mucobuccal fold, infraorbital notch,

infraorbital foramen

5. Deposit local anesthesia and massage postero-

superiorly to diffuse solution

6. Wait 3-5 mins

• CONFIRMING
o SUBJECTIVE: numbness of lower eyelids, side of nose, and
upper lip and areas of ASA, MSA

o OBJECTIVE: no pain during procedure

 MIDDLE SUPERIOR ALVEOLAR
NERVE BLOCK
• MSA nerve is present in only about 28% of the
population--so limited clinical use.
• NERVES AND AREAS ANESTHETIZED
• INDICATIONS
o Where ASA isn’t effective for premolars
o Premolars procedure
• CONTRAINDICATIONS
o Inflammation of the area
o Where no MSA is present
• ADVANTAGES
o Minimizes the volume of solution
o Minimizes the number of injection
• DISADVANTAGES
o Not observed
• TECHNIQUE
1. lip or cheek retracted

2. needle inserted parallel to long axis of tooth

3. Area of insertion: height of mucobuccal fold directly over

second premolar

4. Target area: maxillary bone above apex of maxillary 2nd

premolar

5. landmarks: mucobuccal fold above the maxillary 2nd premolar

6. Aspirate

7. Wait 3-5 mins

• CONFIRMING
• SUBJECTIVE:
o Numbness of upper lip
o Numbness at the areas of MSA
• OBJECTIVE: no pain during procedure
 POSTERIOR SUPERIOR ALVEOLAR
NERVE BLOCK
• NERVES AND AREAS ANESTHETIZED
• INDICATIONS
o Molars procedure
o When infiltration is contraindicated
o When others ineffective

• CONTRAINDICATIONS
o When high risk of hemorrhage

• ADVANTAGES
o Atraumatic
o Minimizes the number of injections
o Minimizes the volume of solution
o High success rate

• DISADVANTAGES
o Hematoma
o No bony landmarks
o 2 injections for first molar
• TECHNIQUE
1. lip or cheek retracted

2. needle inserted upward, inward and backward in one

movement(not three)

3. area of insertion: height of mucobuccal fold directly

over second molar

4. Target area: PSA nerve(posterior, superior and medial

to maxilla posterior border)

5. Landmarks: mucobuccal fold, maxillary tuberosity,

zygomatic process of maxilla
• CONFIRMING
o SUBJECTIVE: Numbness at the areas of PSA
o OBJECTIVE:
• no pain during procedure
• Negative electrical pulp test
 PALATAL INFILTRATION
• NERVE AND AREA ANESTHETIZED
• INDICATIONS
o Hemostasis
o Pain control

• CONTRAINDICATIONS
o Inflammation of the site
o Multiple teeth involved

• ADVANTAGES
o Minimum area involved

• DISADVANTAGES
o traumatic
• STEPS OF PALATAL INFILTRATION
1. mirror is used to retract tongue and reflect light to the area
2. Point needle ,between gingival margin of tooth and medial
palatine raphe, along long axis of tooth.
3. Needle is inserted making 90° with palate.
4. Needle is pushed through soft tissue until bone is reached
5. Deposit the solution.

• CONFIRMING ANESTHESIA
 GREATER PALATINE NERVE
BLOCK
• NERVE AND AREA ANESTHETIZED
• INDICATIONS
o Multiple teeth procedure
o Palatal surgical procedures

• CONTRAINDICATIONS
o One or two teeth procedure
o Inflammation of the area

• ADVANTAGES
o Minimizes the needle penetration
o Minimizes volume of solution
o Minimizes patient’s discomfort

• DISADVANTAGES
o traumatic
• TECHNIQUE
1. Locate the greater palatine foramen

2. lip or cheek retracted

3. Target area: GP nerve

4. area of insertion: soft tissue slightly anterior to GP

foramen

5. needle inserted from opposite side of mouth at right

angle

6. Slowly advance needle until palataine bone is gently

contacted.Depth of penetration: less than 10 mm.

7. Retract needle and confirm anesthesia

 INCISIVE NERVE BLOCK
(nasopalatine Nerve block)
• NERVES AND AREAS ANESTHETIZED
o Nasopalatine nerve bilaterally
o Anterior branches of ASA
• AREA ANESTHETIZED
o Anterior portion of hard palate bilaterally
• INDICATIONS
o Pain control
o Multiple anterior teeth involved

• CONTRAINDICATIONS
o Inflammation of the site
o Smaller area of therapy

• ADVANTAGES
o Minimizes needle penetration
o Minimal patient’s discomfort

• DISADVANTAGES
o Traumatic
• TECHNIQUE
1. a mirror is used to retract tongue and reflect light to
the area
2. Preparatory injections given
3. Then needle inserted at 45 degree
4. area of insertion: palatal mucosa /Depression
around incisive papilla
5. Target area: incisive foramen
6. landmarks: central incisors and incisive papilla

7. CONFIRMING ANESTHESIA
 MAXILLARY NERVE BLOCK
• NERVE AND AREAS ANESTHETIZED
• INDICATIONS
o Extensive oral surgery (quadrant)
o Others are contraindicated
• CONTRAINDICATIONS
o Inexperience
o Pediatric patient
o Uncooperative patients
o Inflammation of the site
o Inability to gain access
• ADVANTAGES
o Atraumatic
o High success rate
o Minimizes the number of needle penetration
o Minimizes the volume of solution
• DISADVANTAGES
o Hematoma
o Painful
 TECHNIQUES
HIGH TUBEROSITY METHOD
1-lip or cheek retracted
2- needle inserted in an upward,
inward and backward direction as
for PSA
3- area of insertion: mucobuccal
fold above the distal aspect of
maxillary 2nd molar
4- Target area: maxillary nerve as
it passes through pterygopalatine
fossa
5- landmarks:
– mucobuccal fold at distal
aspect of maxillary 2nd molar
– Maxillary tuberosity
– Zygomatic process of maxilla
GREATER PALATINE CANAL
APPROACH
1-open mouth wide
2- needle inserted from opposite
site of mouth at right angle
3- area of insertion: palatal soft
tissue directly over GP foramen
4- Target area: maxillary nerve as
it passes through pterygopalatine
fossa
5- landmarks:
– greater palatine foramen
– Junction of maxillary alveolar
process and palatine bone
MANDIBLE
NERVE SUPPLY TO MANDIBULAR
TEETH
PULP AND INVESTING STRUCTURES
Anterior teeth (1,2,3) Incisive nerve
Posterior teeth (4,5,6) Inferior alveolar nerve

LABIAL (BUCCAL) MUCOPERIOSTEUM

Anterior teeth(1,2,3) and
premolars (4.5)
Posterior teeth (6,7,8)
Mental nerve
Cutaneous coli nerve(branch of
cervical plexus C2, C3) giving
additional sensory supply to (4,5)
in 20% pts
Long buccal nerve

LINGUAL MUCOPERIOSTEUM
Anterior (1,2,3) premolars (4,5) , Lingual nerve
molars (6,7,8)
 Anterior labial
infiltration
Anterior lingual
Infiltration
infiltration

Mandibular anesthesia
Long buccal
infiltration
Inferior alveolar
NB

Incisive NB

Gow gates
mandibular NB
Block
Mental nerve
block
Buccal nerve
block

Vazirani-Akinosi
ANTERIOR LABIAL INFILTRATION
• NERVE ANESTHETIZED
o Incisive nerve
o Inferior dental plexus

• AREA ANESTHETIZED
o Buccal mucosa and periosteum of the area
o Respective tooth

One or two teeth procedure

Limited buccal soft tissue procedure
• TECHNIQUE
1. lip or cheek retracted
2. needle inserted into mucobuccal fold keeping
needle at 45°
3. check the effects
• CONFIRMING
– SUBJECTIVE: numbness of the area near lip
– OBJECTIVE: no pain during the procedure
ANTERIOR LINGUAL INFILTRATION
• NERVE ANESTHETIZED
o Terminal branches of lingual nerve
• AREA ANESTHETIZED
o Lingual soft tissue of the area
o Area of floor of mouth

Limited lingual tissue procedure

One or two teeth procedure
• TECHNIQUE
1. lip or cheek retracted

2. needle inserted
– For right side approach from corner of mouth at left side
and vice verse

3. area of insertion: point of intersection of two line

o Vertical long axis of tooth
o Horizontal mucolingual fold

4. target area
– apical to the tooth to be anesthetized lingually

• CONFIRMING
o SUBJECTIVE: numbness of the area
o OBJECTIVE: no pain during the procedure
 INFERIOR ALVEOLAR NERVE
BLOCK
• NERVES AND AREAS ANESTHETIZED
• INDICATIONS
– Multiple teeth procedure
– For buccal soft tissue procedure
– For lingual soft tissue procedure

• CONTRAINDICATIONS
– Inflammation of the area
– handicapped patient
– Children

• ADVANTAGES
– One injection, large area anesthesia

• DISADVANTAGES
– Inadequate
– Not for localized procedures
– Variable landmarks
– Trauma (self inflicted)
• Area of insertion:
Mucous membrane on the medial (lingual) side
of the mandibular ramus

• Target area:
Inferior alveolar nerve before it enters into the
mandibular foramen

• Landmarks
–Coronoid notch
–Pterygomandibular raphe
–Occlusal plane
• TECHNIQUE
1. Retract lip and cheek
2. Insert needle at right angle from opposite side of
mouth, premolar region

3. Point of injection: deepest part of the

pterygomandibular raphe
5. When the bone is contacted aspirate.

6. Slowly withdraw the syringe, and when

approximately half its length remains within tissues,
reaspirate to anesthetize the lingual nerve

• CONFIRMING
o SUBJECTIVE:
• numbness of the lower lip
• Numbness of the tongue
o OBJECTIVE: no pain during the procedure
 LINGUAL NERVE BLOCK
• Done with inferior alveolar nerve block
 INCISIVE NERVE BLOCK
• NERVES AND AREAS ANESTHETIZED
• INDICATIONS
– Teeth procedure anterior to mental foramen
– When IANB is not indicated

• CONTRAINDICATION
– Inflammation of the area

• ADVANTAGES
– Provides anesthesia without lingual tissue
– High success rate

• DISADVANTAGES
– No lingual anesthesia
– Partial anesthesia due to nerve overlap from opposite
site
• TECHNIQUE
1. lip or cheek retracted

2. needle inserted: From canine or 1st premolar towards

foramen

3. area of insertion:
mucobuccal fold at or anterior to mental foramen

4. target area: mental foramen

5. landmarks:
– mandibular premolars
– Mucobuccal fold
• CONFIRMING
– SUBJECTIVE: numbness of the lower lip
– OBJECTIVE: no pain during the procedure
 MENTAL NERVE BLOCK
• NERVES AND AREAS ANESTHETIZED
• INDICATIONS
– For buccal soft tissue procedure
• CONTRAINDICATIONS
– Inflammation of the area
• ADVANTAGES
– Easy technique
– Atraumatic
• DISADVANTAGES
– Hematoma
• TECHNIQUE
1. lip or cheek retracted

2. needle inserted

3. area of insertion: mucobuccal fold at or anterior to mental

foramen

4. target area: mental nerve as it exits the foramen (between apices

of 1st and 2nd premolar)

5. landmarks:
– mandibular premolars
– Mucobuccal fold

6. CONFIRMING
– SUBJECTIVE: numbness of the lower lip
– OBJECTIVE: no pain during the procedure
 BUCCAL NERVE BLOCK
• NERVE ANESTHETIZED
– Buccal nerve

• AREA ANESTHETIZED
– Buccal soft tissue and periosteum of molar teeth

For buccal soft tissue procedure

• TECHNIQUE
1. lip or cheek retracted

2. needle inserted parallel to the occlusal plane of same

side

3. area of insertion: mucosa distal and buccal to most

distal molar of the arch

4. target area: buccal nerve as it passes over anterior

border of ramus

5. landmarks:
– mandibular molars
– Mucobuccal fold
• CONFIRMING
– SUBJECTIVE: numbness of area but rarely
– OBJECTIVE: no pain during the procedure
 GOW GATES TECHNIQUE
• NERVE ANESTHETIZED
• AREA ANESTHETIZED
• INDICATIONS
– Multiple teeth procedure
– When IANB is unsuccessful
• CONTRAINDICATIONS
– Children
– Handicapped patient
– Trismus
• ADVANTAGES
– One injection
– Few complications
• DISADVANTAGES
– Dangerous for patient
– Longer onset
– Experience required
• TECHNIQUE
1. The mouth is opened as wide as possible

2. Insert the needle into the mucosa at the level of the

2nd maxillary molar just distal to the mesiolingual
cusp
3. target area: lateral side of condylar neck, just below
the insertion of lateral pterygoid muscle
• LANDMARKS

EXTRAORAL INTRAORAL
– Intertragic notch – Maxillary 2nd molar,
– Corner of mouth mesiolingual cusp
– Mucosa distal to maxillary 2nd
molar
• CONFIRMATORY ANESTHESIA
• SUBJECTIVE– numbness of lower lip, tongue
• OBJECTIVE– no pain during procedure
CLOSED MOUTH TECHNIQUE
 VAZIRANI-ALKINOSI TECHNIQUE
• NERVES AREAS ANESTHETIZED
• INDICATIONS
– Limited mandibular opening
– Multiple teeth procedure
• CONTRAINDICATIONS
– Handicapped patient
– Children
– Inability to find the area
• ADVANTAGES
– Atraumatic
– No need to open mouth
• DISADVANTAGES
– Difficult to visualize the area
– May be painful
• TECHNIQUE
1. Have the patient close the mouth
2. needle inserted
– At level of mucogingival junction of maxillary
2nd/3rd molar
– Parallel to maxillary occlusal plane
3. area of insertion:
– soft tissue at medial border of ramus
– Adjacent to maxillary tuberosity
– At level of mucogingival junction of maxillary third
molar
4. target area:
– medial border of ramus in region of IAN, lingual nerve,
mylohyoid nerve

5. landmarks:
– Mucogingival junction of maxillary third molar
– Maxillary tuberosity
– Coronoid notch

• CONFIRMING
• SUBJECTIVE:
– numbness of the lower lip
– Numbness of the tongue
• OBJECTIVE: no pain during the procedure