anesth mouth

Local Anesthesia Techniques in Local Anesthesia Techniques in Oral and Maxillofacial SurgeryOral and Maxillofacial Surgery

Sean M. Healy, D.D.S.Sean M. Healy, D.D.S.Oral and Maxillofacial SurgeryOral and Maxillofacial Surgery

Francis B. Quinn, M.D.Francis B. Quinn, M.D.Otolaryngology Otolaryngology –– Head and Neck SurgeryHead and Neck Surgery

University of Texas Medical BranchUniversity of Texas Medical BranchOctober 2004October 2004

Overview:Overview:

•• Purpose of local anesthesiaPurpose of local anesthesia•• Anatomy of maxillary and mandibular Anatomy of maxillary and mandibular

nervous innervationnervous innervation•• Techniques of local anesthesia blocksTechniques of local anesthesia blocks•• Commonly used local anestheticsCommonly used local anesthetics•• Complications with local anesthesiaComplications with local anesthesia

Local Anesthetics:Local Anesthetics:

•• Role:Role:–– Decrease intraoperative and postoperative Decrease intraoperative and postoperative

painpain–– Decrease amount of general anesthetics used Decrease amount of general anesthetics used

in the ORin the OR–– Increase patients cooperationIncrease patients cooperation–– Diagnostic testing/examinationDiagnostic testing/examination

Anatomical considerations:Anatomical considerations:

•• Trigeminal nerve:Trigeminal nerve:–– Sensory divisions:Sensory divisions:

•• Ophthalmic division V1Ophthalmic division V1•• Maxillary division V2Maxillary division V2•• Mandibular division V3Mandibular division V3

–– Motor division:Motor division:•• MasticatoryMasticatory-- masseter, temporalis, medial and lateral masseter, temporalis, medial and lateral

pterygoidspterygoids•• MylohyoidMylohyoid•• Anterior belly of the digastricAnterior belly of the digastric•• Tensor tympaniTensor tympani•• Tensor veli palatiniTensor veli palatini

Maxillary Division (V2):Maxillary Division (V2):

•• Exits the cranium via foramen rotundum of the Exits the cranium via foramen rotundum of the greater wing of the sphenoidgreater wing of the sphenoid

•• Travels at the superior most aspect of the Travels at the superior most aspect of the pterygopalatine fossa just posterior to the pterygopalatine fossa just posterior to the maxillamaxilla

•• Branches divided by location:Branches divided by location:–– InterInter--cranialcranial–– PterygopalatinePterygopalatine–– Infraorbital Infraorbital –– FacialFacial


•• Branches:Branches:–– Within the craniumWithin the cranium-- middle meningeal nerve middle meningeal nerve

providing sensory innervation to the dura providing sensory innervation to the dura matermater

–– Within the pterygopalatine fossaWithin the pterygopalatine fossa--•• Zygomatic nerveZygomatic nerve•• Pterygopalatine nervesPterygopalatine nerves•• Posterior superior alveolar nervePosterior superior alveolar nerve


•• Within the pterygopalatine fossaWithin the pterygopalatine fossa--–– Zygomatic nerve:Zygomatic nerve:

•• Zygomaticofacial nerveZygomaticofacial nerve-- skin to cheek prominenceskin to cheek prominence•• Zygomaticotemporal nerveZygomaticotemporal nerve-- skin to lateral foreheadskin to lateral forehead

–– Pterygopalatine nerves:Pterygopalatine nerves:•• Serves as communication for the pterygopalatine Serves as communication for the pterygopalatine

ganglion and the maxillary nerveganglion and the maxillary nerve•• Carries postganglionic secretomotor fibers through Carries postganglionic secretomotor fibers through

the zygomatic branch to the lacrimal glandthe zygomatic branch to the lacrimal gland


•• Within the pterygopalatine fossaWithin the pterygopalatine fossa--–– Pterygopalatine nerves:Pterygopalatine nerves:

•• Orbital branchesOrbital branches-- supplies periosteum of the orbitssupplies periosteum of the orbits•• Nasal branchesNasal branches-- supplies mucous membranes of supplies mucous membranes of

superior and middle conchae, lining of posterior superior and middle conchae, lining of posterior ethmoid sinuses, and posterior nasal septum.ethmoid sinuses, and posterior nasal septum.

–– Nasopalatine nerveNasopalatine nerve-- travels across the roof of nasal travels across the roof of nasal cavity giving branches off to the anterior nasal septum cavity giving branches off to the anterior nasal septum and floor of nose. Enters incisive foramen and provides and floor of nose. Enters incisive foramen and provides palatal gingival innervation to the premaxillapalatal gingival innervation to the premaxilla



•• Palatine branchesPalatine branches-- greater (anterior) and lesser greater (anterior) and lesser (middle or posterior) palatine nerves(middle or posterior) palatine nerves

–– Greater palatine: travels through the pterygopalatine Greater palatine: travels through the pterygopalatine canal and enters the palate via the greater palatine canal and enters the palate via the greater palatine foramen. Innervates palatal tissue from premolars to foramen. Innervates palatal tissue from premolars to soft palate. Lies 1cm medial from 2soft palate. Lies 1cm medial from 2ndnd molar regionmolar region

–– Lesser palatine: emerges from lesser palatine foramen Lesser palatine: emerges from lesser palatine foramen and innervates the mucous membranes of the soft palate and innervates the mucous membranes of the soft palate and parts of the tonsillar region and parts of the tonsillar region



•• Pharyngeal branchPharyngeal branch-- exits the pterygopalatine exits the pterygopalatine ganglion and travels through the pharyngeal canal. ganglion and travels through the pharyngeal canal. Innervates mucosa of the portions of the nasal Innervates mucosa of the portions of the nasal pharynxpharynx

•• Posterior superior alveolar nerve (PSA): branches Posterior superior alveolar nerve (PSA): branches from V2 prior to entrance into infraorbital groove. from V2 prior to entrance into infraorbital groove. Innervates posterior maxillary alveolus, periodontal Innervates posterior maxillary alveolus, periodontal ligament, buccal gingiva, and pulpal tissue (only ligament, buccal gingiva, and pulpal tissue (only for 1for 1stst, 2, 2ndnd, and 3, and 3rdrd molars)molars)


•• Infraorbital canal branches:Infraorbital canal branches:–– Middle superior alveolar (MSA):Middle superior alveolar (MSA):

•• Provides innervation to the maxillary alveolus, Provides innervation to the maxillary alveolus, buccal gingiva, periodontal ligament, and pulpal buccal gingiva, periodontal ligament, and pulpal tissue for the premolars onlytissue for the premolars only

–– Anterior superior alveolar (ASA):Anterior superior alveolar (ASA):•• Provides innervation to the maxillary alveolus, Provides innervation to the maxillary alveolus,

buccal gingiva, periodontal ligament, and pulpal buccal gingiva, periodontal ligament, and pulpal tissue for the canines, lateral and central incisorstissue for the canines, lateral and central incisors

•• Branches 6Branches 6--8mm posterior to the infraorbital nerve 8mm posterior to the infraorbital nerve exit from infraorbital foramenexit from infraorbital foramen


•• Facial branches:Facial branches:–– Emerges from the infraorbital foramenEmerges from the infraorbital foramen–– Branches consist of:Branches consist of:

•• Inferior palpebralInferior palpebral-- lower eyelidlower eyelid•• External nasalExternal nasal-- lateral skin of noselateral skin of nose•• Superior labial branchSuperior labial branch-- upper lip skin and mucosaupper lip skin and mucosa

Mandibular division (V3):Mandibular division (V3):

•• Largest branch of the trigeminal nerveLargest branch of the trigeminal nerve•• Composed of sensory and motor rootsComposed of sensory and motor roots•• Sensory root:Sensory root:

–– Originates at inferior border of trigeminal ganglionOriginates at inferior border of trigeminal ganglion

•• Motor root:Motor root:–– Arises in motor cells located in the pons and medullaArises in motor cells located in the pons and medulla–– Lies medial to the sensory rootLies medial to the sensory root


•• Branches:Branches:–– The sensory and motor roots emerge from The sensory and motor roots emerge from

the foramen ovale of the greater wing of the the foramen ovale of the greater wing of the sphenoidsphenoid

–– Initially merge outside of the skull and divide Initially merge outside of the skull and divide about 2about 2--3mm inferiorly3mm inferiorly

–– Branches:Branches:•• Branches of the undivided nerveBranches of the undivided nerve•• Branches of the anterior divisionBranches of the anterior division•• Branches of the posterior divisionBranches of the posterior division


•• Branches of the undivided nerve:Branches of the undivided nerve:–– Nervus spinosusNervus spinosus-- innervates mastoids and innervates mastoids and

duradura–– Medial pterygoidMedial pterygoid-- innervates medial pterygoid innervates medial pterygoid

musclemuscle•• Branches intoBranches into

–– Tensor veli palatiniTensor veli palatini–– Tensor tympaniTensor tympani


•• Branches of the anterior division:Branches of the anterior division:–– Buccal nerve (long buccal and buccinator):Buccal nerve (long buccal and buccinator):

•• Travels anteriorly and lateral to the lateral Travels anteriorly and lateral to the lateral pterygoid musclepterygoid muscle

•• Gives branches to the deep temporal (temporalis Gives branches to the deep temporal (temporalis muscle), masseter, and lateral pterygoid musclemuscle), masseter, and lateral pterygoid muscle


•• Branches of the anterior division:Branches of the anterior division:–– Buccal nerve (long buccal and buccinator):Buccal nerve (long buccal and buccinator):

•• Continues to travel in anteroContinues to travel in antero--lateral directionlateral direction•• At level of the mandibular 3At level of the mandibular 3rdrd molar, branches exit molar, branches exit

through the buccinator and provide innervation to through the buccinator and provide innervation to the skin of the cheekthe skin of the cheek

•• Branches also stay within the retromandibular Branches also stay within the retromandibular triangle providing sensory innervation to the buccal triangle providing sensory innervation to the buccal gingiva of the mandibular molars and buccal gingiva of the mandibular molars and buccal vestibulevestibule


•• Branches of the posterior division:Branches of the posterior division:–– Travels inferior and medial to the lateral Travels inferior and medial to the lateral

pterygoidpterygoid•• Divisions:Divisions:

–– AuriculotemporalAuriculotemporal–– LingualLingual–– Inferior alveolar Inferior alveolar


•• Branches of the posterior division:Branches of the posterior division:–– Auriculotemporal: all sensoryAuriculotemporal: all sensory

•• Transverses the upper part of the parotid gland Transverses the upper part of the parotid gland and posterior portion of the zygomatic archand posterior portion of the zygomatic arch

•• Branches:Branches:–– Communicates with facial nerve to provide sensory Communicates with facial nerve to provide sensory

innervation to the skin over areas of the zygomatic, innervation to the skin over areas of the zygomatic, buccal, and mandibular buccal, and mandibular

–– Communicates with the otic ganglion for sensory, Communicates with the otic ganglion for sensory, secretory, and vasomotor fibers to the parotidsecretory, and vasomotor fibers to the parotid


•• Branches of the posterior division:Branches of the posterior division:–– Auriculotemporal: all sensoryAuriculotemporal: all sensory

•• Branches:Branches:–– Anterior auricularAnterior auricular-- skin over helix and tragusskin over helix and tragus–– External auditory meatusExternal auditory meatus-- skin over meatus and skin over meatus and

tympanic membranetympanic membrane–– ArticularArticular-- posterior TMJposterior TMJ–– Superficial temporalSuperficial temporal-- skin over temporal regionskin over temporal region


•• Branches of the posterior division:Branches of the posterior division:–– Lingual:Lingual:

•• Lies between ramus and medial pterygoid within Lies between ramus and medial pterygoid within the pterygomandibular raphethe pterygomandibular raphe

•• Lies inferior and medial to the mandibular 3Lies inferior and medial to the mandibular 3rdrd

molar alveolusmolar alveolus•• Provides sensation to anterior 2/3rds of tongue, Provides sensation to anterior 2/3rds of tongue,

lingual gingiva, floor of mouth mucosa, and lingual gingiva, floor of mouth mucosa, and gustation (chorda tympani)gustation (chorda tympani)


•• Branches of the posterior division:Branches of the posterior division:–– Inferior alveolar:Inferior alveolar:

•• Travels medial to the lateral pterygoid and lateroTravels medial to the lateral pterygoid and latero--posterior to the lingual nerveposterior to the lingual nerve

•• Enters mandible at the lingulaEnters mandible at the lingula•• Accompanied by the inferior alveolar artery and Accompanied by the inferior alveolar artery and

vein (artery anterior to nerve)vein (artery anterior to nerve)•• Travels within the inferior alveolar canal until the Travels within the inferior alveolar canal until the

mental foramenmental foramen•• Mylohyoid nerveMylohyoid nerve-- motor branch prior to entry into motor branch prior to entry into

lingulalingula


•• Branches of the posterior division:Branches of the posterior division:–– Inferior alveolar:Inferior alveolar:

•• Provides innervation to the mandibular alveolus, Provides innervation to the mandibular alveolus, buccal gingiva from premolar teeth buccal gingiva from premolar teeth anteriorlyanteriorly, and , and the the pulpalpulpal tissue of all tissue of all mandibularmandibular teeth on side teeth on side blockedblocked

•• Terminal branchesTerminal branches–– Incisive nerveIncisive nerve-- remains within inferior alveolar canal remains within inferior alveolar canal

from mental foramen to midlinefrom mental foramen to midline–– Mental nerveMental nerve-- exits mental foramen and divides into 3 exits mental foramen and divides into 3

branches to innervate the skin of the chin, lower lip and branches to innervate the skin of the chin, lower lip and labial mucosalabial mucosa

Local anesthetic instruments:Local anesthetic instruments:

•• Anesthetic Anesthetic carpulescarpules•• SyringeSyringe•• NeedleNeedle•• Mouth propsMouth props•• RetractorsRetractors


•• CarpulesCarpules::–– 1.7 or 1.8cc1.7 or 1.8cc–– PrePre--made in blister made in blister

packs or canisterspacks or canisters–– Contains preservatives Contains preservatives

for epinephrine and for epinephrine and local anestheticslocal anesthetics


•• SyringeSyringe–– Aspirating typeAspirating type–– NonNon--aspirating typeaspirating type


•• Needle:Needle:–– Multiple gauges usedMultiple gauges used

•• 25g25g•• 27g *used at UTMB27g *used at UTMB•• 30g30g

–– Length:Length:•• ShortShort-- 26mm26mm•• LongLong-- 36mm *used at 36mm *used at

UTMBUTMB

–– MonobeveledMonobeveled


•• Topical anesthetic:Topical anesthetic:–– Used prior to local Used prior to local

anesthetic injection to anesthetic injection to decrease discomfort in decrease discomfort in nonnon--sedated patientssedated patients

–– Generally Generally benzocainebenzocaine(20%)(20%)

Maxillary anesthesia:Maxillary anesthesia:

•• 3 major types of injections can be 3 major types of injections can be performed in the maxilla for pain controlperformed in the maxilla for pain control–– Local infiltrationLocal infiltration–– Field blockField block–– Nerve blockNerve block


•• Infiltration:Infiltration:–– Able to be performed in the maxilla due to the Able to be performed in the maxilla due to the

thin cortical nature of the bonethin cortical nature of the bone–– Involves injecting to tissue immediately Involves injecting to tissue immediately

around surgical sitearound surgical site•• Supraperiosteal injectionsSupraperiosteal injections•• Intraseptal injectionsIntraseptal injections•• Periodontal ligament injectionsPeriodontal ligament injections


•• Field blocks:Field blocks:–– Local anesthetic deposited near a larger Local anesthetic deposited near a larger

terminal branch of a nerveterminal branch of a nerve•• Periapical injectionsPeriapical injections--


•• Nerve blocks:Nerve blocks:–– Local anesthetic deposited near main nerve Local anesthetic deposited near main nerve

trunk and is usually distant from operative trunk and is usually distant from operative sitesite•• Posterior superior alveolarPosterior superior alveolar --Infraorbital Infraorbital •• Middle superior alveolarMiddle superior alveolar --Greater palatineGreater palatine•• Anterior superior alveolarAnterior superior alveolar --NasopalatineNasopalatine


•• Posterior superior alveolar nerve block:Posterior superior alveolar nerve block:–– Used to anesthetize the Used to anesthetize the pulpalpulpal tissue, tissue,

corresponding alveolar bone, and corresponding alveolar bone, and buccalbuccalgingival tissue to the maxillary 1gingival tissue to the maxillary 1stst, 2, 2ndnd, and 3, and 3rdrd

molars.molars.


•• Posterior superior alveolar nerve block:Posterior superior alveolar nerve block:–– TechniqueTechnique

•• Area of insertionArea of insertion-- height of mucobuccal fold height of mucobuccal fold between 1between 1stst and 2and 2ndnd molarmolar

•• Angle at 45° superiorly and mediallyAngle at 45° superiorly and medially•• No resistance should be felt (if bony contact angle No resistance should be felt (if bony contact angle

is to medial, reposition laterally)is to medial, reposition laterally)•• Insert about 15Insert about 15--20mm20mm•• Aspirate then inject if negativeAspirate then inject if negative


•• Middle superior alveolar nerve block:Middle superior alveolar nerve block:–– Used to anesthetize the maxillary premolars, Used to anesthetize the maxillary premolars,

corresponding alveolus, and buccal gingival corresponding alveolus, and buccal gingival tissuetissue

–– Present in about 28% of the populationPresent in about 28% of the population–– Used if the infraorbital block fails to Used if the infraorbital block fails to

anesthetize premolarsanesthetize premolars


•• Middle superior alveolar nerve block:Middle superior alveolar nerve block:–– Technique:Technique:

•• Area of insertion is height of mucobuccal fold in Area of insertion is height of mucobuccal fold in area of 1area of 1stst/2/2ndnd premolarspremolars

•• Insert around 10Insert around 10--15mm15mm•• Inject around 0.9Inject around 0.9--1.2cc1.2cc


•• Anterior superior alveolar nerve block:Anterior superior alveolar nerve block:–– Used to anesthetize the maxillary canine, Used to anesthetize the maxillary canine,

lateral incisor, central incisor, alveolus, and lateral incisor, central incisor, alveolus, and buccal gingivabuccal gingiva


•• Anterior superior alveolar nerve block:Anterior superior alveolar nerve block:–– Technique:Technique:

•• Area of insertion is height of mucobuccal fold in Area of insertion is height of mucobuccal fold in area of lateral incisor and caninearea of lateral incisor and canine

•• Insert around 10Insert around 10--15mm15mm•• Inject around 0.9Inject around 0.9--1.2cc1.2cc


•• Infraorbital nerve block:Infraorbital nerve block:–– Used to anesthetize the maxillary 1Used to anesthetize the maxillary 1stst and 2and 2ndnd

premolars, canine, lateral incisor, central premolars, canine, lateral incisor, central incisor, corresponding alveolar bone, and incisor, corresponding alveolar bone, and buccal buccal gingivagingiva

–– Combines MSA and ASA blocksCombines MSA and ASA blocks–– Will also cause anesthesia to the lower eyelid, Will also cause anesthesia to the lower eyelid,

lateral aspect of nasal skin tissue, and skin of lateral aspect of nasal skin tissue, and skin of infraorbital regioninfraorbital region


•• Infraorbital nerve block:Infraorbital nerve block:–– Technique:Technique:

•• Palpate infraorbital foramen extraPalpate infraorbital foramen extra--orally and place orally and place thumb or index finger on regionthumb or index finger on region

•• Retract the upper lip and buccal mucosaRetract the upper lip and buccal mucosa•• Area of insertion is the mucobuccal fold of the 1Area of insertion is the mucobuccal fold of the 1stst

premolar/canine areapremolar/canine area•• Contact bone in infraorbital regionContact bone in infraorbital region•• Inject 0.9Inject 0.9--1.2cc of local anesthetic1.2cc of local anesthetic


•• Greater palatine nerve block:Greater palatine nerve block:–– Can be used to anesthetize the palatal soft Can be used to anesthetize the palatal soft

tissue of the teeth posterior to the maxillary tissue of the teeth posterior to the maxillary canine and corresponding alveolus/hard canine and corresponding alveolus/hard palatepalate


•• Greater palatine nerve block:Greater palatine nerve block:–– Technique:Technique:

•• Area of insertion is ~1cm medial from 1Area of insertion is ~1cm medial from 1stst/2/2ndnd

maxillary molar on the hard palatemaxillary molar on the hard palate•• Palpate with needle to find greater palatine Palpate with needle to find greater palatine

foramenforamen•• Depth is usually less than 10mmDepth is usually less than 10mm•• Utilize pressure with elevator/mirror handle to Utilize pressure with elevator/mirror handle to

desensitize region at time of injectiondesensitize region at time of injection•• Inject 0.3Inject 0.3--0.5cc of local anesthetic0.5cc of local anesthetic


•• Nasopalatine nerve block:Nasopalatine nerve block:–– Can be used to anesthetize the soft and hard Can be used to anesthetize the soft and hard

tissue of the maxillary anterior palate from tissue of the maxillary anterior palate from canine to caninecanine to canine


•• Nasopalatine nerve block:Nasopalatine nerve block:–– Technique:Technique:

•• Area of insertion is incisive papilla into incisive Area of insertion is incisive papilla into incisive foramenforamen

•• Depth of penetration is less than 10mmDepth of penetration is less than 10mm•• Inject 0.3Inject 0.3--0.5cc of local anesthetic0.5cc of local anesthetic•• Can use pressure over area at time of injection to Can use pressure over area at time of injection to

decrease paindecrease pain


•• Maxillary nerve block (V2 block):Maxillary nerve block (V2 block):–– Can be used to anesthetize maxillary teeth, Can be used to anesthetize maxillary teeth,

alveolus, hard and soft tissue on the palate, alveolus, hard and soft tissue on the palate, gingiva, and skin of the lower eyelid, lateral gingiva, and skin of the lower eyelid, lateral aspect of nose, cheek, and upper lip skin and aspect of nose, cheek, and upper lip skin and mucosa on side blockedmucosa on side blocked


•• Maxillary nerve block (V2 block):Maxillary nerve block (V2 block):–– Two techniques exist for blockade of V2Two techniques exist for blockade of V2

•• High tuberosity approachHigh tuberosity approach•• Greater palatine canal approachGreater palatine canal approach


•• Maxillary nerve block (V2 block):Maxillary nerve block (V2 block):–– High tuberosity approach technique:High tuberosity approach technique:

•• Area of injection is height of mucobuccal fold of Area of injection is height of mucobuccal fold of maxillary 2maxillary 2ndnd molarmolar

•• Advance at 45° superior and medial same as in the Advance at 45° superior and medial same as in the PSA blockPSA block

•• Insert needle ~30mmInsert needle ~30mm•• Inject ~1.8cc of local anestheticInject ~1.8cc of local anesthetic


•• Maxillary nerve block (V2 block):Maxillary nerve block (V2 block):–– Greater palatine canal technique:Greater palatine canal technique:

•• Area of insertion is greater palatine canalArea of insertion is greater palatine canal•• Target area is the maxillary nerve in the Target area is the maxillary nerve in the

pterygopalatine fossapterygopalatine fossa•• Perform a greater palatine block and wait 3Perform a greater palatine block and wait 3--5 mins5 mins•• Then insert needle in previous area and walk into Then insert needle in previous area and walk into

greater palatine foramengreater palatine foramen•• Insert to depth of ~30mmInsert to depth of ~30mm•• Inject 1.8cc of local anestheticInject 1.8cc of local anesthetic

Mandibular anesthesia:Mandibular anesthesia:

•• Infiltration techniques do not work in the adult Infiltration techniques do not work in the adult mandible due to the dense cortical bonemandible due to the dense cortical bone

•• Nerve blocks are utilized to anesthetize the Nerve blocks are utilized to anesthetize the inferior alveolar, lingual, and buccal nervesinferior alveolar, lingual, and buccal nerves

•• Provides anesthesia to the pulpal, alveolar, Provides anesthesia to the pulpal, alveolar, lingual and buccal gingival tissue, and skin of lingual and buccal gingival tissue, and skin of lower lip and medial aspect of chin on side lower lip and medial aspect of chin on side injectedinjected


•• Inferior alveolar nerve block (IAN):Inferior alveolar nerve block (IAN):–– Technique involves blocking the inferior Technique involves blocking the inferior

alveolar nerve prior to entry into the alveolar nerve prior to entry into the mandibular lingula on the medial aspect of mandibular lingula on the medial aspect of the mandibular ramusthe mandibular ramus

–– Multiple techniques can be used for the IAN Multiple techniques can be used for the IAN nerve blocknerve block•• IANIAN•• AkinosiAkinosi•• GowGow--GatesGates


•• Inferior alveolar nerve block (IAN):Inferior alveolar nerve block (IAN):–– Technique:Technique:

•• Area of insertion is the mucous membrane on the Area of insertion is the mucous membrane on the medial border of the mandibular ramus at the medial border of the mandibular ramus at the intersection of a horizontal line (height of injection) intersection of a horizontal line (height of injection) and vertical line (anteroposterior plane)and vertical line (anteroposterior plane)

•• Height of injectionHeight of injection-- 66--10 mm above the occlusal 10 mm above the occlusal table of the mandibular teethtable of the mandibular teeth

•• Anteroposterior planeAnteroposterior plane-- just lateral to the just lateral to the pterygomandibular raphepterygomandibular raphe

Mandibular anesthesia:Mandibular anesthesia:Mandibular anesthesia:Mandibular anesthesia:

•• Inferior alveolar nerve block (IAN):Inferior alveolar nerve block (IAN):–– Mouth must be open for this technique, best to utilize Mouth must be open for this technique, best to utilize

mouth propmouth prop–– Depth of injection: 25mmDepth of injection: 25mm–– Approach area of injection from contralateral Approach area of injection from contralateral

premolar regionpremolar region–– Use the nonUse the non--dominant hand to retract the buccal soft dominant hand to retract the buccal soft

tissue (thumb in coronoid notch of mandible; index tissue (thumb in coronoid notch of mandible; index finger on posterior border of extraoral mandible)finger on posterior border of extraoral mandible)


•• Inferior alveolar nerve block (IAN):Inferior alveolar nerve block (IAN):–– Inject ~0.5Inject ~0.5--1.0cc of local anesthetic1.0cc of local anesthetic–– Continue to inject ~0.5cc on removal from Continue to inject ~0.5cc on removal from

injection site to anesthetize the lingual branchinjection site to anesthetize the lingual branch–– Inject remaining anesthetic into coronoid Inject remaining anesthetic into coronoid

notch region of the mandible in the mucous notch region of the mandible in the mucous membrane distal and buccal to most distal membrane distal and buccal to most distal molar to perform a long buccal nerve blockmolar to perform a long buccal nerve block


•• Akinosi closedAkinosi closed--mouth mandibular block:mouth mandibular block:–– Useful technique for infected patients with Useful technique for infected patients with

trismus, fractured mandibles, mentally trismus, fractured mandibles, mentally handicapped individuals, childrenhandicapped individuals, children

–– Provides same areas of anesthesia as the IAN Provides same areas of anesthesia as the IAN nerve blocknerve block


•• Akinosi closedAkinosi closed--mouth mandibular block:mouth mandibular block:–– Area of insertion: soft tissue overlying the Area of insertion: soft tissue overlying the

medial border of the mandibular ramus medial border of the mandibular ramus directly adjacent to maxillary tuberositydirectly adjacent to maxillary tuberosity

–– Inject to depth of 25mmInject to depth of 25mm–– Inject ~1.0Inject ~1.0--1.5cc of local anesthetic as in the 1.5cc of local anesthetic as in the

IANIAN–– Inject remaining anesthetic in area of long Inject remaining anesthetic in area of long

buccal nerve buccal nerve


•• Mental nerve block:Mental nerve block:–– Mental and incisive nerves are the terminal Mental and incisive nerves are the terminal

branches for the inferior alveolar nervebranches for the inferior alveolar nerve–– Provides sensory input for the lower lip skin, Provides sensory input for the lower lip skin,

mucous membrane, pulpal/alveolar tissue for mucous membrane, pulpal/alveolar tissue for the premolars, canine, and incisors on side the premolars, canine, and incisors on side blockedblocked


•• Mental nerve block:Mental nerve block:–– Technique:Technique:

•• Area of injection mucobuccal fold at or anterior to Area of injection mucobuccal fold at or anterior to the mental foramen. This lies between the the mental foramen. This lies between the mandibular premolarsmandibular premolars

•• Depth of injection ~5Depth of injection ~5--6mm6mm•• Inject 0.5Inject 0.5--1.0cc of local anesthesia1.0cc of local anesthesia•• Message local anesthesia into tissue to manipulate Message local anesthesia into tissue to manipulate

into mental foramen to anesthetize the incisive into mental foramen to anesthetize the incisive branchbranch

Local anesthetics:Local anesthetics:

•• Types:Types:–– EstersEsters-- plasma plasma pseudocholinesterasepseudocholinesterase–– AmidesAmides-- liver enzymesliver enzymes

•• Duration of action:Duration of action:–– ShortShort–– MediumMedium–– LongLong


•• Agent:Agent: Dose: Dose: Onset/Duration:Onset/Duration:•• LidocaineLidocaine with with epiepi (1 or 2%)(1 or 2%) 7mg/kg7mg/kg Fast/mediumFast/medium•• LidocaineLidocaine without without epiepi 4.5mg/kg4.5mg/kg Fast/shortFast/short•• MepivacaineMepivacaine without without epiepi (3%)(3%) 5.5mg/kg5.5mg/kg Fast/shortFast/short•• BupivacaineBupivacaine with with epiepi (0.5%)(0.5%) 1.3mg/kg1.3mg/kg Long/longLong/long•• ArticaineArticaine with with epiepi (4.0%)(4.0%) 7mg/kg7mg/kg Fast/mediumFast/medium

*ADULT DOSES IN PATIENTS WITHOUT CARDIAC HISTORY*ADULT DOSES IN PATIENTS WITHOUT CARDIAC HISTORY


•• Dosing considerations:Dosing considerations:–– Patient with cardiac history:Patient with cardiac history:

•• Should limit dose of epinephrine to 0.04mgShould limit dose of epinephrine to 0.04mg•• Most local anesthesia uses 1:100,000 epinephrine Most local anesthesia uses 1:100,000 epinephrine

concentration (0.01mg/ml)concentration (0.01mg/ml)

–– Pediatric dosing:Pediatric dosing:•• Clark’s rule:Clark’s rule:

–– Maximum dose=(weight child in lbs/150) X max adult dose Maximum dose=(weight child in lbs/150) X max adult dose (mg)(mg)

•• Simple method= 1.8cc of 2% lidocaine/20lbsSimple method= 1.8cc of 2% lidocaine/20lbs

Local anesthesia complications:Local anesthesia complications:

•• Needle breakageNeedle breakage•• Pain on injectionPain on injection•• Burning on injectionBurning on injection•• Persistent anesthesia/parathesiaPersistent anesthesia/parathesia•• TrismusTrismus•• HematomaHematoma•• InfectionInfection


•• EdemaEdema•• Tissue sloughingTissue sloughing•• Facial nerve paralysisFacial nerve paralysis•• PostPost--anesthetic intraoral lesionanesthetic intraoral lesion

–– Herpes simplexHerpes simplex–– Recurrent aphthous stomatitisRecurrent aphthous stomatitis


•• ToxicityToxicity–– Clinical manifestationsClinical manifestations

•• Fear/anxietyFear/anxiety•• RestlessnessRestlessness•• Throbbing headachesThrobbing headaches•• TremorsTremors•• WeaknessWeakness•• DizzinessDizziness•• PallorPallor•• Respiratory difficulty/palpitationsRespiratory difficulty/palpitations•• Tachycardia (Tachycardia (PVCsPVCs, V, V--tachtach, V, V--fib)fib)


•• Allergic reaction:Allergic reaction:–– More common with ester based local More common with ester based local

anestheticsanesthetics–– Most allergies are to preservatives in preMost allergies are to preservatives in pre--

made local anesthetic carpulesmade local anesthetic carpules•• MethylparabenMethylparaben•• Sodium bisulfiteSodium bisulfite•• metabisulfitemetabisulfite

References:References:

•• Evers, H and Haegerstam, G. Evers, H and Haegerstam, G. Handbook Handbook of Dental Local Anesthesiaof Dental Local Anesthesia. Schultz . Schultz Medical Information. London. 1981.Medical Information. London. 1981.

•• Malamed, S. Handbook of Local Malamed, S. Handbook of Local Anesthesia. 3Anesthesia. 3rdrd edition. Mosby. St. Louis. edition. Mosby. St. Louis. 1990.1990.

•• Netter, F. Netter, F. Atlas of Human AnatomyAtlas of Human Anatomy. . CIBA. 1989.CIBA. 1989.

anesth mouth

Health & Medicine

anterior division branches

posterior division

maxillary nerve

undivided nerve branches

facial branches

buccal nerve

themaxilla branches

infraorbital foramen