Follow me in researchgate for more articles.

2. LOCAL ANESTHETIC TECHNIQUE’S
Presented by :
Dr. Suman Mukherjee
1st Yr MDS
V.S.D.C.H.
Yr : 2017-18

3. Contents :
• Introduction
• Regional anesthesia
 Field block
 Nerve block
 Local infiltration
• Local Anesthesia Injection
Technique
 Supraperiosteal injections
 Intraligamentary injections
 Intraosseous injections
 Intraseptal injections
 Subperiosteal injections
• Maxillary injection techniques
 PSAN
 ASAN
 MSAN
 Nasopalatine nerve block
 Greater Palatine nerve block
 Maxillary nerve block
• Mandibular Injection Technique’s
 IANB
 Incisive nerve block
 Gow–Gates nerve block
 Vazirani–Akinosi nerve block
• Regional anesthesia to soft tissue
 Buccal nerve block
 Mental nerve block
• Conclusions
• Reference.

4. Introduction
Pain control in dentistry presents one of the greatest
challenges. (Pain leads to increased stress, release of
endogenous catecholamines and unexpected
cardiovascular responses) Before anesthetization,
dentists should evaluate the medical history of each
patient and document data on the systemic and
psychological status of the patients in order to
determine whether the patient is able to tolerate the
treatment with no risk from the systemic and
psychological points of views.

5. Before the injection of the local anesthetic, the dentist should
recognize the potential risks. However, most adverse reactions to local
anesthetics are not related to the drug itself, but to the injection of
the drug. The injection of the local anesthesia is the most reported
cause for fear and discomfort of dental patients.

6. NEEDLE GAUGE
• Gauge refers to the diameter of the lumen of the needle; the smaller the number,
the greater the diameter of the lumen.
• There is increased resistance to aspiration of blood through a thinner needle
(eg,30-gauge) compared with a larger-diameter needle (eg,27- or 25-gauge).
• Needle deflection along the axis of the bevel and breakage must also be
examined.
• The smaller the diameter of the needle, the more it deflects.
• Thirty-gauge needles deflect significantly, whereas 25-gauge needles essentially
do not deflect at all. Likewise,25-gauge needles very rarely, if ever, break during
an intraoral injection, and 99% of the needles that do break are 30-gauge
needles.

8. Regional anesthesia :
• Regional anesthesia or “the nerve block” is a form of anesthesia in which
only a part of the body is anesthetized (“made numb”).
• Field block : In a field block, local anesthetic is infiltrated around the
border of the surgical field, leaving the operative area undisturbed.
• Field block also may be considered when operating on the ear or lips. Eg.
Gow gates technique is a kind of field block.
American Academy of Family Physicians: http://www.aafp.org

9. • Nerve block : In a nerve block, anesthetic is injected directly adjacent to the nerve
supplying the surgical field. Supraorbital, supratrochlear, infraorbital, and mental
nerve blocks can provide adequate anesthesia in procedures on parts of the face.
Nerve blocks are used for pain treatment and management.
• Often a group of nerves, called a plexus or ganglion, that causes pain to a specific
organ or body region can be blocked with the injection of medication into a specific
area of the body. The injection of this nerve-numbing substance is called a nerve
block. Eg. IANB, PNB
American Academy of Family Physicians: http://www.aafp.org

10. Local infiltration :
Local infiltration is used when anesthesia is
required in small areas (e.g., for repair of minor
lacerations, skin biopsies). The anesthetic solution
is infiltrated to the deep dermis, where the
sensory plexus supplying the skin begins to branch.
The amount of solution used depends on the area
that needs to be infiltrated; however, extensive
local infiltration is not recommended.
American Academy of Family Physicians: http://www.aafp.org

11. Local Anesthesia Injection
Technique’s :

12. Supra periosteal injection :
• Pulpal and Soft tissue anesthesia in maxillary anterior teeth.
• A short 25 or 27 gauge needle is recommended for this technique.
• Sometimes this injection technique is referred to as infiltration, but
the solution is deposited near terminal branches of nerves so it is
actually a type of field block.
• It is inserted at the height of the mucobuccal fold near the apex of
the tooth to be treated. The bevel of the needle should be toward
the bone.
• Pulp, root, buccal periosteum, connective tissue, and mucous membrane are the areas anesthetized

14. Intraligamentary injection/ PDL injection
• Approximately 0.2mL of anesthetic solution is deposited over a minimum of 20
seconds forced under pressure into the gingival sulcus of maxillary and mandibular
teeth. This injection may be uncomfortable if the rate of injection is too rapid or
the tissues are inflamed.
• The PDL injection method of anesthetizing an individual tooth is utilized to avoid the
undesirable consequences of regional block anesthesia.
• A 27-gauge short needle with the bevel toward the tooth is inserted through the
gingival sulcus on the mesial of the tooth to be anesthetized and inserted as far
apically as possible.

15. PDL
injection

16. Intraosseous injections :
Aim of intra-osseous anesthesia is to inject
local anesthesia solution into cancellous bone
adjacent to the apex of the tooth by piercing
bucal gingiva and bone in relation to the tooth
to be anesthetized. It can be used as a
supplemental technique with mandibular nerve
blocks to enhance deep pulpal anesthesia or as
a primary technique so that patients do not
experience numb lips or tongues
postoperatively.

17. intraosseous

18. Intra Septal
injections
• used for hemostasis,
soft tissue anesthesia,
and osseous anesthesia.
• Use a 27 gauge short
needle and insert it into
the papilla of the area
to be anesthetized at
an angle of 90º to the
tissue.
• Slowly deposit 0.2 ml of
solution.

19. Intra pulpal injection
• A 27-gauge short needle is inserted into the pulp chamber and wedged
firmly into the root canal.
• A small volume (0.2to0.3mL) of local anesthetic is injected.
• While this technique may prove uncomfortable for the patient, it
invariably works to provide effective pain control.
• In most cases, the duration is adequate to permit extirpation of the
pulpal tissues.

20. Maxillary injection technique:

21. PSAN (posterior superior alveolar
nerve block)
• Anesthetize the maxillary molars except for
the mesio buccal aspect of the first molars.
• Clinically, the PSA injection is given with the
insertion point at the height of the buccal
vestibule at a point just distal to the malar
process.

22. Advance the needle slowly in an upward, inward and backward direction.
• TECHNIQUES –
• Landmarks –
• MUCOBUCCAL FOLD
• MAXILLARY TUBEROSITY
• ZYGOMATIC PROCESS OF MAXILLA
• Prepare the tissues and orient the bevel of the needle towards the bone.
• Advance the needle slowly in an upward, inward and backward direction.
• The needle is inserted distally and superiorly at approximately 45 degrees to the
mesiodistal and buccolingual planes at the Height of mucobuccal fold above maxillary
second molar is the area of insertion
• The depth of insertion is approximately 15 mm, and following careful aspiration, 1.0 mL
of solution is slowly deposited.
• short 25 or 27 gauge needle is recommended to decrease the risk of a hematoma.

23. COMPLICATIONS:
• HAEMATOMA – needle placed most posteriorly into pterygoid plexus of veins and
chances of maxillary artery perforation. Short needle use is recommended.
• Visible intraoral hematoma develops within several minutes in mandibular buccal
region. Bleeding continues until the pressure of extravascular blood equals the
intravascular blood.
• MANDIBULAR ANESTHESIA – since mandibular division is located lateral to PSA
nerves.
• CONTRAINDICATION – risk of hemorrhage is great in hemophilics. (Supraperiosteal
injection or PDL injection recommended)

24. MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK
• MSAN - present in only about 28% of the population.
• The (MSA) injection will anesthetize the mesiobuccal aspect of the maxillary first
molar, both premolars, PDL, buccal bone, and periosteum, along with the soft
tissue lateral to this area.

25. • TECHNIQUES – 27 gauge short or long needle is used. 1 ml of anesthetic
solution should slowly be introduced after careful aspiration.
• AREA OF INSERTION – height of the mucobuccal fold above the
maxillary second premolar. The needle tip should approximate the apex of
the tooth, which usually requires a penetration of about 5 mm.
• TARGET AREA – maxillary bone above the apex of the maxillary second
premolar.
• LANDMARK – mucobuccal fold above the maxillary second premolar.

26. ANTERIOR SUPERIOR ALVEOLAR NERVE BLOCK
• Also called Infraorbital Nerve Block.
• The ASA injection will anesthetize the PDL, alveolar bone, periosteum, buccal
soft tissue, and teeth from the canine to the midline.
• The penetration is over the maxillary canine
• A 25 gauge long needle is recommended
• The needle depth will be about 16 mm for an average sized adult with varying
depths proportional to the size of the patient and the bony structure of the
cheek.

27. • AREA OF INSERTION – height of the mucobuccal fold directly over the
first premolar.
• TARGET AREA – infraorbital foramen (below the infraorbital notch)
• Landmarks
• - mucobuccal fold
• -Infraorbital notch
• -Infraorbital foramen
• ORIENTATION OF THE BEVEL – Toward bone

29. • To transform it into Anterior Superior alveolar nerve block –
• Maintain firm pressure over injection site both during and after the
injection for 1 min.
• Withdraw the syringe slowly.
• Maintain direct pressure after withdrawal for 2 minute to allow more
diffusion of solution into the foramen.
• Wait for 3 to 5 min before the start of dental procedure.
 Maintain firm pressure over injection site both during and after the injection for 1 min.
 Withdraw the syringe slowly.
 Maintain direct pressure after withdrawal for 2 minute to allow more diffusion of solution into the foramen.
 Wait for 3 to 5 min before the start of dental procedure.

30. Infraorbital nerve block

31. Failures of anesthesia –
• When needle contacts bone of lower border of infraorbital foramen,
anesthesia developes in the desired soft tissue area only. That is why a
failed ASA is supraperiosteal injection over the first premolar.
• Needle deviation medial or lateral to infraorbital foramen.
• Complications – hematoma may develop across the lower eyelid around
infraorbital foramen

32. Other techniques..
• There are two approaches to Infraorbital nerve block, the most commonly
being bicuspid and central incisor approach.
• BICUSPID APPROACH – needle is inserted into the mucosa and areolar tissue
using the maxillary bicuspid as the guide and the needle should pass beneath
and lateral to the external maxillary artery and the anterior facial vein.
• CENTRAL INCISOR APPROACH – needle is inserted into the mucosa and
areolar tissue using the central incisor as guide and it passes beneath the
angular head of quadratus labii superioris muscle. It proceeds anteriorly to the
origin of the caninus muscle and beneath the external maxillary artery and the
anterior facial vein.

33. Extra-oral approach

34. NASOPALATINE NERVE BLOCK
• Also called incisive and sphenopalatine nerve block.
• The nasopalatine (NP)injection will anesthetize the tissues of the palatal aspect
of the premaxilla.
• Two approaches –
• Single penetration
• Multiple penetration
• Two approaches –
 One tissue penetration
 Three needle punctures
• Two approaches –
 One tissue penetration
 Three needle punctures

35. Single penetration technique…
• A 25 or 27 gauge short or ultra-short needle may be used.
• The area of insertion is the palatal mucosa just lateral to the incisive
papilla (located in the midline behind the central incisors).
• The path of insertion is approaching the incisive papilla at a 45 degree
angle with the orientation of the bevel toward the palatal tissue.

36. Technique (multiple penetration)
• A 25 or 27 gauge short or ultra-short needle is recommended.
• There are 3 points of insertion:
• The labial frenum between the maxillary central incisors.
• The interdental papilla between the maxillary central incisors.
• The palatal soft tissue lateral to the incisive papilla.
• First injection: If labial anesthesia has not been achieved with labial local
infiltration of the area, the following injection is performed. If the area is
anesthetized, proceed to the second injection.
• The path of insertion is into the labial frenum with the orientation of the bevel
of the needle toward the bone. Retract the upper lip to improve visibility.
• Insert the needle into the frenum and deposit 0.3ml anesthetic solution over 15
seconds. The tissue may balloon. Anesthesia of the tissue should develop
immediately.

37. • Second injection:
• Hold the needle at right angles to the papilla. The orientation of the bevel is not
relevant.
• Insert the needle into the papilla just above the crest of bone.
• Direct it toward the incisive papilla on the palatal side of the interdental papilla
while slowly injecting anesthetic solution. Do not penetrate through the palatal
tissue.
• When blanching is noted in the incisive papilla, aspirate.
• If negative administer 0.3ml of anesthetic solution over 15 seconds.

38. • Third injection:
• Proceed as above for the single penetration injection; however, application of
topical anesthetic and pressure anesthesia is unnecessary.

39. Greater Palatine Nerve Block
• TECHNIQUES – 27 gauge short needle is used
• AREAS OF INSERTION – soft tissues slightly anterior to the greater
palatine foramen.
• TARGET AREA – greater palatine nerve passing anteriorly between soft
tissues and bone of the hard palate.
• LANDMARKS -
• Greater palatine foramen
• Junction of the maxillary alveolar process and palatine bone
• PATH OF INSERTION – advance the syringe from the opposite side of the
mouth at a right angle to the target area.
• ORIENTATION OF THE BEVEL – towards palatal soft tissues.

40. • Anatomically, this is generally 5 mm anterior to the junction of the hard and
soft palates. Penetration will occur through the epithelium, and the needle
will appear to ‘‘fall into’’ a space of less resistance. The needle should be
inserted until bone is contacted. The depth of penetration is variable, but
usually less than 5 mm is sufficient. After aspiration, 0.5mL of anesthetic
solution is very slowly deposited.
• Areas anesthesized : Posterior portion of the hard palate and overlying soft
tissues anteriorly as far as the first premolar and medially to the midline.
• COMPLICATION –
• Rare hematoma
• Ischemia and necrosis of soft tissues

41. Greater palatine nerve block

42. Maxillary Nerve Block
• It is an effective method of achieving profound anesthesia of a hemi-maxilla.
• Useful in procedures involving quadrant dentistry and in extensive surgical
procedures.
• INDICATIONS –
• Pain control before extensive oral surgical, periodontal or restorative procedures
requiring anesthesia of entire maxillary division.
• When tissue inflammation or infection exceeds the use of another regional nerve
block.
• Diagnostic or therapeutic procedures for neuralgias.

43. • TECHNIQUES – HIGH TUBEROSITY APPROACH
• AREA OF INSERTION – height of the mucobuccal fold above the distal
aspect of the maxillary second molar.
• TARGET AREA – maxillary nerve as it passes through the
pterygopalatine fossa.
• LANDMARKS –
• Mucobuccal fold at the distal aspect of the maxillary second molar.
• Maxillary tuberosity.
• Zygomatic process of the maxilla.
• The long 25 gauge needle is recommended with the bevel of the needle
facing the bone. The needle is guided into the foramen to 30 mm.

44. • Subjective signs – pressure behind the upper jaw on the side being injected;
this subsides rapidly, progressing to tingling and numbness of the lower
eyelid, side of the nose and upper lip.
• Subjective symptoms – sensation of numbness in the teeth and buccal soft
tissues on the side of injection.
• complications –
• Risk of hematoma.
• Arbitrary approach, over insertion is possible because of absence of bony
landmarks if proper technique not followed.

45. Maxillary nerve block

47. Recommended volumes of local
anesthetic for
maxillary techniques
Technique VOLUME, ml
Posterior superior alveolar 0.9-1.8
Middle superior alveolar 0.9-1.2
Anterior superior alveolar 0.9-1.2
Greater palatine 0.45-0.6
Nasopalatine 0.45
Maxillary nerve block 1.8

48. Mandibular Injection Technique’s

49. IANB (INFERIOR ALVEOLAR NERVE BLOCK)
• Also called mandibular nerve block.
• Second most frequently used after
infiltration.
• For quadrant dentistry.
NERVES ANESTHETIZED –
• Inferior alveolar nerve.
• Incisive, Mental and Lingual nerves.

50. • TECHNIQUE – 25 gauge long needle is preferred
• AREA OF THE INSERTION –
• mucous membrane on the medial side of the ramus
• Target area – inferior alveolar nerve as it passes downward before entering
the mandibular foramen.
• LANDMARKS –
• Coronoid notch
• Pterygomandibular raphe
• Occlusal plane of mandibular teeth

52. Traditionally, the IA injection is described with an insertion point 1.0 cm
above the mandibular occlusal plane.
IANB

53. • SIGNS AND SYMPTOMS –
• Tingling or numbness –
• Of the lower lip indicates anesthesia of the mental nerve.
• Of the tongue indicates anesthesia of the lingual nerve.
• PRECAUTIONS –
• Do not deposit anesthesia when no bone contact
• Do not contact bone forcefully
• COMPLICATIONS –
• Hematoma
• Trismus
• Transient facial paralysis

54. Incisive nerve block:
• TECHNIQUES – 27 gauge short needle
• Area of insertion – mucobuccal fold at or just anterior
to the mental foramen
• Target area – mental foramen through which the mental
nerve exits and inside of which incisive nerve is located.
• Landmarks – mandibular premolars and mucobuccal fold.
• FAILURES OF ANESTHESIA –
• Inadequate volume of anesthetic solution
• Failure to achieve anesthesia of second premolar
• COMPLICATIONS –
• Hematoma
• Paresthesia of lip and chin

55. Gow-Gates Mandibular (Open-Mouth) Nerve Block
• George A. E. Gow-Gates first published this technique in 1973.
• Significant advantages of the Gow-Gates technique over the IA nerve
block include its higher success rate, it slower incidence of positive
aspiration, and the absence of problems with accessory sensory
innervation to the mandibular teeth.
• The Gow Gates injection anesthetizes the inferior alveolar, lingual,
auriculotemporal, buccal (75% of the time), and mylohyoid nerves.The
injection blocks the nerves at a point that is proximal to their division
into inferior alveolar, buccal, and lingual nerves.

56. Bennett C.R, Trigeminal Nerve. In: Monheim’s Local anaesthesia and pain control in dental
practise.7:CBS;2010:26-53

58. The needle endpoint is the lateral aspect of the anterior portion of the condyle, just
inferior to the insertion of the lateral pterygoid muscle.
A 25-gauge long needle is inserted slowly to a depth of 25 to 30mm; the end point is
inferior and lateral to the condylar head.

59. Gow Gates Mandibular anesthesia technique

60. Vazirani-Akinosi (Closed-Mouth) Nerve Block
• In 1977, Dr. Sunder J. Vazirani and Dr.
Joseph Akinosi reported on a closed mouth
approach to mandibular anesthesia.
• It is an intraoral approach to provide both
anesthesia and motor blockade in cases of
severe unilateral trismus. This injection is
useful for patients with trismus because it is
performed while the jaw is in the physiologic
rest position
• Other common names – Tuberosity technique.

61. Malamed Stanley, Techniques of mandibular anesthesia. In: Hand Book of Local Anesthesia.6:ELSEVEIR;2014:225-252
• This form of injection, also known as
the closed mouth mandibular block,
anesthetizes the inferior alveolar,
lingual, buccal, and mylohyoid nerves.
• A 25-gauge long needle is inserted
parallel to the maxillary occlusal plane
at the height of the maxillary buccal
vestibule.
• AREAS OF INSERTION – soft tissue
in the lingual border of the mandibular
ramus directly adjacent to the
maxillary tuberosity at the height of
the mucogingival injection adjacent to
the maxillary third molar.

62. • TARGET AREA – soft tissue of the
medial border of the ramus where they
run towards the mandibular foramen.
• The depth of insertion will vary with the
anteroposterior size of the patient’s
ramus.TheVazirani-Akinosi injection is
performed ‘‘blindly’’ because no bony
endpoint exists. However, in adult
patients, a rule of thumb is that the hub
of the needle should be opposite the
mesial aspect of the maxillary second
molar.
• COMPLICATION – hematoma, trismus,
facial nerve paralysis

64. Regional Anesthesia to Soft Tissue
Mental Nerve Block :
• this injection technique can be useful when bilateral anesthesia is desired for
procedures on premolars and anterior teeth.
• A 25- or 27-gauge short needle is inserted at the mucobuccal fold at or just
anterior to the mental foramen, which is typically located between the apices
of the 2 premolars
• The difference between the mental nerve block and the incisive nerve block is
that the incisive nerve block requires pressure to direct local anesthetic
solution into the mental foramen.

65. • INDICATIONS –
• soft tissue biopsies and suturing of soft tissues.
• COMPLICATIONS –
• Hematoma.
• Paresthesia of lip/chin.

66. Buccal Nerve Block :
• Also called long buccal nerve block and buccinator nerve block.
• The buccal injection will anesthetize the buccal soft tissue lateral to the
mandibular molars.
• The needle is inserted into the tissue in the distobuccal vestibule opposite the
second or third mandibular molar just medial to the coronoid notch until bone is
contacted (approximately1to 3 mm), and 0.25 mL of anesthetic is deposited.
• A 25 gauge long needle is recommended (because the injection usually follows an
inferior alveolar nerve block, so the same needle can be used after more
anesthetic is loaded).

67. • TECHNIQUES – 25 Gauge Needle
• AREAS OF INSERTION – mucous membrane distal and buccal to the most distal
molar tooth in the arch.
• TARGET AREA – buccal nerve as it passes over the anterior border of the ramus.
• LANDMARKS – mandibular molars, mucobuccal fold

68. • Direct the syringe, facing downward towards bone and parallel to the occlusal
plane.
• Penetrate the mucous membrane at the injection site, distal and buccal to the
last molar.
• INDICATIONS –
• Scaling and curettage.
• Placement of a rubber dam clamp on soft tissues.
• Removal of subgingival caries.
• Subgingival tooth preparation.
• Placement of gingival retraction cord.
• Placement of matrix bands.
• DISADVANTAGES – painful if contacts the periosteum
• COMPLICATIONS – Hematoma.

69. Lingual nerve block
• The lingual nerve block will anesthetize
the lingual gingiva, floor of the mouth, and
tongue from the third molar anteriorly to
the midline. This nerve may be
anesthetized directly, by inserting the
needle as in the IA to approximately
10mm and injecting.

70. Recommended volumes of local anesthetic solution
for mandibular injection technique
TECHNIQUE VOLUME,ml
Inferior alveolar 1.5ml
Buccal 0.3ml
Mental 0.6ml
Incisive 0.6 - 0.9ml
Gow – Gates 1.8 - 3.0ml
Vazirani – Akinosi 1.5 – 1.8ml

71. COMPUTER-CONTROLLED LOCAL
ANESTHETIC DELIVERY SYSTEMS
[CCLAD]
• In 1997, a new delivery system using
computer technology to control the rate
and flow of anesthetic solutions evolved,
and are called as computer controlled local
anesthetic delivery systems. The first of
them is the Wand, followed by Wand Plus
and CompuDent.

72. • Fukayama et al. conducted a controlled clinical study evaluating pain
perception of a CCLAD device.
• They concluded that “the new system provides comfortable anesthesia for
patients and can be a good alternative for conventional manual syringe
injection.”
• There are three modes of flow rate available: slow, fast and turbo mode. In
2001, the Comfort Control Syringe (Dentsply International, N. York, USA)
was marketed as an alternative to the Wand and has two components; base
unit and syringe and there is no foot pedal.
• The most important functions of this unit is injection and aspiration can be
controlled directly from the syringe.
• Five different basic injection rate settings for specific applications, block,
infiltration, PDL, IO and Palatal regions.

73. Single-Tooth Anesthesia [STA]
In 2006, the manufacturers of the
original CCLAD, the Wand, introduced
a new device, Single Tooth Anesthesia
(STA™) which incorporates dynamic
pressure-sensing (DPS) technology
that provides a constant monitoring of
the exit pressure of the local
anesthetic solution in real time during
all phases of the drug’s administration.

74. JET INJECTORS
Jet injection technology is based on the
principle of using a mechanical energy source to
create a pressure sufficient to push a liquid
medication through a very small orifice, that it
can penetrate into the subcutaneous tissues
without a needle. Advantages are painless
injection, less tissue damage, faster injection
and faster rate of drug absorption into the
tissues. Drawbacks are: it cannot be used for
nerve blocks, only infiltration and surface
anesthesia are possible.

75. VIBROTACTILE DEVICES
These devices work on the principle of ‘gate
control’ theory thereby reduces pain. It acts
based on the fact that the vibration message
is carried to brain through insulated nerves
and pain message through smaller uninsulated
nerves. The insulated nerves overrule the
smaller uninsulated nerves. The devices are:
VibraJect, Dental Vibe, Accupal.

76. • VibraJect has a battery operated device which is attached to the standard
anesthetic syringe, causing the syringe and needle apparatus to vibrate.
Nanitsos et al and Blair have recommended the use of VibraJect for painless
injection.
• Accupal is a cordless device which applies both vibration and pressure at the
injection site.

77. Dental vibe
• Dental Vibe is a cordless hand held device which
gently stimulates the sensory receptors at the
injection site causing the neural pain gate to
close.
• Advantage is, the tissues are vibrated before the
needle penetrates.
• Disadvantage is, it is not directly attached to the
syringe and a separate unit is required, so both
hands are engaged.
• Dentalvibe and syringe micro vibrator uses micro-
vibration to the site where an injection is being
administered.

78. SAFETY DENTAL SYRINGES
• Aim of these devices is to prevent from the risk
of accidental needle stick injury occurring with a
contaminated needle after local anesthesia
administration.
• These syringes possess a sheath that locks over
the needle when it is removed from the patient’s
tissues preventing accidental needle stick injury.
• Eg are 1. Ultra safe syringe, 2. Ultra safety plus
XL syringe, 3.hyposafety syringe, 4.safety wand
5. Rev Vac safety syringe.

79. DENTIPATCH [INTRAORAL LIGNOCAINE PATCH]
• Dentipatch contains 10-20% lidocaine, which is
placed on dried mucosa for 15 minutes.
• Hersh et al (1996) studied the efficacy of this
patch and recommended it for use in achieving
topical anesthesia for injections in both maxilla
and mandible.
• It is not recommended in children.
Disadvantages include central nervous system
and cardiovascular system complications.

80. Comfort Control Syringe
• This syringe (Dentsply) is an electronic pre programmed anesthesia
delivery device that uses a 2-stage delivery rate.
• The rate of injection varies based on the injection technique
chosen.
• It begins with as low rate; the flow the increases to a pre
programmed technique-specific rate selected by the dentist.
• The operation of this syringe (initiation and termination of the
injection, controlled aspiration and flow rate) is controlled by a
button on the handpiece.
• A disposable cartridges heath is required for each patient, but a
standard dental needle and anesthetic cartridge can be used with
this device.

81. Intranasal Local Anesthesia
The major problem that remains is the patient’s
fear of the needle. Phase 3 clinical trials on the use
of a nasal spray to provide pulpal anesthesia to
maxillary teeth are on going . Cocaine and
tetracaine have been commonly used intranasally to
provide anesthesia (both drugs) or vasoconstriction
(cocaine only) prior to surgical procedures in
otolaryngology in the extremely vascular nasal
cavity or prior to passage of a tube through the
nares .

82. Increasing comfort during injection
• Warming
• Buffering
• Slow injection
• Bevel of the needle
• Needle guage

83. LOCAL ANESTHEISA COMPLICATIONS
• An anesthetic complication is defined as – any deviation from the normally
expected pattern during or after the securing of regional analgesia.
• Complications may be further divided into two groups –
• Those attributed to the solutions used.
• Those attributed to the insertion of the needle.

84. COMPLICATION CAUSED BY THE INSERTION OF THE NEEDLE
• NEEDLE BREAKAGE – extremely rare.
• long dental needles are more prone to break.
• Retrieval of the fragment with a hemostat is
easily accomplished.
• Bent needles
• Defective needles
• MANAGEMENT –
• Remain calm, don’t explore
• Have the patient keep opening wide and
remove it if visible
• Locate the retained fragment through
computed tomographic scanning.

85. FACIAL NERVE PARALYSIS
• Caused by local administration of local anesthesia into the capsule of parotid
gland and damage to peripheral branches of facial nerve.
• Overinsertion during closed mouth technique or inferior alveolar nerve block
• Unilateral paralysis of facial muscles
• MANAGEMENT – reassure the patient, contact lenses removed, and follow up

86. TRISMUS –
• Tetanic spasm of the jaw muscles by which the normal opening of the mouth is
restricted.
• Causes – trauma to muscles or blood vessels
• excessive volumes of local anesthesia deposited into a restricted area produce
distention of tissues.
• Contaminated solutions
• Infection
• MANAGEMENT –
• Prevention
• Heat therapy, warm saline rinses, analgesics, muscle relaxants
• Diazepam (muscle relaxant)10mg twice daily
• Chewing gum (lateral movement of temporomandibular joint)
• Referred to oral surgeons for evaluation.

87. HEMATOMA –
• Effusion of blood into extravascular spaces caused by nicking of a blood
vessel during administration of local anesthesia.
• MANAGEMENT –
• If hematoma is visible apply direct pressure if possible
• Once bleeding has stopped – instruct the patients
• Apply ice for first 6 hrs and heat the next day
• Analgesics prescribed
• Discoloration expected and if it persists – treat as trismus

88. BURNING ON INJECTION -
• pH of the solution deposited in the soft tissues
• Plain LA has pH of 6.5 but 3.5 when vasoconstrictors are added.
• Rapid injection of LA in dense area
• Prevention – buffered solution uesd
• Slow deposit of the solution

89. Conclusion:
Due to the advancement of technology, many newer delivery systems for local
anesthesia have evolved and the dental practitioners must be well aware of their
usage and applications. The required armamentarium may be chosen according to the
patient’s needs. Dentists must be well aware of these newer delivery systems, their
usage and must have an up-to-date knowledge, so as to provide the benefits of latest
technology to their patients. The ability to deliver painless injections and a
desirable level and duration of anesthesia results in reduced patient fear, reduced
patient stress and therefore reduced stress for the clinician and can aid patient
compliance with dental treatment.

90. bibliography:
1. Malamed, SF Handbook of Local Anesthesia,
6th Edition , Mosby-Year Book Inc.
2. Snell, RS Clinical Anatomy for Medical
Students, 5th Edition 1995, Little, Brown and
Company Inc.
3. Loestscher CA, and Walton RE Patterns of
Innervation of the Maxillary First Molar: A
Dissection Study Oral Surgery Oral Medicine
Oral Pathology 65: 86-90, 1988
4. McDaniel, WM Variations in Nerve
Distributions of the Maxillary Teeth Journal of
Dental Research 35: 916-921, 1956
5. Heasman PA, Clinical Anatomy of the Superior
Alveolar Nerves British Journal of Oral and
Maxillofacial Surgery 22: 439-447, 1884

91. 6. Malamed SF and Trieger N Intraoral
Maxillary Nerve Block: an Anatomical and
Clinical Study Anesthesia Progress 30: 44-
48, 1983
7. Poore, TE and Carney F Maxillary Nerve
Block: A Useful Technique Journal of Oral
Surgery 31: 749-755, 1973
8. Gow-Gates, GAE Mandibular Conduction
Anesthesia: a New Technique Using Extraoral
Landmarks Oral Surgery 36: 321-328, 1973
9. Akinosi JO, A New Approach to the
Mandibular Nerve Block British Journal of
Oral and Maxillofacial Surgery 15: 83-
87, 1977
10. Vazirani, SJ, Closed Mouth Mandibular
Nerve Block: A New Technique Dental Digest
66: 10-13, 1960
11. Local Anesthesia in Pediatric Dentistry
Nasopalatine Nerve Block . Course Author(s):
Steven Schwartz, DDS

92. 12.Tandon S. Local anesthesia. In:
Textbook of pedodontics. 2: Paras
med78Oical publisher;2009:528-529
13.Gupta Saurabh, Saxena Payal,
Newaskar Vilas. Advanced local anesthesia
techniques. National J Maxillofac surg
2013;4(1):19-24
14.Bennett C.R, Trigeminal Nerve. In:
Monheim’s Local anaesthesia and pain
control in dental practise. 7:CBS;2010:26-
53
15. AnesthProg59:127-137;2012
16. Anesth Prog 51:138-142 2004
17. M.P. Santhosh Kumar/J. Pharm. Sci. &
Res. Vol. 7(5), 2015, 252-255
18. Local Anesthesia in Pediatric Dentistry
Nasopalatine Nerve Block Course
Author(s): Steven Schwartz, DDS

93. Thank you ..