INTRAORAL INJECTIONS
( Local Anesthesiology)
DEN 035
CONTENTS:
Overview and Topographic Anatomy
Mandibular Injections
Maxillary Injections
Overview and Topographic Anatomy
GENERAL INFORMATION
Intraoral injections provide adequate pain control for various dental procedures
Many techniques have been developed
All require detailed understanding of head and neck anatomy to maximize proper administration and
minimize complications
Injections should not be performed in areas of infection or inflammation
The application of topical anesthetic to the site of injection will help lessen the pain caused by the
insertion of the needle
Classification
● Local injections (field blocks)
● Nerve blocks
Common Blocks
Mandibular:
● Inferior alveolar
● Long buccal
● Mental
● Gow-Gates
● Akinosi
Maxillary:
● Posterior superior alveolar
● Nasopalatine
● Greater palatine
● Infraorbital
● Maxillary division
Anesthesiology| Belie Jean T. Vallespin, DMD
Mandibular Injections
INNERVATION AND OSTEOLOGY LANDMARKS
Mandible: General Considerations and Landmarks
The strongest and largest facial bone
Composed of 2 pieces of thick cortical bone: a lingual plate and a buccal plate
Teeth are contained in the horseshoe-shaped body
Ramus extends superiorly from the angle of the mandible
The coronoid notch is the concavity on the anterior portion of the ramus used to estimate the height of
the mandibular foramen, which also
is located at the height of the occlusal plane
Associated Nerves
● Inferior alveolar nerve enters the mandible at the mandibular foramen
● Lingual nerve enters the oral cavity passing against the lingual tuberosity
● Buccal nerve lies on the buccal shelf
Anesthesiology| Belie Jean T. Vallespin, DMD
Mandibular Injections
INFERIOR ALVEOLAR NERVE BLOCK
OVERVIEW
Clinically acceptable mandibular anesthesia is more difficult to achieve than maxillary anesthesia
because of the thickness of the cortical bone
Requires anesthetic deposition in the pterygomandibular space at the region of the mandibular
foramen lateral to the sphenomandibular ligament
Requires proper needle penetration and correct needle angulation in the pterygomandibular space
Properly performed, it anesthetizes 2 nerves:
● Inferior alveolar nerve (and its branches—the incisive and mental nerves)
● Lingual nerve
Areas anesthetized:
● All mandibular teeth (inferior alveolar nerve)
● Epithelium of the anterior 2/3rds of the tongue (lingual nerve)
● All lingual gingiva and lingual mucosa (lingual nerve)
● All buccal gingiva and mucosa from the premolars to the midline (mental nerve)
● Skin of the lower lip (mental nerve)
GENERAL METHODOLOGY
Steps:
● Insert the needle into the mucosa between the deepest portion of the coronoid notch (which
should represent the vertical height of the mandibular foramen) and just lateral to the
pterygomandibular raphe
● Orient the needle from the contralateral premolars and advance it along the occlusal plane of
the mandible
● The needle contacts the mandible after entering 20 to 25mm (if bone is contacted
immediately on penetration into the mucosa, then the temporal crest has been contacted; the
needle should be reoriented to allow insertion to the proper depth)
● Withdraw the needle slightly and perform aspiration to determine whether the needle is in a
blood vessel (inferior alveolar vessels)
● After a negative result on aspiration (no blood observed in the syringe), slowly inject the
anesthetic into the pterygomandibular space
● If the result of aspiration is positive, readjust the needle position and perform aspiration
again before injecting into the pterygomandibular space
CONSIDERATIONS
In children, the mandibular foramen is located closer to the posterior border of the mandible until
more bone is added with age
In edentulous patients, the alveolar bone is lost; thus, the deepest part of the coronoid notch is
lower than normal, which could lead the clinician to aim the needle too low
In class II malocclusion, when the mandible is hypoplastic, the mandibular foramen is typically
located more inferior than the clinician may think
In class III malocclusion, when the mandible is hyperplastic, the mandibular foramen is typically
located more superior than the clinician may think
A transient, dental-induced Bell’s palsy can result if the needle is placed too far posteriorly in the
parotid bed and anesthetic is introduced close to the facial nerve
Anesthesiology| Belie Jean T. Vallespin, DMD
Mandibular Injections
INFERIOR ALVEOLAR NERVE BLOCK CONTINUED
Anesthesiology| Belie Jean T. Vallespin, DMD
Mandibular Injections
LONG BUCCAL NERVE BLOCK
OVERVIEW
A branch of the mandibular division of the trigeminal nerve, the long buccal nerve is not
anesthetized in an inferior alveolar injection
This block anesthetizes all buccal gingiva opposite the mandibular molars, including the retromolar
trigone
GENERAL METHODOLOGY
Steps:
● Insert the needle into the mucosa posterior to the last molar in the mandibular arch on the
buccal side (the needle will be inserted a very short distance—about 2mm)
● Perform aspiration; after a negative result, inject the anesthetic
CONSIDERATIONS
A hematoma is rare with this block
This injection seldom fails
Anesthesiology| Belie Jean T. Vallespin, DMD
Mandibular Injections
MENTAL NERVE BLOCK
OVERVIEW
A Branch of the inferior alveolar nerve within the mandibular canal
Areas anesthetized:
● All buccal gingiva and mucosa from the premolars to the midline (mental nerve)
● Skin of the lower lip (mental nerve)
GENERAL METHODOLOGY
Steps:
● Locate the mental foramen via palpation
● Insert the needle into the mucosa at the mucobuccal fold at the location of the
mental foramen (normally around the 2nd mandibular premolar) (the needle will
be inserted a short distance in the direction of the mental foramen)
● Perform aspiration; after a negative result, slowly inject the anesthetic
CONSIDERATIONS
X-ray imaging can help the clinician locate the mental foramen if palpation does not do so
This block seldom fails
Anesthesiology| Belie Jean T. Vallespin, DMD
Mandibular Injections
GOW – GATES BLOCK
OVERVIEW
A variation of the inferior alveolar nerve block, it anesthetizes the following nerves:
● Inferior alveolar nerve (and its branches, the mental and incisive nerves)
● Mylohyoid nerve
● Lingual nerve
● Long buccal nerve (often)
● Auriculotemporal nerve (often)
Low positive aspiration rate relative to that for the standard inferior alveolar nerve block
injection
When the injection is properly administered, the needle contacts the neck of the
mandibular condyle
Areas anesthetized:
● All mandibular teeth (inferior alveolar nerve)
● Epithelium of the anterior 2/3rds of the tongue (lingual nerve)
● All lingual gingiva and lingual mucosa (lingual nerve)
● All buccal gingiva and mucosa (long buccal and mental nerves)
● Skin of the lower lip (mental nerve)
● Skin along the temple, anterior to the ear, and posterior part of the cheek
(auriculotemporal and buccal nerves)
GENERAL METHODOLOGY
Steps:
● The mouth is opened as wide as possible
● Insert the needle high into the mucosa at the level of the 2nd maxillary molar just
distal to the mesiolingual cusp
● Use the intertragic notch as an extraoral landmark to help reach the neck of the
mandibular condyle
● Advance the needle in a plane from the corner of the mouth to the intertragic
notch from the contralateral premolars (this position varies in accordance with
individual flare of the mandible) until it contacts the condylar neck
● Withdraw the needle slightly and perform aspiration to observe whether the needle
is in a blood vessel
● After a negative result on aspiration, slowly inject the anesthetic
● Have the patient keep the mouth open for a few minutes after injection, to allow
the anesthetic to diffuse around the nerves
CONSIDERATIONS
X Useful for multiple procedures on mandibular teeth and buccal soft tissue Few complications
Works well for a bifid inferior alveolar nerve
Anesthesiology| Belie Jean T. Vallespin, DMD
Mandibular Injections
GOW – GATES BLOCK CONTINUED
Anesthesiology| Belie Jean T. Vallespin, DMD
Mandibular Injections
AKINOSI BLOCK
OVERVIEW
A closed-mouth approach for the mandibular nerve block, it anesthetizes the following nerves:
● Inferior alveolar nerve (and its branches, the mental and incisive nerves)
● Mylohyoid nerve
● Lingual nerve
Useful when mandibular depression (opening) is limited, such as with trismus Considered a
“blind” injection
Areas anesthetized:
● All mandibular teeth (inferior alveolar nerve)
● Epithelium of the anterior 2/3rds of the tongue (lingual nerve)
● All lingual gingiva and lingual mucosa (lingual nerve)
● All buccal gingiva and mucosa from the premolars to the midline (mental nerve)
● Skin of the lower lip (mental nerve)
GENERAL METHODOLOGY
Steps:
● Have the patient close the mouth
● Insert the needle into the mucosa between the medial border of the mandibular
ramus and the maxillary tuberosity at the level of the cervical margin of the
maxillary molars
● Advance the needle parallel to the maxillary occlusal plane
● Once the needle is advanced approximately 23 to 25mm, it should be located in
the middle of the pterygomandibular space near the inferior alveolar and lingual
nerves (note: no bone will be contacted)
● After a negative result on aspiration, slowly inject the anesthetic
CONSIDERATIONS
Often used in patients with a limited ability to open the mouth and when intraoral landmarks for
a standard inferior alveolar nerve block are difficult to view
A transient, dental induced Bell’s palsy can result if the needle is placed too far posteriorly in the
parotid bed and anesthetic is introduced close to the facial nerve
Good for patients with a strong gag reflex or macroglossia
Anesthesiology| Belie Jean T. Vallespin, DMD
Mandibular Injections
AKINOSI BLOCK CONTINUED
Anesthesiology| Belie Jean T. Vallespin, DMD
Maxillary Injections
INNERVATION AND OSTEOLOGY LANDMARKS
MAXILLA: GENERAL CONSIDERATIONS AND LANDMARKS
One of the largest facial bones
Porous bone, which aids in achieving anesthesia of the maxillary teeth
Teeth
● Contained in the alveolar bone
● Maxillary teeth are supplied by the anterior, middle, and posterior superior alveolar
nerves (in some patients, the middle superior alveolar nerve may not be present)
Hard Palate
● Composed of the palatal process of the maxilla and the horizontal plate of the palatine
● Supplied by the nasopalatine and greater palatine nerves
Anesthesiology| Belie Jean T. Vallespin, DMD
Maxillary Injections
INNERVATION AND OSTEOLOGY LANDMARKS CONTINUED
Anesthesiology| Belie Jean T. Vallespin, DMD
Maxillary Injections
POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK
OVERVIEW
A frequently used block
OVERVIEW
The injection is in the infratemporal fossa
Areas anesthetized:
• All maxillary molars, with the possible exception of the mesiobuccal root of the 1st maxillary
molar
• Buccal gingiva opposite the teeth
GENERAL METHODOLOGY
Steps:
• With the mouth open, the patient is instructed to deviate the mandible toward the same side
as the injection, to produce more work space for the clinician
• Insert the needle into the mucosa at the mucobuccal fold just superior to the maxillary 2nd
molar, between the medial border of the ramus of the mandible and the maxillary tuberosity
• In a single motion, the needle needs to be advanced approximately 15 mm in the following x-
y-z plane at the same time, to reach the posterior superior alveolar nerve along the posterior
surface of the maxilla:
o Medially at a 45-degree angle to the maxillary occlusal plane
o Superiorly at a 45-degree angle to the maxillary occlusal plane
o Posteriorly at a 45-degree angle to the maxillary occlusal plane
• Perform aspiration due to the close proximity of the pterygoid plexus
• After a negative result on aspiration, slowly inject the anesthetic
CONSIDERATIONS
Significant potential for formation of a hematoma involving the pterygoid plexus
Short needles are preferred, to reduce the risk of hematoma
Anesthesiology| Belie Jean T. Vallespin, DMD
Maxillary Injections
NASOPALATINE NERVE BLOCK
OVERVIEW
Considered the most painful of dental injections
Because of the sensitivity of the area, pressure anesthesia (e.g., using a cotton swab applicator) is
helpful at the site of injection
Areas anesthetized:
• The area’s palatal gingiva and mucosa from the maxillary canine on the right to the maxillary
canine on the left side of the maxilla
• Both the right and left nasopalatine nerves, because they exit onto the hard palate in close
proximity
Oral mucosa in this region is tightly adhered to the hard palate; thus deposition of anesthetic
in the area has less space to diffuse
GENERAL METHODOLOGY
Steps:
• Use a cotton swab applicator to apply pressure to the injection site
• Insert the needle into the palatal mucosa lateral to the incisive papilla
• Deposit a small amount of anesthetic to help lessen the trauma; the
vasoconstrictor norepinephrine then causes the area’s soft tissue to blanch
• Advance the needle until it contacts the hard palate
• Withdraw the needle slightly and perform aspiration
• After a negative result on aspiration, very slowly inject the anesthetic
CONSIDERATIONS
Pressure anesthesia is beneficial to help lessen the pain
Because the tissue is so dense and is attached to the bone, this block requires a slow injection
Anesthesiology| Belie Jean T. Vallespin, DMD
Maxillary Injections
GREATER PALATINE NERVE BLOCK
OVERVIEW
Another commonly used block to anesthetize areas of the hard palate Not as traumatic for the
patient as the nasopalatine nerve block
Because of the sensitivity of the area, pressure anesthesia (e.g., using a cotton swab applicator) is
helpful at the site of injection
Areas anesthetized:
● Palatal gingiva and mucosa in the area from the maxillary 1st premolar (anteriorly) to the
posterior portion of the hard palate to the midline
GENERAL METHODOLOGY
Steps:
• Locate the greater palatine foramen by using a cotton swab applicator to press down on the
tissue in the region of the 1st maxillary molar, moving posteriorly until the swab dips into
the tissue (usually posterior to the 2nd maxillary molar)
• Use a cotton swab applicator to apply pressure to the injection site
• Insert the needle and inject a small amount of anesthetic to lessen patient
discomfort; the tissue of the area will begin to blanch from the effects of the
anesthetic agent
• Advance the needle until it contacts the hard palate
• Withdraw the needle slightly and perform aspiration
• After a negative result on aspiration, slowly inject the anesthetic
CONSIDERATIONS
The clinician should be able to feel the needle contact bone; otherwise, the needle could be too
posterior in the soft palate
Anesthesiology| Belie Jean T. Vallespin, DMD
Maxillary Injections
MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK
OVERVIEW
The middle superior alveolar nerve is reported to be present in about 30% of all people
Areas anesthetized:
• All maxillary premolars and possibly the mesiobuccal root of the 1st maxillary molar
• Buccal gingiva opposite the teeth
GENERAL METHODOLOGY
Steps:
• Insert the needle into the mucosa at the mucobuccal fold just superior to the area of the
maxillary 2nd premolar
• Advance the needle until the tip is superior to the apex of the maxillary 2nd premolar for
maximum anesthesia
• After a negative result on aspiration, slowly inject the anesthetic
CONSIDERATIONS
Local infiltrations are a common substitute for this block
This area is somewhat avascular, and hematoma formation is rare
Anesthesiology| Belie Jean T. Vallespin, DMD
Maxillary Injections
INFRAORBITAL/ ANTERIOR SUPERIOR ALVEOLAR NERVE BLOCK
OVERVIEW
Less frequently used because of the risk of the clinician injuring the patient’s eye
This block anesthetizes the following nerves:
• Anterior superior alveolar nerve
• Middle superior alveolar nerve
• Infraorbital nerve
Areas anesthetized:
• All maxillary teeth from the central incisor to the premolars, with the possible inclusion of
the mesiobuccal root of the 1st maxillary molar
• Buccal gingiva opposite these teeth
• Lateral aspect of nose, lower eyelid, and upper lip
GENERAL METHODOLOGY
Steps:
• Locate the infraorbital foramen via palpation
• Insert the needle into the mucosa at the mucobuccal fold in the area superior to
the 1st maxillary premolar
• Advance the needle parallel to the long axis of the tooth until it contacts the bone
of the infraorbital foramen
• After a negative result on aspiration, slowly inject the anesthetic
CONSIDERATIONS
No significant potential for a hematoma
Useful when pulpal anesthesia cannot be achieved in a local infiltration because of dense bone or
when anesthesia is required on multiple teeth that would need more than one injection
Anesthesiology| Belie Jean T. Vallespin, DMD
Maxillary Injections
MAXILLARY DIVISION BLOCK
OVERVIEW
An excellent technique to achieve hemimaxillary anesthesia
Anesthetizes all of the branches of the maxillary division of the trigeminal nerve Useful in extensive
quadrant procedures and surgery
With blocking of the entire division, the following nerves are anesthetized:
• Posterior superior alveolar nerve
• Middle superior alveolar nerve
• Anterior superior alveolar nerve
• Nasopalatine nerve
• Greater palatine nerve
• Infraorbital nerve
Areas anesthetized:
• All maxillary teeth
• All buccal gingiva
• All palatal gingiva and mucosa
• Lateral aspect of nose, lower eyelid, and upper lip
GENERAL METHODOLOGY
Goal: to deposit the anesthetic in the pterygopalatine fossa using its eventual connection with the
greater palatine foramen
Steps:
• Locate the greater palatine foramen by using a cotton swab applicator to press in the region
of the 1st maxillary molar, moving posteriorly until the swab dips into the tissue (usually
posterior to the 2nd maxillary molar)
• Use a cotton swab applicator to apply pressure to the injection site
• Insert the needle into the mucosa and inject a small amount of anesthetic to
lessen patient discomfort; the tissue will begin to blanch as a result of effects of
the anesthetic agent
• Insert the needle further and locate the greater palatine foramen with the needle
• Once the foramen is located, insert the needle and advance it approximately 28 to
30mm; at this location, the needle should be in the pterygopalatine fossa
• During the passage, if any bony resistance is met, the needle may be rotated to aid
insertion (note: under NO circumstances should the needle be forced)
• After a negative result on aspiration, slowly inject the anesthetic
CONSIDERATIONS
The needle should NEVER be forced into the greater palatine foramen, because occasionally the
canal is not vertical, so that forced entry will fracture the bone
Because the orbit is located superior to the pterygopalatine fossa, if the needle is placed too far
superiorly, the anesthetic can be deposited in this region, affecting the eye
Because the palatine vessels also are contents of the canal, care must be taken to prevent hematoma
Anesthesiology| Belie Jean T. Vallespin, DMD
Maxillary Injections
MAXILLARY DIVISION BLOCK CONTINUED
Anesthesiology| Belie Jean T. Vallespin, DMD
