LOCAL ANAESTHESIA

IN DENTAL PRACTICE
 rd
LA 3 Year
• Administer safe and effective Local
Anesthesia for Oral and Dental Treatment
based on sound pharmacological and
anatomical basis.
 This Lecture
Attendees will be able to
•Describe Nerve Physiology related to Pain
Perception
•Enlist contents of a Local Anesthesia Cartridge
•Classify Local Anesthetics
 Nerve Conduction
• Noxious Stimulus
• Generation of Action Potential
• Propagation of Action Potential

1st order Trigemina Decussate Thalamu

Nerv neuron l
e Nucleus s
(Medulla)
Nucleus
Pain subcaudalis Thalamu
Fibres (Medullary s
Dorsal
horn)
 Nerve Types
Fibre Myelination Function Fibre
type Diameter
(μm)
Aα Myelinated Proprioception 12-20
Aβ Myelinated Somatic motor 5-12
Aγ Myelinated Touch, pressure 3-6
Aδ Thinly myelinated Pain, cold, touch 2-5

B Myelinated Preganglionic <3

autonomic
C Unmyelinated Pain, temperature, 0.4-1.2
Mechanoreceptor
Sympat Post gang symp 0.3-1.3
 Nerve Conduction
• Larger the dia, faster the conduction
• Greater the myelination, Faster the
conduction
• Smaller the dia, faster the anaesthetization
GATE CONTROL
THEORY
• The description of this area
as a "gate" symbolizes the
net result of excitatory and
inhibitory influences acting
on the second-order neuron
or transmission cell (T).
Multiple neurotransmitters
act on the T cell and
determine the fate of the
nociceptive signal. If the
nociceptive signal is not
inhibited, it will "pass through
the gate" for transmission to
higher centers; if interacting
neurons cancel the
nociceptive signal, it will not
pass through the gate.
Pain Modulating System
 LOCAL ANAESTHESIA
CARTRIDGE
• LA Agent
• Vasoconstrictor
• Reducing Agent
• Fungicide
• Carrier solution
 LA AGENT
• Pharmacological Characteristics
• Mechanism
 Chemical Structure

• Water repellent (hydrophobic) part of

molecule
• Intermediate linking chain
• Amide
• Ester
• Water attractant (hydrophilic) part of
molecule
Classification of Local
Anaesthetics
 This Lecture
Attendees will be able to
•Describe Nerve Physiology related to Pain
Perception
•Enlist contents of a Local Anesthesia Cartridge
•Classify Local Anesthetics
 Mechanism
• Blockage of Sodium
Channels
• Either prevents the
generation of
polarization or
prevents propagation
• Ionized anaesthetic binds
to sodium channel.
• Sodium entry is blocked
into these channels.
• Sodium channel blockade
prevents propagation of
action potentials.
• Lack of propagation
blocks sensation, as
signal is not transmitted
to brain.
 Onset of Action

• Diffusion to the site

• Nerve morphology
• Concentration
• Lipid solubility
• The pH of the tissue and pKa of the
agent
 Diffusion to the site
• The further away from the nerve the local
anaesthetic is deposited, the longer it
takes for onset of action.
• Thus, the onset for the infiltration
technique is quite rapid.
• The onset for different blocks is variable.
 Nerve morphology
• Thinner

• Myelination
 Concentration
• To a very limited extent, increases in the
dose administered result in a more rapid
onset
 Lipid solubility
• Lipid solubility has only a minor effect on
onset of action, but uptake by the nerve is
facilitated with the more lipid-soluble
(lipophilic) agents, as these allow
penetration through the nerve sheath
The pH of the tissue and pKa of
the agent
• the most important factors
• pH of the tissue determines the ratio of
ionized to non-ionized drug
• This ratio, in turn, depends on the pKa of
the drug
• pKa equals the pH where the ionized and
non-ionized forms are at equilibrium
The pH of the tissue and pKa of
the agent
• Only the non-ionized form (L) can cross
over into the highly lipid nerve sheath and
into the nerve membrane, where it once
again establishes an equilibrium with the
ionized molecule.
• Once inside the nerve membrane, it is the
ionized form that is necessary for effective
blockage of the sodium influx.
The pH of the tissue and pKa of
the agent
• The less ionization, the better the uptake
into the nerve, but the more ionization, the
better the effect at the membrane itself.
• The pKa of amides ranges from 7.6 to 8.1
• At physiologic pH (7.4), most of the local
anaesthetic is in the ionized state (a
charged base).
• the ester procaine has a pKa of 8.9
The pH of the tissue and pKa of
the agent
• lidocaine has been shown to have an
onset range of 2 to 3 minutes and
procaine to have an onset range of 6 to 12
minutes
• The pH of the tissue becomes relevant in
conditions of infection or inflammation (pH
4.9), in which the natural pH may be more
acidic
LECTURE 2
 Onset of Action
Summary
• Low pH as found in sites of infection will slow or
prevent onset.
• The pKa values of most amides are similar;
therefore, onsets are similar.
• Bupivacaine's higher pKa results in a slightly
slower onset.
• The time for diffusion to the nerve is a factor
--infiltrations are rapid; Gow-Gates may be slow.
 Duration of action
• Depends primarily on the redistribution of
the drug away from the site of action.
• Diffusion away from the site
• Concentration
• Lipid solubility
• Protein binding
 Diffusion away from the site
• the most important factor.
• It is potentiated by the property of most
local anaesthetics as inherently
vasodilating.
• Diffusion away is reduced by the addition
of vasoconstrictor, usually epinephrine.
 Concentration
• Total dose administered is a factor.
• Doubling the dose increases duration by
about one half-life.
 Lipid solubility
• To a very small extent, the more lipid
soluble (lipophilic) the agent, the more
potent it is.
• This increased potency is due to the
greater ease of penetrating into the lipid
nerve sheath.
 Protein binding
• Highly protein-bound agents such as
bupivacaine, which is 95% protein bound,
have a much longer duration of action.
• It is assumed that the degree of plasma
protein binding of local anaesthetics
correlates with the degree of binding to the
receptor site in the ion channels.
VASOCONSTRICTORS
 Indications for
Vasoconstrictors
• Increase depth of anaesthesia
• Increase duration of anaesthesia
• Reduce systemic toxicity
• Hemostasis
 Vasoconstrictor agent
• most commonly used in dental
anaesthesia is epinephrine, in
concentrations of 1:50,000, 1:100,000 or
1:200,000.
• A second vasoconstrictor is levonordefrin
• Vasoconstriction is due to epinephrine’s
stimulation of alpha-1 receptors in mucous
membranes.
Epinephrine concentration in
diluted solution
DILUTION Mg/ml
1:1,000 1.0
1:10,000 0.1
1:50,000 0.02
1:80,000 0.0125
1:100,000 0.01
1:200,000 0.005
 Vasoconstrictor agent
• It stimulates the beta-1 receptor in the
heart to increase heart rate, strength of
contraction and myocardial oxygen
consumption, whereas beta-2 stimulation
vasodilates blood vessels in skeletal
muscle.
• potential interactions
 Epinephrine
• should be minimized and certain
precautions followed for some patients,
• taking drugs such as non-selective beta blockers,
tricyclic antidepressant (levonordefrin), halothane,
cocaine
• with significant cardiovascular disease, especially
angina or a prior history of myocardial infarction.
• Hyperthyroidism
• Local conditions
• Monitor blood pressure and heart rate pre-operatively.
• Minimize epinephrine or levonordefrin administration.
• Monitor blood pressure and heart rate 5 minutes
post-injection.
• Consider limiting epinephrine to 0.04 mg or levonordefrin
to 0.2 mg.
• Avoid 1:50,000 epinephrine.
• Never use epinephrine-impregnated retraction cord.
 Duration of Action
Summary
• Duration depends on the length of time the
drug is within the nerve.
• Action is terminated by redistribution away
from the nerve, not metabolic breakdown.
• Block anaesthesia lasts longer than
infiltration anaesthesia. Soft tissue
anaesthesia lasts longer than pulpal
anaesthesia.
 Duration of Action
Summary
• Soft tissue anaesthesia lasts longer than
pulpal anaesthesia.
• Local anaesthetics without a
vasoconstrictor (mepivacaine or
prilocaine) provide short duration of action.
• A vasoconstrictor with articaine, lidocaine,
mepivacaine or prilocaine provides
intermediate duration.
 Duration of Action
Summary
• Bupivacaine provides prolonged duration
of action for mandibular pulp and maxillary
and mandibular soft tissue.
Duration of Action

Maxillary infilt Mandibular block

Pulp S.T. Pulp S.T.
Duration of Action

Maxillary infilt Mandibular block

S. T Pulp S. T. Pulp
 Biotransformation
(Metabolism) and Elimination
• Amides - Liver
• Esters - Plasma cholinestrase
 Biotransformation
(Metabolism) and Elimination
• Biotransformation is not a major factor in
clinical application except for patients with
severe liver dysfunction.
• For patients with hepatic disease, the
usual dose per site is still required, but the
total dose needs to be reduced.
• For patients with hepatic disease, treat
one quadrant per appointment if possible
Recommended Maximum
Doses of Local Anaesthetic
 Toxicity
• due to systemic absorption of an
excessive amount of the drug.
• Because local anaesthetics block
conduction in many tissues in addition to
the peripheral nerve, toxicity could result if
sufficient amounts of the anaesthetic
reach these other tissues, such as the
heart or brain.
 Toxicity
• High blood levels of the drug may be
secondary to repeated injections or could
be a result of a single intravascular
administration.
• This risk is one reason why aspiration prior
to every injection is so important.
 Toxicity
• The likelihood of toxicity depends on
factors such as the site of administration,
the speed of injection and the presence of
a vasoconstrictor.
 Calculations of Doses
• Percent solutions represent grams per 100
mL
• Move the decimal place to the right and
this value = mg/mL (i.e. lidocaine 2% = 20
mg/mL)
• Most cartridges = 1.8 mL.
• Therefore, one cartridge of 2% lidocaine
contains 1.8 mL x 20 mg/mL = 36 mg.
 20 kg child
• 7 mg/kg x 20 kg = 140 mg
• 2% lidocaine = 20 mg/mL
• 140 mg / (20 mg/mL) = 7.0 mL
• Each cartridge = 1.8 mL, therefore
maximum dose = 7.0 mL / 1.8 mL
• Therefore maximum dose = 3.9 cartridges
 Pharmacology
• https://www.youtube.com/watch?v=MoZzc
WyuNk8
• https://www.youtube.com/watch?v=8LU4I
wdDbx8
13/5/2022
Topical Anaesthesia
 Topical Anaesthetics
• to minimize sensation from needle
insertion or for very brief relief from painful
mucosal lesions.
• Their effectiveness in preventing pain from
injection has not always been
demonstrated in studies, but they may be
of value for many patients.
 Topical Anaesthetics
• benzocaine is available in concentrations
up to 20%
• lidocaine is available as a solution or
ointment in concentrations up to 5% or as
a spray in a concentration of 10% or 15%.
 Infiltration
Local Anaesthesia
 Field Block
Local Anaesthesia
 Block
Local Anaesthesia
(19) EP 2 Instruments for local anesthetic administration –
YouTube
LA syringe
LA syringe
LA syringe
The Needle
LA cartridge
LA cartridge
 Maxillary LA

https://youtu.be/px1zQh7HJp
M
Neuroanatomy
 Maxillary Nerve
Foramen Rotundum

•Ganglionic
•Zygomatic
•Post sup Alv

Contnues as infraorbital
Giving middle & ant
sup
alveolar nerves
Maxillary Nerve
Maxillary nerve
Needle bevel
https://www.youtube.com/watch?v=E7bbu
Dnu8JA
 Maxillary LA
• https://youtu.be/px1zQh7HJpM
 Incisors - premolar

• Sulcus adjacent to the root

 First Molar
• Mesial root - Middle
sup alv n

• Post & palatal - Post

sup alv n

• Ant to zyg buttress &

post to zyg buttress
 2nd & 3rd Molars
• 1 ml. Distal to zyg buttress

• Not too deep as close to pterygoid plexus

Greater Palatine Block
Greater Palatine Block
Incisive Block
Incisive Block
 Posterior superior alveolar
nerve block
• Preferred alternative for maxillary molars
when more than one tooth is involved or
when infection is present.
• Anesthetizes the pulps of the second
and third maxillary molars and, in about
70% of patients, the entire first molar
 Posterior superior alveolar
nerve block
(1) Apply topical anesthetic to the apex of
the mucobuccal fold above the second
maxillary molar.
 Posterior superior alveolar
nerve block
(2) Have the patient partially open the
mouth, and deviate the mandible toward
the side being injected, to create more
room.
 Posterior superior alveolar
nerve block
(3) With the index finger, retract the
patient's cheek on the side being
injected and pull the tissue taut.
 Posterior superior alveolar
nerve block
(4) Insert the needle into the target area,
with the bevel of the needle facing the
bone.
 Posterior superior alveolar
nerve block
(5) In one combined movement, slowly
advance the needle through the soft
tissue superiorly (at a 45° angle to the
plane of occlusion), medially (again at a
45° angle to the plane of occlusion), and
posteriorly (at a 45° angle to the long
axis of the second maxillary molar).
 Posterior superior alveolar
nerve block
(6) Penetrate to a depth of 10 to 14 mm in
a child or small adult and 16 mm in an
average-sized adult.
 Posterior superior alveolar
nerve block
(7) Aspirate once, then rotate the bevel of
the needle 90° and aspirate again. If no
blood is returned, inject 1 to 2 mL of
anesthetic over 30 to 60 seconds,
aspirating periodically during the
injection.
 Posterior superior alveolar
nerve block
(8) If aspiration is positive, withdraw the
needle about 1 cm and redirect more
medially and superiorly.
 Posterior superior alveolar
nerve block
• When in doubt, be conservative with the
depth of needle penetration; hematomas
most often result from overpenetration,
whereas underpenetration may still
provide adequate pain relief.
 Posterior superior alveolar
nerve block
• If a hematoma does form, it is generally
apparent in the mandibular buccal soft
tissues.
• A hematoma stops enlarging only when
the intravascular and extravascular
blood pressures equalize, since the
bleeding originates from a location
inaccessible to direct pressure.
 Posterior superior alveolar
nerve block
• Highly effective but carries a greater risk
of intravascular injection and hematoma
formation than most other injections.
• Because of the need for frequent
aspiration during the procedure, a 25- to
27-gauge 3/4-in. to 1-in. needle is
recommended.
 Posterior superior alveolar
nerve block
• Have the patient partially open the
mouth, and deviate the mandible toward
the side being injected, to create more
room.
• With the index finger, retract the patient's
cheek on the side being injected and pull
the tissue taut.
• Insert the needle into the target area,
with the bevel of the needle facing the
bone.
 Posterior superior alveolar
nerve block
• In one combined movement, slowly advance
the needle through the soft tissue superiorly
(at a 45° angle to the plane of occlusion),
medially (again at a 45° angle to the plane of
occlusion), and posteriorly (at a 45° angle to
the long axis of the second maxillary molar).
• Penetrate to a depth of 10 to 14 mm in a child
or small adult and 16 mm in an average-sized
adult.
• Aspirate & inject
LECTURE
Mandibular Anesthesia
• Applied Anatomy
• Techniques used
• Pits & falls
 Mandibular Nerve
Oval
e
Nerve to Mandibul
med Pteryg ar
Ant Trunk

Motor Long
Buccal
 Mandibular Nerve
Oval Nervous
e Sponosis
Nerve to Mandibul Auricultemporal
med Pteryg ar
Post Trunk
Ant Trunk

Motor Long Lingual

Inf alv
Buccal
 Mandibular Nerve
Oval Nervous
e Sponosis
Nerve to Mandibul Auricultemporal
med Pteryg ar
Post Trunk
Ant Trunk

Motor Long Lingual

Inf alv
Buccal
Anatomy

Dr. Abid Ashar (FDSRCS)

Anatomy

Dr. Abid Ashar (FDSRCS)

Anatomy

Dr. Abid Ashar (FDSRCS)

Dr. Abid Ashar (FDSRCS)
Inferior Alveolar Nerve
Block

Dr. Abid Ashar (FDSRCS)

Dr. Abid Ashar (FDSRCS)
Dr. Abid Ashar (FDSRCS)
Dr. Abid Ashar (FDSRCS)
Prof. Abid Ashar (FDSRCS)
Mandibular Nerve
 Inferior Alveolar Nerve
Block
ADVANTAGES DISADVANTAGES
• Practitioner • Area of injection is
vascular; 10 -15% chance
acceptance
of positive aspiration
• Faster onset than • Unlikely to anaesthetize
higher blocks accessory nerves
• Bony landmark • Unlikely to anaesthetize
long buccal nerve
• Difficult to see landmarks
in some patients (e.g.,
macroglossia)
 Inferior Alveolar Nerve
Block
ADVANTAGES DISADVANTAGES
• Practitioner • 71 to 87 percent
acceptance • Area of injection is
vascular; 10 -15% chance
• Faster onset than of positive aspiration
higher blocks • Unlikely to anaesthetize
accessory nerves
• Bony landmark
• Unlikely to anaesthetize
long buccal nerve
• Difficult to see landmarks
in some patients (e.g.,
Dr. Abid Ashar (FDSRCS)
macroglossia)
Inferior Alveolar Nerve
Block
 landmarks

• The coronoid notch (the greatest

depression on the anterior border of the
ramus), also called the external oblique
ridge
• the internal oblique ridge
• the pterygomandibular raphe
• the pterygotemporal depression
• the contralateral mandibular bicuspids
Dr. Abid Ashar (FDSRCS)
Inferior Alveolar Nerve
Block

Dr. Abid Ashar (FDSRCS)

Dr. Abid Ashar (FDSRCS)
Dr. Abid Ashar (FDSRCS)
 landmarks
• The coronoid notch (the
greatest depression on
the anterior border of the
ramus), also called the
external oblique ridge
• the internal oblique ridge
• the pterygomandibular
raphe
• the pterygotemporal
depression
• the contralateral
mandibular bicuspids

Dr. Abid Ashar (FDSRCS)

Dr. Abid Ashar (FDSRCS)
Inferior Alveolar Nerve
Block

Dr. Abid Ashar (FDSRCS)

Inferior Alveolar Nerve
Block

Dr. Abid Ashar (FDSRCS)

Inferior Alveolar Nerve
Block

Dr. Abid Ashar (FDSRCS)

Inferior Alveolar Nerve
Block
Inferior Alveolar Nerve
Block
 Inferior Alveolar Nerve
Block
• Insert the in the
pterygotemporal
depression.
• Approximate the height is
the middle of the palpating
fingernail or thumbnail.
 Inferior Alveolar Nerve
Block

• Ensure that the barrel of the

syringe is located over the
contralateral mandibular bicuspids.
• Insert until bone is contacted, and
then withdraw ~1 mm. The depth
of insertion for the average-sized
adult is approximately 25 mm.
• Aspirate.
• Inject a full cartridge
 Onset and duration
• Onset for hard tissue anaesthesia is 3 to 4
minutes.
• Duration for hard tissue anaesthesia is 40
minutes to 4 hours, depending on the type
of local anaesthetic used and whether a
vasoconstrictor is used.
• It is unlikely that the long buccal nerve will
be anaesthetized
LECTURE
Long Buccal Nerve
Block
Dr. Abid Ashar (FDSRCS)
Dr. Abid Ashar (FDSRCS)
Dr. Abid Ashar (FDSRCS)
 The Gow-Gates Mandibular
Block
ADVANTAGES DISADVANTAGES
• Perceptible end point (bone)
• Fewer blood vessels at this level,
therefore less chance of positive • Mouth wide open
aspiration
• Must use extraoral landmarks,
• Long buccal nerve anaesthesia which may increase the difficulty of
likely this procedure
• Possible longer duration of
anaesthesia
• Greater chance of anaesthetizing
accessory nerves
Dr. Abid Ashar (FDSRCS)
Dr. Abid Ashar (FDSRCS)
 Landmarks

• 10 mm above the coronoid notch

• The mesiolingual cusp of the maxillary 2nd
molar - the height of the injection.
• the internal oblique ridge
• the pterygomandibular raphe
• the neck of the condyle
• the contralateral mandibular bicuspids
• an imaginary line from the corner of the mouth
to the tragal notch of the ear (extraorally).
Dr. Abid Ashar (FDSRCS)
• Ask the patient to open
his or her mouth wide.
• Palpate the coronoid
notch and slide the finger
or thumb to rest on the
internal oblique ridge.
• Move the finger or thumb
superiorly approximately
10 mm

Dr. Abid Ashar (FDSRCS)

• Rotate the finger or
thumb to parallel
an imaginary line
from the ipsilateral
corner of the mouth
to the tragal notch
of the ear.

Dr. Abid Ashar (FDSRCS)

• Insert until bone is
contacted (at the
neck of the
condyle), which
should occur at a
depth of
approximately 25
mm.

Dr. Abid Ashar (FDSRCS)

• Insert the needle at a
point between the
palpating fingernail and
the pterygomandibular
raphe at the middle
aspect of the fingernail.
• Ensure that the barrel of
the syringe is located
over the contralateral
bicuspids.

Dr. Abid Ashar (FDSRCS)

Dr. Abid Ashar (FDSRCS)
• Once bone is contacted, withdraw the
needle tip 1 mm to prevent injecting into
the periosteum, which would be painful.
• Aspirate.
• Inject a full cartridge
• Not a deeper
injection, the
condyle has
translocated
anteriorly with
the mouth open
to provide a
target.

Dr. Abid Ashar (FDSRCS)

• Onset for hard tissue anaesthesia is 4 to
12 minutes, with the anterior areas taking
the longest amount of time.
• The long buccal nerve will likely be
anaesthetized.
 Onset and duration
• Onset for hard tissue anaesthesia is 4 to
12 minutes, with the anterior areas taking
the longest amount of time.
• The long buccal nerve will likely be
anaesthetized.
Dr. Abid Ashar (FDSRCS)
 The Vazirani-Akinosi Closed
Mouth Mandibular Block
Advantages Disadvantages
• Can be used for • Difficult to visualize
patients with trismus depth of injection
• Can be used for • Difficult in patients
patients with a strong with widely flaring
gag reflex ramus
• Mouth is closed, so
injection may be less
threatening to patient
Dr. Abid Ashar (FDSRCS)
 The Vazirani-Akinosi Closed
Mouth Mandibular Block
Advantages Disadvantages
• Possibly less pain, • Difficult in patients
because tissues are with pronounced
relaxed zygomatic ridge or
• Good for internal oblique ridge
macroglossic patients

Dr. Abid Ashar (FDSRCS)

 Landmarks
• the maxillary buccal mucogingival line or
root apices of the maxillary teeth
• the coronoid notch
• the internal oblique ridge
• the occlusal plane

Dr. Abid Ashar (FDSRCS)

Dr. Abid Ashar (FDSRCS)
Dr. Abid Ashar (FDSRCS)
Dr. Abid Ashar (FDSRCS)
 The Vazirani-Akinosi Closed
Mouth Mandibular Block
• Prepare the needle and syringe by
bending the needle approximately
15o to 20o. This bend
accommodates for the flare of the
ramus. Do not bend the needle
more than once when preparing.
• Ask the patient to slightly open (a
few millimeters) his or her mouth
and execute a lateral excursion
toward the side that is being
injected.
• Palpate the coronoid notch and
slide the finger or thumb to rest on
the internal oblique ridge. Dr. Abid Ashar (FDSRCS)
• Move the finger or
thumb superiorly
approximately 10 mm

Dr. Abid Ashar (FDSRCS)

 The Vazirani-Akinosi Closed
Mouth Mandibular Block
• Insert the needle tip
between the finger and
maxilla at the height of the
maxillary buccal
mucogingival line. Orient
the bend of the needle
such that the needle looks
as though it is going
laterally in the direction of
the ear lobe on the
injection side. The needle
remains parallel to theDr. Abid Ashar (FDSRCS)
occlusal plane.
 The Vazirani-Akinosi Closed
Mouth Mandibular Block
• After the needle has been inserted
5 mm, remove the palpating finger
or thumb and use it to reflect the
maxillary lip to enhance vision.
• Inject to the final depth of
approximately 28 mm for the
average-sized adult, therefore
visualizing 7 mm of needle
remaining outside the tissue (if
using a long needle).
• Aspirate.
• Inject a full cartridge.
Dr. Abid Ashar (FDSRCS)
Dr. Abid Ashar (FDSRCS)
LECTURE
 Reasons for Incomplete
Anaesthesia
• local anaesthetic pka - ph factors and tissue ph
factors
• needle-to-jaw size discrepancy
• needle deflection
• volume factors
• skeletal and neuroanatomic variations
• local anaesthetic or vasoconstrictor degradation
• Unco-operative patients
 Accessory Mandibular Innervation
• Branches of inferior alveolar nerve.
• Mylohyoid nerve - 60 percent.
• Premolars
• Canines
• Incisors
• Branches of the mandibular division (V3) of the
trigeminal nerve arising high in the infratemporal
fossa
• long buccal nerve
• crosses the ramus at maxillary molars occlusal with
the mouth wide open

Dr. Abid Ashar (FDSRCS)

Dr. Abid Ashar (FDSRCS)
Dr. Abid Ashar (FDSRCS)
Dr. Abid Ashar (FDSRCS)
Dr. Abid Ashar (FDSRCS)
 PROBLEM SUGGESTION
Anesthetic is deposited below the Reinject at a higher site.
mandibular foramen.
Anesthetic is deposited too far Reinject with the needle tip more
anteriorly on the ramus. posterior.
Needle deflected by tissue, Use a 25 gauge long needle.
anesthetic deposited to the left or
right of the foramen.
Anesthetic doesn’t reach the nerve. Use and anesthetic without
vasoconstrictor for second injection
to allow for diffusion.
There may be accessory nerves Reinject distal & lingual to tooth not
supplying the mandibular teeth. anesthetized at the lingual border
of the mandible or use a
periodontal ligament injection.
OR
Use higher level block
Dr. Abid Ashar (FDSRCS)
Dr. Abid Ashar (FDSRCS)
 Onset and duration

• Onset for hard tissue anaesthesia is 3 to 4

minutes
• There is an increased possibility of
obtaining long buccal nerve anaesthesia
as compared to the inferior alveolar nerve
block.
 pka - ph factors and tissue ph
factors
• When a local anaesthetic is injected into tissue, two
particles are in equilibrium: a lipophilic (lipid-soluble)
neutral particle and a positively charged hydrophilic
(water-soluble) particle.
• Initially, it is advantageous to have the greatest
proportion possible of lipophilic particles, because
these particles can pass through the lipid membrane
of the nerve.
• Once inside the nerve, a new equilibrium is
established, and a new set of hydrophilic particles
form. These hydrophilic, charged molecules work to
stop the action potential inside the nerve.
 pka - ph factors and tissue ph
factors
• Higher pKa equates to decreased potency
• An infection in the area of injection
• Local anaesthetics with a vasoconstrictor
contain the preservative sodium
metabisulphite
• preservative is quite acidic, and in high
concentrations it can lower the overall pH
of the local anaesthetic solution to 4 or 5
 pka - ph factors and tissue ph
factors
• local anaesthetic with 1:100,000
epinephrine
• Another injected for lack of anaesthesia
• More acidic - no LA effect
• Try plain LA
 Needle-to-jaw size
discrepancy
• Two popular lengths of needles
• 25 mm or one inch long
• 35 – 41 mm
• For a mandibular block for the
average-sized adult is 25 mm
• Short needles cannot be recommended
• For the average-sized adult, the
practitioner would observe 10 mm of
needle remaining outside the tissues
 Needle deflection

• Needle deflects due to the density of the

tissue pushing against the bevel
• Thinner the needle, greater is the
deflection.
• 30 gauge - upto 4 mm.
• 27 gauge - upto 2 mm.
• 25 gauge - upto 1 mm.
 Volume factors
• Time - 3-4 minutes
• Anatomic structures
• Vasculature - intravascular inj. Less vol for
LA
• Nerve thickness
• Mand n vs Inf alv n
• Volume - thicker nerves & larger pts
 Anatomic structures

• Anatomical structure that

can physically stop the
local anaesthetic from
travelling to the inferior
alveolar nerve.
• Too far medially away
from the inferior alveolar
nerve, it is blocked from
travelling laterally by the
sphenomandibular
ligament and its
associated fascia.
 Skeletal and neuroanatomic
variations
• Skeletal factors
• Class of occlusion and the width of the ramus
• Change the location of the lingula relative to the
intraoral landmarks
• A ramus that flares widely from the midline requires
the syringe to be located more over the contralateral
molars when blocking the hemi-mandible, while a
ramus that is more parallel to the mid-sagittal plane
requires the syringe to be more over the contralateral
cuspids
 Skeletal and neuroanatomic
variations
• Skeletal factors
• Width of the internal oblique ridge. If the patient has
an exceedingly wide internal oblique ridge and the
practitioner's finger is not resting on this ridge of bone,
it is very difficult to negotiate the needle past this bony
ridge to approach the inferior alveolar nerve. More
posteriorly, toward the contralateral molars.
 Skeletal and neuroanatomic
variations
• Skeletal factors
• Position of the mandibular foramen. The location of
this foramen can vary both in its anterior - posterior
position and its inferior - superior position. Blocks
given more superiorly, more successful due to the
increased chance of being superior to this foramen.
• The mylohyoid nerve can send branches through
foramina located anywhere on the lingual aspect of
the mandible and thus directly supply accessory
innervation to any of the mandibular teeth.
 Skeletal and neuroanatomic
variations
• Correcting the lack of complete anaesthesia
is possible through a number of different
techniques.
• First, a Gow-Gates block can be given; because
this block is more superior in the
pterygomandibular triangle, it is more likely to be
superior to the location of where the accessory
nerve leaves the core nerve.
• Second, 0.4 mL to 0.5 mL of local anaesthetic can
be injected into the retromolar area or lingual to
the tooth being treated.
 Local anaesthetic or
vasoconstrictor degradation
• Expiry date.
• Local anaesthetic molecules are
relatively stable and degrade very
slowly.
• Depends mostly on the stability of the
vasoconstrictor. For this reason, sodium
metabisulphite is used as a preservative
or stabilizer for the vasoconstrictor
molecule.
 Local anaesthetic or
vasoconstrictor degradation
• Extreme temperatures, excessive light and
oxygen exposure.
• To maximize the shelf life, should be
stored at room temperature away from
sunlight and room light.
• Delivery to the office.
 Local anaesthetic or
vasoconstrictor degradation
• Autoclaving or repeatedly using cartridge
warmers.
• Local anaesthetics should not be
purchased for stockpiling in such amounts
that the stale date arrives before the
solution can be utilized.
 Unco-operative patients

• Incomplete anaesthesia is not only

frustrating for the practitioner but is also
uncomfortable at best or devastating at
worst for the patient.
• Many dental-phobic patients report a prior
dental visit in which they experienced pain.
 Unco-operative patients

• Many of these patients may have had

other reasons for incomplete
anaesthesia.
• Patient's co-operation through
reassurance and explanation.
• If the patient's anxiety is strong enough
that it impedes their ability to co-operate,
conscious sedation such as nitrous oxide
and oxygen may be considered.
 Needle length and gauge
• The three standard dental needle
lengths are long (~35 mm), short (~25
mm) and ultra-short (~12 mm).
• Long needles should be used for
deeper injections such as blocks in the
mandible.
• Short needles can be used elsewhere
• Ultra-short needles may be useful for a
PDL injection.
 Needle length and gauge
• The three standard dental needle gauges, or
thicknesses, are 25-gauge, 27-gauge and 30-gauge.
The choice depends on two main factors.
• First, the thicker the needle, the more stable it is and
the less it deflects when pushed into tissue therefore,
a practitioner may decide to use thicker needles on
heavier-set individuals.
• Second, neither 27-gauge nor 30-gauge needles are
reliable aspirators of blood; therefore, whenever the
practitioner is injecting into an area where there is the
possibility of entering a blood vessel, a 25-gauge
needle should be used.
 Needle length and gauge
• The patient will not be able to discern the difference
between the prick of a 25-, 27- or 30-gauge needle.
One needle will not hurt more than another.
• The key to reducing pain during injection, regardless
of the needle gauge, is to inject slowly.
 Burning on injection

A burning sensation on injection may

occur for two reasons.
• First, local anaesthetics with a vasoconstrictor
are acidic because of the preservative
required for the vasoconstrictor.
• Second, the sterilizing solution can cause a
burning sensation upon injection.
• use fresh anaesthetics with little or no
vasoconstrictor and by injecting slowly.
 Mental nerve block
• From the midline to the second premolar
and the skin of the chin and lower lip
• It is ideal for patients with trauma to this
area who require thorough debridement or
laceration repair.
• A cosmetically important structure, such as
the vermilion border of the lip.
 Mental nerve block
(1) Apply topical anesthetic to the region
of the mental nerve foramen, which is
generally at the apex of the second
premolar and can be palpated as a
slight concavity.
(2) Retract the lower lip to facilitate a
painless injection.
 Mental nerve block
(3) Introduce the needle with the bevel
toward the bone, into the mucobuccal
fold inferior to the second premolar,
overlying or slightly anterior to the
mental nerve foramen.
 Mental nerve block
(4) Advance the needle slowly about 5 or
6 mm.
(5) Aspirate. If no blood is returned, slowly
inject 1 to 2 mL of anesthetic.
(6) If aspiration is positive, withdraw and
redirect the needle, then repeat step 5.
• The patient should experience complete
anesthesia within 5 minutes of injection.
 Infraorbital nerve block
• For pain involving the upper teeth from the
midline to the canine or for lacerations
involving the upper lip
• It also anesthetizes the maxillary
premolars and the mesiobuccal root of the
first maxillary molar in about 70% of
patients.
 Infraorbital nerve block
• Palpate the infraorbital foramen, which
is just inferior to the infraorbital notch;
the patient should note mild discomfort
when pressure is applied over the
foramen.
• Apply topical anesthetic to the apex of
the mucobuccal fold directly superior to
the first maxillary premolar.
• Keeping one finger over the infraorbital
foramen, lift the lip and pull the tissue
taut.
 Infraorbital nerve block

• Insert the needle into the target area with

the bevel facing the bone.
• Holding the needle parallel to the long
axis of the first premolar, direct the
syringe toward the infraorbital foramen.
• Slowly advance the needle until it meets
bone (about 1.6 cm in an adult weighing
70 to 80 kg [154 to 176 lb]).
• Aspirate & inject.
 Adverse Reactions
• Systemic

• Local
 Systemic Adverse Reactions
• Psychogenic reactions
• Allergy
• Toxicity
• Methemoglobinemia
 Psychogenic
• Anxiety-induced reactions are by far the
most common adverse event
• Fainting (syncope) is the most common
• Other common reactions include
hyperventilation, nausea, vomiting and
changes in heart rate or blood pressure.
 Allergy
• Reports of allergic reactions to local
anaesthetics are somewhat common, but
investigation finds most of these reactions
to be of psychogenic origin.
• A confirmed allergy to an amide is rare;
the ester procaine is somewhat more
allergenic.
• An allergy to one ester rules out using
another ester.
 Allergy
• Conversely, an allergy to one amide does
not rule out using another amide.
• Epinephrine has not been shown to have
any allergenic potential.
• Allergies to the other contents in the
cartridge are possible.
 Allergy
• In the past, methylparabens were often
found to be the source of allergy; thus, a
patient's history of allergy "to dental
anaesthetic" may originate from a time
when methylparabens were in use.
 Methemoglobinemia
• Most notably with prilocaine, but may also occur
with articaine or the topical anaesthetic
benzocaine.
• induced by an excess of metabolites of these
drugs and presents as a cyanotic appearance
that does not respond to the administration of
100% oxygen.
• One of the metabolites of prilocaine is
ortho-toluidine, which reduces hemoglobin to
methemoglobin, which, in turn, may lead to
methemoglobinemia if produced in excess
 Methemoglobinemia
• Cyanosis becomes apparent when
methemoglobin levels are low, but additional
symptoms of nausea, sedation, seizures and
even coma may result when levels are very high.
• Prilocaine, articaine and benzocaine are best
avoided in patients with hereditary
methemoglobinemia.
Adverse Reactions: Systemic
• Psychogenic
∙ Syncope (fainting)
∙ Hyperventilation
∙ Nausea and vomiting
∙ Increases or decreases in heart rate
∙ Increases or decreases in blood pressure
∙ Appearance as allergic reaction
• Allergy
• Potential allergens:
∙ Esters
∙ Amide allergy very rare; if so, amides are not expected to
cross-react
∙ Metabisulfite (present with epinephrine or levonordefrin)
∙ Methylparabens (now removed from all cartridgessince
1984)
• Toxicity
∙ May initially present as sedation, lightheadedness,
slurred speech, mood alteration, diplopia, sensory
disturbances, disorientation, muscle twitching
∙ Higher blood levels may result in tremors, respiratory
depression, tonic/clonic seizures
∙ If severe, may result in coma, respiratory arrest,
cardiovascular collapse
• Methemoglobinemia
∙ Associated primarily with prilocaine; to a lesser extent
with articaine, benzocaine
 Adverse Reactions
• Systemic

• Local
Adverse Reactions: Localized
• Trismus
• hematoma
• prolonged anaesthesia or paraesthesia
• pain on injection
• needle breakage
• soft tissue injury
• facial nerve paralysis
• superfluous anaesthesia
• infection.
 Trismus
• Due to needle insertion into one of the
muscles of mastication, leading to
bleeding, spasm or both. - medial
pterygoid
• Injection of local anaesthetic directly into
muscle may cause a mild myotoxic
response, which can lead to necrosis.
 Trismus
• often associated with pain, arise anywhere from
1 to 6 days following an injection.
• The duration of symptoms and their severity are
both variable.
• With management as described later,
improvement should be noted within 2 to 3 days.
If there is no improvement within this time, the
dentist should consider other possible causes
(e.g., infection) and treat accordingly.
 Trismus
• Prevention
• Follow basic principles of atraumatic
injection technique.
• Management
• Apply hot moist towels to the site for
approximately 20 minutes every hour.
• Use analgesics as required.
• Advise the patient to gradually open and
close the mouth as a means of
physiotherapy.
 Hematoma
• inadvertent nicking of a blood vessel
during the injection or when withdrawing
the needle.
• Blood vessels are often pierced during
intraoral injections, but only when there is
sufficient blood extravasation is there a
hematoma.
 Hematoma
• The vessels most commonly associated
with a hematoma are the pterygoid plexus
of veins, the posterior superior alveolar
vessels, the inferior alveolar vessels and
the mental vessels.
• The patient will notice swelling and
discolouration (bruising) lasting 7 to 14
days.
 Hematoma
• Prevention
• Follow basic principles of atraumatic injection
technique.
• Use a short needle for the posterior superior
alveolar nerve block.
 Hematoma
• Management
• If hematoma is visible immediately following the
injection, apply direct pressure, if possible.
• Once bleeding has stopped, discharge patient with
instructions to
• Apply ice intermittently to the site for the
first 6 hours.
• Do not apply heat for at least 6 hours.
• Use analgesics as required.
• Expect discolouration.
• If difficulty in opening occurs, treat as with trismus,
described above.
 Prolonged anaesthesia or
paraesthesia
• tongue or lip
• These reactions are most often found after
block techniques and much less
commonly after infiltrations.
• The precise causes of paraesthesia are
not certain, but they may include needle
trauma or the injection of alcohol or
sterilizing solutions.
 Prolonged anaesthesia or
paraesthesia
• The vast majority of paraesthesias are
transient, resolving within 2 months, but
they can become permanent.
• A change in the character of the symptoms
is encouraging in that it may indicate
healing of the nerve and resolution of
symptoms; with time, the patient may
regain normal sensation.
 Prolonged anaesthesia or
paraesthesia
• The patient who has had no change in
symptoms over a prolonged period, such
as several months, is less likely to have a
satisfactory outcome. Unfortunately, there
is no guaranteed method of treating
prolonged anaesthesia or paraesthesia.
 Prolonged anaesthesia or
paraesthesia
• Prevention
∙ If patient feels "electric shock", move the
needle away from the site before injecting.
∙ Do not store cartridges of local anaesthetic in
disinfecting solutions.
∙ Minimize the use of articaine and prilocaine for
block technique.
 Prolonged anaesthesia or
paraesthesia
• Management

∙ Advise the patient that the paraesthesia or anaesthesia is

usually temporary, although, rarely, it can remain
indefinitely.
∙ Note the signs and symptoms and follow up within 1
month.
∙ If symptoms persist for more than 2 months, refer the
patient to an oral and maxillofacial surgeon who has
experience in this field.
 Pain/burning on injection
• if the needle goes into a sensitive structure
such as muscle or tendon.
• if the solution is administered too quickly
and distends the tissue rapidly.
• Local anaesthetic solutions at extremes of
temperature may also cause discomfort.
Solutions that are more acidic (i.e., those
containing a vasoconstrictor) may cause a
short-lasting burning sensation.
 Pain/burning on injection
• Cartridges stored in a disinfecting solution
such as alcohol may have residual
amounts of solution on the end of the
cartridge, which can then be administered
inadvertently during injection.
 Pain/burning on injection
• Prevention
∙ Inject slowly: Try to take at least 1 minute to administer 1
cartridge.
∙ Store cartridge at room temperature.
∙ Do not store cartridges of local anaesthetic in disinfecting
solutions.

• Management
∙ Pain or burning on injection is usually self-limiting, as it is
treated by the onset of anaesthesia.
 Needle breakage
• Rare. The sudden unexpected movement
of the patient is the primary cause.
• It is believed that smaller-diameter
needles (i.e., 30 gauge), are more likely to
break than the larger diameter (i.e., 25
gauge).
• Needle breakage usually occurs at the
hub, which is why needles should never
be inserted completely into tissue.
 Needle breakage
• Although bending a needle may be
considered for injection techniques, it is
important to do so only once, as repeated
bending weakens the connection at the
hub and predisposes to breakage.
 Needle breakage
• Prevention
∙ Do not insert a needle into tissues to its hub;
always leave a portion exposed.
∙ Use long needles if a depth of more than 18
mm is required.
∙ Use larger-diameter needles (25 gauge is ideal)
for deeper blocks such as the mandibular
blocks (conventional technique, Gow-Gates
and Vazirani-Akinosi) and the maxillary nerve
block.
 Needle breakage
• Prevention
∙ Do not apply excessive force on the needle
once it is inserted in tissue.
∙ If redirecting a needle is required, withdraw it
almost completely before doing so.
∙ Do not bend a needle more than once.
 Needle breakage

• Management
∙ Remain calm.
∙ Ask the patient to remain still; keep the
mouth open by not removing your hand.
∙ If a portion of the needle is visible,
remove it with a hemostat or similar
instrument.
 Needle breakage
• Management
∙ If the needle is not visible,
□ Inform the patient.
□ Record the events in the patient's chart.
□ Refer the patient to an oral and maxillofacial
surgeon. Surgical removal should only be attempted
by someone experienced with surgery of the involved
region and after radiographs have been taken to help
localize the needle.
 Soft-tissue injury

• bite into the lip or tongue when there is the

loss of sensation that accompanies successful
anaesthesia.
• most common in children and in patients who
are mentally challenged or demented, such as
those with Alzheimer's disease.
• The parent, guardian or caregiver should be
advised to observe the patient carefully for the
expected duration of anaesthesia.
 Soft-tissue injury
• Prevention
∙ For the paediatric, mentally challenged
or demented patient, warn the parent,
guardian or caregiver to watch the
patient carefully for the duration of
soft-tissue anaesthesia.
 Soft-tissue injury
• Management
∙ Use analgesics as required.
∙ Use rinses or applications with lukewarm
dilute solutions of salt or baking soda.
∙ Consider applying petroleum jelly over
the lip lesion.
 Facial nerve paralysis
• The facial nerve may be anaesthetized if
the needle penetrates the parotid gland
capsule.
• Needle placement into the parotid may
occur if there is over-insertion during an
inferior alveolar nerve block
• Anaesthesia may cause a transient
unilateral paralysis of the muscles of the
chin, lower lip, upper lip, cheek and eye.
 Facial nerve paralysis
• Temporary and lasts the expected duration
of anaesthesia of soft tissue for the
anaesthetic administered.
• Potential risks may exist if the patient is
unable to close the eyelid (protective
reflex).
 Facial nerve paralysis
• Prevention
∙ Follow basic principles of atraumatic
injection technique.
∙ Avoid over-insertion of the needle.
∙ For the conventional inferior alveolar
nerve block, do not inject unless bone
has been contacted at the appropriate
depth.
 Facial nerve paralysis
• Management
∙ Reassure the patient of the transient
nature of the paralysis.
∙ Advise the patient to use an eyepatch
until motor function returns.
∙ If contact lenses are worn, they should
be removed.
∙ Record the details in the patient's chart.
 Superfluous anaesthesia
• Unwanted anaesthesia of other nerves
may also occur.
• Ocular complications following temporary
paralysis of cranial nerves II, III, IV or VI
have been described.
• The proposed mechanism for these events
is intravenous transport of local
anaesthetic to the cavernous sinus.
 Superfluous anaesthesia
• Careful aspiration to avoid intravenous
injection should prevent this complication.
• The lesser palatine nerve is commonly
anaesthetized when performing a greater
palatine injection. The patient will notice a
transient loss of sensation on the affected
side when swallowing.
 Superfluous anaesthesia
• Prevention
∙ As always, aspirate well.
∙ Superfluous anaesthesia is often
unavoidable.
• Management
∙ Reassure the patient of the transient
nature of the superfluous anaesthesia.
∙ If there is ocular involvement, monitor
and manage symptomatically.
 Infection
• Extremely rare complication of local
anaesthetic administration, since sterile
disposable needles are used
universally.
• It may occur if the needle has been
contaminated before insertion inside the
patient's mouth.
• The normal flora of the oral cavity are
not a concern, because they do not lead
to infection in patients who are not
significantly immunocompromised.
 Infection
• In severely immunocompromised patients, a
topical antiseptic or an antiseptic rinse such as
chlorhexidine could be considered prior to needle
insertion.
• manifest initially as pain and trismus one-day
post-injection.
• When there is an active site of infection, such as
an abscess, needles should not be inserted within
the site. Not only would the low pH prevent onset
of local anaesthetic action, but the infection could
spread.
 Infection
• Prevention
∙ Use sterile disposable needles.
∙ Do not contaminate the needle by contacting
non-sterile surfaces outside the mouth.
∙ In severely immunocompromised patients, consider a
topical antiseptic prior to injection.

• Management
∙ Prescribe antibiotics, such as penicillin, in an
appropriate dose and duration.
∙ Record the details in the patient's chart and follow up
to determine progress