Local Anesthesia Techniques in Oral and Maxillofacial Surgery

Local Anesthesia Techniques Local Anesthesia Techniques in Oral and Maxillofacial in Oral and Maxillofacial

SurgerySurgery

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

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

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

Overview:Overview:

• Purpose of local anesthesiaPurpose of local anesthesia

• Anatomy of maxillary and Anatomy of maxillary and mandibular nervous innervationmandibular nervous innervation

• Techniques of local anesthesia blocksTechniques of local anesthesia blocks

• Commonly used local anestheticsCommonly used local anesthetics

• Complications with local anesthesiaComplications with local anesthesia

Local Anesthetics:Local Anesthetics:

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

postoperative painpostoperative pain– Decrease amount of general anesthetics Decrease amount of general anesthetics

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

Anatomical considerations:Anatomical considerations:

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

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

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

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

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

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

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

• Branches divided by location:Branches divided by location:– Inter-cranialInter-cranial– PterygopalatinePterygopalatine– Infraorbital Infraorbital – FacialFacial


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

nerve providing sensory innervation to nerve providing sensory innervation to the dura materthe dura mater

– Within the pterygopalatine fossa-Within the pterygopalatine fossa-•Zygomatic nerveZygomatic nerve

•Pterygopalatine nervesPterygopalatine nerves

•Posterior superior alveolar nervePosterior superior alveolar nerve


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

•Zygomaticofacial nerve- skin to cheek prominenceZygomaticofacial nerve- skin to cheek prominence

•Zygomaticotemporal nerve- skin to lateral foreheadZygomaticotemporal nerve- skin to lateral forehead

– Pterygopalatine nerves:Pterygopalatine nerves:

•Serves as communication for the pterygopalatine ganglion and Serves as communication for the pterygopalatine ganglion and the maxillary nervethe maxillary nerve

•Carries postganglionic secretomotor fibers through the Carries postganglionic secretomotor fibers through the zygomatic branch to the lacrimal glandzygomatic branch to the lacrimal gland


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

•Orbital branches- supplies periosteum of the orbitsOrbital branches- supplies periosteum of the orbits

•Nasal branches- supplies mucous membranes of superior Nasal branches- supplies mucous membranes of superior and middle conchae, lining of posterior ethmoid sinuses, and middle conchae, lining of posterior ethmoid sinuses, and posterior nasal septum.and posterior nasal septum.

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



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

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

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



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

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


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

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

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

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

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


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

• Inferior palpebral- lower eyelidInferior palpebral- lower eyelid

•External nasal- lateral skin of noseExternal nasal- lateral skin of nose

•Superior labial branch- upper lip skin and Superior labial branch- upper lip skin and mucosamucosa

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

• Largest branch of the trigeminal nerveLargest branch of the trigeminal nerve

• Composed of sensory and motor rootsComposed of sensory and motor roots

• Sensory root:Sensory root:– Originates at inferior border of trigeminal Originates at inferior border of trigeminal

ganglionganglion

• Motor root:Motor root:– Arises in motor cells located in the pons and Arises in motor cells located in the pons and

medullamedulla– Lies medial to the sensory rootLies medial to the sensory root


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

from the foramen ovale of the greater from the foramen ovale of the greater wing of the sphenoidwing of the sphenoid

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

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


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

and duraand dura– Medial pterygoid- innervates medial Medial pterygoid- innervates medial

pterygoid musclepterygoid muscle•Branches intoBranches into

– Tensor veli palatiniTensor veli palatini– Tensor tympaniTensor tympani


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

buccinator):buccinator):•Travels anteriorly and lateral to the lateral Travels anteriorly and lateral to the lateral

pterygoid musclepterygoid muscle

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


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

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

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

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


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

pterygoidpterygoid•Divisions:Divisions:

– AuriculotemporalAuriculotemporal– LingualLingual– Inferior alveolar Inferior alveolar


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

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

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

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

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


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

•Branches:Branches:– Anterior auricular- skin over helix and tragusAnterior auricular- skin over helix and tragus– External auditory meatus- skin over meatus and External auditory meatus- skin over meatus and

tympanic membranetympanic membrane– Articular- posterior TMJArticular- posterior TMJ– Superficial temporal- skin over temporal regionSuperficial temporal- skin over temporal region


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

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

•Lies inferior and medial to the mandibular 3Lies inferior and medial to the mandibular 3rdrd molar alveolusmolar alveolus

•Provides sensation to anterior 2/3rds of Provides sensation to anterior 2/3rds of tongue, lingual gingiva, floor of mouth tongue, lingual gingiva, floor of mouth mucosa, and gustation (chorda tympani)mucosa, and gustation (chorda tympani)


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

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

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

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

until the mental foramenuntil the mental foramen•Mylohyoid nerve- motor branch prior to Mylohyoid nerve- motor branch prior to

entry into lingulaentry into lingula


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

•Provides innervation to the mandibular Provides innervation to the mandibular alveolus, buccal gingiva from premolar teeth alveolus, buccal gingiva from premolar teeth anteriorly, and the pulpal tissue of all anteriorly, and the pulpal tissue of all mandibular teeth on side blockedmandibular teeth on side blocked

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

canal from mental foramen to midlinecanal from mental foramen to midline– Mental nerve- exits mental foramen and divides Mental nerve- exits mental foramen and divides

into 3 branches to innervate the skin of the chin, into 3 branches to innervate the skin of the chin, lower lip and labial mucosalower lip and labial mucosa

Local anesthetic Local anesthetic instruments:instruments:

• Anesthetic carpulesAnesthetic carpules

• SyringeSyringe

• NeedleNeedle

• Mouth propsMouth props

• RetractorsRetractors

Local anesthetic Local anesthetic instruments:instruments:• Carpules:Carpules:

– 1.7 or 1.8cc1.7 or 1.8cc– Pre-made in blister Pre-made in blister

packs or canisterspacks or canisters– Contains Contains

preservatives for preservatives for epinephrine and epinephrine and local anestheticslocal anesthetics

Local anesthetic Local anesthetic instruments:instruments:• SyringeSyringe

– Aspirating typeAspirating type– Non-aspirating typeNon-aspirating type

Local anesthetic Local anesthetic instruments:instruments:• Needle:Needle:

– Multiple gauges usedMultiple gauges used• 25g25g

• 27g *used at UTMB27g *used at UTMB

• 30g30g

– Length:Length:• Short- 26mmShort- 26mm

• Long- 36mm *used at Long- 36mm *used at UTMBUTMB

– MonobeveledMonobeveled

Local anesthetic Local anesthetic instruments:instruments:• Topical anesthetic:Topical anesthetic:

– Used prior to local Used prior to local anesthetic injection anesthetic injection to decrease to decrease discomfort in non-discomfort in non-sedated patientssedated patients

– Generally Generally benzocaine (20%)benzocaine (20%)

Local anesthetic Local anesthetic instruments:instruments:

Maxillary anesthesia:Maxillary anesthesia:

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


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

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

around surgical sitearound surgical site•Supraperiosteal injectionsSupraperiosteal injections

• Intraseptal injectionsIntraseptal injections

•Periodontal ligament injectionsPeriodontal ligament injections


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

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


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

nerve trunk and is usually distant from nerve trunk and is usually distant from operative siteoperative site•Posterior superior alveolarPosterior superior alveolar -Infraorbital -Infraorbital

•Middle superior alveolarMiddle superior alveolar -Greater -Greater palatinepalatine

•Anterior superior alveolarAnterior superior alveolar -Nasopalatine -Nasopalatine


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

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


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

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

•Angle at 45° superiorly and mediallyAngle at 45° superiorly and medially

•No resistance should be felt (if bony contact angle No resistance should be felt (if bony contact angle is to medial, reposition laterally)is to medial, reposition laterally)

• Insert about 15-20mmInsert about 15-20mm

•Aspirate then inject if negativeAspirate then inject if negative


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

premolars, corresponding alveolus, and premolars, corresponding alveolus, and buccal gingival tissuebuccal gingival tissue

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

anesthetize premolarsanesthetize premolars


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

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

• Insert around 10-15mmInsert around 10-15mm

• Inject around 0.9-1.2ccInject around 0.9-1.2cc


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

canine, lateral incisor, central incisor, canine, lateral incisor, central incisor, alveolus, and buccal gingivaalveolus, and buccal gingiva


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

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

• Insert around 10-15mmInsert around 10-15mm

• Inject around 0.9-1.2ccInject around 0.9-1.2cc


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

22ndnd premolars, canine, lateral incisor, premolars, canine, lateral incisor, central incisor, corresponding alveolar central incisor, corresponding alveolar bone, and buccal gingivabone, and buccal gingiva

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

eyelid, lateral aspect of nasal skin eyelid, lateral aspect of nasal skin tissue, and skin of infraorbital regiontissue, and skin of infraorbital region


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

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

•Retract the upper lip and buccal mucosaRetract the upper lip and buccal mucosa

•Area of insertion is the mucobuccal fold of Area of insertion is the mucobuccal fold of the 1the 1stst premolar/canine area premolar/canine area

•Contact bone in infraorbital regionContact bone in infraorbital region

• Inject 0.9-1.2cc of local anestheticInject 0.9-1.2cc of local anesthetic


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

soft tissue of the teeth posterior to the soft tissue of the teeth posterior to the maxillary canine and corresponding maxillary canine and corresponding alveolus/hard palatealveolus/hard palate


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

•Area of insertion is ~1cm medial from 1Area of insertion is ~1cm medial from 1stst/2/2ndnd maxillary molar on the hard palatemaxillary molar on the hard palate

•Palpate with needle to find greater palatine Palpate with needle to find greater palatine foramenforamen

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

to desensitize region at time of injectionto desensitize region at time of injection• Inject 0.3-0.5cc of local anestheticInject 0.3-0.5cc of local anesthetic


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

hard tissue of the maxillary anterior hard tissue of the maxillary anterior palate from canine to caninepalate from canine to canine


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

•Area of insertion is incisive papilla into Area of insertion is incisive papilla into incisive foramenincisive foramen

•Depth of penetration is less than 10mmDepth of penetration is less than 10mm

• Inject 0.3-0.5cc of local anestheticInject 0.3-0.5cc of local anesthetic

•Can use pressure over area at time of Can use pressure over area at time of injection to decrease paininjection to decrease pain


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

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


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

•High tuberosity approachHigh tuberosity approach

•Greater palatine canal approachGreater palatine canal approach


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

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

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

• Insert needle ~30mmInsert needle ~30mm

• Inject ~1.8cc of local anestheticInject ~1.8cc of local anesthetic


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

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

pterygopalatine fossapterygopalatine fossa•Perform a greater palatine block and wait 3-5 Perform a greater palatine block and wait 3-5

minsmins•Then insert needle in previous area and walk Then insert needle in previous area and walk

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

Mandibular anesthesia:Mandibular anesthesia:

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

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

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


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

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

– Multiple techniques can be used for the Multiple techniques can be used for the IAN nerve blockIAN nerve block• IANIAN•AkinosiAkinosi•Gow-GatesGow-Gates


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

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

•Height of injection- 6-10 mm above the occlusal Height of injection- 6-10 mm above the occlusal table of the mandibular teethtable of the mandibular teeth

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




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

mouth propmouth prop

– Depth of injection: 25mmDepth of injection: 25mm

– Approach area of injection from contralateral premolar Approach area of injection from contralateral premolar regionregion

– Use the non-dominant hand to retract the buccal soft Use the non-dominant hand to retract the buccal soft tissue (thumb in coronoid notch of mandible; index tissue (thumb in coronoid notch of mandible; index finger on posterior border of extraoral mandible)finger on posterior border of extraoral mandible)

Mandibular anesthesia:


• Inferior alveolar nerve block (IAN):Inferior alveolar nerve block (IAN):– Inject ~0.5-1.0cc of local anestheticInject ~0.5-1.0cc of local anesthetic

– Continue to inject ~0.5cc on removal from Continue to inject ~0.5cc on removal from injection site to anesthetize the lingual branchinjection site to anesthetize the lingual branch

– Inject remaining anesthetic into coronoid notch Inject remaining anesthetic into coronoid notch region of the mandible in the mucous region of the mandible in the mucous membrane distal and buccal to most distal membrane distal and buccal to most distal molar to perform a long buccal nerve blockmolar to perform a long buccal nerve block


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

with trismus, fractured mandibles, with trismus, fractured mandibles, mentally handicapped individuals, mentally handicapped individuals, childrenchildren

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


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

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

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

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

buccal nerve buccal nerve


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

terminal branches for the inferior terminal branches for the inferior alveolar nervealveolar nerve

– Provides sensory input for the lower lip Provides sensory input for the lower lip skin, mucous membrane, pulpal/alveolar skin, mucous membrane, pulpal/alveolar tissue for the premolars, canine, and tissue for the premolars, canine, and incisors on side blockedincisors on side blocked


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

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

•Depth of injection ~5-6mmDepth of injection ~5-6mm• Inject 0.5-1.0cc of local anesthesiaInject 0.5-1.0cc of local anesthesia•Message local anesthesia into tissue to Message local anesthesia into tissue to

manipulate into mental foramen to manipulate into mental foramen to anesthetize the incisive branchanesthetize the incisive branch

Local anesthetics:Local anesthetics:

• Types:Types:– Esters- plasma pseudocholinesteraseEsters- plasma pseudocholinesterase– Amides- liver enzymesAmides- liver enzymes

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


• Agent:Agent: Dose: Dose: Onset/Duration:Onset/Duration:• Lidocaine with epi (1 or 2%)Lidocaine with epi (1 or 2%) 7mg/kg7mg/kg Fast/mediumFast/medium• Lidocaine without epiLidocaine without epi 4.5mg/kg4.5mg/kg Fast/shortFast/short• Mepivacaine without epi (3%)Mepivacaine without epi (3%) 5.5mg/kg5.5mg/kg Fast/shortFast/short• Bupivacaine with epi (0.5%)Bupivacaine with epi (0.5%) 1.3mg/kg1.3mg/kg Long/longLong/long• Articaine with epi (4.0%)Articaine with epi (4.0%) 7mg/kg7mg/kg Fast/mediumFast/medium

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


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

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

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

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

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

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

Local anesthesia Local anesthesia complications:complications:

• Needle breakageNeedle breakage

• Pain on injectionPain on injection

• Burning on injectionBurning on injection

• Persistent anesthesia/parathesiaPersistent anesthesia/parathesia

• TrismusTrismus

• HematomaHematoma

• InfectionInfection


• EdemaEdema

• Tissue sloughingTissue sloughing

• Facial nerve paralysisFacial nerve paralysis

• Post-anesthetic intraoral lesionPost-anesthetic intraoral lesion– Herpes simplexHerpes simplex– Recurrent aphthous stomatitisRecurrent aphthous stomatitis

Local anesthesia Local anesthesia complications:complications:• ToxicityToxicity

– Clinical manifestationsClinical manifestations• Fear/anxietyFear/anxiety• RestlessnessRestlessness• Throbbing headachesThrobbing headaches• TremorsTremors• WeaknessWeakness• DizzinessDizziness• PallorPallor• Respiratory difficulty/palpitationsRespiratory difficulty/palpitations• Tachycardia (PVCs, V-tach, V-fib)Tachycardia (PVCs, V-tach, V-fib)


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

anestheticsanesthetics– Most allergies are to preservatives in Most allergies are to preservatives in

pre-made local anesthetic carpulespre-made local anesthetic carpules•MethylparabenMethylparaben

•Sodium bisulfiteSodium bisulfite

•metabisulfitemetabisulfite

References:References:

• Evers, H and Haegerstam, G. Evers, H and Haegerstam, G. Handbook of Dental Local AnesthesiaHandbook of Dental Local Anesthesia. . Schultz Medical Information. London. Schultz Medical Information. London. 1981.1981.

• Malamed, S. Handbook of Local Malamed, S. Handbook of Local Anesthesia. 3Anesthesia. 3rdrd edition. Mosby. St. edition. Mosby. St. Louis. 1990.Louis. 1990.

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

Local Anesthesia Techniques in Oral and Maxillofacial Surgery

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