Basic techniques of local anesthesia (Brief)

There are several methods of achieving pain control with local anesthetic Agents.
A variety of techniques used in administration and deposition of these local
anesthetic agents which include :-
1. Topical anesthetic technique (surface or topical anesthesia)
2. Infiltration technique
3. Block technique (regional)

Q\ Selection of the technique depends on:

 the area of injection

 the type of the surgery
 the volume of anesthetic solution

1- Topical or surface anesthesia :- By this method small terminal nerves

in the surface area of the intact mucosa or the skin up to the depth of
about 2 mm are anesthetized by application of a local anesthetic agent
directly to the area. This method commonly used to Obtain anesthesia of
mucosa prior to injection.

- We have several forms (preparations) as :-

A-Sprays :- The active ingredient is 10% or 15% lignocaine hydrochloride in
water base which have rapidity of onset. The onset time of anesthesia is
approximately 1 minute and the duration of anesthesia is approximately 10
minutes.

B-Ointments :- containing 5% lignocaine hydrochloride, can be used for a

similar purpose but it takes 3-4 minutes to produce surface anesthesia.

C- An emulsion :- containing 2% lignocaine hydrochloride is also available. This

is of value when full-mouth impressions have to be taken in patients who are
prone to retching .
D- Ethyl chloride spray
2- Infiltration anesthesia :- In this method, the anesthetic solution deposited
near the terminal fibers of any nerve

The maxilla has thin labial / buccal cortical plate, shows area of porosity make the
maxilla more favorable for infiltration anesthesia technique. The mandibular bone
is generally dense and has thicker cortical plates than the maxilla, particularly in
the posterior region, so only the anterior part of the mandible presents sufficient
porosity, which is favorable for the infiltration.

Types of infiltration anesthesia: There are several types of infiltration

anesthesia depending upon the site of deposition of the local anesthetic solution.
On the basis of deposition site this technique include :-

A- Sub-mucous injection : the solution deposited just beneath the mucous

membrane it is often employed to anesthetize the long buccal nerve prior to the
extraction of mandibular molars .

B- Supra-periosteal injection
In these areas when the anesthetic solution is deposited outside the periosteum,
anesthesia of the dental pulp can be obtained by injecting alongside the
approximate of the tooth apex.

C- Sub-periosteal injection : the solution is deposited between the

periosteum .

D- Supplementary injections : These are the other methods of

producing anesthesia. These are satisfactory when executed properly.
I- Intraligamentary (Periodontal) Injection :-
 The local anesthetic solution is deposited into the periodontal
ligament or membrane
 anesthetic solution is carried from the alveolar bone and through the apical
foramen into the pulp chamber.
 The local anesthetic solution is injected along the periodontal membrane of
the maxillary and mandibular teeth
 This technique can anesthetize only single individual tooth. The single
rooted tooth should be injected on the mesial and the distal sides; or
 buccal and lingual sides.
II- Intrapulpal Anesthesia :- This technique is indicated for obtaining
anesthesia for procedures which require direct instrumentation of the pulpal
tissue.
lll- Intraosseous Injection Technique :- In this method, the local anesthetic
solution is deposited directly into the cancellous bone adjacent to the tooth to be
anesthetized .

Local infiltration of the palate :- It is advisable to inform the patient prior to

injection about the pain during the injection. This helps in preparing the patient
psychologically. The palatal injections are one of the most painful injections.
between gingival margin and the Median palatine line
Technique :
• Needle: The recommended gauge is 25 , 27 or 30 and the recommended length
is 25 mm
• Bevel of the needle: the bevel should be facing the bone
• Point of insertion : it is in the middle of the area to be operated
• Depth of the penetration : it is beneath the mucous membrane into the
connective tissue

Q\ Care should be taken to avoid injury to the tissue in the following ways ?
1. Avoid injecting the solution too rapidly .
2. Avoid injecting too large volume of the local anesthetic solution .
3. Avoid injecting too superficially .

- Signs and symptoms:

1. Numbness in the area of deposition of the local anesthetic solution.
2. Lack of demonstration of pain with instrumentation.
3. Absence of pain during the procedure

3- Regional (block) anesthesia

In this technique, the anesthetic solution deposited near the main nerve trunk,
by placing the anesthetic solution in the pterygomandibular space, near the
mandibular foramen it is of particular value in dentistry for producing anesthesia
in the mandible. The use of infiltration technique in the mandible is unreliable
due to the density of the outer cortical plate of bone.
1. Nerve blocks for maxillary nerve and its branches:
a. Intraoral nerve blocks:
(i) Infraorbital nerve block
(ii) Posterior superior alveolar nerve block
(iii) Greater palatine nerve block,
(iv) Nasopalatine nerve block
(v) Maxillary nerve block.
b. Extraoral nerve blocks:
(i) Infraorbital Nerve Block
(ii) Maxillary Nerve Block.
2. Nerve blocks for mandibular nerve and its branches:
a. Intraoral nerve blocks:
(i) Pterygomandibular block, Direct and indirect Techniques
(ii) Lingual nerve block
(iii) Long buccal nerve block
(iv) Mental nerve block
(v) Gow-Gates nerve block
(vi) Vazirani-Akinosi nerve Block.
b. Extraoral nerve blocks: Mandibular Nerve Block.
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local anesthesia in the upper jaw (maxilla)
1- Anesthesia for upper molar teeth The pulp of the upper third molar ,
second molar and the first molar with the exception of the mesiobuccal
root of the first molar are innervated by the posterior superior alveolar
nerve.

 One of the disadvantages of this technique is the possibility of damaging

the pterygoid venous plexus

2- Anesthesia of the upper premolar teeth

The mesio-buccal root of the upper 1st molar, both premolars, innervated via the
middle superior alveolar nerve.
3- Anesthesia of the upper anterior teeth The upper central, lateral
incisor, and canine teeth
innervated via anterior superior dental nerve. It may also be employed for
anesthetizing an anterior tooth where the use of infiltration technique is precluded
by the presence of infection at the site of injection.

4- The infra-orbital block injection:

This technique is rarely used since the infiltration techniques are so effective in
the maxilla, however, It may also be employed for anesthetizing an anterior tooth
where the use of infiltration technique is precluded by the presence of infection
at the site of injection.

- block technique could be achieved either by an intra-oral or extra-oral

approach.

5- Anesthesia of the upper deciduous teeth

In children, multiple vascular canals perforate the thin labio-buccal
alveolar plate. For this reason, infiltration techniques are highly
effective

Local anesthesia in the lower jaw (Mandible)

Due to the density of the buccal bone plate, infiltration techniques are of limited
value in the mandible and block anesthesia is most frequently employed. This is
achieved by the deposition of solution around the inferior dental nerve in the
pterygomandibular space.

The inferior dental nerve block (IDB):-

this technique will anesthetize the inferior alveolar nerve and its terminal
branches (mental and incisive nerve).

The dentist should stand in front of his patient for the right IDB and behind the
chair for the left IDB ( this is for right handed dentist ).
 This technique introduces a local anesthetic solution to the inferior dental
nerve as it enters the mandibular foramen on the medial aspect of the
ramus”
Nerve block for the mandibular nerve
The entire mandibular branch of trigeminal nerve is anesthetized, which includes
the following:
i (i) Inferior alveolar nerve along with its terminal branches; mental and
incisive nerves
ii (ii) lingual
iii (iii) mylohyoid
iv (iv) auriculotemporal
v (v) long buccal nerves.

The mandibular nerve could be blocked by :

1- Intra-oral approach as in Gaws-Gates mandibular nerve block, and in Akinosi
(closed mouth) mandibular nerve block
2- Extra-oral mandibular nerve block

long buccal nerve block (LBB):

the long buccal nerve provides sensory innervation to the buccal soft tissues
adjacent to the mandibular molar only (buccal gingiva).
Infiltration technique is used.

The mental nerve block

This block will anesthetize the pulp and periodontal membrane of the lower
incisors, canine, first premolar and sometimes the second premolar. In dentate
patient, the mental foramen lies below and between apices of the lower premolar
teeth, In edentulous patients, the foramen may lie near the crest of the ridge
because of bone resorption.
Anesthesia of the lower anterior teeth:
supplied by the terminal branch of the inferior dental nerve (incisive nerve).
labial alveolar palate in this region is thinner and more porous than elsewhere;
because of that the infiltration technique could be used in this area.
Anesthesia of the lower deciduous teeth:
In children, multiple vascular canals perforate the labio-buccal alveolar plate. For
this reason, infiltration techniques are highly effective.

Testing for anesthesia

dental probe may be pushed into the gingival crevice on both the labio-buccal and the lingual surface of
the tooth. the presence of sharpness is an indication of a further injection.