LOCAL ANESTHESIA TECHNIQUE FOR

CHILDREN AND ADULT

(TEKNIK PEMBERIAN ANESTHESI LOKAL PADA ANAK DAN DEWASA)
Drg. Moh. Gazali Sp.BM(K), MARS

ORAL AND MAXILLOFACIAL DEPARTEMENT

FACULTY OF DENTISTRY HASANUDDIN UNIVERSITY
 ▪ Goals of Physical and Psychological Evaluation
1. to determine the patient’s ability to tolerate physically the
stresses involved in the planned dental treatment

2. to determine the patient’s ability to tolerate psychologi-

cally the stresses involved in the planned dental treatment

3. to determine whether treatment modification is indi- cated

Physical and to enable the patient to better tolerate the stresses

Psychological associated with the dental treatment

4. to determine whether the use of psychosedation is indi-
Evaluation cated
5. to determine which technique of sedation is most appro-
priate for the patient
6. to determine whether contraindications exist to (a) the

planned dental treatment or (b) any of the drugs to be used

 Physical Evaluation

MEDICAL HISTORY PHYSICAL EXAMINATION DIALOGUE HISTORY

QUESTIONNAIRE
 ▪ The use of a written, patient-completed medical
history questionnaire is a moral and legal

Medical History necessity in the practice of both medicine and

dentistry. Such questionnaires pro- vide the
Questionnaire dentist and the hygienist with valuable
information about the physical status and in
some cases the psychologi- cal status of the
prospective patient.
 The six vital signs are:
1. BP
2. heart rate (pulse) and rhythm

Physical 3. respiratory rate

4. temperature
Examination 5. height
6. weight
a. body mass index (BMI)
 ▪ Class 1. A healthy patient (no physiologic, physical,
or psychological abnormalities).
▪ Class 2. A patient with mild systemic disease
without limitation of daily activities.
Physical Status ▪ Class 3. A patient with severe systemic disease that
Classification limits activity but is not incapacitating.
▪ Class 4. A patient with incapacitating systemic
System disease that is a constant threat to life.
▪ Class 5. A moribund patient not expected to
survive 24 hours with or without the operation.
▪ Class 6. A brain-dead patient whose organs are
being removed for donor purposes.
ASA Classification
• Fig. 10.13 American Society of Anesthesiologists (ASA) classification. (Courtesy Dr. Law rence Day.)

ASA 1
ASA 2

ASA 3

ASA 5 ASA 4
In Children

▪ To create a relation of calm confidence between the

child and dental surgeon/ dentist.
▪ Optimilized cooperation during the treatment
▪ Painlessly as possible
▪ In some case proper sedation is needed to break the
mental isolation caused by anxiety and fear of pain.

▪ A suitable premedication
▪ to obtain safe anesthetic effect it is necessary to
have specific knowledge about some anatomical
characteristic.
Basic Injection
Technique
 ◆ Step 1: Use
a Sterilized
Sharp Needle
Fig 1. a fishhook-type
barb may appear on the
tip
 ◆ Step 2: Check the Flow of Local
AnestheticSolution
After the cartridge has been properly loaded into
the syringe, and with the aspirator tip (harpoon)
embedded in the sili- cone rubber stopper
(unless a self-aspirating syringe is being used), a
few drops of local anesthetic should be expelled
from the cartridge.
 ◆ Step 3: Determine Whether to Warm
the AnestheticCartridge or Syringe
If the cartridge is stored at room temperature
(approxi- mately 22°C, 72°F), there is no reason for
a local anesthetic cartridge to be warmed before
injection of the anesthetic into soft tissues
 ◆ Step 4: Position the Patient
it is recommended that during local anesthetic
administration, the patient should be placed in a
supine position (head and heart parallel to the
floor) with the feet elevated slightly
Fig. 2 .Physiologic position of patient for receipt of local
anesthetic injection.
 ◆ Step 5:
Dry the
Tissue
Fig. 3. A 2- × 2-inch gauze
should be used to dry the
tissue in and around the site
of needle penetration and to
remove any gross debris
 To do so requires a steady hand so that tissue penetra-
tion may be accomplished readily, accurately, and without
inadvertent nicking of tissues. A firm hand rest is

◆ Step 7: necessary. The types of hand rest differ according to the

practitioner’s likes, dislikes, and physical abilities.
Establish a Firm Fig.11.4
Hand Rest Two techniques to be avoided are (1) using no syringe
stabiliza- tion of any kind and (2) placing the arm holding
the syringe directly onto the patient’s arm or shoulder (
Fig.11.5
Fig. 4 .Hand positions for injections. (A) Palm down: poor control over the syringe; not
recom- mended. (B) Palm up: better control over the syringe because it is supported by the
wrist; recommended. (C) Palm up and finger support: greatest stabilization; highly
recommended.
Fig..5 (A) Incorrect position: no hand or finger rest for stabilization of the syringe.
(B) Incorrect position: administrator resting elbow on patient’s arm
Fig.6 (A) Use of the patient’s chest for stabilization of the syringe during right inferior alveolar nerve block (circle). Never use
the patient’s arm to stabilize a syringe. (B) Use of the chin (1) as a finger rest, with the syringe barrel stabilized by the
patient’s lip (2). (C) When necessary, stabilization may be increased by the administrator drawing his or her arm in against
his or her chest (3).
 ◆ Step 8: Make the Tissue Taut

The tissues at the site of needle

penetration should be stretched before
insertion of the needle.

Fig. 7 (A) Tissue at needle penetration site is pulled taut, aiding both visibility and
atraumatic needle insertion. (B) Taut tissue provides excellent visibility of the
penetration site for a posterior superior alveolar nerve block.
 ◆ Step 9 : Keep the Syringe Out of
the Patient’s Line of Sight

▪ With the tissue prepared and the patient

positioned, the assistant should pass the syringe to
the administrator out of the patient’s line of sight
either behind the patient’s head (Fig..8.A ) or
across and in front of the patient .Fig. 8.B
 With the needle bevel properly oriented (see the
specific injection technique for bevel orientation;
◆ Step 10: however, as a gen- eral rule, the bevel of the

Insert the needle should be oriented toward bone), insert

the needle gentltly into the tissue at the injec- tion
Needle Into the site (where the topical anesthetic was placed) to
the depth of its bevel. With a firm hand rest and
Mucosa adequate tissue preparation, this potentially
traumatic procedure is accom- plished without the
patient ever being aware of it.
◆ Step 11: Inject Several Drops of
Local AnestheticSolution
(Optional)
◆ Step 12: Slowly Advance the
Needle Toward the Target
◆ Step 13: Deposit Several Drops
of Local Anesthetic Before
Touching the Periosteum

◆ Step 14: Aspirate

 Fig.9 (A) Negative aspiration (No blood noticed). With the needle in position at the injection site, the administrator pulls
the thumb ring of the harpoon-aspirating syringe 1 or 2 mm. (B) Positive aspiration. A slight reddish discoloration at the
diaphragm end of the cartridge (arrow) on aspiration usually indicates venous penetration. (C) Positive aspiration.
Bright red blood rapidly filling the cartridge usually indicates arterial penetration.

Aspiration mustalwaysbeperformed beforea volume of local anestheticisdepositedat any site. Aspiration dramatically minimizes
thepossibilityofintravascularinjection.Thegoalofaspirationistodeterminewheretheneedletipissituated(withinabloodvesselor
without)
Fig. 10 (A) Needle tip within blood vessel but bevel abuts the wall of the vein. (B) On
aspiration the vein wall is sucked into the needle tip, producing a false negative aspiration
test result. (C) Rotating the syringe 45 degrees and reaspirating will provide a true “positive”
aspiration in this scenario.
 ◆ Step 15:
Slowly Deposit Slow injection is defined ideally as the deposition

the Local of 1 mL of local anesthetic solution in not less than

60 seconds. Therefore a full 1.8-mL cartridge
Anesthetic requires approximately 2 minutes to be deposited.

Solution
 ◆ Step 16: Slowly
Withdraw the
Syringe Fig. 11. “Scoop” technique for recapping needle after
use.

After completion of the injection, the syringe should be

slowly withdrawn from the soft tissues and the needle
made safe by capping it immediately with its plastic
sheath via the scoop technique.
 After completion of the injection, the doctor,
hygien- ist, or assistant should remain with the
patient while the anesthetic begins to take effect

◆ Step 17: (and its blood level increases). Most true adverse
drug reactions, especially those related to
Observe the intraorally administered local anesthet- ics,
develop either during the injection or within 5 to
Patient 10 minutes of its completion

Patients should not be left unattended after

administration of a local anesthetic.
Techniques of Maxillary
Anesthesia
Anatomical nerve maxilla and
mandible region
Fig. 12.. Distributionof the Maxillary Division
(V ). 1, Posterior 2
superior alveolar branches; 2, infraorbital
nerve; 3, maxillary nerve; 4, foramen
rotundum; 5, greaterpalatine nerve; 6,
nasopalatine nerve. (From Haglund J, Evers
H. Local Anaesthesia in Dentistry. 2nd ed.
Sodertalje:Astra Lakemedel.)
 Fig. 13. AnteriorSuperiorAlveolar (Asa)
Nerve (Bone Overthe Nerves Removed).1,
Branches of the ASAnerve; 2, superior
dental plexus; 3, dental branches; 4,
interdental and interradicular branches.
(From Haglund J,EversH. Local Anaesthesia
in Dentistry. 2nd ed. Sodertalje:Astra
Lakemedel.)
 Fig.14 Thepathway of theposterior
trunk of the mandibularnerveof the
trigeminal nerveis high-lighted. (From
FehrenbachMJ, Herring SW. Anatomy
of the Head and Neck. 3rd ed. St Louis:
Saunders; 2007.)
Fig. 15. The mandibular foramen is located on the plane indicated by the stripted peg.
Note the changing angle between this plane and the occlusal plane at different ages
 ▪ 1. supraperiosteal (infiltration), recommended for
limited treatment protocols;

▪ 2. periodontal ligament (PDL; intraligamentary) injec-

tion, recommended as an adjunct to other techniques or
for limited treatment protocols;

▪ 3. intraseptal injection, recommended primarily for

peri- odontal surgical techniques;
Maxillary Injection
▪ 4. intracrestal injection, recommended for single teeth
Techniques (primarily mandibular molars) when other techniques
have failed;

▪ 5. intraosseous injection, recommended for single teeth

(primarily mandibular molars) when other techniques
have failed;
6.posterior superior alveolar (PSA) nerve block, recommended for management of several molar teeth
in one quadrant;
7.middle superior alveolar (MSA) nerve block, recommended for management of premolars in one
quadrant;
8.anterior superior alveolar (ASA) nerve block, recommended for management of anterior teeth in one
quadrant;
9.maxillary (V2, second division) nerve block, recommended for extensive buccal, palatal, and pulpal
management in one quadrant;
10.greater (anterior) palatine nerve block, recommended for palatal soft and osseous tissue treatment
distal to the canine in one quadrant;
11.nasopalatine nerve block, recommended for palatal soft and osseous tissue management from
canine to canine bilaterally anterior middle superior alveolar (AMSA) nerve
12.block, recommended for extensive management of anterior teeth and palatal and buccal soft and
hard tissues;
13.palatal approach ASA (P-ASA) nerve block, recommended for treatment of maxillary anterior teeth
and their palatal and facial soft and hard tissues.
 Fig. 13.2 Field block. Local anesthetic is deposited near the larger
Fig. 13.1 Local infiltration. The area of treatment is flooded with
terminal nerve endings (arrow). An incision is made away from
local anesthetic. An incision is made into the same area (arrow).
the site of injection.

Fig. 13.3 Nerve block. Local anesthetic is deposited close to the

main nerve trunk, located at a distance from the site of incision
(arrow).
 Other Common Names
Local infiltration, paraperiosteal injection.
Nerves Anesthetized
Large terminal branches of the dental plexus.
Areas Anesthetized
The entire region innervated by the large terminal branches of
this plexus: pulp and root area of the tooth, buccal periosteum,
Supraperiosteal connective tissue, and mucous membrane
Injection
 Other Common Names
Tuberosity block, zygomatic block.
Nerves Anesthetized
PSA nerve and branches.
Areas Anesthetized
1. Pulps of the maxillary third, second, and first molars (entire
Posterior 1st molar = 72% success rate; mesiobuccal root of the maxillary
Superior Alveolar first molar not anesthetized = 28% of PSA nerve blocks)
2. Buccal periodontium and bone overlying these teeth
Nerve Block
 Nerves Anesthetized
MSA nerve and terminal branches.
Areas Anesthetized
1. Pulps of the maxillary first and second premolars, mesio-
buccal root of the first molar
2. Buccal periodontal tissues and bone over these same teeth (
Middle Superior
Alveolar Nerve
Block

Fig. 13.14 Position of needle between

maxillary premolars for a middle superior
alveolar nerve block.
Fig.13.16. Needle penetration for a middle superior
alveolar nerve block.
 Other Common Name
Infraorbital nerve block (technically, the infraorbital nerve block provides
anesthesia of the soft tissues of the anterior portion of the face, not to the
teeth or intraoral soft and hard tissues; therefore it is inaccurate to call the
ASA nerve block the infraorbital nerve block when anesthesia of
teeth is the desired goal).
Anterior Superior Nerves Anesthetized
Alveolar Nerve Block Anterior superior alveolar nerve
MSA nerve
(Infraorbital Nerve Block) Infraorbital nerve
a. Inferior palpebral b. Lateralnasal
c. Superior labial
Areas Anesthetized
1. Pulps of the maxillary central incisor through the canine on the
injected side
2. In about 72% of patients, pulps of the maxillary premo- lars and
mesiobuccal root of the first molar
3. Buccal (labial) periodontium and bone of these same teeth
4. Lowereyelid,lateralaspectofthenose,upperlip
 Other Common Name
Anterior palatine nerve block.
Nerve Anesthetized
Greater palatine nerve.
Areas Anesthetized
The posterior portion of the hard palate and its
overlying soft tissues, anteriorly as far as the first
premolar and medi- ally to the midline
Greater Palatine
Nerve Block
 Nasopalatine Nerve Block

▪ Other Common Names

▪ Incisive nerve block (thus confusion with
the “other” incisive nerve block in the
mandible that is described in
sphenopalatine nerve block.
▪ Nerves Anesthetized
▪ Nasopalatine nerves bilaterally.
▪ Areas Anesthetized
▪ Anterior portion of the hard palate (soft
and hard tissues) bilaterally from the mesial
aspect of the right first premolar to the
mesial aspect of the left first premolar
 Local Infiltration of the Palate

Other Common Names

None.
Nerves Anesthetized
Terminal branches of the nasopalatine and greater palatine
nerves.
Areas Anesthetized
Soft tissues in the immediate vicinity of the injection (Fig.
Local Infiltration 13.43).
of the Palate

Fig. 13.43 Area anesthetized by a palatal

infiltration.

Anterior Middle Superior
Alveolar Nerve Block
Other Common Name
Palatal approach AMSA nerve block. Nerves Anesthetized
1. ASA nerve
2. MSA nerve, when present
3. Subneural dental nerve plexus of the ASA and MSA nerves
Areas Anesthetized
1. Pulpal anesthesia of the maxillary incisors, canines, and
premolars (Fig. 13.48)
2. Buccal attached gingiva of these same teeth
3. Attached palatal tissues from midline to free gingival
margin on associated teeth

Fig. 13.50 Anterior middle superior alveolar nerve block.

Note syringe angulation from the opposite side of the
mouth.

Palatal Approach Anterior
Superior Alveolar Nerve Block
Other Common Name
Palatal approach maxillary anterior field block. Nerves
Anesthetized
1. Nasopalatine nerve
2. Anterior branches of the ASA nerve
Areas Anesthetized
1. Pulps of the maxillary central incisors, the lateral inci- sors,
and (to a lesser degree) the canines (Fig. 13.51)
2. Facial periodontal tissue associated with these same teeth 3.
Palatal periodontal tissue associated with these same teeth

Fig. 13.51 Area of needle insertion for a palatal

approach anterior superior alveolar nerve block.

Maxillary Nerve Block
Fig. 13.54 Maxillary nerve block, high-tuberosity approach.
Nerve Anesthetized
Maxillary division of the trigeminal nerve.
Areas Anesthetized
Pulpal anesthesia of the maxillary teeth on the side of
the block (Fig. 13.54)
Buccal periodontium and bone overlying these teeth
Soft tissues and bone of the hard palate and part of the
soft palate, medial to midline
Skin of the lower eyelid, side of the nose, cheek, and
upper lip
Techniques of
Mandibular
Anesthesia
 Other Common Name
Mandibular block.

Nerves Anesthetized
1.Inferior alveolar nerve, a branch of the posterior
division of the mandibular division of the trigeminal
nerve (V3)
2.Incisive nerve

Inferior Alveolar 3.Mental nerve

4.Lingual nerve (commonly)
Nerve Block Areas Anesthetized
1.Mandibular teeth to the midline (Fig. 14.1)
2.Body of the mandible, inferior portion of the ramus
3.Buccal mucoperiosteum, mucous membrane anterior to
the mental foramen (mental nerve)
4.Anterior two-thirds of the tongue and floor of the oral
cavity (lingual nerve)
5.Lingual soft tissues and periosteum (lingual nerve)
Three parameters must be considered during administra- tion of an IANB:
(1) the height of the injection,
(2) the anteroposterior placement of the needle (which helps to locate a
precise needle entry point), and
(3) the depth of penetration (which determines the location of the inferior
alveolar nerve).
Technique

1.A long dental needle is recommended for the adult patient or any pediatric patient where the soft tissue depth at the
injection site is approximately 20 mm. A 25-gauge long needle is preferred; a 27-gauge long is acceptable.
2.Area of insertion: mucous membrane on the medial (lingual) side of the mandibular ramus, at the intersection of two
lines—one horizontal, representing the height of needle insertion, the other vertical, representing the anteroposterior
plane of injection.
3.Target area: inferior alveolar nerve as it passes downward toward the mandibular foramen but before it enters into
the foramen.
4.Landmarks (Figs. 14.2 and 14.3):
a. Coronoid notch (greatest concavity on the anterior
5.border of the ramus).
b. Pterygomandibular raphe (vertical portion).
c. Occlusal plane of the mandibular posterior teeth.
6.Orientation of the needle bevel: less critical than with other nerve blocks, because the needle approaches the IAN at
roughly a right angle.
1.Procedure:
a. Assume the correct position:
i. For a right IANB, a right-handed administra- tor should sit at the 8 o’clock position facing the patient (Fig. 14.4A).
ii. For a left IANB, a right-handed administrator should sit at the 10 o’clock position facing in the same direction as the
patient (see Fig. 14.4B).
b.Position the patient supine (recommended) or semisupine (if necessary). The mouth should be opened wide to
allow greater visibility of, and access to, the injection site.
c. Prepare tissue at the injection site:
1. Dry it with sterile gauze.
2. Apply topical antiseptic (optional).
3. Apply topical anesthetic for 1 to 2 minutes.
4. Place the barrel of the syringe in the corner of the mouth on the contralateral side
5.Locate the needle penetration (injection) site.
1. Height of injection: Place the index finger or the thumb of your left hand in the coronoid notch.
An imaginary line extends posteriorly from the fingertip in the coronoid notch to the deepest part of
thepterygomandibular raphe (as it turns vertically upward toward the maxilla), determining the height of injection.
This imaginary line should be parallel to the occlusal plane of the mandibular molar teeth. In most patients, this line
lies 6 to 10 mm above the occlusal plane.
2. The finger on the coronoid notch is used to pull the tissues laterally, stretching them over the injection site, making
them taut, and enabling needle insertion to be less traumatic, while providing better visibility. If possible, use a mouth
mirror to minimize the risk of accidental needlestick injury to the administrator.
3. The needle insertion point lies three-fourths of the anteroposterior distance from the coronoid notch back to the
deepest part of the pterygomandibular raphe: The line should begin at the midpoint of the notch and terminate at the
deepest (most posterior) portion of the pterygomandibular raphe as the raphe bends vertically upward toward the
palate.
4. The posterior border of the mandibular ramus can be approximated intraorally by use of the pterygoman- dibular
raphe as it bends vertically upward toward the maxilla (see Fig. 14.3).a
5. An alternative method of approximating the length of the ramus is to place your thumb on the coronoid notch and
your index finger extraorally on the pos- terior border of the ramus and estimate the distance between these points.
However, many practitioners (including this author) have difficulty envisioning the width of the ramus in this manner.
2. Anteroposterior site of injection: Needle penetration occurs at the intersection of two points. (Fig. 14.7):
a. Point 1 falls along the horizontal line from the coronoid notch to the deepest part of the pterygoman- dibular raphe as it
ascends vertically toward the palate as just described.
b. Point 2 is on a vertical line through point 1 about three-fourths of the distance from the anterior border of the ramus. This
determines the anteroposterior site of the injection.
3. Penetration depth: In the third parameter of the IANB, bone should be contacted. Slowly advance the needle until you can feel
it contact bone. For most patients, it is not necessary to inject any Local anesthetic solution as soft tissue is penetrated.
2.For anxious or sensitive patients, it may be advisable to deposit small volumes as the needle is advanced. Buffered local
anesthetic solutions are recommended as they decrease the patient’s sensitivity during needle advancement.
3.The average depth of penetration to bony contact, in the adult, is 20 to 25 mm, approximately two-thirds to three-fourths the
length of a long dental needle (Fig. 14.8).
4.The needle tip should now be located slightly superior to the mandibular foramen (where the IAN enters [disappears into]
bone). The foramen can neither be seen nor be palpated clinically. If bone is contacted too soon (less than half the length of a
long dental needle in an adult), the needle tip is usually located too far anteriorly (laterally) on the ramus. To correct this (Fig.
14.9):
i. Withdraw the needle slightly but do not remove it from the tissue.
ii. Bring the syringe barrel more toward the front of the mouth, over the canine or lateral incisor on the contralateral side.
iii. Redirect the needle until a more appropriate depth of insertion is obtained. The needle tip is now located more posterio rly in
the mandibular sulcus.
If bone is not contacted, the needle tip is usually located too far posterior (medial) (Fig. 14.10). To correct this: i. Withdraw
it slightly in tissue (leaving approximately one-fourth of its length in tissue) and reposition the syringe barrel more
posteriorly (over the mandibular molars).
Continue needle insertion until contact with bone is made at an appropriate depth (20 to 25 mm).
7. Insert the needle. When bone is contacted, withdraw approximately the needle by 1 mm to prevent sub- periosteal
injection.
8. Aspirate in two planes. If negative, slowly deposit 1.5 mL of anesthetic over a minimum of 60 seconds. (Because of the
high incidence of positive aspiration and the natural tendency to deposit solution too rap- idly, the sequence of slow
injection, reaspiration, slow injection, and reaspiration is strongly recommended.)
9. Slowly withdraw the syringe, and when approximately half its length remains within tissues, reaspirate. If nega- tive,
deposit a portion of the remaining solution (0.2 mL) to anesthetize the lingual nerve.
in most patients, this deliberate injection for lingual nerve anesthesia is not necessary because local anes- thetic from the
IANB anesthetizes the lingual nerve.
10. Withdraw the syringe slowly and make the needle safe.
11. After approximately 20 seconds, return the patient to comfortably upright or semiupright position.
12. Wait 3 to 5 minutes before testing for pulpal anesthesia.
13. Following completion of the IANB, the author strongly recommends the infiltration of approxi- mately 0.6 to 0.9 mL of
articaine hydrochloride (preferably buffered) in the buccal fold at the apex of each mandibular tooth to be treated. This
has been demonstrated to increase the success rate of IANBs (as well as other “mandibular” nerve blocks). 29 (See Chapter
20 for a more detailed dis- cussion of buffered local anesthetic solutions.)
 Pterygomandibular raphe

IANB
IANB
 Other Common Names
Long buccal nerve block, buccinator nerve block. Nerve
Anesthetized
Buccal nerve (a branch of the anterior division of V3). Area
Anesthetized
Soft tissues and periosteum buccal to the mandibular molar
teeth (Fig. 14.13).

Buccal Nerve
Block
 ▪ Other Common Names

Mental Nerve Block ▪ None.

Nerve Anesthetized

▪ Mental nerve, a terminal branch of the inferior alveolar nerve.

▪ Areas Anesthetized
▪ Buccal mucous membranes anterior to the mental foramen (around the second
premolar) to the midline and skin of the lower lip (Fig. 14.28) and chin.
Thank you
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