This document provides information on various local anesthesia techniques used in dentistry. It begins with an introduction to regional anesthesia, including field blocks, nerve blocks, and local infiltration. It then describes different local anesthesia injection techniques such as supraperiosteal, intraligamentary, intraosseous, and intraseptal injections. The document proceeds to explain specific maxillary and mandibular injection techniques including posterior superior alveolar nerve block, anterior superior alveolar nerve block, greater palatine nerve block, and others. It concludes with a brief section on recent advancements in local anesthesia.

1. Techniques of Local
Anaesthesia
Anjali Savita
MDS I Year
Dept of Conservative
and Endodontics

2. Contents
Introduction
Regional anesthesia
 Field block
 Nerve block
 Local infiltration
Local Anesthesia Injection
Technique
 Supraperiosteal injections
 Intraligamentary injections
 Intraosseous injections
 Intraseptal injections
 Subperiosteal injections
Maxillary injection techniques
 PSAN
 ASAN
 MSAN
 Nasopalatine nerve block
 Greater Palatine nerve block
 Maxillary nerve block
 Mandibular Injection Techniques
 IANB
 Mental nerve block
 Long buccal
 Gow–Gates nerve block
 Vazirani–Akinosi nerve block

3. Regional anesthesia to soft tissue.
Buccal nerve block
Mental nerve block
Recent Advancements
Conclusions
Reference

4. Introduction
Pain control in dentistry presents one of the greatest
challenges. (Pain leads to increased stress, release of
endogenous catecholamines and unexpected
cardiovascular responses).
Before anesthetization
Common Questions To Ask The Patient
1. Allergic to any medications?
2. Have you ever had a reaction to local anesthesia?
3. If yes, describe what happened ?
4. Was treatment given? If so, what?

5. Preparation Of The Patient
Careful Preoperative
Assessment
History
A clear explanation of what to
expect

6. PREOPERATIVE ASSESSMENT
Data should be documented which includes:
Baseline vital signs
• Blood pressure
• Laboratory values
• Results of ECG monitoring
• Any other tests.
Weight, height, and age
• Dosage of some drugs is calculated on the basis of body
weight in kilograms (mg/kg).
• Some drugs are contraindicated for age extremes (i.e.,
pediatric or geriatric patients).

7. Current medical problem(s) past history of
medical events, including a history of substance
abuse.
Current medications or drug therapy, such as
insulin for diabetes or hypertensive drugs.
Allergy, or hypersensitivity reactions to previous
anesthetics or other drugs.
Mental status, including emotional state and level
of consciousness.
Communication ability A patient with hearing
impairment or language barrier may be unable to
understand verbal instructions during the
procedure or to respond appropriately.

8. STRESS REDUCTION PROTOCOL
Morning appointments are usually best.
Keep appointments as short as possible.
Freely discuss any questions, concerns, or fears that
the patient has.
Establish a honest, supportive relationship with the
patient.
Maintain a calm, quiet, professional environment.
Provide clear explanations of what the patient should
expect and feel.

9. Premedicate with benzodiazepines if
needed.
Ensure good pain control through judicious
selection of local anesthetic agents
appropriate for treatment.
Maintenance of patient comfort throughout
the procedure.
Use nitrous oxide as needed (avoid
hypoxia).
Use gradual position changes to avoid
postural hypotension.
End the appointment if the patient appears
overstressed.

10. LOCALANESTHETIC USE IN MEDICALLY
COMPROMISED PATIENTS
Disease Precautions
Cardiovascular disease Use stress reduction protocol
Hypertension Minimize vasoconstrictor use
Pulmonary disease
Asthma Stress reduction protocol; minimize vasoconstrictor
use
COPD No special precaution
Renal disease(severe) Reduced dosage; extend time between injections
Pancreatic disease
Diabetes Stress reduction protocol
Blood dyscrasias
Sickle cell anemia Stress reduction protocol; minimize vasoconstrictor
use

11. NEEDLE GAUGE
Gauge
Refers to the diameter of the lumen of the needle;
the smaller the number, the greater the diameter of
the lumen.
There is increased resistance to aspiration of
blood through a thinner needle (eg,30-gauge)
compared with a larger-diameter needle (eg,27- or
25-gauge).
Needle deflection along the axis of the bevel and
breakage must also be examined.
The smaller the diameter of the needle, the more it
deflects.

12. Thirty-gauge needles deflect significantly, whereas 25-gauge
needles essentially do not deflect at all. Likewise,25-gauge needles
very rarely, if ever, break during an intraoral injection, and 99% of
the needles that do break are 30-gauge needle

13. REGIONALANAESTHESIA
Regional anesthesia or “the nerve block” is
a form of anesthesia in which only a part of
the body is anesthetized (“made numb”).
Field block
In a field block, local anesthetic is infiltrated
around the border of the surgical field,
leaving the operative area undisturbed.
Deposited in proximity to the larger nerve
branches.
Field block also may be considered when
operating on the ear or lips. Eg. Gow-gates
technique is a kind of field block.

15. Nerve block
In a nerve block, anesthetic solution is injected
within close proximity to a main nerve trunk.
Nerve blocks are used for pain treatment and
management.
Often a group of nerves, called a plexus or
ganglion, that causes pain to a specific organ or
body region can be blocked with the injection of
medication into a specific area of the body. The
injection of this nerve-numbing substance is called
a nerve block. Eg. IANB
Dose- 1.8- 2.0 mL

17. Local infiltration
Local infiltration is used when anesthesia is
required in small areas (e.g., for repair of
minor lacerations, skin biopsies).
The anesthetic solution is infiltrated to the
deep dermis, where the sensory plexus
supplying the skin begins to branch.
The amount of solution used depends on the
area that needs to be infiltrated; however,
extensive local infiltration is not
recommended.
Dose- 0.6- 1.0 mL

19. Local Anaesthesia Technique
Supra Periosteal Injection
Pulpal and Soft tissue anesthesia in maxillary
anterior teeth.
A short 25 or 27 gauge needle is recommended
for this technique.
Sometimes this injection technique is referred
to as infiltration, but the solution is deposited
near terminal branches of nerves so it is
actually a type of field block.
It is inserted at the height of the mucobuccal
fold near the apex of the tooth to be treated.
The bevel of the needle should be toward the

20. Supra Periosteal Injection

21. Intraligamentary injection/ PDL
injection
Dose- 0.2mL
Depositing the LA solution within PDL
through gingival sulcus.
Provides 30-35 min of anesthesia.
Indicated in patient with bleeding
disorder& young handicapped patients .

22. Intraligamentary Injection

23. Intraosseous Injection
Aim of intra-osseous anesthesia is to inject
local anesthetic solution into cancellous bone
adjacent to the apex of the tooth by piercing
buccal gingiva and bone in relation to the
tooth to be anesthetized.
It can be used as a supplemental technique
with mandibular nerve blocks to enhance
deep pulpal anesthesia or as a primary
technique so that patients do not experience
numb lips or tongues postoperatively.

24. Intraosseous Injection

25. Intra Septal injections
Used for hemostasis, soft tissue
anesthesia, and osseous anesthesia.
Use a 27 gauge short needle and
insert it into the papilla of the area to
be anesthetized at an angle of 90º to
the tissue.
Slowly deposit 0.2 ml of solution.

26. Intraseptal Injection

27. Intra pulpal injection
A 27-gauge short needle is inserted into the
pulp chamber and wedged firmly into the root
canal.
A small volume (0.2-0.3mL) of local anesthetic
is injected.
While this technique may prove uncomfortable
for the patient, it invariably works to provide
effective pain control.
In most cases, the duration is adequate to
permit extirpation of the pulpal tissues.

28. Intrapulpal
Injection

29. MAXILLARY INJECTION TECHNIQUE

30. Posterior Superior Alveolar Nerve Block
Also called as “Tuberosity injection”.
Highly successful technique > 95%.
Potential for hematoma formation.
Area anaesthetized
Maxillary molars except for the mesio buccal
root of maxillary first molar.
Buccal mucoperiosteum of molar area.

31. Anatomical Landmark
Mucobuccal fold
Maxillary tuberosity
Infratemporal surface of maxilla
Anterior border and coronoid process of mandible
Zygomatic process of maxilla.
Position of patient
The patient is placed with maxillary occlusal plane 45º
with the floor.

32. Position of operator
In left side PSA, operator sits in a 9’o clock
position.
In right side PSA, operator sits in a 7’o clock
position.
Armamentarium
Needles
27 gauge short needle
Syringe
Aspirating syringe

33. Technique
 Retract the cheek and prepare site of injection.
 The needle is introduced into the height of the
mucobuccal fold above the 2nd molar.
 Advance the needle slowly upward, backward and
inward.
 The depth of needle insertion is 16 mm for adults and
14 mm for children following careful aspiration.
 If blood comes out then retract and try again, but if
you get blood also the next time then abort the
technique.
 If no blood comes out then deposit 1.5 ml of the
anesthetic solution, wait 3-5 minutes before working.

34. Confirming the Anaesthesia
Subjective findings
No subjective findings
Objective findings
Probing does not lead to pain

36. Middle Superior Alveolar Nerve Block
Present only in about 28% of the population.
Middle superior alveolar nerve is a branch of
trigeminal nerve.
The nerve is anaesthetize along with infraorbital
nerve block but in case adequate anaesthesia is not
achieved it may be given separately.
Area anaesthetize
Pulps of maxillary 1st & 2nd premolar & mesio
buccal root of 1st molar(28%)
Buccal periodontal tissues & bone of these teeth.

37. Anatomical landmarks
Mucobuccal fold above the maxillary 2nd premolar.
Position of patient
The patient is placed with maxillary occlusal plane 45º
with the floor.
Position of operator
For right MSAN 9’o clock position.
For left MSAN 7’o clock position.
Armamentarium
Needles
25 gauge short needle
Syringe
Aspirating syringe

38. Technique
Stretch the upper lip for tissue visibility and
accessibility.
Insert the needle at the height of the mucobuccal
fold above the maxillary 2nd premolar.
Aspirate if negative, slowly deposit 0.9- 1.2 mL of
solution for 30-40 seconds.
Confirming the Anaesthesia
Subjective findings
Numbness of upper lip.
Objective findings
Probing does not lead to pain.

40. Anterior superior alveolar(ASA) nerve block
Also called as Infraorbital nerve block
Nerve anaesthetized
ASA
MSAN
Infraorbital nerve
Inferior palpebral
Lateral nasal
Superior labial

41. Areas anaesthetized
Pulp of maxillary CI through canine on the injected
side.
Pulp of maxillary premolar & mesio-buccal root of
maxillary molar.
Buccal periodontium and bone of these teeth.
Lower eyelid, lateral aspect of the nose, upper lip.
Anatomical landmarks
Infraorbital notch, ridge, depression.
Supraorbital notch.
Pupil of eye
Mucobuccal fold.
Anterior teeth

42. Position of patient
The patient is placed with maxillary occlusal plane
45º with the floor.
Position of operator
For right ASA 9’o clock position.
For left ASA 7’o clock position.
Armamentarium
Needles
A 25 gauge long needle is recommended. The needle
depth will be about 16 mm for an average sized adult.
Syringe
Aspirating syringe

43. Technique
There are two approaches to Infraorbital
nerve block, the most commonly being used
bicuspid and central incisor approach.
Bicuspid Approach
Needle is inserted in a line parallel with the
supraorbital notch, pupil of the eye,
infraorbital notch, 2nd bicuspid tooth.

44. Central Incisor Approach
• The needle bisects the crown of the central
incisor from mesio-incisal angle to disto-
gingival angle.
• In either situation, the needle should not
penetrate more than 3/4 inch, it prevents the
needle from entering the orbital cavity.
Confirming the Anaesthesia
Subjective findings
Numbness of infraorbital region, lateral
aspect of nose and upper lip.
Objective findings
Probing does not lead to pain.

46. Greater palatine nerve block
The greater palatine nerve block is useful for dental
procedures involving palatal soft tissues distal to
canine. Minimum volumes of solution (0.4-0.6ml)
provide profound hard and soft tissue anesthesia.
Nerve anaesthetized
 Greater palatine nerve
Areas anaesthetized
 Posterior part of hard palate and its overlying tissue
 Anteriorly as far as the 1st premolar & medially to the
midline.
Anatomical landmarks
 Greater palatine foramen and junction of the maxillary
alveolar process and palatine bone.

47. Position of patient
Ask the patient who is in a supine position to do the following
1. Open wide 2. Extend the neck 3. Turn the head to the left or
right
Position of operator
 For a right greater palatine nerve block , a right handed
administrator should sit facing the patient at 7’o clock position.
 For a left greater palatine nerve block , a right handed
administrator should sit facing the patient at 11'o clock position
Armamentarium
 Needles
A 27G short needle is recommended
 Syringe
Aspirating syringe

48. Technique
 Locate the greater palatine foremen.
 Place a cotton swab at the junction of the maxillary alveolar
process and the hard palate.
 Start in the region of the maxillary first molar and palpate
posteriorly by pressing firmly into tissues with the swab.
 The swab falls into the depression created by the greater
palatine foramen
 The foramen is most frequently located distal to the maxillary
second molar , but it may be located anterior or posterior to its
usual location.
 Prepare the tissue at the injection site , just 1 – 2mm anterior to
the greater palatine foramen.
Dry with a sterile gauze
Apply a topical antiseptic .
Apply a topical anesthetic for a minimum of 1 minute

49.  After 2 minutes of local anesthetic application move the
swab posteriorly so it is directly over the greater palatine
foramen.
Apply considerable pressure at the area of the foramen with
the swab in the left hand.
Note the ischemia at the injection site.
Apply pressure for a minimum of 30 seconds.
 Direct the syringe in the mouth from the opposite side with
the needle approaching the injection site at a right angle.
 Place the bevel of the needle gently against the previously
blanched soft tissue at the injection site.

50.  With the bevel lying against the tissue
Apply enough pressure to bow the needle slightly.
Deposit a small volume of anesthetic.
 Straighten the needle and permit the bevel to penetrate the
mucosa
Continue to deposit small volumes of anesthetic through
out the procedure.
Ischemia spreads into adjacent tissues as the anesthetic is
deposited.
 Slowly advance the needle until palatine bone is gently
contacted.
The depth of penetration is usually about 5mm.
Continue to deposit small volume of anesthetic.

51.  Aspirate in two planes.
 If negative slowly deposit not more than one fourth to
one third of a cartridge.
 Withdraw the syringe.
 Make the needle safe.
 Wait 2-3 minutes before commencing the procedure.
Confirming the anaesthesia
 Subjective : Numbness in the posterior portion of the
palate
 Objective : No pain during dental therapy.
Blanching of soft tissue on palatal region.

53. Nasopalatine nerve block
Also called incisive and sphenopalatine nerve
block.
It is the most painful injection so it is better to give
a few drops of anaesthesia superficially before
proceeding with the rest of the injection.
Nerve anaesthetize
Nasopalatine nerve inside the incisive canal.
Areas anaesthetize
Mucosa of anterior part of palate opposite to anterior
teeth.

54. Position of patient
Head, neck and trunk on the same straight line.
Patient should be in supine position.
The occlusal plane of maxillary teeth should be near
to the operator’s shoulder.
Position of operator
The operator will sit in 9’0 clock position.
Armamentarium
Needles
A 25-27G short needle is recommended.
Syringe
Non aspirating syringe.

55. Technique
The point of needle insertion is incisive
foramen i.e. the crest of incisive papilla.
The direction of needle insertion into the crest
of incisive papilla between the upper centrals
making 45° to the palatal mucosa
Ask the patient to mouth wide open
The labiolingual crest injection is made to
anaesthetize the incisive papilla first.
The needle is oriented parallel with the labial
alveolar plate with the needle directed towards
crest of incisive papilla

56. The needle is inserted into the crest of incisive
papilla for a distance of 4mm
Inject 0.45- 0.6 mL of anesthetic solution.
Confirming the Anaesthesia
Subjective findings
Numbness of the anterior 1/3rd of the palate.
Objective findings
Probing does not lead to pain in anterior 1/3rd of the
palate.

58. MAXILLARY NERVE BLOCK
It is an effective method of achieving profound anesthesia of
a hemi-maxilla.
Useful in procedures involving quadrant dentistry and in
extensive surgical procedures.
Alternatives
 PSA NB
 ASA NB
 GP NB
 Nasopalatine NB

59. Indications
 Pain control before extensive oral surgical, periodontal or
restorative procedures requiring anesthesia of entire
maxillary division.
 When tissue inflammation or infection exceeds the use of
another regional nerve block.
 Diagnostic or therapeutic procedures for neuralgias.
Areas anaesthetized
 Maxillary teeth on the affected side.
 Alveolar bone & overlying structures
 Hard palate, part of soft palate.
 Upper lip, cheek, side of the nose, lower eye lid

60. Advantages
Minimizes the no. of needle penetrations.
Minimizes the total volume of local anesthetic
solution 1.8ml versus 2.7ml.
High success rates.
Technique
For achieving profound anesthesia of hemi
maxilla.
2 Approaches
1)Greater palatine canal approach
2)High tuberosity approaches

61. Greater Palatine Approach
Target Area
Maxillary nerve as it passes through the pterygopalatine
fossa, the needle passes through greater palatine canal to
reach pterygopalatine fossa
Land Marks
Greater palatine foramen, situated between the 2nd & 3rd
molars about 1cm towards the midline of the palate from the
palatal gingival margin.
Area Of Insertion
Palatal soft tissue directly over the greater palatine foramen.
Procedure
25 gauge 32 mm long needle used to deposit 1.8 ml of the
solution for 1 minute at the target area.

62. Confirming The Anaesthesia
Objective
Instrumentation necessary to demonstrate
absence of pain sensation.
Subjective
Tingling & numbness of the upper lip, side
of the nose, & lower eyelid.

63. HIGH TUBEROSITY APPROACH
Technique
Needle used – 25 gauge 32mm long needle
Land Marks
Mucobuccal fold at the distal aspect of maxillary
second molar.
Maxillary tuberosity
Zygomatic process of the maxilla
Target Area
Maxillary nerve as it passes through pterygopalatine
fossa superior & medial to the target area of PSA
nerve block.

64. Confirming the Anaesthesia
Subjective signs
Pressure behind the upper jaw on the side
being injected; this subsides rapidly,
progressing to tingling and numbness of the
lower eyelid, side of the nose and upper lip.
Subjective symptoms
Sensation of numbness in the teeth and
buccal soft tissues on the side of injection.

66. MANDIBULAR INJECTION TECHNIQUES

67. IANB (Inferior Alveolar Nerve Block)
Also called Mandibular nerve block or
Pterygomandibular nerve block.
Second most frequently used after
infiltration.
For quadrant dentistry.
Nerves anesthetized
Inferior alveolar
Incisive
Mental
Lingual

68. Areas anesthetized
Mandibular teeth to midline
Body of mandible
Inferior portion of the ramus
Buccal mucoperiosteum
Mucous membrane anterior to mand 1 molar
Anterior 2/3 of tongue
Floor of oral cavity
Lingual soft tissue & periosteum

69. Anatomical landmarks:
Mucobuccal fold
Anterior border of ramus of the mandible
External oblique ridge
Retromolar triangle
Internal oblique ridge
Pterygomandibular ligament
Buccal sucking pad
Pterygomandibular space

70. Position of patient
Patient should be in supine position.
The occlusal plane of maxillary teeth should be near to
the operator’s shoulder.
Position of operator
For right IANB 7 o’clock position
For left IANB 9 o’ clock position
Armamentarium
Needles
A 27G long needle is recommended.
Syringe
Aspirating syringe.

71. Technique
Mouth open, body of mandible parallel to floor
Operator right side of patient
Thumb palpates mucobuccal fold
Thumb moves posteriorly to contact external
oblique ridge on anterior border of ramus
Greatest depth is identified-coronoid notch-
height of mand sulcus
Thumb lingually moved-across retromolar
triangle-onto internal oblique ridge.

72. Thumb moved buccally along with buccal
sucking pad-exposure to internal oblique ridge,
pterygomandibular raphe &
pterygomandibular depression.
Index finger- extra orally –behind –ramus of
mandible.
Syringe-parallel to occlusal plane-opposite
side of mouth-bisecting finger.
Moved until gently bone contacted.
Needle withdrawn 1mm,Solution deposited

73. Confirming the Anaesthesia
Subjective signs
Numbness & tingling of lower lip
Subjective symptoms
No pain on probing

75. Mental nerve block
Nerve anesthetized
Mental nerve
Area anesthetised
lower lip
Mucobuccal fold anterior to the mental foramen
Anatomical landmarks
Mandibular bicuspids
Indication
Procedures where manipulation of buccal soft tissue anterior to the
mental foramen is necessary.
Contraindications
Acute inflammation and infection over the injection site.

76. Technique
 Mental foramen lies below the apex of the 2nd
premolar or between the two premolars.
 It faces posteriorly & thus when making an injection
the approach should be from behind.
 Mental foramen palpated.
Symptoms
Tingling & Numbness of lower lip
Advantage
No loss of lingual sensation –better for children
Complication
Hematoma, partial anesthesia of central & lateral
incisors

78. Long buccal nerve block
Nerve anesthetized
Buccal branch of anterior division of V3
Area anesthetised
Buccal mucous membrane& mucoperiosteum of
mandibular molars
Anatomical landmarks
Mandibular molars and mucobuccal fold
Indication
Surgery of mandibular buccal mucosa & adjunct to
IANB

79. Contraindications :
Acute inflammation & infection over the injection site.
Techinque
Inserted into buccal mucosa distal to 3rd molar.
Alternative
Into retromolar triangle
Confirming the anaesthesia
 Subjective
Numbness & tingling
 Objective
Instrumentation

81. Gow-Gates Mandibular (Open-Mouth) Nerve Block
George A. E. Gow-Gates first published this
technique in 1973.
Significant advantages of the Gow-Gates
technique over the IA nerve block include its
higher success rate, it slower incidence of positive
aspiration, and the absence of problems with
accessory sensory innervation to the mandibular
teeth.
Nerve anaesthetize
Inferior alveolar, lingual, auriculotemporal,
buccal (75% of the time), and mylohyoid nerve.
The injection blocks the nerves at a point that is
proximal to their division into inferior alveolar,
buccal, and lingual nerves.

82. Area anesthetised
Mandibular teeth to midline
buccal & lingual mucoperiosteum & mucous
membrane
Anterior 2/3rd of tongue, floor of oral cavity, skin
over the zygoma.
Posterior portion of cheek& temporal region.
Indication
Multiple procedure on mandible, buccal soft
procedures from third molar to midline, lingual soft
tissue anesthesia, IANB unsuccessful. Diagnosis of
facial pain.
Contraindication
Infection & acute inflammation at site, young patients,

83. Landmarks
Extraoral
•External ear
•Intertragic notch
•Corner of the mouth
Intraoral
•Tendon of temporal muscle
•Anterior border of the ramus
•Mesiolingual cusp of maxillary 2nd molar

84. The patient mouth should be wide open, supine
position.
Area of Insertion
25- 27G Needle is used
Mucus membrane on the mesial side of the
mandibular ramus, on a line from intratragic
notch to corner of mouth, just distal to maxillary
second molar.
Target Area
It should be lateral side of the condylar neck, just
below the insertion of lateral pterygoid muscle.

85. Techniques
Position the patient
Locate extra oral landmarks
Visualize intraoral landmarks
Prepare tissues at site of penetration
Direct the syringe
Insert the needle
Align the needle with the plane
Slowly advance the needle
Depth of penetration: 25mm
Withdraw the needle 1mm

86. Aspirate: if –ve slowly deposit 1.8ml in 60-90 secs
Withdraw the syringe
Request the patient to keep mouth open for 1-2mins
Upright position
Wait for 3-5mins before starting dental procedure
Confirming the anaesthesia
By Instrumentation

88. Vazirani- Akinosi Technique Closed Mouth
Mandibular Block
In 1977, Dr. Sunder J. Vazirani and Dr. Joseph Akinosi
reported on a closed mouth approach to mandibular
anesthesia.
It is an intraoral approach to provide both anesthesia and
motor blockade in cases of severe unilateral trismus. This
injection is useful for patients with trismus because it is
performed while the jaw is in the physiologic rest position.
Other common names – Tuberosity technique.
Indication
Patient unable to open mouth.
Contraindication
Where trismus is present due to infection in the tissues
through which a needle would have to pass.

89. Nerve anaesthetize
Inferior alveolar
Lingual
Buccal
Mylohyoid nerves
Landmarks
Occlusal plane of occluding teeth
Mucogingival Junction of the maxillary molar
teeth
Anterior border of the ramus

90. Area of Insertion
 25- 27G Needle is used
 Soft tissue in the lingual border of the mandibular
ramus directly adjacent to the maxillary tuberosity at
the height of the mucogingival injection adjacent to
the maxillary third molar.
Target Area
Soft tissue of the medial border of the ramus where
they run towards the mandibular foramen.

91. Techniques
Step 1
• Barrel of the syringe rests on occlusal surface of the
opp. Premolars.
• Tip of the needle rests on the external oblique ridge at
the midpoint of thumbnail.
• Needle is advanced 6mm and few drops of solution is
deposited to block the long buccal nerve.
Step 2
• Barrel of the syringe is withdrawn slightly and shifted
to the same side so that ,needle glides over temporalis
tendon onto the internal oblique ridge.
• Needle is further advanced for about 8mm,keeping the
barrel of the syringe parallel to mandibular occlusal
plane.

92. • This is to block the lingual nerve.
Step3
• The barrel is returned to opposite Side , near
the 1st premolar and the needle is advanced
further for a distance of 12-15mm, until the
bony resistance is felt by the tip of the needle.
• This is to block the inferior dental nerve.

94. COMPUTER-CONTROLLED LOCALANESTHETIC
DELIVERY SYSTEMS [CCLAD]
In 1997, a new delivery system using computer technology to control
the rate and flow of anesthetic solutions evolved, and are called as
computer controlled local anesthetic delivery systems. The first of
them is the Wand, followed by Wand Plus and CompuDent.
 Fukayama et al. conducted a controlled clinical study evaluating
pain perception of a CCLAD device.
They concluded that “the new system provides comfortable
anesthesia for patients and can be a good alternative for conventional
manual syringe injection.”
There are three modes of flow rate available: slow, fast and turbo
mode. In 2001, the Comfort Control Syringe (Dentsply International,
N. York, USA) was marketed as an alternative to the Wand and has
two components; base unit and syringe and there is no foot pedal.

95. The most important functions of this unit is injection and
aspiration can be controlled directly from the syringe.
Five different basic injection rate settings for specific
applications, block, infiltration, PDL, IO and Palatal regions.

96. Single-Tooth Anesthesia [STA]
In 2006, the manufacturers of the original
CCLAD, the Wand, introduced a new device,
Single Tooth Anesthesia (STA™) which
incorporates dynamic pressure-sensing (DPS)
technology that provides a constant
monitoring of the exit pressure of the local
anesthetic solution in real time during all
phases of the drug’s administration.

97. Jet Injectors (Needleless)
Jet injection technology is based on the principle of
using a mechanical energy source to create a pressure
sufficient to push a liquid medication through a very
small orifice, that it can penetrate into the
subcutaneous tissues without a needle.
Advantages are painless injection, less tissue damage,
faster injection and faster rate of drug absorption into
the tissues.
Drawbacks are: it cannot be used for nerve blocks,
only infiltration and surface anesthesia are possible.

98. Vibrotactile Devices
These devices work on the principle of ‘gate
control’ theory thereby reduces pain. It acts based
on the fact that the vibration message is carried to
brain through insulated nerves and pain message
through smaller uninsulated nerves. The insulated
nerves overrule the smaller uninsulated nerves.
The devices are: VibraJect, Dental Vibe, Accupal.
 VibraJect has a battery operated device which is
attached to the standard anesthetic syringe,
causing the syringe and needle apparatus to
vibrate.

99. Nanitsos et al and Blair have recommended the
use of VibraJect for painless injection.
Accupal is a cordless device which applies both
vibration and pressure at the injection site.

100. Dental vibe
Dental Vibe is a cordless hand held device
which gently stimulates the sensory
receptors at the injection site causing the
neural pain gate to close.
Advantage is, the tissues are vibrated before
the needle penetrates.
Disadvantage is, it is not directly attached
to the syringe and a separate unit is required,
so both hands are engaged.
Dental vibe and syringe micro vibrator uses
microvibration to the site where an injection
is being administered.

101. Safety Dental Syringes
 Aim of these devices is to prevent from the
risk of accidental needle stick injury
occurring with a contaminated needle after
local anesthesia administration.
These syringes possess a sheath that locks
over the needle when it is removed from the
patient’s tissues preventing accidental needle
stick injury.
Eg are 1. Ultra safe syringe, 2. Ultra safety
plus XL syringe, 3.hyposafety syringe,
4.safety wand 5. Rev Vac safety syringe

102. Dentipatch [Intraoral Lignocaine Patch]
 Dentipatch contains 10-20% lidocaine, which is
placed on dried mucosa for 15 minutes.
Hersh et al (1996) studied the efficacy of this patch
and recommended it for use in achieving topical
anesthesia for injections in both maxilla and
mandible.
It is not recommended in children.
Disadvantages include central nervous system and
cardiovascular system complications.

103. Comfort Control Syringe
• This syringe (Dentsply) is an electronic pre programmed
anesthesia delivery device that uses a 2-stage delivery rate.
• The rate of injection varies based on the injection
technique chosen.
• It begins with as low rate; the flow the increases to a pre
programmed technique-specific rate selected by the
dentist.
• The operation of this syringe (initiation and termination of
the injection, controlled aspiration and flow rate) is
controlled by a button on the handpiece.
• A disposable cartridges heath is required for each patient,
but a standard dental needle and anesthetic cartridge can
be used with this device.

104. Intranasal Local Anesthesia
The major problem that remains is the patient’s fear of the
needle. Phase 3 clinical trials on the use of a nasal spray to
provide pulpal anesthesia to maxillary teeth are on going .
Cocaine and tetracaine have been commonly used
intranasally to provide anesthesia (both drugs) or
vasoconstriction (cocaine only) prior to surgical procedures
in otolaryngology in the extremely vascular nasal cavity or
prior to passage of a tube through the nares .

105. Increasing comfort during injection
Warming
Buffering
Slow injection
Bevel of the needle
Needle gauge Conclusion

106. Conclusion
Due to the advancement of technology, many newer
delivery systems for local anesthesia have evolved and the
dental practitioners must be well aware of their usage and
applications. The required armamentarium may be chosen
according to the patient’s needs. Dentists must be well
aware of these newer delivery systems, their usage and
must have an up-to-date knowledge, so as to provide the
benefits of latest technology to their patients. The ability
to deliver painless injections and a desirable level and
duration of anesthesia results in reduced patient fear,
reduced patient stress and therefore reduced stress for the
clinician and can aid patient compliance with dental
treatment.

107. Reference
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