1. LOCAL ANAESTHETIC - Technique EO 006.01
UNCLASSIFIED//REL TO NATO/ISAF

2. Lesson Plan Overview Technique Overview Infiltration Technique
Inferior Alveolar Nerve (IAN) Block Technique
Long Buccal Nerve Injection
Periodontal Ligament Injection

3. Technique Overview Assemble armamentarium
Select appropriate technique and agent
Inspect cartridge
Review patient medical history
Prepare the patient
Apply topical anaesthetic

4. Technique Overview Establish a firm hand rest Make tissue taut
Landmark injection site
Orient bevel
Direct needle to desired location
Insert needle
Slowly advance the needle

5. Technique Overview Stop at desired site ASPIRATE Slowly inject
Communicate with patient
Slowly withdraw needle
Recap SAFELY
Observe patient and assess anaesthesia

6. Technique Overview 1. Assemble Armamentarium Syringe
Cotton tip applicator
Short needle
Long needle
Cartridge of local anaesthetic
Gauze
Mirror
Explorer
Safety capping device (optional)

7. Technique Overview 2. Select appropriate technique and agent
Consider location
Presence of infection
How many teeth
What procedure
3. Inspect cartridge – some things to consider
Expiration date
Solution
Damaged cartridge

8. Technique Overview 4. Review patient medical history:
Look for contraindications – eg allergy to amide local anaesthetic (rare)
Look for systemic problems – high blood pressure, recent heart attack, etc.
5. Prepare the patient
Tell patient what you are doing
Make sure patient has bib and safety glasses
Position patient as required for procedure

9. Technique Overview 6. Apply topical anaesthetic
Pull tissue taut
Dry injection site with gauze
Apply cotton applicator with small amount of topical for at least 1 minute
7. Establish firm hand position
Make sure your hand has at least one point of contact
Two is better

10. Technique Overview 8.Make tissue taut 9. Landmark injection site
Inferior Alveolar Nerve Block
Infiltration
Periodontal Ligament Injection
10. Orient bevel
Important for infiltration and PDL injection
11. Direct needle to desired location
Mental image of where you want the tip to end

11. Technique Overview 12. Insert Needle 13. Slowly advance the needle
14. Stop desired site
For infiltrate = root apex
For IAN Block = bone
PDL = resistance

12. Technique Overview 15. ASPIRATE What is aspiration?
For the nerve block, always aspirate (pull in) to ensure your needle is not inside the artery
If it is inside, the blood will come into the cartridge
If not, the needle is in the right place

13. Technique Overview 16. Inject slowly 17. Communicate with patient
Decreases pain
Decreases risk of intravascular
17. Communicate with patient
18. Slowly withdraw needle
19. RECAP SAFELY
20. Observe patient and assess anaesthesia
Watch for allergic reaction, syncopy, other adverse signs
Anaethesia can take up to 10 minutes or more for a block

14. LOCAL INFILTRATION Local Infiltration
Teeth are anaesthetized by injecting close to the target tooth
The needle is inserted through the mucosa, next to the target tooth, to a estimated depth near the tooth root apex
Local Infiltration
Teeth are anaesthetized by injecting close to the target tooth
The needle is inserted through the mucosa, next to the target tooth, to a estimated depth near the tooth root apex.

15. LOCAL INFILTRATION The anesthetic diffuses through: Local Infiltration
1.Periosteum (thin tissue covering of bone)
2.Outer Cortical Plate (hard bone)
3. Inner Cancellous Bone (soft bone)
4. Alveolar Bone
5. Periodontal Ligament
1.Periosteum (thin tissue covering of bone)
2.Outer Cortical Plate (hard bone)
3. Inner Cancellous Bone (soft bone)
4. Alveolar Bone
5. Periodontal Ligament

16. LOCAL INFILTRATION Point of Insertion
It may be found with ease by pulling the lip or cheek slightly away from the teeth as well as downward in the case of the upper jaw or upward in the case of the lower jaw.
The bevel of the needle should be facing the bone.
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17. LOCAL INFILTRATION mlp
Puncture the tissue by pressing the needle tip against the tissue at this fold
At the same time the tissue is pulled over the needlepoint just as the puncture is made. A drop of anaesthetic is deposited in the tissue.
mlp
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18. LOCAL INFILTRATION
The needle is then advanced slowly toward the root apex in line with the long axis of the tooth.
Anaesthetic is slowly deposited as the needle is advanced.
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19. LOCAL INFILTRATION
The final resting point of the end of the needle should be slightly distal to the apex of the root.
The syringe should then be aspirated to make sure no blood vessels have been entered.
Then inject the rest of the anaesthetic.
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20. LOCAL INFILTRATION
The injection should be made very slowly. All anaesthetic should be given.
Rapid injections will likely result in pain, swelling and poor anaesthesia.
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21. LOCAL INFILTRATION Waiting Time
 It may take 5 minutes to anaesthetize lower teeth and about 3 minutes in the case of upper teeth.
The gingiva area to be operated upon should be tested by puncturing it with the tip of an explorer in order to insure that it is properly anaesthetized.
The patient may sense pressure, but there should be no pain.
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22. LONG BUCCAL NERVE INJECTION
Waiting Time
Results are not as reliable in the lower molar region if the long buccal injection is not done.
The Long Buccal Nerve supplies sensation to the mandibular molar buccal gingiva and mucosa.
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23. TECHNIQUES OF ANAESTHESIA FOR MAXILLARY
General Considerations
Maxilla has very porous bone, with the exception of the zygomatic processes superior to the maxillary first molars.
Anaesthetic will diffuse through it, therefore local infiltrations are adequate for operative work.
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24. TECHNIQUES OF ANAESTHESIA FOR MAXILLARY
General Considerations
Injections made on the buccal side of the tooth only anaesthetize the buccal mucosa. The Periodontal Ligament injection or local infiltration of the palatal gingiva is therefore required to anaesthetize the palatal gingiva for extractions.
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25. TECHNIQUES OF ANAESTHESIA FOR MAXILLARY
General Considerations
You must always be aware of the possibility of a hematoma when infiltrating posterior to the permanent molars due to the proximity of the venous plexus.
(patient will feel burning)
27 or 30-gauge short needle is normally used for all injections in the maxilla.
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26. LOCAL INFILTRATION INJECTION IN THE MAXILLA
Technique
It may help to palpate the underlying bone before the needle is inserted because the root contour of the anterior teeth can usually be felt, and this ensures a more accurate injection.
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27. INFERIOR ALVEOLAR NERVE BLOCK
General Conditions
Mandible has very dense bone, except young children when it can be more porous.
Anaesthetic will therefore not diffuse through the cortical plate very readily. Therefore, a mandibular block is normally employed for all operative/surgical procedures.
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28. INFERIOR ALVEOLAR NERVE BLOCK
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29. INFERIOR ALVEOLAR NERVE BLOCK
The success of a mandibular block lies in the ability to palpate certain anatomical landmarks on the ramus. A thorough understanding of the surrounding anatomy is essential.
Note the position of the IAN in the adult versus the child
Teeth Involved
All the teeth in one mandibular quadrant.

30. INFERIOR ALVEOLAR NERVE BLOCK
Nerves Anaesthetized
 Inferior Alveolar nerve and the Lingual Nerve.
Indications
All operative and surgical procedures in the mandible.
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31. INFERIOR ALVEOLAR NERVE BLOCK
Technique
27-gauge long needle; two carpules are used for adult anaesthesia of the inferior alveolar nerve.
Bevel towards the bone, although for a block this is not critical.
 The patient is in the supine position. The operator is seated on the chairside stool.
 With the thumb or index finger of the left hand, palpate the internal and external oblique ridges on the anterior border of the ramus.
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32. INFERIOR ALVEOLAR NERVE BLOCK
Pterygomandibular raphe
Technique
Move the thumb or finger up and down on the ridges until the greatest depth of the anterior border of the ramus is identified.
With the thumb or finger still contacting the ridges and in the greatest depth of the notch, it is moved buccally to move the buccal sucking pad and give greater visibility.
The thumb or finger rests on the external oblique ridge.
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33. INFERIOR ALVEOLAR NERVE BLOCK
Technique
The puncture point is made from the opposite side of the mouth with the syringe over the second premolar.
The puncture point is ¾ the distance from the external oblique ridge to the pterygomandibular raphe of the deepest point of the coronoid notch.
Small amounts of anaesthetic are deposited as the needle is slowly advanced until it contacts the bone of the ramus.
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34. INFERIOR ALVEOLAR NERVE BLOCK
Technique
At this point normally only ½ to ¾of the length of the needle should be buried in the tissue when it contacts the bone.
If more than ¾ is buried, the injection is likely too deep.
If less than ½ of the needle is buried, the injection is too shallow. In both cases anaesthesia will be inadequate.
¾ of needle is buried
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35. INFERIOR ALVEOLAR NERVE BLOCK
Technique
The needle is backed off ½ millimeter and the syringe is aspirated to make sure the inferior alveolar artery or vein has not been punctured.
¾ of a carpule of anaesthetic is then deposited.
The needle is withdrawn to half the buried depth. Aspirate and deposit the remaining ¼ carpule to anaesthetize the lingual nerve.
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36. INFERIOR ALVEOLAR NERVE BLOCK
Technique
With a new carpule, landmark and deposit another ¾ carpule for the inferior alveolar nerve and without removing the syringe from the mouth, withdraw the needle and hop over the occlusion, and deposit the remaining ¼ carpule to anaesthetize the long buccal nerve.
It is common practice to use two carpules for adults in performing the inferior alveolar nerve block.
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37. INFERIOR ALVEOLAR NERVE BLOCK
Symptoms of Anaesthesia
Lower lip and chin feel fat, thick, or rubbery on the side of the injection.
Complete numbness of the lateral side of the anterior ⅔ of the tongue on the side of the injection.
If the symptoms are not present or are only slight, then the block is not profound enough for operative or surgical work and the technique should be re- evaluated before re-injecting to see if your initial landmarks were incorrect.
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38. INFERIOR ALVEOLAR NERVE BLOCK
Reasons for Failure
Poor technique – strict adherence to the anatomical landmarks is vital for success of the injection.
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39. INFERIOR ALVEOLAR NERVE BLOCK
Reasons for Failure
Injecting too high – if the needle of the syringe is directed too high, there is a possibility of puncturing one of the blood vessels leading down to the mandibular canal. This may result in a hematoma. There is also the possibility of anaesthetizing the auriculotemporal branch of the mandibular division that supplies the temporal region of the head. Injecting too high carries a higher risk of success than injecting too low.
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40. INFERIOR ALVEOLAR NERVE BLOCK
Reasons for Failure
Injecting too low – if the needle of the syringe is directed too low, usually complete failure of the block results without any of the classic signs of anaesthesia because the solution has been deposited below the lingula. The sphenomandibular ligament prevents diffusion of the local anaesthetic to successfully anaesthetize the inferior alveolar nerve.
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41. INFERIOR ALVEOLAR NERVE BLOCK
Reasons for Failure
Injecting too deep – if more than ¾ of the needle disappears into the tissue before the bone is palpated, it means that the needle is too deep and has probably entered into the parotid gland which could possibly result in anaesthesia of the facial nerve with subsequent drooping of the eyelid, asymmetric smile, etc., due to temporary paralysis of the muscles of facial expression.
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42. INFERIOR ALVEOLAR NERVE BLOCK
Reasons for Failure
If pain is felt during injection it means:
You are injecting a volume of anaesthetic too quickly.
You have pushed the needle through the medial pterygoid muscle instead of into the pterygomandibular triangle.
The tip of the needle is sliding along the bone and tearing the periosteum.
The needle has contacted either the lingual or inferior alveolar nerve. This results in an “electric shock” like sensation.
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43. Long Buccal Nerve Injection
Nerve Anaesthetized :
Long Buccal Nerve
Indication
This injection is in addition to the mandibular nerve block and is usually routinely given in order to anaesthetize the buccal gingiva in the molar region. The nerve itself runs from the distobuccal side of the third molar to the mesio- buccal side of the first molar. It is done for all operative and surgical procedures in the area.
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44. Long Buccal Nerve Injection
Technique
Since this injection is in addition to the mandibular nerve block, there is already a long 27-gauge needle in the syringe. A quarter of a carpule of anaesthetic is usually sufficient.
 With the bevel facing down, puncture the muco-buccal fold at a point just posterior and lateral to the third molar tooth at the level of the C-E junction.
Deposit ¼ carpule of anaesthetic with the needle held parallel to the body of the mandible.
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45. Long Buccal Nerve Injection
Symptoms of Anaesthesia
Test the area with the sharp end of an explorer, as no painful sensation will be felt with successful anaesthesia.
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46. Long Buccal Nerve Injection
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47. Periodontal Ligament Injection
Position the patient
A 27 gauge needle is preferred
Apply topical for at least 1 minute unless the area is already numb
Stabilize the syringe
Orient the needle along the long axis of the tooth
Place the bevel against the tooth first on the mesial side (then repeat this on the distal) and insert into the periodontal sulcus until resistance is met

48. Periodontal Ligament Injection
Slowly deposit approximately 0.2 ml of local anaesthetic
You will feel resistance as you inject
You should notice blanching of the tissue

49. Children's Teeth Mlp stuff
The same injections and techniques apply to the deciduous dentition as to the permanent one.
The only variation is that canine, as well as the central and lateral teeth in the mandible can be anaesthetized with a local infiltration technique, but it is usually preferable to anaesthetize the first and second deciduous molars with a mandibular block.
Mlp stuff
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50. UNCLASSIFIED//REL TO NATO/ISAF
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UNCLASSIFIED//REL TO NATO/ISAF