BDS III 2025 Injection Techniques PDF

**BDS III -- 2025** **Injection Techniques** **Department of Maxillo-facial and Oral Surgery** **Faculty of Dentistry UWC** **Content:** **[1) Injection Techniques for Mandibular Anaesthesia]:** **Block Technique** Inferior Alveolar Nerve Long Buccal Nerve **Infiltrations** Incisive nerve L...

**BDS III -- 2025** **Injection Techniques** **Department of Maxillo-facial and Oral Surgery** **Faculty of Dentistry UWC** **Content:** **[1) Injection Techniques for Mandibular Anaesthesia]:** **Block Technique** Inferior Alveolar Nerve Long Buccal Nerve **Infiltrations** Incisive nerve Lingual nerve Mental nerve Long Buccal Nerve **[2) Injection Techniques for Maxillary Anaesthesia:]** **Block Technique** Greater Palatine nerve/ Nasopalatine nerve **Local Infiltrations** Anterior / Middle and Posterior Superior Alveolar Nerve/ Greater Palatine nerve/ Nasopalatine nerve  ***[Please keep this hand out with you at all times during the block course to make sure that you follow each step when performing the injection techniques. ]*** **Nerve supply of the oral structures**  From: Oral and Maxillofacial Surgery for the Clinician: Chapter 13 -- Principles and techniques of exodontia **[INJECTION TECHNIQUES for DENTAL PROCEDURES]** **[Mandibular Anaesthesia]** Due to the dense cortical bone of the adult mandible, infiltration techniques do not work effectively in the posterior segments (34-38; 44-48) compared to the block technique. ***[A. For: Inferior Alveolar Nerve Block ]*** **[Provides anaesthesia to:]** - 8 mandibular teeth of that quadrant including the bone - Buccal soft tissue anterior to the mental foramen - Bone anterior to the mental foramen - The anterior 2/3 of the tongue (lateral border on the affected side) - Floor of mouth, - Lingual soft tissue and periosteum **[Indications: ]** - Multiple mandibular teeth procedures- extractions, root planning, restorations - Lingual anaesthesia - For single teeth in the posterior segment **[There are 3 criteria for locating the correct landmark for needle insertion:]** 1. Height of Injection 2. Antero-posterior position 3. Depth of penetration **Step 1:** Load the syringe with an ampoule and appropriate needle (27G/ 30G long needles are recommended) **Step 2:** Seat patient in upright position with the head tilted backward **Step 3:** Stand in front of the patient for the right inferior alveolar nerve block **For the left IANB, position yourself in front @ a 7 o' clock position** **Step 4:** Ask patient to open the mouth as wide as possible **Step 5:** Use a mirror to retract cheek (on side of injection), do not use your fingers **Step 6:** Identify the following landmarks: external oblique ridge, pterygomandibular raphe (ligamentous band of buccopharyngeal fascia attached superiorly to the hamulus of the medial pterygoid plate and inferiorly to the posterior end of the mylohyoid line), coronoid notch (is the greatest concavity on the anterior border of the ramus) **Step 7:** Place your finger (thumb) of the non-dominant hand on the lingual aspect of ramus and pull anteriorly until the coronoid notch is palpated (to determine the width in its anterior-posterior dimension) **Step 8:** The barrel of the syringe is placed in the corner of the mouth on the opposite side, between the premolars and held parallel to the mandibular occlusal plane **Step 9:** The needle tip, touch the most posterior aspect of the pterygomandibular raphe (PMR) **Step 10:** The needle tip is then moved halfway to the coronoid notch and then half the distance back to the raphe **Step 11:** This is your injection site (puncture site -- 2/3 distance between coronoid notch and raphe) **Step 12:** Needle is inserted and advanced slowly until bone is contacted (if the attempt does not result in contact with bone, reorient the syringe and repeat attempt) **Step 13:** Average depth of penetration is between 20-25mm. Withdraw the needle by 1 millimetre **Step 14:** Aspirate. If no blood returns then the solution can be deposited at a rate of. If aspiration is positive pull back about 5mm and redirect slightly, then repeat attempt at aspiration **Step 15:** Deposit a full ampoule (1.8 ml) or depending on the dental treatment and the region to be anaesthetised.  ***[B. For: Long Buccal nerve block (]NB!! A block or infiltration can be done based on the procedure type)*** ***[Area anaesthetised:]* Soft tissues and periosteum buccal to the mandibular molars (6,7 and 8)** **Step 1:** Load the syringe with an ampoule and appropriate needle (27G or 30G short needles are recommended) **Step 2:** Head, neck and trunk of the patient to be in a straight line. The back of the chair should be tilted so that it has a 45ᴼ angle to the floor. Operator to stand in front of the patient and to the right **Step 3:** Ask patient to open the mouth (not too wide) **Step 4:** Use mirror to retract the buccal mucosa **Step 5:** Apply topical anaesthetic to the area **Step 6:** The injection site is located distal and buccal to the most distal molar in the arch on the anterior border of the ramus. The bevel of the needle should be towards the bone and inserted at a depth of 1-3mm with the buccal soft tissue lateral and taut. The syringe should be parallel to the occlusal plane and directed posteriorly **Step 7:** Aspirate, if negative, slowly deposit 0.5ml of the solution over 10 seconds ***[C. For: Mental Nerve Block] ( NB!! A block or Infiltration can be done based on the procedure type)*** ***[Area anaesthetised: ]*** - buccal mucosa, - lower lip - pulp of the incisors, canines and premolar teeth - chin ***[Indications:]*** - Pulpal anaesthesia to teeth anterior to mental foramen - When inferior alveolar nerve block is not indicated **Step 1:** Load the syringe with an ampoule and appropriate needle (30G short needles are recommended) **Step 2:** Head, neck and trunk of the patient to be in a straight line. The back of the chair should be tilted so that it has a 45ᴼ angle to the floor. Operator to stand in front of the patient and to the right **Step 3:** Ask patient to open the mouth (not too wide) **Step 4:** Use a mirror to retract the lower lip **Step 5:** Apply topical anaesthetic to the area **Step 6:** Point of needle insertion is parallel to the long axis of the tooth in the muco-buccal fold. Direct the needle at a 45 angle to the buccal cortical plate of the bone. **Step 7:** The needle is inserted through the soft tissue until the bone is reached. The needle should be held firmly and the solution is slowly deposited **Step 8:** Inject ⅔ of the solution at the site over 45 seconds **Step 8:** Withdraw the needle and recap ***[D. For: Lingual infiltration]*** ***[Area anaesthetised:]* Terminal branches of the lingual nerve** **Step 1:** Load the syringe with an ampoule and appropriate needle (30G short needles are recommended) **Step 2:** Head, neck and trunk of the patient to be in a straight line. The back of the chair should be tilted so that it has a 45ᴼ angle to the floor. The operator should stand in front of the patient and to the right except for the lower left side. The operator position change to the right rear position **Step 3:** Ask patient to open the mouth (not too wide) **Step 4:** Use a mirror to retract the tongue **Step 5:** Point of needle insertion is parallel to the long axis of the tooth and above the floor of the mouth (at the muco-lingual fold). At least 3-5mm cervical to the free gingival margin **Step 6:** The syringe is directed from the corner of the mouth (on the opposite side) with the bevel towards the bone. The needle is inserted through the soft tissue until the bone is reached. **Step 7:** Administer 0.5ml of the LA solution **Step 8:** Withdraw the needle and recap **[*Maxillary* Anaesthesia ]** This involves blocking of one or more of the peripheral nerves in the maxillary division of the Trigeminal nerve. The infiltration technique is usually performed in the maxilla because the LA solution is capable of penetrating the thin cortical plate and the porous maxillary bone. ***[A. For: Greater Palatine Nerve Block] (NB!! An infiltration can also be performed based on the procedure type)*** Injection of LA into palatal tissue is considered the most uncomfortable of intra --oral injections. Please inform your patient about the possible discomfort. **Indications:** - Maxillary teeth extractions - Palatal surgery - Gingival retraction - Sub-gingival scaling - Curettage **Step 1:** Load the syringe with an ampoule and appropriate needle (30G short needles are recommended) **Step 2:** Seat patient in a semi-fowler's position (angle of 30ᴼ) **Step 3:** Ask patient to open the mouth **Step 4:** Use a mirror to retract cheek (on side of injection) **Step 5:** Locate the greater palatine foramen (located on the lateral aspect of the hard palate, opposite the second or third molar) **Step 6:** A cotton swab can be placed at the junction of the hard palate and the maxillary alveolar process. Starting in the region of the first molar apply pressure with the cotton swab while moving posteriorly. The swab will fall into the depression created by the greater palatine foramen. **Step 6:** Apply topical anaesthetic to the area **Step 7:** Direct the syringe into the mouth from the opposite side of the mouth at a right angle to the target area, with the needle bevel towards the palatal soft tissue **Step 8:** Slowly insert the needle to penetrate the mucosa, while depositing small amounts of anaesthetic solution **Step 9:** Slowly advance the needle to approximately 8mm until palatine bone is contacted **Step 10:** Withdraw 1mm and aspirate **Step 11:** Inject ⅟4 of the solution over 30 seconds Step 12: Withdraw the needle and recap ====================================== ***[B. For: Posterior Superior Alveolar Nerve -Infiltration]*** ***[Indications:]*** - Pulpal anaesthesia of the maxillary teeth- one or two teeth, corresponding alveolar bone - Buccal gingival soft tissue anaesthesia - Maxillary molars **Step 1:** Load the syringe with an ampoule and appropriate needle (30G short needles are recommended) **Step 2:** Seat patient in a semi-fowler's position (angle of 30ᴼ) **Step 3:** Ask patient to open the mouth (not too wide) **Step 4:** Use a mirror to retract cheek (on side of injection) **Step 5:** Apply topical anaesthetic to the area **Step 6:** Area of insertion height of the mucobuccal fold/ sulcus. Needle tip is placed under the mucosa, adjacent to the periosteum of the alveolar bone overlying the apex of the tooth at an angle of 45ᴼ. Penetration is approximately 10mm in depth and directed medially **Step 7:** Inject ⅔ of the solution at the site over 45 seconds **Step 8:** Withdraw the needle and recap ***[C. For: Middle Superior Alveolar MSA Nerve-Infiltration ]*** ***[Indications:]*** - When infra-orbital nerve block fails to provide pulpal anaesthesia distal to the maxillary canine - Dental procedures involving both maxillary premolars only ***[Area anaesthetised: ]*** - Pulps of the maxillary first and second premolars, - Mesio-buccal root of the first molar - Buccal periodontal tissues and bone over these same teeth **Step 1:** A 25-gauge short or long needle is recommended, although the 27-gauge short is more likely to be available and is perfectly acceptable **Step 2:** Area of insertion: height of the mucobuccal folds above the maxillary second premolar **Step 3:** Target area: maxillary bone above the apex of the maxillary second premolar **Step 4:** Landmark: mucobuccal fold above the maxillary second premolar. Orientation of the bevel is towards the bone **Step 5:** For a right MSA nerve infiltration, a right-handed administrator should face the patient from the 10 o'clock position and for a left MSA nerve infiltration; a right-handed administrator should face the patient directly from the 8 or 9 o'clock position. **Step 6:** Stretch the patient's upper lip to make the tissues taut and to gain visibility. Insert the needle into the height of the mucobuccal fold above the second premolar with the bevel directed toward bone. **Step 7:** Penetrate the mucous membrane and slowly advance the needle until its tip is located well above the apex of the second premolar **Step 8:** Aspirate and slowly deposit 0.9 to 1.2 ml (one half to two thirds cartridge) of the solution (approximately 30 to 40 seconds). **Step 9:** Withdraw the syringe and recap by making use of the one hand recapping method ***[D. For: Anterior Superior Alveolar Nerve (13-23) - Infiltration]*** ***[Provides anaesthesia to:]*** - Maxillary canine - Lateral incisor - Central incisor - Alveolar Bone - Buccal gingiva **Indications:** - Dental extractions - Minor oral surgery - Root planning **Step 1:** Load the syringe with an ampoule and appropriate needle (30G short needles are recommended) **Step 2:** Seat patient in a semi-fowler's position (angle of 30ᴼ) **Step 3:** Ask patient to open the mouth **Step 4:** Use a mirror to retract the upper lip **Step 5:** Apply topical anaesthetic to the area **Step 6:** Insert the needle in the mucobuccal fold/ sulcus in the area of the central/ lateral incisor and canine. Needle tip is placed under the mucosa adjacent to the periosteum of the alveolar bone overlying the apex of the tooth. Penetration is approximately 10mm in depth. **Step 7:** Inject ⅔ of the solution at the site over 45 seconds **Step 8:** Withdraw the needle and recap **[Universal Protocol: ]** - applying topical anaesthetic for a few seconds - warm the local anaesthetic solution (close to body temperature) - deposit solution slowly - proper patient positioning - aspiration prior to solution being deposited - making the needle safe after each injection with the scoop technique **Xylotox-E80A (most commonly used LA in the faculty)** **Active Ingredients:** Lidocaine hydrochloride (HCl): 2% (20 mg) Adrenaline: 1:80 000 (12.5 µg) Sodium metabisulphite +-----------------------------------+-----------------------------------+ | **CONSTITUENT** | **FUNCTION** | +===================================+===================================+ | Lidocaine HCl (Analgesic salt) | Produces local anaesthesia | +-----------------------------------+-----------------------------------+ | Adrenaline (Vasoconstrictor) | - Prolongs duration of action | | | of local anaesthetic. | | | | | | - Reduces systemic absorption | | | into the CVS. | | | | | | - Decreases blood flow to the | | | site of injection therefore | | | decreases bleeding. | | | | | | - Decreases risk of toxicity. | +-----------------------------------+-----------------------------------+ | Sodium metabisulphite | - Prevents oxidation of | | (Antioxidant) | vasoconstrictor. | | | | | | - Vasoconstrictors are unstable | | | in solution and may oxidise | | | especially in prolonged | | | exposure to sunlight. | +-----------------------------------+-----------------------------------+ | Citric acid monohydrate | - Maintains stability of active | | (Preservative) | ingredients. | | | | | | - It is also used as an | | | acidulant to control pH.  | +-----------------------------------+-----------------------------------+ | Hydrochloric acid (Buffer) | - To maintain the pH. | | | | | | - To reduce the oxidation of | | | vasoconstrictor. | +-----------------------------------+-----------------------------------+ | Sodium hydroxide (Buffer) | - To maintain the pH. | | | | | | - To reduce the oxidation of | | | vasoconstrictor. | +-----------------------------------+-----------------------------------+ | Silicone (Antiseptic) | Prevents infection at the site of | | | injection. | +-----------------------------------+-----------------------------------+ **CONTRAINDICATIONS** - Hypersensitivity to local anaesthetics of the amide type, i.e. lidocaine HCl. - Children under the age of 2 years. - Patients with thyrotoxicosis. - Patients with cardiac disease, particularly arrhythmia, hypertension, narrow angle glaucoma. - Patients on tricyclic antidepressants. - Patients with myasthenia gravis. - Patients with epilepsy. - Patients with liver conditions. - Patients who have been on Monoamine Oxidase Inhibitors (MAOIs) for depression. - Safety has not been established in pregnant or breast-feeding patients.