GOW GATES

Needle gauge/length

25 gauge long needle

Operator Position
Right side
Left side

8:00 facing the patient

10:00 facing the same direction as the patient

Patient Position

Supine or Semi-supine. Extend neck and open

wide

Pressure

No

Bevel Placement

Not critical

Aspiration Potential

2%

Depth of needle pen

25 mm

Osseous contact

Yes

Amt. solution/Time

1.8 ml over 60 to 90 seconds, pt. stay open 2 mins.

Nerves Anesthetized

Inferior alveolar
Mental
Incisive
Lingual

Areas Anesthetized

Mandibular teeth to the midline

Buccal periosteum and mucous membranes
Anterior 2/3 of the tongue and floor of mouth
Lingual soft tissue and periosteum
Body of the mandible, inferior portion of ramus
Skin over zygoma, posterior portion of cheek and
temporal regions

Landmarks

Extra-oral: Lower border of the tragus

Corner of the mouth on side of injection
Intra-oral: Height of injection is mesiolingual cusp
of maxillary 2nd molar.
Penetrate soft tissues just distal to
max. 2nd molar. (or third molar if present)
Barrel over the bicuspids to cuspid
depending on divergence of the ramus

Updated 11-11-14

Mylohyoid
Auriculotemporal
Buccal (75%of patient)

Target Area

Lateral region of the condylar neck, just below the

insertion of the lateral pterygoid muscle.

Syringe Position/
Locating area of Insertion

- Direct syringe toward site of injection from opposite

side of the mouth
- Align needle with plane extending from the corner
of the mouth to the intertragic notch on the
side of injection. It should be parallel with the
angle between the ear and the face.
- Direct syringe toward target area on the tragus
of ear. Syringe barrel usually lies over
premolars or canines, but may vary from
molars to incisors. Height of injection
above mandibular occlusal plane is
considerably greater (5-10mm) than inferior
alveolar.
- Insert needle distal to maxillary second molar at
height of its mesiolingual cusp. When a
maxillary third molar is present in a normal
occlusion, the site of needle penetration is
just distal to that tooth.

Updated 11-11-14

INFERIOR ALVEROLAR NERVE BLOCK

Needle gauge/length

25 gauge long needle

Operator Position
Right side
Left side

8:00 facing the patient

10:00 facing same direction as the patient

Patient Position

Supine or semi-supine. Mouth should be opened wide.

Head should be turned toward operator for right side
and slightly away for the left side.

Pressure

No pressure needed

Bevel Placement

Not critical

Aspiration Potential

10 to 15 %

Depth of needle pen

20-25 mm, approx. 2/3 to the length of long needle

Osseous contact

yes

Amt. solution/Time

1.5 ml over 60 seconds

Nerves Anesthetized

Inferior Alveolar (a branch of posterior division of the

mandibular)
Incisive
Mental
Lingual

Areas Anesthetized

Mandibular teeth to midline

Body of Mandible, inferior portion of ramus
Buccal mucoperiosteum, mucous membrane anterior to
the mandibular first molar (Mental nerve)
Anterior 2/3 of tongue and floor of the oral cavity
(lingual nerve)
Lingual soft tissue and periosteum (lingual nerve)

Landmarks

Coronoid notch greatest concavity on the anterior

border of the ramus
Pterygomandibular raphe
Parallel to occlusal plane of the mandibular posterior teeth

Target Area

Inferior Alveolar Nerve as it passes downward toward the

mandibular foramen but before it enters into the foramen.

Updated 11-11-14

Syringe Position/
Locating area of Insertion

Updated 11-11-14

- Place the syringe barrel at the corner of the

mouth, usually over bicuspids.
- Finger in the coronoid notch indicates the height
of insertion. Draw an imaginary line extending
horizontally through the coronoid notch,
parallel with the mandibular occlusal plane and
vertically, 2/3 to the distance between the
coronoid notch and the posterior border of the
ramus.

(long) BUCCAL NERVE BLOCK

Needle gauge/length

25 gauge long needle

Operator Position
Right side
Left side

8:00 facing patient

10:00 facing the same direction as the patient

Patient Position

Supine or semi-supine, mouth not open to wide

Pressure

Not necessary

Bevel Placement

Bevel faces down toward bone

Aspiration Potential

0.7%

Depth of needle pen

1 4 mm

Osseous contact

Gently contact periosteum

Amt. solution/Time

0.3 ml over 10 seconds

Nerves Anesthetized

Buccal nerve

Areas Anesthetized

Soft tissue and periosteum Buccal to the

mandibular molar teeth

Landmarks

Mandibular molars, mucobuccal fold

Target Area

Buccal nerve

Syringe Position/
Locating area of Insertion

Updated 11-11-14

- The syringe is aligned parallel with the

occlusal plane on the side of injection
but buccal to the teeth. Penetrate
mucous membrane distal and buccal to
the most distal molar tooth in the arch.
- Angle of insertion should be toward bone.

INCISIVE NERVE BLOCK

Needle gauge/length

25 27 gauge short needle

Operator Position
Right side
Left side

8 or 10:00 position (2:00 OK)

10 to 1:00 position (2:00 OK)

Patient Position

Supine or semi-supine. Patients mouth slightly

closed

Pressure

- During injection, maintain gentle finger pressure

directly over the injection site to increase the
volume of solution entering the mental foramen.
- After the injection is completed, apply pressure at
the injection site for 2 minutes.

Bevel Placement

Bevel toward bone

Aspiration Potential

5.7 %

Depth of needle pen.

5-6mm

Osseous contact

No (advance needle toward mental foramen)

Amt. solution/Time

0.6 to 0.9 ml. (1/3 to cartridge) over 20-30 sec.

Nerves Anesthetized

Mental and Incisive nerves

Areas Anesthetized

Buccal mucous membrane anterior to the mental

foramen, usually from the second premolar
to the midline.
Lower lip and skin of the chin
Pulpal nerve fibers to the premolars, canine and
incisors.

Landmarks

Mandibular premolars and mucobuccal fold

Target Area

Mental foramen

Syringe Position/
Locating area of Insertion

- Patients upper lip and cheek area parallel

to long axis of tooth
- Mucobuccal fold at or just anterior to the mental
foramen

Updated 11-11-14

INFILTRATIONS
Needle gauge/length

27 gauge short needle

Operator Position
Right side or Left side Depends on area
Patient Position

Supine

Pressure

No

Bevel Placement

Bevel faces down toward bone

Aspiration Potential

< 1%

Depth of needle pen

Maxillary bevel at apex of tooth

Mandibular insert until bevel is covered (2-3mm)

Osseous contact

No

Amt. solution/Time

Maxillary 0.6 ml over 20 seconds

Mandible 0.9 ml over 25 seconds

Nerves Anesthetized

Terminal branches

Areas Anesthetized

Maxillary pulp, soft tissue, bone in area of injection

Mandible soft tissue in area of injection

Landmarks

Maxillary mucobuccal fold, parallel to root, close to

bone and apex over target tooth
Mandibular junction of the lingual attached gingiva
and floor of the mouth, parallel to long axis of
tooth, near target tooth, close to bone

Syringe Position/
Locating area of Insertion

Updated 11-11-14

- The syringe is aligned perpendicular with the

occlusal plane on the side of injection but
buccal (max) or ling (man) to the teeth.
Penetrate mucous membrane at the injection
site.

POSTERIOR SUPERIOR ALVEROLAR NERVE BLOCK

Needle gauge/length

25 or 27 gauge short

Operator Position
Right side
Left side

8:00 facing the patient

10:00 facing the same direction as the patient

Patient Position

Supine or semi-supine with patients mouth partially open

pulling the mandible to the side of the injection

Pressure

No pressure needed

Bevel Placement

Bevel towards bone

Aspiration Potential

3.1%

Depth of needle pen.

Approximately 16mm in normal adult (4mm should remain

visible)
NOTE When long needle is used, insert 1/2 its length

Osseous contact

No

Amt. solution/Time

0.9 to 1.8 ml over 30 to 60 seconds

Nerves Anesthetized

Posterior superior alveolar nerve and branches

Areas Anesthetized

Pulps of the maxillary 3rd, 2nd and 1st molars (except the MB
root of the 1st molar in 28% of patients)
Buccal periodontium and bone overlying these teeth

Landmarks

Mucobuccal fold
Maxillary tuberosity
Zygomatic Process of the maxilla

Target Area

PSA nerve Posterior, superior and medial to the posterior

border of the maxilla

Syringe Position/
Insert needle into the height of the mucobuccal fold over
Locating area of Insertion
second molar. Advance the needle slowly in an
upward, inward and backward direction.

Updated 11-11-14

GREATER PALATINE NERVE BLOCK

Needle gauge/length

27 gauge short OR 25 gauge short

Operator Position
Right side
Left side

7 or 8 Oclock facing the patient

11 Oclock with operator facing in the same direction as pt

Patient Position

Supine position with 1) mouth open wide 2) extended neck

3) head turned to the left or right for greater visibility

Pressure

Minimum 30 seconds prior, and during injection

Bevel Placement

Bevel against the palatal soft tissue toward bone

Aspiration Potential

Less than 1%

Depth of needle pen.

Usually less than 10 mm (until osseous is contacted)

Osseous contact

Yes

Amt. solution/Time

1/4 to 1/3 cartridge (0.45 to 0.6 ml) over 30 seconds or more

Nerves Anesthetized

Greater palatine nerve (or anterior palatine nerve)

Areas Anesthetized

Posterior portion of the hard palate and its overlying soft

tissues, anteriorly as far as the first premolar and medially to
the midline

Landmarks

Greater palatine foramen and junction of the maxillary

alveolar process and palatine bone

Target Area

Greater (anterior) palatine foramen as it passes anteriorly

between the soft tissues and bone of the hard palate

Syringe Position/
Area of Insertion

- Advance the syringe from the opposite side of the mouth at

a right angle (90 degree) to the target area
- Soft tissue slightly anterior to the greater palatine foramen

Updated 11-11-14

ANTERIOR MIDDLE SUPERIOR ALVEROLAR NERVE BLOCK

Needle gauge/length

27 gauge short needle

Operator Position
Right side
Left side

9:00 or 10:00 facing same direction as patient

9:00 or 10:00 facing same direction as patient

Patient Position

Supine with slight hyperextension of head and neck

Pressure

Use a Q-tip at injection site

Bevel Placement

Bevel against the palatal soft tissue toward bone

Aspiration Potential

Less than 1%

Depth of needle pen

3-5 mm

Osseous contact

Yes

Amt. solution/Time

1.4 to 1.8 ml at a rate of 0.5 ml/ min (3-4 min)

Nerves Anesthetized

Anterior superior alveolar nerve

Middle superior alveolar nerve (when present)
Sub-neural dental nerve plexus of the anterior & middle
superior alveolar nerves

Areas Anesthetized

Pulpal anesthesia of maxillary incisors, canine & premolars

Buccal attached gingival of these same teeth
Attached palatal tissues from midline to free gingival margin
on the associated teeth

Landmarks

Intersecting point mid-way along a line from the mid-palatine

suture to free gingival margin intersecting the contact point
between the first and second premolar

Target Area

Palatal bone at injection site

Syringe Position/
Area of Insertion

Updated 11-11-14

- Needle approaches the injection site at a 45 to 60 - degree

angle to the mid-point between the premolars and
halfway point between free gingival margin and
palatine suture
- Use comfortable arm and finger rests to avoid
fatigue during the injection

NASOPALATINE NERVE BLOCK

Needle gauge/length

27 gauge short OR 25 gauge short

Operator Position
Right side or Left side 9 or 10 Oclock position facing in the same direction as pt
Patient Position

Supine with 1) mouth open wide, 2) neck extended, 3) head

turned to the left or right for improved visibility

Pressure

Yes

Bevel Placement

Bevel against the palatal soft tissue toward bone

Aspiration Potential

Less than 1%

Depth of needle pen.

Less than 10mm

Osseous contact

Yes

Amt. solution/Time

1/4 cartridge (0.45 ml) over 15 to 30 seconds minimum

Nerves Anesthetized

Nasopalatine nerves bilaterally

Areas Anesthetized

Anterior portion of the hard palate (soft and hard tissue) from
the mesial of the right first premolar to the mesial of the left
first premolar

Landmarks

Central incisors and incisive papilla

Target Area

Incisive foramen located beneath the incisive papilla

Syringe Position/
Area of Insertion

- Needle approaches the injection site at a 45 degree angle

toward the incisive papilla
- Palatal mucosa lateral to the incisive papilla

Updated 11-11-14

ANTERIOR SUPERIOR ALVEROLAR NERVE BLOCK

Needle gauge/length

25 gauge long needle OR 25 gauge short for smaller pts.

Operator Position
Right side or Left side Sit at 10:00 directly facing the patient or facing the same
direction as the patient
Patient Position

Supine (preferred) or semisupine with the neck extended

Slightly. The chest must not interfere with the injection

Pressure

Maintain direct finger pressure over the injection site during

the injection (if possible) and then for at least 1 minute after
the injection

Bevel Placement

Toward bone

Aspiration Potential

0.7%

Depth of needle pen.

16mm (1/2 the length of a long needle)

Osseous contact

Yes

Amt. solution/Time

0.9 to 1.2 ml (1/2 to 2/3 of a cartridge) over 30-40 sec.

Nerves Anesthetized

Anterior superior alveolar, Middle superior alveolar, Inferior

palpebral, Lateral nasal, Superior labial

Areas Anesthetized

Pulps of the max. central incisor through the canine on the

injected side
In about 72% of patients, pulps of the maxillary premolars
and mesiobuccal root of the first molar
Buccal (labial) periodontium and bone of these same teeth
Lower eyelid, lateral aspect of the nose, upper lip

Landmarks

Mucobuccal fold, Infraorbital notch, Infraorbital ridge,

Infraorbital depression, Infraorbital foramen

Target Area

Infraorbital foramen (below the Infraorbital notch)

Syringe Position/
Area of Insertion

- Orient the syringe toward the Infraorbital foramen. The

needle should be held parallel with the long axis of
the tooth.
- Height of Mucobuccal fold over any tooth from the second
premolar anteriorly to the central incisor. (The first
premolar usually provides the shortest route to the
target area.)

Updated 11-11-14