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● The needle is inserted carefully into the papilla, in the
anesthetized mesiobuccal area, and the injection is performed slowly with careful application of pressure. The
papilla will blanche and the pale area will gradually
extend toward the palatal part of the papilla. As the pressure builds up, the blanching extends toward the neighboring palatal area.
● The maneuver can be repeated in the distal- buccal
papilla. If a greater area of the palate is to be covered,
then the needle can be inserted into the area of the palate
affected by blanching to slowly inject while gradually
applying pressure and thus extending the anesthetized
blanched area.
This method rarely leads to palatal ulceration induced by
ischemia. If this does occur, it resolves spontaneously in a
few days.
Minimal Intervention Technique
The minimum technique, or minimum intervention technique (minimum volume/minimum injection time), has
already been examined in the buccal infiltration technique
(Chapter 14). Its advantages are that it is fast, does not
require special equipment, and can be carried out in combination with other techniques such as pressure or cold (if
so desired) to enhance its efficacy. The technique involves
the following steps:
1) Warn the patient that he/she “will feel some discom-
fort” in the palate when the anesthetic is administered.
Stress that this “will be very quick.” This prepares the
patient psychologically, since unexpected events are
perceived as being more painful; in addition, during
the painless part of administration, the patient
relaxes,reassured by the explanation (Jackson1974;
Wepman1978).
2) insert the needle 2–4 mm into the palate in the area to be
treated and inject only one or two drops of solution over
1–2 seconds. Wait 60 seconds after removing the needle.
This ensures that the soft tissue at the injection site is
anesthetized.
3) Once again, inject one or two drops at the same site
(this is usually the same blood spot from the first injection) over 1–2 seconds, only this time wait 30 seconds.
4) After aspirating, inject a greater quantity of anesthetic
(±1/8 of a cartridge, 0.25 ml) slowly over 7–10 seconds
at the same site and wait a further 30 seconds. Do not
inject a large quantity, but rather small quantities to
complement the previous injections and begin anesthesia of the palate.
Notes
● With respect to perception of pain, patients expect the
second injection to be more painful than the first (Martin
etal.1994; Paschos etal.2006; Badcock etal.2007; Kuscu
etal.2014). Injecting the initial drops induces anesthesia
in the soft tissue and thus largely resolves the problem.
● It is important to remember that pain is felt somewhat
less intensely in the posterior part of the hard palate than
in the anterior part (Meechan etal.2005; Özec etal.2010)
because the fibromucosa is less dense and less attached
to the periosteum, therefore this technique is particularly successful in the posterior part.
● In practice, many clinicians use their own methods,
which involve a mix of those described above.
Nasopalatine Nerve Block
In older books, this technique is also known as Scarpa’s
nasopalatine nerve or long sphenopalatine nerve block
technique or the incisive or retroincisive canal injection
technique.
In fact, the technique involves double anesthesia, since
both nasopalatine nerves (right and left), which emerge
together via a single incisive foramen, are anesthetized
simultaneously (Phillips and Maxmen1941).
Anesthetized Area
This area corresponds to the fibromucosa, periosteum, and
palatine bone (Table2.1 and Figure 2.7, Chapter2). The
areas anesthetized are as follows:
○ 100% of the interincisive papilla.
○ 100% of the palate behind the central incisors.
○ 50% of the palate behind the lateral incisors.
○ 25% of the palate behind the canines on both sides.
○ 5% of the palate, together with the first premolar on
both sides.
Technique
● Short 27 G needle (20–25 mm).
● Position of the dentist and patient:
○ The dentist is at 11:00 o’clock.
○ The patient is reclines with his/her head back and
neck extended (hyperextension). The patient’s mouth
is open as wide as possible so that the dentist can see
the palate directly.
The patient’s head can turn slightly to the right or left,
depending on the needs of the dentist.
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(a) (b) (c)
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272
Figure15.2 Nasopalatine nerve block. Indirect approach from the buccal area: (a) buccal infiltration from the frenulum and under
the maxillary central incisors, (b) insertion and infiltration in the gingiva oriented toward the interdental papilla, and (c) perpendicular
insertion that crosses the interdental papilla toward the palatine nerve.
● Approach the interincisive papilla, which is situated on
the palate, immediately behind and between the central
incisors along the midline. There are two methods, as
follows:
1) Indirect approach from the buccal area
Since the papilla is in one of the most sensitive and
painful areas of the mouth, many authors prefer an
indirect approach before injecting directly into the
papilla (Salagaray and Salagaray 1982; Bennett 1984;
Malamed1986), therefore they infiltrate via the buccal
area. It is also important to remember that pain is also
felt more intensely in the anterior part of the buccal
area at the maxilla, although less so than the palate
(Annex 23), therefore the technique should be
performed very carefully.
○ Buccal infiltration technique applied via the buccal
area between the central incisors at the level of the
frenulum using the minimum intervention technique (see Chapter 14) (Figure 15.2a). Remember
that while in this stage, the patient’s position must be
modified in order to approach the anterior buccal
area of the maxilla and not the palate. Then wait
30–60 seconds for the anesthetic to take effect in the
soft tissue.
○ The submucosal bulge can be gently massaged for a
short time in order to extend the anesthetic solution
throughout the soft tissue. Excessive massage will
hamper successful pulpal anesthesia.
○ From the area of the oral mucous membrane of the
anesthetized frenulum, one can gradually infiltrate
along the attached gingiva close to the interdental
papilla of the central incisors. Gingival blanching is
an indicator of the extent of the anesthetized area
(Figure 15.2b). Then, wait 30 seconds.
○ Insert the needle perpendicularly into the interdental
papilla of the central incisors from the buccal area,
immediately above what is estimated to be the top of
the alveolar ridge (if the needle comes into contact
with the bone, raise it a little more to pass over it),
thus ensuring that the needle crosses from the buccal
area to the palate (Figure15.2c).
○ The needle initially penetrates the palate to a small
degree. Inject a few drops under some pressure and
observe the blanching of the interincisive papilla or
of the part that is closest to the buccal area. Wait
some 15–30 seconds before withdrawing the needle
to prevent reflux of the anesthetic solution as a result
of the pressure (remember that the fibromucosa is
attached).
○ Repeat the maneuver by inserting the needle perpen-
dicularly via the buccal area (the position is generally
indicated by a blood spot), thus penetrating more
deeply into the palate in the interincisive papilla, and
inject a few additional drops. Once again, blanching
of the interincisve papilla can be observed.
There are several problems associated with the
indirect approach.
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○ Since this method is time- consuming, many clini-
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cians use it when nasopalatine nerve block is applied
as a complement to buccal infiltration of the anterior
maxilla.
○ When the needle is inserted perpendicularly from the
buccal area, it falls just within the patient’s field of
vision and may prove somewhat uncomfortable in
psychological terms (Malamed1986).
2) Direct approach
○ Press the interincisive papilla firmly with the tip of a
cotton swab, a little bar of ice, or the end of the shaft
of the mirror (see Methods for making palatal anesthesia less painful).
○ The papilla should be injected laterally from the pal-
ate in the area where pressure is being applied (lateral
groove of the papilla that separates the papilla from
the palate) to 1–2
drops in 1–2
nique) and wait 30
○ The maneuver should be repeated to inject a further
one to two drops in 1–2
mm (Figure15.3). Inject one or two
seconds (minimum intervention tech-
seconds.
seconds so that the whole
papilla can be anesthetized.
● Anesthesia of the maxillary incisive canal, which is imme-
diately below the papilla. The procedure is as follows:
○ Insert the needle perpendicularly into the interinci-
sive papilla along the axis of the buccal plate of the
central incisors (Phillips and Maxmen1941; Annex41)
(Figure15.4).
○ Advance the needle to a depth of 5–10 mm
(Figure15.4). Remember that the foramen is 2–4
mm
below the papilla.
○ Aspirate before injecting. Positive aspirations are
observed in approximately 1% of cases (Annex 22).
273
Figure15.4 Insert the needle following the axis of the central
incisors and advance 5–10 mm in the maxillary incisive canal.
○ Slowly inject a few drops of anesthetic (<1/8 of a
cartridge, <0.2
ml), and the papilla will begin
to blanch.
● The subjective symptoms of anesthesia, i.e. the soft tis-
sue anesthesia that patients define as dullness, numbness, or tingling (Table 13.1, Chapter 13), appear in
minute in the anterior part of the palate. This is more
1
obvious when the patient touches the area with his/
her tongue.
● Anesthesia is complete in 2–3 minutes and lasts
hours (80 minutes). The patient should be informed
1–2
about this.
Figure15.3 With the papilla under pressure from the cotton
swab, the needle is inserted laterally into the papilla.
Specific Complications ofThis Technique
The technique has few complications and the most relevant are the following:
1) Inflammation and reddening (erythema) of the interin-
cisive papilla after the procedure. Hematoma appears
more rarely and sterile abscess caused by mucosal
necrosis is even more exceptional. The complications
are usually caused by the high volume of anesthetic
injected or the anesthetic being injected too quickly,
since the capacity of the palatal fibromucosa to distend
is very limited at this level. The lesions resolve spontaneously in a few days.
2) Trophic ulcer is a possible complication, although very
rare (Hartenian and Stenger1976) (see Chapter22 on
local complications).
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3) Overpenetration of the needle by more than 10 mm in the
incisive canal can cause the anesthetic solution to enter
the nostril and cross the choanae to the pharynx, thus
leaving the patient with a sensation of liquid in his/
her throat.
Intranasal Variant
The nasopalatine nerve cannot be anesthetized via the
interincisive papilla when this is infected, therefore the
nerve is blocked at the level of the nasal septum, immediately before entering the interincisive canal, since at this
level it is immediately below the nasal mucosa of the septum (Birn and Winther1977; Evers and Haegerstam1981;
Haglund and Evers1985). This method has the disadvantage of being less efficacious than the previous method
since it requires the diffusion of a topical anesthetic, which
is weaker.
Technique
● The patient’s nose must be perfectly clean and the mouth
must remain open to enable breathing.
● With the cotton tip soaked in topical anesthetic (generally
benzocaine 20% or lidocaine 5% gel, ointment, cream, or
paste), the swabs should be inserted via the nostrils first
on one side and then on the other using the following method:
○ Insert the swab upwards and backwards so that it
enters the nostril (Figure15.5).
○ Once the swab is inside the nostril, adjust the posi-
tion by placing it horizontally to the floor of the nose.
○ Insert the swab approximately 15–20 mm into the nos-
tril while maintaining contact with the floor of the
nose and septum (Figure15.6).
Figure15.6 Swabs in contact with the nasal septum and floor.
Note how far they extend into the nasal cavity. Redrawn
from Birn and Winther (1977).
● With the swab in position, wait 1–3 minutes for the anes-
thetic to take effect (Figure15.5).
● The subjective symptoms of anesthesia may appear after
1–3
minutes in the anterior part of the palate and become
more obvious when the patient touches the interincisive
papilla with the tip of the tongue.
● Before starting the procedure, it is necessary to do the
following:
○ Remove the swabs from the nostrils to facilitate work
on the mouth.
○ Allow the patient to blow his/her nose to remove any
remaining topical anesthetic and to relieve nasal discomfort (mucus and itching).
Greater Palatine Nerve Block
In older books, this technique is known as anterior palatine
nerve block.
Figure15.5 Placement of the cotton swabs inside the nostrils.
Redrawn from Birn and Winther (1977).
Area Anesthetized
The area anesthetized corresponds to the fibromucosa,
periosteum, and palatine bone in the part to be treated
(Table2.1 and Figure2.7, Chapter2), as follows:
○ 100% of the molars on the respective side.
○ 100% of the second premolars on the respective side.
○ 95% of the first premolars on the respective side.
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○ 75% of the canines on the respective side.
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○ 50% of the palate behind the lateral incisor on the respec-
tive side.
Technique
● Short 27 G needle (20–25 mm).
● Position of the dentist and patient:
○ The dentist is positioned as follows:
■ 8:00–9:00 o’clock for the right side.
■ 11:00–12:00 o’clock for the left side.
○ The patient lies down with his/her head backward, the
neck extended (hyperextension), and the mouth open
as wide as possible so that the dentist can see the palate directly. The patient’s head can turn toward the
right for block of the right side and slightly to the left
for block of the left side.
● Location of the insertion point. With this technique, it is
not necessary to accurately locate the greater palatine
foramen, since we are going to block the nerve in
front of it.
○ The nerve is found at the junction of the horizontal hard
palate with the vertical alveolar process (Westmoreland
and Blanton 1982; Malamed and Trieger 1983); in
approximately 85% of cases it lies around the third molar
(Annex 42) (Figure14.15, Chapter14). The third molar
zone is the area ranging from a point slightly forward of
the third molar (between it and the second molar) to a
point slightly backward of the third molar and including
the third molar zone (Annex 42). Thus, the injection
point is in front of the second molar and at the midpoint
between the palatal gingival festoon of the second molar
and the palatine raphe, in other words, some 15 mm
toward the palatine raphe.
○ If the molars are missing, the reference is take as a
point 10–15
mm in front of the limit between the hard
palate (pale gray mucosa) and the soft palate (dark red
mucosa) (Mercuri1979; Wong and Sved1991). It is
also possible to inject in the area where the fibromucousa of the palate is thicker and the connective tissue laxer.
○ Clinical studies have shown that anesthesia of the soft
tissues of the hard palate lasts longer when the anesthetic is administered in front of the greater palatine
foramen (Meechan etal.2000).
● The needle is directed from the opposite side; if it is to be
inserted into the right side of the palate, it is directed
from the left side and vice versa. If necessary, the lower
premolars on the contralateral side can be used for support (Figure15.7).
● The needle is inserted and injected using the minimum
intervention technique, as explained above (minimum
275
Figure15.7 Greater palatine nerve block. The needle is
inserted from the opposite side.
volume/minimum injection time) to reduce the pain of
the injection into the palate.
○ Warn the patient that he/she will feel some “discomfort”
when the anesthetic is injected into the palate, but
emphasize that this will be “very quick.” Prepare the
patient psychologically, given that unexpected painful
events are perceived as being more painful; in addition, during the nonpainful periods of administration,
allow the patient to relax, reassured by explanations
(Jackson1974; Wepman1978).
○ Press firmly on the area to be injected with the head of
a cotton swab or bar of ice or the end of the shaft of the
mirror (see section on methods for making palatal
anesthesia less painful).
○ Inject perpendicularly into the palatal fibromucosa
where pressure is being applied. Insert the needle a
few millimeters (2–5 mm, it is not necessary to
reach the bone) (Figure 15.8), inject only a few
drops of anesthetic in 1–2 seconds, and wait 60 seconds after withdrawing the needle. This ensures
that the soft tissues at the injection site are
anesthetized.
○ Repeat the maneuver and then inject one or two drops
at the same site (the blood spot created by the first
injection is usually visible) in 1–2 seconds and this
time wait only 30 seconds.
○ Finally, at the same site, inject a larger amount of
anesthetic (±1/8 of a cartridge, ±0.25 ml) slowly in
7–10 seconds after aspiration and wait a further 30 seconds. Note that a large amount is not injected, but
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276
nerve
Figure15.8 The needle is inserted perpendicularly into the
palate. It is not necessary to reach the bone.
vein and artery
rather a small amount to reinforce the previous injections and thus begin anesthesia of the palate.
● The aspiration is positive in approximately 1% of cases
(Annex 22).
● The subjective symptoms of anesthesia, i.e. the soft tis-
sue anesthesia that patients define as dullness, numbness, or tingling (Table 13.1, Chapter 13), appear in
1
minute in the hard palate on the same side, from the
midline to the area of the molars and premolars. It is
important to remember that the tissues of the palate
behind the injection site are not anesthetized.
● Anesthesia is completed in 2–3 minutes and lasts around
2
hours (130 minutes). The patient should be told
about this.
isthmus), and the soft palate, thus potentially leading
the patient to retch, feel nauseous, and experience the
subjective sensation of not being able to swallow. In
such cases, reassure the patient and inform him/her
that it is possible to swallow because the muscular
(motor) structures have not been anesthetized or have
only been so partially and that only the sensitive part
has been anesthetized. In addition, when the anesthetic
wears off, the discomfort disappears (Allen1979; Jastak
etal.1995).
Partial Variant ofthe Palate
As we have seen, the area of the palate covering the lateral
incisor and first premolar is an area where the fibers of the
nasopalatine and greater palatine nerve cross (Phillips and
Maxmen1941; Langford1989), therefore direct injection here
makes it possible to anesthetize the area (Nordenram 1971;
Allen1979).
The technique is practically the same as that used for
greater palatine nerve block, although it is performed more
anteriorly (Figure15.9) (Roberts and Sowray1987).
Transpapillary Technique inChildren
In children, palatal techniques can be very painful,
leading to uncontrolled reactions and loss of trust in the
dentist (Roberts and Sowray 1987; Jastak et al. 1995).
Techniques for making palatal anesthesia less painful
Specific Complications ofThis Technique
While this technique has few complications, the following
should be noted.
1) Inflammation and reddening (erythema) at the injec-
tion site, which becomes apparent after the procedure.
Hematoma resulting from puncture of a vessel is more
unusual. Even more uncommon is the appearance of a
sterile abscess resulting from necrosis of the mucosa.
This is usually caused by injecting too much anesthetic
or injecting too quickly, since the capacity of the palatal
fibromucosa to distend is limited. The lesions resolve
spontaneously in a few days.
2) Injecting too far back and anesthetizing the lesser pala-
tine nerves (previously known as the posterior palatine
nerves). In this case, anesthesia affects the velum of the
palate, the uvula, the tonsillar pillars (oropharyngeal
Figure15.9 More anterior block in the area where the greater
palatine nerve and nasopalatine nerve cross.
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may prove ineffective in children (Harbert1989), therefore an indirect approach from the buccal area across
the interdental papilla (intrapapillary technique)
is used.
Technique
● Infiltrate buccally, close to the teeth where the palate is to be
treated, using the minimum intervention technique (minimum volume/minimum injection time) (see Chapter14).
Wait 1–2
● Insert the needle into the attached gingiva, close to the
minutes until the mucosa has been anesthetized.
area anesthetized using buccal infiltration and infiltrate
a few drops while applying pressure. Blanching of the
gingiva can be observed. Wait 30
seconds for the anes-
thetic to take effect.
● Insert the needle at the limit of the blanched attached gin-
giva and direct it toward the interdental papilla. Slowly
infiltrate a few drops of anesthesia while applying pressure
and observe the resulting blanching. Wait a further
30 seconds.
● Insert the needle perpendicularly into the papilla from
the buccal area toward the palate, immediately above
the approximate area of the alveolar ridge (if contact is
made with the ridge and the needle cannot advance,
repeat the maneuver a little higher up to pass over the
bone), but without the needle crossing the palate
(Figure 15.10). Inject a few drops under pressure and
observe the resulting blanching in the palatal gingiva
near the papilla. Wait 30 seconds for the anesthetic to
take effect.
An old trick used by some pediatric dentists during this
maneuver is to place a thick cotton roll between the teeth
and ask the child to bite down on it while the buccal
mucosa is being separated. Thus, the child’s attention is
distracted and the dentist has more buccal space in which
to work.
● Repeat the above maneuver, although this time inserting
the needle a little further along on the palatal gingiva
(Figure15.11) and slowly injecting a few drops of anes-
thetic with a certain degree of pressure. It is very impor-
tant not to perforate the palatal mucous membrane with
the needle since this would lead to injection outside and
leave a hole in the palatal gingiva that prevents pressure
from being applied during the injection (and thus infil-
trating the attached tissue appropriately). In addition,
perforation favors leakage of the anesthetic solution to
the outside.
● As applicable, the area of the palate anesthetized can be
widen using the same system by inserting the needle into
the peripheral anesthetized area (blanched area) and
slowly infiltrating a few drops under pressure and
observing how the area of blanching and therefore the
anesthetized area extend.
Figure15.10 Transpapillary technique. Insert the needle
perpendicularly into the papilla but without allowing it to reach
the palate.
Figure15.11 Insert the needle perpendicularly into the palate
so that it passes toward the palatal gingiva without perforating
the palatine mucosa.
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278
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