LOCAL ANESTHESIA 
SIMPLIFIED 
POSNER 
THE G V. MOSBY CO.-Publishers-St Louis LOCAL ANESTHESIA SIMPLIFIED William Stewart Halsted LOCAL ANESTHESIA 
SIMPLIFIED 
BY 
JOHN JACOB POSNER, D.D.S. 
/ /1 
NEW YORK 
CHIEF OF THE DENTAL DEPARTMENT HARLEM DISPENSARY 
FORMER INSTRUCTOR IN ORAL SURGERY, NEW YORK HOMEO- 
PATHIC MEDICAL COLLEGE AND FLOWER HOSPITAL, VISITING 
DENTAL SURGEON, ST. LUKE’S HOSPITAL, NEW YORK 
FIFT Y-FIVE ILL US TEAT IONS 
ST. LOUIS 
THE C. V. MOSBY COMPANY 
1924 Copyright, 1924, By The C. V. Mosby Company 
(All rights reserved) 
Printed in U. S. A. 
Press of 
The C. V. Mosby Company 
St. Louis, U. S. A. TO 
MY BROTHER 
LOUIS 
AS A TOKEN OF DEEP AFFECTION 
THIS BOOK IS DEDICATED INTRODUCTION 
Were I learning to make a gold inlay, I should watch the 
cavity prepared, the wax pattern made, and carved; see 
the manner of investment, how it is burned out, how cast. 
There can be no question but that this, the objective, is the 
quickest mode of learning, and is the longest retained. 
Often the prepared paper at a meeting is followed by lan- 
tern slides to afford a clearer picture of what the speaker 
wishes to convey. By far the greatest interest is shown in 
table clinics, where a close-up of the technic may be had 
and one can see the thing actually done. 
The value of the printed book is not ojjen to question. 
Its store of information may be culled and digested at 
leisure. Yet the usual textbook leaves much to be desired, 
for too often clearness of the thought and sharpness of the 
picture are blurred by the accumulation of all known data 
relating to the particular subject, so that its perusal points 
no definite course and the right method is obscured in elab- 
orations of all known methods and theories. 
In this book the author has endeavored to overcome 
these drawbacks by brevity, directness and ample illustra- 
tion, yet with due regard for completeness. Such details 
concerning structure and nerve supply as are necessary are 
not obscured by discussions of anatomy, physiology, ma- 
teria medica, and the like. Here you will find an outline 
of simple technic that will meet the practicing dentists’ 
requirements in the great bulk of cases. Emphasis is laid 
upon two injections. They are the new supraperiosteal 
injection for infiltration anesthesia, and the mandibular 
injection for block anesthesia. With these two injections 
alone it will be possible to treat ninety-five per cent of the 
cases that arise in ordinary practice. 
9 10 
INTRODUCTION 
Local anesthesia is a definite science. We are sure of our 
ground and our failures and successes can be quickly re- 
corded. Either you have produced the desired anesthesia 
or you have not. The technic is simple and easily acquired, 
anesthesia is rapid and profound and the picture is not 
confused by opposing views such as obtain in the fields of 
operative and prosthetic dentistry. 
No writer on the subject of local anesthesia can be un- 
mindful of his obligation to the previous workers in that 
field. To them the writer expresses his thanks—to W. S. 
Halsted, Guido Fischer, S. L. Silverman, Harry Sicher and 
Theodor Blum, particularly to the latter for his kindness 
in reading the proofs. The author’s appreciation is also 
expressed to Mr. Martin Ilaggett of New York and Mr. 
Milne of Philadelphia for their photographic assistance. 
John Jacob Posner. 
New York City. CONTENTS 
CHAPTER I page 
General Considerations 17 
CHAPTER II 
Instrumentarium . 20 
Syringe, 21; Platinum Iridium Needles, 21; Thin Needle, 23; Heavy 
Need'e, 23; Guide, 24; Novocaine, 24; Ampules, 24; Suprarenin, 24; 
Applicators, 25; Aconite and Iodine, 25; Boiling Water, 25; Care of 
Syringe, 26; Infection, 27. 
CHAPTER III 
Nerve Supply of the Jaws 28 
Fifth Nerve, 28; Ophthalmic, 28; Maxillary Nerve, 29; Nasopalatine 
Nerve, 30; Anterior Palatine Nerve, 30; Middle and Posterior Pala- 
tine Nerves, 31; Middle Superior Dental Nerve, 31; Anterior Superior 
Dental Nerve, 31; Mandibular Nerve, 32; Lingual Nerve, 33; Long 
Buccal Nerve, 33. 
CHAPTER IV 
Bone Structure 34 
Examination of the Maxillae, 34; Palatal Structure of Maxillae, 36; 
Foramina in Maxillae, 36; Infraorbital Foramen, 36; Posterior Su- 
perior Dental Foramina, 36; The Mandible, 38; Foramina in Mandible, 
40; Mandibular Foramen, 41. 
CHAPTER V 
The Old Technic in Infiltration 42 
CHAPTER VI 
Supraperiosteal Injection—Present Technic of Infiltration .... 45 
The Mucobuccal Fold, 45; Precautions, 47; A Logical Injection, 48; 
Where, How and Why, 48; Preliminary, 48; Filling the Syringe, 49; 
Insertion of the Needle, 49; Conversation, 50; Caution, 50; Fulcrum, 
50; Holding the Syringe, 52; Central Incisor, 52; Effects of a Single 
Buccal Injection, 52; Extent of Anesthesia, 57; Palatal Injection, 
57; Lateral Incisor, 58; Canine, 58; Bicuspids, 58; First Molar, 58; 
Second and Third Molars, 63; Palatal Anesthesia, 64; Pathology, 
67; Infiltration in the Mandible, 70; Mental Fossa Injection, 70; 
Lateral and Central, 70; Lingual Injection, 73; Infected Areas, 73. 
11 12 
CONTENTS 
CHAPTER VII 
PAGE 
Conduction Anesthesia or Nerve-Blocking 75 
Retromolar Triangle, 78; The Injection—Right side, 80; Procedure, 
82; Passing the Internal Oblique Line, 84; Final Stage of the 
Mandibular Injection, 84; Symptoms of Anesthesia, 92; Mandibular 
Anesthesia, Left Side, 92; Extent of Mandibular Anesthesia, 92; 
Long Buccal Injection, 96. 
CHAPTER VIII 
Nerve-Blocking in the Maxillae 99 
The Infraorbital Injection, 99; Former Infraorbital Injection, 99; 
New Infraorbital Injection, 100; General Observations, 103; Tuber- 
osity Injection, 103; The Bicuspids, 106; Conduction Anesthesia of 
the Palate, 106; Nasopalatine Injection, 106; Block Anesthesia of 
Anterior Palatine Nerve, 107. 
CHAPTER IX 
General Observations 108 
Uses of Local Anesthesia in Dentistry, 108; After-pain, 110. ILLUSTRATIONS 
FIG. PAGE 
1. Ampule of novoeaine, 3 c.e. (Metz). Luer Lok Posner syringe 
mounted with one inch needle. Ground glass plunger for syringe. 
Mandibular needle with guide 22 
2. Glass jar for holding syringe 26 
3. Schematic drawing of fifth nerve 29 
4. Skull, front view 35 
5. Palate 37 
6. The tip of the needle indicates the foramina entered by the posterior 
superior dental nerve 38 
7. Structure of the maxillae as seen in cross section, and cross section 
of mandible 39 
8. The mandibular sulcus on the inner surface of the ramus .... 40 
9. The lip and gum form a distinct angle. This line of reflection is 
the mucobuccal fold 46 
10. Holding the syringe while piercing the mucous membrane ... 51 
11. Discharging the solution 51 
12. The needle enters the mucobuccal fold, distal to the central ... 53 
13. The needle is advanced to the apex of the central 54 
14. During the progress of the needle to the apex, the shaft lies on the 
gum 55 
15. The anterior nasal spine is encountered at the conclusion of the in- 
jection for the central 56 
16. Conclusion of the injection for the lateral 57 
17. Reaching the apex of the canine 59 
18. Anesthetizing the first bicuspid. The needle is seen entering the muco- 
buccal fold 60 
19. Injection for the second bicuspid 61 
20. Completion of the injection for the second bicuspid with the orifice 
of the needle at the apex ... 62 
21. The syringe is tilted backward and the needle glides beneath the 
malar process in injecting the first molar 63 
22. It is unnecessary to advance beyond the apices of the second or third 
molars for profound anesthesia 64 
23. The curve of the tuberosity as it comes on to the palate is distinctly 
seen. It marks the path of the anterior superior dental nerve 
directly beneath it 65 
24. The palatal injection is begun by entering the mucosa from the op- 
posite side at an angle to the tooth 66 
25. The needle is advanced to the bone parallel with the long axis of the 
tooth; the syringe in palatal anesthesia is almost horizontal . . 68 
13 14 
ILLUSTRATIONS 
FIG- PAGE 
26. Injection on the palate behind the canine 69 
27. The needle is seen to enter the mucobuccal fold, and is advanced to 
the mental fossa 71 
28. Infiltration of the central incisor. The mucobuccal fold begins at the 
lower border of the dense gum 72 
29. Block anesthesia 76 
30. The needle extending directly beyond the last molar, is far removed 
from the internal oblique line 76 
31. The correct position of die syringe at the outset of mandibular 
anesthesia 77 
32. A wire nail has been inserted into the mandibular foramen, lying 
well to the buccal aspect of the last molar 78 
33. The finger has been correctly placed as a guide in mandibular anes- 
thesia. The lower border of the finger touches the buccal cusps of 
the molars 79 
34. At the outset of the mandibular injection, the needle seeks to en- 
counter the internal oblique line 80 
35. The beginning of mandibular anesthesia, showing the first position of 
the syringe, and correct position of the index finger of the left 
hand 81 
36. First position in mandibular anesthesia, with the needle entering at 
the center of the finger nail 83 
37. The internal oblique line has been passed and the lingual nerve anes- 
thetized from this position 85 
38. In passing the internal oblique line, the syringe is sometimes carried 
across the median line to a position above the teeth on the in- 
jected side 85 
39. Showing an extreme position of the syringe, brought alongside the 
finger in an endeavor to pass the internal oblique line .... 86 
40. From the final position of the syringe in the median line, the needle 
is advanced to the mandibular sulcus 87 
41. Another view of the completed mandibular injection 87 
42. Final position of the syringe in the median line, with the orifice 
of the needle in contact with the inner surface of the ramus . . 88 
43. A successful mandibular injection. The needle is at the mandibular 
sulcus, the syringe in the median line 88 
44. Showing a wire which lias been passed through the mandibular canal 
of a dry mandible 89 
45. Two Peruvian mandibles, adult and child, showing great difference 
in .size of ramus 91 
46. View of inner surface of ramus 91 
47. Mandibular injection on the left side 93 
48. Correct technic for the left side. The left forearm lies across the 
patient’s chest 94 
49. Injection for the right side showing clear view of the field ... 95 ILLUSTRATIONS 
15 
FIG. PAGE 
50. Area supplied by long buccal nerve 96 
51. Entering the mucobuccal fold for the long buccal injection ... 97 
52. The needles in the infraorbital foramina converge towards the median 
line 100 
53. Beginning of the infraorbital injection at the mucobuccal fold near 
the central apex 101 
54. Path of the needle in the infraorbital injection 102 
55. In the tuberosity injection the needle must be carried to the corner 
of the mouth in order to maintain its contact with the tuberosity . 105 LOCAL ANESTHESIA SIMPLIFIED 
CHAPTER I 
GENERAL CONSIDERATIONS 
The very thought of a dental chair fills otherwise cour- 
ageous people with terror. This explains why many who 
are careful of their appearance in every particular never- 
theless go about with decayed teeth or infected mouths. 
Here is a wrong to the public and a wrong to the pro- 
fession as well. Dentistry, by means of local anesthesia, 
can be made painless. The developments and experience 
of the past decade prove this. Yet our profession has been 
so slow—negligently slow—in taking the full advantage 
of this fact that it is not surprising to find the public in 
ignorance of improved methods in controlling pain. The 
patient comes to the dental chair reluctantly and only as a 
last and inescapable resort. 
It follows that if we can dispel or at least mitigate 
the fear of the dentist and his instruments and inform the 
public that in the main our work can be done painlessly, 
and can keep the promise, we shall make great forward 
strides and those who require treatment will visit the den- 
tist more willingly and more frequently. 
Our most powerful ally in the elimination of pain inci- 
dent to dentistry is local anesthesia. Once the simple tech- 
nic of injection is mastered the dentist’s progress and the 
patient’s relief are assured. 
We can readily understand why fear of the dentist be- 
came so deeply rooted, for it is only forty years since the 
discovery of cocaine and its introduction into dental prac- 
tice. More recently, in 1905, Einhorn of Germany gave 
17 18 
LOCAL ANESTHESIA SIMPLIFIED 
novocaine to tlie world. This marked a rapid advance in 
the art of local anesthesia, for here was an agent possessed 
of the anesthetic powers of cocaine, yet without its tox- 
icity. 
In 1913, Dr. Guido Fischer during a visit to the United 
States gave further impetus to the subject of local anes- 
thesia and its uses in dentistry. In a series of clinics con- 
ducted here he conclusively demonstrated the exceptional 
value of novocaine for this purpose. What particularly in- 
terested the profession was the presentation of a novel 
means of obtaining anesthesia, known as the conduction 
method or nerve-blocking. This, however, was not our first 
knowledge of conduction anesthesia; it is but fair to note 
that the honor for accomplishing the first successful result 
of that character belongs to an American. In 1884 Dr. 
William Stewart Halsted of Johns Hopkins University 
blocked the mandibular nerve at the mandibular foramen, 
using a cocaine solution. But this method of nerve-block- 
ing, original as it was, was fraught with danger, owing to 
the toxicity of cocaine, and in consequence was not readily 
adopted by the profession. The method, however, returned 
to favor with the introduction of novocaine. 
Today the mandibular injection is of first importance. 
The blocking of this nerve at the inferior dental foramen 
presents the only dependable means of obtaining anesthe- 
sia of the lower molars. The structure of the body of the 
mandible will not permit infiltration, so there is no other 
feasible mode but that of block anesthesia. Notwithstand- 
ing this fact many dentists still persist in trying to infil- 
trate lower molars—with indifferent success—entirely dis- 
regarding the mandibular injection. This is regrettable 
for, as we shall see, mandibular anesthesia is not difficult 
if properly approached and an earnest effort made to mas- 
ter its simple technic. It is astonishing how limited is the 
extent to which the profession has devoted itself to serious 
effort in the art of local anesthesia. GENERAL CONSIDERATIONS 
19 
The purpose of this writing is to reduce the subject of 
local anesthesia and its technic to a clear working basis, 
to eliminate nonessentials, and to provide the student as 
well as the practising dentist with a simple, safe and effi- 
cient method of procedure. 
I shall endeavor to simplify the involved and twisted pic- 
ture that comes immediately to mind when we speak of 
dental nerve centers and nerve supply—a picture whose 
complicated lines have become often more confused rather 
than defined in the time that has elapsed since our student 
days; to suggest a standard instrumentarium, to describe 
in particular those injections which should be in common 
use, merely mentioning those which demand no place in 
routine practice; and finally to complete the picture with a 
number of illustrations which deal with every required 
injection, and which will bring the subject before the reader 
in a realistic and, I believe, exceedingly helpful manner. 
An attentive study of this volume should enable the 
reader to turn from its pages and carry out the injections 
described. To that end, as already stated, the methods will 
be carefully confined to those of proven value in everyday 
dentistry. CHAPTER II 
INSTRUMENT ARIUM 
Any task can be better and more rapidly accomplished 
with proper working tools than with clumsy, poorly 
adapted contrivances. This should be elementary; yet why 
is it so unusual to find a practical working local anesthesia 
outfit in a dental office? Too often the syringe, needle still 
attached, rests in a cabinet drawer where it wTas carelessly 
thrown after its last adventure; while the novocaine tablets 
and extra needles are in another compartment lying about 
familiarly in the company of separating discs, cleaning 
brushes, etc. 
If you want what you want when you want it, the best 
plan is to keep it where you will find it when you need 
it. With the exercise of ordinary care the anesthesia equip- 
ment can be always at hand, complete, compact and ready 
for instant service. 
In the first place a table or shelf of some kind should be 
reserved exclusively for the outfit. It should be strictly 
maintained as such. The following articles are essential: 
Syringe, capacity 3 c.c. 
Platinum iridium needles. For infiltration one inch 25 
gauge. For conduction, one and one-half inches 22 gauge, 
with guide. 
Novocaine suprarenin solution in ampules. 
Flat glass receptacle for holding needles and syringe. 
Bottle of aconite and iodine. 
Alcohol lamp. 
Wooden applicators. 
Enamel-ware dish and heater. 
When you realize that this simple outfit means better 
work, happier patients, and pleasanter experiences for 
20 IXSTRUMEXTARIUM 
21 
yourself you will cheerfully bear the small expense en- 
tailed. Think of what you must pay for an x-ray machine, 
your dental chair, or your electric engine! These items 
cost hundreds of dollars apiece. Surely then you cannot 
omit a proper anesthesia equipment with its extremely 
modest cost, particularly when you consider the widespread 
benefit accruing from its use. It opens a field of broader 
activity to the dental surgeon and permits operations which 
he would not otherwise venture to undertake. 
Syringe 
The writer has designed a syringe for dental use which 
is particularly suited for the various injections. It may be 
boiled with impunity, although it is constructed for the 
most part of glass. The tip is cone-shaped and the smooth 
hub of the needle slips over it and is locked in position 
with a twist of the fingers. The interchange of needles is 
a matter of but a moment. The extreme lightness of the 
syringe permits an ease and delicacy of manipulation which 
is entirely lacking in the heavier pressure syringes. (Fig. 
1.) 
Platinum Iridium Needles 
After many years of use of both steel and platinum 
needles, the choice at present seems to favor the latter; 
they require no bothersome wires to be kept within them, 
they will not rust or clog, and there is no chance of infec- 
tion. With the new technic of infiltration anesthesia, which 
will be fully described later, the platinum iridium needle 
may be successfully used as it will not bend, neither will 
the point become quickly dulled. Here were two indict- 
ments against the platinum needle under previous methods 
of infiltration. The distinctive feature of such needles is 
the ease with which they may be instantly and absolutely 
sterilized in the open flame. After repeated use the point 
may be quickly dressed on an Arkansas stone by a few 
gentle side to side movements through a drop of oil. 22 
LOCAL ANESTHESIA SIMPLIFIED 
Fig. 1.—Ampule of novocaine 3 c.c. (Metz). Luer Lok Posner syringe 
mounted with one inch needle. Ground glass plunger for syringe. Mandibular 
needle with guide. IXSTRUMEXTARIUM 
23 
Thin Needle 
Wherever infiltration anesthesia is indicated, the fine 25 
gauge needle one inch in length should be used. It is flex- 
ible and easily introduced. It permits insertion with much 
less pain than is possible with the short, hard needle. 
Heavy Needle 
For the mandibular injection a stout needle is advisable; 
22 gauge, one and one-half inches, is just right. One and 
one-lialf inches is the actual length of needle soldered to 
the hub. At first glance it may appear far too heavy and 
one would suppose that the pain of its insertion could not 
be tolerated. This is not the case. After the first few in- 
jections the operator will be decidedly unwilling to return 
to the thinner gauged needle; the dreaded bugbear of a 
broken needle vanishes, and the proper technic may be car- 
ried out with a sense of full security. 
The widespread use of the thin needle for mandibular 
anesthesia is to be discouraged. Dr. Fischer, who advo- 
cated the thin needle for mandibular anesthesia ten years 
ago, is now employing a heavier one in its place. The 
objection is not entirely because of the grave danger of 
breakage. The thin needle is easily deflected from the pro- 
posed course and this may be noticed only as the needle is 
being withdrawn. It is seen to emerge from a direction 
never intended, which means that the novocaine solution 
has been poorly placed. Besides the probable loss of anes- 
thesia, it frequently follows that a muscle has been infil- 
trated, with consequent impairment of function. The tris- 
mus which results, manifested by the inability of the pa- 
tient to open the jaws, is one of the complications which 
can be avoided by the use of a heavy needle. With it the 
operator can make certain that the orifice is in contact with 
the inner surface of the ramus and that the solution is 
being released in close proximity to the bone. 24 
LOCAL AXESTHESIA SIMPLIFIED 
Guide 
A guide should be employed on the mandibular needle 
in order to indicate one inch from the point. The needle 
in this injection should never enter to a greater depth than 
three-quarters of an inch. In consequence, there remains 
always a liberal portion of the needle exposed beyond the 
three-quarters inch insertion and it is then a simple matter 
to grip and remove the needle should it break at the hub. 
Under no circumstance should the full length of the needle 
be inserted. If this is followed as an invariable rule you 
may rest content that in so far as you are concerned the 
danger of broken needles is banished. 
Novocaine 
Naturally the most important part of the equipment is 
the drug itself. For twenty years, novocaine has with- 
stood every clinical test. Dr. Braun’s declaration in the 
early days of its use that it is the ideal agent for inducing 
local anesthesia has been amply supported by the experi- 
ence of later years. A two per cent solution is used 
throughout. 
Ampules 
In addition to novocaine suprarenin in tablet form, this 
anesthetic may now be obtained in ampules, ready for use. 
The novocaine suprarenin is combined with Ringer solution, 
and hermetically sealed in a clear crystal ampule. Abso- 
lute sterility is thereby assured. The use of novocaine 
suprarenin in the ampule form is rapidly growing in favor, 
and this solution when sealed in ampules will remain stable 
for years. 
Suprarenin 
The use of suprarenin in combination with novocaine af- 
fords distinct advantages. The action of the suprarenin 
contracts the little blood vessels with which it comes in mSTRTJMEXTARIUM 
25 
contact. The circulation of blood in the part is thereby 
lessened and the surgeon is provided with a comparatively 
bloodless field of operation. Furthermore, the novocaine 
will not rapidly escape from the point of release and is 
compelled to exercise its anesthetic powers just where 
wanted; the contracted blood vessels, by keeping the novo- 
caine solution from being absorbed into the blood stream 
too rapidly, naturally diminish the possible ill-effects aris- 
ing from this source. 
Applicators 
These are the least expensive and most convenient mem- 
bers of the equipment. Wrap one end with a wisp of cot- 
ton and you have an ideal means of swabbing the proposed 
point of injection. They are about six inches long; and 
should be employed full length. 
Aconite and Iodine 
A mixture of aconite and iodine is used for painting the 
mucosa at the initial point of introduction of the needle. 
Its efficiency is greatly increased if the mucosa is thor- 
oughly dried before the application. 
Boiling Water 
The same sterilizer employed for instruments is not to 
be used for boiling the needles and syringe. Bicarbonate 
of soda is added to the water in the sterilizer to prevent 
the instrument from rusting. Bicarbonate of soda how- 
ever, is not compatible with novocaine and if traces of it 
remain in the syringe the novocaine will be impaired. This 
drug also attacks glass and will cause a syringe to leak 
which has been boiled in its presence. A separate little 
pan should therefore be used for the needed supply of boil- 
ing water. Ordinary tap water is satisfactory. 26 
LOCAL ANESTHESIA SIMPLIFIED 
Care of Syringe 
When the injection has been completed and while the 
needle is still attached draw up some boiling water three 
or four times; you may now detach the needle, remove the 
plunger and place all into the boiling water. To draw 
boiling water into the syringe directly without the needle 
being attached will fracture the glass barrel. Boiling the 
needle cleans the hub; the needle itself, being of platinum 
iridium, should be sterilized in the open flame. A little 
Fig. 2.—Glass jar for holding- syringe. 
wooden spring clip, such as is used by musicians, is well 
suited for the transfer of the syringe and needles to the 
adjacent glass receptacle. The Luer Lok Posner syringe 
need not be suspended in the familiar jar containing alcohol. 
Obtain an ordinary low glass dish with cover and place a 
piece of sterile unbleached muslin in the bottom; here you 
may deposit syringe and needles when not in use. Such 
a jar can be obtained at any department store for not more 
than twenty-five cents. (Fig. 2.) INSTRUMENTARIUM 
27 
Infection 
Much of the trouble arising after the use of local anes- 
thesia may be traced to infection through uncleanliness. 
There may be no control, as to the dentist himself, his 
hands, and the instruments which he uses for the oper- 
ation; but at least his anesthesia outfit has been rendered 
safe. Lack of time is frequently responsible for careless 
sterilization. The busy man will be quick to appreciate 
the speed and safety of the instrumentarium suggested. 
The platinum needle is passed through the flame and is 
sterile. Xovocaine suprarenin in ampules provides a sterile, 
isotonic, safe solution, ready when you are. The syringe 
after each use is permitted to boil while you proceed with 
the operation, and may therefore be safely used for each 
succeeding patient. It reposes in its glass receptacle, 
sterile and ready immediately. A sterile needle, a sterile 
solution, a sterile syringe! CHAPTER III 
NERVE SUPPLY OE THE JAWS 
Since this little volume is designed to be of a practical 
nature, the last thing desired is to betray the reader into 
a troublesome network of names and nerves. 
It is essential of course to know the manner in which 
teeth and their surrounding structures receive sensation; 
otherwise it would be quite impossible intelligently to in- 
sert the needle and know in advance just wliat areas will 
be influenced by the injection. The following few pages 
will simplify and summarize the subject sufficiently for all 
practical purposes. 
Fifth Nerve 
This nerve holds all interest for dentists because it gives 
sensation to the teeth and their surrounding structures. It 
arises from the brain by two roots. One is a root of sen- 
sory nerves, the other of motor impulses. Our chief con- 
cern is the sensory branch, and we therefore note with 
great interest that before it is well started in its course 
it develops a knob known as the gasserian ganglion. All 
this takes place still within the confines of the skull, but 
soon we see that from the gasserian ganglion three 
branches arise, passing from the skull by three separate 
openings. They are, (1) Ophthalmic, (2) Maxillary, (3) 
Mandibular. 
Ophthalmic 
As this branch lias no direct relation to the teeth or their 
surrounding structures we note and leave it. 
28 NERVE SUPPLY OF THE JAWS 
29 
Maxillary Nerve 
This nerve is most important, for it supplies the entire 
upper jaw, soft tissues, bone, teeth and palatal structures. 
After springing from the gasserian ganglion it passes for- 
ward and leaves the skull through the foramen rotundum. 
Emerging from the foramen rotundum it crosses an open 
space the size and shape of an almond and once more en- 
ters bone in the rear of the orbital floor. This point of 
Fig. 3.—Schematic drawing of fifth nerve. 
entrance is in reality tlie beginning of a short canal exist- 
ing in the floor of the orbit which continues forward until 
its termination—the infraorbital foramen. The maxillary 
nerve continues in this canal in the floor of the orbit and 
emerges from the infraorbital foramen. 
From the foramen rotundum to the entrance to the canal 
at the posterior part of the floor of the eye, the distance 
traversed by the maxillary nerve is but one inch. This 
one inch of nerve which crosses the sphenomaxillary fossa 30 
LOCAL ANESTHESIA SIMPLIFIED 
is important to remember because in this fossa, and from 
this portion of the nerve, several important branches are 
given off. It runs from (1) to (2) in Fig 3. Let us for 
convenience call this exposed portion Part A. Let us call 
Part B the segment of the maxillary nerve which lies in the 
canal in the floor of the eye. We may now proceed to 
examine the branches of the maxillary nerve given off in 
its horizontal course. 
Part A.—A little ganglion (Meckel) is formed on Part 
A from which arise all the nerves going to the palate. 
They are the Nasopalatine, Anterior Palatine, Middle 
Palatine, and Posterior Palatine Nerves. 
In addition to these nerves, which all go to the palate, 
there is another given off from Part A known as the Pos- 
terior Superior Dental Nerve. This branch comes down 
to enter the maxilla above the tuberosity. It is distributed 
to the pulps of the three molars, and to the mucous mem- 
brane periosteum and bone on the buccal aspect. It is indi- 
cated on Fig. 3 as a. 
We have seen that all the palatine nerves come from 
Part A of the maxillary nerve. Bear in mind that these 
nerves have nothing to do with the pulps of any of the 
teeth but merely supply the mucous membrane periosteum, 
bone, and soft tissues of the palate. 
Nasopalatine Nerve 
This nerve runs along the septum of the nose and enters 
the palate through the Anterior Palatine Foramen. It 
supplies the mucous membrane, periosteum and bone in the 
triangular space behind the incisors up to a line drawn 
across the canines. 
Anterior Palatine Nerve 
You must not be confused. This nerve enters the palate 
through the Posterior Palatine Foramen adjacent to the 
third molar. It runs forward on the palate and is there- XERVE SUPPLY OF THE JAWS 
31 
fore known as the Anterior Palatine Nerve. It supplies 
the mucous membrane, periosteum and bone of half the 
palate as far forward as the canines, where it interlaces 
with the nasopalatine nerve. 
Middle and Posterior Palatine Nerves 
These nerves are of only secondary interest to us. They 
emerge from the small accessory foramen seen just behind 
the posterior palatine foramen and supply the uvula, soft 
palate and tonsils. Novocaine must therefore be sparingly 
used in the third molar region because the soft tissues 
permit extensive infiltration. Any excess will anesthetize 
these nerves whereupon the patient will complain of gag- 
ging and inability to swallow, with general discomfort 
and uneasiness. Keep in mind always that the palatine 
nerves have no connection with the teeth themselves. 
Part B.—You recall that the posterior superior dental 
nerve originates from Part A in the sphenomaxillary fossa, 
along with all the palatine nerves. It was distributed to 
the molar teeth. The nerves to the bicuspids and incisors, 
are given off from Part B, which is the canal in the floor 
of the orbit. The two nerves given off are the middle 
superior dental and the anterior superior dental. (Fig. 3, 
b, c.) 
Middle Superior Dental Nerve 
This is given off in the infraorbital canal and runs down 
in the outer wall of the antrum to supply the pulps of the 
bicuspid teeth. It also is distributed to the mucous mem- 
brane, periosteum and bone overlying the roots of these 
teeth. (Fig. 3, b.) 
Anterior Superior Dental Nerve 
Tliis nerve is given off in the infraorbital canal a frac- 
tion of an inch before the main nerve reaches the infra- 
orbital foramen. It runs down in the anterior wall of the 32 
LOCAL ANESTHESIA SIMPLIFIED 
antrum, and is distributed to the central, lateral and canine 
pulps, and the overlying mucous membrane, periosteum 
and bone. Once again observe that the nerve which 
emerges from the infraorbital foramen is not the anterior 
superior dental nerve. This portion of the maxillary nerve 
which emerges from the foramen has nothing to do with the 
teeth but merely supplies the soft tissues of the upper lip 
and side of the nose. 
Resume: Note that the palatine nerves need not be an- 
esthetized in such operations as the preparation of sensitive 
cavities which involve only the pulp of the tooth. Note 
that in extractions, where the beaks of your forceps im- 
pinge upon the palatal structures, you must, in addition to 
the buccal injection make an injection to block the palatine 
nerves. 
Mandibular Nerve 
Tlie innervation of the inferior dental nerve is easily fol- 
lowed as it pursues its course through the body of the man- 
dible in a long straight canal. It gives off little twigs to 
each tooth during its progress to the median line. This 
branch of the fifth nerve emerges from the skull through 
the foramen ovale, and joins up with the motor branch 
which conies directly from the gasserian ganglion. This 
makes the mandibular division a mixed nerve, the motor 
nerves going to the muscles of mastication. The mandib- 
ular nerve on emerging from the foramen ovale drops down 
and enters a large foramen on the inner surface of the 
ramus known as the inferior dental foramen. Below and 
between the apices of the bicuspids another opening is 
seen. This is the mental foramen, and provides an exit 
for the mental nerve. This branch on emerging is distrib- 
uted to the soft tissues of the lower lip and has no con- 
nection with the teeth. The inferior dental nerve supplies 
the teeth, alveolar structure and mucous membrane of the 
mandible, with the exception of the lingual mucosa; this 
mucosa is supplied by the lingual nerve. NERVE SUPPLY OF THE JAWS 
33 
Lingual Nerve 
This comes down in company with the inferior dental 
nerve; it does not enter the mandibular foramen but en- 
ters the mucous membrane of the mandible below the 
apices of the molar teeth. 
Long Buccal Nerve 
This supplies the mucous membrane in a small area cov- 
ering the buccal roots of the molars and bicuspids and fre- 
quently requires an independent injection to complete the 
efficiency of the mandibular injection. It comes from the 
mandibular nerve. 
You have now read all you need to know in order to 
comprehend effects and limitations of the various injec- 
tions. There are other branches of the fifth nerve which 
have not been mentioned; these you may study at your 
leisure in Gray’s Anatomy. But they are not necessary 
for our purpose and will not enlarge your knowledge of 
ivhere, how and why to make the various injections to be 
described, and with which alone this modest volume is 
concerned. Study Fig. 3 carefully. Can you reproduce 
it with book closed! Try it a few times and notice how 
easily it may be retained. It summarizes this entire chap- 
ter. CHAPTER IV 
BONE STRUCTURE 
To obtain anesthesia of the teeth it is necessary to reach 
the nerves supplying them. As we have seen, these lie 
for the most part within the bones of the jaws. It is im- 
portant, then, that we carefully Study the structure of the 
maxillae and the mandible. Thus we may best determine 
the method of approach with our novocaine solution in 
order to secure the desired anesthesia. 
From a brief examination it is readily seen that the up- 
per jaw from every aspect is spongy, porous and riddled 
with tiny openings. All upper teeth have but a thin buc- 
cal plate of bone overlying their roots. In consequence 
it is a simple matter for the anesthetizing solution to make 
its way through the bone to the underlying nerves, which 
process we call infiltration. Infiltration anesthesia gen- 
erally speaking is indicated for any of the teeth of the 
maxillae. 
Examination of the Maxillae 
When tlie skull is examined full face we note at once 
the porosity of the bone in the region of the anterior 
nasal spines. (Fig. 4.) These openings are seen beside 
the median line above the apices of the incisors. This char- 
acteristic is also evident between the roots of the teeth and 
above their apices. The alveolar process covering the roots 
of the teeth is so thin that the outline of all the roots is 
clearly visible. In the region of the first molar the malar 
process comes down and loses itself in the process covering 
the first molar roots. This gives additional density to the 
process in this area but the bone itself is not very heavy. 
It may be clearly seen that in the area above the third 
34 BONE STRUCTURE 
35 
Fig. 4.—Skull, front view. 36 
LOCAL ANESTHESIA SIMPLIFIED 
molars, embracing the tuberosity, the character of the 
maxillse is universally spongy and cancellous. (Fig. 6.) 
Palatal Structure of Maxillae 
The palate as seen on the skull is completely riddled with 
openings. (Fig. 5.) Nowhere are conditions so ideal for 
infiltration. This means that we can succeed in obtaining 
anesthesia with a minimum of novocaine solution. Of spe- 
cial interest is the groove at the lateral border for the lodg- 
ment of the anterior palatine nerve. A distinct recess is 
thereby formed which is of great importance in palatal 
anesthesia. 
Foramina in Maxillae 
Several large openings are constant in the maxillse for 
the passage of vessels and nerves. Those on the buccal 
aspect are the Infraorbital F or amen and the Posterior 
Superior Dental Foramina. 
Infraorbital Foramen 
The infraorbital foramen is seen tliree-eigliths of an inch 
beneath the lower border of the eye. It faces toward the 
median line. From it emerge the terminal branches of the 
infraorbital nerve. 
Posterior Superior Dental Foramina 
Above the last molar tooth on the tuberosity are two or 
three small but distinct openings into which the posterior 
superior dental nerves enter to supply the molar teeth, 
(Fig. 6 and Fig. 3, b.) 
Three large foramina may be seen on the palatal aspect 
of the maxillge. One is in the median line, just behind the 
incisors. This is the Anterior or Nas\opalatine Foramen, 
through which enters the Nasopalatine nerve. Adjacent 
to the last molar tooth, on each side, is seen the Posterior BONE STRUCTURE 
37 
Fig. 5.—Palate. 38 
LOCAL ANESTHESIA SIMPLIFIED 
Palatine Foramen. This transmits the Anterior Palatine 
Nerve. Injections into the nasopalatine and two posterior 
palatine foramina will anesthetize the entire palatal mu- 
cous membrane, periosteum and bone. Directly behind the 
posterior palatine foramen may be seen another smaller 
one. This is the accessory palatine foramen and transmits 
the Middle Palatine nerve. 
Fig-. 6.—The tip of the needle indicates the foramina entered by the posterior 
superior dental nerve. 
The Mandible 
Tlie mandible, in direct contrast with the spongy max- 
illae, is like a piece of ivory. It is dense and compact, and 
quite innocent of the minute pores and openings so gener- 
ously distributed in the jaw above. It is impenetrable to 
our anesthetizing solution except very slowly, and then in 
insufficient amounts to reach the mandibular nerve or its BONE STRUCTURE 
39 
branches. Therefore we cannot avail ourselves of the 
method of infiltration which stood us in such good stead 
in the maxillae. Only in the chin portion are to be seen a 
scanty group of foramina which permit anesthesia by in- 
filtration. A cross-section of the mandible in the molar 
Fig'. 7.—A, Structure of the maxillae as seen in cross section ; and B, Cross sec- 
tion of mandible. 1, Incisor region ; 2, bicuspid ; 3, molar. (After Sicher.) 
region shows a solid armor of ivorylike hone, in some 
places more than an eighth of an inch in thickness. The 
lingual structure is no different from the buccal. (Fig. 7.) 
We are not surprised at Nature’s sturdy protection of 
the mandible when we realize that it is the moving part of 
the masticatory apparatus. It is subject to injury owing 40 
LOCAL ANESTHESIA SIMPLIFIED 
to its exposed position and is well constituted to withstand 
rough usage. 
Foramina in Mandible 
Beneath and between the apices of the bicuspids and 
about half-way to the lower border of the mandible buc- 
cally may be seen a fairly large opening; this is the mental 
foramen. 
Fig-. 8.—The mandibular sulcus on the inner surface of the ramus. 
The mental foramen lias no special interest for the den- 
tist, as the mental nerve which emerges from the foramen 
has no connection with the teeth. Occasionally pathologic 
conditions requiring surgical interference exist in the chin 
portion. In these cases injection into the mental foramina 
of either side is performed. Ordinarily to anesthetize 
the bicuspids the mandibular injection is to be preferred 
as it is more certain and more easily accomplished than in- 
jection into the mental foramen. BOiSTE STRUCTURE 
41 
Mandibular Foramen 
Of greatest importance in the entire field of local anes- 
thesia is the mandibular foramen. It is located on the in- 
ner surface of the ramus and receives the inferior dental 
nerve and blood vessels. (Fig. 8.) Leading to the foramen 
is a shallow groove, known as the mandibular sulcus. This 
is the mecca of novocaine injections in the lower jaw. An 
injection at this point provides an anesthesia which is po- 
tent in its intensity and merciful in its marvelous power. 
Dr. Halsted is entitled to everlasting gratitude for his 
achievement in pointing the way, and dentists who are not 
masters of this means of anesthesia fail in their obligation 
to patients. CHAPTER V 
THE OLD TECHNIC OF INFILTRATION 
From the time of the earliest experiments in local anes- 
thesia the underlying idea was to drive the anesthetizing 
solution into the tissue under great pressure. Pressure was 
considered essential to success, and this thought has come 
to us unchanged almost to the present day. 
Despite this customary practice, it must now be recog- 
nized that the employment of force in infiltration anesthe- 
sia is unnecessary, if not unscientific. Injection made in a 
gentle manner, excluding entirely the idea of high pressure, 
will produce anesthesia of great depth. The technic is 
fundamentally different from any heretofore employed; the 
drawbacks of previous methods are avoided and the addi- 
tional advantages are many. 
If we will at this time note the various locations selected 
in times past for the initial insertion of the needle we shall 
readily see why such injections demanded extreme force. 
An interesting means of securing anesthesia which came 
into vogue about thirty years ago began with a cocaine in- 
jection above the apex of the involved tooth. An opening 
was then drilled through the soft tissues and into the al- 
veolar process above the apex. Into this opening a short, 
closely-fitting needle was inserted and the solution was 
discharged under pressure into the body of the bone. This 
is intraosseous anesthesia. 
Dr. Prinz suggested peridental anesthesia, whereby the 
solution is injected beneath the free margin of the gum 
under considerable pressure. It is driven along the peri- 
dental membrane to the tooth apex. 
A third method is that with which we are very familiar, 
42 THE OLD TECHNIC OF INFILTRATION 
43 
and which at present is in general nse. A short needle 
mounted on a powerful syringe is inserted into the dense 
gum just above the neck of the tooth. The anesthetizing 
solution is delivered with all the power of the clenched 
hand and every effort made to pierce the periosteum and 
bone. Anesthesia is usually evidenced by the blanching of 
the gum. Several insertions of the needle are usually made 
on the facial aspect. A variation of this technic consists 
in the use of a longer needle, and after the injection of 
some of the anesthetic into the dense gum the needle is 
advanced beneath the periosteum until the apex is reached, 
where the bulk of the solution is deposited. This is sub- 
periosteal anesthesia. 
Each of these, methods presents at least one serious ob- 
jection. Drilling into the bone near the apex to provide an 
avenue of entrance for the hypodermic needle causes 
undue injury to the tissues, with resulting after-pain and 
enlarged possibilities of infection. Peridental anesthesia 
with its insertion of the needle beneath the free margin of 
the gum will cause injury to the peridental membrane, 
from which the tooth might not readily recover. Its use 
therefore in purely conservative measures is contraindi- 
cated. As to the third method, the enormous pressure ex- 
erted while injecting into the dense gum presents one of 
the disadvantages of infiltration anesthesia which is most 
frequently advanced; the objection, which is well taken, 
lies in the fact that the pressure will frequently spread 
infection into healthy adjacent tissues. 
This third method of infiltration anesthesia just men- 
tioned is crude and unscientific. It has many disadvantages. 
In the first place, it must be evident that here as well as 
in geometry, a straight line is the shortest distance be- 
tween two points. Why then should we drive our novo- 
eaine solution to the apex from some distant point when 
it can be deposited virtually at the apex? The overlying 
bone is extremely thin, and offers no hindrance to the im- 44 
LOCAL ANESTHESIA SIMPLIFIED 
mediate infiltration of the anesthetizing solution. Not 
alone is the injection under pressure at a distance from the 
apex illogical, but the pressure required to he exerted is 
capable of much harm. Besides spreading infection, the 
periosteum may be raised and injury to the bone fol- 
low. Severe after-pain is often due to just this cause. The 
introduction of the needle into the dense gum is productive 
of pain, and has led to many attempts to lessen it by the 
application of some drug to the surface. Once the needle 
has entered the dense gum, it cannot be readily shifted so 
as to correct the direction of the needle. The use of plat- 
inum iridium needles for injection found little favor, as 
they were easily bent and the points quickly dulled when 
driven through the dense gum, beneath the tough perios- 
teum, and into the bone. CHAPTER VI 
SUPRAPERIOSTEAL INJECTION—PRESENT 
TECHNIC OF INFILTRATION 
The Mucobuccal Fold 
Above tlie necks of the teeth facially and covering about 
half of the root is a dense band of firm pink tissue com- 
monly called the gum. This is composed of the mucous 
membrane submucosa and periosteum, all closely united 
and joined to the bone beneath. Beyond the border of the 
gum the mucous membrane separates from the periosteum, 
loses its dense character and continues onward to line the 
lips and cheeks. Its color is now much darker, and of a 
purplish hue. This line of demarcation may be more 
clearly distinguished if the soft tissues above the necks of 
the teeth be painted with iodine. The dense gum changes 
but little; the mucous membrane, however, due to the 
iodine, assumes a dark brown color. 
If the lip be now held between thumb and index finger 
and pulled down and a little away from the teeth you will 
notice that you have formed an angle which is lined with 
mucous membrane. This reflection is known as the muco- 
buccal fold. The apex of the angle is sometimes quite near 
the upper border of the dense gum but more often will be 
found within a quarter of an inch of the apices of the upper 
teeth. Regard this angle well, and closely, for it is the 
scientifically correct point of entry for your needle. (Fig. 
9.) 
With the lip pulled down and away from the necks of 
the teeth, expose the mucobuccal fold. Above all, do not 
push the lip upward, as is commonly done. You succeed 
thereby only in obliterating the mucobuccal fold, which is 
45 46 
LOCAL ANESTHESIA SIMPLIFIED 
Fig'. 9.-—The lip and gum form a distinct angle. This line of reflection is the 
mucobuccal fold. SUPRAPE1UOSTEAL INJECTION 
47 
your constant and unfailing starting point. While main- 
taining downward tension on the lip or cheek, insert the 
needle at the line of reflection of the mucous membrane, 
and mesially to the tooth in question. At once deposit one 
or two drops. The needle at this time forms an acute angle 
with the root. Now permit the shaft of the needle to lie 
flat against the gum and from this position advance it 
until its orifice is opposite the apex of the tooth. Here, 
upon the periosteum, deposit the balance of the solution. 
This the writer has termed the supraperiosteal injection. 
Precautions 
After the first few drops of novocaine have been injected, 
look closely at the needle. Draw the lip down firmly. Is 
the needle really at the apex of the mucobuccal fold! Dur- 
ing the first attempts it is usually found that the injection 
lias been begun too far out in the lip, and that the guide 
line of reflection of the mucous membrane is actually much 
nearer the dense gum. If this be the case withdraw the 
needle and make a corrected insertion. This is of the 
utmost importance, for if you are not injecting at the 
proper point your solution will be deposited too far from 
the bone; in that event your solution will be discharged 
into the soft tissues and an unsatisfactory submucous anes- 
thesia will result, which will be evidenced by ballooning 
of the tissues. This wheal may also be produced if the in- 
jection be made at the correct point, but too rapidly. 
Whenever that occurs, pause for a few moments and gently 
place a finger over the raised mucous membrane, thereby 
distributing the solution. 
Throughout the injection the needle is at no time to be 
forced beneath the periosteum. It should rather slide 
across the surface of the periosteum until the apex of the 
tooth is reached. The depth of needle insertion is from a 
quarter to three-eighths of an inch. No case is ever pre- 
sented where the use of pressure at the mucobuccal fold is 48 
LOCAL ANESTHESIA SIMPLIFIED 
warranted or required. Under no circumstances discharge 
the solution from the syringe under pressure. The gentle 
touch of the finger on the end of the plunger is all that is 
required to cause the novocaine lo flow from the syringe 
and saturate surrounding tissues. 
A Logical Injection 
Infiltration, penetration and anesthetization quickly fol- 
low the supraperiosteal injection. It is accomplished with 
an entire absence of force or pressure and an ease that will 
surprise and delight the operator. The shortest distance 
to the apex of any tooth in the maxillae is opposite the 
apex; the bone, being thinnest here, is most rapidly pene- 
trated by the solution. The pulp, to become anesthetized, 
must come under the action of the novocaine. Surely the 
most reasonable thing to do is to deposit the novocaine 
opposite the apex of the tooth where the pulp enters, in- 
stead of driving to the apex under pressure from some 
distant point. 
Where, How, and Why 
In all cases of infiltration anesthesia through the supra- 
periosteal injection the needle should be inserted at the 
mucobuccal fold. In all cases the needle should be made to 
advance upon the periosteum. In all cases the hulk of the 
solution should be deposited at the apex, for here is the 
shortest distance to the pulp. 
Preliminary 
Before the patient has taken his seat in the chair all 
preparations for the injection should he complete. The 
patient will he in a far better frame of mind if work can 
he begun without undue delay. It is depressing and de- 
moralizing to the patient to he compelled to sit and watch 
the preliminaries incident to the injection. SUPPiAPElUOSTEAL INJECTIONS' 
49 
Filling the Syringe 
Remove the syringe from its glass receptacle, mount the 
proper needle and draw boiling water through the syringe 
several times. Revolve an ampule of novocaine over an 
alcohol lamp until it is comfortably warm to the touch. 
Pass the neck of the ampule over the flame and with the 
neck held downward snap it off in a piece of sterile gauze 
or cotton; the contents will not escape. Flame the needle, 
insert it into the ampule and withdraw the solution. With- 
drawing the novocaine from the ampule is easily accom- 
plished by holding the end of the plunger in the palm with 
three fingers and pushing the barrel upward with the 
thumb and index finger. It may be necessary to repeat this 
process several times to secure the entire contents of the 
ampule. Carefully place loaded syringe upon your bracket 
table so that the needle is not contaminated. Take a cotton 
wound wooden applicator from a wide-mouthed receptacle. 
Dip it in the aconite and iodine. Pull back the lip or cheek, 
dry the mucous membrane and rub the intended point of 
injection and its vicinity with the iodine swab. Just touch- 
ing it is not sufficient. The rubbing mechanically removes 
surface bacteria and effectually prevents them from enter- 
ing the wound caused by the needle. Bear in mind that the 
needle must be flamed for each insertion. Keep an alcohol 
lamp on your bracket table for that purpose. After one 
injection bacteria will be carried to the second point on tin' 
tip of the needle unless the needle is sterilized again in the 
flame. This condition most frequently arises when it is 
necessary to make an additional injection on the palate fol- 
lowing a buccal injection. 
Insertion of the Needle 
No occasion exists to use other than the most gentle 
pressure to insert the needle at the mucobuccal fold. The 
older methods of infiltration meant digging into the al- 
veolar process with a short hard needle, and driving the 50 
LOCAL ANESTHESIA SIMPLIFIED 
solution beneath the periosteum with all the pressure that 
could be summoned. This is crude, and such unnecessary 
measures should be discarded together with the antiquated 
intraosseous and peridental methods of anesthesia. 
Conversation 
Bear in mind that the patient is usually more or less 
nervous. Some will even jump at the touch of the iodine 
swab. It is good practice immediately before inserting the 
needle to say to the patient, “You will feel this for just a 
moment,” introducing the needle at the mucobuccal fold 
with a “There you are,” and at once releasing a few drops 
of novocaine. With but a few moments of pause the needle 
may be painlessly advanced to the apex of the tooth in- 
volved and the balance of the solution deposited there. 
Caution 
During the injection the patient should be observed care- 
fully. Be quick to notice any signs of paleness, tremor or 
perspiration. Some persons faint on trivial occasions. 
Watch the needle. Do not let it bend. See that the solu- 
tion is not escaping at the point of entrance of the needle. 
Do not allow your hand to obstruct the view of the point 
of injection. Inject .slowly. The tissues should be given a 
reasonable chance to take up the solution. Kapid injection 
will cause after-pain; it is often the cause of weakness, 
trembling, and quickened pulse. It lias been proven that 
the toxicity of local anesthetics increases with the rapidity 
of injection. Let the solution -flow from the needle. 
Fulcrum 
A practiced dentist will rest tlie hand or fingers upon 
adjacent teeth while using the engine or in the manipula- 
tion of any hand instrument. Much harm has been done 
when sharp instruments, insecurely held, have suddenly 
slipped out upon the soft tissues. SUPEAPERIOSTEAL INJECT TON 
51 
Fig. 10.—Holding the syringe while piercing the mucous membrane. 
Fig. 11.—Discharging the solution. 52 
LOCAL ANESTHESIA SIMPLIFIED 
Holding the Syringe 
The hypodermic syringe, armed with its slender needle, 
requires a steady hand. Do not introduce the needle with 
the thumb on the plunger. That position of the hand at 
the beginning of the injection is improper. The delicate 
pressure necessary in piercing the mucobuceal fold may be 
carefully controlled when the hand is steadied against the 
neighboring teeth. The syringe should be held as if you 
were going to write with it. (Figs. 10 and 11.) 
Central Incisor 
After proper application of aconite and iodine draw the 
lip down between thumb and index finger. Take up the 
filled syringe and insert the needle into the mucobuceal fold 
at a point just distal to the central. (Fig. 12.) Owing to 
the frenum in the median line, the injection for the central 
incisor begins distally. For all other teeth the needle en- 
ters mesially. After a few drops have been injected the 
needle is advanced to the apex of the tooth, where the bulk 
of the solution is deposited. (Figs. 13 and 14.) The nasal 
spine invariably retards the progress of the needle and 
indicates that the apex has been reached. (Fig. 15.) In 
all cases of infiltration anesthesia no attempt should be 
made to force the needle past bony obstruction. The feel 
of bone in the region of the apex is added reassurance that 
we are releasing our solution in close proximity to the 
periosteum. 
Effects of a Single Buccal Injection 
Following the single injection for the central incisor as 
described, cavities may he painlessly prepared. If necessary 
the pulp may be extirpated. In these cases, a buccal injec- 
tion of one and one-half c.c. of a two per cent novocaine 
solution is ample. A wait of five to ten minutes is neces- 
sary before the pulp becomes anesthetized. Even then it SUPBAPERIOSTEAL INJECTION' 
53 
Fig. 12.—The needle enters the mucobuccal fold, distal to the central. 54 
LOCAL ANESTHESIA SIMPLIFIED 
Fig\ 13.—The needle is advanced to the apex of the central. SUPRAPERIOSTEAL INJECTION 
55 
Fig. 14.—During the progress of the needle to the apex, the shaft lies on the 
gum. 56 
LOCAL ANESTHESIA SIMPLIFIED 
Fig. 15.—The anterior nasal spine is encountered at the conclusion of the in- 
jection for the central. SUPRAPEEIOSTEAL IXJECTIOX 
57 
may also be necessary to apply a pressure pluglet of novo- 
caine to the exposure. Nerve endings are extremely re- 
sistant to all forms of local anesthesia and succumb reluc- 
tantly. 
Extent of Anesthesia 
It will be found that if one tooth is injected the neigh- 
boring tooth distally will also come under the influence of 
the established anesthesia. Additional injection into the 
dense gum at the neck of the tooth is never necessary. 
Fig. 16.—Conclusion of the injection for the lateral. 
Palatal Injection for Extraction 
Where extraction is contemplated it is always necessary, 
in addition to the buccal injection, to give a supplementary 
injection on the palate. The dosage for the buccal injec- 
tion may in sucli cases be reduced to 1 c.c. Not more than 
three drops of novocaine are necessary for palatal anesthe- 
sia of single teeth. You may extract immediately. The 
technic of the palatal injection will be taken up later. 58 
LOCAL ANESTHESIA SIMPLIFIED 
Lateral Incisor 
The point of insertion of the needle for the lateral in- 
cisor is the same as for the central; the needle however is 
now directed toward the lateral apex. (Fig. 16.) When 
the first few drops have been released, immediately upon 
piercing the mucobuecal fold, the needle is advanced to the 
region of the apex, where the balance, one and one-half 
c.c., is deposited. For extraction an additional injection 
on the palate is necessary. 
Canine 
The needle enters the mucobuecal fold between the lat- 
eral and canine. Inject a few drops and advance the needle 
to the canine apex. In making sure to deposit the solution 
at the apex, bear in mind that the canine is the longest root 
in the mouth. Dosage is one and one-half c.c. (Fig. 17.) 
Bicuspids 
The bicuspids are anesthetized by injecting mesially at 
the mucobuecal fold in the manner already described for 
the canine. (Figs. 18, 19 and 20.) Owing to the thin layer 
of bone covering the bicuspid roots, anesthesia of these 
teeth by infiltration is readily accomplished. One and one- 
half c.c. novocaine is ample for this injection. 
First Molar 
It will be found that the needle cannot be advanced 
parallel with the long axis of this tooth, owing to the malar 
process which reaches down over the buccal roots. The 
mucobuecal fold is entered to the mesial of the first molar 
and the usual one or two drops injected. The syringe is 
now tilted distally so that the needle may glide beneath SUPEAPERIOSTEAL USTJECTIOX 
59 
Fig. 17.—Reaching the apex of the canine. 60 
LOCAL ANESTHESIA SIMPLIFIED 
Fig. 18.—Anesthetizing' the first bicuspid. The needle is seen entering the 
mucobuccal fold. SUPRAPERIOSTEAL INJECTION 
61 
Fig-. 19.—Injection for the second bicuspid. 62 
LOCAL ANESTHESIA SIMPLIFIED 
Fig. 20.—Completion of the injection for the second bicuspid with the orifice 
of the needle at the apex. Observe the extreme thinness of bone overlying 
the roots of the first molar. SUPRAPEFJOSTEAL USTJECTIO^- 
63 
the malar process; (Fig. 21). The needle does not tra- 
verse a distance exceeding a quarter of an inch during this 
process, one and one-half c.c. of novocaine is deposited near 
the buccal apices. No distinction is made in anesthetizing 
the molars as to whether the mesiobuccal root or distal 
buccal root is reached. Injection at either apex will rap- 
idly infiltrate the other. 
Fig-. 21.—The syringe is tilted backward and the needle glides beneath the 
malar process in injecting the first molar. 
Second and Third Molars 
Beyond question these teeth are the most easily anes- 
thetized of any in the maxillae by means of the supraperi- 
osteal injection. The structure of the bone in the region of 
the tuberosity is so spongy that infiltration is immediate 
and profound. This injection for the molars readily takes 
the place of the tuberosity injection in routine dental prac- 
tice. (Fig. 22.) 64 
LOCAL AXESTHESIA SIMPLIFIED 
Palatal Anesthesia 
Looking at the roof of the mouth, it would seem at first 
glance that the palatal mucosa is equally dense through- 
out. Upon close observation, however, it can be seen that 
it is divided into a dense area surrounding the necks of 
the teeth and a less resistant area which reaches to the 
median line of the palate. Follow the curve of the tuber- 
osity and its dense mucosa, as it comes on to the palate, and 
Fig. 22.—It is unnecessary to advance beyond the apices of the second or 
third molars for profound anesthesia. 
the line of demarcation between these dissimilar tissues 
becomes apparent. (Fig. 23.) By gently probing with the 
tips of a pair of pliers the difference in texture of the pal- 
atal mucosa can be quickly detected. The line of the tu- 
berosity corresponds with the anterior palatine nerve 
directly beneath it. This nerve lies in a longitudinal 
groove at the junction of the alveolar and palatal processes. 
The groove is rather angular, and forms a slight recess in SUPRAPERIOSTEAL INJECTION 
65 
Fig. 23.—The curve of the tuberosity as it comes on to the palate is dis- 
tinctly seen. It marks the path of the anterior superior dental nerve directly 
beneath it. 66 
LOCAL ANESTHESIA SIMPLIFIED 
Fig. 24.—The palatal injection is begun by entering the mucosa from the op- 
posite side at an angle to the tooth. SUPEAPEEIOSTEAL INJECTION 
67 
its course. The mucous membrane of the palate stretching 
across the nerve in a sort of canopy, provides a fairly loose 
region for infiltration. The needle should be inserted here 
and is at once advanced to the roof of the mouth in line 
with the long axis of the tooth, until bone is encountered. 
Three or four drops of novocaine are sufficient to anesthe- 
tize the branches which are here intercepted just as they 
are given off from the body of the nerve. In consequence 
rapid anesthesia of the mucous membrane periosteum and 
bone in the area behind the tooth ensues. If this injection 
is made opposite the third molar the parts to the median 
line of the palate and as far forward as the canine will be 
anesthetized; the injection will have blocked all impulses 
of the anterior palatine nerve, just as it emerged from the 
posterior palatine foramen. 
The needle in palatal anesthesia should be inserted at the 
desired point along the line of the tuberosity, and at an 
angle to the tooth. (Fig. 24.) Once the mucosa has been 
entered, the needle should be advanced to the bone in line 
with the long axis of the tooth. Depth of penetration here 
is not more than three-eighths of an inch. (Figs. 25 and 
26.) 
Pathology 
It is to be understood that the injections described are 
to be made into tissues which appear to be normal. Where 
infection exists, injection should be made on either or both 
sides of the pathologic area. Here we have the outstand- 
ing feature of the supraperiosteal injection, for the absence 
of pressure at once precludes the danger of driving infec- 
tion into healthy surrounding territory. It is to be noted 
that in the greatest number of cases of acute conditions, at- 
tendant with swelling, and abscess, nitrous oxide and oxygen 
would be the indicated anesthetic. 68 
LOCAL ANESTHESIA SIMPLIFIED 
Fig'. 25.—The needle is advanced to the hone parallel with the long axis 
of the tooth ; the syringe in palatal anesthesia is almost horizontal. SUPRAPEEIOSTEAL INJECTION 
69 
Fig. 26.—Injection on the palate behind the canine. 70 
LOCAL ANESTHESIA SIMPLIFIED 
Infiltration in the Mandible 
The profession has been heretofore much discouraged in 
its attempt to anesthetize the teeth in the mandible, because 
infiltration was the only method employed, although un- 
satisfactory. Conduction anesthesia at the mandibular 
foramen has solved the problem and given us a truly re- 
markable means of effectually blocking sensation to the 
lower teeth. Infiltration anesthesia in the mandible is re- 
stricted practically to the anterior teeth, for reasons which 
will appear. Where any of the lower incisors or canines 
are involved, they may be anesthetized by infiltration as 
directly and effectively as the teeth of the maxillae. The 
technic is practically the same. 
Mental Fossa Injection 
Directly in the median line is the mental protuberance. 
Overlying the canine root is the canine eminence. Between 
these two points lies a depression known as the mental 
fossa. Do not confuse this fossa which is found medially 
to the canine with the mental foramen lying between and 
below the bicuspid apices. Injection in the mental fossa 
will give good anesthesia of the canine. (Fig. 27.) The 
buccal injection is sufficient in order to remove the pulp or 
prepare a cavity in the canine. One and one-half c.c. novo- 
caine is sufficient. If the tooth is to be extracted two or 
three drops of novoeaine should be injected in the lingual 
mucosa directly behind the canine and at a point not more 
than a sixteenth of an inch from the gingival margin. 
Lateral and Central 
For either or both of these teeth, the needle should be 
inserted in the niucobuccal fold between central and lateral, 
carrying the needle downward until bone is felt. (Fig. 28.) 
The needle does not advance very far, being prevented by 
the mental protuberance. The concavity which it helps to SUPRAPERIOSTEAL INJECTION 
71 
Fig. 27.—The needle is seen to enter the mucobuccal fold, and is advanced to 
the mental fossa. 72 
LOCAL ANESTHESIA SIMPLIFIED 
Fig. 28.—Infiltration of the central incisor. The mucobuccal fold begins at 
the lower border of the dense gum. SUPRAPERIOSTEAL INJECTION 
73 
form, holds the novocaine solution, and infiltration takes 
place through the many openings distributed in this area. 
One and one-half c.c. of novocaine is sufficient for cavity 
preparation and pulp extirpation. 
Lingual Injection 
The lingual injection, which is only necessary when the 
lower teeth are to he extracted, should he made with ex- 
treme care. Do not attempt to carry the needle beyond the 
alveolar crest. The needle enters but a sixteenth of an 
inch behind the tooth, and a few drops of novocaine are 
released there. Only at this point can be found the few 
minute openings in the bone which permit infiltration. 
Once the alveolar ridge is passed the bone becomes ex- 
tremely dense and impenetrable to the solution. Any at- 
tempt to carry the needle to the apex of the lower incisors 
on the lingual aspect will succeed only in carrying the solu- 
tion to the floor of the mouth and infection frequently fol- 
lows such a technic. 
Infected Areas 
We have just seen how simple a process it is to anesthet- 
ize the teeth and surrounding structures of the upper jaw, 
and certain teeth of the lower jaw, through infiltration 
anesthesia. To the dentist in general practice the technic 
laid down will suffice for the great majority of cases, and 
satisfactory results may he expected. 
There are times, however, when cases demand attention 
which are not normal, the face is swollen, the eye may he 
closed, a large swelling may be present about the tooth. It 
is of course elementary that we must refrain from passing 
our needle into infected areas or swellings, so that when 
such conditions are present we are compelled to adopt dif- 
ferent measures. These cases are not, comparatively speak- 
ing, frequent, and will as a rule find their way to the spe- 
cialists in mouth surgery. In instances of widespread infec- 74 
LOCAL ANESTHESIA SIMPLIFIED 
tion it will be found that anesthesia through injection must 
give way to nitrous oxide and oxygen. While we cannot 
doubt the high place of novocaine in the field of dentistry, 
we must not lose sight of the fact that nitrous oxide and 
oxygen is the safest general anesthetic known to science, 
and unequalled where indicated. 
In mild cases of circumscribed infection, the involved 
area can be anesthetized through injection at a distant 
point within healthy tissues, where the nerve may be inter- 
cepted in its course, thereby depriving of sensation the 
areas further along the path of the nerve and at the seat 
of the trouble. In such cases, novocaine inhibits nerve im- 
pulses beyond the point of injection. This method is known 
as nerve-blocking, or block anesthesia, and is exceedingly 
valuable in the special conditions mentioned, as shown in 
a succeeding chapter. CHAPTER VII 
CONDUCTION ANESTHESIA OR NERVE-BLOCKING 
In 1884 Dr. Roller, before a medical meeting at Heidel- 
berg, demonstrated the value of cocaine as a local anes- 
thetic. Shortly afterward, in this country, Dr. William 
Stewart Halsted conducted experiments with cocaine. One 
of his most notable achievements was the successful block- 
ing of the mandibular nerve at the mandibular sulcus. All 
authorities are unanimous in crediting Dr. Halsted with 
being the first to suggest nerve-blocking, and the dental 
profession is in deep debt to him for providing a remark- 
able means of obtaining profound anesthesia in the man- 
dible. Yet his name is almost unknown to us, and what is 
as much to be deplored is the failure of the profession more 
generally to acquire the ready knowledge and simple technic 
of the mandibular injection. 
Picture eight electric bulbs in a row, all lighted, each fed 
by a little wire given off from the main line. (Pig. 29.) 
A turn of the key at each bulb will put out these lights one 
at a time. If it is desired to extinguish all at once, you 
have but to turn the main switch placed at a point before 
the first lamp is reached, and the electrical supply is dis- 
connected. To cut off sensation ordinarily at any one of 
the eight teeth on either side of the mandible, we would 
expect to place some novocaine at each apex just as in the 
maxillae. But unlike the maxillae, with its porosity and 
ready susceptibility to infiltration, the mandible as already 
shown, is hard and compact, and yields but unsatisfactory 
results to infiltration processes, excepting only the lower 
canines and incisors. We are therefore compelled to 
resort to block anesthesia in practically all cases relating 
to the mandible. The use of novocaine on either side 
75 76 
LOCAL ANESTHESIA SIMPLIFIED 
Fig-. 29.—Block anesthesia. 
Fig-. 30.—The needle extending directly beyond the last molar, is far removed 
from the internal oblique line. CONDUCTION ANESTHESIA OR NERVE BLOCKING 
77 
will block the nerve supply to the teeth of that side 
as surely as the turn of the main switch disconnects the 
electric current to the series of lamps. This is exactly 
what Dr. Halsted was first to do. He injected a cocaine 
solution inside the ramus at the point where the mandib- 
ular nerve enters the mandibular foramen. This nerve, it 
will be recalled, supplies all the lower teeth on either side. 
The effect of the novocaine on the nerve trunk, when in- 
Fig. 31.—The point of the needle is touching the internal oblique line, the 
barrel of the syringe rests on the canine of the opposite side. The correct 
position of the syringe at the outset of mandibular anesthesia. 
jected at this point, is to prevent any sensation from pass- 
ing that point. In consequence, the eight teeth supplied 
by the mandibular nerve are disconnected from the nervous 
system. The mandibular injection is the most brilliant 
example of block anesthesia in daily use, and is especially 
valuable because of the density of the lower jaw and the 
poor access for satisfactory infiltration. Conduction anes- 
thesia in the mandible is not a method of choice; it is the 78 
LOCAL ANESTHESIA SIMPLIFIED 
only means of effectually anesthetizing the lower molars. 
Unscientific as the present slowly disappearing jdractice of 
high pressure infiltration anesthesia may be, so far as re- 
lates to the maxillae, its crudity and insufficiency are thus 
emphasized when sought to be applied to the mandible. 
No dentist can afford to remain in ignorance of a means of 
anesthesia so easily acquired by ordinary application and 
the strict observance of a few fundamentals. Its benefits 
Pig-. 32.—A wire nail has been inserted into the mandibular foramen, lying 
well to the buccal aspect of the last molar. 
are widespread and a boon to the dentist no less than to 
the patient. We have already seen how important is the 
supraperiosteal injection in the maxillae; of even greater 
importance is the conduction method in the mandible. The 
procedure may be simply described and its technic readily 
acquired. 
Retromolar Triangle 
For every operation in major surgery there are definite 
landmarks which serve as guides. On carrying out the CONDUCTION ANESTHESIA OR NERVE BLOCKING 
79 
mandibular injection we are able to employ certain points 
in the area beyond the third molar which will help us to 
reach the mandibular sulcus. Guided by these landmarks, 
we may be confident of accomplishing the results we seek. 
It is of first importance to become familiar with the retro- 
molar triangle. This triangle is not behind the third molar. 
It lies rather to the buccal of the last molar, as you can 
readily see from Fig. 30. The external oblique line of the 
Fig-. 33.—The finger has been correctly placed as a guide in mandibular 
anesthesia. The lower border of the finger touches the buccal cusps of the 
molars. 
ramus forms one side of tlie triangle; the internal oblique 
line seen in Fig. 31 forms the inside of the triangle. These 
two long sides meet above in the point of the coronoid proc- 
ess. You will form the small base of the triangle if you 
draw a line behind the third molar, thereby uniting the 
internal and external oblique lines. 
Observe that the entire retromolar triangle lies exter- 
nally to the third molar. If you tried, therefore, to reach 80 
LOCAL ANESTHESIA SIMPLIFIED 
the mandibular sulcus by injecting directly beyond the 
third molar, your needle would be at least half an inch 
from your destination—the inside of the ramus. This is 
clearly illustrated by Fig. 30. Bear in mind that the ramus 
spreads outwardly and you will be better able to under- 
stand how to direct the needle. (Fig. 32.) 
Fig\ 34.—At the outset of the mandibular injection, the needle seeks to en- 
counter the internal oblique line. 
The Injection—Right Side 
The left index finger plays an important part in the in- 
jection. It is inserted in the ojjen month so that its lower 
border touches the buccal cusps of the molars. (Fig. 33.) 
Gently probing with the finger tip in this position, a hard 
ridge of bone is felt running upward. This is the external 
oblique line. You cannot feel the internal oblique line with 
the tip of your finger. But when your finger tip is touching 
the external oblique line, and your finger rests along the 
buccal cusps of the molars, you may be certain that your 
finger nail is directly over the internal oblique line. Once CONDUCTION ANESTHESIA OR NERVE BLOCKING 
81 
Fig. 35.—The beginning of mandibular anesthesia, showing the first position 
of the syringe, and correct position of the index finger of the left hand. 82 
LOCAL ANESTHESIA SIMPLIFIED 
the finger lias been properly placed it should be held there 
during the injection. 
Having placed the index finger properly, insert the tip 
of the needle at the center of your finger nail. (Fig. 
34, 35, and 36.) This is how you begin the injection and 
it must be evident that if your finger has been placed too 
low, the injection which follows must necessarily be low, 
and a muscle may be entered. The success of the effort 
begins with the proper and accurate position of the index 
finger as a starting point. 
Procedure 
Take up the loaded syringe. Turn the needle upward 
and press the plunger to expel any air remaining in the 
barrel. Your grip on the syringe is the same as if you 
were about to write with it. Grasp the barrel well up 
near the handle in order to keep the lingers from obstruct- 
ing the view. With the barrel of the syringe resting on 
the canine of the opposite side, set the point of the needle 
at the center of the finger nail of the guiding index finger. 
(Fig. 35.) An operator who starts from this position has 
a clear view of the field and will make the injection with a 
minimum of side-to-side movements. With a little forward 
pressure, the mucous membrane is pierced. Do you feel 
bone? If you are successful, you will, and your needle 
point is touching the internal oblique line as shown in Fig. 
31. If bone is not encountered make one or two attempts to 
find it by moving the needle back and forth slowly, while 
working towards the ramus. If you are still in soft tissues, 
you have injected too far inwardly and at a distance from 
the internal oblique line. Withdraw the needle and make 
a fresh insertion, this time moving the index finger out- 
wardly, and placing it in position with greater care. When 
you have located the internal oblique line the rest is com- 
paratively simple for it is an unfailing guide to the man- 
dibular sulcus. CONDUCTION ANESTHESIA OR NERVE BLOCKING 
83 
Fig. 36.—First position in mandibular anesthesia, with the needle entering at 
the center of the finger nail. 84 
LOCAL AXESTHESIA SIMPLIFIED 
Passing the Internal Oblique Line 
The next step is to pass the internal oblique line and 
reach the lingual nerve which lies immediately beyond it. 
The needle point is in contact with the internal oblique line. 
To pass it, it is necessary to move the syringe toward the 
index finger. (Figs. 37 and 38.) Do not swing it in an arc, 
but begin to move slowly toward the median line with a 
back and forth motion of the syringe. The idea is to free 
the needle from the internal oblique line, so the point is 
gently pressed away from the ramus. After one or two 
attempts the needle will be suddenly felt to slip past the 
internal oblique line. The moment this is accomplished 
deposit three or four drops of novocaine, for now the point 
of the needle is in close proximity to the lingual nerve. 
Thus it is anesthetized and without further injection you 
will secure anesthesia of the entire lingual mucosa. 
Final Stage of the Mandibular Injection 
You have just injected for the lingual nerve. The point 
of the needle lies about a quarter of an inch beyond the 
internal oblique line and still in contact with bone. The 
barrel of the syringe lies somewhere across the lower teeth. 
It may be at the median line, or even alongside the index 
finger, depending upon just when the internal oblique line 
was passed. (Fig. 39.) At any rate, before doing any- 
thing, further move'the syringe until the barrel rests across 
the median line. From this position the injection is com- 
pleted by advancing the needle until three-quarters of an 
inch of needle has been imbedded. Deposit here the re- 
mainder of the novocaine solution, for the orifice of the 
needle is at the mandibular sulcus and in contact with the 
inner surface of the ramus. (Figs. 40, 41, 42, 43 and 44.) 
The mandibular nerve is intercepted at this point and is 
bathed by the anesthetlietic solution before it enters the 
foramen. In consequence of the action of the novocaine CONDUCTION ANESTHESIA OR NERVE BLOCKING 
85 
Fig. 37.—The internal oblique line has been passed, and the lingual nerve 
anesthetized from this position. 
Fig. 38.—In passing the internal oblique line, the syringe is sometimes 
carried across the median line to a position above the teeth on the injected 
side. 86 
LOCAL ANESTHESIA SIMPLIFIED 
Fig. 39.—Here is an extreme position of the syringe, brought alongside the 
finger in an endeavor to pass the internal oblique line. CONDUCTION ANESTHESIA OR NERVE BLOCKING 
87 
Fig. 40.—From the final position of the syringe in the median line, the needle 
is advanced to the mandibular sulcus. 
Fig. 41.—Another view of the completed mandibular injection. 88 
LOCAL ANESTHESIA SIMPLIFIED 
Fig. 42.—Final position of the syringe in the median line, with the orifice of 
the needle in contact with the inner surface of the ramus. 
Fig-. 43.—A successful mandibular injection. The needle is at the mandibular 
sulcus, the syringe in the median line. CONDUCTION ANESTHESIA OR NERVE BLOCKING 
89 
Fig-. 44.—A. indicates radiograph of a wire which has been passed through 
the mandibular canal of a dry mandible. The needle points to the mandibular 
sulcus which is outlined. 90 
LOCAL ANESTHESIA SIMPLIFIED 
on the nerve tissue all sensation past this point is blocked 
and a profound anesthesia of one-half the mandible is 
obtained. 
The depth of penetration of the needle in mandibular 
anesthesia is of importance. A short injection will fail to 
produce the desired anesthesia, while an injection beyond 
the posterior border of the ramus will enter the parotid 
gland. The mandibular injection is greatly simplified when 
we realize that the depth to which the needle is inserted 
is practically the same for all persons. It is not necessary 
to probe about with the needle point in the mandibular 
sulcus in order to locate the posterior boundary of that de- 
pression. It is not even necessary to feel bone at the con- 
clusion of the injection. For if the internal oblique line 
has been found at the outset, and this line is passed as 
described, and contact with the inner surface of the ramus 
maintained on the journey to the sulcus, success will surely 
follow. The writer has recently examined several hundred 
mandibles, ancient and modern, at the Museum of Natural 
History in New York, and the Wistar Institute of Anatomy 
in Philadelphia, and with but one exception, that of an 
abnormal esquimaux, each individual could have been 
anesthetized with a three-quarters of an inch injection. 
The actual distance from the internal oblique line to the 
sulcus was practically half an inch in all cases; the addi- 
tional quarter-inch is allowed for the soft tissues. The 
interesting feature to be noted was that the varying widths 
of the ramii were made up beyond the mandibular sulcus. 
From the mandibular sulcus to the posterior border of the 
ramus the distance was always greater in the wider ramus; 
from the internal oblique line to the mandibular sulcus the 
distance was uniformly constant. 
Figs. 45 and 46 are photographs of two Peruvian man- 
dibles. One is that of a child with the six year molar 
visible but unerupted. The other is an adult showing the 
cusps of the three molars considerably worn through attri- CONDUCTION ANESTHESIA OR NERVE BLOCKING 
91 
Fig. 45.—Two Pei'uvian mandibles, adult and child, showing great difference 
in size of ramus. 
Fig. 46.—View of inner surface of ramus, showing the distance from internal 
oblique line to mandibular sulcus is practically the same for both. 92 
LOCAL ANESTHESIA SIMPLIFIED 
tion. The tremendous discrepancy in their size is apparent 
at a glance. Nevertheless, both could have been nicely 
anesthetized through a mandibular injection with a needle 
penetration of three-quarters of an inch. From the inter- 
nal oblique line to the mandibular sulcus the distance in 
each is almost identical. This constancy has been further 
borne out clinically through injection to a fixed depth over 
a period of ten years. 
Symptoms of Anesthesia 
After a few minutes, the patient will feel a tingling of 
the tip of the tongue, and soon afterward the tongue on the 
injected side feels warm, tingling, cold, or numb, as it is 
variously described. This is followed by a burning, ting- 
ling sensation in the side of the lip, and the patient feels 
as if the lip has become swollen. Beep anesthesia will be 
complete in about fifteen minutes, and one hour of anes- 
thesia ensues. 
Mandibular Anesthesia, Left Side 
For the left side, a slightly different technic is necessary. 
The left index finger is inserted as before, and placed in 
the same relative position it occupied on the right side. 
(Fig. 47.) Now however, it is essential that the left fore- 
arm, instead of being extended straight out, should lie 
diagonally across the patient’s chest. (Figs. 48 and 49.) 
The operator must stand close to the patient. It is then 
possible to introduce the index finger and keep the hand 
and fingers well to one side. (Fig. 47.) Take a comfort- 
able position. See to it that the patient’s head is almost 
erect so that you do not strain your eyes, your neck or your 
back. Be sure that the needle is always clearly in view. 
Extent of Mandibular Anesthesia 
An injection of 2 c.c. of novocaine will be found suffi- 
cient to anesthetize all the teeth of the injected side. CONDUCTION ANESTHESIA OR NERVE BLOCKING 
93 
Fig. 47.—Mandibular injection on the left side. The hand is kept well to one 
side. 94 
LOCAL ANESTHESIA SIMPLIFIED 
Fig. 48.—Correct technic for the left side. The left forearm lies across the 
patient’s chest. CONDUCTION ANESTHESIA OR NERVE BLOCKING 
95 
Fig. 49.—Injection for the right side showing clear view of the field. 96 
LOCAL ANESTHESIA SIMPLIFIED 
The mucous membrane, periosteum and bone on the buccal 
aspect and lingual aspect are also anesthetized. Some- 
times, for complete anesthesia of the incisors, it may be 
necessary to inject into the mental fossa so as to block 
some of the branches which may have come from the other 
side of the mandible. There is a patch of mucous mem- 
brane overlying the buccal roots of the molars which fre- 
quently demands an independent injection. It is supplied 
by the long buccal nerve. 
Fig. 50.—Area supplied by long buccal nerve. 
Long Buccal Injection 
As already stated this nerve supplies only the mucous 
membrane overlying the molar and bicuspid roots. In 
many cases it is anesthetized at the time of the mandibular 
injection. This can be easily determined with a touch of 
an instrument in the molar area. When it has to be sepa- 
rately injected, this can be done very readily. Insert the 
thin needle into the mucobuccal fold opposite the tooth CONDUCT I OX ANESTHESIA OK NERVE BLOCKING 
97 
Fig. 51.—Entering the mucobuccal fold for the long buccal injection. 98 
LOCAL ANESTHESIA SIMPLIFIED 
involved. For convenience tlie needle is introduced in a 
more or less horizontal direction, but need not be advanced 
beyond the tooth in question. Inject one-quarter to one- 
half of a c.c. We secure thereby not merely the anesthesia 
of the long buccal nerve but the benefit of a bloodless field 
of operation. (Figs. 50 and 51.) CHAPTER VIII 
NERVE-BLOCKING IN THE MANILLA 
In normal cases, it will be found that the supraperiosteal 
injection will provide a deep and lasting anesthesia. Many 
operations which were heretofore performed under conduc- 
tion anesthesia may be satisfactorily done by means of the 
supraperiosteal injection. It is far easier to execute than 
is either the tuberosity or the infraorbital injection and pre- 
sents much less danger of complications. There are times 
however, when the tissues in the area to be operated upon 
are swollen, and pus is present. As we have already said, it 
is not good practice to invade these areas with the needle. 
Nitrous oxide and oxygen may be employed but there still 
remains conduction anesthesia. The two methods already 
mentioned are the infraorbital injection and the tuberosity 
injection. 
The Infraorbital Injection 
We know that the central, lateral and canine teeth are 
supplied by the anterior superior dental nerve. This nerve 
is given off in the infraorbital canal a fraction of an inch 
before the infraorbital foramen is reached. To block the 
impulses to the central lateral and canine, we must reach 
this point within the canal with our novocaine. Bear in 
mind that the terminal nerves which emerge from the in- 
fraorbital foramen have nothing to do with any of the 
anterior teeth. 
Former Infraorbital Injection 
The needle was inserted high np in the reflection of the 
mucous membrane in the lip muscle, beginning at a point 
99 100 
LOCAL ANESTHESIA SIMPLIFIED 
just distal to the canine. The needle was then advanced 
upward to a point above the first bicuspid apex, and just 
beneath the eye. 
New Infraorbital Injection 
Dr. Sicher of Vienna has shown that the infraorbital 
foramen faces toward the median line and logically sug- 
gests that entrance to the foramen can be more readily 
Fig. 52.—The needles in the infraorbital foramina converge towards the 
median line. Fine wires may be seen in the mental fossa; needles in mental 
foramina. 
effected when approached from that direction. (Fig. 52.) 
The point selected for the initial introduction of the needle 
is the mucobuccal fold between central and lateral. (Fig. 
53.) The needle is then advanced upward and backward 
and carried to the foramen. An attempt should be made to 
actually guide the orifice of the needle into the foramen in 
order to be certain that the novocaine solution enters. (Fig. NERVE-BLOCKING IN THE MAXILL2E 
101 
54.) The depth of penetration need not be over a quarter 
inch. One finger is kept on constant guard over the for- 
amen in order to guide the oncoming needle. When bone is 
felt at the foramen one c.c. of solution is discharged. Upon 
entering the foramen, another one-half c.c. is released. The 
resulting anesthesia embraces the central lateral and canine 
pulps, the overlying mucous membrane periosteum and 
Fig. 53.—Beginning- of the infraorbital injection at the mucobuccal fold near 
the central apex. Suggested by Dr. Sicher. 
bone, and the side of the nose and upper lip. This injec- 
tion is but rarely to be employed in the general practice of 
dentistry, for equal results may be obtained by means al- 
ready described; it offers greater danger of complication 
than does the simple supraperiosteal injection, and it is 
far more difficult to execute. In the field of oral surgery 
it has its place, yet there it must also share honors with 
nitrous oxide and oxygen. Many cases of necrosis, frac- 102 
LOCAL ANESTHESIA SIMPLIFIED 
Fig. 54.—Path of the needle in the infraorbital injection. (Sicher.) NERVE-BLOCKING IN THE MAXILLiE 
103 
ture, and infection wherein we would be warranted in re- 
sorting to the infraorbital injection nevertheless demand a 
general anesthetic. 
General Observations 
The simple supraperiosteal injection provides an anes- 
thesia which is so profound that it readily lends itself to 
the operations which were heretofore performed under an 
infraorbital injection. The removal of impacted canines, 
root amputations, eradication of cysts, and necrotic areas, 
opening the antrum, and surgical preparation of the mouth 
for dentures, are some of the cases which may be operated 
upon under deep anesthesia by the technic of the supra- 
periosteal injection. The technic is identical with that as 
laid down for the ordinary extraction of a tooth, and these 
operations in minor oral surgery are mentioned in order 
to indicate the intensity and satisfaction of the anesthesia 
which follows the technic suggested in cases that are far 
more complicated than those which fall to the lot of the 
general practitioner. It is interesting to note that many 
operators who succeed in producing anesthesia of the in- 
cisor regions following an intended infraorbital injection 
have failed in that injection but really obtained their re- 
sults in consequence of an infiltration anesthesia through 
the anterior wall of the antrum. 
Tuberosity Injection 
A single injection at the maxillary tuberosity will inter- 
rupt the posterior superior dental nerve, before it gives off 
its branches to the molars. The third and second molars 
are usually anesthetized by this injection but the first molar 
frequently requires the assistance of infiltration. The first 
molar receives some branches of communication from the 
same nerves supplying the bicuspids. The technic of the 
tuberosity injection does not appear difficult but it is a mat- 
ter of frequent occurrence that vessels are penetrated, and 104 
LOCAL AXESTHESIA SIMPLIFIED 
tlie released blood forms a hematoma, the face often swell- 
ing while the patient is still in the chair. The injection is 
begun by introducing the needle at the mucobuccal fold 
near the distal root of the next to the last molar. Where 
this tooth is missing insert the needle bearing in mind its 
former position. As soon as the mucosa has been pierced, 
deposit a few drops of novocaine. The syringe should then 
be moved outwardly to the corner of the month, so that the 
point of the needle may be kept in contact with the curved 
surface of the tuberosity. (Fig. 55.) From this position 
the needle is advanced upward, inward, and backward, 
until three-quarters of an inch of needle lias disappeared. 
The one and one-lialf inch needle 22 gauge is used. It must 
be kept clearly in mind that if the point of the needle 
leaves the bone, there is danger of entering the pterygoid 
plexus of veins in the immediate vicinity, with a resulting 
hematoma. If the operator has been working with sterile 
equipment the swelling will disappear in a few days. Ap- 
plication of ice packs will tend to relieve the condition. 
The writer has had occasion to make but few tuberosity 
injections in a series of at least live hundred consecutive 
cases. The tuberosity injection together with the infraor- 
bital injection are necessary only in special conditions which 
do not confront the general practitioner of dentistry and in 
those instances where this injection could have been made, 
nitrous oxide and oxygen was preferred. Here again, as for 
the anterior teeth, the simple supraperiosteal injection 
gives a deep and satisfactory anesthesia. Bear in mind 
that an injection for the second molar will permit the ex- 
traction of the third molar also. The injection for the 
first molar provides sufficient anesthesia to allow the ex- 
traction also of the second molar. It is impossible to pro- 
duce a hematoma through the supraperiosteal injection, as 
the needle does not advance beyond the apices of the teeth, 
which means that the needle does not travel much more 
than a quarter of an inch. Impacted upper third molars 105 
NERVE-BLOCKING IN THE MAXILLiE 
Fig. 55.—In the tuberosity injection the needle must be carried to the corner 
of the mouth in order to maintain its contact with the tuberosity. 106 
LOCAL ANESTHESIA SIMPLIFIED 
are almost immediately anesthetized and their removal be- 
gun at once following the injection of but one c.c. novocaine 
solution buccally and three drops on the palate. The tuber- 
osity injection for the first molar alone is unsatisfactory, 
since it also demands injection at the tooth itself. If the 
needle may be inserted in the vicinity of the first molar, a 
properly executed supraperiosteal injection will provide all 
the anesthesia needed. 
The Bicuspids 
Conduction anesthesia of the bicuspids has always been 
a mooted question. Some operators contend that these 
teeth are best blocked through injection at the tuberosity, 
while others favor injection at the infraorbital foramen. 
The latter route is undoubtedly the one to be preferred. 
To be successful, the novocaine must be injected within the 
infraorbital canal so that it may work its way backward 
to the point where the middle superior dental nerve is 
given off to the bicuspids. In the absence of pathology 
the bicuspids are best anesthetized by simple infiltration 
at the mucobuccal fold. Once more we call upon the supra- 
periosteal injection, and it is not found wanting. Injec- 
tion for the first bicuspid will provide sufficient anesthesia 
to permit the extraction of either or both bicuspids. 
Conduction Anesthesia of the Palate 
We have just concluded a description of conduction anes- 
thesia of the teeth and buccal structures in the upper jaw. 
In a similar manner, it is possible to anesthetize the entire 
palate by three injections. These consist of the nasopala- 
tine injection, and the two posterior palatine injections. 
Nasopalatine Injection 
Looking at the skull, a large foramen is seen in the 
median line directly behind the incisors. (Fig. 5. ) This XEEVE-BLOCKIXG IX THE MAXILLiE 
107 
is the nasopalatine or anterior palatine foramen, and if the 
novocaine is injected at this point sensation behind the an- 
terior teeth on both sides, up to a line drawn across the 
canines, will be cut off. The foramen is directly beneath 
a rather large papilla in the median line just behind the 
incisors. With the head thrown back, and the syringe held 
horizontally, the needle readily enters the foramen. Since 
injection here is rather painful, it is more advisable to 
inject directly behind the teeth involved as described in 
the chapter on infiltration. For the removal of impacted 
canine teeth by way of the palate, the nasopalatine injec- 
tion is particularly suited. 
Block Anesthesia of Anterior Palatine Nerve 
It is not very frequently that occasion exists to inject at 
the posterior palatine foramen in order to block the ante- 
rior palatine nerve which emerges there. The technic for 
palatal injections as already described in a previous chap- 
ter is to be preferred. Where however the entire palate is 
to be anesthetized on one side this may be accomplished by 
injection into the posterior palatine foramen. This foramen 
is indicated in the living subject by a little depression 
alongside the third molar, and in the path of the curve of 
the tuberosity as it comes on to the palate. (Fig. 23.) 
With the head thrown back, the syringe is held in an al- 
most horizontal position, and the foramen may be easily 
entered. It is important to remember that only four or 
five drops of novocaine should be used, as excess solution 
will infiltrate the middle and posterior palatine nerves in 
the immediate vicinity, with gagging and great discomfort 
to the patient in consequence. CHAPTER IX 
GENERAL OBSERVATIONS 
Uses of Local Anesthesia in Dentistry 
Operative dentistry in almost every branch may be 
greatly assisted through the intelligent application of 
local anesthesia. It is to be used only where indicated. 
The indiscriminate injection of all patients for all 
types of work is unscientific and poor practice. With 
good judgment and discretion, the anesthetization of 
the field of operation affords an opportunity to do work in 
a much more efficient manner. It also permits procedures 
which might otherwise not be possible. These latter em- 
brace operations on cervical cavities which latter are ex- 
tremely sensitive to the slightest thermal change, and refuse 
the touch of an instrument. Under anesthesia, particularly 
in the mandible, several may be prepared at one sitting 
following a mandibular injection. 
The painless preparation of cavities for inlays or inlay 
abutments is of first importance in the field of operative 
dentistry. The outline form of the cavity is often sacri- 
ficed because the tooth is extremely sensitive to drilling 
just at the point where it is most needed for retention. 
The greatest damage occurs where the inlays are intended 
to be used for abutments in the construction of a removable 
bridge. If the inlay is made, and the attachments soldered 
to the inlays, the bridge is completed and placed in the 
mouth. Should the inlay come loose, it is the cement 
alone which determines the future of the piece. The fail- 
ure may ofttimes be traced to faulty preparation of the 
cavity; the retention form was not carried out properly 
because of the extreme pain occasioned by the stone or bur. 
108 GENERAL OBSERVATION'S 
109 
Local anesthesia would have permitted the proper cutting, 
and would have insured the permanence of the restoration. 
This is no plea for fixed bridge work. But it is certain 
that many fixed bridges depending upon crowns have been 
lost because the bite was high. In consecpience of the trau- 
matic occlusion produced, the abutment teeth became 
loosened, and the bridge was lost. The fault was not that 
the bridge was fixed. It goes back to the preparation of 
the tooth to receive the crown. When the enamel was be- 
ing removed from the cusps the process was so painful that 
.sufficient enamel could not be ground away. In consequence, 
after the crown was reinforced, the bite was left high, and 
the bridge and teeth were pounded to their destruction. 
The construction of a bridge with no opposing teeth, there- 
by permitting a minimum of grinding on the abutment 
teeth, has always been delightful. 
There seems to be a growing revival of ceramics in the 
dental art, and the porcelain jacket crown is gaining in 
popularity. Many sensitive teeth may be comfortably pre- 
pared under the influence of novocaine. 
Is there danger of injury to the pulp as a result of the 
anesthesia itself? It has been proven beyond doubt that 
pulp regains its normal tone after the anesthetic effects 
have worn off. Is there danger to the pulp following oper- 
ative measures? There certainly is. There is always danger 
lurking about in the wake of carelessness, in every walk 
of life. You must learn to be careful. Grinding on a tooth 
should proceed slowly and with wet stones so as not to 
overheat the tooth. Be gentle. Remember that you are 
working on living tissues, and not on an inanimate object. 
Every dentist has had occasion to burn his fingers as a 
result of the heat caused by grinding an inlay held in them. 
With proper caution the pulp is in no danger. 
For the extirpation of pulps, local anesthesia is fast, posi- 
tive and painless. The use of arsenic is to be condemned. 
Following a proper injection the pulp may be removed and 110 
LOCAL ANESTHESIA SIMPLIFIED 
a dressing of cotton dipped in alcohol left in the canal. It 
is poor practice immediately to fill the canals, as a second- 
ary hemorrhage often occurs. The sterile cotton absorbs 
the blood in the apical space and keeps the canal clean. 
On the next visit the canal is filled. If there remains a 
sensitive bit of pulp at the apex, it can be removed with 
little discomfort after the application of phenol on a smooth 
broach or sodium and potassium. 
It may sometimes occur that the tooth is drilled pain- 
lessly and the pulp exposed, but when an effort is made to 
enter the pulp with the nerve broach, a twinge of pain is 
felt. The very end plates of the pulp are still active, and 
it is then necessary to apply a pressure pluglet of novocaine 
as in the usual manner in pressure anesthesia. The plug- 
let is applied to the exposure and pressed home under a 
covering of pink wax. 
After-pain 
Much after-pain can be prevented by forethought. It is 
often due to faulty technic of injection. Many cases of 
after-pain can be traced to careless surgical interference. 
Sharp bits of process, excessive trauma, and inflammation 
of the alveolar walls following difficult extraction are some 
of the most common causes of after-pain. It is also to be 
expected that a moderate amount of pain will follow after 
surgical measures, when the effect of the anesthetic has 
worn off. 
Ordinarily there should be no pain due solely to the in- 
jection itself. Postinjection pain may be traced to a 
failure in adhering strictly to the technic of injection as 
laid down. The more common faults are the rapid injec- 
tion of the solution, or the use of a solution that is too hot 
or too cold. Where the solution is taken from a stock 
bottle after-pain may be the result of sepsis; this is 
eliminated through the use of the ampule of isotonic, ster- 
ile solutions of novocaine. The older method of driving GENERAL OBSERVATIONS 
111 
the anesthetic into the bone and soft tissues under consider- 
able pressure was a frequent source of after-pain. Muscle 
infiltration through faulty technic causes after-pain. Fol- 
lowing a mandibular injection which has been made too 
low, the internal pterygoid muscle may be entered. The 
function of the muscle is impaired and trismus results. 
Absorption from muscle tissue is rather slow and several 
days may elapse before the mouth may be fully opened. In 
the absence of sepsis no fear need be felt. The condition 
may be relieved through the application of any agent which 
hastens absorption and antiphlogistine has been found effi- 
cacious in these conditions. Where the operation has been 
of such a nature that pain is expected, it is advisable to 
administer a sedative before the patient leaves the office. 
A tablet of pyramidon may be given, and two more are 
given to the patient to be taken three hours later if pain 
begins to manifest itself. 
Unfortunately we are not as fully advanced in the art of 
controlling pain following an operation as we should like 
to be. The ideal will be reached when we can relieve our 
patients of the pain which often follows a painless opera- 
tion, but we can accomplish much in that direction at pres- 
ent by a faithful observance of the few simple rules of 
technic and asepsis which have been laid down in this little 
volume. INDEX 
A 
After-pain, 110 
Ampule of novocaine, 49 
Anesthesia: 
intraossoous, 42 
mucobuccal fold in, 45 
peridental, 42 
submucous, 47 
subperiosteal, 43 
supraperiosteal, 47 
Anesthetics: 
nitrous oxide, 101 
novocaine, 24 
suprarenin, 24 
Anterior palatine nerve, 30, 36, 64, 
107 
Anterior superior dental nerve, 99 
B 
Bicuspid injection, 58, 106 
Block anesthesia, 76 
of palate, 106 
Blocking: 
anterior palatine nerve, 107 
mandibular injection, SO 
nasopalatine nerve, 106 
upper bicuspids, 106 
upper central, lateral and canine, 99 
upper molars, 103 
waiting period, 92 
C 
Canine injection, 58 
Cavity preparation, 52, 108 
Central incisor injection, 52 
Cocaine—used in 1884 by Holler, 75 
Conduction anesthesia, 75 
D 
Dentistry, use of novocaine in, 108 
Depth of penetration in mandibular 
injection, 90 
E 
Extent of supraperiosteal injection 
in bicuspids, 106 
in molars, 104 
F 
Fifth nerve, 28 
G 
General anesthesia, 101 
Guide for needle, 24 
H 
Hematoma, 104 
High pressure anesthesia, 42 
I 
Incisors anesthesia by infiltration, 52 
Infection due to injection, 27 
Inferior dental nerve, 32 
Infiltration anesthesia: 
mandible, 70 
maxilae, 45 
Infraorbital foramen, 36 
new technic, 100 
old injection, 99 
Instrumentarium, 20 
applicators, 25 
needles, 21-23 
syringe, 21 
Internal oblique line, 79 
Intraosseous anesthesia, 42 
K 
Holler, Karl, 75 
L 
Lateral incisor injection, 58 
Lingual nerve, 33 
Local anesthesia in dentistry, 10& 
Long buccal nerve, 33, 96 
M 
Mandible, infiltration, 77 
Mandibular injection, 80 
depths of penetration, 90 
extent of anesthesia, 92 
first attempt, 18 
guide, use of, 24 
left side, 92 
retromolar triangle, 78 
sulcus, 79 
113 114 
INDEX 
Maxillae: 
nerve blocking, 99 
structure, 34 
Maxillary nerve, 29 
Meckel’s ganglion, 30 
Mental foramen, 40 
nerve, 40 
Middle palatine nerve, 30-31 
Middle superior dental nerve, 31 
Molars, injection for, 58 
Mucobuccal fold, 45 
N 
Nasopalatine foramen, 36 
Needles: 
broken, 23 
for conduction, 23 
for infiltration, 23 
guide for penetration, 24 
Nerve blocking in maxillae, 99 
Nerve supply, 28 
anterior palatine, 30, 36 
inferior dental nerve, 32 
lingual, 33 
long buccal, 33 
maxillary, 29 
mental, 40 
middle palatine, 30, 31, 38 
middle superior and anterior 
dental, 31 
nasopalatine, 30, 106 
nitrous oxide, 101 
ophthalmic, 28 
posterior palatine, 30, 31 
posterior superior dental, 30 
Novocaine: 
ampules, 24 
anesthetic, 24 
discovered by Einhorn, 17 
O 
Operative dentistry under anesthesia, 
108 
Ophthalmic nerve, 28 
P 
Pain, 110 
Palatal anesthesia, 57, 64 
Peridental anesthesia, 42 
Platinum iridium needles, 21 
sharpening, 21 
Posner syringe, 21 
Posterior palatine foramen, 36 
palatine nerve, 30, 31 
superior dental nerve, 30 
Preparation of site for needle punc- 
ture, 49 
Pressure anesthesia, 57 
Pulp extirpation, 110 
Pyramidon in after-pain, 111 
R 
Ramus, varying widths in mandibular 
anesthesia, 91 
Retromolar triangle, 78 
S 
Sicher, new infraorbital injection, 100 
Sphenomaxillary fossa, 29 
Sterilization, 26 
Submucous anesthesia, 47 
Subperiosteal anesthesia, 43 
Supraperiosteal anesthesia, 47 
extent of anesthesia, 57 
waiting time, 57 
Suprarenin, 24 
action and use, 25 
Syringe: 
care of, 25, 26 
Luer Lok Posner syringe, 21 
technic of use, 49 
T 
Time to wait after supraperiosteal 
injection, 57 
Trigeminal nerve, 28 
Tuberosity injection, 103 
U 
Uses of local anesthesia in dentistry, 
108 
W 
Warming novocaine in ampules, 49