Anesthetic techniques - Maxillary anesthetic techniques

Maxillary Anesthetic Techniques

Maxillary Anesthetic
Techniques
Dr Hesham El-Hawary
El-
www.elhawarydentalclinic.com

ELHAWARY


The main factors are:

1. Selection of a suitable syringe and needle
2. Utilization of the proper L.A. drug
3. Insertion of the needle in the correct site for
injection

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1. Middle meningeal nerve
2. Twiges to the
sphenopalatine ganglion
3. Posterior superior alveolar
nerve
4. Zygomatic nerve
5. Infra-Orbital Nerve
1. Middle superior alveolar
nerve
2. Anterior superior alveolar
nerve
3. Terminal branches
1. Inferior palpebral nerve
2. External nasal nerve
3. Superior labial nerve

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Nerve supply of Maxillary teeth
Pulp , Investing structures & Labial (buccal) mucoperiosteum

Anterior teeth
Anterior superior alveolar nerve
(1,2,3)

Premolars (4,5) &
MB root of 1st Middle superior alveolar nerve
molar(6)

Molars except MB
root of 1st Posterior superior alveolar nerve
molar(6)

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Nerve supply of Maxillary teeth Cont.

Palatal mucoperiosteum
Anterior teeth
Nasopalatine nerve
(1,2,3)

Premolars
(4,5)
Greater ( Anterior) palatine nerve
&
Molars (678)

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Local Anesthesia

1. Topical anesthesia
2. Local infiltration
3. Field block
4. Nerve block

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Local Anesthesia
• Topical Anesthesia
– Ointments, gels, sprays and pastes on mucous
membrane or skin
– Application of a topical anesthetic agent on the
mucosa allows for the easy and painless insertion
of the sharp needle
– Affects free nerve endings

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Local Anesthesia
• Local Infiltration
– Flooding of the small terminal nerve endings with
local anesthetic solution

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Local Anesthesia
• Field Block
– Referred to as local infiltration
– local anesthetic solution is deposited in the
vicinity of larger terminal nerve fiber
– so a circumscribed area is anesthetized
– Local anesthesia injection above a tooth apex is
an example of a field block, in spite of being
referred to as paraperiosteal or supraperiosteal
infiltration anesthesia

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Local Anesthesia
• Subperiosteal injection
– Not be attempted
– Because of
• Liability of needle breakage
• Difficulty of forcing the anesthetic agent between
periosteum and bone

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Local Anesthesia
• Nerve Block
– The anesthetic solution is deposited close to a
main nerve trunk
– Usually at a distance from the operative site
before the nerve divided into terminal branches

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Buccal inf.

Infiltiration
Palatal inf.

Incisive N.B.
Maxillary anesthesia
Anterior &
Middle Sup. Alv.
N.B.

Post. Sup. Alv.
Nerve block N.B.

Palatine N.B.

Maxillary N.B.

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Factors affecting selection of the
technique to be used
1. Area to be anesthetized
Depending on the type of bone (density of bone)
– Maxilla and anterior mandibular region are mainly formed
of cancellous bone with thin cortical layer above allowing
infiltration anesthesia or field block anesthesia reaches the
nerve filaments inside the cancellous bone
– Posterior mandible is covered with thick and dense cortical
layer, thus nerve lock anesthesia is indicated

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technique to be used Cont.
2. Extent of surgical procedure
– In multiple extractions, nerve block anesthesia is
preferable to
– Allow anesthesia of the entire operative area
– Prevent multiple needle punctures to attain the
same anesthesia through infiltration

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3. Duration and profoundness of anesthesia
Nerve block anesthesia produces a more profound
and longer duration than infiltration anesthesia
4. Age of the patient
Older individuals have dense bone, thus it is more
difficult for infiltration anesthesia to penetrate into
the bone

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5. Homeostasis
When required for the procedure, infiltration
anesthesia is recommended to allow the
vasoconstrictor present with the local
anesthetic to act directly on the blood vessels
and reduce bleeding

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6. Presence of infection
Infiltration anesthesia should be avoided to
prevent injection into an infected area which
can spread the infection
7. Skill of the operator

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INFILTRATION ANESTHESIA

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 The most commonly used technique
 It is divided into
 Soft tissue infiltration
 Submucosal
 Paraperiosteal
 Bony infiltration

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Soft tissue infiltration anesthesia
In this technique anesthesia is deposited into
the soft tissue in close proximity to bone
which is then absorbed via pores in the bone
surface till it reaches the nerve filaments
inside the cancellous bone

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Soft Tissue Infiltration
Submucosal anesthesia Paraperiosteal Anesthesia
 Needle is inserted at a slight  Called local infiltration
depth just below the  Mostly used for anesthetizing
mucous membrane  All maxillary teeth
 In cases just need  Lower anterior mandibular teeth
superficial anesthesia  It’s action depends on the
 Hypertrophied tissue diffusion of the L.A. solution
 High muscle attachment through the periosteum and the
minute foramina in the cortical bone

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Paraperiosteal Anesthesia
Advantages Disadvantages
1. High success rate • Not suitable for large areas
2. Technically it is an easy – Needs multiple punctures
injection – Administeration of large
3. Usually it is entirely amount of L.A. solution
atraumatic

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MAXILLARY BUCCAL INFILTRATION
ANESTHESIA

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Buccal infiltration anesthesia
Patient position Dentist position
• Head , neck and trunk on the • From infront and to the
same straight line right
• The back of the chair is tilted so
that it make a 45 degree angle
with the floor
• So that when the patient open his
mouth the occlusal plane of the
maxillary teeth makes 45 degree
with the floor
• The occlusal plan of maxillary
teeth near to the operator’s
shoulder

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Buccal infiltration anesthesia Cont.
• Needle:
– 25-27 gauge
– Short needle
• Syringe
– Non-Aspirating syringe
• The target area
– The apical region of the tooth to be anesthetized

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Buccal Infiltration Technique Cont.
The point of needle insertion
The point of intersection of 2
imaginary lines
• 1st line is a vertical line
parallel to the long axis of
the tooth
• 2nd line is a horizontal line
along the mucobuccal fold

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Buccal Infiltration Technique Cont.
Direction of needle insertion
• 45° with the buccal cortical
plate of bone

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Steps for buccal infiltration
 The lip/cheek is retracted using dental mirror or your
finger to make almost a right angle with the
labial/buccal aspect of the jaw
 The point of insertion is determined as mentioned
 The needle is inserted with its bevel toward the bone
and making an angle of 45° with the buccal aspect
 The needle is pushed through the soft tissue until
the bone is reached (within 2mm)

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Steps for buccal infiltiration Cont.
 The needle is held firmly and 1.5cc of the solution is
slowly deposited for buccal/labial injection, and 0.3
cc for lingual anesthesia
 The needle is then withdrawn gently and recap it

 Wait 2-3 minutes before starting your dental
procedure

 Check your anesthesia using the dental probe
(objective finding)
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Confirming the Anesthesia
• Subjective findings
– No subjective findings
• Objective findings
– Probing does not lead to pain

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MAXILLARY PALATAL INFILTRATION
ANESTHESIA

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When you are performing any dental work
except extraction then the buccal infiltration is
enough
but
when it comes to extraction then also a Palatal
injection is to be given

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Palatal Infiltration Technique
 Midway between the
gingival margin of the tooth
and the median palatine
raphe
 Along the long axis of the
tooth

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Palatal Infiltration Technique Cont.
• 90° to the palatine bone
90°

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Steps for palatal infiltration
 A mirror is used to retract the tongue and reflect the light to
the point of insertion
 The point of insertion is determined as mentioned
 The needle is inserted from the opposite side making 90°
degree with the palate
 The needle is pushed through the soft tissue until the bone is
reached (within 2mm)
 On touching the palatal bone deposit 0.3 ml. SLOWLY

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Variations in these techniques
Buccal anesthesia Palatal anesthesia
 Injection for the maxillary • Injection for maxillary third
third molar molar should be at the
Made opposite to the palatal root of the maxillary
maxillary second molar second molar to avoid
tooth to avoid injury to the anesthesia of the lesser
pterygoid plexus of veins palatine nerves which
 upper centrals supply the soft palate and
may lead to gagging
Inject a few drops to the sensation
apical area of the other
central incisor

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Variations in these techniques Cont.
Buccal anesthesia Palatal anesthesia
 Upper centrals  Upper centrals and laterals
Inject a few drops to the Given 0.5 mm along the
apical area of the other palatal long axis of the
central incisor tooth while entering from
the opposite side

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Bony infiltration anesthesia
• In this technique anesthesia is deposited
directly into the bone in close proximity to the
nerve filaments inside the cancellous bone
• Very rarely used

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Bony Infiltration Anesthesia
(Intra osseous)

Techniques Advantages
• A special needle is used to 1. Very profound anesthesia
drill and pierce the outer
2. When other techniques have
cortical plate
failed
• Using rose head round bur
(#2) Disadvantages
1. The needle easily get clogged

2. The needle could fracture

3. Painfull

4. Cause infection inside the bone

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Maxillary Nerve Block Techniques
• Posterior superior alveolar nerve block
• Anterior and middle superior alveolar nerve
block
• Incisive nerve block
• Greater palatine nerve block
• Maxillary nerve block

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Maxillary anesthetic Techniques

POSTERIOR SUPERIOR ALVEOLAR
NERVE BLOCK
(ZYGOMATIC/TUBEROSITY NERVE BLOCK)
ZYGOMATIC/

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 This technique is used to anesthetize the
Posterior Superior Alveolar Nerve before it
enters the posterior surface of the maxilla
while it is in the infra-temporal fossa
infra-

 It will anesthetize the pulp, investing
structures and buccal mucoperiosteum of the
maxillary molars except for the mesio-buccal
root of the 1st molar

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Posterior superior alv. N.B. Technique
• Head , neck and trunk on  In the left p.s.a. sits in a 10
the same straight line o’clock position
• The back of the chair is  In the right p.s.a. he sits in
tilted so that it make a 45 an 8 o’clock position
degree angle with the floor
• So that when the patient
open his mouth the occlusal
plane of the maxillary teeth
makes 45 degree with the
floor

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alv.
Cont.

• Needle:
– 25-27 gauge
– Long needle

• Syringe
– Aspirating syringe

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alv.
Cont.

• Landmarks
– Muccobuccal fold
– Maxillary tuberosity
– Zygomatic process

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alv.
Cont.

• Technique
1. Retract the cheek and prepare site of injection
2. The needle is introduced into the height of the mucobuccal fold
above the 2nd molar
3. Advance the needle slowly upward, backward and inward
4. The needle shouldn’t touch bone, and the max. depth allowed is ½
the length of the long needle, then ASPIRATE
5. If blood comes out then retract and try again, but if you get blood
also the next time then abort the technique
6. If no blood comes out then deposit 1.5 ml of the anesthetic solution,
wait 3-5 minutes before working

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MAXILLARY NERVE BLOCK

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• The purpose of this technique is to block the main
trunk of the maxillary nerve as it traverses the
pterygopalatine fossa after emerging from
foramen rotandum

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Maxillary Nerve Block
 To accomplish this the same landmarks as the
post. Sup. Alv. N. block is used but you have to
enter the needle about 2/3 of its length
 A larger amount is used in this case where
4ml are deposited slowly and after aspiration
to achieve a successful result
 It is very rare to be done

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– Numbness of:
• The palate
• Upper lip
• Lateral aspect of the nose
• Lower eye lid
– Probing does not lead to pain in the palate and
buccal mucosa in any aspect

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INFRAORBITAL NERVE BLOCK
(ANTERIOR AND MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK)

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Infra Orbital N. BLOCK
 The aim is to deposit the anesthetic solution into the
infraorbital canal through the infraorbital foramen
The foramen is shaped like a flattened funnel with the opening directed
downwards and medially. Thus the needle should approach the foramen
from the medial side

 This is to anesthetize the anterior and middle
superior alveolar nerves

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Infra Orbital N. BLOCK Cont.
• In this technique the anterior & middle
superior alveolar nerves are anesthetized in
80% of cases

• In the remaining 20% the middle sup.alv.
nerve has to be given a separate injection

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Infra Orbital N. BLOCK Cont.
 Area to be anesthetized:
 The upper lip

 The lateral aspect of the nose

 The lower eyelid

 The buccal mucosa of the upper anterior teeth and premolars

 Pulp and investing structures of upper anterior teeth and premolars

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Infraorbital N.Block Technique Cont.
• Head , neck and trunk on the • Stands on the right side
same straight line
infront of the patient
that the patient is in a supine for a right side injection
position
• Along side the patient
teeth for a left side injection
– Near to the operator’s
shoulder
– At a 45 degrees angle to the
floor

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• Needle:
– 25-27 gauge
– Long needle
• Syringe
– Aspirating syringe

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The infraorbital foramen

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• Will be discussed in the
technique

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Steps for Infraorbital N.Block
Technique Cont.
1. Clean the tissue to be injected with sterile gauze
2. Apply topical antiseptic followed by topical
anesthetic
3. Pull the upper lip taut
4. Locate the infraorbital foramen which is
– About 5mm below the infraorbital ridge between the middle and inner
thirds
– The foramen also lies in one vertical line with the pupil when the
patient gazes forwards

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Technique Cont.
5. There are 3 acceptable methods of approaching the
infraorbital foramen: First technique
– A vertical imaginary line is drawn from the inner canthus of
the eye until it intersects with another imaginary line
drawn in the mucobuccal fold forming a right angle
– A 25 gauge needle is inserted in the mucobuccal fold about
5 mm lateral to the maxillary alveolar bone directing it to
bisect this imaginary right angle

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Technique Cont.
infraorbital foramen: Second technique
– The crown of the central incisor on the side of the tooth to
be operated on is bisected by the needle from the
mesioincisal edge to the distogingival angle with the point
of insertion 5 mm out from the mucobuccal fold to the
level of the canine apex

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Technique Cont.
infraorbital foramen: Third technique
– The syringe and needle are lined up with a vertical line
with the longitudinal axis of maxillary 2nd premolar in line
with the pupil of the eye while patient gazes forwards
– The needle is inserted 5mm out in the mucobuccal fold

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Technique Cont.
6. The needle is oriented with bevel towards bone and
advanced slowly till it contacts the upper rim of the
infraorbital foramen
The depth of penetration should not exceed 20 mm
6. Aspirate, if negative deposit the anesthetic solution
slowly
7. Wait 3-5 minutes before commencing dental
procedure

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– Numbness of
• The lower eye lid
• Lateral wall of the nose
• Upper lip
– Probing does not lead to pain in the mucosa
opposite to the anterior teeth and premolars

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INCISIVE CANAL NERVE BLOCK
(NASOPALATINE NERVE BLOCK)

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Incisive canal N.Block
 This is a painful injection so it is better to give a few drops of
anesthesia superficially before proceeding with the rest of the
injection

 The aim is to anesthetize the nasopalatine nerve inside the incisive
canal

 Area to be anesthetized:

The mucosa of the Anterior part of the palate opposite to the anterior teeth

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Incisive canal N.Block Technique Cont.
• Head , neck and trunk on the • The operator will sit
same straight line
from infront and to the
that the patient is in a supine right
position
shoulder

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• Needle:
– 25-27 gauge
– Short needle
• Syringe

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The incisive foramen i.e. the
crest of the incisive papilla

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• The needle is inserted into
the crest of the incisive
papilla
• From between the upper
centrals making an angle of
45 degrees to the palatal
mucosa

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Steps for incisive canal N.Block
Technique Cont.
1. Ask patient to open wide
2. A labioginigval crest injection is made to anesthetize the
incisive papilla first
3. The needle is oriented parallel with the labial alveolar plate
with the needle directed towards the crest of the incisive
papilla i.e. The needle approach is from between the upper
centrals making an angle of 45 degrees to the palatal
mucosa
4. The needle is inserted into the crest of the incisive papilla for
a distance of 4 mm
5. Inject 0.3 ml of anesthetic solution
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– Numbness of the anterior 1/3 of the palate
– Probing does not lead to pain in the anterior 1/3
of palate

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GREATER PALATINE NERVE BLOCK

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Greater Palatine N.Block Technique
 The aim of this technique is to block the greater
palatine nerve as it comes out of its foramen

 It’s foramen usually lies distal to the upper 2nd molar,
but it can be more anterior

 Areas to be anesthetized:

Palatal mucosa of the molars and premolars

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Greater Palatine N.Block Technique Cont.
• Head , neck and trunk on the • The operator will sit
same straight line
from infront and to the
that the patient is in a supine right
position
shoulder

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• Needle:
– 25-27 gauge
– Short needle
• Syringe

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The greater palatine foramen
distal to the palatal aspect
of the second molar

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• from the opposite side to
which the injection is to be
made
• The needle approaching the
site of injection at right
angle

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Steps for Greater Palatine N.Block
Technique Cont.
1. Ask patient to open wide
2. Palpate the position of the greater palatine foramen till you feel its
depression
3. Clean the tissue to be injected with sterile gauze
4. Apply topical antiseptic followed by topical anesthetic
5. A 27 gauge needle is inserted from the opposite side to which the
injection is to be made with the needle approaching the site of injection
at right angle
The needle is advanced through soft tissue until bone is contacted
6. About 0.5 ml of the anesthetic solution is deposited
7. Withdraw syringe and recap needle
8. Wait 2-3minutes before commencing dental procedure

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– Numbness of the posterior 2/3 of the palate
– Probing does not lead to pain

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THANK YOU

ELHAWARY

Anesthetic techniques - Maxillary anesthetic techniques

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