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Maxillary Injection Techniques. Anatomy Atraumatic Injection Protocol.

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Presentation on theme: "Maxillary Injection Techniques. Anatomy Atraumatic Injection Protocol."— Presentation transcript:

1 Maxillary Injection Techniques

2 Anatomy

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6 Atraumatic Injection Protocol

7 3 Main Types of Maxillary Injections: 1) Local Infiltration 2) Field Block 3) Nerve Block

8 Local Infiltration Incision (treatment) is done in the same area in which the local anesthetic was deposited (interproximal papilla before Scaling and Root Planing)

9 Field Block Local anesthetic is deposited toward larger nerve terminal branches Treatment is done away from the site of local anesthetic injection Maxillary injections administered above the apex of the tooth to be treated are properly referred to as field blocks not local infiltrations

10 Nerve Block Local anesthetic is deposited close to a main nerve trunk, usually at a site removed from the area of treatment (PSA, IANB, NPB)

11 Types of Injections 1) Supraperiosteal Injection 2) Intraligamentary (PDL) Injection 3) Intraseptal Injection 4) Intracrestal Injection 5) Intraosseous Injection 6) Posterior Superior Alveolar (PSA) Nerve Block 7) Middle Superior Alveolar (MSA) Nerve Block 8) Anterior Superior Alveolar (ASA) Nerve Block 9) Maxillary Nerve Block (2 nd Division) 10) Greater Palatine Nerve Block 11) Nasopalatine Nerve Block 12) Anterior Middle Superior Alveolar (AMSA) Nerve Block 13) Palatal Approach Anterior Superior Alveolar (P-ASA) Nerve Block

12 Maxillary and Mandibular Injections The following are used in both arches: Supraperiosteal Injection Intraligamentary (PDL) Injection Intraseptal Injection Intraosseous Injection

13 Supraperiosteal Injection

14 1) Supraperiosteal Injection Used for pulpal anthesia in maxillary teeth Anesthetizes large terminal branches of the dental plexus Greater than 95% success rate 1 or 2 teeth

15 Supraperiosteal Injection Dense bone covering the apices of the teeth can lead to failure -maxillary molar of children (zygomatic bone obscures) -central incisor of adults (nasal spine obscures) Negligible positive aspiration rate (less than 1%) Should not be used for large areas (multiple sticks/large amount of local anesthetic solution must be used)

16 Technique Supraperiosteal Injection 1) 25 or 27 gauge short needle is recommended 2) Insert needle at height of mucobuccal fold over apex of desired tooth 3) Apply topical anesthetic for at least one minute 4) Orient bevel toward bone; lift lip pulling tissues taut

17 5) Hold syringe parallel to long axis of the tooth being anesthetized 6) No resistance to penetration should be felt and no patient discomfort 7) Aspirate twice 8) Deposit.6 ml (one-third of a cartridge) into tissue over 20 seconds 9) Do not allow tissues to balloon 10) Wait 3 to 5 minutes to begin dental treatment

18 Problems/Failures If tooth does not anesthetize the needle tip could be below the apex of the tooth resulting in inadequate anesthesia If the needle lies too far from the bone then anesthesia will be inadequate because the solution was deposited in the soft tissue (lip) The needle must be oriented toward the periosteum but should be managed properly to avoid tearing the highly innervated periosteum

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22 Supraperiosteal vs. Infiltration These two words are used incorrectly; what most practitioners refer to as an infiltration injection is actually a field block

23 Citing the ongoing economic crisis and growing competition from other insurers, Washington Dental Service will reduce reimbursement rates for all dental procedures by 15% starting June 1. Was it purely a business decision?

24 Posterior Superior Alveolar Nerve Block (PSA)

25 2) Posterior Superior Alveolar Nerve Block Highly successful nerve block with greater than 95% success Effective for maxillary 1 st, 2 nd and 3 rd molars and buccal periodontium Mesiobuccal root of the maxillary 1 st molar is not consistently innervated by the PSA nerve

26 Short dental needle is used for all but the largest of patients Average depth of soft tissue penetration is 16 mm (short needle is 20 mm in length) 28% of maxillary 1 st molars mesiobuccal roots are innervated by the middle superior alveolar nerve (MSA)

27 When the risk of hemorrhage is too great as with a hemophiliac, you should use the supraperiosteal or PDL injections Patient should feel no pain with this injection because bone is not contacted and there is a large area of soft tissue into which the solution is deposited

28 Positive aspiration risk is 3.1% Patient will often say that they do not feel numb; reason why is because they are accustomed to the intense feeling of anesthesia experienced by the IANB; reassure patient that you are going to make sure they are comfortable during the procedure

29 Technique PSA Nerve Block 1) 25 gauge short needle is recommended 2) Insert needle at the height of the mucobuccal fold above the maxillary 2 nd molar 3) Target area is the PSA nerve which is posterior, superior and medial to the posterior border of the maxilla

30 4) Apply topical anesthetic for at least one minute 5) Have patient open their mouth half way which makes more room 6) Retract the patients cheek with mirror 7) Pull the tissues taut 8) Orient bevel toward bone

31 9) Insert needle at height of mucobuccal fold over the 2 nd maxillary molar 10) Advance needle upward, inward and backward direction 11) Odd feeling of having no resistance whatsoever 12) Penetrating to an average depth of mm is adequate 13) Aspirate in two planes by rotating bevel one quarter turn

32 14) Deposit 0.9 ml of a cartridge (1/2 cartridge) 15) Wait 3 to 5 minutes to start treatment Advance the needle in one movement, not three separate movements; usually atraumatic to most patients

33 Problems/Failures (PSA) Hematoma formation if needle is overinserted too far posteriorly Pterygoid plexus of veins leads to this hematoma Visible intraoral hematoma develops within minutes; bleeds until the pressure of the extravascular blood equals that of the intravascular blood which can result in a large, unsightly hematoma

34 Patients will usually claim that they do not feel any anesthesia which is not uncommon because patients can not reach this area to gauge their own level of anesthesia If using a long dental needle the maximum insertion should be one-half on its length or 16 mm Problems/Failures (PSA)

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40 Middle Superior Alveolar Nerve Block (MSA)

41 3) Middle Superior Alveolar Nerve Block Middle Superior Alveolar Nerve is not present in 28% of the population When the infraorbital nerve block fails to provide anesthesia to teeth distal to the maxillary canines, the MSA is indicated MSA provides anesthesia to 1 st and 2 nd premolars and mesiobuccal root of maxillary 1 st molar; anesthetizes buccal periodontium and bone

42 If MSA is absent the premolars and mesiobuccal root of maxillary 1 st molar is innervated by the ASA Positive aspiration risk is less than 3% (negligible) Infraorbital nerve block can block 1 st premolar, 2 nd premolar and mesiobuccal root of the maxillary 1 st molar if you need an alternative block when the MSA is not adequate

43 Technique MSA Nerve Block 1) 25 or 27 gauge long or short needle 2) Insert needle at the height of the mucobuccal fold above 2 nd maxillary premolar 3) Target is the maxillary bone above the apex of the 2 nd maxillary premolar

44 4) Orient bevel toward bone to avoid tearing periosteum 5) Apply topical anesthetic for one minute 6) Pull tissues taut 7) Penetrate tissues placing bevel of needle well above the apex of the 2 nd maxillary premolar

45 Technique- Middle Superior Alveolar Nerve Block 8) Aspirate 9) Slowly deposit ml of solution 10) Wait 3 to 5 minutes before starting treatment

46 Problems/Failures MSA Anesthetic not deposited above the apex of the 2 nd premolar Solution deposited into the soft tissue too far from the periosteum (lip) Hematoma may develop; Dentist should apply pressure to the area with gauze for at least sixty (60) seconds; up to 2 to 3 minutes

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48 Middle Superior Alveolar Nerve Block

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50 Anterior Superior Alveolar Nerve Block (ASA)

51 Highly successful extremely safe block that causes hesitation in most clinicians Provides profound pulpal and soft tissue anesthesia from the maxillary central incisor distal to the premolars in 72% of patients Used in place of the supraperiosteal injection

52 Uses less anesthetic solution than the supraperiosteal injection Supraperiosteal 3.0 ml solution ASA 1.0 ml solution #1 fear is damage to the patients eye which is unfounded Also known as the Infraorbital Nerve Block which is inaccurate Failed ASA is just a supraperiosteal injection over the 1st premolar

53 Areas Anesthetized ASA Nerve Block 1) Pulp of the maxillary central incisor through the canine 2) 72% of patients have premolars and mesiobuccal root of 1 st molar anesthetic 3) Buccal periodontium and bone of the above teeth 4) Lower eyelid, lateral aspects of the nose and upper lip

54 When Do I Use This Block? 1) Dental procedures involving more than one tooth, i.e., central and lateral incisor 2) Inflammation/Infection precluding the use of the supraperiosteal injection 3) Ineffective supraperiosteal injections due to dense cortical bone

55 Technique ASA Nerve Block 1) 25 gauge long needle is recommended 2) Insert needle at the height of the mucobuccal fold over the 1 st premolar 3) Target: Infraorbital Foramen 4) Landmarks: Infraorbital Notch, Mucobuccal fold, Infraorbital Foramen 5) Apply topical anesthetic for at least one minute

56 6) Feel the infraorbital notch moving your finger down the notch palpating the tissues gently; the outward bulge is the lower border of the orbit which is the roof of the infraorbital foramen; continue the finger inferiorly until a depression is felt which is the infraorbital foramen 7) Maintain pressure over the foramen while inserting the needle down the long axis of the 1 st premolar

57 8) Advance the needle slowly until bone is contacted gently which is the upper rim of the infraorbital foramen 9) 16 mm total advancement of needle;1/2 of long needle length 10) Estimate the distance between the infraorbital foramen and mucobuccal fold 11) Aspirate

58 12) Deposit 1.0 ml of anesthetic solution 13) Administrator can feel the anesthetic expanding the tissue with finger tip 14) Maintain finger pressure over the foramen for at least one minute to disperse the anesthetic solution 15) Needle should not be palpable in most patients 16) Wait 3 to 5 minutes for anesthesia to result

59 Problems/Failures (ASA) Failure is from the needle deviating to the medial or lateral away from the infraorbital foramen Failure to reach the infraorbital foramen will result in anesthesia of the lateral side of the nose, upper lip and lower eyelid but not the teeth Hematoma formation can result although rarely; apply pressure to area for 2 to 3 minutes; at least 60 seconds

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65 Palatal Anesthesia

66 Easily one of the most traumatic experiences for dentists due to the pain that is sometimes elicited from the patients Palatal injections can be administered atraumatically

67 STEPS- Results in painless palatal injections 1) Apply topical for two minutes 2) Apply pressure to site both before and during deposition of the solution 3) Deposit solution slowly

68 5 PALATAL INJECTIONS 1) Anterior (Greater) Palatine Nerve Block: no pulpal anesthesia 2) Nasopalatine Nerve Block: no pulpal anesthesia 3) Local Infiltration: no pulpal anesthesia 4) P-AMSA: pulpal and soft tissue 5) P-ASA: pulpal and soft tissue

69 Greater Palatine Nerve Block

70 GP Nerve Block (soft tissue and bone only) Anesthetizes palatal soft tissue distal and medially to the canine (posterior portion of the palate) Tissues around the Greater Palatine Foramen are able to accommodate a larger volume of solution than the tissue in the vicinity of the Nasopalatine Foramen less patient discomfort

71 Indications for palatal injections: 1) Scaling and root planing 2) Subgingival restorations 3) Deep placed matrix bands 4) Extractions (oral surgery)

72 Technique Greater Palatine Nerve Block 1) 27 gauge short needle 2) Insert needle in soft tissue slightly anterior to the greater palatine foramen 3) Target is the greater palatine nerve as it passes from the foramen between the soft tissue and bone of the hard palate

73 Locate the Greater Palatine Foramen: -use cotton swab/mirror handle -place a cotton swab at the junction of the maxillary alveolar process and the hard palate -press firmly into tissues moving posteriorly from the maxillary 1 st molar -swab falls into the depression of the greater palatine foramen

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75 4) Foramen is most often located distal to the 2 nd maxillary molar 5) Apply considerable pressure to cotton swab in area of foramen until a noticeable ischemia occurs; hold pressure for 30 seconds before injection

76 6) Continue to apply pressure throughout the injection with the cotton swab 7) Slowly advance the needle until bone is gently contacted 8) Depth of penetration is usually less than 10 mm 9) Aspirate 10) Deposit solution very slowly

77 Do not enter the greater palatine canal There is no reason to have the needle penetrate the canal There is no negative repercussion except post-operative pain

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82 Nasopalatine Nerve Block

83 Nasopalatine Nerve Block (soft tissue and bone only) Considered by many to be the most traumatic, painful injection of all the dental injections Most important injection to follow the protocol about to be explained Anesthetizes the anterior portion of the hard palate (soft and hard tissues) from the mesial of the left premolar to the mesial of the right premolar Use this injection for the same reasons as Greater Palatine Nerve Block Target area is the incisive foramen beneath the incisive papilla

84 Technique Nasopalatine Nerve Block 1) 27 gauge short needle is recommended 2) Insertion point: palatal mucosa just lateral to the incisive papilla 3) Approach the injection site at a 45 degree angle 4) Apply topical anesthetic for two minutes 5) Apply considerable pressure to the incisive papilla until ischemia

85 6) Continue to apply pressure to the cotton applicator tip while injecting 7) Advance the needle until bone is gently contacted 8) Depth of needle penetration is usually 5 mm 9) Slowly deposit ¼ cartridge over a 30 second interval 10) Wait 2-3 minutes for anesthesia

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87 Other Than P-ASA and Maxillary Nerve Blocks There is no reason to enter the Greater Palatine Foramen or the Nasopalatine Foramen when providing these injections do not advance needle more than 5 mm into the incisive canal because it could enter the floor of the nose causing infection

88 Back Spray During palatal injections, the pressure generated within the syringe will cause the solution to spray into your mask/face; always wear the appropriate safety glasses and mask when giving any injection regardless of how trivial it may seem at the time

89 2 nd Example of Nasopalatine Injection Technique 2 nd Example of Nasopalatine Injection Insertion Points: 1) Labial frenum; midline of maxilla (0.3 ml over 15 seconds) 2) Interdental papilla of #8 and #9 (0.3 ml over 15 seconds) 3) Palatal soft tissues lateral to the incisal papilla (contact bone)

90 2 nd Example of Nasopalatine Injection Important Points: Topical and pressure anesthesia on the palate are not necessary because the first injection anesthetized the palatal tissues Contact bone on the 3 rd injection (incisive papilla) only Interdental papilla between maxillary central incisors is sore for a few days Greater palatine nerve may overlap and lead to inadequate anesthesia of the canine and 1 st premolar

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92 Local Infiltration of the Palate

93 Anesthetizes the terminal branches of the Greater Palatine Nerve and Nasopalatine Nerve Anesthetizes the soft tissue in the immediate vicinity of the injection

94 Indications for Palatal Anesthesia: 1) Hemostasis during procedures of a minimal area of tissue 2) Palatogingival pain control for rubber dam clamps, retraction cord placement and small surgical procedures

95 Local Infiltration of the Palate Important Points: -Gate control method (inhibitory neuron prevents the projection neuron from sending signals to the brain (gate is closed)) of pain removal is used with -these injections using a cotton swab for pressure resulting in blanching tissue -Target area is the palatal tissue 5 to 10 mm from the free gingival margin -Masticatory mucosa of the hard palate is only 3 to 5 mm thick -Palatal Infiltrations are safe areas anatomically to deposit anesthetic

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98 P-ASA

99 P-ASA Palatal Approach Anterior Superior Alveolar Nerve Block Described in the 1990s by the inventors of the CCLAD systems Comparative to the Nasopalatine Nerve Block Insertion: lateral point of the incisive papilla but the big difference: NEEDLE TIP IS POSITIONED IN THE INCISIVE CANAL

100 Deposit 1.4 – 1.8 ml of solution at 0.5 ml per minute Primary method of achieving bilateral pulpal anesthesia of the maxillary anterior six teeth; anterior palatal 1/3 rd Provides profound soft tissue anesthesia of the gingiva and mucoperiosteum

101 Soft tissue of the facial attached gingiva is achieved anterior to the maxillary anterior six teeth P-ASA is the 1 st injection to produce bilateral pulpal anesthesia of the maxillary anterior six teeth from a single injection

102 MAIN POINT OF THIS INJECTION: P-ASA is designed to provide pulpal anesthesia of the maxillary anterior six teeth in addition to the facial gingival soft tissue and mucoperiosteum it does not anesthetize the lip as with the regular mucobuccal fold approach; esthetic Dentistry can then be assessed without dealing with lip anesthesia when smiling

103 Palatal approach allows anesthesia to be limited to the subneural plexus for the maxillary anterior teeth and nasopalatine nerve Minimum volume for injection is 1.8 ml (full cartridge) over 0.5 ml/minute Insert needle very slowly 4% anesthetics should have volume reduced by ½ (Prilocaine/Articaine)

104 Do not use 1:50,000 epinephrine May need supplemental mucobuccal fold injections for canines because of their very long roots Palatal ulcers develop from ischemia 1-2 days after treatment and are self- limiting; healing occurs in 5-10 days

105 Technique P-ASA 1) 27 gauge short needle is recommended 2) Insert needle just lateral to the incisive papilla in the papillary groove 3) Target is the nasopalatine foramen 4) Needle held at 45 degree angle to the palate (same as central incisors)

106 5) Insert needle 6 to 10 mm; if resistance is found do not force needle 6) Insert needle 1-2 mm every 4-6 seconds while administering solution 7) Resistance means you have to reinsert the needle; careful of nose floor 8) Aspirate 9) Deposit 1.8 ml of anesthetic solution very slowly 0.5 ml/minute 10) Patient may feel needle shock very disturbing to patient

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109 Maxillary Nerve Block 1) Greater Palatine Approach 2) High Tuberosity Approach

110 Maxillary Nerve Block Facts Also known as a 2 nd Division block Anesthetizes the maxillary division of the trigeminal nerve

111 Areas Anesthetized : 1) Pulpal anesthesia of all teeth on the side of injection (ipsalateral) 2) Buccal periodontium and bone on the side of injection 3) Soft tissues and bone of the hard palate/soft palate medial to midline 4) Skin of lower eyelid, side of the nose, cheek and upper lip

112 Maxillary Nerve Block Approaches It would require 4 other injections to get the effect of the Maxillary Nerve Block i.e., PSA, Infraorbital, Greater Palatine and Nasopalatine 2 Approaches: 1) Greater Palatine Approach 2) High Tuberosity Approach

113 1) Greater Palatine Approach Technique 25 gauge long needle recommended Insert into palatal soft tissue over greater palatine foramen Target is the maxillary nerve as it passes through the Pterygo-palatine Fossa; the needle passes through the Greater Palatine Canal to reach the Pterygopalatine Fossa

114 Find the foramen by using a cotton swab until it falls into the foramen Most often found at distal of the maxillary 2 nd molar Topical anesthetic for at least two minutes Inject into the area adjacent to the Greater Palatine Foramen in order to block the nerve before probing into the actual foramen itself

115 1) Greater Palatine Approach Technique Remember to apply constant pressure into this area until the tissue blanches which will lessen the discomfort of the needle penetration Probe gently for the foramen with the needle tip at a 45 degree angle After finding the canal advance the needle 30 mm 5 to 15% of foramens have boney obstructions, so if you encounter an obstruction do not force the needle, try again then abort

116 Maxillary Nerve Block Complications 1) Greater Palatine Approach Complications Penetration of the orbit leading to a myriad of complications periorbital swelling or proptosis (bulging eye) block of 6 th cranial nerve producing diplopia (double vision) Retrobulbar (behind the eye) hemorrhage, corneal anesthesia optic nerve anesthesia loss of vision

117 Maxillary Nerve Block Complications Penetration of the nasal cavity (medial wall of the pterygopalatine fossa is paper thin): -patient complains of something draining down their throat -large amounts of air will be aspirated into the cartridge

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121 Maxillary Nerve Block 2 nd Approach 2) High Tuberosity Approach 25 gauge long needle recommended Insert to the height of the mucobuccal fold distal to the 2 nd molar Target is maxillary nerve as it passes through the pterygopalatine fossa Superior and medial to the target site of the PSA

122 Again, advance the needle to a depth of 30 mm Upward, inward and backward direction same as PSA Resistance should not be felt, if it is, the angulation is too medial At 30 mm the needle tip should lie within the pterygopalatine fossa Aspirate several times and inject 1.8 ml (one cartridge) slowly

123 Maxillary Nerve Block 2 nd Approach 2) High Tuberosity Approach Complications Hematoma develops rapidly if the maxillary artery is punctured with the needle tip

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125 Thin, porous substance of the maxillary bone allows for rapid diffusion of solutions into the cancellous bone Most Dentists rely solely on the supraperiosteal injection to provide anesthesia in the maxilla PSA and ASA combined can deliver safe anesthesia to virtually all patients requiring maxillary anesthesia

126 Universal: -applying topical anesthetic for one minute -proper patient positioning -aspiration -making the needle safe after each injection with the scoop technique

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128 References Malamed, Stanley: Handbook of Local Anesthesia. 5 th Edition. Mosby. 2003

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