1. nerve block technique الطالب : مؤمن خالد محمود ابو حمره ID : 1002158
PROF. عمرو السويفي

2. Maxilary nerve block

3. Anatomy

5. 3 Main Types of Maxillary Injections:
1) Local Infiltration
2) Field Block
3) Nerve Block

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

7. 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

8. 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)

9. 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 (2nd 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

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

11. Supraperiosteal Injection

12. 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

13. 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)

14. 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

15. 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

16. 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

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

20. 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?

21. Posterior Superior Alveolar Nerve Block (PSA)

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

23. 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 1st molars’ mesiobuccal roots are innervated by the middle superior alveolar nerve (MSA)

24. 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

25. 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

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

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

28. 9) Insert needle at height of mucobuccal fold over the 2nd 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

29. 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

30. 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

31. Problems/Failures (PSA)
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

36. Middle Superior Alveolar Nerve Block (MSA)

37. 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 1st and 2nd premolars and mesiobuccal root of maxillary 1st molar; anesthetizes buccal periodontium and bone

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

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

40. 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 2nd maxillary premolar

41. 9) Slowly deposit 0.9-1.2 ml of solution
Technique- Middle Superior Alveolar Nerve Block
8) Aspirate
9) Slowly deposit ml of solution
10) Wait 3 to 5 minutes before starting
treatment

42. Problems/Failures MSA
Anesthetic not deposited above the apex of the 2nd 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

44. Middle Superior Alveolar Nerve Block

46. Anterior Superior Alveolar Nerve Block (ASA)

47. 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

48. Uses less anesthetic solution than the supraperiosteal injection
Supraperiosteal  3.0 ml solution
ASA  1.0 ml solution
#1 fear is damage to the patient’s 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

49. 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 1st molar anesthetic 3) Buccal periodontium and bone of the above teeth 4) Lower eyelid, lateral aspects of the nose and upper lip

50. 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

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

52. 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 1st premolar

53. 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

54. 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

55. 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

60. Palatal Anesthesia

61. Palatal Anesthesia
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

62. 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

63. 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

64. Greater Palatine Nerve Block

65. 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

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

67. 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

68. 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 1st molar
-swab “falls” into the depression of the
greater palatine foramen

70. 4) Foramen is most often located distal to the 2nd 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

71. 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

72. 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

77. Nasopalatine Nerve Block

78. 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

79. 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

80. 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

81. 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

82. 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

83. 2nd Example of Nasopalatine Injection
Technique 2nd 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 3) Palatal soft tissues lateral to the incisal papilla (contact bone)

84. 2nd 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 3rd 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 1st premolar

86. P-ASA

87. 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

88. 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 1/3rd
Provides profound soft tissue anesthesia of the gingiva and mucoperiosteum

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

90. 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

91. 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)

92. 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

93. 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)

94. 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

97. Maxillary Nerve Block 1) Greater Palatine Approach
2) High Tuberosity Approach

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

99. 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

100. 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

101. 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

102. Find the foramen by using a cotton swab until it “falls into” the foramen
Most often found at distal of the maxillary 2nd 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

103. 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

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

108. 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

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

111. 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

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

114. Long Buccal Nerve Block
Anterior branch of Mandibular nerve (V3)
Provides buccal soft tissue anesthesia adjacent to mandibular molars
Not required for most restorative procedures

115. Buccal Nerve Block Indications
Anesthesia required - mucoperiosteum buccal to mandibular molars
Contraindications
Infection/inflammation at injection site

116. Buccal Nerve Block Advantages Technically easy High success rate
Disadvantages
Discomfort

117. Buccal Nerve Block Alternatives Buccal infiltration Gow-Gates PDL
Intraseptal

118. Buccal Nerve Block Technique Apply topical
Insertion distil and buccal to last molar
Target - Long Buccal nerve as it passes anterior border of ramus
Insert approx. 2 mm, aspirate
Inject 0.3 ml of solution, slowly
gauge needle
Area of insertion:
- Mucosa adjacent to most distal

119. Buccal Nerve Block
Landmarks
Mandibular molars
Mucobuccal fold

120. Buccal Nerve Block Complications Hematoma (unusual)
Positive aspiration
0.7 %

123. Mental Nerve Block Terminal branch of IAN as it exits mental foramen
Provides sensory innervation to buccal soft tissue anterior to mental foramen, lip and chin

124. Mental Nerve Block Indication Need for anesthesia in innervated area
Contraindication
Infection/inflammation at injection site

125. Mental Nerve Block Advantages Easy, high success rate
Usually atraumatic
Disadvantage
Hematoma

126. Mental Nerve Block Alternatives Local infiltration PDL Intraseptal
Inferior alveolar nerve block
Gow Gates

127. Mental Nerve Block Complications Few Hematoma Positive aspiration
5.7 %

132. Incisive Nerve Block Terminal branch of IAN
Originates in mental foramen and proceeds anteriorly
Good for bilateral anterior anesthesia           
Not effective for anterior lingual anesthesia  

133. Incisive Nerve Block
Nerves anesthetized
Incisive
Mental

134. Incisive Nerve Block Areas Anesthetized
Mandibular labial mucous membranes
Lower lip / skin of chin
Incisor, cuspid and bicuspid teeth

135. Incisive Nerve Block Indication
Anesthesia of pulp or tissue required anterior to mental foramen
Contraindication
Infection/inflammation at injection site

136. Incisive Nerve Block Advantages High success rate
Pulpal anesthesia w/o lingual anesthesia
Disadvantages
Lack of lingual or midline anesthesia

137. Incisive Nerve Block
Complications
Hematoma
Positive aspiration
5.7 %