Maxillary Nerve Block

Guided by Submitted by
Dr. Yogendra Malviya Pooja
Dr. Akanksha Chaturvedi Roll no. 53

Batch –F ( final year)

 Maxillary nerve anatomy
 The maxillary division leaves the skull through the foramen
rotundum and enter into the pterygopalatine fossa, from where
it progresses forward , entering the inferior orbital fissure to
pass into the orbital cavity.
 Hence it turns slightly laterally in a groove called the
infraorbital groove on the orbital surface of the maxilla.
 As it continues forward , it becomes covered over by a thin
plate of bone and then passes through the infraorbital canal.
 Continuing forward, the second division emerges on the front
of the maxilla by the infraorbital foramen.
Types of injection

 Supraperiosteal (infiltration)
 Posterior superior alveolar nerve block
 Maxillary (second division) nerve block
 Anterior middle superior alveolar nerve block
 Anterior superior alveolar nerve block
 Greater (anterior) palatine nerve block
 Nasopalatine nerve block
 SUPRAPERIOSTEAL INJECTION
- Commonly called local infiltration.
- Most frequently used technique for obtaining
pulpal anesthesia in maxillary teeth.
-It is indicated whenever dental procedures are
confined to a relatively circumscribed area in the
maxillary or mandibular incisors region.

Other common names – Para periosteal

injection .
 Nerves anesthetized - terminal branch of dental plexus.
 Areas anesthetized – Entire region innervated by the large terminal branches of
this plexus.
 Indications –
 Pulpal anesthesia of maxillary teeth when treatment is limited to 1 or 2 teeth.
 Soft tissue anesthesia when indicated for surgical procedure
 Contraindications -
 Infection or acute inflammation
 Dense bone covering the apices of teeth
Advantages –High success rate
Technically easy injection .
Usually entirely atraumatic.

Disadvantages – Not recommended for large areas :

Need multiple needle insertion the necessity to administer larger total volumes of local
anesthesia.

Positive aspiration – Negligible, but possible (<1%).

Alternatives - PDL injection, intraosseous injection, regional nerve block.

Complications - Pain on needle insertion with the needle tip against
the periosteum . To correct this , withdraw the needle & reinsert it
farther from the periosteum.
Landmarks - Mucobuccal fold , Crown of the tooth , Root contour of the
tooth

Target area - Apical region of the tooth to be anesthetized.

Area of insertion - Height of the Mucobuccal fold above the apex of the
tooth being anesthetized.

Signs and symptoms - Absence of pain during treatment.

Precautions - It is not recommended for larger areas of treatment.

 Posterior superior alveolar nerve block

- The PSA nerve block is commonly used dental nerve block.

- Highly successful technique (>95%).

Other common names -Tuberosity block, Zygomatic block.

Nerve anesthetized - PSA nerve & branches.

Area anesthetized - The maxillary molars , with the exception of the mesiobuccal
root of the first molar ; the buccal alveolar process of the maxillary molars ,
including the overlying structures- periosteum, connective tissue , and mucous
membrane.
Anatomical Landmarks –
Mucobuccal fold and its concavity.
Zygomatic process of maxilla.
Infratemporal surface of maxilla.
Anterior border and coronoid process of the ramus of the mandible.
Indications –
- When treatment involves two or more maxillary molars.
- When supraperiosteal injection is contraindicated .
- When supraperiosteal injection has proved ineffective.

Contraindications –
- When the risk of hemorrhage is too great as in hemophilia in such case a
supraperiosteal or PDL injection is recommended.

Advantages –
- Atraumatic. - Minimum number of necessary injection.
- High success rate. - Minimizes amount of local anesthesia use.
Disadvantages –
- Risk of hematoma, which is usually diffuse and also discomfiting and
visually embarrassing to the patient.
- Technique somewhat arbitrary: no bony landmarks during insertion.
- Second injection necessary for treatment of the first molar (mesiobuccal
root) in 28% of patients.
- Does not anesthetize first molar completely .

Positive Aspiration – Approximately 3.1 %

Alternatives –
-Suoraperiosteal or PDL injections , Infiltration ,
Technique : Advance the needle slowly in an upward, inward, and
backward direction in one movement (not three):
- Upward : superiorly at a 45-degree angle to the occlusal plane.
- Inward : medially toward the midline at a 45-degree angle to the occlusal
plane .
- Backward : posteriorly at a 45-degree angle to the long axis of the
second molar.
Signs and symptoms –
-Subjective : feeling of numbness in palate when contact with the tongue.
-Objective : Instrumentation is necessary to demonstrate.
- Absence of pain , during treatment.

Safety Features – Slow injection , repeated aspirations.

Precaution –The depth of needle penetration should be checked :

Over insertion – Increases the risk of hematoma.
Little or too shallow – Still provide adequate anesthesia.
Failures of Anesthesia –
- Needle too lateral. To correct this, redirect the needle tip medially.
- Needle not high enough. To correct this, redirect the needle tip superiorly.
- Needle too far posterior. To correct this, withdraw the needle to the proper
depth.
Complications –
- Hematoma : Insertion of the needle too far posteriorly into the pterygoid
Plexus of veins . In addition , the maxillary artery may be perforated.
-Mandibular Anesthesia : The mandibular division of the fifth cranial nerve is
located lateral to PSA nerve.
 Middle superior alveolar nerve block

Nerves Anesthetized : MSA nerve and terminal branches.

Areas Anesthetized : Pulps of the maxillary first and second premolars, mesiobuccal
root of the first molar .
- Buccal periodontal tissue and bone over these same teeth.

Landmarks : Mucobuccal fold above the maxillary second premolar.

Indications : where the ASA nerve block fails to provide Pulpal anesthesia distal to
the maxillary canine.
- Dental procedures involving both maxillary premolars only.
Contraindications : Infection or inflammation in the area of injection or needle
insertion or drug deposition.
- Where the MSA nerve is absent, innervation is through the ASA nerve;
branches of the ASA innervating the pre- molars and the mesiobuccal root of the
first molar can be anesthetized by means of the MSA technique.

Advantages : Minimizes the number of injections and the volume of solution.

Disadvantages : None

Positive Aspiration : Negligible (<3%)

Alternatives : Local infiltration (supraperiosteal), PDL, intraosseous injections
- ASA nerve block for the first and second premolar and the mesiobuccal root
of the first molar.

Chair position : For a right MSA nerve block – 10’o clock position
For a left MSA nerve block – 8 or 9’ o clock position

Signs and Symptoms :

- Subjective: upper lip numb
- Objective: use of a freezing spray (e.g., Endo-Ice) or an EPT with no
response from the tooth with maximal EPT output (80/80)
- Absence of pain during treatment
Precautions : Do not insert the needle too close to the periosteum & do not
inject anesthetic too rapidly.
 Anterior superior alveolar nerve block
( Infraorbital nerve block)
It provides profound pulpal and buccal soft tissue anesthesia from
the maxillary central incisor through the premolars.

Landmarks :
Mucobuccal fold
Infraorbital notch
Infraorbital depression
Infraorbital ridge
Infraorbital foramen
Supraorbital notch
Nerves Anesthetized :
1. Anterior superior alveolar nerve (ASA)
2. MSA nerve
a) Infraorbital nerve
b) Inferior palpebral
c) Lateral nasal
d) Superior labial

Area anesthetized : Pulp of the maxillary CI through the canine , premolars &
mesiobuccal root of the first molar (72% patient ) on the injected side.
- Buccal periodontium & bone of the same teeth & lower eyelid, lateral aspect
of nose , upper lip.
Indications : Inflammation or infection.
- when supraperiosteal injection have been ineffective because of dense
cortical bone.

Contraindications : Hemostasis of localised areas.

Advantages : Comparatively simple technique, safe, minimizes the volume of

solution used
Disadvantage :
1. Psychological – fear of injury to patients eye.
2. Anatomic – difficulty defining landmarks.

Area of insertion : height of the muccobuccal fold directly over the first premolar.
( path of penetration is towards the target area , the infraorbital foramen. The first
premolar usually provides the shortest route to this target area.)

Signs & Symptoms : Subjective – Tingling & numbness of the lower eyelid, side
of the nose & upper lip
Objective – absence of pain during treatment.
Safety Features : Needle contact with bone at the roof of the infraorbital
foramen.
- A finger positioned over the infraorbital foramen helps direct the needle
toward the foramen.

Complication : Hematoma( rare)

 MAXILLARY
NERVE BLOCK
-It is an effective method of achieving profound anesthesia of a hemimaxilla.
-It is useful in procedures involving quadrant dentistry and in extensive
surgical procedures.

Other Common Names –

Second division nerve block, V₂ nerve block.

Nerve Anesthetized –
Maxillary division of the trigeminal nerve.
Areas Anesthetized –
- Pulpal anesthesia of the maxillary teeth on the side of the block .
- Buccal periodontium and bone overlying these teeth.
- Soft tissues and bone of the hard palate and part of the soft palate, medial to
midline.
- Skin of the lower eyelid, side of the nose, check, and upper lip.
Indications –
- Pain control before extensive oral surgical, periodontal, or restorative procedures.
- Tissue inflammation or infection precludes the use of other regional nerve blocks
or supraperiosteal injection.
- Diagnostic or therapeutic procedures for neuralgias or tics of the second division
of the trigeminal nerve.
Contraindications –
-Inexperienced administrator.
- Pediatric patients.
- Uncooperative patients.
- Inflammation or infection of tissues overlying the injection site.
- When hemorrhage is risky.
Advantages –
- Atraumatic injection via the high-tuberosity approach.
- High success rate (>95%).
- Positive aspiration is less than 1%
- Minimizes the number of needle penetrations necessary.
- Minimizes total volume of local anesthetic solution injected to 1.8 mL versus 2.7 ml.
- Neither the high-tuberosity approach nor the greater palatine canal approach is usually
traumatic.

Disadvantages –
- Risk of hematoma.
-The high-tuberosity approach is relatively arbitrary Overinsertion is possible.
- Lack of hemostasis.
Alternatives –
- PSA nerve block .
- ASA nerve block.
- Greater palatine nerve block.
- Nasopalatine nerve block.

Techniques –
2 types High tuberosity approach

Greater Palatine Canal Approach

High Tuberosity approach:
Area of insertion –
Height of the mucobuccal fold above the distal aspect of the maxillary
second molar.
Target areas –
- Maxillary nerve as it passes through the pterygopalatine fossa.
- Superior and medial block to the target area of the PSA nerve block.
Landmarks –
- Mucobuccal fold I at the distal aspect of the maxillary second molar.
- Maxillary tuberosity.
- Zygomatic process of the maxilla.
Greater Palatine Canal Approach:
Area of insertion –
- Palatal soft tissue directly over the greater palatine foramen.

Target area-
The maxillary nerve as it passes through the pterygopalatine fossa; the needle passes
through the greater palatine canal to reach the pterygopalatine fossa.

Landmark-
- Greater palatine foramen.
- Junction of the maxillary alveolar process .
- The palatine bone.
Signs and Symptoms –
- Subjective: pressure behind the upper jaw (rapidly, progressing to
tingling ) and numbness of the lower eyelid, side of the nose, and upper
lip.
Sensation of numbness in the teeth and buccal and palatal soft tissues on
the side of injection.
- Objective: absence of pain during treatment.

Safety Feature –
Careful adherence to technique.
Precautions –
- Pain on insertion of the needle, primarily with the greater palatine
canal approach.
- Overinsertion.
- Resistance to needle insertion in the greater palatine canal
approach ; never try to advance a needle against resistance.
Complications –
- Hematoma develops rapidly if the maxillary artery is punctured.
- Penetration of the orbit may occur during a greater palatine foramen
approach of the needle goes in too far.
solution is running down his or her throat.
- Complications produced by injection of local anesthetic into the
orbit include:
1.Volume displacement of the orbital structures, producing
periorbital swelling and proptosis.
2.Classic retrobulbar block, producing mydriasis, corneal
anesthesia, and ophthalmoplegia.
- Penetration of the nasal cavity :The patient complains that local
anesthetic solution is running down his or her throat.
 Greater palatine nerve block

- Dental procedure involving the palatal soft tissues distal to the canine.

Other common name : Anterior palatine nerve block

Nerve Anesthetized : Greater palatine nerve

Area Anesthetized : posterior portion of hard palate & it’s overlying soft
tissues, anteriorly as far as the first premolar & medially to the midline.
Landmark : Greater palatine foramen & junction of the maxillary alveolar
process & palatine bone .

Indications : When palatal soft tissue anesthesia is necessary for restorative

therapy on more than two teeth
- For pain control during periodontal or oral surgical procedures involving the
palatal soft and hard tissues.

Contraindications : Inflammation & infection at the injection site.

- Smaller areas of therapy.

Advantages : Minimizes needle penetrations, volume of solution & patient

Disadvantage : Potentially traumatic.

Alternative : Local infiltration, Maxillary nerve block

Safety features : Contact with bone, Aspiration

Precautions : Don’t enter the greater palatine canal.

Complication: Ischemia & necrosis of the soft tissues.

Hematoma ( rare)
Failures of anesthesia : Deposited too far anterior to the foramen
- Anesthesia on the palate in the area of the maxillary first premolar may
prove inadequate because of overlapping fibers from the nasopalatine nerve
.
 Anterior Middle Superior Alveolar Nerve Block
Other Common Name - Palatal approach AMSA nerve block.
Nerves Anesthetized - ASA nerve
- MSA nerve, when present
- Subneural dental nerve plexus of the ASA and MSA nerves

Areas Anesthetized -
- Pulpal anesthesia of the maxillary incisors, canines, and premolars .
- Buccal attached gingiva of these same teeth.
- Attached palatal tissues from midline to free gingival margin on associated
teeth.
Landmarks - The intersecting point midway along a line from the midpalatine
suture to the free gingival margin intersecting the contact point between the first
and second premolars.

Indications - More easily performed with a C-CLAD system.

- Procedure involving multiple maxillary anterior teeth or soft tissues.

Contraindications - Patient with thin Palatal tissue.

- Procedure requiring longer than 90 mins.

Advantages - Comparatively simple technique, safe , minimize the volume of

Anesthetic.
Disadvantages –
Can cause operator fatigue with a manual syringe.
- Uncomfortable to patients.
- Cause excessive ischemia.

Signs & Symptoms -

-Subjective:
a sensation of firmness and numbness is experienced
immediately on the palatal
- tissues.
-Objective: blanching of the soft tissues.
- Absence of pain..
Safety features -
- Contact with bone
- Aspiration
-Slow insertion of needle (1 to 2 mm every 4 to 6 seconds).
- Slow administration of local anesthetic (0.5 mL/min).
-Less anesthetic required than if traditional injections are used.

Complications –
- Palatal ulcer at injection site developing 1-2 days post-operatively.
- Unexpected contact with the nasopalatine nerve.
 Nasopalatine Nerve Block

Other Common Names-

- Incisive nerve block.
- Sphenopalatine nerve block.

Nerves Anesthetized - Nasopalatine nerves bilaterally.

Areas Anesthetized - Anterior portion of the hard palate bilaterally from the
mesial aspect of the right first premolar to the mesial aspect of the left first
premolar.
Indications –
-When palatal soft tissue anesthesia is necessary for restorative treatment on
more than two teeth.
-For pain control during oral surgical procedures.

Contraindications –
- Inflammation or infection at the injection site.
- Smaller area of therapy (one or two teeth).

Advantages –
-Minimizes needle penetrations and volume of solution.
-Minimal patient discomfort from multiple needle penetrations.
Disadvantage - No hemostasis except in the immediate area of injection.

Alternatives –
-Local infiltration into specific regions.
-Maxillary nerve block.
- AMSA nerve block (unilateral only).
-Intranasal local anesthetic mist.

Landmarks – Central incisors and incisive papilla.

Technique –
Single – Needle Penetration of the palate:
Area of insertion - Palatal mucosa just lateral to the incisive papilla.

Target area - lncisive foramen, beneath the incisive papilla.

Path of insertion -Approach the injection site at a 45-degree angle toward the
incisive papilla.

- Slowly advance the needle toward the incisive foramen until bone is gently
contacted .The depth of penetration is normally not greater than 5 mm.
Multiple Needle Penetrations:
Areas of insertion –
- Labial frenum in the midline between the maxillary central incisors.
- Interdental papilla between the maxillary central incisors.
- If needed, palatal soft tissues lateral to the incisive papilla.

Target area - Incisive foramen, beneath the incisive papilla.

Path of insertion –
First injection: Infiltration into the labial frenum.
Second injection: Needle held at a right angle to the interdental papilla.
Third injection: Needle held at a 45-degree angle to the incisive papilla.
Orientation of the bevel –
- First injection: bevel toward bone.
- Second and third injection : bevel orientation not relevant.

Procedure –
First injection: Infiltration of 0.3 mL into the labial frenum.
-Retract the upper lip to stretch tissues and improve visibility.
-Gently insert the needle into the frenum and deposit 0.3 mL of anesthetic in
approximately 15 seconds.
- The aim of this first injection is to anesthetize the interdental papilla between
the two central incisors.
Second injection: Penetration through the labial aspect of the papilla
between the maxillary central incisors toward the incisive papilla.
-Holding the needle at a right angle to the interdental papilla, insert it into the
papilla just above the level of crestal bone.
-Stabilization of the syringe in this second injection .Use of a finger from the
other hand to stabilize the needle is recommended.
-Anesthesia within the distribution of the right and left nasopalatine nerves
usually develops in a minimum of 2 to 3 minutes.

Third injection: Place the needle into soft tissue adjacent to the (diamond-
shaped) incisive papilla, aiming toward the most distal portion of the papilla.
- Advance the needle until contact is made with bone.
Signs and Symptoms –
- Subjective: numbness of the upper lip (in the midline) and the anterior portion of
the palate.
-Objective: no pain during dental therapy.

Safety Features – Aspiration.

-Contact with bone (third injection).

Advantage - Entirely or relatively atraumatic.

Disadvantages –
- Requires multiple injections (three).
- Difficult to stabilize the syringe during the second injection.
Precautions –
-Against pain: If each injection is performed as recommended, the entire
technique should be atraumatic.
- Against infection: On the third injection, do not advance the needle into the
incisive canal. With accidental penetration of the nasal floor, the risk of
infection is increased.

Failures of Anesthesia –
- A highly successful (>95%) injection.
- Inadequate anesthesia of palatal soft tissues