Local Anesthesia for Dental Professionals - Anatomy & Maxillary Injections

1. Based on Text- Local Anesthesia for Dental Professionals
1st ed. Dr. StanleyMalamed 2nd ed. Bassett, DiMarco,
Naughton
Local Anesthesia for Dental Professionals

2.  Motor root
 Mastication
 Masseter
 Temporalis
 Medial pterygoid
 Lateral pterygoid
 Mylohyoid
 Anterior belly of
digastric

3.  V2 Maxillary nerve
 Greater palatine nerve
 Lesser palatine nerve
 Posterior superior alveolar
nerve
 Middle superior nerve
 Anterior superior nerve
 Nasopalatine nerve
 V3 Mandibular nerve
 Buccal nerve
 Lingual nerve
 Inferior alveolar nerve
 Mental nerve
 Incisive nerve

4.  Sterile sharp needle
 After cartridge / harpoon engaged check flow of LA
 Position the patient
 Dry the tissue – 2x2 sterile gauze
 Apply topical antiseptic & anesthetic
 Communicate with patient
 Establish firm hand rest

5.  Pull tissue tight
 Keep syringe out of patient’s line of sight
 Insert needle into mucosae
 Watch the patient and needle
 Communicate - ask to breathe slow and deep
 Inject a few drops sub mucosal
 Advance needle and deposit several drops along the
way
 Aspirate
 Inject slowly

6.  Communicate with and watch the patient
 Slowly withdraw the needle
 Observe the patient
 Record the injection into the chart
 Drug name, %, amount of solution
 Vasoconstrictor used and concentration
 Xylocaine 2% 1:100,000, 1.8 ml
 36 mg lidocaine
 .018 mg epi

7.  Local infiltration
 LA is deposited at or above the apex of the tooth to be treated
 technically is really a field block
 Field Block
 LA deposited near larger terminal nerve branch
 Injections administered above the apex of the tooth are termed
a field block
 common terminology identifies them as infiltration or
supraperiosteal
 Nerve Block
 LA deposited close to main nerve trunk at a distance from
operative site

8. Superior Alveolar Nerve

14.  Areas anesthetized
 Pulps of maxillary molars
 1st (except MB root), 2nd, 3rd
 Buccal periosteum and bone
 Indications
 When supra periosteal infiltration is ineffective
 or contraindicated due to infection
 Contraindications
 When risk of hemorrhage is unacceptable
 Hemophiliac, coumadin, pradaxa
 Medical consult needed

15.  Advantages
 Atraumatic
 High success rate
 Minimum # injections for 3 teeth
 Minimizes volume of anesthetic used
 Disadvantages
 Risk of hematoma
 No real bony landmarks – an area
 Secondary injection necessary for Tx of MB of 1st molar
 Positive aspiration
 Less than 3%

16.  Technique
 Needle
 Short 27 or 25 gauge
 Area of insertion –
 MB fold over 2nd molar
 Target
 posterior, superior, and medial to posterior border of maxilla
 Landmarks
 MB fold
 Maxillary tuberosity
 Zygomatic process of maxilla

17.  Prepare as discussed before
 Gauze, topical
 Retract cheek with one finger pulling maxillae to you
 Insert needle at height of MB fold over 2nd molar
 Advance upward and inward
 at 45 degrees to occlusal plane up
 At 45 degrees to saggital / midline plane
 Slowly advance needle to depth desired
 approximately 16mm of a 20 mm needle

18.  Aspirate x2 (rotate) and then slowly inject if negative
 Goal
 Deposit solution close to the posterior superior nerve at
the foramen
 Located posterior, superior and medial to maxillary
tuberosity
 No anatomic barrier
 must be careful to not over insert the needle

20.  Complications
 Hematoma – maxillary artery is in this area
 Caused by inserting needle too far posterior into pterygoid
plexus or maxillary artery
 Mandibular anesthesia
 Mandibular nerve is lateral to PSA nerve
 Depositing solution lateral to desired location
 Tongue, lower lip numb

22. Superior Alveolar Nerve

23.  Areas anesthetized
 Anesthesia of 1st and 2nd premolars
 Buccal periodontal tissues and bone
 Contraindications
 Infection or inflammation in site of MSA
 MSA nerve may be absent - (innervation thru ASA)
 Advantages
 Minimizes number of injections

25.  Disadvantages
 none
 Positive aspiration
 Rare
 Complications
 Minimal if proper administration
 Do not advance too far

26.  Needle
 25 or 27 gauge
 Insertion landmark
 Height of mucobuccal fold over 2nd bicuspid
 Prepare tissues
 Dry with gauze, topical, pull cheek tight
 Goal
 Insert needle into mucosae parallel to alveolus
 Slowly advance until tip is above apex of 2nd premolar
 Aspirate and slowly inject
 Deposit ½ to full cartridge

30.  Complications
 Hematoma is rare
 If it occurs apply pressure with gauze
 Failure of anesthesia
 Solution not high enough over apex
 Solution too far from bone
 due to poor angulation and into cheek
 Dense bone or zygoma prevents diffusion into site

31. Superior Alveolar Nerve

33.  Area anesthetized
 Central thru canine on injected side with some crossover
 Some patients do not have MSA
 These patients will have anesthesia of premolars to MB root
also
 Buccal periodontium and soft tissues of affected teeth
 Contraindications
 Infection or swelling / cellulitis
 Enhanced hemostasis needed
 Advantages
 Simple technique
 Minimizes volume of LA
 Minimized # injections for # teeth

34.  Disadvantages
 Psychological – patient fear and anxiety
 Tissues under nose are very tender
 Positive aspiration
 Rare

39.  Safety feature
 Inject over root of
cuspid
 Lateral fossa area
 Short of infraorbital
foramen
 Will diffuse to ASA
 This will anesthetize
99% of patients ASA

41.  Precautions
 Over insertion is unlikely due to targeting rim of
infraorbital foramen

 Failure of anesthesia
 Deposit solution posterior to site of nerve
 Complications
 Hematoma is rare
 Fear of operator and patient

43. Nerve Block

44.  Continuation of maxillary nerve within infraorbital
groove and canal
 Anesthetize area from central to 2nd premolar, and the
MB of 1st molar in some
 ASA & MSA branch off of the IO nerve within the
infraorbital canal

45.  Needle
 25 or 27 gauge short
 Insertion
 Mucobuccal fold over 1st premolar
 Target area the infraorbital foramen
 Landmarks
 Mucobuccal fold
 Infraorbital notch
 Infraorbital foramen

53. Nerve Block

54.  Needed for soft tissue of palate in posterior quadrant
 Minimal volume .5 ml is plenty of LA solution
 Needle - 25 or 27 guage
 Insertion site
 Junction of maxillary process and palatine
 Just anterior of
 Grater palatine foramen
 Typically located distal to 2nd molar

57.  Topical anesthetic for 1
minute
 Pressure anesthesia may
be as effective
 Depth of penetration is
about 2 - 5 mm
 Deposit enough solution
to see blanching of tissue
 Blanch approximately .5
cm area

58. Nerve Block

60.  Location at anterior portion of hard palate
 Palatal to #8-9 in the incisive papillae
 Anesthetize from canine to canine
 Needle – 25 or 27 gauge short
 Insert at incisive papillae
 Target area is the incisive foramen
 Insert at 45 degrees
 Topical may be used however tissue is firmly bound
and injection is uncomfortable
 Depth of penetration is about 1-2 mm

62.  Insert at incisive papillae
 Target area is the incisive foramen
 Insert at 45 degrees
 Topical may be used however tissue is firmly bound
and injection is uncomfortable
 Depth of penetration is about 1-2 mm

65. Middle Superior Nerve

66.  Muscles of facial
expression not involved
 Field block of ASA from
incisors to premolars
 Subneural dental plexus