8. Techniques of Maxillary Anesthesia
Supraperisoteal infiltration : for limited treatment protocol
Periodontal ligament injection as adjunct to other techniques
Intraseptal injection: for periodontal surgical techniques
Intraosseous injection: for single teeth
Posterior superior alveolar nerve block: for several molar teeth in one
quadrant
Middle superior alveolar nerve block: for premolar in one quadrant
Anterior superior alveolar(Infraorbital ) nerve block: for anterior teeth
in one quadrant
Maxillary (Second division) nerve block: for extensive buccal, palatal
and pulpal management in one quadrant
Greater (Anterior ) palatine nerve block: for palatal soft and osseous
tissue treatment distal to canine in one quadrant
Nasopalatine nerve block:for palatal soft and osseous tissue treatment
from canine to canine bilaterally
9. Supraperiosteal injection
Indication:
pulpal amesthesia for one or two maxillary teeth
and soft tissue surrounding them
Procedure:
syringe should be parallel with long axis of the
tooth and inserted at the height of mucobuccal
fold over the tooth
11. Posterior superior alveolar nerve block
Indication:
Treatment involving two or more maxillary molars
Area anesthesised:
Pulp of maxillary 3rd
, 2nd
and 1st
molar ( entire tooth in 72% and
mesiobuccal root not anesthesised in 28 % as it may be supplied by
MSAN)
Procedure:
Insert needle at height of mucobuccal fold over 2nd
Molar .
Advance upward (45 degrees to occlusal plane), Inwards (medially at
45 degrees to occlusal plane) and backwards ( at 45 degrees to long
axis of 2nd
molar )
Advance depth of 16 mm to reach Alveolar foramina. For smaller
adult and children depth of 14 mm.
Complication:
Hematoma
13. Posterior superior alveolar nerve block
Insert needle at height of mucobuccal
fold over 2nd
Molar
Advance upward (45 degrees to
occlusal plane), Inwards
(medially at 45 degrees to
occlusal plane) and backwards
( at 45 degrees to long axis of 2nd
molar )
14. Middle superior alveolar nerve block
Present in 28 % of population
Indication:
When infraorbital block fails
Area anesthesised:
Pulp of maxillary 1st
and 2nd
premolar and mesiobuccal root
of 1st
molar
Procedure:
Insert needle at height of mucobuccal fold over 2nd
premolar .
Advance till tip of needle reach well above the apex of 2nd
premolar
15. Middle superior alveolar nerve block
Needle reach well above the apex of 2nd
premolar
Area anesthetized
16. Anterior superior alveolar nerve block
(Infraorbital nerve block)
Indication:
Treatment involving two or more maxillary teeth
Area anesthetized:
Pulp of maxillary central incisors to canine, in 72 % maxillary
premolars and mesiobuccal root of 1st
molar, buccal periodontium of
same teeth
Procedure:
Locate infraorbital notch at infraorbital margin.
Move finger downwards>> convex feeling is roof of foramen >>
further downwards concave feeling is Infraorbital foramen pulpated
on face.
Insert needle at height of mucobuccal fold over 1st
premolar with
needle held parallel to long axis of tooth till 16 mm depth and
correlated with external landmark.
17. Anterior superior alveolar nerve block
(Infraorbital nerve block)
Area anesthetized
Locate infraorbital notch at infraorbital
margin and palpate downwards to located
foramen
18. Mucobuccal fold over 1st
premolar with
needle held parallel to long axis of tooth
19. Palatal anesthesia
Traumatic experience for patient with complains of
extreme pain while performing anesthesia.
This can be reduced by
applying topical anesthesia
pressure anesthesia
control over needle
slow deposition of anesthetic
20. Greater palatine nerve block
Indication:
Dental procedures involving palatal soft tissues distal to canine.
Area anesthesised:
Posterior part of hard palate and overlying soft tissue till 1st
premolar
anteriorly and medially midline.
Procedure:
Path of insertion from opposite aside of the mouth at a right angle to
target area.
Locate greater palatine foramen by placing cotton swab at junction of
maxillary alveolar process and hard palate in the groove. Press firmly
posteriorly from first maxillary molar. Swab will fall in the
“Depression” created by greater palatine foramen which is located
usually distal to maxillary 2nd
Molar .
Complication:
Ischemia and necrosis due to concentrated vasocontrictor solution
used for hemostasis.
22. Locate greater palatine foramen by
placing cotton swab at junction of
maxillary alveolar process and hard
palate in the groove. Press firmly
posteriorly from first maxillary molar.
Swab will fall in the “Depression”
created by greater palatine foramen
which is located usually distal to
maxillary 2nd
Molar .
23. Nasopalatine nerve block
Indication:
Restorative therapy for more than two teeth.
Area anesthetized:
Anterior portion of the hard palate and overlying soft tissue from
mesial of right 1st
premolar to mesial of left 1st
premolar.
Procedure:
Single needle penetration
Insert needle at incisive papilla and advance towards incisive
foramen till the depth of 6-10 mm.
Multiple needle penetration
First injection at labial frenulum
Second injection labial aspect of papilla between central incisors
Third injection if second injection has failed then to lateral aspect of
insicive papilla.
27. Nasopalatine nerve block
Multiple Needle Penetration
Second injection labial aspect of
papilla between central incisors
Third injection if second injection
has failed then to lateral aspect of
insicive papilla.
28. Maxillary nerve block
Indication:
Extensive oral surgical, periodontal or restorative procedures requiring anesthesia of
whole maxillary division.
Area anesthetized:
Hemimaxilla including soft and hard tissues.
Procedure:
High tuberosity approach:
Insert needle at height of mucobuccal fold over maxillary 2nd
molar tooth.
Advance needle like PSAN block but depth should be 30 mm. At this depth needle tip
is in proximity to maxillary nerve in pterygopalatine fossa.
Greater palatine approach:
Locate greater palatine foramen
Advance needle into canal to a depth of 30 mm.
Complication:
Maxillary artery injury with hematoma
Penetration into the orbit with ophthalmoplegia.
Due to septa in greater palatine canal procedure may not be successful.
29. Maxillary nerve block
Area anesthetized
Needle at height of mucobuccal fold over
maxillary 2nd
molar tooth
30. Inferior alveolar nerve block
Also known as Mandibular block
Indication:
Procedures on multiple mandibular teeth in one quadrant.
Area anesthetized:
Mandibular teeth, body and ramus of mandible, buccal mucoperiosteum and anterior two
third of tongue(lingual nerve).
Procedure:
Height of injection determined by imaginary line extend posteriorly from coronoid
notch to pterygomandibular raphe as it turns upwards towards maxilla.
Anteroposterior site on injection: about three fourths the distance from anterior
border of ramus
Penetration depth: till bone is touched usually 20-25 mm.
Complication:
Trismus
Transient facial palsy.
Hematoma.
31. Mandibular landmarks
1. Lingula
2. Posterior border of ramus
3. Coronoid notch
4. Coronoid process
5. Masseteric notch
6. Condylar process
33. Inferior alveolar nerve block
Height of injection determined by imaginary line
extend posteriorly from coronoid notch to
pterygomandibular raphe as it turns upwards
towards maxilla.
34. Buccal nerve block
Indication:
When buccal soft tissue anesthesia is required for dental
procedures in the mandibular molar region.
Area anesthetized:
Soft tissues and periosteum buccal to mandibular molar
teeth.
Procedure:
Injection at distal and buccal to last molar near anterior
border of ramus of mandible.
Depth usually 1-2 mm rarely above 2-4 mm.
Complication:
Hematoma - bluish discolouration at the injection site..
37. Mental nerve block
Indication:
Dental procedures requiring pulpal anesthesia on
mandibular teeth anterior to mental foramen.
Area anesthetized:
Pulpal nerve fibres supplying premolars, canine and
incisors.
Buccal mucous membrane anterior to mental foramen to
the midline and skin of lower lip and chin.
Procedure:
Injection at mucobuccal fold at mental foramen located
between apices of two premolars or canine and deposit
the content at the foramen.
39. Incisive nerve block
Indication:
When buccal soft tissue anesthesia is required for
procedures in the mandible anterior to the mental
foramen like biopsy and suturing of tissue.
Area anesthetized:
Buccal mucous membrane anterior to mental foramen to
the midline and skin of lower lip and chin.
Procedure:
Injection at mucobuccal fold at mental foramen located
between apices of two premolars.
Complication:
Hematoma - bluish discolouration at the injection site..
41. Mandibular nerve block:
The Gow-Gates Technique
Higher success rate
Indication:
Procedures on multiple mandibular teeth in one quadrant and inferior alveolar nerve
block fails.
Area anesthetized:
Mandibular teeth to midline, body and ramus of mandible, buccal mucoperiosteum and
anterior two third of tongue(lingual nerve).
Landmarks and procedure:
Extraoral: lower border of tragus and corner of mouth (Imaginary line joining these
two points)
Intraoral: Height of injection determined by tip of needle just below the mesiolingual
(mesiopalatal) cusp of maxillary second molar.
Penetration just distal to maxillary second molar tooth aligning needle to line
mentioned in Extraoral landmark with average depth about 25 mm.
Complication:
Trismus
Temporary paralysis of III, IV and VI.
Hematoma.
43. Mandibular nerve block:
The Gow-Gates Technique
Extraoral landmark: lower border of
tragus and corner of mouth
(Imaginary line joining these two points)
45. Vazirani-Akinosi Mouth Mandibular nerve block:
Indication:
Limited mandibular opening.
Area anesthetized:
Mandibular teeth to midline, body and ramus of mandible, buccal
mucoperiosteum and anterior two third of tongue(lingual nerve).
Landmarks and procedure:
Insert needle at mucogingival junction of maxillary third molar.
Advance needle slightly laterally and posteriorly with average depth
about 25 mm.
Complication:
Temporary paralysis of VII.
Trismus (rare)
Hematoma.