Anterior middle superior alveolar nerve

oral surery

1. Anterior middle superior alveolar nerve

2. Other common names- palatal approach anterior middle superior alveolar(AMSA). Nerves anesthesia – 1. ASA nerve ,2. MSA nerve , when present 3. subneural dental nerve plexus of the anterior and middle superior alveolar nerves. Areas Anesthetized – 1. pulpal anesthesia of the maxillary incisors , canine and premolars. 2. buccal attached gingiva of these same teeth. 3. attached palatal tissues from midline to free gingival margin on associated teeth. Indications- is more easily performed with a C-CLAD system, dental procedures involving multiple maxillary anterior teeth or soft tissues are to be performed. When anesthesia to multiple maxillary anterior teeth is desired from a single –site injection, when scaling and root planing of the anterior teeth are to be performed. When anterior cosmetic procedures are to be performed and a smile- line assessment is important for a successful outcome , when a facial approach supraperiosteal injection has been ineffective because of dense cortical bone. CONTRAINDICATIONS patients with unusually thin palatal tissues , patients unable to tolerate the 3-4 minute administration time, procedures requiring longer than 90 minutes.

3. Advantages- provides anesthesia of multiple maxillary teeth with a single injection , comparatively simple technique, comparatively safe; minimizes the volume of anesthetic and the number of punctures required compared with traditional maxillary infiltrations of these teeth. Allows effective soft tissue and pulpal anesthesia for periodontal scaling and root planing of associated maxillary teeth. Allows an accurate smile-line assessment to be performed after anesthesia has occurred during cosmetic dentistry procedures. Eliminates the postoperative inconvenience of numbness to the upper lip and muscles of facial expression , can be performed comfortably with a C-CLAD system. Disadvantages – requires a slow administration (0.5 mL/min ) time ,cause operator fatigue with manual syringe because of extended injection time , uncomfortable for the patient if administered improperly, may need supplemental anesthesia for central and lateral incisor teeth, may cause excessive ischemia id administered too rapidly, use of local anesthesia containing epinephrine with a concentration of 1:50,000 is contraindicated. Positive aspiration- less than 1%. alternatives- multiple supraperiosteal of PDL injections for each tooth , ASA and MSA nerve blocks, maxillary nerve block.

4. Technique- 27 gauge needle is recommended Area of insertion : on the hard palate about halfway along an imaginary line connecting the midpalatal suture to the free gingival margin; the location of the line is at the contact point between the first and second premolars. Target area – palatal bone at injection site. 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. Orientation of the bevel- the bevel of the needle is placed “faced down” against the epithelium. The needle is typically held at 45-degree angle to the palate . Anesthetic is delivered at a rate of approximately 0.5 mL per minute during the injection for a total dosage of approximately 1.4 to 1.8 mL . Signs and symptoms- subjective- a sensation of firmness and numbness is experienced immediately on the palatal tissues, numbness of the teeth and associated soft tissues extends from the central incisor to the second premolar on the side of injection. Objective- blanching of the soft tissues (if a vasoconstrictor is used) of the palatal and facial attached is evident , extending from the central incisor to the premolar region , use of electrical pulp testing with no response from the teeth with maximal EPT output(80/80)., absence of pain during treatment , no anesthesia of the face and upper lip.

5. Safety features- contact with bone , low risk of positive 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. Precautions – against pain : a. extremely slow insertion of needle , b. slow administration during insertion with simultaneous administration of anesthetic solution , C-CLAD device recommended. Against tissue damage – a. avoid excessive ischemia by avoiding local anesthetics containing vasoconstrictors with a concentration of 1:50,000, b. avoid multiple infiltrations of local anesthetic with vasoconstrictor in the same area at a single appointment. Failure of anesthesia- may need supplemental anesthesia for central and lateral incisors. Complications- palatal ulcer at injection site developing 1 to 2 days postoperatively ,unexpected contact with the nasopalatine nerve , density of tissues at injection site causing squirt-back of anesthetic and bitter taste.

6. Palatal approach – anterior superior alveolar Defined by Friedman and Hochman. Nerves anesthetized – nasopalatine , anterior branches of the ASA. Areas anesthetized- 1. pulps of the maxillary central incisors, the lateral incisors, and (to a lesser degree) the canines. 2. facial periodontal tissue associated with these same teeth. 3. palatal periodontal tissue associated with these same teeth. Indications- dental procedures involving the maxillary anterior teeth nd soft tissues are to be performed , when bilateral anesthesia of the maxillary anterior teeth is desired from a single site injection , when scaling and root planning of the anterior teeth are to be performed , when anterior cosmetic procedures are to be performed and a smile line assessment is important to a successful outcome , when a facial approach supraperiosteal injection has been ineffective because of dense cortical bone. Contraindications – 1. patients with extremely long canine roots may not achieve profound anesthesia of these teeth from a palatal approach alone. 2. patients who cannot tolerate the 3 to 4 minute administration time . 3. procedures requiring longer than 90 minutes.

7. Advantages- 1. provides bilateral maxillary anesthesia from a single injection site , comparatively simple technique to perform , comparatively safe; minimizes the volume of anesthetic and the number of punctures necessary compared with traditional maxillary infiltrations of these teeth, allows fr accurate smile –line assessment to be performed after anesthesia has occurred , which may be useful during cosmetic dentistry procedures. Eliminates the postoperative inconvenience of numbness to the upper lip and muscles of facial expression , can be performed comfortably with a C-CLAD system. Disadvantages – requires slow administration (0.5 mL/min ), operator fatigue with a manual syringe because of extended injection time, may be uncomfortable for the patient if administered improperly , may require supplemental anesthesia for canine teeth , may cause excessive ischemia if administered too rapidly, use of local anesthesia containing epinephrine with a concentration of 1:50,000 is contraindicated. Positive aspiration – less than 1% (assumed from data on nasopalatine block) . alternatives – supraperiosteal or PDL injections for each tooth , right and left (bilateral) ASA nerve blocks , right and left (bilateral) maxillary nerve blocks. Techniques – 27 gauge short needle is recommended . Area of insertion – just lateral to the incisive papilla in the papillary groove . Target area – nasopalatine foramen Landmarks- nasoplalatine papilla

8. Orientation of the bevel – the bevel of the needle is placed “ face down” against the epithelium . The needle is typically held at a 45-degree angle to the palate. Anesthetic is delivered at a rate of approximately 0.5 mL during the injection to a total volume of 1.4 to 1.8 mL. Signs and symptoms- subjective – a sensation of firmness and anesthesia is immediately experienced in he anterior palate , numbness of the teeth and associated soft tissues extends from the right to the left canine. Objective – ischemia (blanching) of the soft tissues (if a vasoconstrictor is used ) of the palatal and the facial attached gingiva is evident extending from the right to the left canine region., use of electrical pulp testing with no response from teeth with maximal EPT output (80/80) , absence of pain during treatment , no anesthesia of the face and upper lip.