Maxillary blocks

MAXILLARY NERVE BLOCK LOCAL ANESTHESIA

1. Techniques of Maxillary nerve block… By Dr DAVIS NADAKKAVUKARAN ASSTITANT PROFESSOR Dept. of OMFS MDC MANOOR

2. NERVE BLOCK LA deposited close to the main nerve trunk usually at distance from the site of operative intervention.

3. FIELD BLOCK Local anaesthetic solution is deposited near the larger terminal branch, so the anaesthetized area will be circumscribed.Treatment is done in an area away from the site of injection

4. LOCAL INFILTRATION Small terminal nerve endings in the area of dental treatment are flooded with local anesthetic solution. Treatment is done in the same area of in which solution has been deposited.

5. MAXILLARY INJECTION TECHNIQUES

6. SUPRA PERIOSTEAL INJECTION: ( Local Infiltration ) INDICATIONS : Pulpal anesthesia of maxillary teeth when treatment is limited to one or two tooth . Soft tissue anesthesia for surgical procedure in a circumscribed area.

7. TECHNIQUE : needle is injected beneath the mucous membrane & the solution is infiltrated slowly throughout the area. AMOUNT TO BE DEPOSITED - 0.6ml over 20 sec. CONTRAINDICATION : Infection or acute inflammation in the area of injection. DISADVANTAGES : Need for multiple needle insertions. Necessary to administer large volume of solution.

8. TECHNIQUES OF NERVE BLOCK

9. INTRA ORAL TECHNIQUES

10. POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK : OTHER NAMES : Tuberosity block / Zygomatic block AREAS ANAESTHETIZED : Pulps of maxillary III,II and I molar except mesio buccal root of I molar. Buccal periosteum and bone overlying the teeth.

11. LAND MARKS : Mucobuccal fold. Zygomatic process of maxilla. Infra temporal surface of maxilla. Anterior border & coronoid process of the ramus of the mandible. Tuberosity of maxilla . TECHNIQUE : PATIENT POSITION- pt is positioned such that maxillary occlusal plane is 45 degree angle to the floor. 25 gauge short needle is used. Insertion- height of mucobuccal fold above the maxillary II molar.

12. The operators left forefinger over the muccobuccal fold in a post direction from the bicuspid area until the zygomatic process of maxilla is reached At its post surface finger will feel a concavity in the mucobuccal fold. Then rotate the finger so that the fingernail is adjacent to the mucosa, & its bulbous portion still in contact with the posterior surface of the zygomatic process. Now needle is held in pen grasp & inserted in a line parallel with the index finger, going UPWARD INWARD & BACKWARD ( this places the needle in the immediate vicinity of the foramen through which the nerves enter the maxilla).

13. SYMPTOMS- OBJECTIVE - instrumentation necessary to demonstrate absence of pain. SUBJECTIVE - None.

14. DEPTH OF NEEDLE PENETRATION - 16 mm. DEPOSIT: - 0.9 to 1.8 ml in 30 to 60 sec . COMPLICATIONS : Hematoma

15. OTHER NAME : Infra orbital. AREAS ANAESTHETIZED : Incisors, cuspids , bicuspids & mesiobuccal root of 1 st molar. Upper lip Lower eye lid. Portion of the nose of the injected site.

16. ANATOMICAL LANDMARKS : Infra orbital ridge. Infra orbital depression. Supra orbital notch. Infra orbital notch. Bicuspid teeth. Mental foramen. Pupil of the eyes. An imaginary straight line drawn vertically through these landmarks will pass through the pupil of the eye, infraorbital foramen(when the infraorbital notch is located, the palpatating finger should be moved downward about 0.5mm, where a shallow depression will be felt), bicuspids, & mental foramen.

17. Maxillary occlusal plane at 45degree to the floor NEEDLE PATHWAY BICUSPID APPROACH- The needle is inserted in a line parallel with the supraorbital notch, the pupil of the eye,infra orbital notch, & 2 nd biscuspid tooth CENTAL INCISOR APPROACH- The neeedle bisects the crown of the central incisor from the mesioincisal angle to the distogingival angle. In either situatin , the needle should not penetrate more than ¾ inch, it prevents the needle from entering the orbital cavity

18. TECHNIQUE : NEEDLE - 25 gauge needle. SOLUTION DEPOSITED - 0.9 to 1.5 ml. SYMPTOMS- SUBJECTIVE- Tingling & numbness of the upper lip, side of the nose OBJECTIVE- instrumentation necessary to demonstrate absence of pain. COMPLICATION : Hematoma. Facial nerve paralysis.

19. GREATER PALATINE NERVE BLOCK : OTHER NAME : Anterior palatine nerve block AREAS ANAESTHETIZED : Posterior portion of hard palate and its over lying soft tissues. Anteriorly up to I premolar and medially up to midline.

20. ANATOMICAL LANDMARKS : II and III maxillary molars. Palatal gingival margin of II and III maxillary molar. Midline of the palate. Line approximating 1cm from the palatal gingival margin towards midline of the palate. TECHNIQUE : NEEDLE- 25 gauge needle. INSERTION - From the opposite side of the mouth at right angles to the target area. DEPOSITION -0.25 to 0.5 ml in 30 sec.

21. NASO PALATINE NERVE BLOCK : OTHER NAMES : Incisive nerve block. Spheno palatine nerve block . AREAS ANAESTHETIZED : Anterior portion of hard palate from mesial of Rt. I premolar to mesial of the Lt.I premolar. LANDMARKS : Central incisors Incisive papilla.

22. TECHNIQUE : INSERTION - At a 45 degree angle towards incisive papilla. OPERATOR - In 9 or 10 o’ clock position. DEPOSIT - 0.45 ml of solution in 15 to 30 sec at a depth of 6 to 10 mm. COMPLICATIONS : Necrosis of soft tissue due to highly concentrated vasoconstrictor solution.

23. For achieving profound anesthesia of hemi maxilla. 2 approaches 1) Greater palatine canal approach 2) High tuberosity approaches OTHER NAMES:- Second division block, V2 nerve block AREAS ANESTHETIZED:- 1) Maxillary teeth on the affected side 2) Alveolar bone & overlying structures 3) Hard palate,part of soft palate 4) Upper lip, cheek, side of the nose, lower eye lid MAXILLARY NERVE BLOCK

24. ADVANTAGES: - 1) Minimizes the no. of needle penetrations 2) Minimizes the total volume of local anesthetic solution 1.8ml versus 2.7ml 3) high success rates

25. GREATER PALATINE APPROACH :- TARGET AREA:- Maxillary nerve as it passes through the pterygopalatine fossa , the needle passes through greater palatine canal to reach pterygopalatine fossa LAND MARKS:- Greater palatine foramen, situated between the 2 nd & 3 rd molars about 1cm towards the midline of the palate from the palatal gingival margin. AREA OF INSERTION:- Palatal soft tissue directly over the greater palatine foramen. PROCEDURE:- 25 gauge 32 mm long needle used 1.8 ml of the solution in 1 minute is deposited at the target area

26. COMPLICATIONS:- Hematoma Penetration of the orbit during greater palatine foramen approach if the needle goes too far Penetration of the nasal cavity occurs when the needle deviates medially during insertion

27. SYMPTOMS- OBJECTIVE- instrumentation necessary to demonstrate absence of pain sensation SUBJECTIVE- tingling & numbness of the upper lip, side of the nose, & lower eyelid.

28. HIGH TUBEROSITY APPROACH Technique : - needle used – 25 gauge 32mm long needle LAND MARKS :- Muco buccal fold at the distal aspect of maxillary second molar. Maxillary tuberosity Zygomatic process of the maxilla TARGET AREA :- Maxillary nerve as it passes through pterygopalatine fossa superior & medial to the target area of PSA nerve block. DISADVANTAGES:- Risk of hematoma with high tuberosity approaches

29. INTRALIGAMENTARY ANESTHESIA This is achieved by injecting an analgesic solution directly into the periodontal membrane of the tooth. USES: For extraction of teeth in hemophilic patients to avoid bleeding. Useful in pedodontic patients. Indicated prior to immediate replacement dentures.

30. TECHNIQUE: Finer needles of gauge 30 are inserted in the periodontal membrane to a depth of 2mm.Needle is inserted parallel with the long axis of the root of the tooth until it contacts the alveloar bone. 0.2ml of solution is injected over a period of 30secs.Maxillary Molars require 3 injections and mandibular molar 2 injections . PERIOD OF ANESTHESIA : 30-45 mins DISADVANTAGES: Infection of the site. Discomfort after the analgesia wears off.

31. SUPRA PERIOSTEAL PSA ASA GREATER PALATINE NASOPALATINE PALATAL INFILTRATION MAXILLARY NERVE BLOCK 0.6ML 0.9-1.8 0.9-1.2 0.45-0.6 0.45 0.2-0.3 1.8 Recommended volume of local anesthetic for maxillary techniques

32. EXTRA ORAL TECHNIQUES

33. INFRA ORBITAL BLOCK Indications: Infection, Trauma resulting in impossible intra oral approach . Anatomical Land marks: Pupil of the eye. Infra orbital ridge. Infra orbital notch. Infra orbital depression.

34. Technique: Using the available landmarks, the dentist should locate the infra orbital foramen. The skin & subcutaneous tissue is anesthesized by local infiltration 25 gauge needle used, and is directed slightly upward & laterally which facilitates entrance into the foramen, which open downward & medially. SYMPTOMS SUBJECTIVE- tingling & numbness of the upper lip, side of the nose & lower eyelid OBJECTIVE- instrumentation necessary to demonstrate absence of pain.

35. MAXILLARY NERVE BLOCK Indications: During extensive surgery To block all sub divisions of maxillary nerve with one needle insertion Local infection and trauma causing difficulty for intraoral approach For diagnostic and therapeutic purposes Anatomical land marks: Mid point of the zygomatic arch Zygomatic notch Coronoid process of the ramus of mandible Lateral pterygoid plate

36. AREA ANAESTHETIZED- Maxillary teeth on the affected side Alveolar bone & the overlying structure Hard palate & portion of soft palate Upper lip, cheek, side of the nose & lower eyelid

37. Technique: The midpoint of the zygomatic process is located & the depression in its inferior surface is marked A skin wheal is raised just below this mark, which the dentist identifies by having the patient open & close the jaw The needle is inserted through the skin wheal, until the needle point gently contacts the lateral pterygoid plate.

38. The needle is withdrawn , with only the point left in the tissue, & re directed in a slight forward & upward direction untill the needle is inserted to the depth of the marker. After careful aspiration, 2-3ml of LA is injected Care should be exercised to aspirate after each 0.5ml of solution injected .

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