Maxillary Injection Technique

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1. MAXILLARY INJECTION MAXILLARY INJECTION
TECHNIQUE TECHNIQUE
Chinthamani Laser Dental Clinic

2. Introduction Introduction
A number of injection techniques are available to aid in A number of injection techniques are available to aid in
providing clinically adequate anesthesia of the teeth and soft and providing clinically adequate anesthesia of the teeth and soft and
hard tissues in maxilla. hard tissues in maxilla.
Injection techniques are as follows Injection techniques are as follows
1.1.Supra periosteal infiltration Supra periosteal infiltration
2.2.Periodontal ligament injection Periodontal ligament injection
3.3.Intraseptal injection Intraseptal injection
4.4.Intracrestal injection Intracrestal injection
5.5.Intraosseous injection Intraosseous injection
6.6.Posterior superior alveolar nerve block Posterior superior alveolar nerve block
7.7.Middle superior alveolar nerve block Middle superior alveolar nerve block
8.8.Anterior superior alveolar nerve block Anterior superior alveolar nerve block
9.9.Maxillary nerve block Maxillary nerve block
10.10.Greater palatine nerve block Greater palatine nerve block
11.11.Nasopalatine nerve block Nasopalatine nerve block
12.12.Anterior middle superior alveolar nerve block Anterior middle superior alveolar nerve block
13.13.Palatal approach – anterior superior alveolar nerve blockPalatal approach – anterior superior alveolar nerve block

3. SUPRAPERIOSTEAL INJECTION SUPRAPERIOSTEAL INJECTION
Other common names – Local infiltration Other common names – Local infiltration
paraperiosteal injection paraperiosteal injection
Nerves anesthetized - Large terminal branches Nerves anesthetized - Large terminal branches
of dental plexus of dental plexus
Areas anesthetized – Entire region innervated by Areas anesthetized – Entire region innervated by
the large terminal branches of this plexus the large terminal branches of this plexus
Pulp and root area of the tooth and mucous Pulp and root area of the tooth and mucous
membrane membrane

4. Indications Indications
Pulpal anesthesia of maxillary teeth Pulpal anesthesia of maxillary teeth
Soft tissue anesthesia Soft tissue anesthesia
Contra indications Contra indications
Infections or acute inflammation Infections or acute inflammation
Dense bone covering the apices of teeth Dense bone covering the apices of teeth
Advantages Advantages
High success rate High success rate
Technically easy injection Technically easy injection
Usually entirely atraumatic Usually entirely atraumatic
Disadvantages Disadvantages
Not recommended for larger areas Not recommended for larger areas

5. Technique Technique
Procedures Procedures
Prepare tissue at the injection site Prepare tissue at the injection site
Orient needle so bevel faces bone Orient needle so bevel faces bone
Insert the needle into the height of the mucobuccal Insert the needle into the height of the mucobuccal
fold over the target area fold over the target area
Advance the needle until its bevel is at or above the Advance the needle until its bevel is at or above the
apical region of tooth apical region of tooth

Aspirate Aspirate
Weight 3 – 5 mins before commencing the dental Weight 3 – 5 mins before commencing the dental
procedure procedure

6. POSTERIOR SUPERIOR ALVEOLAR POSTERIOR SUPERIOR ALVEOLAR
NERVE BLOCKNERVE BLOCK
Other names -Other names -Tuberosity block Tuberosity block
Zygomatic blockZygomatic block
Nerves anesthetized - Posterior superior alveolar nerveNerves anesthetized - Posterior superior alveolar nerve
Indications Indications
Two or more maxillary molar - supra periosteal is contra indicated and ineffective Two or more maxillary molar - supra periosteal is contra indicated and ineffective
Contra indications Contra indications
Hemorrhage is highHemorrhage is high
Advantages Advantages
AtraumaticAtraumatic
Highly successful Highly successful
DisadvantagesDisadvantages
Risk of hematomaRisk of hematoma
No bony land mark No bony land mark

7. Technique Technique
Align 10o clock position for the left side Align 10o clock position for the left side
and 8 o clock position for the rightand 8 o clock position for the right
Prepare the tissue and insert the needle Prepare the tissue and insert the needle
at the height of the muco buccal foldat the height of the muco buccal fold
Advance the needleAdvance the needle
Upward-45 degree to the occlusal planeUpward-45 degree to the occlusal plane
Inward –medially towardes the midline Inward –medially towardes the midline
45 degree to the occlusal plane45 degree to the occlusal plane
Backward-45 degree to the long axis of Backward-45 degree to the long axis of
second molarsecond molar
Advance the needle to the desired depthAdvance the needle to the desired depth
AspirateAspirate
Deposite l.aDeposite l.a
Withdraw the syringe Withdraw the syringe

8. MIDDLE SUPERIOR ALVEOLAR NERVE MIDDLE SUPERIOR ALVEOLAR NERVE
BLOCKBLOCK

Nerves anesthetized-middle superior alveolarNerves anesthetized-middle superior alveolar nerve nerve
block block
IndicationsIndications
Infra orbital nerve block fails when both premolars Infra orbital nerve block fails when both premolars
involvedinvolved
ContraindicationsContraindications
Infection when MSA nerve is absentInfection when MSA nerve is absent
AdvantagesAdvantages
Minimum needle prick & volumeMinimum needle prick & volume

9. TechniqueTechnique
Align the position Align the position
10o clock position for right MSA 10o clock position for right MSA
nerve & 8or 9 for the left nerve nerve & 8or 9 for the left nerve
blockblock
Prepare the tissuePrepare the tissue
Insert the needle to the height of Insert the needle to the height of
mucobuccal fold mucobuccal fold
Advance the needle to the apex Advance the needle to the apex
of second pre molarof second pre molar
AspirateAspirate
Deposite and withdrawDeposite and withdraw

10. ANTERIOR SUPERIOR ALVEOLAR NERVE ANTERIOR SUPERIOR ALVEOLAR NERVE
BLOCKBLOCK
Other name-infra orbital nerve block Other name-infra orbital nerve block
IndicationsIndications
When more than two maxillary teeth are involvedWhen more than two maxillary teeth are involved
Inflammation or infectionInflammation or infection
When supra periosteal injection –ineffectiveWhen supra periosteal injection –ineffective
ContraindicationsContraindications
Discrete treatment areaDiscrete treatment area
When hemostasis involvedWhen hemostasis involved
AdvantagesAdvantages
Simple techniques,minimal volumeSimple techniques,minimal volume
DisadvantagesDisadvantages
Improper handling injures patient eye, difficulty in defining land marksImproper handling injures patient eye, difficulty in defining land marks

11. Technique Technique
Assume 10 o position for right Assume 10 o position for right
and left infra orbital nerve blockand left infra orbital nerve block
Patient position –supine or Patient position –supine or
semisupinesemisupine
Prepare the tissue at the height of Prepare the tissue at the height of
mucobuccal foldmucobuccal fold
Locate the infra orbital foramenLocate the infra orbital foramen
Retract the lip and insert the Retract the lip and insert the
needleneedle
To the upper rim of infraorbital To the upper rim of infraorbital
foramenforamen
AspirateAspirate
Deposite and withdrawDeposite and withdraw

12. PALATAL PALATAL
ANESTHESIAANESTHESIA

13. STEPS IN THE ATRAUMATIC STEPS IN THE ATRAUMATIC
ADMINISTRATION OF PALATAL ADMINISTRATION OF PALATAL
ANESTHESIAANESTHESIA
Provide adequate topical anesthesia at site of Provide adequate topical anesthesia at site of
needle penetration.needle penetration.
Use pressure anesthesia at site of needle Use pressure anesthesia at site of needle
penetration.penetration.
Maintain control over the needle.Maintain control over the needle.
Deposit the anesthetic solution slowly.Deposit the anesthetic solution slowly.
Trust yourself… that u can complete the Trust yourself… that u can complete the
procedure atraumatically.procedure atraumatically.

14. GREATER PALATINE NERVE GREATER PALATINE NERVE
BLOCKBLOCK
This technique is useful for dental procedures involving the This technique is useful for dental procedures involving the
palatal soft tissues distal to the canine.palatal soft tissues distal to the canine.
OTHER NAMEOTHER NAME :: Anterior palatine nerve block. Anterior palatine nerve block.
NERVE ANAESTHETISEDNERVE ANAESTHETISED : Greater palatine nerve: Greater palatine nerve
AREA ANEASTHETISEDAREA ANEASTHETISED : The posterior portion of the hard : The posterior portion of the hard
palate and its overlying soft tissue, anteriorly as far as the first palate and its overlying soft tissue, anteriorly as far as the first
molar & medially to the midline.molar & medially to the midline.

15. INDICATIONS:INDICATIONS:
Palatal soft tissue anesthesia necessary for restorative therapy on Palatal soft tissue anesthesia necessary for restorative therapy on
more than two teeth.more than two teeth.
For pain control during periodontal or oral surgical procedure For pain control during periodontal or oral surgical procedure
involving the palatal soft and hard tissueinvolving the palatal soft and hard tissue
CONTRA INDICATIONS:CONTRA INDICATIONS:
Inflammation or infection at injection site.Inflammation or infection at injection site.
Smaller areas of therapy (one or two teeth)Smaller areas of therapy (one or two teeth)
ADVANTAGES:ADVANTAGES:
It minimize needle penetration and volume of solution.It minimize needle penetration and volume of solution.
Minimizes patient discomfort.Minimizes patient discomfort.
DISADVANTAGES:DISADVANTAGES:
No hemostasis except in the immediate area of infection.No hemostasis except in the immediate area of infection.
Potentially traumatic.Potentially traumatic.

16. TECHNIQUE TECHNIQUE

17. Nasopalatine Nerve BlockNasopalatine Nerve Block
Other common name: Other common name:
Incisive nerve block, Incisive nerve block,
Spenopalatine nerve block Spenopalatine nerve block
Nerves Anesthetized: Nerves Anesthetized:
Nasopalatine nerves bilaterally Nasopalatine nerves bilaterally
Areas Anesthetized Areas Anesthetized
Anterior portion of the hard palate from mesial of the Anterior portion of the hard palate from mesial of the
right first premolar to the mesial of the left first premolar. right first premolar to the mesial of the left first premolar.

18. IndicationsIndications
When palatal soft tissue anesthesia is necessary for When palatal soft tissue anesthesia is necessary for
restorative therapy on more than two teeth restorative therapy on more than two teeth
For pain control during periodontal or oral surgical For pain control during periodontal or oral surgical
procedures involving palatal soft and hard tissues. procedures involving palatal soft and hard tissues.
ContraindicationsContraindications
Inflammation or infection at the injection site Inflammation or infection at the injection site
Smaller area of therapy Smaller area of therapy

19. Advantages Advantages
Minimizes needle penetrations and volume of Minimizes needle penetrations and volume of
solutionsolution
Minimal patient discomfort from multiple Minimal patient discomfort from multiple
needle penetration needle penetration
Disadvantages Disadvantages
No hemostasis except in the immediate area of No hemostasis except in the immediate area of
injection injection
Potentially the most traumatic intra oral Potentially the most traumatic intra oral
injection however, the protocol for an injection however, the protocol for an
atraumatic injection or use of a CCLAD System atraumatic injection or use of a CCLAD System
can minimize or entirely eliminate discomfort can minimize or entirely eliminate discomfort

20. TechniqueTechnique

21. Precautions Precautions
Against pain Against pain
Do not insert directly into the incisive papillaDo not insert directly into the incisive papilla
Do not deposit solution too rapidly Do not deposit solution too rapidly
Do not deposit too much solution Do not deposit too much solution
Against injection Against injection
Do not insert the needle more than 5mm into the incisive Do not insert the needle more than 5mm into the incisive
canals because it may enter into nose & may cause infectioncanals because it may enter into nose & may cause infection

22. FailuresFailures
Unilateral anaesthesiaUnilateral anaesthesia
In adequate palatal soft-tissue anesthesia in the In adequate palatal soft-tissue anesthesia in the
area of maxillary canine and I premolar area of maxillary canine and I premolar
Complications Complications
Few of significance Few of significance
Hematoma – extremely rare Hematoma – extremely rare
Necrosis of soft tissue Necrosis of soft tissue

23. Anterior middle superior alveolar Anterior middle superior alveolar
nerve block nerve block
Other common name: Other common name:
Palatal approach anterior middle superior alveolar Palatal approach anterior middle superior alveolar
nerve nerve
Nerves anesthetized Nerves anesthetized
ASA Nerve ASA Nerve
MSA Nerve MSA Nerve
Subneural dental nerve plexus Subneural dental nerve plexus

24. Areas anesthetizedAreas anesthetized
Pulpal anesthesia of maxillary incisors canines & Pulpal anesthesia of maxillary incisors canines &
Premolars Premolars
Buccal attached gingiva of these same teeth Buccal attached gingiva of these same teeth
Attached palatal tissues from midline to tree gingival Attached palatal tissues from midline to tree gingival
margin on associated tooth. margin on associated tooth.

25. Indications Indications
Easier to perform Easier to perform
Dental procedure involving the maxillary anterior Dental procedure involving the maxillary anterior
teeth teeth
When anesthesia to multiple maxillary teeth When anesthesia to multiple maxillary teeth
When scaling and root planning of anterior teeth When scaling and root planning of anterior teeth
Contraindications Contraindications
Patients with unusual thin palatal tissue Patients with unusual thin palatal tissue
Procedures requiring more than 90mins Procedures requiring more than 90mins

26. Advantages Advantages
Provides anesthesia of multiple maxillary teeth with Provides anesthesia of multiple maxillary teeth with
single injection single injection
Simpler technique Simpler technique
Comparatively safe Comparatively safe
Eliminates post, operative inconvenience Eliminates post, operative inconvenience
Disadvantages Disadvantages
Requires slow administration Requires slow administration
May be uncomfortable to patient May be uncomfortable to patient
May need supplement anesthesia May need supplement anesthesia

27. Technique Technique

28. Failures Failures
May need suplemental anesthesia for central and lateral May need suplemental anesthesia for central and lateral
incisors incisors
Complications Complications
Palatal ulcer at injection site developing 1-2 days post Palatal ulcer at injection site developing 1-2 days post
operative operative
Un expected contact with the nasopalatine nerve Un expected contact with the nasopalatine nerve
density of injection site causing squirt back of density of injection site causing squirt back of
anesthetic & bitter taste anesthetic & bitter taste

29. Palatal approach – Anterior superior Palatal approach – Anterior superior
alveolar nerve alveolar nerve
Other common name: palatal approach ASA or palatal Other common name: palatal approach ASA or palatal
approach maxillary anterior block approach maxillary anterior block
Nerves anesthetized: Nerves anesthetized:
Nasopalatine Nasopalatine
Anterior branches of ASA Anterior branches of ASA
Areas anesthetized Areas anesthetized
Pulps of the maxillary central incisors, lateral incisors & Pulps of the maxillary central incisors, lateral incisors &
canines canines
Facial periodontal tissue associated with these same Facial periodontal tissue associated with these same
teeth teeth

30. Indications Indications
Procedure involving the maxillary ansterior teeth & soft Procedure involving the maxillary ansterior teeth & soft
tissues tissues
Bilateral anesthesia of maxillary anterior teeth Bilateral anesthesia of maxillary anterior teeth
Scaling & root planning of anterior teeth. Scaling & root planning of anterior teeth.
Contraindications Contraindications
Patients with extremely long canine roots Patients with extremely long canine roots
Patients who cannot tolerate 3-4 mins administration Patients who cannot tolerate 3-4 mins administration
time time
Procedures requiring more than 90 minsProcedures requiring more than 90 mins

31. Advantages Advantages
Provides bilateral maxillary anesthesia from single site Provides bilateral maxillary anesthesia from single site
injection injection
Simple technique Simple technique
Safer technique Safer technique
DisadvantagesDisadvantages
Requires slow administration Requires slow administration
May cause excessive ischemia May cause excessive ischemia
May need suplemental anesthesia for canine teeth May need suplemental anesthesia for canine teeth

32. Technique Technique

33. FailuresFailures
Highly successful injection for maxillary incisors Highly successful injection for maxillary incisors
May need supplemental anesthesia for canines in May need supplemental anesthesia for canines in
patient with long roots patient with long roots
Unilateral anesthesia Unilateral anesthesia
Complications Complications
Palatal ulcer at injection site developing 1-2 days Palatal ulcer at injection site developing 1-2 days
postoperative postoperative
Unexpected nerve contract of the nasopalatine nerve Unexpected nerve contract of the nasopalatine nerve
Density of injection site causing squirt-back of Density of injection site causing squirt-back of
anesthetic and bitter taste. anesthetic and bitter taste.

34. Maxillary nerve block Maxillary nerve block
Other common names: Second division block, Other common names: Second division block,
VV
2 2 nerve blocknerve block
. .
Nerve anesthetized – Maxillary division of Nerve anesthetized – Maxillary division of
trigeminal nervetrigeminal nerve
Areas anesthetized Areas anesthetized
Pulpal anesthesia of maxillary teeth Pulpal anesthesia of maxillary teeth
Buccal periodontium & bone Buccal periodontium & bone
Soft tissues & bone of the hard palate & part of Soft tissues & bone of the hard palate & part of
soft palate soft palate

35. Indications Indications
Pain control before extensive oral surgical Pain control before extensive oral surgical
periodontal, restorative procedures periodontal, restorative procedures
Diagnostic or therapeutic procedures Diagnostic or therapeutic procedures
Contraindications Contraindications
Inexperienced administrator Inexperienced administrator
Pediatric patients Pediatric patients
Uncooperative patients Uncooperative patients
Inflammation or injection of tissue Inflammation or injection of tissue

36. Advantages Advantages
Atraumatic injection Atraumatic injection
High success rate High success rate
Minimises number of needle penetration Minimises number of needle penetration
Disadvantages Disadvantages
Risk of hematoma Risk of hematoma
lack of hemostasis lack of hemostasis
Pain Pain
Positive aspiration is less than 1% Positive aspiration is less than 1%

37. TechniqueTechnique

38. Failures Failures
Partial anesthesia Partial anesthesia
Inability to negotiate the greater palatine canal Inability to negotiate the greater palatine canal
Complications Complications
Hematoma develops rapidly Hematoma develops rapidly
Penetration of nasal cavity Penetration of nasal cavity
penetration of orbit may occur. penetration of orbit may occur.

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