Maxillary nerve block

Dr, Kathirvel Gopalakrishnan
M.D.S (OMFS)
Presentation on Maxillary nerve block which helps for a quick refresh.
Applied aspects described well and slides contains images for easy understanding of the subject.

1. MAXILLARY NERVE BLOCK Dr. Kathirvel G PG OMFS

2. CONTENTS: Introduction Anatomy of maxilla Nerve supply Local anesthesia Intra-oral techniques Extra-oral techniques

3. MAXILLA: OSSEOUS ANATOMY: Alveolar process Palatine process Frontal process Zygomatic process

4. NERVE SUPPLY: Maxillary division of trigeminal nerve Origin : Trigeminal ganglion located in the m eckel's cave In Middle Cranial Fossa : Meningeal branch In Pterygopalatine Fossa : Ganglionic branches Zygomatic Posterior superior alveolar Sphenopalatine ganglion Greater and lesser palatine nerves Nasal branch Nasopalatine nerve Pharyngeal nerve In Infraorbital Canal : Middle superior alveolar Anterior superior alveolar On Face: Inferior Palpebral branch Superior Labial branch Nasal branch

5. Local anesthesia: Definition: “Local anesthesia is defined as a reversible loss of sensation in a circumscribed area of the body caused by depression of excitation in nerve endings or an inhibition of the conduction process in peripheral nerves” STANLEY F.MALAMED Local Infiltration: Local anesthetic solution deposited over small terminal nerve endings in the area of the dental treatment  

6. Field Block: Local anesthetic is deposited near the larger terminal nerve branches Maxillary injections administered above the apex of the tooth to be treated are properly termed field blocks Nerve Block: Local anesthetic is deposited close to a main nerve trunk, usually at a distance from the site of operative intervention Ex: Posterior superior alveolar, nasopalatine injections

7. Intra oral techniques: Posterior superior alveolar nerve block Middle superior alveolar nerve block Anterior superior alveolar nerve block Anterior middle superior alveolar nerve block (AMSA) Greater palatine nerve block Nasopalatine nerve block Anterior superior alveolar nerve block - Palatal approach Maxillary nerve block - Greater palatine approach - High tuberosity approach

8. Posterior superior alveolar nerve block : Areas Anesthetized: 1.Pulps of the maxillary third, second and first molars ( mesiobuccal root of the maxillary first molar not anesthetized = 28%) 2.Buccal periodontium and bone overlying these teeth Indication: 1.When treatment involves two or more maxillary molars 2. When supraperiosteal injection has proved ineffective

9. Technique: Landmarks: a. Mucobuccal fold b. Maxillary tuberosity c. Zygomatic process of the maxilla Target area: PSA nerve Area of insertion: Height of mucobuccal fold

10. Procedure: Insert the needle into the height of the mucobuccal fold over the second molar Advance the needle slowly in an upward, inward and backward direction Upward: superiorly at a 45-degree angle to the occlusal plane Inward: medially toward the midline at a 45-degree angle to the occlusal plane Backward: posteriorly at a 45-degree angle to the long axis of the second molar Depth of penetration: 16 mm

11. Complications 1.Hematoma: Needle too far posteriorly into the pterygoid plexus of veins. A visible intraoral hematoma develops within several minutes, usually noted in the buccal tissues of the mandibular region . 2.Mandibular anesthesia : The mandibular division of the fifth cranial nerve (V3) is located lateral to the PSA nerves. Deposition of local anesthetic lateral to the desired location may produce varying degrees of mandibular anesthesia

12. Middle Superior Alveolar Nerve Block: The middle superior alveolar (MSA) nerve is present in only about 28% of the population Areas Anesthetized: 1.Pulps of the maxillary first and second premolars, mesiobuccal root of the first molar 2.Buccal periodontal tissues and bone over these same teeth Indications: 1.Where the ASA nerve block fails to provide pulpal anesthesia distal to the maxillary canine 2.Dental procedures involving both maxillary premolars

13. Technique: Landmark: Mucobuccal fold above the maxillary second premolar Target area : Maxillary bone above the apex of the maxillary second premolar Area of insertion : Height of the mucobuccal fold above the maxillary second premolar

14. Procedure: Insert the needle into the height of the mucobuccal fold above the second premolar with the bevel directed toward bone. Penetrate the mucous membrane and slowly advance the needle until its tip is located well above the apex of the second premolar Complications : A hematoma may develop at the site of injection. Management: Apply pressure with sterile gauze over the site of swelling and discoloration for a minimum of 60 seconds.

15. Anterior superior alveolar nerve block: (Infraorbital Nerve Block) Nerves Anesthetized: 1.Anterior superior alveolar 2.Middle superior alveolar 3.Infraorbital nerve a. Inferior palpebral b. Lateral nasal c. Superior labial Areas Anesthetized: 1.Pulps of the maxillary central incisor to canine on the injected side 2.In about 72% of patients, pulps of the maxillary premolars and mesiobuccal root of the first molar 3.Buccal (labial) periodontium and bone of these same teeth 4.Lower eyelid, lateral aspect of the nose, upper lip

16. Technique: Landmarks: a.Mucobuccal fold b.Infraorbital notch c.Infraorbital foramen Target area: Infraorbital foramen Area of insertion: Height of the mucobuccal fold directly over the first premolar

17. Procedure: Feel the infraorbital notch. Move your finger downward from the notch, applying gentle pressure to the tissues. The bone immediately inferior to the notch is convex . This represents the lower border of the orbit and the roof of the infraorbital foramen As your finger continues inferiorly, a concavity is felt; this is the infraorbital foramen. While applying pressure, feel the outlines of the infraorbital foramen at this site. The patient senses a mild soreness when the foramen is palpated as the infraorbital nerve is pressed against bone.

18. Complications: Hematoma (rare) may develop across the lower eyelid and the tissues between it and the infraorbital foramen. Management: Apply pressure on the soft tissue over the foramen for 2 to 3 minutes.

19. Anterior Middle Superior Alveolar Nerve Block: Friedman and Hochman Areas Anesthetized: 1.Pulpal anesthesia of the maxillary incisors, canines and premolars 2.Buccal attached gingiva of these same teeth 3.Attached palatal tissues from midline to free gingival margin on associated teeth Indications: 1.When anesthesia to multiple maxillary anterior teeth is desired from a single-site injection 2.When scaling and root planning of the anterior teeth are to be performed 3. When anterior cosmetic procedures are to be performed and a smile-line assessment is important for a successful outcome

20. Technique: 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 Target area: Palatal bone at injection site 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

21. Procedure: Very slowly advance the needle tip into the tissue. Rotating the needle allows the needle to penetrate the tissue more effciently . Orientation of needle from the contralateral premolars Complications: Palatal ulcer at injection site developing 1 to 2 days postoperatively Self-limiting (Heals in 5 to 10 days) Prevention : Slow administration to avoid excessive ischemia Avoid excessive concentrations of vasoconstrictor Avoid multiple needle injuries at the site of injection

22. Greater Palatine Nerve Block: Areas Anesthetized: The posterior portion of the hard palate and its overlying soft tissues, anteriorly as far as the first premolar and medially to the midline Indications: 1.When palatal soft tissue anesthesia is necessary for restorative therapy on more than two teeth 2.For pain control during periodontal or oral surgical procedures involving the palatal soft and hard tissue

23. Technique: Target area: Greater palatine nerve Landmarks: Greater palatine foramen (found palatal to 2 nd molar) and junction of the maxillary alveolar process and palatine bone Area of insertion : Soft tissue slightly anterior to the greater palatine foramen Path of insertion : Advance the syringe from the opposite side of the mouth at a right angle to the target area

24. Procedure: 1. Location of greater palatine foramen

25. Procedure: 2. Direct the syringe into the mouth from the opposite side with the needle approaching the injection site at a right angle 3.The depth of penetration is usually about 5 mm. Complications 1.Ischemia and necrosis of soft tissues when highly concentrated vasoconstricting solution used for hemostasis over a prolonged period 2.Hematoma is possible but rare because of the density and firm adherence of palatal tissues to underlying bone.

26. Nasopalatine Nerve Block: Areas Anesthetized: Anterior portion of the hard palate (soft and hard tissues) bilaterally from the mesial of the right first premolar to the mesial of the left first premolar

27. Technique: Landmarks : Central incisors and incisive papilla Target area : Incisive foramen, beneath the incisive Papilla Area of insertion : Palatal mucosa just lateral to the incisive papilla (located in the midline behind the central incisors) Path of insertion : Approach the injection site at a 45-degree angle toward the incisive papilla.

28. Procedure: Single needle penetration 2. Multiple needle penetration

29. Complications 1.Ischemia and necrosis of soft tissues while using high concentration of vasoconstrictor 2.Hematoma is possible but rare because of the density and firm adherence of palatal tissues to underlying bone. 3.Interdental papillae between the maxillary incisors sometimes are tender for several days after injection.

30. Anterior Superior Alveolar nerve block - Palatal approach: Nerves Anesthetized: 1.Nasopalatine 2.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

31. Indications 1.When bilateral anesthesia of the maxillary anterior teeth is desired from a single site injection 2.When anterior cosmetic procedures are to be performed and a smile-line assessment is important to a successful outcome 3.When a facial approach supraperiosteal injection has been ineffective because of dense cortical bone Technique: Area of insertion: Just lateral to the incisive papilla in the papillary groove Target area : Nasopalatine foramen Landmarks : Nasopalatine papilla

32. Procedure: Rotating the needle allows the needle to penetrate the tissue more efficiently. Continue the slow insertion technique into the nasopalatine canal. Orientation of the needle should be parallel to the long axis of the central incisors. The needle is advanced to a depth of 6 to 10 mm Complication: 1. Palatal ulcer at the site of injection postoperatively Prevention : Slow administration to avoid excessive ischemia. Avoid excessive concentrations of vasoconstrictor 2. Density of soft tissues at injection site causing squirt back LA

33. Maxillary nerve block Areas Anesthetized: 1.Pulpal anaesthesia of the maxillary teeth on the side of the block 2.Buccal periodontium and bone overlying these teeth 3.Soft tissues and bone of the hard palate and part of the soft palate, medial to midline 4.Skin of the lower eyelid, side of the nose, cheek and upper lip Indications: 1.Pain control before extensive oral surgical or periodontal procedures requiring anesthesia of the entire maxillary division 2.When tissue inflammation or infection precludes the use of other regional nerve blocks or supraperiosteal injection 3.Diagnostic or therapeutic procedures for neuralgias of the second division of the trigeminal nerve

34. Technique – Greater palatine approach: Target area : The maxillary nerve as it passes through the pterygopalatine fossa; the needle passes through the greater palatine canal to reach the pterygopalatine fossa Landmark : Greater palatine foramen, junction of the maxillary alveolar process and the palatine bone Area of insertion : Palatal soft tissue directly over the greater palatine foramen After locating the foramen, very slowly advance the needle into the greater palatine canal to a depth of 30 mm.

35. Technique – High tuberosity approach: Landmarks : a. Mucobuccal fold at the distal aspect of the maxillary second molar b. Maxillary tuberosity c. Zygomatic process of the maxilla Target area : a. Maxillary nerve as it passes through the pterygopalatine fossa b. Superior and medial to the target area of the PSA nerve block Area of insertion : Height of the mucobuccal fold above the distal aspect of the maxillary second molar

36. Complications: 1.Penetration of the orbit a. Periorbital swelling and proptosis b. Regional block of the sixth cranial nerve (abducent), producing diplopia c. Possible optic nerve block with transient loss of vision (Amaurosis) d. Possible retrobulbar hemorrhage 2.Penetration of the nasal cavity On aspiration, large amounts of air appear in the cartridge. On injection, the patient complains that local anesthetic solution is running down his or her throat. Prevention: 1.Keep the patient’s mouth wide open and take care during penetration that the advancing needle stays in the correct plane. 2.Do not force needle if resistance is encountered

37. Extra-oral technique Extra oral Infra orbital nerve block Extra oral Maxillary nerve block – Supra zygomatic approach Extra oral Maxillary nerve block – Infra zygomatic approach

38. Extraoral infra orbital nerve block: Area anesthetized: Complete anesthesia to the teeth and facial structures of the anterior part of the maxilla Indications : Multiple Extractions in the anterior part of the maxilla Surgical removal of impacted teeth Surgical exploration in the anterior part of the maxilla Endodontic surgery in the anterior part of the maxilla Treatment of acute trauma requiring suturing of soft tissues or repositioning of alveolar bone and associated teeth, or both The extraoral approach to the infraorbital nerve block; Donald J. Kleier , DMD Deborah K. Deeg , DDS Robert E. Averbach , DDS

39. Technique: Target area : Infraorbital foramen, which is located 5 to 10 mm inferior to the zygomaticomaxillary suture. Area of insertion : Just below the operator’s palpating infraorbital foramen Procedure: The needle was inserted through the skin and directed upward at a 45° angle The extraoral approach to the infraorbital nerve block; Donald J. Kleier , DMD Deborah K. Deeg , DDS Robert E. Averbach , DDS

40. Complications: Bruising - Bruising in the infraorbital area would be highly visible Post injection soreness If anesthetic solution should inadvertently enter the orbit, a transient diplopia or loss of vision could occur. The extraoral approach to the infraorbital nerve block; Donald J. Kleier , DMD Deborah K. Deeg , DDS Robert E. Averbach , DDS

41. Efficacy of Extra-Oral Maxillary Nerve Block Technique Using Frontozygomatic Approach; Dr. Prashanth .R V. S Dental College, Bangalore. Dr. Smriti Ticku V. S Dental College, Bangalore Extra oral Maxillary nerve block – Supra zygomatic approach: Nerve anesthetized: Maxillary branch of trigeminal nerve Point of insertion: Skin projection of the frontozygomatic angle Target area: Foramen rotundum

42. Procedure: After confirming that the needle was in contact with the greater wing of sphenoid bone, it was advanced through the infratemporal fossa angulated at approximately 60° and 10° towards the sagittal and horizontal planes respectively. When the rubber marker (50mm) approached the surface of the skin, patients were instructed to warn the surgeon when they felt local anaesthetic dropping in their nose or throat. This meant that the tip of the needle had reached the posterior wall of the pterygopalatine fossa and penetrated the nasal mucosa. Efficacy of Extra-Oral Maxillary Nerve Block Technique Using Frontozygomatic Approach; Dr. Prashanth .R V. S Dental College, Bangalore. Dr. Smriti Ticku V. S Dental College, Bangalore

43. Efficacy of Extra-Oral Maxillary Nerve Block Technique Using Frontozygomatic Approach; Dr. Prashanth .R V. S Dental College, Bangalore. Dr. Smriti Ticku V. S Dental College, Bangalore The needle was then withdrawn for 3–5 mm to avoid intranasal injection The remaining drug was slowly deposited into the vicinity of the foramen rotundum where the maxillary nerve leaves the base of the skull to enter the pterygopalatine fossa. COMPLICATIONS Hematoma Ecchymosis Visual disturbance Limitation of mouth opening Deviation of the lower jaw

44. Efficacy of Extra-Oral Maxillary Nerve Block Technique Using Frontozygomatic Approach; Dr. Prashanth .R V. S Dental College, Bangalore. Dr. Smriti Ticku V. S Dental College, Bangalore Extra oral Maxillary nerve block – Infra zygomatic approach: Area of insertion: Mandibular fossa between the condylar and coronoid process of the mandible. Target area: Pterygopalatine fossa Procedure: After skin infiltration, a 6 cm needle is introduced at an angle of 45degree in the direction back of the eyeball.

45. 4-4.5 cm the lateral part of the pterygoid process is reached and the needle is withdrawn slightly in the pterygopalatine fossa (about 0.5 cm medial to pterygoid) Aspiration in various levels, local anesthesia is carefully injected in several doses. COMPLICATIONS Transient visual weakness (Rarely) Horner’s syndrome (Extremely rare usually occurs due to administration of local anesthesia solution in higher doses) Hematoma over the cheek or in the orbital cavity due to blood vessel puncture Efficacy of Extra-Oral Maxillary Nerve Block Technique Using Frontozygomatic Approach; Dr. Prashanth .R V. S Dental College, Bangalore. Dr. Smriti Ticku V. S Dental College, Bangalore

46. Thank you