Superior Alveolar Nerve Block.pptx

Explains about the maxillary injection technique

1. SUPERIOR ALVEOLAR NERVE BLOCK BY DEZLIN DARLY JOHN IIIrd year

2. CONTENTS POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK ANTERIOIR SUPERIOR ALVEOLAR NERVE BLOCK

3. POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK

4. POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK INTRODUCTION Most commonly used dental nerve block. Other Common Names :- Tuberosity Block , Zygomatic Block Nerves Anesthetised :- PSA and its Branches.

5. AREAS ANESTHETISED Pulps of maxillary third, second and First Molar, except the mesiobuccal root. And hence a second supraperiosteal injection is indicated after PSA to achieve an effective anaesthesia of first Molar. Buccal peridontium and bone overlying these teeth.

6. INDICATIONS When the treatment involves two or more maxillary molar. When supraperiosteal injection is contraindicated ( acute inflammation). When the supraperiosteal injection has been proved ineffective. CONTRAINDICATIONS Risk of haemorrhage is great; such cases, periosteal / PDL injection recommended.

7. ADVANTAGES Atraumatic; if administered properly. High success rate Minimum number of necessary injections. Minimises the total volume of L.A. solution administered. DISADVANTAGES Risk of Hematoma Technique somewhat arbitrary. Second injection required for the Treatment of first molar.

8. POSITIVE ASPIRATION - Approximately 3.1% ALTERNATIVES. 1.Supraperiosteal / PDL infection for pulpal and root anaesthesia. 2.Infilteration for the buccal peiodontium and hard tissues. 3. Maxillary Nerve Block.

9. TECHNIQUE 1. A 25 gauge needle recommended, 27 gauge also acceptable. 2 . Area of insertion:- height of the muccobuccal fold above and maxillary 2 nd molar. 3 .Target Area:- PSA Nerve- posterior, superior, medial to the posterior border of the maxilla. 4. Landmarks:- Mucobuccal fold Maxillary Tuberosity Zygomatic process of Maxilla 5. Orientation of the bevel:- towards the bone during injection. If the bone is accidently touched, the sensation is less unpleasant.

10. PROCEDURE a.) Assume the correct position:- Left PSA Nerve Block:- 10’o’ clock position. Right PSA Nerve Block:- 8’o’ clock position. b.) Prepare the tissue at the height of the mucobuccal fold of penetration. c.) Orient the bevel of the needle towards the bone. d.) Partially open the mouth of the patient , pulling to the side of the injection. e.)Retract the cheek with fingers and pull the tissues at the injection site taut. f.) Inject he needle to the height of the mucobuccal fold over the second Molar.

11. Advance the needle slowly in an upward, inward & backward direction in one moment. Upward:- superiorly at 45° to the occlusal plane. Inward:- medially towards the midline at 45° angle to the occlusal plane. Backward:- posteriorly at a 45°angle to the long axis of 2 nd Molar. In an adult of normal size, penetration to a depth of 16mm; When a long needle of average length 32mm, half the length of the needle is to be inserted. With a short needle of 20mm, approximately 4mm should remain visible. The goal is to deposit the L.A close to the PSA Nerve, located posterosuperior and medial to the maxillary tuberosity. Aspirate in two planes If both the planes are negative, slowly over 30-60sec, deposit 0.9-1.8ml of anesthetic solution. Wait 3-5 min before commencing the dental procedure.

12. SIGNS AND SYMPTOMS Subjective:- usually none Objective:-absence of pain during therapy. SAFETY FEATURES Slow injections and repeated aspirations. Careful observation is necessary as there is no anatomical safety features to prevent over insertion. PRECAUTION Depth of penetration of the needle needs to be checked. Overinsertion:- hematoma Too shallow:- inadequate anaesthesia

13. FAILURES OF ANESTHESIA Needle too lateral; to correct- redirect the needle tip medially. Needle not too high; to correct- redirect the needle tip superiorly. Needle too far posterior; to correct- withdraw the needle to the proper depth. COMPLICATIONS Hematoma:- when needle inserted too deeply into the pterygoid plexus. Use of a short needle can avoid it. Visible intraoral hematoma:- usually noted in the buccal tissue of the mandible. Mandibular anesthesia:- As mandibular nerve is located lateral to PSA.

14. MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK

15. MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK INTRODUCTION The Middle Superior Alveolar nerve is present only in 28%of the population; hence limiting the clinical importance. Indicated if the infraorbital nerve fails to anesthetise the area distal to maxillary canine MSA Nerve Block is indicated for procedures on Premolar and for the mesiobuccal root of Maxillary first Molar. Succes rate is high. NERVES ANESTHETISED:- Middle Superior Alveolar Nerve and its terminal Branches.

16. AREAS ANESTHETISED BY MSA NERVE BLOCK Pulps of the Maxillary first and second premolar, mesiobuccal root of First Molar. Buccal periodontal tissues and bone over the same teeth.

17. INDICATIONS Failure of infraorbital nerve block Dental procedures involving Maxillary premolars only CONTRAINDICATIONS Inflammations at the site of injection. ADVANTAGES Minimises the no. Of injections and the volume of solution. DISADVANTAGES None. POSITIVE ASPIRATION – Negligible (<3%) ALTERNATIVES 1.Local infilteration( supraperiosteal), PDL 2.Infraorbital Nerve Block

18. TECHNIQUE A 25 gauge / long needle is recommended, 27 gauge perfectly acceptable. Area of insertion:- height of the mucobuccal above the maxillary second Premolar. Target Area:- Maxillary bone above the apex of the Maxillary 2 nd Premolar. Landmarks:- Muccobuccal fold above maxillary 2 nd premolar. Orientation of the bevel:- towards the bone

19. PROCEDURE a.) Assume the correct Position:- Right MSA Nerve Block: 10 ’o’ clock Left MSA Nerve Block: 8 / 9’o’clock b.) Prepare the tissue at the site of injection. c.)stretch the patient’s upper lip to make the tissues taut and to gain visibility. d.)insert the needle to the height of the mucobuccal fold above the second premolar with the bevel directed towards the bone. e.) Aspirate f.) slowly deposit 0.9-1.2ml of solution in approximately 30-40 sec. g.)wait for 3-5min before commencing the therapy.

20. SIGNS AND SYMPTOMS. Subjective:- upper lip numb. Objective:- No pain during dental therapy. SAFETY FEATURES Relatively avascular area, anatomically safe. PRECAUTION To prevent pain do not insert too close to the periosteum should not do too rapidly.

21. FAILURE OF ANESTHETICS Anaesthetic solution not deposited high above the apex of second Premolar; to correct: check radiograph ; increase the depth of penetration. Deposition of solution far from the maxillary bone with the needle placed in tissue lateral to the height of the mucobuccal fold; to correct: Reinsert at the height of the mucobuccal fold. Bone of Zygomatic arch at the site of injection preventing diffusion of anesthetic; to correct : use supraperiosteal/ PSA injection in place of MSA. COMPLICATIONS 1.Rare

22. ANTERIOR SUPERIOR ALVEOLAR NERVE BLOCK

23. ANTERIOR SUPERIOR ALVEOLAR NERVE BLOCK INTRODUCTION Used in place of supraperiosteal injections. High success rate Not so popular as PSA Nerve Block. NERVES ANESTHETISED 1.)Anterior Superior Alveolar 2.) Middle Superior Alveolar 3.)Infraorbital Nerve a.)Inferior Palpebral b.)Lateral Nasal c.) Superior Labial

24. AREAS ANESTHETISED 1.Pulps of maxillary Central Incisors through the canine on the injected side. 2. Pulps of the maxillary premolars and mesiobuccal root of the first molar. 3.Labial peridontium and bone over these teeth. 4.Lower eyelid and lateral aspect of nose, upper lip.

25. INDICATIONS Dental procedures involving more than two maxillary teeth Inflammations contraindicating supraperiosteql injections. Failure of supraperiosteal injection due to dense cortical bone. CONTRAINDICATIONS Discrete treatment areas Haemostasis of localised area, when desired ,cannot be achieved. Local infiltration into the treatment area is indicated.

26. ADVANTAGES Comparatively simple technique. Comparatively safe ; minimises the volume of the L.A Solution used. Minimal number of needle puncture. DISADVANTAGES 1.Psychological a.) Administrator: There may be initial fear of injury to the patients' eye. But experience with the technique leads to confidence. b.)Patient: an extra oral approach of infraorbital nerve; however intraoral ones are rarely a problem. c.)Difficulty in defining the anatomical landmarks.

27. POSITIVE ASPIRATION- 0.7% ALTERNATIVES Supraperiosteal, PDL / IO injection foe each tooth. Infiltration for the periodontium and the hard tissues. Maxillary Nerve Block.

28. TECHNIQUE 1. 25Gauge needle is used. 2. Area of insertion: height of mucobuccal fold directly over 1 st Premolar or over any tooth from second premolar to the central incisors. Usually first premolar is preferred as it provides the shortest route to the target area. 3. Target Area: infraorbital foramen. 4 .Landmarks: Mucobuccal fold Infraorbital Notch Infraorbital Foramen 5.) Orientation of the bevel: towards the bone.

29. PROCEDURE a.) Assume the correct position- For both Right and Left ASA Nerve Block: 10 ’o ‘ clock position b.) Position of patient: supine position more preferred; semi supine position with neck extended slightly. c.) Prepare the tissue at the injection site. d.) Locate he infraorbital foramen. 1. Feel the infraorbital notch, apply gentle pressure to the tissues. 2. The bone inferior to the notch is convex (lower border of the orbit) As your fingers continue a concavity is felt; this is infraorbital foramen . 3. Apply pressure , feel the outlines of infraorbital foramen, palpate it. e.) Mark the skin at the site. f.) Retract the lip, pulling the tissues in the mucobuccal fold over the first premolar with the bevel facing bone. g.)Orient the needle towards the infraorbital foramen

30. h.) The needle must be held parallel to the long axis of the tooth as it is advanced to avoid premature contact with the bone. i.) The pt. Of contact should be the upper rim of infraorbital foramen. j.) The general depth of needle penetration is 16mm for an adult of average height. k.) Before injecting the L.A Solution, check for the following. 1.) Depth of needle penetration 2.) Any lateral deviation of the needle from the infraorbital foramen. 3.) Orientation of the bevel facing the bone. l.) Position of the needle with the bevel facing into the infraorbital foramen and the needle tip touching the roof of the foramen. m.) Aspirate n.) Slowly deposit 0.9-1.2 ml over 30-40sec.

31. o.) The administrator is able to feel the deposited L.A.Solutin beneath the fingers. At the conclusion of the injection, the foramen should no longer be palpable. p .) Maintain firm pressure with your finger over the injection site both during and for at least 1- 2 minute after the injection site to diffuse the L.A Solution into the infraorbital foramen q.) Wait 3-5 minutes after the completion of injection before commencing the dental procedure.

32. SIGNS AND SYMPTOMS 1.) Subjective:- tingling and numbness of lower eyelid, side of nose, upper lip indicate anesthesia of infraorbital nerve not ASA/ MSA Nerve . 2.)Subjective & Objective:- Numbness in the teeth and soft tissue along the distribution of ASA and MSA ( develops 3-5 minute if pressure is maintained over the injection site.) 3.)Objective:- no pain during the dental therapy. SAFETY FEATURES 1.Needle contact with the bone at the roof of the infraorbital foramen prevent over insertion and possible puncture of the orbit. 2. A finger placed directly over the infraorbital foramen helps to direct the needle towards the foramen. 3. The needle should not be palpable; if it is, then it is too superficial. To correct it withdraw the needle slightly and redirect to the target area.

33. PRECAUTIONS For pain on insertion of the needle and tearing of the periosteum, reinsert the needle in a more lateral position. For over insertion of the needle, estimate the depth of penetration before injection and exert finger pressure over the infraorbital foramen. Overinsertion is unlikely because the rim of the bone that forms the superior rim of infraorbital foramen. The needle tip contacts this rim.

34. FAILURES OF ANESTHESIA 1.) Needle contacting the bone below the infraorbital foramen; causes anesthesia of the lower eyelid, lateral side of nose and upper lip develop with little or no dental anesthesia. 2.) A failed ASA is a supraperiosteal injection over the first Premolar; to correct: keep the needle in line with the infraorbital foramen during penetration. Do not direct the needle towards the bone. 3.) Needle deviation medial or lateral to the infraorbital foramen; to correct; Direct the needle towards the foramen immediately through the tissue. 4.) Recheck the needle placement before aspirating and depositing the Anesthetic solution.

35. COMPLICATIONS 1.) Hematoma:- rarely develops ; across the lower eyelid and tissues between it and infraorbital foramen. To manage, apply pressure on the soft tissue over the foramen for 2-3 minutes. 2. Hematoma is extremely rare as pressure is routinely applied to the injury site both during and after ASA Nerve Block.

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