Technique of maxillay anesthesia
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This document discusses various techniques for blocking nerves that innervate the oral cavity, including both intraoral and extraoral approaches. Intraoral techniques include local infiltration of nerve endings, blocking terminal branches through paraperiosteal or intraosseous injections, and blocking specific nerves like the anterior and middle superior alveolar nerves. Extraoral techniques allow blocking of nerves like the anterior and middle superior alveolar nerves from outside the mouth. Each technique aims to anesthetize specific nerves, areas, and teeth while avoiding pain and complications from the injections.
Technique of maxillay anesthesia
- 1. By •Foram kamani •Monali joshi
- 2. Transmission in nerve fibers of the second division that innervate the oral cavity may be interrupted by the following approaches: 1. Intraoral techniques A. Local infiltration of nerve endings B. Block of the terminal branches C. Anterior & middle superior alveolar nerve block D. Posterior superior alveolar nerve block E. Nasopalatine nerve block F. Anterior palatine nerve block G. maxillary nerve block 2. Extraoral techniques A. anterior & middle superior alveolar nerve block B. maxillary nerve block
- 3. 1. Intraoral technique A. Local infiltration of nerve endings 1) AREAS ANESTHETIZED: only that area into which the local anesthetic solution is infiltrated 2) NERVES ANESTHETIZED: terminal branches or free nerve endings 3) ANATOMICAL LANDMARKS: no landmark 4) INDICATION: local infiltration techniques are indicated when only mucous membrane & underlying connective tissues are to be anesthetized. This method can be use for incision in the mucous membrane or before insertions of other needles.
- 4. 5. TECHNIQUE: in the oral cavity a 1-inch, 25-gauge needle is inserted beneath the mucous membrane into the connective tissue in the area to be anesthetized, and the anesthetic solution is infiltrate slowly throughout the area. Care should be exercised to the solution is not injected too rapidly or in too large volume. To do so many cause injury to the tissue resulting in postinjection pain & in more sever cases, slough. This technique require more then one needle insertion, depending on the size of the area to be anesthetized. When the incision or surgical procedure is within the injection area, this method is referred to as local infiltration.
- 5. B. Block of the terminal branchs 1) NERVES ANESTHETIZED: large terminal branches 2) AREAS ANESTHETIZED: all of the area innervated by the larger terminal branches affected 3) ANATOMICAL LANDMARK: there will depend on the areas to be anethetized 4) INDICATION: this technique is indicated for producing analgesia of one or two maxillary teeth or of a limited area of the maxilla. It is most commonly confined because the maxilla’s prosity lends itself to this method. Blocking the larger terminal branches in the mandible is usually difficult because of its denseness.
- 6. 5) TECHNIQUES a. Paraperiosteal technique: the paraperiosteal technique is most commonly used for anesthetizing the larger terminal branches within the oral cavity. As previously stated, the term paraperiosteal is used in preference to the term supraperiosteal because the solution is deposited alongside & not above the periosteam. • The paraperiosteal injection is indicated & more widely used in the porous maxilla than in the dense mandible.
- 7. It should be kept in mind that there is a variation in the thickness of the body plate covering the root of the maxillary teeth. the bony plate covering the roots of the deciduous maxillary teeth. A 1-inch, 25-guage needle is inserted through the mucous membrane & underlying connective tissue until it gentely comes in contact with the periosteum. The solution should be deposited slowly. When one or two teeth are to be anesthetized, the needle is inserted into the mucobuccal & buccolabial fold so that it makes contact with the periosteum opposite & just above the apex of the root of the tooth.
- 8. b. intraosseous technique: a second technique for blocking the large terminal branches in the interosseus method. Interosseus means, as a term implies, injecting directly in to the bone. This is not only a painful but also a dangerous procedure because of the possibility of needle breakage. This technique is indicated primarily for the maxillary incisors, cuspids & bicuspids & should be used when the anterior & middle superior alveolar nerve block or parapariosteal method is ineffective.
- 9. An opening of the interosseous structure should then be made, with a suitable bone burr or interseptal drill. • A 1-inch, 23–gauge needle is inserted through the tissue incision & into the previously made opening in the bone. The solution is deposite in this area. • This technique may at times be used in the mandible with varying degrees of success. Its effectiveness will depend largely on the age of patient & porosity of mandible.
- 10. c. Interseptal technique. It is most effective in children & young adults. A 23- or 25-gauge needle is pressed gently into the thin porous interseptal bone on either side of the tooth to be anesthetized. • The anesthetic solution is then forced under pressure into the cancellous bone. • It is important that the superficial mucous membrane be anesthetized before a large-gauge needle is inserted into the bone.
- 11. d. Intraligamentary technique. recently a technique has been described for effectively anesthetizing single teeth by injecting the local anesthetic into the periodontal ligament. • Special syringes have been developed & the needle is introduced through the gingival sulcus & into the periodontal ligament. • High pressure cause the solution to be forced, rather than difused, through the ligament to the nerves in the area. • It is advised that single-rooted teeth be injected on the mesial & distal sides or buccal & lingual sides & that multirooted teeth be injected over each root.
- 12. e. Intrapulpal technique. For those procedures that involve direct instrumentation of pulp, anesthesia may be achived with this injection technique. • A 25-gauge needle may be introduced directly into the operative site. • Ideally the needle should be wedged firmly into the pulp chamber or root canal. it is best achived by combination of the pharmacological action of the anesthetic solution & the pressure used to apply it. • The needle is always visible & is only being inserted into the pulp of the tooth, breakage is not likely to occur.
- 13. C. Block of anterior & middle superior alevolar nerves 1) NERVES ANESTHETIZED: infraorbital, anterior, & middle superior alveolar nerves, inferior palpebral, lateral nasal, & superior labial nerves. 2) AREAS ANESTHETIZED: incisors, cuspid, bicuspid, & mesiobuccal root of first molar on the side injected, including bony support & soft tissue; upper lip, lower eyelid, & a portion of the nose on the same side. 3) ANATOMICAL LANDMARKS: infraorbital ridge, infraorbital depression, supraorbital notch, infraorbital notch, anterior teeth & pupils of eyes.
- 14. 4) INDICATIONS: when the anterior & middle superior alveolar nerves are to be blocked Any procedures, surgical or operative, may be performed on the five anterior maxillary teeth on the same side of the median line. 5) TECHNIQUE: the patient is placed comfortably in the chair & tilted so that the maxillary occlusal plane is at a 45- degree angle to the floor. an imaginary straight line drawn will pass through the pupils of the eyes, the infraorbital foramen, the bicuspid teeth, the mental foramen.
- 15. For an infraorbital block of the right side the dentist stands on the right side of the chair partially facing the patient. the thumb of the operator's left hand is placed over the previously located infraorbital foramen,& the index finger is used to retract the lip, exposing the mucolabial fold. 25-gauge needle is taken inserted into the mucolabial fold from either one or two directions. In using the first direction, the dentist inserts the needle in a line parallel with the supraorbital notch, the pupil of the eye, infraorbital notch, & the second bicuspid tooth, if it is in place.
- 16. The needle should be inserted a sufficient distance from the labial plate to pass over the canine fossa. The second direction of insertion bisects the crown of the central incisor from the mesioincisal angle to the distogingival angle. The needle is again inserted about 5mm from the mucobuccal fold & guided into position by the thumb marking the location of the infraorbital foramen. the anterior & middle superior alveolar nerves are blocked on the left side with exactly the same technique as that used on the right side,with the exception that the operator stands slightly more to the front of the patient.
- 19. D. Posterior superior alveolar nerve block 1) NERVES ANESTHETIZED: posterior superior alveolar nerve 2) AREAS ANESTHETIZED: the maxillary molars, with the exception of the mesiobuccal root of the first molar; the buccal alveolar process of the maxillary molars, including the overling structure-periosteum, connective tissue, & mucous membrane.
- 20. 3) ANATOMIACL LANDMARKS: a. mucobuccal fold & its concavity b. zygomatic process of maxilla c. infratemporal surface of the maxilla d. anterior border & coronoid process of the ramus of the mandible e. tuberosity of the maxilla 4) INDICATIONS: for oprative procedures of the molar teeth & suporting structures. This injection must be combine with palatal injection for extractions or when instrumentation extends into this area.
- 21. 5) TECHNIQUE FOR RIGHT SIDE: the area of insertion should be dried & painted with a suitable antiseptic solution. A previously loaded syringe, with a 1 5/8 inch, 25-gauge needle, is held in a pen grasp & inserted into the tissue in a line parallel with the index finger & bisecting the fingernail. The insertion is made for a distance of about ½ to ¾ inch, going upward, inward, & backward. This should place the needle point in the immediate vicinity of the foramina through which the nerves enter the maxilla.
- 22. 6) TECHNIQUE FOR LEFT SIDE: for injection on the left side the operator stands on the right side of the patient, & the left arm is passed around the patient’s head so that the area may be palpated with the left forefinger. The technique for injection after palpation is the same as that for the right side.
- 24. E. Nasopalatine nerve block (incisive canal injection) 1) NERVES ANESTHETIZED: nasopalatine nerve as it emerges from the anterior palatine foramen 2) AREAS ANESTHETIZED: the anterior portion of the hard palate & overling structures back to the bicuspid area, where branches of the anterior palatine nerve coursing forward create a dual innervation. 3) ANATOMICAL LANDMARKS: a. central incisor b. incisive papilla in the midline of the palate.
- 25. 4) INDICATION: for palatal anesthesia. a. to supplement the block of the anterior & middle superior alveolar nerves. b. to augment analgesia of six maxillary incisors. c. to complet anasthesia of the nasal septum. 5) TECHNIQUE: the nasopalatine nerve block is extremely painful injection unless a preparatory injection is made. The preparatory injection is made by a inserting a 1 inch, 25-gauge needle into the labial interseptal tissue between the maxillary central incisors.
- 26. This needle is inserted at a right angle to the labial plate & pass into the tissue until the resistance is met; then 0.25 ml of anesthetic solution is deposited. The needle is slowly into the crest of the papilla, making certain that it is in line with the labial alveolar plate. The needle is then advanced slowly into the incisive foramen, about 0.5 cm into the canal. About 0.25 to 0.5 ml should be injected very slowly to prevent distention of the surrounding tissues.
- 28. F. Anterior palatine nerve block 1) NERVES ANESTHETIZED: anterior palatine nerve as it leaves the greater palatine foramen. 2) AREAS ANESTHETIZED: posterior portion of the hard palate & overlying structure up to the first bicuspid area on the side injected. At the first bicuspid area, branches of the nasopalatine nerve will b met. 3) ANATOMICAL LANDMARKS: a. second & third maxillary molars b. palatal gingival margin of second & third maxillary molars. c. midline of the palate
- 29. d. a line approximately 1 cm from the palatal gingival margin toward the midline of the palate 4) INDICATIONS: a. for palatal anesthesia to be used in conjunction with the posterior superior alveolar block or middle superior alveolar nerve block. b. for surgery of the posterior portion of hard palate. 5) TECHNIQUE:the anterior palatine nerve emerges onto the palate through the greater palatine nerve foramen. It is situated between the second & third maxillary molars. • The needle should be inserted very slowly until the palatal bone is contacted.
- 30. The anesthetic solution, 0.25 to 0.5 ml, is injected very slowly. It will be advantageous to insert the needle & deposit the solution so that the anterior palatine nerve will be anesthetized anteriorly to the foramen. Anesthesia of the mucoperiosteum of the palate will be obtained forward from the area of injection.
- 31. G. Maxillary nerve block 1) NERVES ANESTHETIZED: entire maxillary nerve & all its subdivisions peripheral to the site of the injection. 2) AREAS ANETHETIZED: a. maxillary teeth on the affected side. b. alveolar bone & overlying structures. c. hard palate & portion of soft palate d. upper lip, cheek, side of nose, & lower eyelid
- 32. 3) ANATOMICAL LANDMARKS: the landmarks will differ according to the technique. a. high tuberosity technique. Same landmarks as for the posterior superior alveolar nerve block. b. greater palatine canal technique. Same landmarks as for the locating the greater palatine foramen to block the anterior palatine nerve. 4) INDICATION: a. when anesthesia of the entire distribution of the maxillary nerve is required for extensive surgery.
- 33. b. when local infection or other conditions make blocks of the main terminal branches unfeasible. c. for diagnostic or therapeutic purposes such as tics or neuralgias of the maxillary division of the fifth nerve. 5) TECHNIQUES: a. High tuberosity technique. The high tuberosity is exactly the same as that described for the posterior superior alveolar nerve, with the exception that a 1 5/8-inch, 25- gauge needle is inserted in an upward, inward, & backward direction to a previously marked depth of 1 1/4-inches. Two to 4 ml of solution are taken slowly injected.
- 34. b. Greater palatine canal technique. Both the left & right greater palatine canals can b entered with the operator standing in front of & to the right side of the patient. • In performing the maxillary block by the greater palatine canal approach, the operator must insert the needle in the canal very slowly & against no resistance. • Both of these methods of blocking the entire maxillary nerve by the intraoral approach could be considered as being technically difficult. They should be attempted only when definitely indicted.
- 35. 2. EXTRAORAL TECHNIQUES A. Anterior & middle superior alveolar nerve block 1) NERVES ANESTHETIZED: a. infraorbital nerves b. inferior palpebral, lateral nasal, & superior labial nerves c. anterior & middle superior alveolar nerves d. sometimes posterior superior alveolar nerve 2) AREAS ANETHETIZED: a. incisors & bicuspids on the side injected b. labial alveolar plate & overlying tissues c. upper lip, portions of side of nose, & lower eyelid d. sometimes maxillary molars & their buccal supporting structures
- 36. 3) ANATOMICAL LANDMARKS: a. pupil of eye b. infraorbital ridge c. infraorbital notch d. infraorbital depression 4) INDICATIONS: a. when the anterior & middle superior alveolar nerves are to be anesthetized & the intraoral approach is not possible because of infection, trauma, or other reasons. b. when attempts to secure anesthesia by the intraoral methods have been ineffective.
- 37. 5) TECHNIQUES: a. Using the available landmarks, the dentist should locate & mark the position of the infraorbital foramen. The skin & subcutaneous tissues should be anesthetized by local infiltration. b. A 1 1/2-inch, 25-gauge needle attached to an aspirating syringe is inserted through the marked & anesthetized area. Directing the needle slightly upward & laterally facilitates its entrance into the foramen, which opens downward & medially.
- 38. c. With a slight, gently probing motion the foramen is located & entered to a depth not to exceed 1/8 inch . After careful aspiration, 1 ml of anesthetic solution is slowly injected.
- 39. B. Maxillary nerve block 1) NERVES ANESTHETIZED:maxillary nerve & all its subdivisions peripheral to the site of injection. 2) AREAS ANESTHETIZED: a. anterior temporal & zygomatic regions b. lower eyelid c. side of nose d, anterior cheek e. upper lip f. maxillary teeth g. tonsil
- 40. h. maxillary alveolar bone & overlying structures i. hard & soft palate j. part of the pharynx k. nasal septum & floor of the nose l. posterior lateral mucosa & turbinate bones 3) ANATOMICAL LANDMARKS: a. midpoint of the zygomatic arch b. zygomatic notch c. coronoid process of ramus of mandible located by opening & closing the jaw d. lateral pterygoid plate
- 41. 4) INDICATIONS: a. when anesthesia of the entire distribution of the maxillary nerve is required for extensive surgery. b. when it is desirable to block all the subdivisions of the maxillary nerve with only one needle insertion & a minimum of anesthetic solution. c. when local infection, trauma, or other conditions make blocks of the more terminal branches difficult or impossible. d. for diagnostic or therapeutic purposes, such as tics or neuralgias of the maxillary division of the fifth nerve.
- 42. 5) TECHNIQUE: a. The midpoint of the zygomatic process is located & the depression in its inferior surface is marked. With a 25- gauge hypodermic needle, a skin wheal is raised just below this mark in the depression, which the dentist indentifies by having the patient open & close the jaw. b. The needle is inserted through the skin wheal, perpendicular to the median sagittal plane until the needle point gently contacts the lateral pterygoid plate. The needle should never be inserted beyond the depth of the marker. The needle is withdrawn, with only the point left in the tissue, & redirected in a slight forward & upward direction until the needle is inserted to the depth of the marker.
- 43. The needle is withdrawn, with only the point left in the tissue, & redirected in a slight forward & upward direction until the needle is inserted to the depth of the marker. After careful aspiration, 2 or 3 ml of a suitable anesthetic solution is slowly injected. Care should be exercised to aspirate after each o.5 ml of the solution is injected.