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1. Local infiltration- type of injection that anesthetizes a small area (one
or two teeth and asscociated areas)- anesthesia deposited at nerve terminals
1. Nerve block- type of injection that anesthetizes a larger area- anesthesia deposited near larger nerve trunks
Methods: Reducing temperature.
Is used only to produce surface anaesthesia e.g. ethyl chloride spray.
Physical damage to nerve trunk e.g. nerve sectioning. Unsafe for therapeutic uses, only in Trigeminal Neuralgia.
Chemical damage to nerve trunk e.g. neurolytic agents. Silver nitrate, Phenol - Unsafe for therapeutic use.
Methods: Cont
Anoxia or hypoxia resulting in lack of oxygen to nerve. Unsafe as well.
Stimulation of large nerve fibres, blocking the perception of smaller diameter fibres. includes Acupuncture and TENS (Transcutaneous
Electronic Nerve Stimulation)
Drugs that block transmission at sensory nerve endings or along nerve fibres. There action is fully reversible and without permanent
damage to the tissues.
Classified according to their chemical structures and the determining factor is the intermediate chain, into two groups:
Ester Amide
They differ in two important respect: Their ability to induce hypersensitivity reaction. Their pharmacokinetics - fate and metabolism.
MaxillaryA. posterior superior
alveolar blockB. middle superior alveolar
blockC. anterior superior alveolar
blockD. greater palatine blockE. infraorbital blockF. nasopalatine block
MandibularA. inferior alveolar blockB. buccal blockC. mental blockD. incisive blockE. Gow-Gates mandibular
nerve block
dental procedures can usually commence after 3 – 5 minutes
failure requires re-administration using another method
never re-administer using the same method keep in mind the total # of injections and the
dosages never inject into an area with an abcess, or
other type of abnormality
Chart 9-1 pulpal anesthesia: through anesthesia of each nerve’s dental
branches as they extend into the pulp tissue (via the apical foramen)
periodontal: through the interdental and interradicular branches palatal: soft and hard tissues of the palatal periodontium (e.g.
gingiva, periodontal ligaments, alveolar bone) PSA block: recommended for maxillary molar teeth and
associated buccal tissues in ONE quadrant MSA block: recommended for maxillary premolars and
associated buccal tissues ASA block: recommended for maxillary canine and the incisors in
ONE quadrant greater palatine block: recommended for palatal tissues distal to
the maxillary canine in ONE quadrant nasopalatine block: recommended for palatal tissues between the
right and left maxillary canines
figures 9-2 through 9-7 pulpal anesthesia of the
maxillary 3rd, 2nd and 1st molars required for procedures
involving two or more molars sometimes anesthesia of the 1st
molar also required block of the MSA nerve
associated buccal periodonteum overlying these molars including the associated
buccal gingiva, periodontal ligament and alveolar bone
useful for periodontal work on this area
target: PSA nerve as it enters the maxillar through
the PSA foramen on the maxilla’s infratemporal service – Figure 9-2 & 9-3
into the tissues of the mucobuccal fold at the apex of the 2nd maxillary molar (figures 9-4 and 9-5)
mandible is extended toward the side of the injection, pull the tissues at the injection site until taut
needle is inserted distal and medial to the tooth and maxilla
depth varies from 10 to 16 mm depending on age of patient
no overt symptoms (e.g. no lip or tongue involvement)
can damage the pterygoid plexus and maxillary artery
limited clinical usefulness can be used to extend the infraorbital
block distal to the maxillary canine can be indicated for work on maxillary
pre-molars and mesiobuccal root of 1st molar (Figure 9-8)
if the MSA is absent – area is innervated by the ASA
blocks the pulp tissue of the 1st and 2nd maxillary premolars and possibly the 1st molar + associated buccal tissues and alveolar bone
useful for periodontal work in this area to block the palatine tissues in this area
– may require a greater palatine block
target area: MSA nerve at the apex of the maxillary 2nd premolar (figures 9-8 and 9-9) mandible extended towards injection site stretch the upper lip to tighten the injection site needle is inserted into the mucobuccal fold tip is located well above the apex of the 2nd premolar
figure 9-11
harmless tingling or numbness of the upper lip overinsertion is rare
figures 9-12 through 9-14 can be considered a local
infiltration used in conjunction with an MSA
block the ASA nerve can cross the
midline of the maxilla onto the opposite side!
used in procedures involving the maxillary canines and incisors and their associated facial tissues pulpal and facial tissues involved –
restorative and periodontal work blocks the pulp tissue + the
gingiva, periodontal ligaments and alveolar bone in that area
target: ASA nerve at the apex of the maxillary canine – figures 9-12 & 9-13
at the mucobuccal fold at the apex of the maxillary canine – figure 9-13
harmless tingling or numbness of the upper lip overinsertion is rare
figures 9-15 through 9-17 anesthetizes both the MSA and
ASA used for anesthesia of the
maxillary premolars, canine and incisors
indicated when more than one premolar or anterior teeth pulpal tissues – for restorative work facial tissues – for periodontal work
also numbs the gingiva, periodontal ligaments and alveolar bone in that area
the maxillary central incisor may also be innervated by the nasopalatine nerve branches
target: union of the ASA and MSA with the IO nerve after the IO enters the IO foramen – figure 9-15
also anesthesizes the lower eyelid, side of nose and upper lip
IO foramen is gently palpated along the IO rim move slightly down about 10mm until you feel the depression
of the IO foramen – figure 9-16 locate the tissues at the mucobuccal fold at the apex of the 1st
premolar place one finger at the IO foramen and the other on the injection site
– figure 9-17 locate the IO foramen, retract the upper lip and pull the tissues taut the needle is inserted parallel to the long axis of the tooth to avoid
hitting the bone harmless tingling or numbness of the upper lip, side of
nose and eyelid
figures 9-19 through 9-21 used in restorative procedures that involve more than
two maxillary posterior teeth or palatal tissues distal to the canine
also used in periodontal work – since it blocks the associated lingual tissues
anesthetizes the posterior portion of the hard palate – from the 1st premolar to the molars and medially to the palate midline
does NOT provide pulpal anesthesia – may also need to use ASA, PSA, MSA or IO blocks
may also need to be combined with nasopalatine block
target: GP nerve as it enters the GP foramen located at the junction of the maxillary
alveolar process and the hard palate – at the maxillary 2nd or 3rd molar – figure 9-19
palpate the GP foramen – midway between the median palatine raphe and lingual gingival margin of the molar tooth – figure 9-21
can reduce discomfort by applying pressure to the site before and during the injection produces a dull ache to block pain
impulses also slow deposition of anesthesia will
also help needle is inserted at a 90 degree angle
to the palate – figure 9-22
figure 9-23 through 9-26 useful for anesthesia of the bilateral portion of the hard
palate from the mesial of the right maxillary 1st premolar to the mesial
of the left 1st premolar for palatal soft tissue anesthesia
periodontal treatment required for two or more anterior maxillary teeth for restorative procedures or extraction of the anterior
maxillary teeth – may need an ASA or MSA block also blocks both right and left nerves
target: both right and left nerves as they enter the incisive foramen from the mucosa of the anterior hard palate – figure 9-23 & 9-25 posterior to the incisive papilla
injection site is lateral to the incisive papilla – figure 9-26 head turned to the left or right inserted at a 45 degree angle about 6-10 mm – gently contact the
maxillary bone and withdraw about 1mm before administering can reduce discomfort by applying pressure to the site before and
during the injection produces a dull ache to block pain impulses also slow deposition of anesthesia will also help
can anesthetize the labial tissues between the central incisors prior to palatal block can block some branches of the nasopalatine prior to injection
3 Main Types of Maxillary Injections:
1) Local Infiltration
2) Field Block
3) Nerve Block
Incision (treatment) is done in the same area in which the local anesthetic was deposited (interproximal
papilla before Scaling and Root Planing)
• Local anesthetic is deposited toward larger nerve terminal branches
• Treatment is done away from the site of local anesthetic injection
• Maxillary injections administered above the apex of the tooth to be treated are properly referred to as field blocks not local infiltrations
• Local anesthetic is deposited close to a main nerve trunk, usually at a site removed from the area of treatment (PSA, IANB, NPB)
1) Supraperiosteal Injection2) Intraligamentary (PDL) Injection3) Intraseptal Injection4) Intracrestal Injection5) Intraosseous Injection6) Posterior Superior Alveolar (PSA) Nerve Block7) Middle Superior Alveolar (MSA) Nerve Block8) Anterior Superior Alveolar (ASA) Nerve Block9) Maxillary Nerve Block (2nd Division)10) Greater Palatine Nerve Block11) Nasopalatine Nerve Block12) Anterior Middle Superior Alveolar (AMSA) Nerve Block13) Palatal Approach Anterior Superior Alveolar (P-ASA) Nerve
Block
The following are used in both arches: Supraperiosteal Injection
Intraligamentary (PDL) Injection Intraseptal Injection
Intraosseous Injection
Supraperiosteal Injection
1) Supraperiosteal Injection
Used for pulpal anthesia in maxillary teeth
Anesthetizes large terminal branches of the dental plexus
Greater than 95% success rate
1 or 2 teeth
Dense bone covering the apices of the teeth can lead to failure-maxillary molar of children (zygomatic bone
obscures)-central incisor of adults (nasal spine obscures)
Negligible positive aspiration rate (less than 1%)
Should not be used for large areas (multiple sticks/large amount of local anesthetic solution must be used)
Technique Supraperiosteal Injection
1) 25 or 27 gauge short needle is recommended
2) Insert needle at height of mucobuccal fold over apex of desired tooth
3) Apply topical anesthetic for at least one minute
4) Orient bevel toward bone; lift lip pulling tissues taut
5) Hold syringe parallel to long axis of the tooth being anesthetized6) No resistance to penetration should be felt and no patient discomfort7) Aspirate twice8) Deposit .6 ml (one-third of a cartridge) into tissue over 20 seconds 9) Do not allow tissues to balloon10) Wait 3 to 5 minutes to begin dental treatment
Problems/Failures If tooth does not anesthetize the needle tip could be below
the apex of the tooth resulting in inadequate anesthesia If the needle lies too far from the bone then anesthesia will
be inadequate because the solution was deposited in the soft tissue (lip)
The needle must be oriented toward the periosteum but should be managed properly to avoid tearing the highly innervated periosteum
These two words are used incorrectly; what most practitioners refer to as an infiltration injection is actually a field
block
Posterior Superior Alveolar Nerve Block (PSA)
2) Posterior Superior Alveolar Nerve Block
Highly successful nerve block with greater than 95% success
Effective for maxillary 1st, 2nd and 3rd molars and buccal periodontium
Mesiobuccal root of the maxillary 1st molar is not consistently innervated by the PSA nerve
Short dental needle is used for all but the largest of patients
Average depth of soft tissue penetration is 16 mm (short needle is 20 mm in length)
28% of maxillary 1st molars’ mesiobuccal roots are innervated by the middle superior alveolar nerve (MSA)
When the risk of hemorrhage is too great as with a hemophiliac, you should use the supraperiosteal or PDL injections
Patient should feel no pain with this injection because bone is not contacted and there is a large area of soft tissue into which the solution is deposited
Positive aspiration risk is 3.1%
Patient will often say that they do not feel numb; reason why is because they are accustomed to the intense feeling of anesthesia experienced by the IANB; reassure patient that you are going to make sure they are comfortable during the procedure
Technique PSA Nerve Block
1) 25 gauge short needle is recommended
2) Insert needle at the height of the mucobuccal fold above the maxillary 2nd molar
3) Target area is the PSA nerve which is posterior, superior and medial to the
posterior border of the maxilla
4) Apply topical anesthetic for at least one minute
5) Have patient open their mouth half way which
makes more room
6) Retract the patient’s cheek with mirror
7) Pull the tissues taut
8) Orient bevel toward bone
9) Insert needle at height of mucobuccal fold over the
2nd maxillary molar
10) Advance needle upward, inward and backward
direction
11) Odd feeling of having no resistance whatsoever
12) Penetrating to an average depth of 10-14 mm is
adequate
13) Aspirate in two planes by rotating bevel one
quarter turn
14) Deposit 0.9 ml of a cartridge (1/2 cartridge)
15) Wait 3 to 5 minutes to start treatment
Advance the needle in one movement, not three
separate movements; usually atraumatic to most patients
Problems/Failures (PSA) Hematoma formation if needle is overinserted too far
posteriorly
Pterygoid plexus of veins leads to this hematoma
Visible intraoral hematoma develops within minutes; bleeds until the pressure of the extravascular blood equals that of the intravascular blood which can result in a large, unsightly hematoma
Patients will usually claim that they do not feel any anesthesia which is not uncommon because patients can not reach this area to gauge their own level of anesthesia
If using a long dental needle the maximum
insertion should be one-half on its length or
16 mm
Problems/Failures (PSA)
Middle Superior Alveolar Nerve Block (MSA)
3) Middle Superior Alveolar Nerve Block
Middle Superior Alveolar Nerve is not present in 28% of the population
When the infraorbital nerve block fails to provide anesthesia to teeth distal to the maxillary canines, the MSA is indicated
MSA provides anesthesia to 1st and 2nd premolars and mesiobuccal root of maxillary 1st molar; anesthetizes buccal periodontium and bone
If MSA is absent the premolars and mesiobuccal root of maxillary 1st molar is innervated by the ASA
Positive aspiration risk is less than 3% (negligible)
Infraorbital nerve block can block 1st premolar, 2nd premolar and mesiobuccal root of the maxillary 1st molar if you need an alternative block when the MSA is not adequate
Technique MSA Nerve Block
1) 25 or 27 gauge long or short needle
2) Insert needle at the height of the mucobuccal fold above 2nd maxillary premolar
3) Target is the maxillary bone above the apex of the 2nd maxillary premolar
4) Orient bevel toward bone to avoid tearing periosteum
5) Apply topical anesthetic for one minute
6) Pull tissues taut
7) Penetrate tissues placing bevel of needle well above the apex of the 2nd maxillary premolar
Technique- Middle Superior Alveolar Nerve Block
8) Aspirate
9) Slowly deposit 0.9-1.2 ml of solution
10) Wait 3 to 5 minutes before starting treatment
Problems/Failures MSA
Anesthetic not deposited above the apex of the 2nd premolar
Solution deposited into the soft tissue too far from the periosteum (lip)
Hematoma may develop; Dentist should apply pressure to the area with gauze for at least sixty (60) seconds; up to 2 to 3 minutes
Anterior Superior Alveolar Nerve Block (ASA)
Highly successful extremely safe block that causes hesitation in most clinicians
Provides profound pulpal and soft tissue anesthesia from the maxillary central incisor distal to the premolars in 72% of patients
Used in place of the supraperiosteal injection
Uses less anesthetic solution than the supraperiosteal injection
Supraperiosteal 3.0 ml solutionASA 1.0 ml solution
#1 fear is damage to the patient’s eye which is unfounded
Also known as the Infraorbital Nerve Block which is inaccurate
Failed ASA is just a supraperiosteal injection over the 1st premolar
Areas Anesthetized ASA Nerve Block
1) Pulp of the maxillary central incisor through the
canine
2) 72% of patients have premolars and mesiobuccal
root of 1st molar anesthetic
3) Buccal periodontium and bone of the above teeth
4) Lower eyelid, lateral aspects of the nose and upper
lip
When Do I Use This Block?
1) Dental procedures involving more than
one tooth, i.e., central and lateral incisor
2) Inflammation/Infection precluding the use
of the supraperiosteal injection
3) Ineffective supraperiosteal injections due
to dense cortical bone
Technique ASA Nerve Block1) 25 gauge long needle is recommended
2) Insert needle at the height of the mucobuccal fold over the 1st premolar
3) Target: Infraorbital Foramen
4) Landmarks: Infraorbital Notch, Mucobuccal fold, Infraorbital Foramen
5) Apply topical anesthetic for at least one minute
6) Feel the infraorbital notch moving your finger down the notch palpating the tissues gently; the outward bulge is the lower border of the orbit which is the roof of the infraorbital foramen; continue the finger inferiorly until a depression is felt which is the infraorbital foramen
7) Maintain pressure over the foramen while inserting the needle down the long axis of the 1st premolar
8) Advance the needle slowly until bone is contacted
gently which is the upper rim of the infraorbital
foramen
9) 16 mm total advancement of needle;1/2 of long
needle length
10) Estimate the distance between the infraorbital
foramen and mucobuccal fold
11) Aspirate
12) Deposit 1.0 ml of anesthetic solution
13) Administrator can feel the anesthetic expanding
the tissue with finger tip
14) Maintain finger pressure over the foramen for
at least one minute to disperse the anesthetic
solution
15) Needle should not be palpable in most patients
16) Wait 3 to 5 minutes for anesthesia to result
Problems/Failures (ASA)
Failure is from the needle deviating to the medial or lateral away from the infraorbital foramen
Failure to reach the infraorbital foramen will result in anesthesia of the lateral side of the nose, upper lip and lower eyelid but not the teeth
Hematoma formation can result although rarely; apply pressure to area for 2 to 3 minutes; at least 60 seconds
Palatal Anesthesia
Palatal Anesthesia Easily one of the most traumatic experiences
for dentists due to the pain that is sometimes elicited from the patients
Palatal injections can be administered atraumatically
STEPS- Results in painless palatal injections
1) Apply topical for two minutes
2) Apply pressure to site both before and during deposition of the solution
3) Deposit solution slowly
5 PALATAL INJECTIONS
1) Anterior (Greater) Palatine Nerve Block: no pulpal anesthesia 2) Nasopalatine Nerve Block: no pulpal anesthesia
3) Local Infiltration: no pulpal anesthesia
4) P-AMSA: pulpal and soft tissue
5) P-ASA: pulpal and soft tissue
Greater Palatine Nerve Block
GP Nerve Block (soft tissue and bone only)
Anesthetizes palatal soft tissue distal and medially to the canine
(posterior portion of the palate)
Tissues around the Greater Palatine Foramen are able to accommodate a larger volume of solution than the tissue in the vicinity of the
Nasopalatine Foramen less patient discomfort
Indications for palatal injections:
1) Scaling and root planing
2) Subgingival restorations
3) Deep placed matrix bands
4) Extractions (oral surgery)
Technique Greater Palatine Nerve Block
1) 27 gauge short needle
2) Insert needle in soft tissue slightly anterior
to the greater palatine foramen
3) Target is the greater palatine nerve as it
passes from the foramen between the soft
tissue and bone of the hard palate
Locate the Greater Palatine Foramen:
-use cotton swab/mirror handle
-place a cotton swab at the junction of the
maxillary alveolar process and the hard palate
-press firmly into tissues moving posteriorly
from the maxillary 1st molar
-swab “falls” into the depression of the
greater palatine foramen
4) Foramen is most often located distal to the 2nd maxillary molar
5) Apply considerable pressure to cotton swab in area of foramen until a noticeable ischemia occurs; hold pressure for 30 seconds before injection
6) Continue to apply pressure throughout the injection with the cotton swab
7) Slowly advance the needle until bone is gently contacted
8) Depth of penetration is usually less than 10 mm
9) Aspirate
10) Deposit solution very slowly
Do not enter the greater palatine canal
There is no reason to have the needle penetrate the canal
There is no negative repercussion except post-operative pain
Nasopalatine Nerve Block
Nasopalatine Nerve Block (soft tissue and bone only)
Considered by many to be the most traumatic, painful injection of all the dental injections
Most important injection to follow the protocol about to be explained
Anesthetizes the anterior portion of the hard palate (soft and hard tissues) from the mesial of the left premolar to the mesial of the right premolar
Use this injection for the same reasons as Greater Palatine Nerve Block
Target area is the incisive foramen beneath the incisive papilla
Technique Nasopalatine Nerve Block
1) 27 gauge short needle is recommended
2) Insertion point: palatal mucosa just lateral to the
incisive papilla
3) Approach the injection site at a 45 degree angle
4) Apply topical anesthetic for two minutes
5) Apply considerable pressure to the incisive papilla
until ischemia
6) Continue to apply pressure to the cotton applicator
tip while injecting
7) Advance the needle until bone is gently contacted
8) Depth of needle penetration is usually 5 mm
9) Slowly deposit ¼ cartridge over a 30 second
interval
10) Wait 2-3 minutes for anesthesia
There is no reason to enter the GreaterPalatine Foramen or the Nasopalatine
Foramen when providing these injections
do not advance needle more than 5 mminto the incisive canal because it could
enter the floor of the nose causing infection
During palatal injections, the pressuregenerated within the syringe will cause
the solution to spray into your mask/face;always wear the appropriate safety
glasses and mask when giving any injectionregardless of how trivial it may seem
at the time
Technique 2nd Example of Nasopalatine InjectionInsertion Points:1) Labial frenum; midline of maxilla (0.3 ml over 15 seconds)2) Interdental papilla of #8 and #9 (0.3 ml over 15 seconds)3) Palatal soft tissues lateral to the incisal papilla (contact bone)
Important Points:• Topical and pressure anesthesia on the palate are not necessary because the first injection anesthetized the
palatal tissues• Contact bone on the 3rd injection (incisive papilla) only• Interdental papilla between maxillary central incisors is
sore for a few days• Greater palatine nerve may overlap and lead to inadequate
anesthesia of the canine and 1st premolar
Local Infiltration of the Palate
Anesthetizes the terminal branches of the Greater Palatine Nerve and Nasopalatine Nerve
Anesthetizes the soft tissue in the immediate vicinity of the injection
Indications for Palatal Anesthesia:
1) Hemostasis during procedures of a minimal area of tissue
2) Palatogingival pain control for rubber dam clamps, retraction cord placement and small
surgical procedures
Important Points: -Gate control method (inhibitory neuron prevents the projection neuron from sending signals to the brain (gate is closed)) of pain removal is used with -these injections using a cotton swab for pressure resulting in blanching tissue -Target area is the palatal tissue 5 to 10 mm from the free gingival margin -Masticatory mucosa of the hard palate is only 3 to 5 mm thick -Palatal Infiltrations are safe areas anatomically to deposit anesthetic
P-ASA
P-ASA Palatal Approach Anterior Superior Alveolar Nerve Block
• Described in the 1990s by the inventors of the CCLAD systems
• Comparative to the Nasopalatine Nerve Block• Insertion: lateral point of the incisive papilla but the big
difference:
NEEDLE TIP IS POSITIONED IN THE INCISIVE CANAL
• Deposit 1.4 – 1.8 ml of solution at 0.5 ml per minute
• Primary method of achieving bilateral pulpal anesthesia of the maxillary anterior six teeth; anterior palatal 1/3rd
• Provides profound soft tissue anesthesia of the gingiva and mucoperiosteum
• Soft tissue of the facial attached gingiva is achieved anterior to the maxillary anterior six teeth
• P-ASA is the 1st injection to produce bilateral pulpal anesthesia of the maxillary anterior six teeth from a single injection
MAIN POINT OF THIS INJECTION:
P-ASA is designed to provide pulpal anesthesia of the maxillary anterior six teeth in addition to the facial
gingival soft tissue and mucoperiosteum
it does not anesthetize the lip as with the regular mucobuccal fold approach; esthetic Dentistry can then be assessed
without dealing with lip anesthesia when smiling
• Palatal approach allows anesthesia to be limited to the subneural plexus for the maxillary anterior teeth and nasopalatine nerve
• Minimum volume for injection is 1.8 ml (full cartridge) over 0.5 ml/minute
• Insert needle very slowly
• 4% anesthetics should have volume reduced by ½ (Prilocaine/Articaine)
• Do not use 1:50,000 epinephrine
• May need supplemental mucobuccal fold injections for canines because of their very long roots
• Palatal ulcers develop from ischemia 1-2 days after treatment and are self- limiting; healing occurs in 5-10 days
Technique P-ASA
1) 27 gauge short needle is recommended2) Insert needle just lateral to the incisive papilla in the papillary groove3) Target is the nasopalatine foramen4) Needle held at 45 degree angle to the palate (same as central incisors)
5) Insert needle 6 to 10 mm; if resistance is found do not force needle6) Insert needle 1-2 mm every 4-6 seconds while administering solution7) Resistance means you have to reinsert the needle; careful of nose floor8) Aspirate9) Deposit 1.8 ml of anesthetic solution very slowly 0.5 ml/minute10) Patient may feel “needle shock” very disturbing to patient
Maxillary Nerve Block
1) Greater Palatine Approach
2) High Tuberosity Approach
Also known as a 2nd Division block
Anesthetizes the maxillary division of the trigeminal nerve
Areas Anesthetized:
1) Pulpal anesthesia of all teeth on the side of injection (ipsalateral)2) Buccal periodontium and bone on the side of injection3) Soft tissues and bone of the hard palate/soft palate medial to midline4) Skin of lower eyelid, side of the nose, cheek and upper lip
It would require 4 other injections to get the effect of the Maxillary Nerve Block i.e., PSA, Infraorbital, Greater Palatine and Nasopalatine
2 Approaches:1) Greater Palatine Approach2) High Tuberosity Approach
1) Greater Palatine Approach Technique
25 gauge long needle recommended
Insert into palatal soft tissue over greater palatine foramen
Target is the maxillary nerve as it passes through the Pterygo-palatine Fossa; the needle passes through the Greater Palatine Canal to reach the Pterygopalatine Fossa
Find the foramen by using a cotton swab until it “falls into” the foramen
Most often found at distal of the maxillary 2nd molar
Topical anesthetic for at least two minutes
Inject into the area adjacent to the Greater Palatine Foramen in order to block the nerve before probing into the actual foramen itself
1) Greater Palatine Approach Technique
Remember to apply constant pressure into this area until the
tissue blanches which will lessen the discomfort of the needle penetration
Probe gently for the foramen with the needle tip at a 45 degree angle After finding the canal advance the needle 30 mm 5 to 15% of foramens have boney obstructions, so if you encounter an obstruction do not force the needle, try again
then abort
1) Greater Palatine Approach Complications
Penetration of the orbit leading to a myriad of complications
periorbital swelling or proptosis (bulging eye)block of 6th cranial nerve producing diplopia
(double vision)Retrobulbar (behind the eye) hemorrhage,
corneal anesthesiaoptic nerve anesthesia loss of vision
Penetration of the nasal cavity (medial wall of the pterygopalatine fossa is paper thin):
-patient complains of something draining down their throat
-large amounts of air will be aspirated into the cartridge
2) High Tuberosity Approach
25 gauge long needle recommendedInsert to the height of the mucobuccal fold distal
to the 2nd molarTarget is maxillary nerve as it passes through the
pterygopalatine fossaSuperior and medial to the target site of the PSA
Again, advance the needle to a depth of 30 mmUpward, inward and backward direction same as
PSAResistance should not be felt, if it is, the
angulation is too medialAt 30 mm the needle tip should lie within the
pterygopalatine fossaAspirate several times and inject 1.8 ml (one
cartridge) slowly
2) High Tuberosity Approach Complications
Hematoma develops rapidly if the maxillary artery is punctured with the needle tip
Thin, porous substance of the maxillary bone allows for rapid diffusion of solutions into the cancellous bone
Most Dentists rely solely on the supraperiosteal injection to provide anesthesia in the maxilla
PSA and ASA combined can deliver safe anesthesia to virtually all patients requiring maxillary anesthesia
Universal:
-applying topical anesthetic for one minute
-proper patient positioning
-aspiration
-making the needle safe after each injection with the scoop technique
Chart 9-2 infiltration is not as successful as maxillary anesthesia substantial variability in the anatomy of landmarks when
compared to the maxilla pulpal anesthesia: block of each nerve’s dental branches periodontal: through the interdental and interradicular branches Inferior Alveolar block: for mandibular teeth + associated lingual
tissues and for the facial tissues anterior to the mandibular 1st molar
Buccal block: tissues buccal to the mandibular molars Mental block: facial tissues anterior to the mental foramen
(mandibular premolars and anterior teeth) Incisive block: for teeth and facial tissue anterior to the mental
foramen Gow-Gates: most of the mandibular nerve
for quadrant dentistry
also called the mandibular block most commonly used in dentistry for restorative, extraction and periodontal
work pulpal anesthesia for extractions and
restorative lingual periodonteal anesthesia facial periodonteal anesthesia of anterior
mandibular teeth and premolars may be combined with the buccal block can overlap with the incisive block local infiltrations in the anterior area are
more successful than posterior injections variability in the location of the
mandibular foramen on the ramus can lessen the success of this injection
usually avoid bi-lateral injections since they will completely anesthetize the entire tongue and can affect swallowing and speech
target: slightly superior to the mandibular foramen – figure 9-27 the medial border of the ramus
will also anesthetize the adjacent anterior lingual nerve – figure 9-30
injection site is found using hard landmarks palpate the coronoid notch – above the 3rd
molar imagine a horizontal line from the coronoid
notch to the pterygomandibular fold which covers the pterygomandibular raphe – figure 9-32
this fold becomes more prominent as the patient opens their mouth wider
refer to video notes figure 9-33
needle is inserted into the pterygomandibular space until the mandible is felt – retract about 1 mm
average depth: 20-25mm diffusion of anesthesia will affect the
lingual nerve
symptoms: harmless tingling and numbness of the lower lip due to block of the mental nerve
tingling and numbness of the body of the tongue and floor of mouth – lingual nerve involvement
complications: failure to penetrate enough can numb the tongue but not block
sufficiently lingual shock – involuntary movement as the needle passes the
lingual nerve transient facial paralysis – facial nerve involvement if inserted
into the deeper parotid gland – figure 9-34 inability to close the eye and drooping of the lips on the affected side hematoma can occur
some muscle soreness patient-inflicted trauma – lip biting etc...
figures 9-36 and 9-37 for buccal periodonteum of mandibular molars,
gingiva, periodontal ligament and alveolar bone
for restorative and periodontal work buccal nerve is readily located on the surface of
the tissue and not within bone
target: buccal nerve as it passes over the anterior border of the ramus through the buccinator – figure 9-36
injection site is the buccal tissues distal and buccal to the most distal molar – on the anterior border of the ramus as it meets the body – figure 9-37
pull the buccal tissue tight and advance the needle until you feel bone – only about 1 to 2mmfigure 9-38 patient-inflicted trauma – lip
biting etc...
figures 9-39 through 9-41
for facial periodonteum of mandibular premolars and anterior teeth on one side
for restorative work – incisive block should be considered instead
target site: mental nerve before it enters the mental foramen where it joins with the incisive nerve to form the IA nerve – figure 9-39
palpate the foramen between the apices of the 1st and 2nd premolars palpate it intraorally – find the
mucobuccal fold between the apices of the 1st and 2nd premolars – figure 9-42
in adults, the foramen faces posterosuperiorly
may be anterior or posterior can be found using radiographs
insertion site is the mucobuccal fold tissue directly over or slight anterior to the foramen site
avoid contact with the mandible with the needle
depth is 5 to 6mm no need to enter the foramen
for pulp and facial tissues of the teeth anterior to the mental foramen same as the mental block except pulpal anesthesia is
provided also restorative and periodontal work IA block indicated for extractions – no lingual
anesthesia with an incisive block target: mental foramen – figure 9-43
injection site: figure 9-44 same as for the mental block directly over or anterior to the
mental foramen in the mucobuccal fold at the
apices of the 1st and 2nd premolars pull the buccal tissues laterally more anesthesia is used for this
block when compared to the mental block
pressure is applied during the injection – forces for anesthetic solution into the foramen and block the deeper incisive nerve
the increased injection solution may balloon the facial tissues
figures 9-45 through 9-50
blocks the IA, mental, incisive, lingual, mylohyoid, auriculotemporal and buccal nerves – figure 9-28 and 9-45
used for quadrant dentistry
buccal and lingual soft tissue from most distal molar to the midline
greater success than an IA block
target site: anteromedial border of the mandibular condylar neck – figure 9-46
just inferior to the insertion of the lateral pterygoid muscle
injection site is intraoral locate the intertragic notch and labial
commisure extraorally draw a line from the tragus/intertragic
notch to the labial commisure – figure 9-47
place your thumb on the condyle (just in front of the tragus when the mouth is open)
pull buccal tissue away place the needle inferior to the
mesiolingual cusp of the MAXILLARY 2nd molar
the needle penetrates distal to the maxillary 2nd molar
see the video
MAXILLARY :1) Supraperiosteal2) PDL3) Intraseptal Injection4) Intracrestal Injection5) Intraosseous Injection6) PSA Nerve Block7) MSA Nerve Block8) ASA Nerve Block9) Maxillary Nerve Block10) Greater Palatine Nerve Block11) Nasopalatine Nerve Block12) AMSA Nerve Block 13) P-ASA Nerve Block
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Greater palatine nerve block
Nasopalatine nerve block
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MANDIBULAR INJECTION TECHNIQUES:
1) IANB Nerve block
2) Buccal Nerve Block
3) Mandibular nerve block techniques:- Gow Gates technique- Vazirani Akinosi closed mouth
mandibular block
4) Mental Nerve block
5) Incisive nerve block
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INCISIVE NERVE BLOCK
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surface anesthesia for intact skin.
DentiPatch (lidocaine transoral delivery system) Preinjection – 10-15 minutes exposure prior to injection - Root scaling/planing – apply 5-10 minutes prior to beginning procedure.
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PRESSURE SYRINGE : Used in IL injection techniques,
especially in mandibular teeth (types: pistol-grip, pen-grip).
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