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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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