Maxillary injection techniques

LECTURE 5

MAXILLARY INJECTION TECHNIQUES

Boundary- Lateral edge of eye

Boundary Lateral edge of mouth
TRIGEMINAL NERVE – SENSORY INNERVATION TO SKIN OF HEAD – 3 DIVISIONS V1 – OPHTHALMICDIVISIONV2 – MAXILLARYDIVISONV3 – MANDIBULARDIVISION

V2 - MAXILLARY - Foramen rotundum – V3 - MANDIBULAR - - Foramen ovale – TRIGEMINAL NERVE - V
V1
V2
V3

Pterygomaxillary Fissure

V2 - Maxillary enters Pterygopalatine Fossa
V2 - MAXILLARY -
note: Pterygomaxillary fissure is slit between lateral pterygoid plate and maxillary bone; Pterygopalatine fossa is space medial to slit
MAXILLARY BONE
LATERAL PTERYGOID PLATE
NOSE



1. Meningeal Branch Dura of Middle Cranial Fossa (not shown) 2. Ganglionic branches a) Greater Palatine N. Hard Palate b) Lesser Palatine N. Soft Palate c) Nasopalatine Nasal Cavity Ant. part of hard Palate d) Nasal Branches Nasal Cavity
V2
Nasal Branches
Naso- Palatine
Greater Palatine
Lesser Palatine
V2 - MAXILLARY -
Note: V2 branches from Pterygopalatine Fossa to Nasal Cavity are deep and can only be seen on bisected head

Post. Sup Alveolar For.

Pterygomaxillary Fissure
Inferior Orbital Fissure
V2 - MAXILLARY -

Zygomatic

Infraorbital
3. Posterior Superior Alveolar Maxillary molar teeth 4. Infraorbital Lower eyelid, nose, upper lip a) Ant. & Mid Sup Alveolar Other Maxillary teeth 5. Zygomatic - br. a) Zygomaticofacial b) Zygomaticotemporal Skin of check, temporal region
Post Sup. Alveolar
V2 - MAXILLARY -
Nose
V2



TRIGEMINAL – SENSORY BRANCHES TO FACE V1 – OPHTHALMIC -to skin above orbit -LacrimalSupraorbitalSupratrochlearInfratrochlearExternal Nasal Nerve V2 – MAXILLARY -to skin of cheek below orbit -a. Zygomatico- temporal b. Zygomaticofacialc. Infraorbital V3- MANDIBULAR - to skin of jaw and face below angle of mouth - Auriculotemporal Buccal Mental
NOTE: These are branches of V to face - Full list of all branches of V is on CD: Reference_handout_list_of_Trigeminal_nerve_branches_2010.doc
INFRAORBITAL N.
ZYGOMATICOTEMPORAL N.
ZYGOMATICOFACIAL N.

Maxillary anesthesia is more successful than mandibular anesthesia. This success may reach 90-95%.The reason behind this is related to two facts: 1- Maxillary cortical plate of bone is thin and more porous. 2- Easy access to main nerve branches.

FOR CONSERVATIVE DENTAL TREATMENTFOR SURGICAL DENTAL TREATMENT

Outer and Inner nerve loop anesthesia
Outer nerve loop anesthesia

MAXILLARY INJECTION TECHNIQUES

Supraperiosteal injection (infiltration). Infraorbital nerve block (A.S.A.nerve block). Posterior superior alveolar nerve block. Palatal local infiltration Nasopalatine nerve block. Greater palatine nerve block.

SUPRAPERIOSTEAL INJECTION (INFILTRATION TECHNIQUE)

This technique is the most commonly used in maxillary nerve anesthesia. Nerves anesthetized are the large terminal branches. For anesthesia of one or two teeth. Contraindicated at the sites of acute infection. Not suitable for large areas of anesthesia as multiple injections and a larger volume is required.

POSITION OF DENTIST

AREA OF NEEDLE INSERTION IS THE HEIGHT OF MUCOBUCCAL FOLD ABOVE THE APEX OF THE TOOTH TO BE ANESTHETIZED AT THE GREATEST CONCAVITY OF THE MUCOLABIAL OR BUCCAL FOLD ON REFLECTION.


DEPTH OF NEEDLE INSERTION IS 3-4MM.THE TARGET AREA IS THE APICAL REGION OF THE TOOTH TO BE ANESTHETIZED. IF NEEDLE CONTACTS BONE, SLIGHTLY WITHDRAW AND SLOWLY GIVE SOLUTION (0.5-1.5ML). THE NEEDLE IS DIRECTED PARALLEL TO LONG AXIS OF TOOTH AND TOWARDS THE APICAL REGION.

VOLUME OF SOLUTION DEPENDS ON

Tooth to be operated on (anterior teeth require less) Type of dental procedure (conservative less than surgery) Patients age and size.

IMPORTANT NOTES

For anesthesia of the 1, needle insertion should be closer to the lateral incisor to avoid the sensitive ANS. For anesthesia of buccal aspect of 6 , two injections are required one mesial and the other distal to this tooth.?? For anesthesia of 8 , the injection should not be given posterior to the 7 to avoid possible injury to the PVp or PSA artery.
For palatal anesthesia the injection should not be made distal to the 7 to avoid possible anesthesia of lesser palatine nerve. For palatal anesthesia of anterior teeth avoid injection in the sensitive rogue area.


Local infiltration is contraindicated in areas of acute infection: Spread of infection. High vascularity in the area will wash the effect of anesthetic solution. Failure of dissociation.


SLOWLY INSERT THE NEEDLE AS PARALLEL TO THE LONG AXIS OF TOOTH TO BE ANESTHETIZED AS POSSIBLE (FOR INFILTRATION AND SOME BLOCK TECHNIQUES) AND AT 90*TO THE MUCOUS MEMBRANE. THE BEVEL OF NEEDLE SHOULD FACE THE BONE. THIS IS APPLICABLE IN THE MAXILLARY ANTERIOR TEETH ,PREMOLAR REGION AND LOWER ANTERIOR TEETH.



ADJUST YOUR SELF CORRECTLY AND USE FINGER RESTS FOR GOOD STABILIZATION DURING THE INJECTION


SLOWLY INSERT NEEDLE TO INTENDED POSITION. TRY AVOID TOUCHING BONE. FOR INFILTRATION ITS ONLY 3-4MM.


AFTER REACHING THE TARGET AREA GENTLY ASPIRATE ,IF POSITIVE REPOSITION NEEDLE AND IF NEGATIVE SLOWLY INJECT SOLUTION .THIS IS MANDATORY IN BLOCK TECHNIQUES.


FOR ANTERIOR AND PREMOLAR TEETH THE NEEDLE IS PARALLEL WITH THE LONG AXIS OF TOOTH AND SLIGHTLY INWARDS TOWARDS THE BONE.

THE INFRAORBITAL NERVE BLOCK(ANTERIOR AND MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK)

NERVES ANESTHETIZED
Anterior superior alveolar nerve Middle superior alveolar nerve Infraorbital nerve Inferior palpebral Lateral nasal Superior labial

AREAS ANESTHETIZED

Pulps of maxillary anterior teeth, premolars and sometimes the MB root of the upper first molar. Labial and buccal peridontium and bone of these teeth. Lower eyelid, lateral aspect of the nose and upper lip

Areas anesthetized

Indications Extensive dental procedures (surgical) on maxillary anterior or premolar teeth and there overlying labial and buccal hard and soft tissues. Infection which contraindicates the Supraperiosteal injection. When the infiltration technique proves to be ineffective because of dense cortical bone.
Contraindications small treatment areas When haemostasis of localized areas is required.

ADVANTAGES

Simple and highly effective technique Safe , minimizes the volume of solution required (0.9-1.2ml) and reduces the number of needle punctures required to achieve anesthesia.
Disadvantages: Psychological Anatomical difficulties

Infraorbital foramen below the infraorbital notch

Target area

ANATOMICAL LANDMARKS

Infraorbital foramen
Infraorbital notch
Infraorbital ridge
Needle direction

ANATOMICAL LANDMARKS

Infraorbital notch
Infraorbital foramen area
Infraorbital ridge
Pupil of eye

PALPATION TO CONFIRM LOCATION OF INFRAORBITAL FORAMEN

THE LOCATION OF INFRAORBITAL FORAMEN IS CONFIRMED


WITH THE FINGER PLACED OVER THE FORAMEN EXTRAORALY THE LIP IS RETRACTED WITH THE THUMB TO VIEW THE MUCOBUCCAL FOLD AND KEEP THE TISSUES TAUT (USE A STERILE PIECE OF GAUZE).


Area of needle insertion is the height of the mucobuccal fold directly over the upper first and second premolar

Variation in depth of needle insertion

High mucobuccal fold
Shallow mucobuccal fold



The dental needle is inserted parallel with the long axis of the upper first premolar with the bevel facing towards the bone and directed towards the infraorbital foramen


Advance the needle slowly until bone is gently contacted (upper rim of infraorbital foramen). The approximate depth of needle insertion is about 16mm.
Roof
16 mm


After reaching the target area aspirate and if negative slowly deposit 0.9-1.2ml of solution. Little or no swelling should be visible as the solution is deposited. Maintain firm pressure with your finger over the injection site both during and for at least 1 minute after the injection


THE MAJOR FACTOR THAT INHIBITS THE DENTIST FROM USING THIS TECHNIQUE IS FEAR OF INJURY TO THE PATIENTS EYE.

NERVE ANESTHETIZED

Posterior superior alveolar nerve
Areas anesthetized
Pulps of the maxillary third, second and first molar (except the MB root in about 28% of subjects). Buccal peridontium overlying these teeth.
Posterior superior alveolar nerve block technique

INDICATIONS

When treatment involves two or more maxillary molars. Supraperiosteal injection is contraindicated. Supraperiosteal injection is ineffective.

CONTRAINDICATIONS

Risk of hemorrhage is too high. Inexperienced operator.

ADVANTAGES

Atraumatic (soft tissue available and no bone contact). High success rate. Minimum number of injections. Less volume of solution required.

DISADVANTAGES

Risk of hematoma. Technique is a blind one. Second injection sometimes required for the upper first molar.

AREA OF NEEDLE INSERTION

The height of mucobuccal fold above the maxillary second molar.
Target area
Posterior , superior and medial to posterior border of the maxilla.



Partially open the patients mouth. Move the mandible to the side of injection. Retract the cheek for good access.


The goal is to deposit the solution close to the PSAN located posteriosuperior and medial to the maxillary tuberosity.

Insert needle into height of mucobuccal fold above second molar Advance needle slowly in an upward , inward and backward direction in one movement.
Aspirate and if negative slowly deposit 0.9-1.8ml of solution


Upward superiorly at a 45-degree angle to the occlusal plane.Inward medially towards the midline at a 45 –degree angle to the occlusal plane.Backwards posteriorly at a 45 – degree angle to the long axis of the upper second molar.

Occlusal plane

Long axis of tooth


Advance needle slowly through soft tissue. No resistance is noticed and so no discomfort to the patient. Depth of needle penetration is usually 16mm.In small adults and children the depth is usually 10-14mm.
Long needle

Area anesthetized

Palatal infiltration Nasopalatine nerve block Greater palatine nerve block

PALATAL ANESTHESIA

PALATAL ANESTHESIA

Manipulation of palatal soft and hard tissue.Most painful injectionAlways use the term “discomfort” and not “pain” when talking to the patient.

STEPS FOR PAINLESS PALATAL ANESTHESIA.

Topical anesthesia (At least two minutes). Use pressure anesthesia at the site before and during needle insertion and deposition of solution (use a cotton applicator stick to produce ischemia). Maintain control over the needle (secure a firm hand rest). Deposit solution slowly.

LOCAL INFILTRATION

Terminal branches of the Nasopalatine and greater palatine nerves. Area anesthetized is the soft tissues in the immediate vicinity of injection. Mainly for hemostasis

PATHWAY OF NEEDLE INSERTION IS TO APPROACH THE INJECTION SITE AT 45 DEGREE ANGLE WITH BEVEL TOWARDS SOFT TISSUE.
Area of needle insertion and target point is the attached gingiva 5-10mm from the free gingival margin in the estimated center of the treatment area.


APPLY TOPICAL ANESTHETIC FOR TWO MINUTES. AFTER THAT THE SWAB IS PLACED ON THE TISSUE ADJACENT TO THE INJECTION SITE TO APPLY PRESSURE UNTIL ISCHEMIA IS OBSERVED.



PERMIT THE NEEDLE TO PENETRATE MUCOSA AND AT THE SAME TIME CONTINUE TO APPLY PRESSURE THROUGHOUT THE INJECTION.


ADVANCE THE NEEDLE AND DEPOSIT ANESTHETIC SOLUTION UNTIL BONE IS GENTLY CONTACTED. TISSUE THICKNESS IS ONLY 3-5MM.

IN USUAL PRACTICE ONLY 0.2-0.3ML IS ADEQUATE.

COMPLICATIONS
Necrosis of soft tissues is observed if a highly concentrated v.c such as noradrenalin is used or if large volume injected

NASOPALATINE NERVE BLOCK(SPHENOPALATINE NERVE BLOCK)

For anterior region of palate from upper canine to the incisive papilla region in both site in single injection Reducing pain is important: Avoiding papilla itself Slow rate Topical anesthesia

NASOPALATINE NERVE BLOCK

GREATER PALATINE NERVE BLOCK
For palatal anesthesia posteriorly to upper canine Indicated if palatal infiltration contraindicated Point of injection anteriorly to foramina?