1. ByForam kamaniMonali joshi

2. Transmission in nerve fibers of the second division that innervate theoral cavity may be interrupted by the following approaches:1. Intraoral techniquesA. Local infiltration of nerve endingsB. Block of the terminal branchesC. Anterior & middle superior alveolar nerve blockD. Posterior superior alveolar nerve blockE. Nasopalatine nerve blockF. Anterior palatine nerve blockG. maxillary nerve block2. Extraoral techniquesA. anterior & middle superior alveolar nerve blockB. maxillary nerve block 3. 1. Intraoral techniqueA. Local infiltration of nerve endings1) AREAS ANESTHETIZED: only that area into whichthe local anesthetic solution is infiltrated2) NERVES ANESTHETIZED: terminal branches or freenerve endings3) ANATOMICAL LANDMARKS: no landmark4) INDICATION: local infiltration techniques areindicated when only mucous membrane &underlying connective tissues are to be anesthetized.This method can be use for incision in the mucousmembrane or before insertions of other needles. 4. 5. TECHNIQUE: in the oral cavity a 1-inch, 25-gauge needle isinserted beneath the mucous membrane into theconnective tissue in the area to be anesthetized, and theanesthetic solution is infiltrate slowly throughout the area.Care should be exercised to the solution is not injected toorapidly or in too large volume. To do so many cause injuryto the tissue resulting in postinjection pain & in more severcases, 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 theinjection area, this method is referred to as localinfiltration. 5. B. Block of the terminal branchs1) NERVES ANESTHETIZED: large terminal branches2) AREAS ANESTHETIZED: all of the area innervated by thelarger terminal branches affected3) ANATOMICAL LANDMARK: there will depend on theareas to be anethetized4) INDICATION: this technique is indicated for producinganalgesia of one or two maxillary teeth or of a limitedarea of the maxilla. It is most commonly confinedbecause the maxillas prosity lends itself to this method.Blocking the larger terminal branches in the mandible isusually difficult because of its denseness. 6. 5) TECHNIQUESa. Paraperiosteal technique: the paraperiostealtechnique is most commonly used for anesthetizingthe larger terminal branches within the oral cavity.As previously stated, the term paraperiosteal is usedin preference to the term supraperiosteal because thesolution is deposited alongside & not above theperiosteam. The paraperiosteal injection is indicated & morewidely used in the porous maxilla than in the densemandible. 7. It should be kept in mind that there is a variation in thethickness of the body plate covering the root of themaxillary teeth. the bony plate covering the roots of thedeciduous maxillary teeth. A 1-inch, 25-guage needle is inserted through the mucousmembrane & underlying connective tissue until it gentelycomes in contact with the periosteum. The solution shouldbe deposited slowly. When one or two teeth are to be anesthetized, the needle isinserted into the mucobuccal & buccolabial fold so that itmakes contact with the periosteum opposite & just abovethe apex of the root of the tooth. 8. b. intraosseous technique: a second technique forblocking the large terminal branches in theinterosseus method. Interosseus means, as a term implies, injecting directlyin to the bone. This is not only a painful but also adangerous procedure because of the possibility ofneedle breakage. This technique is indicated primarily for the maxillaryincisors, cuspids & bicuspids & should be used whenthe anterior & middle superior alveolar nerve block orparapariosteal method is ineffective. 9. An opening of the interosseous structure should thenbe made, with a suitable bone burr or interseptal drill. A 1-inch, 23gauge needle is inserted through thetissue incision & into the previously made opening inthe bone. The solution is deposite in this area. This technique may at times be used in the mandiblewith varying degrees of success. Its effectiveness willdepend largely on the age of patient & porosity ofmandible. 10. c. Interseptal technique. It is most effective in children &young adults. A 23- or 25-gauge needle is pressedgently into the thin porous interseptal bone on eitherside of the tooth to be anesthetized. The anesthetic solution is then forced under pressureinto the cancellous bone. It is important that the superficial mucous membranebe anesthetized before a large-gauge needle is insertedinto the bone. 11. d. Intraligamentary technique. recently a technique has beendescribed for effectively anesthetizing single teeth byinjecting the local anesthetic into the periodontalligament. Special syringes have been developed & the needle isintroduced through the gingival sulcus & into theperiodontal ligament. High pressure cause the solution to be forced, rather thandifused, through the ligament to the nerves in the area. It is advised that single-rooted teeth be injected on themesial & distal sides or buccal & lingual sides & thatmultirooted teeth be injected over each root. 12. e. Intrapulpal technique. For those procedures that involvedirect instrumentation of pulp, anesthesia may be achivedwith this injection technique. A 25-gauge needle may be introduced directly into theoperative site. Ideally the needle should be wedged firmly into the pulpchamber or root canal. it is best achived by combination ofthe pharmacological action of the anesthetic solution & thepressure used to apply it. The needle is always visible & is only being inserted intothe pulp of the tooth, breakage is not likely to occur. 13. C. Block of anterior & middle superior alevolar nerves1) NERVES ANESTHETIZED: infraorbital, anterior, &middle superior alveolar nerves, inferior palpebral, lateralnasal, & 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, lowereyelid, & a portion of the nose on the same side.3) ANATOMICAL LANDMARKS: infraorbital ridge,infraorbital depression, supraorbital notch, infraorbitalnotch, anterior teeth & pupils of eyes. 14. 4) INDICATIONS: when the anterior & middle superioralveolar nerves are to be blocked Any procedures,surgical or operative, may be performed on the fiveanterior maxillary teeth on the same side of themedian line.5) TECHNIQUE: the patient is placed comfortably in thechair & tilted so that the maxillary occlusal plane is ata 45- degree angle to the floor. an imaginary straightline drawn will pass through the pupils of the eyes, theinfraorbital foramen, the bicuspid teeth, the mentalforamen. 15. For an infraorbital block of the right side the dentist standson the right side of the chair partially facing the patient.the thumb of the operator's left hand is placed over thepreviously located infraorbital foramen,& the index fingeris used to retract the lip, exposing the mucolabial fold. 25-gauge needle is taken inserted into the mucolabial foldfrom either one or two directions. In using the firstdirection, the dentist inserts the needle in a line parallelwith the supraorbital notch, the pupil of the eye,infraorbital notch, & the second bicuspid tooth, if it is inplace. 16. The needle should be inserted a sufficient distance fromthe labial plate to pass over the canine fossa. The second direction of insertion bisects the crown of thecentral incisor from the mesioincisal angle to thedistogingival angle. The needle is again inserted about5mm from the mucobuccal fold & guided into position bythe thumb marking the location of the infraorbitalforamen. the anterior & middle superior alveolar nerves are blockedon the left side with exactly the same technique as thatused on the right side,with the exception that the operatorstands slightly more to the front of the patient. 17. D. Posterior superior alveolar nerve block1) NERVES ANESTHETIZED: posterior superioralveolar nerve2) AREAS ANESTHETIZED: the maxillary molars, withthe exception of the mesiobuccal root of the firstmolar; the buccal alveolar process of the maxillarymolars, including the overling structure-periosteum,connective tissue, & mucous membrane. 18. 3) ANATOMIACL LANDMARKS:a. mucobuccal fold & its concavityb. zygomatic process of maxillac. infratemporal surface of the maxillad. anterior border & coronoid process of the ramus ofthe mandiblee. tuberosity of the maxilla4) INDICATIONS: for oprative procedures of the molar teeth& suporting structures. This injection must be combinewith palatal injection for extractions or wheninstrumentation extends into this area. 19. 5) TECHNIQUE FOR RIGHT SIDE: the area of insertionshould be dried & painted with a suitable antisepticsolution. A previously loaded syringe, with a 1 5/8inch, 25-gauge needle, is held in a pen grasp & insertedinto the tissue in a line parallel with the index finger &bisecting the fingernail. The insertion is made for adistance of about to inch, going upward, inward,& backward. This should place the needle point in theimmediate vicinity of the foramina through which thenerves enter the maxilla. 20. 6) TECHNIQUE FOR LEFT SIDE: for injection on theleft side the operator stands on the right side of thepatient, & the left arm is passed around the patientshead so that the area may be palpated with the leftforefinger. The technique for injection after palpationis the same as that for the right side. 21. E. Nasopalatine nerve block (incisive canal injection)1) NERVES ANESTHETIZED: nasopalatine nerve as itemerges from the anterior palatine foramen2) AREAS ANESTHETIZED: the anterior portion of the hardpalate & overling structures back to the bicuspid area,where branches of the anterior palatine nerve coursingforward create a dual innervation.3) ANATOMICAL LANDMARKS:a. central incisorb. incisive papilla in the midline of the palate. 22. 4) INDICATION: for palatal anesthesia.a. to supplement the block of the anterior & middlesuperior alveolar nerves.b. to augment analgesia of six maxillary incisors.c. to complet anasthesia of the nasal septum.5) TECHNIQUE: the nasopalatine nerve block isextremely painful injection unless a preparatoryinjection is made. The preparatory injection is madeby a inserting a 1 inch, 25-gauge needle into the labialinterseptal tissue between the maxillary centralincisors. 23. This needle is inserted at a right angle to the labialplate & pass into the tissue until the resistance is met;then 0.25 ml of anesthetic solution is deposited. Theneedle is slowly into the crest of the papilla, makingcertain that it is in line with the labial alveolar plate.The needle is then advanced slowly into the incisiveforamen, about 0.5 cm into the canal. About 0.25 to 0.5ml should be injected very slowly to prevent distentionof the surrounding tissues. 24. F. Anterior palatine nerve block1) NERVES ANESTHETIZED: anterior palatine nerve as itleaves the greater palatine foramen.2) AREAS ANESTHETIZED: posterior portion of the hardpalate & overlying structure up to the first bicuspid areaon the side injected. At the first bicuspid area, branchesof the nasopalatine nerve will b met.3) ANATOMICAL LANDMARKS:a. second & third maxillary molarsb. palatal gingival margin of second & third maxillarymolars.c. midline of the palate 25. d. a line approximately 1 cm from the palatal gingival margintoward the midline of the palate4) INDICATIONS:a. for palatal anesthesia to be used in conjunction with theposterior superior alveolar block or middle superioralveolar nerve block.b. for surgery of the posterior portion of hard palate.5) TECHNIQUE:the anterior palatine nerve emerges onto thepalate through the greater palatine nerve foramen. It issituated between the second & third maxillary molars. The needle should be inserted very slowly until the palatalbone is contacted. 26. The anesthetic solution, 0.25 to 0.5 ml, is injected veryslowly. It will be advantageous to insert the needle &deposit the solution so that the anterior palatine nervewill be anesthetized anteriorly to the foramen. Anesthesia of the mucoperiosteum of the palate willbe obtained forward from the area of injection. 27. G. Maxillary nerve block1) NERVES ANESTHETIZED: entire maxillary nerve &all its subdivisions peripheral to the site of theinjection.2) AREAS ANETHETIZED:a. maxillary teeth on the affected side.b. alveolar bone & overlying structures.c. hard palate & portion of soft palated. upper lip, cheek, side of nose, & lower eyelid 28. 3) ANATOMICAL LANDMARKS: the landmarks willdiffer according to the technique.a. high tuberosity technique. Same landmarks as forthe posterior superior alveolar nerve block.b. greater palatine canal technique. Same landmarks asfor the locating the greater palatine foramen to blockthe anterior palatine nerve.4) INDICATION:a. when anesthesia of the entire distribution of themaxillary nerve is required for extensive surgery. 29. b. when local infection or other conditions make blocks ofthe main terminal branches unfeasible.c. for diagnostic or therapeutic purposes such as tics orneuralgias of the maxillary division of the fifth nerve.5) TECHNIQUES:a. High tuberosity technique. The high tuberosity is exactlythe same as that described for the posterior superioralveolar nerve, with the exception that a 1 5/8-inch, 25-gauge needle is inserted in an upward, inward, & backwarddirection to a previously marked depth of 1 1/4-inches. Twoto 4 ml of solution are taken slowly injected. 30. b. Greater palatine canal technique. Both the left & rightgreater palatine canals can b entered with the operatorstanding in front of & to the right side of the patient. In performing the maxillary block by the greaterpalatine canal approach, the operator must insert theneedle in the canal very slowly & against no resistance. Both of these methods of blocking the entire maxillarynerve by the intraoral approach could be considered asbeing technically difficult. They should be attemptedonly when definitely indicted. 31. 2. EXTRAORAL TECHNIQUESA. Anterior & middle superior alveolar nerve block1) NERVES ANESTHETIZED:a. infraorbital nervesb. inferior palpebral, lateral nasal, & superior labial nervesc. anterior & middle superior alveolar nervesd. sometimes posterior superior alveolar nerve2) AREAS ANETHETIZED:a. incisors & bicuspids on the side injectedb. labial alveolar plate & overlying tissuesc. upper lip, portions of side of nose, & lower eyelidd. sometimes maxillary molars & their buccal supportingstructures 32. 3) ANATOMICAL LANDMARKS:a. pupil of eyeb. infraorbital ridgec. infraorbital notchd. infraorbital depression4) INDICATIONS:a. when the anterior & middle superior alveolar nerves areto be anesthetized & the intraoral approach is not possiblebecause of infection, trauma, or other reasons.b. when attempts to secure anesthesia by the intraoralmethods have been ineffective. 33. 5) TECHNIQUES:a. Using the available landmarks, the dentist shouldlocate & mark the position of the infraorbitalforamen. The skin & subcutaneous tissues should beanesthetized by local infiltration.b. A 1 1/2-inch, 25-gauge needle attached to anaspirating syringe is inserted through the marked &anesthetized area. Directing the needle slightlyupward & laterally facilitates its entrance into theforamen, which opens downward & medially. 34. c. With a slight, gently probing motion the foramen islocated & entered to a depth not to exceed 1/8 inch .After careful aspiration, 1 ml of anesthetic solution isslowly injected. 35. B. Maxillary nerve block1) NERVES ANESTHETIZED:maxillary nerve & all itssubdivisions peripheral to the site of injection.2) AREAS ANESTHETIZED:a. anterior temporal & zygomatic regionsb. lower eyelidc. side of nosed, anterior cheeke. upper lipf. maxillary teethg. tonsil 36. h. maxillary alveolar bone & overlying structuresi. hard & soft palatej. part of the pharynxk. nasal septum & floor of the nosel. posterior lateral mucosa & turbinate bones3) ANATOMICAL LANDMARKS:a. midpoint of the zygomatic archb. zygomatic notchc. coronoid process of ramus of mandible located byopening & closing the jawd. lateral pterygoid plate 37. 4) INDICATIONS:a. when anesthesia of the entire distribution of themaxillary nerve is required for extensive surgery.b. when it is desirable to block all the subdivisions of themaxillary nerve with only one needle insertion & aminimum of anesthetic solution.c. when local infection, trauma, or other conditions makeblocks of the more terminal branches difficult orimpossible.d. for diagnostic or therapeutic purposes, such as tics orneuralgias of the maxillary division of the fifth nerve. 38. 5) TECHNIQUE:a. The midpoint of the zygomatic process is located & thedepression in its inferior surface is marked. With a 25-gauge hypodermic needle, a skin wheal is raised justbelow this mark in the depression, which the dentistindentifies by having the patient open & close the jaw.b. The needle is inserted through the skin wheal,perpendicular to the median sagittal plane until theneedle point gently contacts the lateral pterygoid plate.The needle should never be inserted beyond the depth ofthe marker. The needle is withdrawn, with only the pointleft in the tissue, & redirected in a slight forward &upward direction until the needle is inserted to the depthof the marker. 39. The needle is withdrawn, with only the point left inthe tissue, & redirected in a slight forward & upwarddirection until the needle is inserted to the depth ofthe marker. After careful aspiration, 2 or 3 ml of a suitableanesthetic solution is slowly injected. Care should beexercised to aspirate after each o.5 ml of the solution isinjected.