Maxillary anesthesia: its technique

MAXILLARY ANESTHESIA

Seminar on -

Presented by –Hemam Shankar Singh

A branch of trigeminal nervePurely sensoryCourse foramen rotundum pterygopalatine fossa

inferior orbital fissure infraorbital foramenPart of the maxillary nerve distal to the inferior orbital fissure is called

infraorbital nerve

Maxillary nerve:

A. Branch in middle cranial fossa:

before entering foramen rotundum gives off meningeal branch to dura materof the middle cranial fossa

B. Branhes arising in pterygopalatine fossa:i. Greater palatine n.:- emerges through the

greater palatine foramen & then runs forward on the inferior surface of hard palate supplying mucous membrane & glands

ii. Lesser palatine n.:- emerge through lesser palatine foramen, & runs backwards into the soft palate, supply tonsil

iii. Nasopalatine n.:- runs downward & forward on the nasal septum, pass through incisive foramen, supply ant. Part of hard palate

Branches

iv. Posterior superior alveolar(PSA) n.:- runs down on the posterior surface of the maxilla it lie in the wall of maxillary sinus where it supplies. It supply sensory innervation to—

-buccal gingiva in maxillary molar region-mucous membrane of the sinus-alveoli, PDL, & pulpal tissue of the maxillary 3rd, 2nd & 1st

molar with exception (in 28%of patients) of mesiobuccal root of the 1st molar

C. Branch in infraorbital groove & canalv. Middle superior alveolar (MSA) n.:- arise within the canal, provide

sensory innervation to two maxillary premolars & mesiobuccal root of maxillary 1st molar (28%), periodontal tissues, buccal soft tissue, & bone of the premolar region

vi. Anterior superior alveolar (ASA) n.:- arise from infraorbital n. provide pulpal innervation to C.I. & L.I., & canine, to periodontal tissue, buccal bone, & mucous membrane of these teeth

Contd.

1. Local Infiltration

2. Field Block

3. Nerve Block

Techniques of Maxillary Anesthesia

I. Supraperiosteal (infiltration)

II. Periodontal ligament (PDL, intraligamentary)

III. Intraseptal injection

IV. Posterior superior alveolar nerve block

V. Middle superior alveolar nerve block

VI. Anterior superior alveolar nerve block

VII. Greater (anterior) palatine nerve block

VIII. Nasopalatine nerve block

IX. Maxillary (second division) nerve block

X. Anterior meddle superior alveolar nerve block

XI. Palatal approach-anterior superior alveolar n block

Maxillary Injection Techniques

Nerves anesthetized– terminal branch of dental plexus

Areas anesthetizedEntire region innervated by the large terminal branches of this

plexus

Indications1. Pulpal anesthesia of maxillary teeth when treatment is limited

to 1 or 2 teeth2. Soft tissue anesthesia when indicated for surgical procedure

Contraindications3. Infection or acute inflammation4. Dense bone covering the apices of teeth

Supraperiosteal Injection

Advantages1. High success rate (>95%)2. Easy & usually entirely atraumatic

DisadvantagesNot recommended for larger areas because of multiple injection

Alternatives– PDL, IO, regional block

Anatomical landmark:Mucobuccal foldCrown of the toothRoot contour of the tooth


Technique1. Lift the lip, pulling the tissue taut2. Hold the syringe parallel to the long axis of the tooth3. Insert the needle at the height of the mucobuccal fold over

the target tooth4. Advance the needle until its bevel is at or above the apical

region of the tooth5. Aspirate, if –ve , deposit 0.6 ml slowly over 20 seconds

Sighs & symptoms6. Subjective: feeling of numbness in the area of administration7. Objective: no pain during therapy


Safety features1. Minimal risk of intravascular administration2. Slowness of injection, aspiration

Precautionsshould not be used for larger areas

Complicationspain on needle insertion with the tip against periosteum


Fig: PSA nerve

Nerves Anesthetized- Posterior superior alveolar and its branches

Areas Anesthetized-1) Pulps of the maxillary 3rd , 2nd and 1st

molars 2) Buccal periodontium and bone overlying

these teeth

Anatomical Landmarks-1. Mucobuccal fold and its concavity2. Zygomatic process of the maxilla3. Infratemporal surface of the maxilla4. Anterior border and coronoid process of the

ramus of the mandible5. Maxillary tuberosity

Posterior superior alveolar(PSA) nerve block

Indications –1. When treatment involves two or more maxillary molars2. When supraperiosteal injection is contraindicated (e.g. with

infection or acute inflammation)3. When supraperiosteal injection has proved ineffective

Contraindications-When the risk of hematoma is too high ( as in hemophilic), in which case a supraperiosteal or PDL is recommended.

Advantages-4. Atraumatic 5. High success rate6. Less number of injections 7. Minimize amount of local used


Disadvantages-1. Risk of hematoma2. Does not anesthetize first molar completely3. No bony landmarks during insertion4. Second injection necessary for 1st maxillary molar in 28% of

patients

Positive Aspiration-Approximately 3.1%


Needle pathway during insertion-Needle penetrates the mucosa, alveolar tissue, and possibly the buccal pad of fat. It penetrates the posterior fiber of buccinator muscle.

Approximating structures when needle is in position-when needle is in final position, it should be as follow:1. Posterior to the posterior surface of the maxilla2. Anterior and lateral to the anterior margin of the external

pterygoid muscle3. Anterior to the pterygoid plexus of veinsNeedle will be in proximity to the posterior superior alveolar

canal


Technique For Right Side-a) Operator stands on the right side of the patientb) Patient is positioned so that maxillary occlusal plane is at 45º angle to

the floorc) Move the left forefinger over the mucobuccal fold in a posterior

direction from bicuspid area until the zygomatic process of the maxilla is reached.

d) at its posterior surface fingertip will rest in a concavity in the mucobuccal fold

e) Rotate the finger so that the fingernail is adjacent to the mucosa and its bulbous portion is still in contact with the posterior surface of the zygomatic process.

f) Hand is lowered so that the finger is in a plane right angle to the maxillary occlusal surface and 45º angle to patients sagittal plane

g) Area of insertion should be dried and painted with a suitable antiseptic solution


Technique For Right Side(contd.)-h) Previously loaded syringe, with a ¾ inch, 25-gauge, is

held in a pen grasp orienting the bevel towards the bone and inserted into the tissue in a line parallel with the index finger and bisecting the fingernail

i) Insert for a distance of about ½ to ¾ inch, going upward, inward and backward

j) After aspirating and making certain that the needle is not within a vessel, slowly, over 30-60 seconds about 0.9-1.8ml, inject the solution maintaining the position of the needle throughout


Signs and symptoms-1. Subjective : none2. Objective : Instrumentation is necessary to demonstrate

absence of pain

Safety Measures-3. Slow injection, repeated aspiration

Precaution-The depth of the needle penetration should be checked;

overinsertion increases the risk of hematoma


Failures of Anesthesia-1. Needle too lateral2. Needle too high3. Needle too far posterior

Complications-4. Hematoma5. Mandibular anesthesia


Nerves anaesthetized

MSA & terminal branch

Areas anaesthetized1. Pulps of maxillary 1st & 2nd premolar & mesiobuccal

root of 1st molar(28%)2. Buccal periodontal tissues & bone of these teeth

Anatomical landmarksMucobuccal fold above the maxillary 2nd premolar

Advantages– minimizes no. of injection & volume of solution

Middle Superior Alveolar Nerve Block

Indications 1. When infraorbital n. block fails to provide pulpal

anaesthesia distal to maxillary canine 2. Dental procedures involving both maxillary premolars

Contraindications

-infection or inflammation in the area of injection

-where the MSA n. in absent

Alternatives3. Local infiltration, PDL, IO injections4. Infraorbital n. block


Technique1. Chair position– 10 0’clock for right & 8 or 9

0’clock for left handed2. Stretch the upper lip to make the tissues taut

& to gain visibility3. Insert the needle into the height of the

mucobuccal fold above the 2nd premolar 4. Aspirate, if –ve, slowly deposit 0.9 to 1.2 ml

Signs & symptoms5. Subjective: upper lip numb6. Objective: no pain

Safety features: relatively avascular area, anatomically safety

Precaution– do not insert too rapidly & too close to the periosteum


-- also called infraorbital n. block

Nerves anaesthetized1. ASA nerve2. MSA nerve3. Infraorbital nerve – inferior palpebral

-- lateral nasal -- superior labial

Areas anaesthetized4. Pulps of maxillary C.I. through canine on the injected side5. Pulps of maxillary premolars(72% of patients) & mesiobuccal

root of the molar

Anterior superior alveolar(ASA) nerve block

3. Buccal(labial) periodontium and bone of these teeth4. Lower eyelid, lateral aspect of the nose, upper lip

Anatomical landmarks1. Infraorbotal notch2. Infraorbital depression 3. Infraorbital ridge4. Supraorbital notch5. Anterior teeth6. Pupils of eye


Needle pathway during insertion1. Bicuspid approach: it passes through the mucosa & areolar

tissue, and during insertion should pass beneath & lateral to the external maxillary artery & anterior facial vein

2. C.I. approach: it pass through mucosa & areolar tissue & beneath the angular head of the levator labii superioris m., proceeds anteriorly to the origin of levator anguli oris m. & beneath external maxillary artery & anterior facial vein

Approximating structures when the needle is in positionWhen in final position at the orifice of infraorbital canal, it should be

a) Beneath infraorbital head of levator labii superioris m.b) Above the origin of levator anguli oris m.


Technique — Patient seated comfortably in the chair & tilted so that the

maxillary plane is at a 45º angle to the floor— Patient is ask to look directly forward as the supraorbital &

infraorbital notchs are palpated— Imaginary straight line drawn vertically through these

landmarks will pass through pupils of the eye, the infraorbital foramen, bicuspid teeth, mental foramen

— Palpating finger should be moved downward about 0.5cm from th infraorbital notch, where a shallow depression will be felt

— For block on right side– thumb of the operator left hand is placed over the previously located infraorbital foramen, lip retracted with index finger exposing the mucolabial fold


– A 1 5/8-inch, 25-gauge needle is inserted with either one of the two direction, while for first– inserted in a line parallel with supraorbital notch, pupil of eye, infraorbital notch, & 2nd bicuspid tooth

– insert about 5mm from the labial plate to pass over the canine fossa– Thumb which is in placed should be used tto maneuver the needle

into a position so that it contacts the bone at the entrance to the foramen

– 2nd direction—insertion bisects the crown of the C.I. from the mesioincisal angle to distogingival angle

– Needle inserted about 5mm from the mucobuccal fold– Needle should gently contact the boundary of the foramen– Approx. 2ml of solution is deposited & the thumb is held until the

injection is completed– It is necessary to allow for midline or overlapping innervation by

infiltration over the apex of the opposite C.I.

ASA nerve block

ASA nerve block

Indications 1. Dental procedures involving more than two maxillary teeth &

their overlying buccal tissue2. Inflammation & infection (which C/I the supraperiosteal injection)3. When supraperiosteal injections have been ineffective because

of dense cortical bone

Contraindications4. Discrete treatment areas (supraperiosteal preferred)5. Hemostasis of localized area (infiltration indicated)

Advantages6. Comparatively simple technique7. Coparatively safe, minimized volume of solution & number of

needle punctures necessary to achieved anaesthesia

ASA nerve block

Steps in atraumatic administration of palatal anesthesia1. Provide adequate topical anesthesia at site of needle

penetration--- by allowing topical anesthetic to remain in contact with soft tissues for atleast 2 minutes

2. Use pressure anesthesia at site both before & during needle insertion & deposition of solution--- by applying considerable pressure to the tissues adjacent to the injection site with a firm object

3. Maintain control over the needle--- with a firm hand rest4. Slow deposition--- density of the palatal soft tissues & firm

adherence to the underlying bone. Rapid deposition tears the palatal soft tissues & leads to both pain on injection & localised soreness when anesthetic action is terminated

Palatal anesthesia

Nerves anesthetizedGreater palatine nerve

Areas anesthetizedPosterior portion of the hard palate & its overlying tissues Anteriorly as far as the 1st premolar & medially to the midline

Indications 1. When palatal soft tissue anesthesia is necessary for

restorative therapy on more than 2 teeth2. Pain control during periodontal or oral surgical procedures

involving the palatal soft & hard tissues

Greater palatine nerve block

Contraindications1. Inflammation or infection at the injection site2. Smaller areas of therapy

Advantages 3. Minimizes needle penetration4. Minimizes volume of solution5. Minimizes patients discomfort

Disadvantage6. No hemostasis except in the immediate area of injection7. Potentially traumatic


Alternatives 1. Local infiltration in specific regions2. Maxillary n. block

Technique 3. Greater palatine n. emerge from greater palatine foramen &

course forward in a groove parallel to maxillary molar teeth4. This foramen is situated between 2nd & 3rd maxillary molars

about 1cm from the palatal gingival margin towards the midline

5. Insertion is approach from the opposite side with an 1-inch, 27-gauge needle, which is kept as near to a right angle as possible with the curvature of the palatal bone

6. Needle should be inserted slowly


5. 0.25-0.5ml of anesthetic solution is injected slowly6. When bicuspid has to be anesthetized, it is advantageous to

insert the needle & deposit the solution palatal curvature opposite the bicuspid

7. Procedure– a) For right nerve block a right handed administrator should sit facing

the patient at 7 or 8 o’clock positionb) For left nerve block a right handed administrator should sit facing

the same direction as the patient at 11 o’clock positionc) Then ask the patient to open wide, extend the neck & turn head left

or right for improved visibility d) Then the foramen is located as follow:

Cotton swap is placed at the junction of the alveolar process & the hard palate starting from 1st molar & palpate posteriorly by pressing firmly into the tissue till it falls into a depression (foramen)


e) Apply topical anesthesia for 2 min & apply considerable pressure at the area of foramen with the swap in the left hand (if right handed), then note ischemia at the injection site

f) Apply pressure for 30 seconds then direct the syringe g) Continue to apply pressure anesthesia throughout the depositionh) Slowly advance the needle until palatine bone is gently contactedi) Depth of penetration is usually less than 10 mm

Signs & symptoms1. Subjective: numbness in the posterior portion of the palate2. Objective: no pain during dental therapy

Safety features3. Contact with bone4. Aspiration



PrecautionsDo not enter the foramen

Failures of anesthesia1. Not technically difficult 2. Deposited too far anterior to the foramen3. Anesthesia in the area of 1st premolar may prove inadequate

because of overlapping from nasopalatine n.

Complications4. Ischemia & necrosis of the soft tissue when highly

concentrated vasoconstricting solution used for hemostasis over a prolonged period (norepinephrine)

5. Hematoma is possible, but rare because of density & firm adherence


Nerves anesthetizedNasopalatine n.

Areas anesthetizedAnterior portion of hard palate, hard & soft tissue, from the mesial of the right 1st premolar to mesial of left 1st premolar

Indications1. To supplement the block of ASA & MSA n. 2. To augment analgesia of six maxillary incisors3. To complete anesthesia of the nasal septum

Anatomical landmarkCentral incisor teeth & incisive papilla

Nasopalatine nerve block

Contraindications1. Inflammation or infection at the injection site2. Smaller area of therapy

Advantages3. Minimized needle penetration & volume of solution4. Minimal patient discomfort from multiple needle penetration

Disadvantages5. No hemostasis except in the immediate area of injection6. Potentially most traumatic intraoral injection

Alternatives7. Local infiltration in specific regions8. Maxillary n. block


Technique

Two types of technique– 1. single penetration

2. multiple penetration

Technique-1 (single)1. Area of insertion– palatal mucosa just lateral to the

incisive papilla2. Target area– incisive foramen beneath the papilla3. Path– approach the injection site at 45 degree angle

toward the papilla4. Chair position– 9 or 10 o’clock position facing in the

same direction as the patient5. Slowly advance the needle towards the foramen

until bone is gently contacted (depth approx. 5 mm)6. Slowly deposit 0.45 ml in 15-30 second minimum


Signs & symptoms1. Subjective: numbness in anterior portion of the palate2. Objective: no pain during procedure

Safety features3. Contact with the bone4. Aspiration

Precautions5. Do not directly into the papilla6. Do not deposit too rapidly7. Do not deposit too much solution8. If needle penetration is more than 5 mm then the floor of the

nose is entered & infection may result


Complications1. Hematoma 2. Necrosis of soft tissue

Technique-2 (multiple)3. Areas of insertion–

a) labial frenum in the midline between maxillary two C.I.b) Interdental papilla between maxillary two C.I.

4. Path– a) First injection: infiltration into the labial frenumb) Second injection: needle held at a right angle to the

interdental papillac) Third injection: needle held at a 45 degree angle to the

incisive papilla


3. Procedure a) 1st injection: retract the upper lip to stretch tissues &

improve visibility. Gently insert in the frenum & deposit 0.3 ml in approx. 15 seconds

b) 2nd injection: at 11 or 12 o’clock position, tilting the patients head in the right, & needle at right angle to interdental papilla needle is inserted into the papilla just above the level of crestal bone. Aspirate when ischemia is noted in the incisive papilla or needle tip become visible just beneath the tissue surface

c) 3rd injection: same as single penetration

Signs & symptoms4. Subjective: numbness in the upper lip & anterior

portion of the hard palate5. Objective: no pain therapy

Safety features6. Aspiration 7. Contact with bone


Advantage– entirely or relatively atraumatic

Disadvantage1. Requires multiple injection2. Difficult to stabilized the syringe

Complications3. Necrosis of soft tissue4. Tender of interdental papilla for several days


Nerves anesthetized– maxillary division of the trigeminal nerve

Areas anesthetized1. Pulpal anesthesia of maxillary teeth on the side of block2. Buccal periodontium bone overlying these teeth3. Soft tissues & bone of the hard palate & part of soft palate,

medially to the miidline4. Skin of the lower eyelid, side of the nose, cheek & upper lip

LandmarksMucobuccal fold at the distal aspect of the maxillary 2nd molarMaxillary tuberosityZygomatic process of maxillaGreater palatine foramen, junction of maxillary alveolar process &

palatine bone

Maxillary nerve block

Indications1. Pain control before extensive oral surgical, periodontal, or

restorative procedures requiring anesthesia of the entire maxillary division

2. Inflammation or infection3. Diagnostic or therapeutic procedures for neuralgia or tics of

the 2nd division of trigeminal nerve

Contraindication4. Inexperience administrator5. Pediatric patient6. Uncooperative patients7. Inflammation or infection8. When hemorrhage is risky e.g. hemophilliac


Advantages1. Atraumatic injection via high tuberosity approach2. High success rate (>95%)3. Minimize no. of needle penetration & volume of local

anesthesia4. Neither high tuberosity nor greater palatine canal approach

usually is traumatic

Disadvantage5. Risk of hematoma6. Lack of hemostasis


Alternatives1. PSA nerve block2. ASA nerve block3. GP nerve block4. Nasopalatine nerve block

Technique– 2-type: high tuberosity approach & GP canal approach

High-tuberosity approach5. Area of insertion– height of mucobuccal

fold above the distal aspect of 2nd molar6. Target area– maxillary n. as it passes

through the pterygopalatine fossa superior and medial to the target area of

PSA n. block


3. Procedure: chair position 10 o’clock for left side & 8 o’clock for right side--Place the needle into the height of mucobuccal fold over the maxillary 2nd molar--Advance the needle slowly in an upward, inward, & backward direction also to the depth of 30 mm. At this depth the needle tip should lie in the pterygopalatine fossa--Aspirate. If –ve, deposit 1.8 ml slowly (>60 seconds)

Greater palatine canal approach4. Area of insertion– palatal soft tissue directly over the GP

foramen5. Target area– maxillary n as it passes through the

pterygopalatine fossa: the needle passes through the GP canal to reach the pterygopalatine fossa

6. Chair position– 7 or 8 o’clock for right side & 10 or 11 o’clock for left side


4. Locate the foramen as stated earlier5. Direct the syringe into the mouth the opposite

side with the needle approaching injection site at a right angle

6. Very slowly advance the needle into the GP canal to a depth of 30 mm.

7. Aspirate & if –ve slowly deposit 1.8 ml of solution

Signs & symptoms8. Subjective: pressure behind the upper jaw on the

side being injected; this usually subsides rapidly, progressing to tingling & numbness of the lower eyelid, side of the nose, & upper lip

9. Subjective: sensation of numbness in the teeth & buccal & palatal soft tissues on the side of injection

10. Objective: no pain


Precautions1. Pain on insertion of injection; primarily GP approach2. Overinsertion 3. Resistance to needle insertion in the GP approach

Complications4. Hematoma develops rapidly if the maxillary artery is punctured5. Penetration of the orbit may occur during a GP approach if the

needle goes too far6. Complications produced by injection of LA

a. Volume displacement of the orbital structures, producing periorbital swelling & proptosis

b. Diplopia (VI cranial n), Mydriasis, c. Penetration nasal cavity complaining of anesthetic solution running

down the throat


Nerves anesthetized1. ASA nerve2. MSA nerve3. Subdural dental nerve plexus of the ASA & MSA n

Areas anesthetized4. Pulpal anesthesia of maxillary C.I. canines & premolars5. Buccal attached gingiva of these same teeth6. Attached palatal tissues from midline to free gingival margin

on the associated teeth

Anterior middle superior alveolar nerve block

Indications1. Is easier to perform with a CCLAD system2. Dental procedures involving the maxillary anterior teeth or

soft tissues are to be performed3. Multiple maxillary teeth anesthesia 4. Scaling & root planing of anterior teeth 5. Facial approach supraperiosteal injection

Contraindications6. Thin palatal tissues7. Who cannot tolerate a 3-4 min administration time8. Procedure requiring more than 90 min


Advantages1. Provides anesthesia of multiple teeth with single injection2. Minimizes volume of anesthesia & no. of puncture3. Allows effective soft tissue & pulpal anesthesia for periodontal

scaling 7 root planing4. Allows accurate smile line assessment5. Eliminates postoperative inconvenience of numbness to the

upper lip & muscle of facial expression6. Can be perform comfortably with a CCLAD

Disadvantages7. Requires a slow administration time ( 0.5 ml/min)8. Can cause operator fatigue with a manual syringe9. May need supplemental anesthesia for C.I. & L.I.


4. May cause excessive ischemia if administered rapidly5. Use of LA containing epinephrine with a conc. of 1:50,000 is

contraindicated

Alternatives6. Multiple supraperiosteal or PDL injections7. ASA & MSA n block8. Maxillary n block

Technique9. Area of insertion: on the hard palate about halfway along an

imaginary line connecting the midpalatal suture to free gingival margin; the location of the line is at the contact point between the 2nd 1st premolars

10.Target area: palatal bone at injection site11.Chair position: 9 or 10 o’clock, patient in supine position


4. Needle 45 degree angle with a tangent to the palate5. A prepuncture technique can be utilized. Apply the bevel of

the needle toward the palatal tissue. Place a sterile cotton applicator on top of the needle tip. Apply light pressure & initiate delivery of LA to the surface of the epithelium.

6. An “anesthetic pathway technique” can be utilized. Very slowly advance the needle tip into the tissue, rotation allows efficient penetration. Advance the needle 1 to 2 mm every 4 to 6 seconds while administrating solution.

7. Ensure that the needle contact is maintained with bony surface of the bone

8. Aspirate. Solution is delivered at 0.5 ml of approx. 1.4 to 1.8 ml

9. Advice the patient that he/she will experience a sensation of firm pressure



Signs & symptoms1. Subjective: (1) A sensation of firmness & numbness is

immediately experienced on the palatal tissues. (2) Numbness of the teeth & associated soft tissues extends from C.I. to 2nd premolar on one side of injection

2. Objective: (1) blanching of soft tissues on palatal & facial attached gingiva from C.I. to premolar region. (2) no pain. (3) no anesthesia of the face & upper lip.

Safety features3. Contact with the bone4. Aspiration5. Slow insertion & administration6. Less anesthetic than necessary for a traditional facial

approach


Precautions1. Against pain– (i) extremely slow insertion, (ii) slow

administration during insertion with simultaneous administration

2. Against tissue damage– (i) when using 4% LA, reduce the volume (ii) avoid excessive ischemia

Complications3. Palatal ulcer at injection site4. Unexpected contact with the nasopalatine n5. Density of injection site causing squirk-back of anesthetic &

bitter taste


Nerves anesthetized1. Nasopalatine n2. Anterior branch of ASA

Areas anesthetized3. Pulps of the maxillary C.I., L.I. & canines4. Facial periodontal tissue associated with these same teeth5. Palatal periodontal tissues associated with these same teeth

Alternatives6. Supraperiosteal or PDL7. ASA (bilateral) n block8. Maxillary (bilateral) n block

Palatal approach-anterior superior alveolar

Indications1. Procedures involving the maxillary anterior teeth & soft

tissues are to be performed2. Bilateral anesthesia of maxillary anterior is desired in single

injection3. Scaling & root planing of anterior4. Anterior cosmetic procedure

Cotraindications5. With extremely long canine roots 6. Who cannot tolerate 3-4 min administration time7. Procedures requiring more than 90 min


Advantages1. Provides bilateral maxillary anesthesia from a single injection2. Minimizes no. of punctures & volume of solution3. Eliminates postoperative inconvenience of numbness to the

upper lip & muscles of facial expression

Disadvantages4. Requires slow administration 5. May need supplemental anesthesia for canine6. May cause excessive ischemia if administered too rapidly7. Use of LA containing epinephrine is contraindicated


Technique1. Area of insertion: just lateral to the incisive

papilla in the papillary groove2. Target area: nasopalatine foramen3. Chair position: 9 or 10 o’clock4. Initial orientation of bevel is “face down” toward

the epithelium holding the needle at approx. a 45 degree angle with a tangent to the palate

5. A prepuncture technique and “anesthetic pathway technique” can be utilized as in AMSA n block

6. Ensure that the needle is in contact with the inner bony wall of the canal

7. Anesthetic is delivered at a rate of 0.5 ml during the injection for a final dosage of approx. 1.4 to 1.8 ml


Signs & symptoms1. Subjective: (i) a sensation of firmness & anesthesia is

immediately experienced in the anterior palate. (ii) numbness of teeth associated soft tissues extends from right to left canine

2. Objective: ischemia of soft tissues of the palatal & facial attach gingiva, no pain, no anesthesia of the face & upper lip

Safety features3. Contact with the bone4. Aspiration5. Slow insertion6. Slow administration7. Less anesthetic than necessary for a traditional facial

approach


Complications1. Palatal ulcer at injection site developing 1 to 2 days

postoperative2. Unexpected nerve contact of the nasopalatine nerve3. Density of injection site causing squirk-back of anesthetic and

bitter taste.


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Health & Medicine

Maxillary anesthesia: its technique