MAXILLARY INJECTION MAXILLARY INJECTION TECHNIQUE TECHNIQUE

Chinthamani Laser Dental Clinic

Introduction Introduction A number of injection techniques are available to aid in A number of injection techniques are available to aid in

providing clinically adequate anesthesia of the teeth and soft and providing clinically adequate anesthesia of the teeth and soft and hard tissues in maxilla. hard tissues in maxilla.

Injection techniques are as follows Injection techniques are as follows 1.1. Supra periosteal infiltration Supra periosteal infiltration 2.2. Periodontal ligament injection Periodontal ligament injection 3.3. Intraseptal injection Intraseptal injection 4.4. Intracrestal injection Intracrestal injection 5.5. Intraosseous injection Intraosseous injection 6.6. Posterior superior alveolar nerve block Posterior superior alveolar nerve block 7.7. Middle superior alveolar nerve block Middle superior alveolar nerve block 8.8. Anterior superior alveolar nerve block Anterior superior alveolar nerve block 9.9. Maxillary nerve block Maxillary nerve block 10.10. Greater palatine nerve block Greater palatine nerve block 11.11. Nasopalatine nerve block Nasopalatine nerve block 12.12. Anterior middle superior alveolar nerve block Anterior middle superior alveolar nerve block 13.13. Palatal approach – anterior superior alveolar nerve blockPalatal approach – anterior superior alveolar nerve block

SUPRAPERIOSTEAL INJECTION SUPRAPERIOSTEAL INJECTION

Other common names – Local infiltration Other common names – Local infiltration paraperiosteal injection paraperiosteal injection

Nerves anesthetized - Large terminal branches Nerves anesthetized - Large terminal branches of dental plexus of dental plexus

Areas anesthetized – Entire region innervated by Areas anesthetized – Entire region innervated by the large terminal branches of this plexus the large terminal branches of this plexus

Pulp and root area of the tooth and mucous Pulp and root area of the tooth and mucous membrane membrane

Indications Indications Pulpal anesthesia of maxillary teeth Pulpal anesthesia of maxillary teeth Soft tissue anesthesia Soft tissue anesthesia

Contra indications Contra indications Infections or acute inflammation Infections or acute inflammation Dense bone covering the apices of teeth Dense bone covering the apices of teeth

Advantages Advantages High success rate High success rate Technically easy injection Technically easy injection Usually entirely atraumatic Usually entirely atraumatic

Disadvantages Disadvantages Not recommended for larger areas Not recommended for larger areas

Technique Technique Procedures Procedures Prepare tissue at the injection site Prepare tissue at the injection site Orient needle so bevel faces bone Orient needle so bevel faces bone Insert the needle into the height of the mucobuccal Insert the needle into the height of the mucobuccal

fold over the target area fold over the target area Advance the needle until its bevel is at or above the Advance the needle until its bevel is at or above the

apical region of tooth apical region of tooth Aspirate Aspirate Weight 3 – 5 mins before commencing the dental Weight 3 – 5 mins before commencing the dental

procedure procedure

POSTERIOR SUPERIOR ALVEOLAR POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCKNERVE BLOCK

Other names -Other names - Tuberosity block Tuberosity block Zygomatic blockZygomatic block

Nerves anesthetized - Posterior superior alveolar nerveNerves anesthetized - Posterior superior alveolar nerve

Indications Indications Two or more maxillary molar - supra periosteal is contra indicated and ineffective Two or more maxillary molar - supra periosteal is contra indicated and ineffective

Contra indications Contra indications Hemorrhage is highHemorrhage is high

Advantages Advantages AtraumaticAtraumaticHighly successful Highly successful

DisadvantagesDisadvantagesRisk of hematomaRisk of hematomaNo bony land mark No bony land mark

Technique Technique Align 10o clock position for the left side Align 10o clock position for the left side

and 8 o clock position for the rightand 8 o clock position for the right Prepare the tissue and insert the needle Prepare the tissue and insert the needle

at the height of the muco buccal foldat the height of the muco buccal fold Advance the needleAdvance the needle Upward-45 degree to the occlusal planeUpward-45 degree to the occlusal plane Inward –medially towardes the midline Inward –medially towardes the midline

45 degree to the occlusal plane45 degree to the occlusal plane Backward-45 degree to the long axis of Backward-45 degree to the long axis of

second molarsecond molar Advance the needle to the desired depthAdvance the needle to the desired depth AspirateAspirate Deposite l.aDeposite l.a Withdraw the syringe Withdraw the syringe

MIDDLE SUPERIOR ALVEOLAR NERVE MIDDLE SUPERIOR ALVEOLAR NERVE BLOCKBLOCK

Nerves anesthetized-middle superior alveolarNerves anesthetized-middle superior alveolar nerve nerve block block

IndicationsIndications Infra orbital nerve block fails when both premolars Infra orbital nerve block fails when both premolars

involvedinvolved

ContraindicationsContraindications Infection when MSA nerve is absentInfection when MSA nerve is absent

AdvantagesAdvantages Minimum needle prick & volumeMinimum needle prick & volume

TechniqueTechnique Align the position Align the position 10o clock position for right MSA 10o clock position for right MSA

nerve & 8or 9 for the left nerve nerve & 8or 9 for the left nerve blockblock

Prepare the tissuePrepare the tissue Insert the needle to the height of Insert the needle to the height of

mucobuccal fold mucobuccal fold Advance the needle to the apex Advance the needle to the apex

of second pre molarof second pre molar AspirateAspirate Deposite and withdrawDeposite and withdraw

ANTERIOR SUPERIOR ALVEOLAR NERVE ANTERIOR SUPERIOR ALVEOLAR NERVE BLOCKBLOCK

Other name-infra orbital nerve block Other name-infra orbital nerve block

IndicationsIndications When more than two maxillary teeth are involvedWhen more than two maxillary teeth are involved Inflammation or infectionInflammation or infection When supra periosteal injection –ineffectiveWhen supra periosteal injection –ineffective

ContraindicationsContraindications Discrete treatment areaDiscrete treatment area When hemostasis involvedWhen hemostasis involved

AdvantagesAdvantages Simple techniques,minimal volumeSimple techniques,minimal volume

DisadvantagesDisadvantages Improper handling injures patient eye, difficulty in defining land marksImproper handling injures patient eye, difficulty in defining land marks

Technique Technique Assume 10 o position for right Assume 10 o position for right

and left infra orbital nerve blockand left infra orbital nerve block Patient position –supine or Patient position –supine or

semisupinesemisupine Prepare the tissue at the height of Prepare the tissue at the height of

mucobuccal foldmucobuccal fold Locate the infra orbital foramenLocate the infra orbital foramen Retract the lip and insert the Retract the lip and insert the

needleneedle To the upper rim of infraorbital To the upper rim of infraorbital

foramenforamen AspirateAspirate Deposite and withdrawDeposite and withdraw

PALATAL PALATAL ANESTHESIAANESTHESIA

STEPS IN THE ATRAUMATIC STEPS IN THE ATRAUMATIC ADMINISTRATION OF PALATAL ADMINISTRATION OF PALATAL

ANESTHESIAANESTHESIA

Provide adequate topical anesthesia at site of Provide adequate topical anesthesia at site of needle penetration.needle penetration.

Use pressure anesthesia at site of needle Use pressure anesthesia at site of needle penetration.penetration.

Maintain control over the needle.Maintain control over the needle. Deposit the anesthetic solution slowly.Deposit the anesthetic solution slowly. Trust yourself… that u can complete the Trust yourself… that u can complete the

procedure atraumatically.procedure atraumatically.

GREATER PALATINE NERVE GREATER PALATINE NERVE BLOCKBLOCK

This technique is useful for dental procedures involving the This technique is useful for dental procedures involving the palatal soft tissues distal to the canine.palatal soft tissues distal to the canine.

OTHER NAMEOTHER NAME:: Anterior palatine nerve block. Anterior palatine nerve block.

NERVE ANAESTHETISEDNERVE ANAESTHETISED: Greater palatine nerve: Greater palatine nerve

AREA ANEASTHETISEDAREA ANEASTHETISED: The posterior portion of the hard : The posterior portion of the hard palate and its overlying soft tissue, anteriorly as far as the first palate and its overlying soft tissue, anteriorly as far as the first molar & medially to the midline.molar & medially to the midline.

INDICATIONS:INDICATIONS: Palatal soft tissue anesthesia necessary for restorative therapy on Palatal soft tissue anesthesia necessary for restorative therapy on

more than two teeth.more than two teeth. For pain control during periodontal or oral surgical procedure For pain control during periodontal or oral surgical procedure

involving the palatal soft and hard tissueinvolving the palatal soft and hard tissue

CONTRA INDICATIONS:CONTRA INDICATIONS: Inflammation or infection at injection site.Inflammation or infection at injection site. Smaller areas of therapy (one or two teeth)Smaller areas of therapy (one or two teeth)

ADVANTAGES:ADVANTAGES: It minimize needle penetration and volume of solution.It minimize needle penetration and volume of solution. Minimizes patient discomfort.Minimizes patient discomfort.

DISADVANTAGES:DISADVANTAGES: No hemostasis except in the immediate area of infection.No hemostasis except in the immediate area of infection. Potentially traumatic.Potentially traumatic.

TECHNIQUE TECHNIQUE

Nasopalatine Nerve BlockNasopalatine Nerve Block

Other common name: Other common name: Incisive nerve block, Incisive nerve block, Spenopalatine nerve block Spenopalatine nerve block

Nerves Anesthetized: Nerves Anesthetized: Nasopalatine nerves bilaterally Nasopalatine nerves bilaterally

Areas Anesthetized Areas Anesthetized Anterior portion of the hard palate from mesial of the Anterior portion of the hard palate from mesial of the

right first premolar to the mesial of the left first premolar. right first premolar to the mesial of the left first premolar.

IndicationsIndications When palatal soft tissue anesthesia is necessary for When palatal soft tissue anesthesia is necessary for

restorative therapy on more than two teeth restorative therapy on more than two teeth

For pain control during periodontal or oral surgical For pain control during periodontal or oral surgical procedures involving palatal soft and hard tissues. procedures involving palatal soft and hard tissues.

ContraindicationsContraindications Inflammation or infection at the injection site Inflammation or infection at the injection site

Smaller area of therapy Smaller area of therapy

Advantages Advantages Minimizes needle penetrations and volume of Minimizes needle penetrations and volume of

solutionsolution Minimal patient discomfort from multiple Minimal patient discomfort from multiple

needle penetration needle penetration Disadvantages Disadvantages No hemostasis except in the immediate area of No hemostasis except in the immediate area of

injection injection Potentially the most traumatic intra oral Potentially the most traumatic intra oral

injection however, the protocol for an injection however, the protocol for an atraumatic injection or use of a CCLAD System atraumatic injection or use of a CCLAD System can minimize or entirely eliminate discomfort can minimize or entirely eliminate discomfort

TechniqueTechnique

Precautions Precautions

Against pain Against pain Do not insert directly into the incisive papillaDo not insert directly into the incisive papilla Do not deposit solution too rapidly Do not deposit solution too rapidly Do not deposit too much solution Do not deposit too much solution

Against injection Against injection Do not insert the needle more than 5mm into the incisive Do not insert the needle more than 5mm into the incisive

canals because it may enter into nose & may cause infectioncanals because it may enter into nose & may cause infection

FailuresFailures Unilateral anaesthesiaUnilateral anaesthesia In adequate palatal soft-tissue anesthesia in the In adequate palatal soft-tissue anesthesia in the

area of maxillary canine and I premolar area of maxillary canine and I premolar

Complications Complications Few of significance Few of significance Hematoma – extremely rare Hematoma – extremely rare Necrosis of soft tissue Necrosis of soft tissue

Anterior middle superior alveolar Anterior middle superior alveolar nerve block nerve block

Other common name: Other common name: Palatal approach anterior middle superior alveolar Palatal approach anterior middle superior alveolar

nerve nerve

Nerves anesthetized Nerves anesthetized ASA Nerve ASA Nerve MSA Nerve MSA Nerve Subneural dental nerve plexus Subneural dental nerve plexus

Areas anesthetizedAreas anesthetized Pulpal anesthesia of maxillary incisors canines & Pulpal anesthesia of maxillary incisors canines &

Premolars Premolars Buccal attached gingiva of these same teeth Buccal attached gingiva of these same teeth Attached palatal tissues from midline to tree gingival Attached palatal tissues from midline to tree gingival

margin on associated tooth. margin on associated tooth.

Indications Indications Easier to perform Easier to perform Dental procedure involving the maxillary anterior Dental procedure involving the maxillary anterior

teeth teeth When anesthesia to multiple maxillary teeth When anesthesia to multiple maxillary teeth When scaling and root planning of anterior teeth When scaling and root planning of anterior teeth

Contraindications Contraindications Patients with unusual thin palatal tissue Patients with unusual thin palatal tissue Procedures requiring more than 90mins Procedures requiring more than 90mins

Advantages Advantages Provides anesthesia of multiple maxillary teeth with Provides anesthesia of multiple maxillary teeth with

single injection single injection Simpler technique Simpler technique Comparatively safe Comparatively safe Eliminates post, operative inconvenience Eliminates post, operative inconvenience

Disadvantages Disadvantages Requires slow administration Requires slow administration May be uncomfortable to patient May be uncomfortable to patient May need supplement anesthesia May need supplement anesthesia

Technique Technique

Failures Failures May need suplemental anesthesia for central and lateral May need suplemental anesthesia for central and lateral

incisors incisors

Complications Complications Palatal ulcer at injection site developing 1-2 days post Palatal ulcer at injection site developing 1-2 days post

operative operative Un expected contact with the nasopalatine nerve Un expected contact with the nasopalatine nerve density of injection site causing squirt back of density of injection site causing squirt back of

anesthetic & bitter taste anesthetic & bitter taste

Palatal approach – Anterior superior Palatal approach – Anterior superior alveolar nerve alveolar nerve

Other common name: palatal approach ASA or palatal Other common name: palatal approach ASA or palatal approach maxillary anterior block approach maxillary anterior block

Nerves anesthetized: Nerves anesthetized: Nasopalatine Nasopalatine Anterior branches of ASA Anterior branches of ASA

Areas anesthetized Areas anesthetized Pulps of the maxillary central incisors, lateral incisors & Pulps of the maxillary central incisors, lateral incisors &

canines canines Facial periodontal tissue associated with these same Facial periodontal tissue associated with these same

teeth teeth

Indications Indications Procedure involving the maxillary ansterior teeth & soft Procedure involving the maxillary ansterior teeth & soft

tissues tissues Bilateral anesthesia of maxillary anterior teeth Bilateral anesthesia of maxillary anterior teeth Scaling & root planning of anterior teeth. Scaling & root planning of anterior teeth.

Contraindications Contraindications Patients with extremely long canine roots Patients with extremely long canine roots Patients who cannot tolerate 3-4 mins administration Patients who cannot tolerate 3-4 mins administration

time time Procedures requiring more than 90 minsProcedures requiring more than 90 mins

Advantages Advantages Provides bilateral maxillary anesthesia from single site Provides bilateral maxillary anesthesia from single site

injection injection Simple technique Simple technique Safer technique Safer technique

DisadvantagesDisadvantages Requires slow administration Requires slow administration May cause excessive ischemia May cause excessive ischemia May need suplemental anesthesia for canine teeth May need suplemental anesthesia for canine teeth

Technique Technique

FailuresFailures Highly successful injection for maxillary incisors Highly successful injection for maxillary incisors May need supplemental anesthesia for canines in May need supplemental anesthesia for canines in

patient with long roots patient with long roots Unilateral anesthesia Unilateral anesthesia

Complications Complications Palatal ulcer at injection site developing 1-2 days Palatal ulcer at injection site developing 1-2 days

postoperative postoperative Unexpected nerve contract of the nasopalatine nerve Unexpected nerve contract of the nasopalatine nerve Density of injection site causing squirt-back of Density of injection site causing squirt-back of

anesthetic and bitter taste. anesthetic and bitter taste.

Maxillary nerve block Maxillary nerve block Other common names: Second division block, Other common names: Second division block,

VV2 2 nerve blocknerve block . .

Nerve anesthetized – Maxillary division of Nerve anesthetized – Maxillary division of trigeminal nervetrigeminal nerve

Areas anesthetized Areas anesthetized Pulpal anesthesia of maxillary teeth Pulpal anesthesia of maxillary teeth Buccal periodontium & bone Buccal periodontium & bone Soft tissues & bone of the hard palate & part of Soft tissues & bone of the hard palate & part of

soft palate soft palate

Indications Indications Pain control before extensive oral surgical Pain control before extensive oral surgical

periodontal, restorative procedures periodontal, restorative procedures Diagnostic or therapeutic procedures Diagnostic or therapeutic procedures

Contraindications Contraindications Inexperienced administrator Inexperienced administrator Pediatric patients Pediatric patients Uncooperative patients Uncooperative patients Inflammation or injection of tissue Inflammation or injection of tissue

Advantages Advantages Atraumatic injection Atraumatic injection High success rate High success rate Minimises number of needle penetration Minimises number of needle penetration

Disadvantages Disadvantages Risk of hematoma Risk of hematoma lack of hemostasis lack of hemostasis Pain Pain Positive aspiration is less than 1% Positive aspiration is less than 1%

TechniqueTechnique

Failures Failures

Partial anesthesia Partial anesthesia Inability to negotiate the greater palatine canal Inability to negotiate the greater palatine canal

Complications Complications Hematoma develops rapidly Hematoma develops rapidly Penetration of nasal cavity Penetration of nasal cavity penetration of orbit may occur. penetration of orbit may occur.

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