MAXILLARY INJECTION TECHNIQUES

local infiltration

•NA: Small terminal nerve endings

•AT: same as injection area

Field block

• NA: Larger terminal nerve branches

• AT: an area away from the site of injection

Nerve block

• NA: Main nerve Trunk

• AT: Distant from the site of injection

infiltration (incorrectly termed as FIELD BLOCK)

an injection in which the local anesthetic solution is deposited at or above the apex of the tooth to be treated.

Supraperiosteal (infiltration)

what injection technique is recommended for limited treatment protocols?

Periodontal ligament (PDL, intraligamentary) injection

what injection technique is recommended as an adjunct to other techniques or for limited treatment protocols?

intrasseptal injection

what injection technique is recommended primarily for periodontal surgical techniques?

Intracrestal injection

Intraosseous injection

what injection techniques are recommended for single teeth (primarily mandibular molars) when other techniques have failed?

Anterior middle superior alveolar (AMSA) nerve block

what injection technique is recommended for extensive management of anterior teeth, palatal and buccal soft and hard tissues?

Palatal approach-anterior superior alveolar (P-ASA) nerve block

what injection technique is recommended for treatment of maxillary anterior teeth and their palatal and facial soft and hard tissues?

towards the bone

How do you orient the bevel upon insertion?

LA overdose (in lighter-weight patients) and post-injection pain

what happens when larger volume of supraperiosteal injection is made?

blood vessels (hematoma)

nerves (paresthesia)

Needle puncture of tissue can lead to permanent or transient damage to structures in the area such as?

large terminal branches of the plexus:

1. pulp and root area of the tooth

2. buccal periosteum

3. connective tissue

4. mucous membrane

what are the 4 areas anesthetized in supraperiosteal injection?

• Pulpal anesthesia of the maxillary teeth when treatment is limited to one or two teeth

• Soft tissue anesthesia when indicated for surgical procedures in a circumscribed area

what are the 2 indications for supraperiosteal injection?

- infection acute inflammation in the area of injection

- dense bone covering the apices

what are the 2 contraindications for supraperiosteal injection?

• High success rate (>95%)

• Technically easy injection

• Usually entirely atraumatic

what are the 3 advantages of supraperiosteal injection?

large areas because of the need for multiple needle insertions and the necessity to administer larger total volumes of local anesthetic.

what is the disadvantage of supraperiosteal injection?

• Mucobuccal fold

• Crown of the tooth

• Root contour of the tooth

what are the 3 landmarks of supraperiosteal injection?

1. Needle tip lies below the apex

2. Needle tip lies too far from the bone

what are the 2 causes of failure of supraperiosteal injection?

Pain on needle insertion

what is the complication of supraperiosteal injection?

tuberosity block/zygomatic block

what are the other names for PSAN block?

- extent of anesthesia produced (mandibular anesthesia)

- hematoma

what are the 2 complications of PSAN block?

use 27-g short needle

how do you minimize hematoma in PSAN block?

- When treatment involves two or more maxillary molars

- When supraperiosteal injection is contraindicated (e.g., with infection or acute inflammation)

- When supraperiosteal injection has proved ineffective

what are the 3 indications for PSAN block?

When the risk of hemorrhage is too great

what is the contraindication for PSAN block?

• Atraumatic

• High success rate (>95%)

• Minimum number of necessary injections

• Minimizes the total volume of local anesthetic solution administered

what are the 4 advantages of PSAN block?

• Risk of hematoma

• Technique somewhat arbitrary: no bony landmarks during insertion

• Second injection necessary for treatment of the first molar

what are the 3 disadvantages of PSAN block?

height of the mucobuccal fold above the maxillary second molar

area of insertion for PSAN block

PSA nerve—posterior, superior, and medial to the posterior border of the maxilla

target area of PSAN block

• Mucobuccal fold

• Maxillary tuberosity

• Zygomatic process of the maxilla

what are the 3 landmarks of PSAN block?

16 mm

what is the depth of insertion for PSAN block?

• Needle too lateral

• Needle not high enough

• Needle too far posterior

what are the 3 failures of anesthesia for PSAN block?

27-g short or long needle

recommended needle for MSAN block?

height of the mucobuccal fold above the maxillary second premolar

area of insertion for MSAN block

maxillary bone above the apex of the maxillary second premolar

target area for MSAN block

mucobuccal fold above the maxillary second premolar

landmark for MSAN block

MSAN block

what is the least used blocking technique?

• Where the ASA nerve block fails to provide pulpal anesthesia distal to the maxillary canine

• Dental procedures involving both maxillary premolars only

what are the 2 indications of MSAN block?

• Infection or inflammation in the area of injection or needle insertion or drug deposition

• Where the MSA nerve is absent

what are the 2 contraindications of MSAN block?

Minimizes the number of injections and the volume of solution

what is the advantage of MSAN block?

• Anesthetic solution not deposited high above the apex of the second premolar

• Deposition of solution too far from the maxillary bone

• Bone of the zygomatic arch at the site of injection preventing the diffusion of anesthetic

what are the 3 failures of MSAN block?

hematoma

the complication of MSAN block?

1. Anterior superior alveolar

2. Middle superior alveolar

3. Infraorbital nerve branches (Inferior palpebral, Lateral nasal, Superior labial)

what are the 3 nerves anesthetized in ASAN block?

25 or 27 g long needle

(27g short for children and smaller adults)

what is the needle used in ASAN block?

height of the mucobuccal fold directly over the first premolar (shortest route)

what is the area of insertion for ASAN block?

a. Mucobuccal fold / pupil of the eye

b. Infraorbital notch

c. Infraorbital foramen

what are the 3 landmarks of ASAN block?

infraorbital foramen

what is the target area of ASAN block?

Height of mucobuccal fold over any tooth from 2nd PM anteriorly

what is the area of insertion of ASAN block?

Quadratus Labii Superioris/Levator Anguli Oris

what muscle is pierced during ASAN block?

Needle below infraorbital foramen

needle medial/ lateral to foramen

what are the 2 failures of ASAN block?

- he/she can feel the anesthetic solution being deposited beneath the finger

- foramen is no longer palpable at the end of injection

- maintain firm pressure with finger over the injection site both during and at least 1 minute after the injection

what should the operator do during ASAN block?

to increase the diffusion of local anesthetic solution into the infraorbital foramen

why do we need to maintain firm pressure with finger over the injection site in ASAN block?

due to anatomy

why is palatal anesthesia traumatic?

➢Forewarn patients

➢Slow deposition

➢Pressure anesthesia

➢Use 27-g needle ➢Stabilize needle

how can you avoid trauma in palatal anesthesia?

applicator stick

what is used to produce ischemia or blanching of soft tissues during pressure anesthesia?

dull and tolerable

describe the pressure felt during pressure anesthesia

gate control theory

what theory is used by pressure anesthesia?

- Greater Palatine Foramen

- Distal to the second molar 10mm away from gingival margin

what are the 2 landmarks for GP nerve block?

27 gauge short

what needle is used for GP nerve block?

soft tissue slightly anterior to the greater palatine foramen

what is the area of insertion for GP nerve block?

cotton applicator

what is used to stabilize during GP nerve block?

- needle too anteriorly positioned

- Partial anesthesia at the area of 1st PM

what are the 2 failures of GP nerve block?

• Ischemia and Necrosis

• Hematoma

• Soft Palate anesthesi

what are the 3 complications of GP nerve block?

incisive nerve block

sphenopalatine nerve block

What are other names for the Nasopalatine nerve block?

- SP: 0.6 ml over 20 seconds

- NP: one quarter of a cartridge

describe the volume of anesthetic solution in supraperiosteal injection vs nasopalatine nerve block

nasopalatine nerve block

It has the distinction of being a potentially highly traumatic

one tissue penetration lateral to the incisive papilla on the palatal aspect of the maxillary central incisors

explain the single penetration technique of NP nerve block

soft tissue in the area is:

1. dense

2. firmly adherent to underlying bone

3. quite sensitive

3 factors that increase patient discomfort during NP nerve block

27g short needle

recommended needle for NP nerve block

palatal mucosa just lateral to the incisive papilla

area of insertion for NP nerve block

incisive foramen (beneath the incisive papilla)

target area of NP nerve block

central incisors and incisive papilla

what are the 2 landmarks of NP nerve block?

Approach the injection site at a 45-degree angle toward the incisive papilla.

what is the path of insertion for NP nerve block?

1. topical anesthesia onto frenum

2. injection into frenum

3. interdental papilla

4. nasopalatine area

enumerate the steps nasopalatine nerve block in multiple penetration technique

• Hematoma

• Necrosis

• Inadequate hemostasis (at areas away from deposition)

• Solution can squirt back

what are the 4 complications of NP nerve block?

Partial Anesthesia at the area of Canine

what is a sign of a failed NP nerve block?

- hemostasis during surgical procedures (primary reason)

- palatogingival pain control for applying rubber dam clamp, packing of retraction cord in the sulcus, or operative procedures on not more than two teeth

what are the 2 indications for local infiltration of the palate?

palatal approach maxillary anterior field block

palatal appraoch - ASA nerve block is also known as?

nasopalatine, ASAN (no infraorbital)

what are the nerves anesthetized by palatal approach ASA nerve block?

CCLAD

what anesthetic device is best suited with palatal approach - ASA nerve block?

maxillary / v2 nerve block

an effective method of achieving profound anesthesia of a hemimaxilla and quadrant dentistry

1. high-tuberosity approach

2. greater palatine canal approach

what are the 2 approaches of maxillary nerve block?

- mucobuccal fold at the distal of the MX second molar

- 30 mm

what is the landmark and depth of maxillary nerve block (high-tuberosity approach)?

- 25-gauge long needle

- greater palatine foramen

what is the recommended needle and landmark of maxillary nerve block (greater palatine canal approach)?

- hematoma

- penetration of the orbit

- penetration of the nasal cavity

what are the complications of the maxillary nerve block?

high-tuberosity approach

what maxillary nerve block approach is more likely associated with hematoma?

- needle goes too far

- smaller than average skull

what are the factors that causes penetration of the orbit during the maxillary nerve block (greater palatine foramen approach)?

- volume displacement

- diplopia

- retrobulbar block, mydriasis, corneal anesthesia, opthamoplegia

- amaurosis

- retrobulbar hemorrhage

what are the complications of penetration of the orbit?

- aspiration: large amounts of air in cartridge

- injection: LA solution runs on px throat

what happen the needle deviates medially during insertion through the greater palatine canal? (penetration of the nasal cavity - mx nerve block)