Quiz #3: Maxillary Anesthesia

MSA Injection

Errors:

• Deposition distal or mesial to apex of 2nd premolar

• penetration depth too shallow (not near apex of 2nd premolar)

• too lateral away from bone

• scraping bevel along bone

• not enough anesthetic

• watch out for dense bone associated with the zygomatic process of the maxilla

Note:

• may also innervate the maxillary sinus (4.28% of population)

• may serve as a supplement to the PSA for anesthesia of the MB root of 1st molar

• Penetration depth: 4-6mm (depends on anatomy)

• may touch bone associated with the zygomatic process of the maxilla

ASA Injection

Errors:

• deposition distal to canine eminence

• penetration depth too shallow (not near apex of canine)

• too lateral away from bone

• scraping bevel along bone

• not enough anesthetic

• midline cross-over: may need to inject above the central incisor on the opposite side

Note:

• Penetration depth: 4-6+mm (depends on anatomy)

SP Injection

Contraindications:

• tissue infection

• dense bone

• multiple teeth/large tissue area

Errors:

• penetration depth too shallow (not at apex of target tooth)

• too lateral away from bone

• scraping bevel along bone

• not enough anesthetic

Note:

• The penetration point involves bisecting the long axis of the tooth!

• Penetration depth: 3-5mm (depends on anatomy)

IO Injection

Errors:

• penetration site too lateral or too medial (aim in line with pupil!)

• deposition site too inferior to infraorbital foramen (you MUST contact bone and use a LONG needle!)

• not enough anesthetic

Indications:

• pulpal anesthesia on the mx anterior and premolar teeth

• pulpal anesthesia on more than two teeth

• inflammation which contraindicates an SP injection

• SP injection is ineffective due to dense cortical bone

Contraindications:

• treatment of one/two teeth only

• need for hemostasis

Note:

• if the needle buzzes the nerve bundle, stop advancing, pull back 2mm, aspirate, and inject

• penetration depth: 12-25mm depending on anatomy

• alternatives: ASA & MSA; SP

PSA Injection

Errors:

• penetration depth is too lateral, distal, or shallow

• scraping the bevel along the bone

• not enough anesthetic

• deposited anesthesia too far laterally and anesthetized the mandibular nerve instead

Indications:

• pulpal anesthesia for more than one tooth

• bone too dense for SP

• periodontal/surgical procedures requiring anesthesia of buccal tissue and bone adjacent to the molar teeth

Contraindications:

• hemophiliacs at risk of hemorrhage

• infection/inflammation

Note:

• may also numb the mucous membrane of the maxillary sinus

• positive aspiration ≠ hematoma

  • PSA has the HIGHEST risk of post-injection hematoma

  • hematomas can happen when you enter the pterygoid plexus and nick the maxillary artery

• you are entering the pterygomaxillary fossa

• insertion depth: 13-16 mm depending on anatomy (“hubba-hubba” = stop penetrating when the hub is parallel with the CEJ of the 2nd molar)

GP Injection

Errors:

• too fast/too much deposited: ischemia and necrosis

• too fast deposit: sloughing

• soft palate anesthetized

Contraindications:

• inflammation/infection at injection site

Note:

• insertion depth: 5-6mm depending on anatomy

• hematomas are rare

• deposit 0.4-0.6 mL (1/4-1/3 cart) over 30 sec

NP Injection

Errors:

• too fast/too much deposited: ischemia and necrosis

• sterile abscess

• too fast deposit: sloughing

• soft palate anesthetized

• inserted directly into incisive papilla/penetrated foramen

Contraindications:

• inflammation/infection at injection site

Note:

• you will see tissue blanching

Local Infiltration

Field Block

Nerve Block

1.) GP means __________________

Greater Palatine

2.) NP means __________________

Nasopalatine

3.) PSA means __________________

Posterior Superior Alveolar

4.) Which type of needle is used for the following injections?

a. ASA

b. MSA

c. IO

d. PSA

e. GP

f. NP

a. ASA: 27 gauge short

b. MSA: 27 gauge short

c. IO: 25 gauge long

d. PSA: 27 gauge short

e. GP: 27 gauge short

f. NP: 27 gauge short

5.) The teeth anesthetized for the ASA are:

a) Maxillary central incisors

b) Maxillary central and lateral incisors

c) Maxillary central incisor to the canine

d) Maxillary central incisor to the MB root of the 1st molar

a) Maxillary central incisors

b) Maxillary central and lateral incisors

c) Maxillary central incisor to the canine

d) Maxillary central incisor to the MB root of the 1st molar

6.) The deposition site for the ASA is the:

a) Apex of the central incisor

b) Medial to the apex of the lateral incisor

c) Distal to the apex of the canine

d) Mesial to the apex of the canine

a) Apex of the central incisor

b) Medial to the apex of the lateral incisor

c) Distal to the apex of the canine

d) Mesial to the apex of the canine

7.) The deposition site for the MSA is the:

a) Above the apex of the 2nd premolar

b) distal of the canine

c) above the apex of the MB root of the 1st molar

d) infraorbital foramen

a) above the apex of the 2nd premolar

b) distal of the canine

c) above the apex of the MB root of the 1st molar

d) infraorbital foramen

8.) The teeth anesthetized for the MSA are:

a) maxillary 1st and 2nd premolars and MB root of the 1st molar

b) maxillary 1st and 2nd premolars and mesial of the canine

c) maxillary 1st, 2nd, and 3rd molars

d) maxillary 1st, 2nd, and 3rd molars except for the MB root of the 1st molar

a) maxillary 1st and 2nd premolars and MB root of the 1st molar

b) maxillary 1st and 2nd premolars and mesial of the canine

c) maxillary 1st, 2nd, and 3rd molars

d) maxillary 1st, 2nd, and 3rd molars except for the MB root of the 1st molar

9.) The deposition site for the IO is:

a) inside the infraorbital foramen

b) above the apex of the 1st premolar

c) 2mm superior to the infraorbital foramen

d) 2mm inferior to the infraorbital foramen

a) inside the infraorbital foramen

b) above the apex of the 1st premolar

c) 2mm superior to the infraorbital foramen

d) 2mm inferior to the infraorbital foramen

10.) The teeth anesthetized for the IO are the:
a) maxillary central incisor to the MB root of the 1st molar

b) maxillary 1st and 2nd premolars and MB root of the 1st molar

c) maxillary 1st, 2nd, and 3rd molars

d) maxillary central incisor to the canine

a) maxillary central incisor to the MB root of the 1st molar

b) maxillary 1st and 2nd premolars and MB root of the 1st molar

c) maxillary 1st, 2nd, and 3rd molars

d) maxillary central incisor to the canine

11.) The deposition site for the nasopalatine nerve block is:
a) behind the canine

b) 2mm inferior to the greater palatine foramen

c) over the nasopalatine foramen

d) inside the nasopalatine foramen

a) behind the canine

b) 2mm inferior to the greater palatine foramen

c) over the nasopalatine foramen

d) inside the nasopalatine foramen

12.) The nasopalatine nerve block anesthetizes the:

a) central incisor to canine

b) anterior palatal tissues from canine to canine

c) palatal soft tissues distal to canine

d) palatal soft tissues in the molar region only

a) central incisor to canine

b) anterior palatal tissues from canine to canine

c) palatal soft tissues distal to canine

d) palatal soft tissues in the molar region only

13.) The greater palatine nerve block anesthetizes the:

a) canine to MB root of the 1st molar

b) anterior hard palate from canine to canine

c) palatal tissues distal to the canine

d) palatal tissues in the molar region only

a) canine to MB root of the 1st molar

b) anterior hard palate from canine to canine

c) palatal tissues distal to the canine

d) palatal tissues in the molar region only

14.) The deposition site for the greater palatine nerve block is:
a) behind the 3rd molar

b) 2mm inferior to the greater palatine foramen

c) over the nasopalatine foramen

d) inside the greater palatine foramen

a) behind the 3rd molar

b) 2mm inferior to the greater palatine foramen

c) over the nasopalatine foramen

d) inside the greater palatine foramen

15.) What is a potential but rare complication while administering the PSA injection?

PSA injections can result in an extraoral hematoma.

16.) What is the correct sequence for managing a PSA hematoma?

a) rest, ice, compression

b) nothing as it will go away on its own

c) administer more anesthetic

d) compression, ice, analgesics, time

a) rest, ice, compression

b) nothing as it will go away on its own

c) administer more anesthetic

d) compression, ice, analgesics, time

17.) Give reasons related to the clinician as to why PSA hematomas may happen.

• inexperience

• probing with needle

• inappropriate needle length/using long needles in highly vascular areas

• multiple penetrations into the same site

• rough handling of pt

18.) Give reasons related to the patient as to why PSA hematomas may happen.

• bleeding disorders (e.g. hemophilia)

• Blood Thinners

• Fragile tissues from inflammation / age (loss of fat pads)

19.) TRUE or FALSE: All positive PSA aspirations result in extensive hematomas.

FALSE

20.) Describe the deposition site for the PSA injection.

posterior, superior, and medial to the maxillary tuberosity

21.) What structures are innervated by the PSA?

pulps, buccal bone, and buccal soft tissues of the maxillary molars on one side (possible exception: MB root of 1st molar)

22.) Upon aspiration, you see a worm of blood enter the cartridge. Your next step is to:

pull back a few mm, reposition the needle, then reaspirate in two planes

23.) Upon aspiration, you see a cloud of blood entering the cartridge. Your next step is to:

completely remove the needle from the tissues, change the needle and cartridge, then reinsert the needle and reaspirate in two planes

24.) Topical anesthetic for palatal injections should last for:
a) 1 minute of topical and pressure together

b) 1 minute of pressure followed by 1 minute of topical

c) 1 minute of topical followed by pressure

d) 1 minute of topical only

a) 1 minute of topical and pressure together

b) 1 minute of pressure followed by 1 minute of topical

c) 1 minute of topical followed by pressure

d) 1 minute of topical only

25.) Topical anesthetic should stay on the injection site for how long before an injection is administered?

1 minute

26.) Aspiration must be done:
a) as the needle advances

b) in two planes

c) at the penetration site

d) after withdrawal

a) as the needle advances

b) in two planes

c) at the penetration site

d) after withdrawal

27.) A blue needle is _____ gauge.

A blue needle is 30 gauge.

28.) A red needle is _____ gauge.

A red needle is 25 gauge.

29.) A yellow needle is _____ gauge.

A yellow needle is 27 gauge.

30.) 1.5 cartridges of 3% mepivacaine contains _____mg of mepivacaine.

1.5 cartridges of 3% mepivacaine contains 76.5 mg of mepivacaine.

.

1.5 cart × 51mg/cart = 76.5mg mepivacaine

31.) 1.75 cartridges of 2% lidocaine with 1:100,000 epinephrine contains _____mg lidocaine and _____mg epinephrine.

1.75 cartridges of 2% lidocaine with 1:100,000 epinephrine contains 59.5 mg lidocaine and 0.02975 mg epinephrine.

.

1.75 cart x 34mg/cart = 59.5mg lidocaine

1.75 cart x 0.017mg/cart = 0.02975mg epi

32.) 1.25 cartridges of 4% prilocaine with 1:200,000 epinephrine contains _____mg prilocaine and _____mg epinephrine.

1.25 cartridges of 4% prilocaine with 1:200,000 epinephrine contains 85 mg prilocaine and 0.010625 mg epinephrine.

.

1.25 cart x 68mg/cart = 85mg prilo

1.25 cart x 0.0085mg/cart = 0.010625mg epi

33.) 2.5 cartridges of 4% articaine with 1:100,000 epinephrine contains _____mg articaine and _____mg epinephrine.

2.5 cartridges of 4% articaine with 1:100,000 epinephrine contains 170 mg articaine and 0.0425 mg epinephrine.

.

2.5 cart x 68mg/cart = 170mg art

2.5 cart x 0.017mg/cart = 0.0425mg epi

34.) 3 cartridges of 0.5% bupivacaine with 1:200,000 epinephrine contains _____mg bupivacaine and _____mg epinephrine.

3 cartridges of 0.5% bupivacaine with 1:200,000 epinephrine contains 25.5 mg bupivacaine and 0.0255 mg epinephrine.

.

3 cart x 8.5mg/cart = 25.5mg bup

3 cart x 0.0085mg/cart = 0.0255mg epi