maxillary injection techniques. anatomy atraumatic injection protocol
TRANSCRIPT
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Maxillary Injection Techniques
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Anatomy
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Anatomy
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Atraumatic Injection Protocol
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3 Main Types of Maxillary Injections:
1) Local Infiltration
2) Field Block
3) Nerve Block
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Local Infiltration• Incision (treatment) is done in the same area in which the
local anesthetic was deposited (interproximal papilla before Scaling and Root Planing)
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Field Block• Local anesthetic is deposited toward larger nerve terminal
branches• Treatment is done away from the site of local anesthetic
injection• Maxillary injections administered above the apex of the tooth
to be treated are properly referred to as field blocks not local infiltrations
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Nerve Block• Local anesthetic is deposited close to a main
nerve trunk, usually at a site removed from the area of treatment (PSA, IANB, NPB)
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Types of Injections1) Supraperiosteal Injection2) Intraligamentary (PDL) Injection3) Intraseptal Injection4) Intracrestal Injection5) Intraosseous Injection6) Posterior Superior Alveolar (PSA) Nerve Block7) Middle Superior Alveolar (MSA) Nerve Block8) Anterior Superior Alveolar (ASA) Nerve Block9) Maxillary Nerve Block (2nd Division)10) Greater Palatine Nerve Block11) Nasopalatine Nerve Block12) Anterior Middle Superior Alveolar (AMSA) Nerve Block13) Palatal Approach Anterior Superior Alveolar (P-ASA) Nerve Block
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Maxillary and Mandibular Injections
The following are used in both arches:
• Supraperiosteal Injection
• Intraligamentary (PDL) Injection
• Intraseptal Injection
• Intraosseous Injection
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Supraperiosteal Injection
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1) Supraperiosteal Injection
Used for pulpal anthesia in maxillary teeth
Anesthetizes large terminal branches of the dental plexus
Greater than 95% success rate
1 or 2 teeth
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Supraperiosteal InjectionDense bone covering the apices of the teeth can lead to
failure
-maxillary molar of children (zygomatic bone
obscures)
-central incisor of adults (nasal spine obscures)
Negligible positive aspiration rate (less than 1%)
Should not be used for large areas (multiple sticks/large amount of local anesthetic solution must be used)
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Technique Supraperiosteal Injection
1) 25 or 27 gauge short needle is recommended
2) Insert needle at height of mucobuccal fold over apex of desired tooth
3) Apply topical anesthetic for at least one minute
4) Orient bevel toward bone; lift lip pulling tissues taut
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5) Hold syringe parallel to long axis of the tooth
being anesthetized
6) No resistance to penetration should be felt and no
patient discomfort
7) Aspirate twice
8) Deposit .6 ml (one-third of a cartridge) into tissue
over 20 seconds
9) Do not allow tissues to balloon
10) Wait 3 to 5 minutes to begin dental treatment
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Problems/Failures
If tooth does not anesthetize the needle tip could be below the apex of the tooth resulting in inadequate anesthesia
If the needle lies too far from the bone then anesthesia will be inadequate because the solution was deposited in the soft tissue (lip)
The needle must be oriented toward the periosteum but should be managed properly to avoid tearing the highly innervated periosteum
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Supraperiosteal vs. Infiltration
These two words are used incorrectly; what most practitioners refer to as an infiltration injection is actually a field
block
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Citing the ongoing economic crisis and growing competition from
other insurers, Washington Dental Service will reduce reimbursement rates for all dental procedures by
15% starting June 1. Was it purely a business decision?
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Posterior Superior Alveolar Nerve Block (PSA)
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2) Posterior Superior Alveolar Nerve Block
Highly successful nerve block with greater than 95% success
Effective for maxillary 1st, 2nd and 3rd molars and buccal periodontium
Mesiobuccal root of the maxillary 1st molar is not consistently innervated by the PSA nerve
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Short dental needle is used for all but the largest of patients
Average depth of soft tissue penetration is 16 mm (short needle is 20 mm in length)
28% of maxillary 1st molars’ mesiobuccal roots are innervated by the middle superior alveolar nerve (MSA)
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When the risk of hemorrhage is too great as with a hemophiliac, you should use the supraperiosteal or PDL injections
Patient should feel no pain with this injection because bone is not contacted and there is a large area of soft tissue into which the solution is deposited
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Positive aspiration risk is 3.1%
Patient will often say that they do not feel numb; reason why is because they are accustomed to the intense feeling of anesthesia experienced by the IANB; reassure patient that you are going to make sure they are comfortable during the procedure
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Technique PSA Nerve Block
1) 25 gauge short needle is recommended
2) Insert needle at the height of the mucobuccal fold above the maxillary 2nd molar
3) Target area is the PSA nerve which is posterior, superior and medial to the posterior border of the maxilla
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4) Apply topical anesthetic for at least one minute
5) Have patient open their mouth half way which
makes more room
6) Retract the patient’s cheek with mirror
7) Pull the tissues taut
8) Orient bevel toward bone
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9) Insert needle at height of mucobuccal fold over the 2nd maxillary molar
10) Advance needle upward, inward and backward direction
11) Odd feeling of having no resistance whatsoever 12) Penetrating to an average depth of 10-14 mm is adequate
13) Aspirate in two planes by rotating bevel one quarter turn
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14) Deposit 0.9 ml of a cartridge (1/2 cartridge)
15) Wait 3 to 5 minutes to start treatment
Advance the needle in one movement, not three
separate movements; usually atraumatic to most patients
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Problems/Failures (PSA)
Hematoma formation if needle is overinserted too far posteriorly
Pterygoid plexus of veins leads to this hematoma
Visible intraoral hematoma develops within minutes; bleeds until the pressure of the extravascular blood equals that of the intravascular blood which can result in a large, unsightly hematoma
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Patients will usually claim that they do not feel any anesthesia which is not uncommon because patients can not reach this area to gauge their own level of anesthesia
If using a long dental needle the maximum
insertion should be one-half on its length or
16 mm
Problems/Failures (PSA)
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Middle Superior Alveolar Nerve Block (MSA)
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3) Middle Superior Alveolar Nerve Block
Middle Superior Alveolar Nerve is not present in 28% of the population
When the infraorbital nerve block fails to provide anesthesia to teeth distal to the maxillary canines, the MSA is indicated
MSA provides anesthesia to 1st and 2nd premolars and mesiobuccal root of maxillary 1st molar; anesthetizes buccal periodontium and bone
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If MSA is absent the premolars and mesiobuccal root of maxillary 1st molar is innervated by the ASA
Positive aspiration risk is less than 3% (negligible)
Infraorbital nerve block can block 1st premolar, 2nd premolar and mesiobuccal root of the maxillary 1st molar if you need an alternative block when the MSA is not adequate
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Technique MSA Nerve Block
1) 25 or 27 gauge long or short needle
2) Insert needle at the height of the mucobuccal
fold above 2nd maxillary premolar
3) Target is the maxillary bone above the
apex of the 2nd maxillary premolar
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4) Orient bevel toward bone to avoid
tearing periosteum
5) Apply topical anesthetic for one minute
6) Pull tissues taut
7) Penetrate tissues placing bevel of needle
well above the apex of the 2nd maxillary
premolar
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Technique- Middle Superior Alveolar Nerve Block
8) Aspirate
9) Slowly deposit 0.9-1.2 ml of solution
10) Wait 3 to 5 minutes before starting
treatment
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Problems/Failures MSA
Anesthetic not deposited above the apex of the 2nd premolar
Solution deposited into the soft tissue too far from the periosteum (lip)
Hematoma may develop; Dentist should apply pressure to the area with gauze for at least sixty (60) seconds; up to 2 to 3 minutes
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Middle Superior Alveolar Nerve Block
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Anterior Superior Alveolar Nerve Block (ASA)
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Highly successful extremely safe block that causes hesitation in most clinicians
Provides profound pulpal and soft tissue anesthesia from the maxillary central incisor distal to the premolars in 72% of patients
Used in place of the supraperiosteal injection
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Uses less anesthetic solution than the supraperiosteal injection
Supraperiosteal 3.0 ml solutionASA 1.0 ml solution
#1 fear is damage to the patient’s eye which is unfounded
Also known as the Infraorbital Nerve Block which is inaccurate
Failed ASA is just a supraperiosteal injection over the 1st premolar
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Areas Anesthetized ASA Nerve Block
1) Pulp of the maxillary central incisor through the
canine
2) 72% of patients have premolars and mesiobuccal
root of 1st molar anesthetic
3) Buccal periodontium and bone of the above teeth
4) Lower eyelid, lateral aspects of the nose and upper
lip
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When Do I Use This Block?
1) Dental procedures involving more than
one tooth, i.e., central and lateral incisor
2) Inflammation/Infection precluding the use
of the supraperiosteal injection
3) Ineffective supraperiosteal injections due
to dense cortical bone
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Technique ASA Nerve Block
1) 25 gauge long needle is recommended
2) Insert needle at the height of the mucobuccal fold over the 1st premolar
3) Target: Infraorbital Foramen
4) Landmarks: Infraorbital Notch, Mucobuccal fold, Infraorbital Foramen
5) Apply topical anesthetic for at least one minute
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6) Feel the infraorbital notch moving your finger down the notch palpating the tissues gently; the outward bulge is the lower border of the orbit which is the roof of the infraorbital foramen; continue the finger inferiorly until a depression is felt which is the infraorbital foramen
7) Maintain pressure over the foramen while inserting the needle down the long axis of the 1st premolar
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8) Advance the needle slowly until bone is contacted
gently which is the upper rim of the infraorbital
foramen
9) 16 mm total advancement of needle;1/2 of long
needle length
10) Estimate the distance between the infraorbital
foramen and mucobuccal fold
11) Aspirate
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12) Deposit 1.0 ml of anesthetic solution
13) Administrator can feel the anesthetic expanding the tissue with finger tip
14) Maintain finger pressure over the foramen for at least one minute to disperse the anesthetic solution
15) Needle should not be palpable in most patients
16) Wait 3 to 5 minutes for anesthesia to result
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Problems/Failures (ASA)
Failure is from the needle deviating to the medial or lateral away from the infraorbital foramen
Failure to reach the infraorbital foramen will result in anesthesia of the lateral side of the nose, upper lip and lower eyelid but not the teeth
Hematoma formation can result although rarely; apply pressure to area for 2 to 3 minutes; at least 60 seconds
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Palatal Anesthesia
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Palatal AnesthesiaEasily one of the most traumatic experiences
for dentists due to the pain that is sometimes elicited from the patients
Palatal injections can be administered atraumatically
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STEPS- Results in painless palatal injections
1) Apply topical for two minutes
2) Apply pressure to site both before and
during deposition of the solution
3) Deposit solution slowly
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5 PALATAL INJECTIONS
1) Anterior (Greater) Palatine Nerve Block: no pulpal anesthesia 2) Nasopalatine Nerve Block: no pulpal anesthesia
3) Local Infiltration: no pulpal anesthesia
4) P-AMSA: pulpal and soft tissue
5) P-ASA: pulpal and soft tissue
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Greater Palatine Nerve Block
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GP Nerve Block (soft tissue and bone only)
Anesthetizes palatal soft tissue distal and medially to the canine
(posterior portion of the palate)
Tissues around the Greater Palatine Foramen are able to accommodate a larger volume of
solution than the tissue in the vicinity of the Nasopalatine Foramen less patient
discomfort
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Indications for palatal injections:
1) Scaling and root planing
2) Subgingival restorations
3) Deep placed matrix bands
4) Extractions (oral surgery)
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Technique Greater Palatine Nerve Block
1) 27 gauge short needle
2) Insert needle in soft tissue slightly anterior
to the greater palatine foramen
3) Target is the greater palatine nerve as it
passes from the foramen between the soft
tissue and bone of the hard palate
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Locate the Greater Palatine Foramen:
-use cotton swab/mirror handle
-place a cotton swab at the junction of the
maxillary alveolar process and the hard palate
-press firmly into tissues moving posteriorly
from the maxillary 1st molar
-swab “falls” into the depression of the
greater palatine foramen
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4) Foramen is most often located distal to the 2nd maxillary molar
5) Apply considerable pressure to cotton swab in area of foramen until a noticeable ischemia occurs; hold pressure for 30 seconds before injection
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6) Continue to apply pressure throughout the
injection with the cotton swab
7) Slowly advance the needle until bone is
gently contacted
8) Depth of penetration is usually less than 10 mm
9) Aspirate
10) Deposit solution very slowly
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Do not enter the greater palatine canal
There is no reason to have the needle penetrate the canal
There is no negative repercussion except post-operative pain
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Nasopalatine Nerve Block
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Nasopalatine Nerve Block (soft tissue and bone only)
Considered by many to be the most traumatic, painful injection of all the dental injections
Most important injection to follow the protocol about to be explained
Anesthetizes the anterior portion of the hard palate (soft and hard tissues) from the mesial of the left premolar to the mesial of the right premolar
Use this injection for the same reasons as Greater Palatine Nerve Block
Target area is the incisive foramen beneath the incisive papilla
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Technique Nasopalatine Nerve Block
1) 27 gauge short needle is recommended
2) Insertion point: palatal mucosa just lateral to the
incisive papilla
3) Approach the injection site at a 45 degree angle
4) Apply topical anesthetic for two minutes
5) Apply considerable pressure to the incisive papilla
until ischemia
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6) Continue to apply pressure to the cotton applicator
tip while injecting
7) Advance the needle until bone is gently contacted
8) Depth of needle penetration is usually 5 mm
9) Slowly deposit ¼ cartridge over a 30 second
interval
10) Wait 2-3 minutes for anesthesia
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Other Than P-ASA and Maxillary Nerve BlocksThere is no reason to enter the Greater
Palatine Foramen or the Nasopalatine
Foramen when providing these injections
do not advance needle more than 5 mm
into the incisive canal because it could
enter the floor of the nose causing infection
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Back SprayDuring palatal injections, the pressure
generated within the syringe will cause
the solution to spray into your mask/face;
always wear the appropriate safety
glasses and mask when giving any injection
regardless of how trivial it may seem
at the time
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2nd Example of Nasopalatine Injection
Technique 2nd Example of Nasopalatine Injection
Insertion Points:
1) Labial frenum; midline of maxilla (0.3 ml over
15 seconds)
2) Interdental papilla of #8 and #9 (0.3 ml over
15 seconds)
3) Palatal soft tissues lateral to the incisal
papilla (contact bone)
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2nd Example of Nasopalatine Injection
Important Points:• Topical and pressure anesthesia on the palate are not
necessary because the first injection anesthetized the palatal
tissues• Contact bone on the 3rd injection (incisive papilla) only• Interdental papilla between maxillary central incisors is sore
for a few days• Greater palatine nerve may overlap and lead to inadequate
anesthesia of the canine and 1st premolar
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Local Infiltration of the Palate
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Local Infiltration of the Palate
Anesthetizes the terminal branches of the Greater Palatine Nerve and Nasopalatine Nerve
Anesthetizes the soft tissue in the immediate vicinity of the injection
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Indications for Palatal Anesthesia:
1) Hemostasis during procedures of a minimal area of tissue
2) Palatogingival pain control for rubber dam clamps, retraction cord placement and small
surgical procedures
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Local Infiltration of the PalateImportant Points: -Gate control method (inhibitory neuron prevents the projection neuron from sending signals to the brain (gate is closed)) of pain removal is used with -these injections using a cotton swab for pressure resulting in blanching tissue -Target area is the palatal tissue 5 to 10 mm from the free gingival margin -Masticatory mucosa of the hard palate is only 3 to 5 mm thick -Palatal Infiltrations are safe areas anatomically to deposit anesthetic
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P-ASA
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P-ASA Palatal Approach Anterior Superior Alveolar Nerve Block
• Described in the 1990s by the inventors of the CCLAD systems
• Comparative to the Nasopalatine Nerve Block
• Insertion: lateral point of the incisive papilla but the big difference:
NEEDLE TIP IS POSITIONED IN THE
INCISIVE CANAL
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• Deposit 1.4 – 1.8 ml of solution at
0.5 ml per minute
• Primary method of achieving bilateral pulpal anesthesia of the maxillary anterior six teeth; anterior palatal 1/3rd
• Provides profound soft tissue anesthesia of the gingiva and mucoperiosteum
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• Soft tissue of the facial attached gingiva is achieved anterior to the maxillary anterior six teeth
• P-ASA is the 1st injection to produce bilateral pulpal anesthesia of the maxillary anterior six teeth from a single injection
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MAIN POINT OF THIS INJECTION:
P-ASA is designed to provide pulpal anesthesia of the maxillary anterior six teeth in addition to the facial
gingival soft tissue and mucoperiosteum
it does not anesthetize the lip as with the regular mucobuccal fold approach; esthetic Dentistry can
then be assessed without dealing with lip anesthesia when smiling
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• Palatal approach allows anesthesia to be limited to the subneural plexus for the maxillary anterior teeth and nasopalatine nerve
• Minimum volume for injection is 1.8 ml (full cartridge) over 0.5 ml/minute
• Insert needle very slowly
• 4% anesthetics should have volume reduced by ½ (Prilocaine/Articaine)
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• Do not use 1:50,000 epinephrine
• May need supplemental mucobuccal fold injections for canines because of their very long roots
• Palatal ulcers develop from ischemia
1-2 days after treatment and are self-
limiting; healing occurs in 5-10 days
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Technique P-ASA
1) 27 gauge short needle is recommended
2) Insert needle just lateral to the incisive
papilla in the papillary groove
3) Target is the nasopalatine foramen
4) Needle held at 45 degree angle to the palate
(same as central incisors)
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5) Insert needle 6 to 10 mm; if resistance is found do not force needle6) Insert needle 1-2 mm every 4-6 seconds while administering solution7) Resistance means you have to reinsert the needle; careful of nose floor8) Aspirate9) Deposit 1.8 ml of anesthetic solution very slowly 0.5 ml/minute10) Patient may feel “needle shock” very disturbing
to patient
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Maxillary Nerve Block
1) Greater Palatine Approach
2) High Tuberosity Approach
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Maxillary Nerve Block Facts
Also known as a 2nd Division block
Anesthetizes the maxillary division of the trigeminal nerve
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Areas Anesthetized:
1) Pulpal anesthesia of all teeth on the side of
injection (ipsalateral)
2) Buccal periodontium and bone on the side of
injection
3) Soft tissues and bone of the hard palate/soft palate
medial to midline
4) Skin of lower eyelid, side of the nose, cheek and
upper lip
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Maxillary Nerve Block Approaches
It would require 4 other injections to get the effect of the Maxillary Nerve Block i.e., PSA, Infraorbital, Greater Palatine and Nasopalatine
2 Approaches:
1) Greater Palatine Approach
2) High Tuberosity Approach
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1) Greater Palatine Approach Technique
25 gauge long needle recommended
Insert into palatal soft tissue over greater palatine foramen
Target is the maxillary nerve as it passes through the Pterygo-palatine Fossa; the needle passes through the Greater Palatine Canal to reach the Pterygopalatine Fossa
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Find the foramen by using a cotton swab until it “falls into” the foramen
Most often found at distal of the maxillary 2nd molar
Topical anesthetic for at least two minutes
Inject into the area adjacent to the Greater Palatine Foramen in order to block the nerve before probing into the actual foramen itself
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1) Greater Palatine Approach Technique
Remember to apply constant pressure into this area until the
tissue blanches which will lessen the discomfort of the needle penetration
Probe gently for the foramen with the needle tip at a
45 degree angleAfter finding the canal advance the needle 30 mm 5 to 15% of foramens have boney obstructions, so if you
encounter an obstruction do not force the needle, try again then abort
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Maxillary Nerve Block Complications
1) Greater Palatine Approach Complications
Penetration of the orbit leading to a myriad of complications
periorbital swelling or proptosis (bulging eye)block of 6th cranial nerve producing diplopia
(double vision)Retrobulbar (behind the eye) hemorrhage,
corneal anesthesiaoptic nerve anesthesia loss of vision
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Maxillary Nerve Block Complications
Penetration of the nasal cavity (medial wall of the pterygopalatine fossa is paper thin):
-patient complains of something draining down their throat
-large amounts of air will be aspirated into the cartridge
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Maxillary Nerve Block 2nd Approach
2) High Tuberosity Approach
25 gauge long needle recommendedInsert to the height of the mucobuccal fold distal
to the 2nd molarTarget is maxillary nerve as it passes through the
pterygopalatine fossaSuperior and medial to the target site of the PSA
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Again, advance the needle to a depth of 30 mmUpward, inward and backward direction same as
PSAResistance should not be felt, if it is, the
angulation is too medialAt 30 mm the needle tip should lie within the
pterygopalatine fossaAspirate several times and inject 1.8 ml (one
cartridge) slowly
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Maxillary Nerve Block 2nd Approach
2) High Tuberosity Approach Complications
Hematoma develops rapidly if the maxillary artery is punctured with the needle tip
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Thin, porous substance of the maxillary bone allows for rapid diffusion of solutions into the cancellous bone
Most Dentists rely solely on the supraperiosteal injection to provide anesthesia in the maxilla
PSA and ASA combined can deliver safe anesthesia to virtually all patients requiring maxillary anesthesia
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Universal:
-applying topical anesthetic for one minute
-proper patient positioning
-aspiration
-making the needle safe after each injection with the scoop technique
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References
Malamed, Stanley: Handbook of Local Anesthesia. 5th Edition. Mosby. 2003
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