MAXILLARY NERVE BLOCK

CONTENTS…..o TRIGEMINAL NERVEo MAXILLARY NERVEo COURSE OF MAXILLARY NERVEo BRANCHES OF MAXILLARY NERVEo LOCAL ANESTHESIAo COMPOSITION OF LOCAL

ANESTHESIAo MAXILLARY INJECTION TECHNIQUEo COMPLICATION OF LOCAL

ANESTHESIAo COMPLICATION OF NERVE BLOCKo REFERENCE

TRIGEMINAL NERVE

It is the LARGEST CRANIAL NERVE, contains

both sensory and motor fibres. The trigeminal

nerve is attached to the lateral part of the pons

by its 2 ROOTS, motor & sensory.

 

TRIGEMINAL

 Ophthalmic Maxillary Nerve Mandibular Nerve

MAXILLARY NERVE The maxillary nerve originates at the

middle of the semilunar ganglion and

continues forward in the lower part of the

cavernous sinus. It then passes from the foramen

rotandum leaving the CRANIAL FOSSA

enters PTERYGOPALATINE FOSSA

In the pterygopalatine fossa, the nerve is

intimately related to the pterygopalatine

ganglion, and gives off the ZYGOMATIC &

POSTERIOR SUPERIOR ALVEOLAR NERVE.

. PSA Nerve enters the body of the maxilla, and supplies the upper molar teeth and the adjoining part of the gum

It further moves forward to the INFERIOR ORBITAL FISSURE, to pass into the orbital cavity, then laterally into

orbital groove k/a INFRA ORBITAL GROOVE continuing forward,

the second division emerges on the anterior surface of maxilla through the infra orbital foramen, where it divides into anterior and middle superior alveolar nerve, supplying the maxillary anterior teeth

.

PTERYGOPALATINE GANGLION It is the largest parasympathetic

peripheral ganglion.

It serves as a relay station for the secretomotor fibres to the lacrimal gland & to the mucous glands of the nose, the paranasal sinuses, palate & pharynx

Topographically it is related to the maxillary nerve but functionally it is related to the facial nerve through its greater petrosal branch.

.

The flattened ganglion lie in the

pterygopalatine fossa just below the

maxillary nerve, in front of the

pterygoid canal & lateral to the

sphenopalatine foramen

BRANCHES OF MAXILLARY NERVE

BRANCHES IN THE PTERYGOPALATINE GANGLION

ZYGOMATIC NERVE INFRA ORBITAL NERVEPOSTERIOR SUPERIOR ALVEOLAR

NERVEMIDDLE SUPERIOR ALVEOLAR NERVEANTERIOR SUPERIOR ALVEOLAR

NERVE

Branches of pterygopalatine ganglion

ORBITAL BRANCH- pass through the inferior

orbital fissure & supply the periosteum of the

orbit, & the obitalis muscle.

PALATINE BRANCHES- the GREATER OR

ANTERIOR palatine nerve descends through

the greater palatine canal, & supplies the hard

palate & the lateral wall of the nose. The

LESSER OR MIDDLE & POSTERIOR

PALATINE NERVES supply the soft palate &

the tonsil.

NASAL BRANCHES- enters the nasal cavity through

the sphenopalatine foramen. The LATERAL

POSTERIOR SUPERIOR NASAL NERVES, supply

the posterior part of the superior & middle

conchae.

The MEDIAL POSTERIOR SUPERIOR NASAL

NERVES, supply the posterior part of the roof of

the nose & of the nasal septum. The largest nerve

is known as the NASOPALATINE NERVE, which

descends upto the anterior part of the hard palate

through the incisive foramen.

PHARYNGEAL BRANCH- passes through

the palatinovaginal canal & supplies the

part of the nasopharynx behind the

auditory tube.

LACRIMAL BRANCH- to supply

secretomotor fibres to the lacrimal

gland

ZYGOMATIC NERVE Zygomatico temporal

Zygomatico Facial Arises from the temporal surface Emerges through

zygomatico

of zygomatic bone facial foramen

Supply the skin of the temple. Supplies skin of cheek.

BRANCHES IN THE INFRAORBITAL FORAMEN

the nerve passes through the infra orbital foramen giving off its 3

branches –

Palpebral Branch- Supply lower eyelid

Nasal Branch- Skin on lateral side of nose

Superior Labial Branch- Upper lip & part of

of nose

POSTERIOR SUPERIOR ALVEOLAR NERVE It arises from the trunk of the maxillary

nerve, just before it enters the infraorbital groove

They descends on the tuberosity of the maxilla & gives off several twigs to the gums & neighboring parts of the mucous membrane of the cheek

They then enters the alveolar canal on the infratemporal surface of the maxilla & passing from behind forward in the substance of the bone, communicate with the middle superior alveolar nerve, & gives off branches to the lining of the maxillary sinus & gingival and dental branches to each molar tooth from a superior dental plexus.

MIDDLE SUPERIOR ALVEOLAR NERVE

This nerve arises from the infra orbital nerve as it runs in the infra orbital groove, and runs down and forwards in the lateral wall of the maxillary sinus

It supply the sinus mucosa, the roots of the maxillary premolars, & the mesiobuccal root of the 1st molar.

ANTERIOR SUPERIOR ALVEOLAR NERVE

It is given off from the maxillary nerve just before its exit from the infraorbital foramen

It descends in a canal in the anterior wall of the maxillary sinus, & divides into branches that supplies the3 incisors & canines.

Local anesthesia

It is defined as transient regional loss

of sensation to a painful or

potentionally painful stimulus

resulting from a reversible

interruption of a peripheral

conduction along a specific neural

pathway to its central integration &

perception in the brain. (laskin)

Composition of local anaesthesia

Lignocaine Hcl 2%- anesthetic solution Adrenaline- vasoconstrictor 1: 80000 Methyl paraben- preservative ( 0.1%) Thymol- fungicide Sodium metabisulphite- reducing

agent(0.5mg) Distilled water- diluting agent/ Vehicle Sodium chloride- to maintain the

isotonicity of the solution (6mg)

NERVE BLOCK

LA deposited close to the main nerve trunk

usually at distance from the site of operative

intervention.

FIELD BLOCK

Local anaesthetic solution is deposited near

the larger terminal branch, so the

anaesthetized area will be

circumscribed.Treatment is done in an area

away from the site of injection

LOCAL INFILTRATION

Small terminal nerve endings in the area of

dental treatment are flooded with local

anesthetic solution. Treatment is done in

the same area of in which solution has

been deposited.

MAXILLARY INJECTION TECHNIQUES

SUPRA PERIOSTEAL INJECTION: ( Local Infiltration )

INDICATIONS: Pulpal anesthesia of maxillary teeth

when treatment is limited to one or two tooth .

Soft tissue anesthesia for surgical procedure in a circumscribed area.

TECHNIQUE: needle is injected beneath the mucous membrane & the solution is infiltrated slowly throughout the area.

AMOUNT TO BE DEPOSITED- 0.6ml over 20 sec.

CONTRAINDICATION: Infection or acute inflammation in the area of

injection.

DISADVANTAGES: Need for multiple needle insertions. Necessary to administer large volume of solution.

POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK:

OTHER NAMES: Tuberosity block / Zygomatic block

AREAS ANAESTHETIZED: Pulps of maxillary III,II and I molar

except mesio buccal root of I molar. Buccal periosteum and bone overlying

the teeth.

LAND MARKS: Mucobuccal fold. Zygomatic process of maxilla. Infra temporal surface of maxilla. Anterior border & coronoid process of the ramus

of the mandible. Tuberosity of maxilla.

TECHNIQUE: PATIENT POSITION- pt is positioned such that

maxillary occlusal plane is 45 degree angle to the floor.

25 gauge short needle is used.

Insertion- height of mucobuccal fold above the maxillary II molar.

The operators left forefinger over the muccobuccal fold in a post direction from the bicuspid area until the zygomatic process of maxilla is reached

At its post surface finger will feel a concavity in the mucobuccal fold. Then rotate the finger so that the fingernail is adjacent to the mucosa, & its bulbous portion still in contact with the posterior surface of the zygomatic process.

Now needle is held in pen grasp & inserted in a line parallel with the index finger, going UPWARD INWARD & BACKWARD ( this places the needle in the immediate vicinity of the foramen through which the nerves enter the maxilla).

SYMPTOMS- a) OBJECTIVE- instrumentation

necessary to demonstrate absence of pain.

b) SUBJECTIVE- None.

DEPTH OF NEEDLE PENETRATION-16 mm.

DEPOSIT:- 0.9 to 1.8 ml in 30 to 60 sec .

COMPLICATIONS: Hematoma

ANTERIOR SUPERIOR ALVEOLAR NERVE BLOCK

OTHER NAME: Infra orbital.

AREAS ANAESTHETIZED: Incisors, cuspids, bicuspids &

mesiobuccal root of 1st molar. Upper lip Lower eye lid. Portion of the nose of the injected site.

ANATOMICAL LANDMARKS: Infra orbital ridge. Infra orbital depression. Supra orbital notch. Infra orbital notch. Bicuspid teeth. Mental foramen. Pupil of the eyes. An imaginary straight line drawn vertically

through these landmarks will pass through the pupil opf the eyee, infraorbital foramen(when the infraorbital notch is located, the palpatating finger should be moved downward about 0.5mm, where a shallow depression will be felt), bicuspids, & mental foramen.

Maxillary occlusal plane at 45degree to the floor

NEEDLE PATHWAYBICUSPID APPROACH- The needle is

inserted in a line parallel with the supraorbital notch, the pupil of the eye,infra orbital notch, & 2nd biscuspid tooth

CENTAL INCISOR APPROACH- The neeedle bisects the crown of the central incisor from the mesioincisal angle to the distogingival angle.

In either situatin, the needle should not penetrate more than ¾ inch, it prevents the needle from entering the orbital cavity

TECHNIQUE: NEEDLE- 25 gauge needle. SOLUTION DEPOSITED- 0.9 to 1.5 ml. SYMPTOMS- SUBJECTIVE- Tingling & numbness of the

upper lip,side of the noseOBJECTIVE- instrumentation necessary to

demonstrate absence of pain.

COMPLICATION: Hematoma. Facial nerve paralysis.

GREATER PALATINE NERVE BLOCK:

OTHER NAME: Anterior palatine nerve block

AREAS ANAESTHETIZED: Posterior portion of hard palate and its over

lying soft tissues. Anteriorly up to I premolar and medially up to

midline.

ANATOMICAL LANDMARKS: II and III maxillary molars. Palatal gingival margin of II and III

maxillary molar. Midline of the palate. Line approximating 1cm from the palatal

gingival margin towards midline of the palate.

TECHNIQUE: NEEDLE- 25 gauge needle. INSERTION- From the opposite side of the

mouth at right angles to the target area. DEPOSITION-0.25 to 0.5 ml in 30 sec.

NASO PALATINE NERVE BLOCK:

OTHER NAMES: Incisive nerve block. Spheno palatine nerve block.

AREAS ANAESTHETIZED: Anterior portion of hard palate from mesial of Rt.

I premolar to mesial of the Lt.I premolar.

LANDMARKS: Central incisors Incisive papilla.

TECHNIQUE: INSERTION- At a 45 degree angle towards

incisive papilla. OPERATOR- In 9 or 10 o’ clock position. DEPOSIT- 0.45 ml of solution in 15 to 30

sec at a depth of 6 to 10 mm.

COMPLICATIONS: Necrosis of soft tissue due to highly

concentrated vasoconstrictor solution.

MAXILLARY NERVE BLOCK

For achieving profound anesthesia of hemi maxilla.

2 approaches 1) Greater palatine canal approach

2) High tuberosity approaches

OTHER NAMES:- Second division block, V2 nerve block AREAS ANESTHETIZED:- 1) Maxillary teeth on the affected side 2) Alveolar bone & overlying structures 3) Hard palate,part of soft palate 4) Upper lip, cheek, side of the nose, lower

eye lid

ADVANTAGES:-

1) Minimizes the no. of needle

penetrations

2) Minimizes the total volume of

local anesthetic solution 1.8ml

versus 2.7ml

3) high success rates

GREATER PALATINE APPROACH:- TARGET AREA:- Maxillary nerve as it passes

through the pterygopalatine fossa, the needle passes through greater palatine canal to reach pterygopalatine fossa

LAND MARKS:- Greater palatine foramen, situated between the 2nd & 3rd molars about 1cm towards the midline of the palate from the palatal gingival margin.

AREA OF INSERTION:- Palatal soft tissue directly over the greater palatine foramen.

PROCEDURE:- 25 gauge 32 mm long needle used 1.8 ml of the solution in 1 minute is deposited at the target area

COMPLICATIONS:- Hematoma Penetration of the orbit during

greater palatine foramen approach if the needle goes too far

Penetration of the nasal cavity occurs when the needle deviates medially during insertion

SYMPTOMS- OBJECTIVE- instrumentation

necessary to demonstrate absence of pain sensation

SUBJECTIVE- tingling & numbness of the upper lip, side of the nose, & lower eyelid.

HIGH TUBEROSITY APPROACH Technique:- needle used – 25 gauge 32mm long

needle LAND MARKS:- Muco buccal fold at the distal aspect of maxillary

second molar. Maxillary tuberosity Zygomatic process of the maxilla TARGET AREA:- Maxillary nerve as it passes through

pterygopalatine fossa superior & medial to the target area of PSA nerve

block.

DISADVANTAGES:- Risk of hematoma with high tuberosity approaches

INTRALIGAMENTARY ANESTHESIA

This is achieved by injecting an analgesic

solution directly into the periodontal

membrane of the tooth.

USES:

For extraction of teeth in hemophilic

patients to avoid bleeding.

Useful in pedodontic patients.

Indicated prior to immediate replacement

dentures.

TECHNIQUE: Finer needles of gauge 30

are inserted in the periodontal membrane to a

depth of 2mm.Needle is inserted parallel with

the long axis of the root of the tooth until it

contacts the alveloar bone. 0.2ml of solution is

injected over a period of 30secs.Maxillary

Molars require 3 injections and mandibular

molar 2 injections.PERIOD OF ANESTHESIA: 30-45 mins

DISADVANTAGES:

Infection of the site.

Discomfort after the analgesia wears off.

SUPRA PERIOSTEAL PSAASAGREATER PALATINE

NASOPALATINE

PALATAL INFILTRATION

MAXILLARY NERVE BLOCK

0.6ML

0.9-1.8 0.9-1.2 0.45-0.6 0.45 0.2-0.3

1.8

Recommended volume of local anesthetic for maxillary techniques

EXTRA ORAL TECHNIQUES INFRA ORBITAL BLOCKIndications:Infection, Trauma resulting in impossible

intra oral approach .

Anatomical Land marks: Pupil of the eye. Infra orbital ridge. Infra orbital notch. Infra orbital depression.

Technique: Using the available landmarks, the

dentist should locate the infra orbital foramen. The skin & subcutaneous tissue is anesthesized by local infiltration

25 gauge needle used, and is directed slightly upward & laterally which facilitates entrance into the foramen, which open downward & medially.

SYMPTOMS SUBJECTIVE- tingling & numbness of the

upper lip, side of the nose & lower eyelid OBJECTIVE- instrumentation necessary to

demonstrate absence of pain.

MAXILLARY NERVE BLOCK

Indications: During extensive surgery To block all sub divisions of maxillary

nerve with one needle insertion Local infection and trauma causing

difficulty for intraoral approach For diagnostic and therapeutic purposes

Anatomical land marks: Mid point of the zygomatic arch Zygomatic notch Coronoid process of the ramus of mandible Lateral pterygoid plate

AREA ANAESTHETIZED- Maxillary teeth on the affected side Alveolar bone & the overlying

structure Hard palate & portion of soft palate Upper lip, cheek, side of the nose &

lower eyelid

Technique: The midpoint of the zygomatic process

is located & the depression in its inferior surface is marked

A skin wheal is raised just below this mark, which the dentist identifies by having the patient open & close the jaw

The needle is inserted through the skin wheal, until the needle point gently contacts the lateral pterygoid plate.

The needle is withdrawn , with only the point left in the tissue, & re directed in a slight forward & upward direction untill the needle is inserted to the depth of the marker.

After careful aspiration, 2-3ml of LA is injected

Care should be exercised to aspirate after each 0.5ml of solution injected.

Complications of local anesthesia LOCAL Needle breakage Paresthesia Facial nerve paralysis Trismus Hematoma Pain on injection Burning on injection Edema Sloughing of tissues Post anesthetic intra oral lesions

SYSTEMIC COMPLICATIONS- Toxicity Idiosyncracy Allergy Anaphylactoid reaction

CLINICAL CONSIDERATION OF BLOCKS

Paraesthesia Needle breakage Haematoma Facial nerve paralysis

PARASTHESIA It is defined as persistent anesthesia,

(anesthesia well beyond the expected duration )

HYPERESTHESIA(increased sensitivity to noxious stimuli) & DYSESTHESIA(painful sensation occuring to non noxious stimuli) , in both of these patient experience PAIN & NUMBNESS.

CAUSE- Trauma to any nerve. Haemorrhage into or around the neural

sheath.

Injection of a LA solution contaminated by alcohol(alcohol are neurolytic & sometimes can produce long term trauma to the nerve) or sterilizing solution( produces irritation, resulting in edema & increased pressure in the region of the nerve, leading to parasthesia)

Trauma to the nerve sheath

PROBLEM May lead to self inflicted injury Biting or thermal or chemical insult can

occur without a patient awareness

PREVENTION- strict adherence to injection protocol & proper

care & handling of dental cartridgesMANAGEMENT- Reassure the patient, speak to the pt

personally, & explain is not uncommon after LA adminstration

Examine the patient- determine the degree & extent of the paresthesia

TINCTURE OF TIME- medicine Reschedule the pt for examination every 2

months Dental treatment may continue, but avoid

readminstration LA into the region of the previously traumatized nerve.

NEEDLE BREAKAGECAUSES- Weakening of the dental needle by bending it Sudden unexpected movement by the patient.PREVENTION- Use larger gauge needle (25gauge) Use long needles for injection requiring

penetration of significant depth of soft tissues Do not insert the needle into tissues to its hub Do not redirect a needle once it is inserted

into tissues.

MANAGEMENT Remain calm, do not panic Instruct the patient not to move, keep

the pt mouth open. If possible use a bite block

If fragment is visible, try to remove it with a SMALL HEMOSTAT OR A MAGILL INTUBATION FORCEPS

If the needle is lost, & cannot be retrieved

a) do not proceed with incision & probing

b) calmly inform the pt

• c) refer the patient to an oral & maxillofacial surgeon for consultation, & not for removal of the needle.

Despite attempted removal, it is then prudent to abandon the attempt & allow the needle fragment to remain

HEMATOMA The effusion of blood into extravascular

spaces can, result from inadvertently nicking a blood vessel during the injection of local anesthetic. Injecting the LA solution into the pterygoid plexus.

CAUSE- An arterial & venous puncture after PSA or IAN block, the tissue surrounding these vessels more readily accommodate significant volume of blood until extravascular pressure exceeds intravasular pressure.

HEMATOMA AFTER PSA ARE VISIBLE EXTRA ORALLY, WHILE WITH IAN VISIBLE INTRA ORALLY.

PROBLEM- A hematoma rarely produces

significant problems, aside from the resulting bruise, which may or may not be visible extraorally.

Swelling & discoloration subsides within 7-14 days.

Possible complication includes trismus & pain

PREVENTION1. Knowledge of the normal anatomy2. The depth of penetration for PSA may

be decreased in a patient with smaller facial characteristics

3. Use shorter needle for PSA.4. Minimize the no. of needle penetration

into tissue5. Never use a needle as a probe in

tissue.

MANAGEMENTIMMEDIATE- Direct pressure should be

applied to the site of bleeding.

PSA usually produces largest & unappealing hematoma. Digital pressure can be applied in the soft tissues in the mucobuccal fold as far distally as can be tolerated by the patient.

Apply pressure in a medial & superior direction

Ice should be applied to increase pressure on the site,& helps constricts the vessels.

ANTERIOR SUPERIOR ALVEOLAR NERVE BLOCK

pressure is applied to the skin directly over the infraorbital foramen

Clinical manifestation is discoloration of the skin below the lower eyelid

Hematoma is unlikely to arise from ASA, because the techniques described requires application of pressure to the injection site throughout drug administration & for a period of 2-3 min.

SUBSEQUENT- Patient should be discharged once the

bleeding stops, advise the patient about possible soreness and limitation of movement.

For soreness, take an analgesic Do not apply heat for the next 4-6hrs,

heat produces VASODILATION thereby increasing the size of hematoma.

Heat may be applied beginning the next day, that will increase the rate at which blood elements are resorbed.

FACIAL NERVE PARALYSIS

CAUSE-paralysis of some of the terminal branches

of the 7th cranial nerve, when infra orbital nerve block is injected or when maxillary canine are infilterated.

PROBLEM- Loss of motor functions to the muscles

of facial expression, there is usually minimal or no sensory loss

Inability to close the eyelid Drooping of lip on the affected side

Winking and blinking becomes impossible

Patients face appear lobsided.

MANAGEMENT- Reassure the patient- situation is

transitory Contact lenses must be removed

until muscle movement returns Eye patch should be applied,

periodically lubricate the eyes

REFERENCES

HANDBOOK OF LOCAL ANESTHESIA- 5th EDITION BY- STANLEY F. MALAMED

MONHEIM’S LOCAL ANESTHESIA AND PAIN CONTROL IN DENTAL PRACTICE BY- C.RICHARD BENNETT

B.D CHAURASIA