Maxillary Anesthetic Techniques

Maxillary Anesthetic Techniques
Maxillary Anesthetic
Techniques
Dr Hesham El-
El-Hawary
www.elhawarydentalclinic.com
ELHAWARY
The main factors are:
1. Selection of a suitable syringe and needle

2. Utilization of the proper L.A. drug
3. Insertion of the needle in the correct site for
injection
ELHAWARY
1. Middle meningeal nerve

2. Twiges to the
sphenopalatine ganglion
3. Posterior superior alveolar
nerve
4. Zygomatic nerve
5. Infra-Orbital Nerve
1. Middle superior alveolar
nerve
2. Anterior superior alveolar
nerve
3. Terminal branches
1. Inferior palpebral nerve
2. External nasal nerve
3. Superior labial nerve
ELHAWARY
Nerve supply of Maxillary teeth

Pulp , Investing structures & Labial (buccal) mucoperiosteum
Anterior teeth
Anterior superior alveolar nerve
(1,2,3)
Premolars (4,5) &

MB root of 1st Middle superior alveolar nerve
molar(6)
Molars except MB
root of 1st Posterior superior alveolar nerve
molar(6)
ELHAWARY
Nerve supply of Maxillary teeth Cont.
Palatal mucoperiosteum
Anterior teeth
Nasopalatine nerve
(1,2,3)
Premolars
(4,5)
Greater ( Anterior) palatine nerve
&
Molars (678)
ELHAWARY
Local Anesthesia
1. Topical anesthesia
2. Local infiltration
3. Field block
4. Nerve block
ELHAWARY
Local Anesthesia
Topical Anesthesia
Ointments, gels, sprays and pastes on mucous
membrane or skin
Application of a topical anesthetic agent on the
mucosa allows for the easy and painless insertion
of the sharp needle
Affects free nerve endings
ELHAWARY
Local Anesthesia
Local Infiltration
Flooding of the small terminal nerve endings with
local anesthetic solution
ELHAWARY
Local Anesthesia
Field Block
Referred to as local infiltration
local anesthetic solution is deposited in the
vicinity of larger terminal nerve fiber
so a circumscribed area is anesthetized
Local anesthesia injection above a tooth apex is
an example of a field block, in spite of being
referred to as paraperiosteal or supraperiosteal
infiltration anesthesia
ELHAWARY
Local Anesthesia
Subperiosteal injection
Not be attempted
Because of
Liability of needle breakage
Difficulty of forcing the anesthetic agent between
periosteum and bone
ELHAWARY
Local Anesthesia
Nerve Block
The anesthetic solution is deposited close to a
main nerve trunk
Usually at a distance from the operative site
before the nerve divided into terminal branches
ELHAWARY
Buccal inf.
Infiltiration
Palatal inf.
Incisive N.B.
Maxillary anesthesia
Anterior &
Middle Sup. Alv.
N.B.
Post. Sup. Alv.

Nerve block N.B.
Palatine N.B.
Maxillary N.B.
ELHAWARY
Factors affecting selection of the

technique to be used
1. Area to be anesthetized
Depending on the type of bone (density of bone)
Maxilla and anterior mandibular region are mainly formed
of cancellous bone with thin cortical layer above allowing
infiltration anesthesia or field block anesthesia reaches the
nerve filaments inside the cancellous bone
Posterior mandible is covered with thick and dense cortical
layer, thus nerve lock anesthesia is indicated
ELHAWARY

technique to be used Cont.
2. Extent of surgical procedure
In multiple extractions, nerve block anesthesia is
preferable to
Allow anesthesia of the entire operative area
Prevent multiple needle punctures to attain the
same anesthesia through infiltration
ELHAWARY

3. Duration and profoundness of anesthesia
Nerve block anesthesia produces a more profound
and longer duration than infiltration anesthesia
4. Age of the patient
Older individuals have dense bone, thus it is more
difficult for infiltration anesthesia to penetrate into
the bone
ELHAWARY

5. Homeostasis
When required for the procedure, infiltration
anesthesia is recommended to allow the
vasoconstrictor present with the local
anesthetic to act directly on the blood vessels
and reduce bleeding
ELHAWARY

6. Presence of infection
Infiltration anesthesia should be avoided to
prevent injection into an infected area which
can spread the infection
7. Skill of the operator
ELHAWARY
INFILTRATION ANESTHESIA
ELHAWARY
The most commonly used technique

It is divided into
Soft tissue infiltration
Submucosal
Paraperiosteal
Bony infiltration
ELHAWARY
Soft tissue infiltration anesthesia

In this technique anesthesia is deposited into
the soft tissue in close proximity to bone
which is then absorbed via pores in the bone
surface till it reaches the nerve filaments
inside the cancellous bone
ELHAWARY
Soft Tissue Infiltration

Submucosal anesthesia Paraperiosteal Anesthesia
Needle is inserted at a slight Called local infiltration
depth just below the Mostly used for anesthetizing
mucous membrane All maxillary teeth
In cases just need Lower anterior mandibular teeth
superficial anesthesia Its action depends on the
Hypertrophied tissue diffusion of the L.A. solution
High muscle attachment through the periosteum and the
minute foramina in the cortical bone
ELHAWARY
Paraperiosteal Anesthesia
Advantages Disadvantages
1. High success rate Not suitable for large areas
2. Technically it is an easy Needs multiple punctures
injection Administeration of large
3. Usually it is entirely amount of L.A. solution
atraumatic
ELHAWARY
MAXILLARY BUCCAL INFILTRATION

ANESTHESIA
ELHAWARY
Buccal infiltration anesthesia

Patient position Dentist position
Head , neck and trunk on the From infront and to the
same straight line right
The back of the chair is tilted so
that it make a 45 degree angle
with the floor
So that when the patient open his
mouth the occlusal plane of the
maxillary teeth makes 45 degree
with the floor
The occlusal plan of maxillary
teeth near to the operators
shoulder
ELHAWARY
Buccal infiltration anesthesia Cont.

Needle:
25-27 gauge
Short needle
Syringe
Non-Aspirating syringe
The target area
The apical region of the tooth to be anesthetized
ELHAWARY
Buccal Infiltration Technique Cont.

The point of needle insertion
The point of intersection of 2
imaginary lines
1st line is a vertical line
parallel to the long axis of
the tooth
2nd line is a horizontal line
along the mucobuccal fold
ELHAWARY
Buccal Infiltration Technique Cont.

Direction of needle insertion
45 with the buccal cortical
plate of bone
ELHAWARY
Steps for buccal infiltration

The lip/cheek is retracted using dental mirror or your
finger to make almost a right angle with the
labial/buccal aspect of the jaw
The point of insertion is determined as mentioned
The needle is inserted with its bevel toward the bone
and making an angle of 45 with the buccal aspect
The needle is pushed through the soft tissue until
the bone is reached (within 2mm)
ELHAWARY
Steps for buccal infiltiration Cont.

The needle is held firmly and 1.5cc of the solution is
slowly deposited for buccal/labial injection, and 0.3
cc for lingual anesthesia
The needle is then withdrawn gently and recap it
Wait 2-3 minutes before starting your dental

procedure
Check your anesthesia using the dental probe

(objective finding)
ELHAWARY
Confirming the Anesthesia

Subjective findings
No subjective findings
Objective findings
Probing does not lead to pain
ELHAWARY
MAXILLARY PALATAL INFILTRATION

ANESTHESIA
ELHAWARY
When you are performing any dental work

except extraction then the buccal infiltration is
enough
but
when it comes to extraction then also a Palatal
injection is to be given
ELHAWARY
Palatal Infiltration Technique

Midway between the
gingival margin of the tooth
and the median palatine
raphe
Along the long axis of the
tooth
ELHAWARY
Palatal Infiltration Technique Cont.

90
90 to the palatine bone
ELHAWARY
Steps for palatal infiltration

A mirror is used to retract the tongue and reflect the light to
the point of insertion
The point of insertion is determined as mentioned
The needle is inserted from the opposite side making 90
degree with the palate
The needle is pushed through the soft tissue until the bone is
reached (within 2mm)
On touching the palatal bone deposit 0.3 ml. SLOWLY
ELHAWARY

Subjective findings
Objective findings
ELHAWARY
Variations in these techniques

Buccal anesthesia Palatal anesthesia
Injection for the maxillary Injection for maxillary third
third molar molar should be at the
Made opposite to the palatal root of the maxillary
maxillary second molar second molar to avoid
tooth to avoid injury to the anesthesia of the lesser
pterygoid plexus of veins palatine nerves which
upper centrals supply the soft palate and
may lead to gagging
Inject a few drops to the sensation
apical area of the other
central incisor
ELHAWARY
Variations in these techniques Cont.

Buccal anesthesia Palatal anesthesia
Upper centrals Upper centrals and laterals
Inject a few drops to the Given 0.5 mm along the
apical area of the other palatal long axis of the
central incisor tooth while entering from
the opposite side
ELHAWARY
Bony infiltration anesthesia

In this technique anesthesia is deposited
directly into the bone in close proximity to the
nerve filaments inside the cancellous bone
Very rarely used
ELHAWARY
Bony Infiltration Anesthesia

(Intra osseous)
Techniques Advantages
A special needle is used to 1. Very profound anesthesia
drill and pierce the outer
2. When other techniques have
cortical plate
failed
Using rose head round bur
(#2) Disadvantages
1. The needle easily get clogged
2. The needle could fracture
3. Painfull
4. Cause infection inside the bone
ELHAWARY
Maxillary Nerve Block Techniques

Posterior superior alveolar nerve block
Anterior and middle superior alveolar nerve
block
Incisive nerve block
Greater palatine nerve block
Maxillary nerve block
ELHAWARY
Maxillary anesthetic Techniques
POSTERIOR SUPERIOR ALVEOLAR

NERVE BLOCK
(ZYGOMATIC
ZYGOMATIC//TUBEROSITY NERVE BLOCK)
ELHAWARY
This technique is used to anesthetize the

Posterior Superior Alveolar Nerve before it
enters the posterior surface of the maxilla
while it is in the infra
infra--temporal fossa
It will anesthetize the pulp, investing

structures and buccal mucoperiosteum of the
maxillary molars except for the mesio-buccal
root of the 1st molar
ELHAWARY
Posterior superior alv. N.B. Technique

Head , neck and trunk on In the left p.s.a. sits in a 10
the same straight line oclock position
The back of the chair is In the right p.s.a. he sits in
tilted so that it make a 45 an 8 oclock position
degree angle with the floor
So that when the patient
open his mouth the occlusal
plane of the maxillary teeth
makes 45 degree with the
floor
ELHAWARY
Posterior superior alv

alv.. N.B. Technique
Cont.
Needle:
25-27 gauge
Long needle
Syringe
Aspirating syringe
ELHAWARY

Cont.
Landmarks
Muccobuccal fold
Maxillary tuberosity
Zygomatic process
ELHAWARY

Cont.
Technique
1. Retract the cheek and prepare site of injection
2. The needle is introduced into the height of the mucobuccal fold
above the 2nd molar
3. Advance the needle slowly upward, backward and inward
4. The needle shouldnt touch bone, and the max. depth allowed is
the length of the long needle, then ASPIRATE
5. If blood comes out then retract and try again, but if you get blood
also the next time then abort the technique
6. If no blood comes out then deposit 1.5 ml of the anesthetic solution,
wait 3-5 minutes before working
ELHAWARY

Subjective findings
Objective findings
ELHAWARY
MAXILLARY NERVE BLOCK
ELHAWARY
The purpose of this technique is to block the main

trunk of the maxillary nerve as it traverses the
pterygopalatine fossa after emerging from
foramen rotandum
ELHAWARY
Maxillary Nerve Block

To accomplish this the same landmarks as the
post. Sup. Alv. N. block is used but you have to
enter the needle about 2/3 of its length
A larger amount is used in this case where
4ml are deposited slowly and after aspiration
to achieve a successful result
It is very rare to be done
ELHAWARY

Subjective findings
Numbness of:
The palate
Upper lip
Lateral aspect of the nose
Lower eye lid
Objective findings
Probing does not lead to pain in the palate and
buccal mucosa in any aspect
ELHAWARY
INFRAORBITAL NERVE BLOCK

(ANTERIOR AND MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK)
ELHAWARY
Infra Orbital N. BLOCK

The aim is to deposit the anesthetic solution into the
infraorbital canal through the infraorbital foramen
The foramen is shaped like a flattened funnel with the opening directed
downwards and medially. Thus the needle should approach the foramen
from the medial side
This is to anesthetize the anterior and middle

superior alveolar nerves
ELHAWARY
Infra Orbital N. BLOCK Cont.

In this technique the anterior & middle
superior alveolar nerves are anesthetized in
80% of cases
In the remaining 20% the middle sup.alv.

nerve has to be given a separate injection
ELHAWARY
Infra Orbital N. BLOCK Cont.

Area to be anesthetized:
The upper lip
The lateral aspect of the nose
The lower eyelid
The buccal mucosa of the upper anterior teeth and premolars
Pulp and investing structures of upper anterior teeth and premolars
ELHAWARY
Infraorbital N.Block Technique Cont.

Head , neck and trunk on the Stands on the right side
same straight line
infront of the patient
that the patient is in a supine for a right side injection
position
Along side the patient
teeth for a left side injection
Near to the operators
shoulder
At a 45 degrees angle to the
floor
ELHAWARY

Needle:
25-27 gauge
Long needle
Syringe
Aspirating syringe
ELHAWARY

The infraorbital foramen
ELHAWARY

Will be discussed in the
technique
ELHAWARY
Steps for Infraorbital N.Block

Technique Cont.
1. Clean the tissue to be injected with sterile gauze
2. Apply topical antiseptic followed by topical
anesthetic
3. Pull the upper lip taut
4. Locate the infraorbital foramen which is
About 5mm below the infraorbital ridge between the middle and inner
thirds
The foramen also lies in one vertical line with the pupil when the
patient gazes forwards
ELHAWARY

Technique Cont.
5. There are 3 acceptable methods of approaching the
infraorbital foramen: First technique
A vertical imaginary line is drawn from the inner canthus of
the eye until it intersects with another imaginary line
drawn in the mucobuccal fold forming a right angle
A 25 gauge needle is inserted in the mucobuccal fold about
5 mm lateral to the maxillary alveolar bone directing it to
bisect this imaginary right angle
ELHAWARY

Technique Cont.
infraorbital foramen: Second technique
The crown of the central incisor on the side of the tooth to
be operated on is bisected by the needle from the
mesioincisal edge to the distogingival angle with the point
of insertion 5 mm out from the mucobuccal fold to the
level of the canine apex
ELHAWARY

Technique Cont.
infraorbital foramen: Third technique
The syringe and needle are lined up with a vertical line
with the longitudinal axis of maxillary 2nd premolar in line
with the pupil of the eye while patient gazes forwards
The needle is inserted 5mm out in the mucobuccal fold
ELHAWARY

Technique Cont.
6. The needle is oriented with bevel towards bone and
advanced slowly till it contacts the upper rim of the
infraorbital foramen
The depth of penetration should not exceed 20 mm
6. Aspirate, if negative deposit the anesthetic solution
slowly
7. Wait 3-5 minutes before commencing dental
procedure
ELHAWARY

Subjective findings
Numbness of
The lower eye lid
Lateral wall of the nose
Upper lip
Objective findings
Probing does not lead to pain in the mucosa
opposite to the anterior teeth and premolars
ELHAWARY
INCISIVE CANAL NERVE BLOCK

(NASOPALATINE NERVE BLOCK)
ELHAWARY
Incisive canal N.Block

This is a painful injection so it is better to give a few drops of
anesthesia superficially before proceeding with the rest of the
injection
The aim is to anesthetize the nasopalatine nerve inside the incisive

canal
Area to be anesthetized:
The mucosa of the Anterior part of the palate opposite to the anterior teeth
ELHAWARY
Incisive canal N.Block Technique Cont.

Head , neck and trunk on the The operator will sit
same straight line
from infront and to the
that the patient is in a supine right
position
shoulder
ELHAWARY

Needle:
25-27 gauge
Short needle
Syringe
ELHAWARY

The incisive foramen i.e. the
crest of the incisive papilla
ELHAWARY

The needle is inserted into
the crest of the incisive
papilla
From between the upper
centrals making an angle of
45 degrees to the palatal
mucosa
ELHAWARY
Steps for incisive canal N.Block

Technique Cont.
1. Ask patient to open wide
2. A labioginigval crest injection is made to anesthetize the
incisive papilla first
3. The needle is oriented parallel with the labial alveolar plate
with the needle directed towards the crest of the incisive
papilla i.e. The needle approach is from between the upper
centrals making an angle of 45 degrees to the palatal
mucosa
4. The needle is inserted into the crest of the incisive papilla for
a distance of 4 mm
5. Inject 0.3 ml of anesthetic solution
ELHAWARY

Subjective findings
Numbness of the anterior 1/3 of the palate
Objective findings
Probing does not lead to pain in the anterior 1/3
of palate
ELHAWARY
GREATER PALATINE NERVE BLOCK
ELHAWARY
Greater Palatine N.Block Technique

The aim of this technique is to block the greater
palatine nerve as it comes out of its foramen
Its foramen usually lies distal to the upper 2nd molar,

but it can be more anterior
Areas to be anesthetized:
Palatal mucosa of the molars and premolars
ELHAWARY
Greater Palatine N.Block Technique Cont.

Head , neck and trunk on the The operator will sit
same straight line
from infront and to the
that the patient is in a supine right
position
shoulder
ELHAWARY

Needle:
25-27 gauge
Short needle
Syringe
ELHAWARY

The greater palatine foramen
distal to the palatal aspect
of the second molar
ELHAWARY

from the opposite side to
which the injection is to be
made
The needle approaching the
site of injection at right
angle
ELHAWARY
Steps for Greater Palatine N.Block

Technique Cont.
1. Ask patient to open wide
2. Palpate the position of the greater palatine foramen till you feel its
depression
3. Clean the tissue to be injected with sterile gauze
4. Apply topical antiseptic followed by topical anesthetic
5. A 27 gauge needle is inserted from the opposite side to which the
injection is to be made with the needle approaching the site of injection
at right angle
The needle is advanced through soft tissue until bone is contacted
6. About 0.5 ml of the anesthetic solution is deposited
7. Withdraw syringe and recap needle
8. Wait 2-3minutes before commencing dental procedure
ELHAWARY

Subjective findings
Numbness of the posterior 2/3 of the palate
Objective findings
ELHAWARY
THANK YOU
ELHAWARY

Maxillary Anesthetic Techniques

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Maxillary Anesthetic Techniques

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Maxillary Anesthetic Techniques

The main factors are:

1. Selection of a suitable syringe and needle

1. Middle meningeal nerve

Nerve supply of Maxillary teeth

Premolars (4,5) &

Nerve supply of Maxillary teeth Cont.

Post. Sup. Alv.

Factors affecting selection of the

Factors affecting selection of the

Factors affecting selection of the

Factors affecting selection of the

Factors affecting selection of the