Maxillary Local Anesthesia, Palatal Anesthesia, and Maxillary Nerve Block Techniques PDF

Techniques of Maxillary Anesthesia ▪ Palatal Anesthetic Techniques ▪ Maxillary Nerve Block Technique Dr. Ahmed Mohammed Saaduddin Assistant Professor Of Oral & Maxillofacial Surgery Consultant of Oral Surgery Division of Oral Surgery – Clinical Science Department – Dentistry Program Batterjee M...

Techniques of Maxillary Anesthesia ▪ Palatal Anesthetic Techniques ▪ Maxillary Nerve Block Technique Dr. Ahmed Mohammed Saaduddin Assistant Professor Of Oral & Maxillofacial Surgery Consultant of Oral Surgery Division of Oral Surgery – Clinical Science Department – Dentistry Program Batterjee Medical College – Jeddah Monday 2nd September 2024 Palatal Anesthesia Nasopalatine Nerve Block Technique ─ Provide adequate topical anesthesia at the site of needle penetration. ─ The topical anesthetic should remain in contact with the palatal soft tissues for at least two minutes and the dentist should hold the cotton swab in position the entire time. ─ Use pressure anesthesia at the site before and during needle insertion and solution deposition. ─ Maintain control over the needle [the administrator must secure a firm hand rest]. ─ Deposit the anesthetic solution slowly. ─ Trust in yourself…that you can complete the procedure atraumatically. Palatal Injections: FIVE PALATAL INJECTIONS ARE DESCRIBED: ►Techniques to achieve soft tissue anesthesia and hemostasis but cannot provide any pulpal anesthesia of the maxillary teeth: 1. Anterior (Greater) palatine nerve block provides anesthesia for the posterior portion of the hard palate; 2. Nasopalatine nerve block provides anesthesia for the anterior portion of the hard palate; 3. Local infiltration of the hard palate provides soft tissue anesthesia in a circumscribed area of the hard palate. ►Techniques to achieve soft tissue anesthesia and hemostasis and pulpal anesthesia of the maxillary teeth: 4. Anterior-middle superior alveolar nerve block technique. 5. Palatally injected anterior superior alveolar nerve block [P-ASA] technique. With the introduction of computer-controlled local anesthetic delivery (C-CLAD) systems (The Wand, Comfort Control Syringe, and STA Single Tooth Anesthesia System) delivery of atraumatic palatal injections has become even more simplified. NPNB ASANB – Palatal Approach  Palatal Infiltration Technique Palatal Infiltration Technique ► Nerves Anesthetized: − Terminal branches of the nasopalatine and greater palatine nerves. ► Areas Anesthetized − Soft tissues in the immediate vicinity of the injection. ► Indications − To achieve hemostasis during surgical procedures − Palatogingival pain control for operative procedures (application of a rubber dam clamp, packing of retraction cord) not more than two teeth. ► Contraindications − Inflammation or infection at the injection site − Pain control in soft tissue areas involving more than two teeth. ► Advantages − Provides acceptable hemostasis when a vasoconstrictor is used − Provides a minimum area of numbness ► Disadvantage − Potentially traumatic injection. Palatal Infiltration Technique ► Alternatives: − For pain control: 1. Nasopalatine nerve block 2. Greater palatine nerve block, 3. AMSA nerve block, 4. Maxillary nerve block ► Positive Aspiration − Negligible. ► Procedure: − Point of insertion: Midway between the gingival margin and the median palatine raphe. − Path of Needle Insertion: The needle is directed to the point of insertion from the opposite side and at an angle of 90° to the palatal vault. − Depth of Penetration: The needle penetrates the tissue until it gently touches the palatal bone. − Dose of LA: Deposit (0.3 ml) of the solution over 20 seconds. (Soft Tissue Anesthesia)  Greater Palatine Nerve Block [GPNB] Technique Greater Palatine Nerve Block [GPNB] Technique ► Indication: − To anesthetize the palatal soft tissue distal to the canine (opposite to premolars and molars). ► Contraindications: − Infection or inflammation at the injection site. − Small field of therapy (one or two teeth) ► Advantage: [In comparison with the palatal infiltration technique] − Reduced patient discomfort [single needle penetration with a small volume of anesthetic solution] − Insignificant positive aspiration rate [less than 1%]. ► Disadvantage:[In comparison with the palatal infiltration technique] − No hemostasis except in the immediate area of injection − Potentially traumatic. However, the GPNP is less traumatic than the NPNB because tissues surrounding the greater palatine foramen are not as firmly adherent to bone and therefore can better accommodate the recommended volume of anesthetic solution. ► Alternatives: − Local infiltration into specific regions − Maxillary nerve block Greater Palatine Nerve Block [GPNB] Technique ► Nerve Anesthetized − The greater palatine nerve. ► Area Anesthetized: − The soft tissues covering the posterior portion of the hard palate [Anteriorly as far as the first premolar - Medially to the midline – Laterally: palatal gingival margin – Posteriorly: Third molar]. ► Target Area: − Greater (anterior) palatine nerve as it passes anteriorly between soft tissues and bone of the hard palate. ► Landmark: − Greater palatine foramen (located in between the maxillary second and third molars distal to the maxillary second molar) − Junction of the maxillary alveolar process and palatine bone. Greater Palatine Nerve Block [GPNB] Technique ► Procedure: 1. Path of insertion: advance the syringe from the opposite side of the mouth at a right angle to the target area. 2. Orientation of the bevel: toward the palatal soft tissues 3. Apply enough pressure to permit the bevel to penetrate the mucosa and slowly advance the needle until the palatine bone is gently contacted 4. Depth of penetration: it is usually about 5 mm. 5. Aspirate in two planes. If negative, slowly deposit one-third of the cartridge contents (0.6 mL) over 20 seconds. 6. Withdraw the syringe and make the needle safe. 7. Wait 2 to 3 minutes before commencing the procedure. Greater Palatine Nerve Block [GPNB] Technique ► Complications: # Complication Cause Management Inadequate anesthesia of the Overlapping nerve supply from the nasopalatine 1 Additionally administer the NP block. maxillary first premolar nerve Inadvertent anesthetization for the lesser palatine Reassure the patient and have the patient avoid swallowing 2 Soft palate anesthesia [LP] nerve that lies near the greater palatine foramen any food or drink until the anesthesia wears off. Postoperative tissue ischemia 3 Excessive blanching on the palatal tissue Tissue massage to allow the spread of the anesthetic agent and sloughing  Nasopalatine Nerve Block [GPNB] Technique Nasopalatine Nerve Block [NPNB] Technique ► Other Names” − Incisive nerve block (confusion with the “other” incisive nerve block in the mandible), − Sphenopalatine nerve block. ► Indication: − To anesthetize the palatal soft tissue mesial to the canine (opposite to the six anterior teeth). ► Contraindications: − Infection or inflammation at the injection site. − Small field of therapy (one or two teeth) ► Advantage: [In comparison with the palatal infiltration technique] − Reduced patient discomfort [single needle penetration with a small volume of anesthetic solution] − Insignificant positive aspiration rate [less than 1%]. ► Disadvantage:[In comparison with the palatal infiltration technique] − No hemostasis except in the immediate area of injection − Potentially traumatic. Nasopalatine Nerve Block [GPNB] Technique ► Nerve Anesthetized − The nasopalatine [long sphenopalatine] nerve. ► Area Anesthetized: − Anterior portion of the hard palate (soft and hard tissues) opposite to the six anterior teeth. ► Alternatives: − Local infiltration into specific regions − Intranasal local anesthetic mist. − Maxillary nerve block − AMSA nerve block (unilateral only) Nasopalatine Nerve Block Technique Approaches: (A)Single penetration technique. (C) Intranasal local anesthetic mist [Kovanaze (3% Tetracaine with 0.05% oxymetazoline)] (B) Multiple penetrations technique. Nasopalatine Nerve Block Technique Single Penetration Technique ▪ Landmarks Palatal tissue lateral to incisive papilla and palatal to maxillary central incisors. ▪ Area of Insertion Palatal mucosa lateral to the incisive papilla which is a highly sensitive tissue. ▪ Target Area Incisive foramen deep to incisive papilla [palatal to maxillary central incisors at the anterior part of the hard palate]. ▪ Path of Insertion The needle should approach the injection site at an angle of 45O toward the incisive papilla from the opposite side of the mouth. ▪ Dose One-fourth (1/4) of a cartridge (0.45 mL) is injected over 20 seconds. 0.6 ml Nasopalatine Nerve Block Technique Single Penetration Technique Nasopalatine Nerve Block Technique First Injection Second Injection Third Injection ▪ Location: base of labial frenum. ▪ Location: base of the interdental papilla ▪ Location: incisive papilla. ▪ Amount of LA to be Deposited: 0.3 ml. between the central incisors and above ▪ Amount of LA to be Deposited: 0.3 ml the crest of bone ▪ Amount of LA to be Deposited: 0.3 ml. Nasopalatine Nerve Block Technique First injection Second injection Third injection  Nasopalatine Nerve Block Technique ► Complications: # Complication Cause Management Inadequate anesthesia of the 1 Overlapping nerve supply from greater palatine nerve Additionally, administer the GPNB. maxillary canine Escape of anesthesia from the Density of the tissue and constricted area for 2 Inject slowly and rinse patient’s mouth tissue anesthetic deposition Postoperative tissue ischemia 3 Excessive blanching on the palatal tissue Tissue massage to allow the spread of the anesthetic agent and sloughing Maxillary Nerve Block (V2 - NB) Maxillary Nerve Block (V2 NB) Other Names Alternatives Indication & Contraindications Advantages & Disadvantages Armamentarium Approaches Steps Complications Anatomy Maxillary Nerve Block Technique Other Names Second Division Nerve Block (V2-NB). Anesthetized Nerve Branches Maxillary division of the trigeminal nerve: 1. Posterior superior alveolar nerve 2. Middle superior alveolar nerve 3. Anterior superior alveolar nerve 4. Nasopalatine nerve 5. Greater palatine nerve Approaches A. Intra-Oral [High Tuberosity Approach] B. Intra-Oral [Greater Palatine Approach] C. Extra-Oral Approach Maxillary Nerve Block Technique Alternatives To achieve the same distribution of anesthesia present with a maxillary nerve block, all of the following must be administered: 1) Posterior Superior Alveolar Nerve Block 2) Anterior Superior Alveolar (Infraorbital) Nerve Block 3) Nasopalatine Nerve Block 4) Greater Palatine Nerve Block Areas Anesthetized 1. Ipsilateral buccal mucoperiosteum 2. Ipsilateral buccal alveolar bone plate 3. Ipsilateral buccal periodontal tissues 4. Ipsilateral pulps of all maxillary teeth 5. Ipsilateral palatal periodontal tissues 6. Ipsilateral palatal alveolar bone plates 7. Ipsilateral palatal mucoperiosteum 8. Ipsilateral buccal skin of the lower eyelid, side of the nose, upper lip, and skin over cheek zygomaticofacial. Maxillary Nerve Block Technique Advantages 1. Large field of anesthesia with a long duration of action. 2. It minimizes the number of needle penetrations. 3. It minimizes the total volume of local anesthetic solution injected. Disadvantages: 1. Lack of hemostasis (If necessary, infiltration of local anesthetic with vasoconstrictor at the surgical site). Indication: 1. Pain control before extensive dental procedures (quadrant dentistry procedures) requiring anesthesia of the entire maxillary division. 2. When tissue inflammation or infection precludes the use of other regional nerve blocks (e.g., PSA, ASA) or supraperiosteal injection. 3. Diagnostic and therapeutic procedures of trigeminal neuralgias involving the maxillary division. Contraindications 1. Inexpert administrator. 2. Uncooperative patient. 3. Presence of infection at the site of injection. 4. Increased possibility of hemorrhage. 5. In the greater palatine canal approach: bony obstructions may be present in 5% to 15% of canals that result in inability to gain access to the canal. Maxillary Nerve Block Technique V2-NB Technique High-Tuberosity Approach V2-NB Technique - High-Tuberosity Approach ▪ Advantage: Less painful than a greater palatine approach. ▪ Disadvantage: Increased risk of hematoma. ▪ Armamentariums: Long large gauge (25 - 27 G) needle, Aspirating syringe and Local anesthetic carpule. ▪ Area of insertion: Height of the mucobuccal fold above the distal aspect of the maxillary 2nd molar. ▪ Target Area: Maxillary nerve as it passes through the pterygopalatine fossa, superior and medial to the target area of the PSA nerve block. ▪ Landmarks: − Mucobuccal fold at the distal aspect of the maxillary second molar. − Maxillary tuberosity. − Zygomatic process of the maxilla. V2-NB Technique - High-Tuberosity Approach ▪ Procedures: 1. Preparation of Tissues at the height of the mucobuccal fold above the maxillary second molar. Dry with sterile gauze --- Apply topical antiseptic (optional) ---Apply topical anesthetic. 2. Ask the patient to open his mouth partially and to push the mandible toward the side of the injection. 3. Retract the cheek in the injection area with a mouth mirror 4. Pull the tissues taut. 5. Point of insertion: The height of the mucobuccal fold over the maxillary second molar. 6. Needle Orientation: The bevel is directed toward the bone as follows: − Upward (45o angle to the occlusal plane). − Backward (45o angle to the long axis of the molar). − Inward (45o angle to the occlusal plane). 7. Depth of Needle Insertion: 30 mm “This means all the needle length except 2 mm away from the Hub”. − The needle tip will lie in the pterygopalatine fossa close to the maxillary division of the trigeminal nerve. − No resistance to needle penetration should be felt (resistance indicates too great medial “toward the midline” needle orientation). V2-NB Technique - High-Tuberosity Approach 8. Aspirate in two perpendicular planes to exclude the possibility of false-negative aspiration. 9. Slowly deposit 1.8 ml over 60 seconds. 10. Withdraw the syringe and make the needle safe. 11. Wait a minimum of 3 to 5 minutes before commencing the dental procedure. 1.8 ml Maxillary Nerve Block Technique V2-NB Technique Greater Palatine Approach Pterygopalatine Approach V2-NB Technique - Greater Palatine Approach ▪ Advantage: Decreased risk of hematoma. ▪ Disadvantage: More painful than the high-tuberosity approach ▪ Armamentariums: Long large gauge (25 - 27 G) needle, Aspirating syringe and Local anesthetic carpule. ▪ Area of insertion: Palatal soft tissue directly over the greater palatine foramen (The foramen is most frequently located distal to the maxillary second molar). ▪ Target Area: Maxillary nerve as it passes through the pterygopalatine fossa [So, the needle should pass through the greater palatine canal to reach the pterygopalatine fossa]. ▪ Landmarks: Greater palatine foramen. V2-NB Technique - Greater Palatine Approach ▪ Procedures: 1. Ask the patient to do the following: − Open his mouth widely. − Extend the neck. − Turn the head to the side of the operator to improve visibility. 2. Locate the greater palatine foramen. − Place a cotton swab at the junction of the maxillary alveolar process & hard palate. − Locate the greater palatine foramen at the distal aspect of the maxillary second molar tooth (the swab “falls” into the depression created by the greater palatine foramen). − The foramen is most frequently located distal to the maxillary second molar. 3. Prepare The Tissues Directly Over The Greater Palatine Foramen: − Clean & dry with sterile gauze. − Apply topical antiseptic (optional). − Apply topical anesthetic for 2 minutes − Apply pressure to the tissue with the cotton swab, held in the left hand & note ischemia at the injection site. V2-NB Technique - Greater Palatine Approach 4. Injection of Greater Palatine Nerve Block: − Direct the syringe from the opposite side of the mouth so that the needle approaches the injection site at a right angle. − Place the bevel against the ischemic soft tissue at the injection site. − Slowly advance the needle until the palatine bone is gently contacted “The depth of penetration is usually about 5 mm”. − Deposit a small volume of local anesthetic 0.5 ml. − Ischemia spreads into adjacent tissues as the anesthetic is deposited. 1.8 ml − Continue to apply pressure with the cotton applicator stick during this procedure. 5. Maxillary Nerve Block: − Probe gently for the greater palatine foramen. − Advance the needle very slowly into the greater palatine canal to a depth of 30 mm. − Approximately 10% of greater palatine canals have bony obstructions that prevent the passage of the needle Never attempt to force the needle against resistance and if resistance is felt, Withdraw the needle slightly & slowly attempt to advance it at a different angle. V2-NB Technique - Greater Palatine Approach 6. Injection of Maxillary Nerve Block: − Aspiration in two perpendicular planes (to exclude the possibility of false-negative aspiration). − Slowly deposit 1.8 mL of solution over a minimum of 1 minute. − Withdraw the syringe & make the needle safe. − Wait a minimum of 3 to 5 minutes before commencing the dental procedure. 1.8 ml V2-NB Technique - Greater Palatine Approach Signs & Symptoms of V2-NB Technique  Subjective: 1. Pressure behind the upper jaw on the side being injected; this usually subsides rapidly 2. Tingling and numbness of the lower eyelid, side of the nose, and upper lip 3. Sensation of numbness in the teeth and buccal and palatal soft tissues on the side of injection  Objective: 1. Electrical pulp Tester (EPT): No response for maximal EPT output (80/80). 2. Absence of pain in probing test. 3. Absence of pulpal response to the thermal pulp test (End-Ice) 4. Absence of pain during treatment Complications of V2-NB Technique A. Complications Associated with High-Tuberosity Approach: ─ Hematoma develops due to maxillary artery puncture. B. Complications Associated with Greater Palatine Foramen Approach: I. Penetration of the Orbit: ─ It may occur if the needle goes in too far in the smaller-than-average skull. ─ Complications produced by injection of local anesthetic into the orbit include the following: 1. Retrobulbar hemorrhage 2. Proptosis due to volume displacement of the orbital structures, 3. Amaurosis “transient loss of vision” due to Optic Nerve Block (CN II), 4. Retrobulbar Block (CN II, III and VI) Causing: o Mydriasis “dilation of the pupil” o Corneal anesthesia, o Ophthalmoplegia 5. Diplopia due to Abducens Nerve Block (CN VI) II. Penetration of the Nasal Cavity ─ It may occur if the needle deviates medially during insertion through the greater palatine canal, the paper-thin medial wall of the pterygopalatine fossa is penetrated and the needle enters the nasal cavity. ─ Signs: i. On aspiration, large amounts of air appear in the cartridge. ii. On injection, the patient complains that local anesthetic solution is running down his or her throat. ▪ OPTIC [CN-II]: Vision ▪ Oculomotor [CN-III]: Opens eyelid, Accommodation, Moves the eye up, down and medially ▪ Trochlear [CN-IV]: Moves the eye down and inward ▪ Trigeminal [CN-V]: Sensory to cornea and conjunctiva ▪ Abducens [CN-VI] : Moves the eye laterally Complications of V2-NB Technique Proptosis of Right Eyeball Mydriasis (dilation of the pupils) Amaurosis Ophthalmoplegia Retrobulbar Hemorrhage Reference  Reference Techniques of Maxillary Anesthesia. Malamed S. Stanley. Handbook of Local Anesthesia. Elsevier. 7th Edition; Chapter 13: 204 - 238. THANK YOU