Maxillary injection techniques

1. DEPT. OF
CONSERVATIVE DENTISTRY
&
ENDODONTICS
1

2. MAXILLARY INJECTION TECHNIQUES IN
LOCAL ANESTHESIA
Presented by-
Dr NISHANT KHURANA
PG Final yr

3. • Malamed (1980):Defines local anesthesia as loss of
sensation in a circumscribed area of the body caused by a
depression of excitation in the nerve endings or an inhibition
of the conduction process in peripheral nerves.

4. COMPOSITION
Local anesthetic agent – Lignocaine
Vaso constrictor – Adrenaline
Reducing agent – sodium meta bisulphate
Preservatives – Methyl parabin
Fungicide – Thymol
Vehical – Ringer solution

5. Action of vasoconstictors
By constricting blood vessels, vasoconstrictors decrease blood flow to
the site of injection.
 Absorption of the local anesthetics into the cardiovascular system is
slowed resulting in lower anesthetic blood levels.
Lower local anesthestic blood levels decrease the risk of local
anesthestic toxicity.
Higher volumes of local anesthestic agent remain in and around the
nerve for longer periods, thereby increasing the duration of action of
most local anestshestics.
Vasoconstrictors decrease bleeding at the site of their administration
and are useful when increased bleeding is anticipated.

6. Long actionMedium action Short action Long action
(bupivacaine,
ropivacaine)
(lidocaine) (procaine) (tetracaine)
Local Anesthetics
Surface action
(benzocaine,
cocaine)
Note: The choice of “which” LA to use clinically is often
based upon its duration of action
EstersAmides
(Novocaine ®)(Xylocaine ®)
CLASSIFICATION

7. Recommended Maximum Doses of Local Anaesthetic
Drug Maximum dose Maximum no.
of cartridges
Articaine 4% with
epinephrine
7 mg/kg in adults
(up to 500 mg)
5 mg/kg in children
7
Bupivacaine 0.5% with
epinephrine
2 mg/kg (up to 200 mg) 10
Lidocaine 2% with
epinephrine
7 mg/kg (up to 500 mg) 13
Mepivacaine 2% with
levonordefrin
6.6 mg/kg (up to 400 mg) 11
Mepivacaine 3% plain 6.6 mg/kg (up to 400 mg) 7
Prilocaine 4% plain or
with epinephrine
8 mg/kg (up to 500 mg) 8

8. Advantages of LA
 Local anesthesia Is well tolerated in the dental office for minor oral surgical & RCT
procedures and has multiple uses.
 Patient is awake and co-operative
 Patient does not have to omit the previous night meals as in case of GA.
 No additional expenses to the patient or any additional trained persons are required in the
dental office for this purpose.
 There is very negligible incidence of morbidity.
 The patient can leave the dental office unescorted as practically there is no distortion of
normal physiology.
 The technique are not at all difficult to master and hence, the failure rate is very small.

9. INDICATIONS
 Extraction & surgical removal of teeth
 Cavity preparations
 Pulp procedures like pulpotomy & pupectomy
 Alveolopasty
 I & D of abscesses
 Periodontal & gingival surgery
 For relief from sore spots of dentures
 Treatment of trismus
 Diagnostic test of various facial pains especially trigeminal neuralgia
 In radiography when the patient is gagging due to placement of film in the mouth
 For anaesthesia of oral cavity and jaw bones for routine surgical procedures like treatment of fractures,
growths etc.

10. Contraindication
 Allergy/hypersensitivity to LA / sol. Additives
 Adrenalin is contraindicated forTachycardia! (thyrotoxicosis,CCF,IHD)
 Anesthesia around end arteries
 Iv regional anaesthesia
 Epidural/spinal anaesthesia in the presence of significant
Hypotention/hypovolaemia Coagulopathy
 Presence of local tissue sepsis
 Patient refusal

11. Techniques for local Anesthesia
administeration
Local infilteration
Field block
Nerve block
Intra ligamentary
Intra septal
Intra papillary
Intra pulpal

12. Intrapulpal injection (IP)
Disadvantages:
Exquisitely painful
Short duration for pulpectomy
Need pulpal exposure
Pain control by pharmacological action of LA and by applied pressure. -
used when pulp chamber is exposed either surgically or pathologically.
Advantages:
Predictable profound anesthesia
Immediate onset
No special instruments required

13. Intraosseous Injections
 With intraosseous injections, the local anaesthetic solution is deposited directly
into the cancellous bone surrounding the teeth being treated.
 These techniques can be considered if one of the primary nerve blocks has
failed.
 Early techniques for delivering the local anaesthetic into the cancellous bone
used a round bur to perforate the cortical plate, with the drug then being
injected through this hole.

14.  Advantages
 Immediate onset of anaesthesia
 No soft tissue (lip or tongue) anaesthesia
 Can operate bilaterally in the mandible
 Can anaesthetize a "hot" tooth
 Good approach for accessory innervation
 High success rate
Disadvantages
 Short duration of anaesthesia
 Must limit volume due to increased vascularity in the cancellous bone
 Difficult access to posterior mandible
 Anatomical limitations
 Some patients experience palpitations
 Cannot use in areas of periodontal disease

15. Periodontal Ligament Injection

In the periodontal ligament (PDL) injection, local anaesthetic is injected with pressure
into the PDL space. A number of devices are available to facilitate this type of injection
by providing the necessary pressure; however, this technique can be done with a
standard syringe.
 If using a standard syringe, the practitioner can express three-quarters of the volume
within the local anaesthetic cartridge to lessen the pressure that has to be pushed
against and to decrease the chance that the glass cartridge will break.

16. Advantages
 Immediate onset of anaesthesia
 No soft tissue anaesthesia
 Works well for "hot" teeth
 Good approach for accessory innervation
 High success rate
Disadvantages
 Patient may experience post-operative pain
 There is a transient decrease in pulpal blood flow to the tooth
 Cannot be used in areas of periodontal disease
 Pressure is required to inject into the PDL space
 Multiple injections are required for multi-rooted teeth (one injection per root)
 May not work on long roots (e.g., cuspids)

17. Maxillary injection Techniques.
1.Supra periosteal Injection: Infilteration
The supraperiosteal injection is the frequently used
local anesthetic technique for obtaining anesthesia in
maxillary teeth.
2. Periodontal ligament injection, recommended as an
adjunct to other techniques or for limited treatment
protocols.
3.Intra osseous injection, recommended for a single
tooth when other techniques have failed.

18. 4.Posterior superior alveolar nerve block
recommended for management of several molar tooth
in one quadrant.
5.Middle superior alveolar nerve block recommended
for management of premolars in one quadrant.
6.Anterior superior alveolar nerve block,
recommended for management of anterior teeth in
one quadrant.

19. 7.Maxillary nerve block, recommended for extensive
buccal. Palatal and pulpal management in one
quadrant.
8.Greater palatine nerve block, recommended for
palatal and soft osseous tissue treatment distal to the
canine in one quadrant.
9.Nasopalatine nerve block, recommended for
palatal soft and osseous tissue management from
canine to canine bilaterally.
10. Infraorbital Nerve Block

20. Distribution of
infraorbital nerve

21. INFRAORBITAL NERVE BLOCK:
Areas anesthetised:
• Pulps of maxillary incisors, canines, premolars, mesio-buccal root of first molar.
•Buccal periodontium and bones of same teeth
•Lower eyelid, lateral aspect of nose, upper lip.
Anatomical landmarks
Infra orbital ridge, infra orbital depression, supra orbital notch,anterior teeth, pupils of
eye.
Approach
i) Bicuspid approach
ii) Central incisor approach

22. Advantages: Comparatively simple, safe
Minimizes the volume of solution used and number of needle
punctures required.
Disadvantages: Difficulty is defining landmarks.
Psychological trauma because of fear of injury to eyes. Extra
oral approach may be disturbing.
Symptoms: Subjective - numbness over area supplied by
above nerves
Objective - instrumentation will demonstrate absence of pain.
Complication - hematoma may develop across the lower
eyelid.

23. Posterior superior alveolar nerve block:
Nerves anesthetized:
Posterior superior alveolar and branches
Areas anesthetized:
Pulps of maxillary 1st ,2nd 3rd molars
Buccal periodotium & bone
Anatomical landmarks:
Muco-buccal fold
Maxillary tuberosity
Zygomatic process

26. Symptoms of anesthesia. Usually no symptoms Absence of pain
during treatment
Advantages: Atraumatic High success rate
Minimum number of injections required Minimizes the total volume
of solution deposited
Disadvantages:
Risk of hematoma
No bony landmarks Second injection needed for treatment of first
molars
Complication:
Hematoma-maxillary artery or the pterygoid plexus Mandibular
anaesthesia
Palatal anesthesia

27. NASOPALATINE NERVE BLOCK (INCISIVE CANAL
INJECTION)
Nerves anesthetized:
 Nasopalatine nerve bilaterally Area
anesthetized:
 Anterior portion of hard palate
Anatomical landmarks:
 Palatal mucosa just lateral to the
incisive papilla Central incisors and
papilla

28. Symptoms - subjective:
Numbness of anterior portion of palate No pain during treatment
Advantages:
minimizes needle penetration and volume of solution Minimal
patient discomfort
DisadvantAges:
No hemostasis except in the immediate area of injection
Potentially the most traumatic intraoral injection
Complication: Necrosis of soft tissue
Squirting back of solution

29. Greater palatine nerve block :
Nerves anesthetised
 Greater palatine nerve
Areas Anesthetised:
 Posterior portion of the hard palate its
overlying soft tissues, anteriorly as
 far as the first premolar,medially to
the midline.
Landmarks:
 Greater palatine foramen and
junctionof the maxillary alveolar
process
 and palatine bone.

30. Symptoms:
Numbness of posterior portion of palate
Absence of pain during treatment
Advantages:
Minimizes needle penetration and volume of solution Minimal
patient discomfort
Disadvantages:
No heamostasis except in the immediate area of injection
Potentially traumatic.
Complication:
Ischaemia and necrosis of soft tissues.

31. Topical anesthesia:
Anesthesia can be obtained by the application of a
suitable agent to an area of either the skin or mucous
membrane which it penetrates to anesthetize
superificial nerve endings.

32. Topical Anesthetic
Minimize sensation of needle penetrating the soft
tissue.
Used in greater concentration than LA in order to
penetrate the mucous membrane

33. Lidocaine
5% ointment, gel, liquid
10% metered spray
Onset 3-5 minutes
Benzocaine
14-20% liquid, gel
Onset 30 seconds
Longer duration than the others
Lower toxicity potential than
the others
Best one for Pedo although
some children say it feels “hot”

34. Topical Anesthesia
15% Lidocaine spray
Ethyl amonobenzoate spray
Wait for atleast 3 min

35. Sprays:
Rapidity of action. 10% lignocaine
hydrochloride in water miscible base, which is
expelled in small quantities from a aerosol
container.
Ointments and Jelly:
EMLA (Eutectic mixture of local anesthetics)
Clark et al. in 1986 suggested the use of EMLA
cream for numbing the skin of local anesthetics.