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Anesthetic techniques - Maxillary anesthetic techniques

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Anesthetic techniques - Maxillary anesthetic techniques

  1. 1. Maxillary Anesthetic Techniques Maxillary Anesthetic Techniques Dr Hesham El-Hawary El- www.elhawarydentalclinic.com ELHAWARY
  2. 2. Maxillary Anesthetic Techniques 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
  3. 3. Maxillary Anesthetic Techniques 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
  4. 4. Maxillary Anesthetic Techniques 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
  5. 5. Maxillary Anesthetic Techniques 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
  6. 6. Maxillary Anesthetic Techniques Local Anesthesia 1. Topical anesthesia 2. Local infiltration 3. Field block 4. Nerve block ELHAWARY
  7. 7. Maxillary Anesthetic Techniques 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
  8. 8. Maxillary Anesthetic Techniques Local Anesthesia • Local Infiltration – Flooding of the small terminal nerve endings with local anesthetic solution ELHAWARY
  9. 9. Maxillary Anesthetic Techniques 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
  10. 10. Maxillary Anesthetic Techniques Local Anesthesia • Subperiosteal injection – Not be attempted – Because of • Liability of needle breakage • Difficulty of forcing the anesthetic agent between periosteum and bone ELHAWARY
  11. 11. Maxillary Anesthetic Techniques 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
  12. 12. Maxillary Anesthetic Techniques 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
  13. 13. Maxillary Anesthetic Techniques 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
  14. 14. Maxillary Anesthetic Techniques Factors affecting selection of the 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
  15. 15. Maxillary Anesthetic Techniques Factors affecting selection of the technique to be used Cont. 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
  16. 16. Maxillary Anesthetic Techniques Factors affecting selection of the technique to be used Cont. 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
  17. 17. Maxillary Anesthetic Techniques Factors affecting selection of the technique to be used Cont. 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
  18. 18. Maxillary Anesthetic Techniques Maxillary Anesthetic Techniques INFILTRATION ANESTHESIA ELHAWARY
  19. 19. Maxillary Anesthetic Techniques  The most commonly used technique  It is divided into  Soft tissue infiltration  Submucosal  Paraperiosteal  Bony infiltration ELHAWARY
  20. 20. Maxillary Anesthetic Techniques 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
  21. 21. Maxillary Anesthetic Techniques 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  It’s 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
  22. 22. Maxillary Anesthetic Techniques 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
  23. 23. Maxillary Anesthetic Techniques Maxillary Anesthetic Techniques MAXILLARY BUCCAL INFILTRATION ANESTHESIA ELHAWARY
  24. 24. Maxillary Anesthetic Techniques 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 operator’s shoulder ELHAWARY
  25. 25. Maxillary Anesthetic Techniques 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
  26. 26. Maxillary Anesthetic Techniques 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
  27. 27. Maxillary Anesthetic Techniques Buccal Infiltration Technique Cont. Direction of needle insertion • 45° with the buccal cortical plate of bone ELHAWARY
  28. 28. Maxillary Anesthetic Techniques 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
  29. 29. Maxillary Anesthetic Techniques 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
  30. 30. Maxillary Anesthetic Techniques Confirming the Anesthesia • Subjective findings – No subjective findings • Objective findings – Probing does not lead to pain ELHAWARY
  31. 31. Maxillary Anesthetic Techniques Maxillary Anesthetic Techniques MAXILLARY PALATAL INFILTRATION ANESTHESIA ELHAWARY
  32. 32. Maxillary Anesthetic Techniques 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
  33. 33. Maxillary Anesthetic Techniques Palatal Infiltration Technique The point of needle insertion  Midway between the gingival margin of the tooth and the median palatine raphe  Along the long axis of the tooth ELHAWARY
  34. 34. Maxillary Anesthetic Techniques Palatal Infiltration Technique Cont. Direction of needle insertion • 90° to the palatine bone 90° ELHAWARY
  35. 35. Maxillary Anesthetic Techniques 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
  36. 36. Maxillary Anesthetic Techniques Confirming the Anesthesia • Subjective findings – No subjective findings • Objective findings – Probing does not lead to pain ELHAWARY
  37. 37. Maxillary Anesthetic Techniques 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
  38. 38. Maxillary Anesthetic Techniques 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
  39. 39. Maxillary Anesthetic Techniques 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
  40. 40. Maxillary Anesthetic Techniques 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
  41. 41. Maxillary Anesthetic Techniques 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
  42. 42. Maxillary Anesthetic Techniques Maxillary anesthetic Techniques POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK (ZYGOMATIC/TUBEROSITY NERVE BLOCK) ZYGOMATIC/ ELHAWARY
  43. 43. Maxillary Anesthetic Techniques  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-temporal fossa infra-  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
  44. 44. Maxillary Anesthetic Techniques Posterior superior alv. N.B. Technique Patient position Dentist position • Head , neck and trunk on  In the left p.s.a. sits in a 10 the same straight line o’clock 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 o’clock 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
  45. 45. Maxillary Anesthetic Techniques Posterior superior alv. N.B. Technique alv. Cont. • Needle: – 25-27 gauge – Long needle • Syringe – Aspirating syringe ELHAWARY
  46. 46. Maxillary Anesthetic Techniques Posterior superior alv. N.B. Technique alv. Cont. • Landmarks – Muccobuccal fold – Maxillary tuberosity – Zygomatic process ELHAWARY
  47. 47. Maxillary Anesthetic Techniques Posterior superior alv. N.B. Technique alv. 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 shouldn’t touch bone, and the max. depth allowed is ½ 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
  48. 48. Maxillary Anesthetic Techniques Confirming the Anesthesia • Subjective findings – No subjective findings • Objective findings – Probing does not lead to pain ELHAWARY
  49. 49. Maxillary Anesthetic Techniques Maxillary anesthetic Techniques MAXILLARY NERVE BLOCK ELHAWARY
  50. 50. Maxillary Anesthetic Techniques • 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
  51. 51. Maxillary Anesthetic Techniques 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
  52. 52. Maxillary Anesthetic Techniques Confirming the Anesthesia • 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
  53. 53. Maxillary Anesthetic Techniques Maxillary anesthetic Techniques INFRAORBITAL NERVE BLOCK (ANTERIOR AND MIDDLE SUPERIOR ALVEOLAR NERVE BLOCK) ELHAWARY
  54. 54. Maxillary Anesthetic Techniques 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
  55. 55. Maxillary Anesthetic Techniques 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
  56. 56. Maxillary Anesthetic Techniques 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
  57. 57. Maxillary Anesthetic Techniques Infraorbital N.Block Technique Cont. Patient position Dentist position • Head , neck and trunk on the • Stands on the right side same straight line • The back of the chair is tilted so infront of the patient that the patient is in a supine for a right side injection position • Along side the patient • The occlusal plan of maxillary teeth for a left side injection – Near to the operator’s shoulder – At a 45 degrees angle to the floor ELHAWARY
  58. 58. Maxillary Anesthetic Techniques Infraorbital N.Block Technique Cont. • Needle: – 25-27 gauge – Long needle • Syringe – Aspirating syringe ELHAWARY
  59. 59. Maxillary Anesthetic Techniques Infraorbital N.Block Technique Cont. The point of needle insertion The infraorbital foramen ELHAWARY
  60. 60. Maxillary Anesthetic Techniques Infraorbital N.Block Technique Cont. Direction of needle insertion • Will be discussed in the technique ELHAWARY
  61. 61. Maxillary Anesthetic Techniques 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
  62. 62. Maxillary Anesthetic Techniques Steps for Infraorbital N.Block 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
  63. 63. Maxillary Anesthetic Techniques Steps for Infraorbital N.Block Technique Cont. 5. There are 3 acceptable methods of approaching the 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
  64. 64. Maxillary Anesthetic Techniques Steps for Infraorbital N.Block Technique Cont. 5. There are 3 acceptable methods of approaching the 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
  65. 65. Maxillary Anesthetic Techniques Steps for Infraorbital N.Block 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
  66. 66. Maxillary Anesthetic Techniques Confirming the Anesthesia • 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
  67. 67. Maxillary Anesthetic Techniques Maxillary anesthetic Techniques INCISIVE CANAL NERVE BLOCK (NASOPALATINE NERVE BLOCK) ELHAWARY
  68. 68. Maxillary Anesthetic Techniques 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
  69. 69. Maxillary Anesthetic Techniques Incisive canal N.Block Technique Cont. Patient position Dentist position • Head , neck and trunk on the • The operator will sit same straight line • The back of the chair is tilted so from infront and to the that the patient is in a supine right position • The occlusal plan of maxillary teeth near to the operator’s shoulder ELHAWARY
  70. 70. Maxillary Anesthetic Techniques Incisive canal N.Block Technique Cont. • Needle: – 25-27 gauge – Short needle • Syringe – Non-Aspirating syringe ELHAWARY
  71. 71. Maxillary Anesthetic Techniques Incisive canal N.Block Technique Cont. The point of needle insertion The incisive foramen i.e. the crest of the incisive papilla ELHAWARY
  72. 72. Maxillary Anesthetic Techniques Incisive canal N.Block Technique Cont. Direction of needle insertion • 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
  73. 73. Maxillary Anesthetic Techniques 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
  74. 74. Maxillary Anesthetic Techniques Confirming the Anesthesia • 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
  75. 75. Maxillary Anesthetic Techniques Maxillary anesthetic Techniques GREATER PALATINE NERVE BLOCK ELHAWARY
  76. 76. Maxillary Anesthetic Techniques Greater Palatine N.Block Technique  The aim of this technique is to block the greater palatine nerve as it comes out of its foramen  It’s 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
  77. 77. Maxillary Anesthetic Techniques Greater Palatine N.Block Technique Cont. Patient position Dentist position • Head , neck and trunk on the • The operator will sit same straight line • The back of the chair is tilted so from infront and to the that the patient is in a supine right position • The occlusal plan of maxillary teeth near to the operator’s shoulder ELHAWARY
  78. 78. Maxillary Anesthetic Techniques Greater Palatine N.Block Technique Cont. • Needle: – 25-27 gauge – Short needle • Syringe – Non-Aspirating syringe ELHAWARY
  79. 79. Maxillary Anesthetic Techniques Greater Palatine N.Block Technique Cont. The point of needle insertion The greater palatine foramen distal to the palatal aspect of the second molar ELHAWARY
  80. 80. Maxillary Anesthetic Techniques Greater Palatine N.Block Technique Cont. Direction of needle insertion • from the opposite side to which the injection is to be made • The needle approaching the site of injection at right angle ELHAWARY
  81. 81. Maxillary Anesthetic Techniques 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
  82. 82. Maxillary Anesthetic Techniques Confirming the Anesthesia • Subjective findings – Numbness of the posterior 2/3 of the palate • Objective findings – Probing does not lead to pain ELHAWARY
  83. 83. Maxillary Anesthetic Techniques Maxillary Anesthetic Techniques THANK YOU ELHAWARY

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