Maxillary nerve block anesthetic technique (with photos)

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Maxillary nerve block anesthetic technique (with photos)

  1. 1. Hesham El-Hawary Maxillary Nerve Block Techniques Maxillary  Anesthe/c                       Techniques   Dr.  Hesham  El-­‐Hawary   Assistant  Professor  OMFS     www.elhawarydentalclinic.com      
  2. 2. Hesham El-Hawary Maxillary Nerve Block Techniques Surat An-Naml (The Ant) ‫النمل‬ ‫سورة‬  
  3. 3. Hesham El-Hawary Maxillary Nerve Block Techniques
  4. 4. Hesham El-Hawary Maxillary Nerve Block Techniques 1.  Middle meningeal nerve 2.  T w i g e s t o t h e 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
  5. 5. Hesham El-Hawary Maxillary Nerve Block Techniques Pulp  ,  Inves/ng  structures  &  Labial  (buccal)  mucoperiosteum Anterior  superior  alveolar  nerve Anterior  teeth   (1,2,3) Middle  superior  alveolar  nerve Premolars  (4,5)  &     MB  root  of  1st   molar(6) Posterior  superior  alveolar  nerve Molars  except  MB   root  of  1st   molar(6) Nerve  supply  of  Maxillary  teeth  
  6. 6. Hesham El-Hawary Maxillary Nerve Block Techniques Palatal mucoperiosteum Nasopalatine nerve Anterior teeth (1,2,3) Greater ( Anterior) palatine nerve Premolars (4,5) & Molars (678) Nerve  supply  of  Maxillary  teeth   Cont.  
  7. 7. Hesham El-Hawary Maxillary Nerve Block Techniques Keep  In  Mind   •  Chair  posiNon  (right  handed  –  right  side)   •  DenNst  posiNon  (right  handed  –  right  side)   •  Nerve  to  be  anestheNzed   •  Armamentarium:  Syringe  (type)  -­‐  Needle  (size)   •  Landmarks  (soV  Nssue  –  bony)   •  Technique     – Point  of  inserNon   – DirecNon  of  inserNon   •  Confirming  the  anesthesia  (subjecNve  –  0bjecNve)  
  8. 8. Hesham El-Hawary Maxillary Nerve Block Techniques Nerve  Block  Technique   Maxillary  Nerve  Block  Techniques  
  9. 9. Hesham El-Hawary Maxillary Nerve Block Techniques Local  Anesthesia   •  Nerve  Block   – The   anestheNc   soluNon   is   deposited   close   to   a   main  nerve  trunk     – Usually   at   a   distance   from   the   operaNve   site   before  the  nerve  divided  into  terminal  branches  
  10. 10. Hesham El-Hawary Maxillary Nerve Block Techniques Maxillary  NB  anesthesia   Incisive  N.B.   Anterior  &  Middle   Sup.  Alv.  N.B.   Post.  Sup.  Alv.  N.B.   PalaNne  N.B.   Maxillary  N.B.  
  11. 11. Hesham El-Hawary Maxillary Nerve Block Techniques
  12. 12. Hesham El-Hawary Maxillary Nerve Block Techniques POSTERIOR  SUPERIOR  ALVEOLAR   NERVE  BLOCK   (ZYGOMATIC/TUBEROSITY  NERVE  BLOCK)   Maxillary  anesthe/c  Techniques  
  13. 13. Hesham El-Hawary Maxillary Nerve Block Techniques Nerves  to  be  anesthe/zed   •  Posterior  Superior  Alveolar  Nerve     – before   it   enters   the   posterior   surface   of   the   maxilla  while  it  is  in  the  infra-­‐temporal  fossa   •  It   will   anestheNze   the:   Pulp   &   invesNng   structures  and  buccal  mucoperiosteum  of  the   maxillary   molars   except   for   the   mesio-­‐buccal   root  of  the  1st  molar  
  14. 14. Hesham El-Hawary Maxillary Nerve Block Techniques PosiNons     Pa/ent  posi/on   •  Head   ,   neck   and   trunk   on   the  same  straight  line   •  The   back   of   the   chair   is   Nlted   so   that   it   make   a   45   degree  angle  with  the  floor   •  So   that   when   the   paNent   open  his  mouth  the  occlusal   plane  of  the  maxillary  teeth   makes   45   degree   with   the   floor   Den/st  posi/on   §  In  the  leV  p.s.a.  sits  in  a  10   o’clock  posiNon     §  In  the  right  p.s.a.  he  sits  in   an  8  o’clock  posiNon  
  15. 15. Hesham El-Hawary Maxillary Nerve Block Techniques Armamentarium     •  Needle:   – 25-­‐27  gauge     – Long  needle   •  Syringe     – AspiraNng  syringe  
  16. 16. Hesham El-Hawary Maxillary Nerve Block Techniques Landmarks     •  Landmarks   – Muccobuccal  fold   – Maxillary  tuberosity   – ZygomaNc  process  
  17. 17. Hesham El-Hawary Maxillary Nerve Block Techniques Technique     1.  Retract  the  cheek  and  prepare  site  of  injecNon   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  Nme  then  abort  the  technique   6.  If   no   blood   comes   out   then   deposit   1.5   ml   of   the   anestheNc  soluNon,  wait  3-­‐5  minutes  before  working  
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  24. 24. Hesham El-Hawary Maxillary Nerve Block Techniques Confirming  the  Anesthesia   •  SubjecNve  findings   – No  subjec/ve  findings   •  ObjecNve  findings     – Probing  does  not  lead  to  pain  
  25. 25. Hesham El-Hawary Maxillary Nerve Block Techniques MAXILLARY  NERVE  BLOCK   Maxillary  anesthe/c  Techniques  
  26. 26. Hesham El-Hawary Maxillary Nerve Block Techniques •  The  purpose  of  this  technique  is  to  block  the  main   trunk   of   the   maxillary   nerve   as   it   traverses   the   pterygopalaNne   fossa   aVer   emerging   from   foramen  rotandum  
  27. 27. Hesham El-Hawary Maxillary Nerve Block 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  aVer  aspiraNon   to  achieve  a  successful  result   §     It  is  very  rare  to  be  done  
  28. 28. Hesham El-Hawary Maxillary Nerve Block Techniques Confirming  the  Anesthesia   •  SubjecNve  findings   – Numbness  of:   •  The  palate   •  Upper  lip   •  Lateral  aspect  of  the  nose   •  Lower  eye  lid   •  ObjecNve  findings     – Probing   does   not   lead   to   pain   in   the   palate   and   buccal  mucosa  in  any  aspect  
  29. 29. Hesham El-Hawary Maxillary Nerve Block Techniques INFRAORBITAL  NERVE  BLOCK   (ANTERIOR  AND  MIDDLE  SUPERIOR  ALVEOLAR  NERVE  BLOCK)   Maxillary  anesthe/c  Techniques  
  30. 30. Hesham El-Hawary Maxillary Nerve Block Techniques Infra  Orbital  N.  BLOCK   §  The  aim  is  to  deposit  the  anestheNc  soluNon  into  the   infraorbital  canal  through  the  infraorbital  foramen   §  In   this   technique   the   anterior   &   middle   superior   alveolar  nerves  are  anestheNzed  in  80%  of  cases   •  In   the   remaining     20%   the   middle     sup.alv.   nerve  has  to  be  given  a  separate  injecNon    
  31. 31. Hesham El-Hawary Maxillary Nerve Block Techniques Nerves  to  be  anesthe/zed     •  The  terminals  of  the  infraorbital  nerve   •  The  anterior  superior  alveolar  nerves   •  The  middle  superior  alveolar  nerve  
  32. 32. Hesham El-Hawary Maxillary Nerve Block Techniques Areas  to  be  anestheNzed   §  The  upper  lip   §  The  lateral  aspect  of  the  nose   §  The  lower  eyelid   §  The  buccal  mucosa  of  the  upper  anterior    teeth  and    premolars   §  Pulp   and   invesNng   structures   of   upper   anterior   teeth   and   premolars  
  33. 33. Hesham El-Hawary Maxillary Nerve Block Techniques PosiNons     Pa/ent  posi/on   •  Head   ,   neck   and   trunk   on   the   same  straight  line   •  The  back  of  the  chair  is  Nlted  so   that   the   paNent   is   in   a   supine   posiNon   •  The   occlusal   plan   of   maxillary   teeth     –  Near   to   the   operator’s   shoulder   –  At  a  45  degrees  angle  to  the   floor   Den/st  posi/on   •  Stands  on  the  right  side   infront   of   the   paNent   for  a  right  side  injecNon     •  Along   side   the   paNent   for  a  leV  side  injecNon  
  34. 34. Hesham El-Hawary Maxillary Nerve Block Techniques •  Needle:   – 25-­‐27  gauge     – Long  needle   •  Syringe     – AspiraNng  syringe   Armamentarium    
  35. 35. Hesham El-Hawary Maxillary Nerve Block Techniques Needle  inserNon   The  point  of    needle  inser/on     The  infraorbital  foramen     Direc/on  of  inser/on   •  Will   be   discussed   in   the   technique  
  36. 36. Hesham El-Hawary Maxillary Nerve Block Techniques 1.  Clean  the  Nssue  to  be  injected  with  sterile  gauze   2.  Apply   topical   anNsepNc   followed   by   topical   anestheNc   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   verNcal   line   with   the   pupil   when  the  paNent  gazes  forwards   Technique    
  37. 37. Hesham El-Hawary Maxillary Nerve Block Techniques 5.  There  are  3  acceptable  methods  of  approaching  the   infraorbital  foramen:  First  technique   –  A  verNcal  imaginary  line  is  drawn  from  the  inner  canthus   of   the   eye   unNl   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  direcNng   it  to  bisect  this  imaginary  right  angle   Technique    
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  43. 43. Hesham El-Hawary Maxillary Nerve Block Techniques 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   inserNon   5   mm   out   from   the   mucobuccal   fold   to   the   level  of  the  canine  apex   Technique  
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  52. 52. Hesham El-Hawary Maxillary Nerve Block Techniques 5.  There  are  3  acceptable  methods  of  approaching  the   infraorbital  foramen:  Third  technique   –  The   syringe   and   needle   are   lined   up   with   a   verNcal   line   with  the  longitudinal  axis  of  maxillary  2nd  premolar  in  line   with  the  pupil  of  the  eye  while  paNent  gazes  forwards   –  The  needle  is  inserted  5mm  out  in  the  mucobuccal  fold   Technique  
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  64. 64. Hesham El-Hawary Maxillary Nerve Block Techniques 6.  The  needle  is  oriented  with  bevel  towards  bone  and   advanced  slowly  Nll  it  contacts  the  upper  rim  of  the   infraorbital  foramen    The  depth  of  penetraNon  should  not  exceed  20  mm   6.  Aspirate,  if  negaNve  deposit  the  anestheNc  soluNon   slowly   7.  Wait   3-­‐5   minutes   before   commencing   dental   procedure   Technique  
  65. 65. Hesham El-Hawary Maxillary Nerve Block Techniques Confirming  the  Anesthesia   •  SubjecNve  findings   – Numbness  of     •  The  lower  eye  lid   •  Lateral  wall  of  the  nose   •  Upper  lip   •  ObjecNve  findings     – Probing   does   not   lead   to   pain   in   the   mucosa   opposite  to  the  anterior  teeth  and  premolars  
  66. 66. Hesham El-Hawary Maxillary Nerve Block Techniques INCISIVE  CANAL  NERVE  BLOCK   (NASOPALATINE  NERVE  BLOCK)   Maxillary  anesthe/c  Techniques  
  67. 67. Hesham El-Hawary Maxillary Nerve Block Techniques Nerves  to  be  anestheNzed   §  This   is   a   painful   injecNon   so   it   is   beier   to   give   a   few   drops   of   anesthesia   superficially   before   proceeding   with   the   rest   of   the   injecNon   §  The  aim  is  to  anestheNze  the  nasopalaNne  nerve  inside  the  incisive   canal   §  Area  to  be  anestheNzed:   The  mucosa  of  the  Anterior  part  of  the  palate  opposite  to  the  anterior  teeth  
  68. 68. Hesham El-Hawary Maxillary Nerve Block Techniques PosiNons   Pa/ent  posi/on   •  Head   ,   neck   and   trunk   on   the   same  straight  line   •  The  back  of  the  chair  is  Nlted  so   that   the   paNent   is   in   a   supine   posiNon   •  The   occlusal   plan   of   maxillary   teeth   near   to   the   operator’s   shoulder   Den/st  posi/on   •  The   operator   will   sit   from  infront  and  to  the   right  
  69. 69. Hesham El-Hawary Maxillary Nerve Block Techniques •  Needle:   – 25-­‐27  gauge     – Short  needle   •  Syringe     – Non-­‐AspiraNng  syringe   Armamentarium  
  70. 70. Hesham El-Hawary Maxillary Nerve Block Techniques Incisive  canal  N.Block  Technique  Cont.     The  point  of    needle  inser/on     The   incisive   foramen   i.e.   the   crest  of  the  incisive  papilla     Direc/on  of  needle  inser/on   •  into  the  crest  of  the  incisive   papilla   between   the   upper   centrals  making  45◦  degrees   to  the  palatal  mucosa    
  71. 71. Hesham El-Hawary Maxillary Nerve Block Techniques 1.  Ask  paNent  to  open  wide   2.  A   labioginigval   crest   injecNon   is   made   to   anestheNze  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  anestheNc  soluNon     Technique  
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  73. 73. Hesham El-Hawary Maxillary Nerve Block Techniques
  74. 74. Hesham El-Hawary Maxillary Nerve Block Techniques Confirming  the  Anesthesia   •  SubjecNve  findings   – Numbness  of  the  anterior  1/3  of  the  palate   •  ObjecNve  findings     – Probing  does  not  lead  to  pain  in  the  anterior  1/3   of  palate  
  75. 75. Hesham El-Hawary Maxillary Nerve Block Techniques GREATER  PALATINE  NERVE  BLOCK   Maxillary  anesthe/c  Techniques  
  76. 76. Hesham El-Hawary Maxillary Nerve Block Techniques Nerves  to  be  anesthe/zed   §    The   aim   of   this   technique   is   to   block   the   greater   palaNne  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  anestheNzed:     Palatal  mucosa  of  the  molars  and  premolars  
  77. 77. Hesham El-Hawary Maxillary Nerve Block Techniques PosiNons     Pa/ent  posi/on   •  Head   ,   neck   and   trunk   on   the   same  straight  line   •  The  back  of  the  chair  is  Nlted  so   that   the   paNent   is   in   a   supine   posiNon   •  The   occlusal   plan   of   maxillary   teeth   near   to   the   operator’s   shoulder   Den/st  posi/on   •  The   operator   will   sit   from  infront  and  to  the   right  
  78. 78. Hesham El-Hawary Maxillary Nerve Block Techniques •  Needle:   – 25-­‐27  gauge     – Short  needle   •  Syringe     – Non-­‐AspiraNng  syringe   Armamentarium  
  79. 79. Hesham El-Hawary Maxillary Nerve Block Techniques Needle  InserNon   The  point  of    needle  inser/on     The   greater   palaNne   foramen   distal   to   the   palatal   aspect   of  the  second  molar   Direc/on  of  needle  inser/on   •  from   the   opposite   side   at   right  angle  
  80. 80. Hesham El-Hawary Maxillary Nerve Block Techniques 1.  Ask  paNent  to  open  wide   2.  Palpate   the   posiNon   of   the   greater   palaNne   foramen  Nll  you  feel  its  depression   3.  Clean  the  Nssue  to  be  injected  with  sterile  gauze     4.  Apply   topical   anNsepNc   followed   by   topical   anestheNc   Technique  
  81. 81. Hesham El-Hawary Maxillary Nerve Block Techniques 5.  A   27   gauge   needle   is   inserted   from   the   opposite   side  to  which  the  injecNon  is  to  be  made  with  the   needle   approaching   the   site   of   injecNon   at   right   angle.   The   needle   is   advanced   through   soV   Nssue   unNl  bone  is  contacted   6.  About  0.5  ml  of  the  anestheNc  soluNon  is  deposited   7.  Withdraw  syringe  and  recap  needle   8.  Wait   2-­‐3minutes   before   commencing   dental   procedure   Technique  
  82. 82. Hesham El-Hawary Maxillary Nerve Block Techniques Confirming  the  Anesthesia   •  SubjecNve  findings   – Numbness  of  the  posterior  2/3  of  the  palate   •  ObjecNve  findings     – Probing  does  not  lead  to  pain  
  83. 83. Hesham El-Hawary Maxillary Nerve Block Techniques THANK  YOU   Maxillary  Anesthe/c  Techniques  

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