Maxillary nerve block anesthetic technique (with photos)

Hesham El-Hawary
Maxillary Nerve Block Techniques
Maxillary
Anesthe/c

Techniques

Dr.
Hesham
El-‐Hawary

Assistant
Professor
OMFS

www.elhawarydentalclinic.com

Hesham El-Hawary
Surat An-Naml (The Ant) ‫النمل‬ ‫سورة‬

Hesham El-Hawary

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
Palatal mucoperiosteum
Nasopalatine nerve
Anterior teeth
(1,2,3)
Greater ( Anterior) palatine nerve
Premolars (4,5)
&
Molars (678)
Nerve
supply
of
Maxillary
teeth

Cont.

Hesham El-Hawary
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)

Hesham El-Hawary
Nerve
Block
Technique

Maxillary
Nerve
Block
Techniques

Hesham El-Hawary
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

Hesham El-Hawary
Maxillary
NB
anesthesia

Incisive
N.B.

Anterior
&
Middle

Sup.
Alv.
N.B.

Post.
Sup.
Alv.
N.B.

PalaNne
N.B.

Maxillary
N.B.

Hesham El-Hawary
POSTERIOR
SUPERIOR
ALVEOLAR

NERVE
BLOCK

(ZYGOMATIC/TUBEROSITY
NERVE
BLOCK)

Maxillary
anesthe/c
Techniques

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
Armamentarium

•  Needle:

– 25-‐27
gauge

– Long
needle

•  Syringe

– AspiraNng
syringe

Hesham El-Hawary
Landmarks

•  Landmarks

– Muccobuccal
fold

– Maxillary
tuberosity

– ZygomaNc
process

Hesham El-Hawary
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

Hesham El-Hawary
Confirming
the
Anesthesia

•  SubjecNve
findings

– No
subjec/ve
findings

•  ObjecNve
findings

– Probing
does
not
lead
to
pain

Hesham El-Hawary
MAXILLARY
NERVE
BLOCK

Maxillary
anesthe/c
Techniques

Hesham El-Hawary
•  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

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
INFRAORBITAL
NERVE
BLOCK

(ANTERIOR
AND
MIDDLE
SUPERIOR
ALVEOLAR
NERVE
BLOCK)

Maxillary
anesthe/c
Techniques

Hesham El-Hawary
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

Hesham El-Hawary
Nerves
to
be
anesthe/zed

•  The
terminals
of
the
infraorbital
nerve

•  The
anterior
superior
alveolar
nerves

•  The
middle
superior
alveolar
nerve

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
•  Needle:

– 25-‐27
gauge

– Long
needle

•  Syringe

– AspiraNng
syringe

Armamentarium

Hesham El-Hawary
Needle
inserNon

The
point
of

needle
inser/on

The
infraorbital
foramen

Direc/on
of
inser/on

•  Will
be
discussed
in
the

technique

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
INCISIVE
CANAL
NERVE
BLOCK

(NASOPALATINE
NERVE
BLOCK)

Maxillary
anesthe/c
Techniques

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
•  Needle:

– 25-‐27
gauge

– Short
needle

•  Syringe

– Non-‐AspiraNng
syringe

Armamentarium

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
GREATER
PALATINE
NERVE
BLOCK

Maxillary
anesthe/c
Techniques

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
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

Hesham El-Hawary
Confirming
the
Anesthesia

•  SubjecNve
findings

– Numbness
of
the
posterior
2/3
of
the
palate

•  ObjecNve
findings

– Probing
does
not
lead
to
pain

Hesham El-Hawary
THANK
YOU

Maxillary
Anesthe/c
Techniques

Maxillary nerve block anesthetic technique (with photos)

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