Anatomical consideration for local anesthesia [innervation]

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Anatomical consideration for local anesthesia [innervation]

  1. 1. Hesham El-Hawary Anatomical Consideration for dental local Anesthesia The innervation of maxillary and mandibular teeth
  2. 2. Hesham El-Hawary
  3. 3. Hesham El-Hawary
  4. 4. Hesham El-Hawary Middle meningeal nerve
  5. 5. Hesham El-Hawary Twigs to the sphenopalatine ganglion
  6. 6. Hesham El-Hawary Posterior superior alveolar nerve
  7. 7. Hesham El-Hawary Zygomatic nerve
  8. 8. Hesham El-Hawary Infra-Orbital Nerve
  9. 9. Hesham El-Hawary Middle superior alveolar nerve
  10. 10. Hesham El-Hawary Anterior superior alveolar nerve
  11. 11. Hesham El-Hawary Terminal branches of ION
  12. 12. Hesham El-Hawary Branches of Maxillary nerve 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. Lateral nasal nerve 3. Superior labial nerve
  13. 13. Hesham El-Hawary The Posterior Superior Alveolar Neve
  14. 14. Hesham El-Hawary • It arises from the maxillary nerve just before it enter the infraorbital groove
  15. 15. Hesham El-Hawary • Generally , posterior superior alveolar nerve is two in number • One branch descends on the post. Surface of the maxilla & gives off several twigs to m.m. of the cheek
  16. 16. Hesham El-Hawary • Other branch enters small foramen on the post. Surface of the maxilla to run in the post. Sup. Alveolar canal located in the posterior & lateral walls of the max. sinus
  17. 17. Hesham El-Hawary  It communicate freely with the middle & anterior superior alveolar nerves to form a superior dental plexus from which small twigs enter the apical foramina of the maxillary teeth & other twigs supply the overlying buccal mucoperiosteum
  18. 18. Hesham El-Hawary Posterior superior alveolar nerve  Specifically posterior superior alveolar nerve supplies – The Pulp – The Investing structures – The buccal mucoperiosteum of Upper Molars except MB root of 1st molar(6)
  19. 19. Hesham El-Hawary The Zygomatic Nerve
  20. 20. Hesham El-Hawary • Arises from the maxillary nerve as it enters the orbital cavity • Divides into two branches: – Zygomatico-Tempopral – Zygomatico-Facial The Zygomatic Nerve
  21. 21. Hesham El-Hawary Infra-Orbital Nerve
  22. 22. Hesham El-Hawary
  23. 23. Hesham El-Hawary The Infra-Orbital Nerve • The maxillary nerve enters the inferior orbital fissure to pass into the orbital cavity • It turns slightly laterally in the infra-orbital groove and continues forward in the orbital canal • In the middle of the course in the canal it gives off the middle superior alveolar nerve • Just before the exit of the maxillary nerve from the infra-orbital foramen and still in the infra-orbital canal it gives off the anterior superior alveolar nerve • As it leaves the infra-orbital foramen it gives off the terminal branches
  24. 24. Hesham El-Hawary Middle superior alveolar nerve • Approximately in the middle of the infraorbital canal it gives off the middle superior alveolar nerve • It runs downward and forwards in a canal in the lateral wall of the maxillary sinus to form part of the superior dental plexus • It Supplies – Pulp – Investing structures – buccal mucoperiosteum of Premolars & MB root of 1st molar(6)
  25. 25. Hesham El-Hawary Anterior superior alveolar nerve • Just before the exit of the maxillary nerve from the infraorbital foramen, and while still in infraorbital canal • It gives off the anterior superior alveolar nerve which runs in a canal in the anterior wall of the maxillary sinus to form part of the superior dental plexus • It supplies – Pulp – Investing structures – labial mucoperiosteum of anterior teeth(1,2,3).
  26. 26. Hesham El-Hawary Terminal branches of the maxillary nerve • As the maxillary nerve leaves the infraorbital foramen, it gives off its three terminal branches, which are: – Inferior palpebral nerve – External nasal nerve – Superior labial nerve
  27. 27. Hesham El-Hawary The Sphenopalatine Ganglion
  28. 28. Hesham El-Hawary • Nature: parasympathetic ganglion • Site: pterygopalatine fossa hangs from the maxillary nerve • Roots: – Sensory root: twigs from the maxillary nerve to the sphenopalatine ganglion – Sympathetic root: deep petrosal nerve – Parasympathetic root: great superficial petrosal nerve of the 7th cranial nerve (Vidian nerve of facial nerve)
  29. 29. Hesham El-Hawary • Branches: – Orbital nerve – Nasal nerve – Palatine nerve – Pharyngeal nerve
  30. 30. Hesham El-Hawary • Branches: – Orbital nerve – Nasal nerve – Palatine nerve – Pharyngeal nerve
  31. 31. Hesham El-Hawary • Branches: – Orbital nerve – Nasal nerve – Palatine nerve – Pharyngeal nerve
  32. 32. Hesham El-Hawary • Branches: – Orbital nerve – Nasal nerve – Palatine nerve – Pharyngeal nerve
  33. 33. Hesham El-Hawary • Branches: – Orbital nerve – Nasal nerve – Palatine nerve – Pharyngeal nerve
  34. 34. Hesham El-Hawary Palatine Branches • Palatine Branches Divides into: –Greater (anterior) palatine nerve –Lesser (posterior) palatine nerve
  35. 35. Hesham El-Hawary Palatine Branches • The greater (anterior) palatine nerve – Emerges from greater (anterior) palatine foramen in the horizontal part of the palatine bone medial to the upper third molar – Supplies palatal mucoperiosteum of maxillary molars & premolars
  36. 36. Hesham El-Hawary Palatine Branches • The lesser ( posterior ) palatine nerve – Emerges from Lesser (Posterior) palatine foramen in the horizontal part of the palatine bone medial to the upper third molar – supplies uvula, soft palate & posterior part of the hard palate
  37. 37. Hesham El-Hawary Nasal Branches • Nasal Branches Divides into: – Long sphenopalatine nerve (nasopalatine nerve) – Short sphenopalatine nerve
  38. 38. Hesham El-Hawary Nasal Branches • The Long sphenopalatine nerve (nasopalatine nerve) – Emerges from the incisive foramen in the anterior part of the median plane of the palate – supplies palatal mucoperiosteum of maxillary anterior teeth
  39. 39. Hesham El-Hawary Nasal Branches • At the palatal side of the canine region, there is anastomosis between the nasopalatine nerve & greater palatine nerve • The origin of these two nerves (nasopalatine nerve& greater palatine nerve ) comes from the sensory root of the sphenopalatine gangalion (twigs from the maxillary nerve)
  40. 40. Hesham El-Hawary Summary
  41. 41. Hesham El-Hawary Pulp , Investing 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
  42. 42. 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
  43. 43. Hesham El-Hawary The accessory innervations of the teeth • The buccal mucoperiosteum, the pulp and investing structures of upper anterior teeth cross innervation may take place i.e. branch from the anterior superior nerve of the other side • The palatal mucoperiosteum of the upper canine is supplied by interlacing fibers between the greater palatine nerve and the nasopalatine nerve
  44. 44. Hesham El-Hawary
  45. 45. Hesham El-Hawary
  46. 46. Hesham El-Hawary Main Trunk
  47. 47. Hesham El-Hawary Nervous Spimosum
  48. 48. Hesham El-Hawary Nerve to medial pterygoid
  49. 49. Hesham El-Hawary N. to Temporalis msc.
  50. 50. Hesham El-Hawary N. to Massetter msc.
  51. 51. Hesham El-Hawary N. to Lateral Pterygoid msc.
  52. 52. Hesham El-Hawary Long Buccal N.
  53. 53. Hesham El-Hawary Long Buccal N.
  54. 54. Hesham El-Hawary Lingual Nerve
  55. 55. Hesham El-Hawary Nerve to Mylohyoid muscle
  56. 56. Hesham El-Hawary Inferior Alveolar Nerve
  57. 57. Hesham El-Hawary Mental Nerve
  58. 58. Hesham El-Hawary Incisive Nerve
  59. 59. Hesham El-Hawary Branches of Mandibular Nerve 1. Main Trunk 2. Nervous Spimosum 3. Nerve to medial pterygoid 4. Anterior Division – N. to Temporalis msc. – N. to Massetter msc. – N. to Lateral Pterygoid msc. – Long Buccal N. 5. Posterior Division – Auriculo-temporal N. – Lingual Nerve – Nerve to mylohyoid muscle – Inferior Alveolar N.
  60. 60. Hesham El-Hawary The Auriculo-Temporal nerve
  61. 61. Hesham El-Hawary • It arises by a medial & a lateral root that unite below the foramen spinosum • The united nerve passes deep to the lateral pterygoid muscle • It gives off : – Parotid branch – Articular branch – Auricular branch – Temporal branch – Terminal branch
  62. 62. Hesham El-Hawary The Long Buccal Nerve
  63. 63. Hesham El-Hawary Long Buccal Nerve • Purely sensory nerve • Passes between two heads of the lateral pterygoid muscles • It emerges beneath the anterior border of the masseter muscle • It crosses the anterior border of the ramus at the level of the occlusal plane of the lower 7 & 8
  64. 64. Hesham El-Hawary Long Buccal Nerve Cont. It sends fibers to: • M.M. of the cheek Except the postero-superior area which receive sensory fibers from posterior superior alveolar nerve • Skin of the cheek • M.M. of the lower buccal vestibule • Buccal mucoperiosteum
  65. 65. Hesham El-Hawary The Lingual Nerve
  66. 66. Hesham El-Hawary • Purely sensory nerve • Passes between the medial pterygoid muscle and the ramus of the mandible in the pterygomandibular space • In the pterygomandibular space, it lies parallel to the inferior alveolar nerve, but anterior and medial (lingual) to it • Then , it passes below the mandibular attachment of the superior constrictor muscle of the pharynx to reach the side of the base of the tongue a short distance below & behind the lower third molar (8)
  67. 67. Hesham El-Hawary It supplies: • M.M. of the ant. 2/3 of the tongue • M.M. of the floor of the mouth • M.M. of the lateral lingual vestibule • Lingual mucoperiosteum of the all lower teeth (1, 2, 3, 4, 5, 6, 7, & 8)
  68. 68. Hesham El-Hawary The Inferior Alveolar Nerve
  69. 69. Hesham El-Hawary • Mixed nerve (Sensory & Motor) • Passes in the pterygomandibular space • Before it enters the mandibular foramen, it gives off the mylohyoid nerve, which contains sensory & motor fibers The Inferior Alveolar nerve
  70. 70. Hesham El-Hawary The Inferior Alveolar Nerve • Mylohyoid nerve – Motor Fibers supply the • Mylohyoid muscle • Anterior belly of digastric muscles – Sensory fibers supply the Pulp and investing structures of the lower molars
  71. 71. Hesham El-Hawary The Inferior Alveolar Nerve • Within the mandible , the inferior alveolar nerve descends in the inferior alveolar canal • In the region of the mental foramen, it divides into two terminal branches – The mental nerve – The Incisive nerve
  72. 72. Hesham El-Hawary The Inferior Alveolar Nerve Mental nerve • leaves the mandible through the mental foramen • It supply: – Skin of the chin – Skin of the lower lip – M.M. of the lower lip – Buccal mucoperiosteum of the mandibular anterior teeth and premolars
  73. 73. Hesham El-Hawary The Inferior Alveolar Nerve Incisive nerve • Supplies – pulp & investing structures of the lower anterior teeth (1, 2,& 3) • Main trunk of the inferior
  74. 74. Hesham El-Hawary Summary
  75. 75. Hesham El-Hawary Nerve supply to the mandibular teeth Pulp , Investing structures Incisive nerve Anterior teeth (1,2,3) Inferior alveolar nerve Premolars (4,5) & Molars (678)
  76. 76. Hesham El-Hawary Nerve supply to the mandibular teeth Labial (buccal) mucoperiosteum Mental nerve Cutaneous coli nerve ( branch of cervical plexus C2 & c3 ) gives additional sensory supply for premolars ( 4 , 5 ) in about 20 % of the pt. Anterior teeth (1,2,3) & Premolars (45) Long buccal nerveMolars (678)
  77. 77. Hesham El-Hawary Nerve supply to the mandibular teeth Lingual mucoperiosteum Lingual nerve Anterior teeth (1,2,3) Premolars (4,5) & Molars (678)
  78. 78. Hesham El-Hawary The accessory innervations of the teeth • The pulp and investing structures of the lower anterior teeth cross innervation may take place i.e. branch from the incisive nerve of the other side • The buccal mucoperiosteum of the lower premolar may receive additional nerve supply from the cutaneous coli nerve (branch from the cervical plexus of nerves) • The pulp and investing structures of the lower molars may receive additional nerve supply from the nerve to mylohyoid
  79. 79. Hesham El-Hawary

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