MAXILLARY AND MANDIBULAR NERVE BLOCKS

1. NERVE BLOCK
PRESENTED BY: Dr Md Mahbubul Hoda
Moderator: Dr Sri Hari

2. HISTORY
• In 1884 , William Halsted used a local injection of
cocaine to perform the first peripheral nerve block .
• During first world war , Dr. Harvey Cook created
first dental cartridge for dentistry

3. LOCAL INFILTRATION:
Small terminal nerve endings in the area of dental
treatment are flooded with local anesthetic solution.
Treatment is done in the same area of in which
solution has been deposited.

4. FIELD BLOCK:
Local anaesthetic solution is deposited near the larger
terminal branch, so the anaesthetized area will be
circumscribed to prevent the passage of impulse from the
tooth to CNS.

5. NERVE BLOCK:
LA deposited close to the main nerve trunk
usually at a distance from the site of operative
intervention.
Eg: posterior superior alveolar nerve
block, Inferior alveolar nerve block.

6. • Eliminate or decrease intraoperative and
postoperative pain
• Increase patients cooperation
• To reduce intraoperative bleeding

7. Maxillary nerve blocks

8. Intra oral techniques
• Local infiltration of nerve endings
• Anterior and middle superior alveolar nerve
block(infraorbital nerve block)
• Postrior superior alveolar nerve block
• Greater (anterior) palatine nerve block
• Nasopalatine nerve block
• Maxillary nerve block

9. Extra oral techniques
• Anterior and middle superior alveolar nerve
block(infraorbital nerve block)
• Maxillary nerve block

10. SUPRA PERIOSTEAL INJECTION:
( Local Infiltration )
INDICATIONS:
 Pulpal anaesthesia of maxillary teeth when treatment is limited to
one or two tooth.
 Soft tissue anaesthesia for surgical procedure in a circumscribed
area.
TECHNIQUE:
Area of insertion:
Height of mucobuccal fold above the apex of tooth to be anesthetized
Landmarks:
• Mucobuccal fold
• Crown of the tooth
• Root contour of the tooth

11. AMOUNT TO BE DEPOSITED- 0.6ml over 20 sec.
SIGNS AND SYMPTOMS:
Subjective: numbness in the area of administration
Objective: absence of pain during treatment
CONTRAINDICATION:
 Infection or acute inflammation in the area of injection.
DISADVANTAGES:
 Need for multiple needle insertions.
 Necessary to administer large volume of solution.

12. POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK:
OTHER NAMES:
• Tuberosity block / Zygomatic block
AREAS ANAESTHETIZED:
• Pulps of maxillary III,II and I molar except mesio buccal root of I
molar.
• Buccal periosteum and bone overlying the teeth.

13. LAND MARKS:
• Mucobuccal fold.
• Zygomatic process of maxilla.
• Infra temporal surface of maxilla.
• Tuberosity of maxilla.
TECHNIQUE:
• 27 gauge short needle used.
• Insertion- height of mucobuccal fold above the
maxillary II molar.
• Upward, inward and backward direction

15. DEPTH OF NEEDLE PENETRATION-16 mm.
DEPOSIT:- 0.9 to 1.8 ml in 30 to 60 sec .
COMPLICATIONS:
• Hematoma
• Mandibular anaesthesia.

16. Areas anesthetized:
•Pulps of 1st and 2nd premolar,
mesiobuccal root of 1st molar
•Buccal periodontal tissues and
bone over the same area
Technique:
Target area:
Maxillary bone above the apex of
2nd premolar

17. Landmark:
• Mucobuccal fold of 2nd premolar
• 0.9 to 1.2ml of solution app 30 to 40 seconds
Signs and symptoms:
• Upper lip numbness
• No pain during dental therapy

18. ANTERIOR SUPERIOR ALVEOLAR NERVE BLOCK:
OTHER NAME:
• Infra orbital nerve block
AREAS ANAESTHETIZED:
• Incisors, cuspids and bicuspids.
• Upper lip
• Lower eye lid
• Portion of the nose of the
injected site.

19. ANATOMICAL LANDMARKS:
Mucobuccal fold of 1st premolar
Infra orbital notch
Infra orbital foramen
NEEDLE PATHWAY:
Feel the infraorbital notch moving your finger down the
notch palpating the tissues gently; the outward bulge is
the lower border of the orbit which is the roof of the
infraorbital foramen; continue the finger inferiorly
until a depression is felt which is the infraorbital
foramen
Maintain pressure over the foramen while inserting the
needle down the long axis of the 1st premolar

22. TECHNIQUE:
• NEEDLE- 25 gauge needle.
• SOLUTION DEPOSITED- 0.9 to 1.2 ml.
Maintain finger pressure over the foramen for at least one
minute to disperse the anesthetic solution
COMPLICATION:
• Hematoma

23. GREATER PALATINE NERVE BLOCK:
OTHER NAME:
• Anterior palatine nerve block
AREAS ANAESTHETIZED:
• Posterior portion of hard palate and its over lying soft tissues.
• Anteriorly up to I premolar and medially up to midline.

24. ANATOMICAL LANDMARKS:
Greater palatine foramen and junction of maxillary alveolar
process and palatine bone
Area of insertion:
Soft tissue slightly anterior to greater palatine foramen
TECHNIQUE:
• NEEDLE- 25 gauge needle.
• INSERTION- From the opposite side of the mouth at right
angles to the target area.
• DEPOSITION-0.25 to 0.5 ml in 30 sec.

26. NASO PALATINE NERVE BLOCK:
OTHER NAMES:
• Incisive nerve block.
• Spheno palatine nerve block.
AREAS ANESTHETIZED:
• Anterior portion of hard palate from mesial of
right 1st premolar to mesial of the Left 1st
premolar

27. LANDMARKS:
• Central incisors
• Incisive papilla.
Area of insertion:
• Palatal mucosa lateral to incisive papilla
TECHNIQUE:
• INSERTION- At a 45 degree angle towards incisive
papilla.
• DEPOSIT- 0.45 ml of solution in 15 to 30 sec at a depth
of 6 to 10 mm.

29. COMPLICATIONS:
• Hematoma.
• Necrosis of soft tissue due to highly concentrated
vasoconstrictor solution.

30. MAXILLARY NERVE BLOCK
OTHER NAMES:-
Second division block, V2 nerve block
AREAS ANESTHETIZED:-
1) Maxillary teeth on the injected side
2) Alveolar bone & overlying structures
3) Hard palate, part of soft palate
4) Upper lip, cheek, side of the nose, lower eye lid

31. For achieving profound anesthesia of hemi maxilla.
2 approaches
1) Greater palatine canal approach
2) High tuberosity approaches
ADVANTAGES:-
1) Minimizes the number of needle penetrations
2) Minimizes the total volume of local anesthetic
solutions 1.8ml versus 2.7ml
3) high success rates

32. GREATER PALATINE APPROACH:-
TARGET AREA:- Maxillary nerve as it passes through the
pterygopalatine fossa, the needle passes through greater
palatine canal to reach pterygopalatine fossa
LAND MARKS:- Greater palatine foramen
AREA OF INSERTION:- Palatal soft tissue directly over the
greater palatine foramen.
PROCEDURE:- 25 gauge 32 mm long needle used 1.8 ml of the
solution in 1 minute is deposited at the target area

34. COMPLICATIONS:-
• Hematoma
• Penetration of the orbit during greater palatine
foramen approach if the needle goes too far
• Penetration of the nasal cavity occurs when
the needle deviates medially during insertion

35. HIGH TUBEROSITY APPROACH
Technique:- needle used – 25 gauge 32mm long needle
LAND MARKS:-
• Muco buccal fold at the distal aspect of maxillary second molar.
• Maxillary tuberosity
• Zygomatic process of the maxilla
.

36. TARGET AREA:- Maxillary nerve as it passes through
pterygopalatine fossa
superior & medial to the target area of PSA nerve
block.
DISADVANTAGES:-
• Risk of hematoma with high tuberosity approaches
• Lack of hemostasis
• This approach is relatively arbitrary

38. MAXILLARY NERVE BLOCK- extra oral
Indications:
• During extensive surgery
• To block all sub divisions of maxillary nerve with one needle insertion
• Local infection and trauma causing difficulty for intraoral approach
Anatomical land marks:
• Mid point of the zygomatic arch
• Zygomatic notch
• Coronoid process of the ramus of mandible
• Lateral pterygoid plate

39. Technique:
22 gauge,4 inch needle used
Depth of penetration: 4.5cms contacting lateral pterygoid
plate needle is withdrawn with only point left in the tissue
and redirected in slight forward and upward direction.
Amount of solution deposited 2 to 3ml
The needle passes through the following structures:
skin, subcuteneous tissue, massester muscle, mandibular
notch and lateral pterygoid muscle

42. EXTRA ORAL TECHNIQUES
INFRA ORBITAL BLOCK
Indications:
Infection or trauma resulting in impossible intra oral approach
Anatomical Land marks:
• Infra orbital ridge.
• Infra orbital notch.
• Infra orbital depression.
Technique:
Procedure should be carried out under aseptic conditions .
Needle used-1½ inch 25 gauge needle used.
1 ml of the solution is injected.

43. MANDIBULAR NERVE BLOCK

45. INFERIOR ALVEOLAR NERVE BLOCK
Other common name- Mandibular block
Different techniques are:
• DIRECT METHOD
• INDIRECT METHOD
• METHOD OF CLARKE & HOLMES
• VAZIRANI- AKINOSI TECHNIQUE
• GOW-GATE’S TECHNIQUE

46. FACTORS AFFECTING THE POSITION OF
THE MANDIBULAR FORAMEN
• Width of the ascending ramus
• Width of the arch of the mandible
• Obliquity of the angle of the mandible
THREE PARAMETERS DURING
ADMINISTERATION OF IANB
• Height of the injection
• Antero posterior site of the injection
• Penetration depth
THE MOST COMMONLY USED
TECHNIQUES:
• Direct Method
• Indirect Method

47. Anatomical Land marks:
• Coronoid notch
• Anterior border of ramus of mandible
• External oblique ridge
• Pterygomandibular raphe
• Occlusal plane
TECHNIQUE: 25 gauge needle used, height of penetration 6
to10 mm from occlusal plane
Amount of solution: 1-1.8ml in 1-2 min.

50. COMPLICATIONS:-
1) Hematoma
2) Trismus
3) Transient facial paralysis
FAILURE OF ANESTHESIA :
• Deposition of the anesthetic too low
• Deposition of the anesthetic too far anteriorly
• Accessory innervation to the mandibular teeth

51. VAZIRANI- AKINOSI TECHNIQUE
A closed mouth approach to mandibular nerve block.
INDICATIONS:-
 Limited mandibular opening
 Inability to visualize landmarks of IANB
AREAS ANASTHETIZED:-
 All mandibular hard & soft tissues to the mid-line.
 Lingual soft tissues & periosteum
 Anterior 2/3 of tongue, floor of the oral cavity
 Buccal periosteum
 Body of mandible
ADVANTAGES:-
Provide successful anesthesia in bifid inferior alveolar & mandibular
canals

53. ANATOMICAL LANDMARKS:-
• Occlusal plane of the occluding teeth
• Muco gingival junction of the maxillary molar teeth
• Anterior boarder of the ramus
TARGET AREA
Soft tissue on the medial boarder of the ramus in the region
of the inferior alveolar, lingual & mylohyoid nerves between
foramen ovale & mandibular foramen.
The height of the injection is below the Gow-gates technique,
but above inferior alveolar block.

54. BEVEL: must be oriented away from the bone of
mandibular ramus, i.e; bevel faces towards the mid
line
PROCEDURE:
25 gauge needle used
Depth of penetration is 25mm
1.5-1.8 ml in 60seconds is deposited.

56. COMPLICATIONS:-
• Hematoma
• Trismus
• Transient facial nerve paralysis
FAILURES OF ANASTHESIA:
• Due to failure to appreciate the flaring nature of the ramus
• Medial insertion point too low
• Under insertion or over insertion of the needle

57. GOW-GATES TECHNIQUE
In 1973,Gow-Gates described a true mandibular nerve by
means of intra oral approach using intraoral and extraoral
landmarks to deposit the anesthetics solution at the neck of
the mandible
Anatomical Land Marks
•Anterior border of the ramus
•Corner of the mouth
•Inter Tragic notch of the ear
Target area
Lateral side of the condylar
neck just below the insertion
of the lateral pterygoid
muscle.

58. Area of Insertion
• Mucous membrane on the
mesial surface of the mandibular
ramus
• On a line from the intertragic
notch to the corner of the mouth
just distal to the maxillary 2nd
molar
• Height of the injection is
established by placing the needle
tip just below the mesolingual
cusp of maxillary 2nd molar

60. Procedure
• Needle used-25 gauge.
• Depth of penetration-25 to 27mm
• 1.8ml of solution deposited in 60 to 90sec
Complications
• Hematoma
• Trismus
Failure of Anesthesia
• Too little volume of the anesthetic solution
• Anatomical difficulties : Do not deposit the solution unless
bone is contacted.

61. Nooh and Abdullah
• This technique is a modified version of Malamed's indirect
technique.[1]
• In this technique the needle is inserted 1.5 cm above the occlusal
plane with syringe barrel located at the premolars area in the
opposite site.
• After touching the bone, the syringe is then moved to the same
side of injection and the needle then advanced while it is in contact
with bone to a distance of 30-34 mm.
• The authors claimed that this technique has a lower failure rate
(1%), lower positive aspiration, and lower incidence of
complications.

62. METHOD OF CLARKE &
HOLMES
• It involves deposition of solutions at a higher level than usual. It is a
modification of indirect technique. In the standard direct/indirect technique,
the analgesic is placed immediately behind the mandibular foramen, which
is 1cm above the occlusal plane of molar teeth. At this level the nerve is
concealed by lingula & sphenomandibular ligament. Depositing the
solution at a higher level causing complete anesthesia.4

63. METHOD OF ANGELO
SARGENTI
• This technique is a modification of direct method. The difference is that the nerve
is approached from a higher level than usual.
•
• Technique:
• Syringe with 1 5/8 inch 26gauge needle is used. The index finger is placed in the
retro molar fossa with nail facing lingually. The needle is inserted opposite to the
midpoint of the finger nail. The barrel of the syringe is now placed between and in
contact with the upper premolars of the opposite side. Needle is slowly inserted in a
downwards & backwards direction until it touches the bone, depth is 1cm. 1.5ml of
solution is deposited.

65. LONG BUCCAL NERVE BLOCK
OTHER NAME
Buccal nerve block or buccinator nerve block.
TARGET AREA
Buccal nerve as it passes over the anterior border of the
ramus
LAND MARKS
 External oblique ridge
 Retromolar triangle
 Distal to 3rd molar
TECHNIQUE
25 gauge needle is inserted in to the buccal mucosa just distal
to the lower 3rd molar.
0.25 to 0.5ml of solution is deposited.

67. MENTAL NERVE BLOCK
AREAS ANESTHETIZED:
ANATOMICAL LANDMARKS
• Mandibular Bicuspids
• Muco-buccal fold
TARGET AREA
Mental nerve as it exits the
mental foramen usually
between the apices of the
1st and 2nd premolar

68. AREA OF INSERTION
Muco-buccal fold at or just
anterior to the mental
foramen.
25 gauge needle inserted until
the periosteum of the
mandible is gently contacted.
0.5 to 1ml of solution is
deposited.

69. RECOMMENDED VOLUME OF THE LOCAL ANESTHETIC
FOR MANDIBULAR INJECTIONS:
Inferior Alveolar 1.5ml
Buccal 0.3ml
Gow gates 1.8ml
Vazirani-Akinosi 1.5-1.8ml
Mental 0.6ml

70. REFERENCE
• Handbook of local anesthesia;Malamed , 5th
edition
• Texxtbook of local anaesthesia ;Monenims
• Thangavelu K, Kannan R, Senthil Kumar N.
Inferior alveolar nerve block: Alternative
technique. Anesth Essays Res. 2012;6:53–7.
[PMC free article] [PubMed]