This document provides information on maxillary anesthesia techniques. It discusses the anatomy of the maxillary nerve and its branches that innervate the maxilla. Several injection techniques are described including posterior superior alveolar nerve block, middle superior alveolar nerve block, anterior superior alveolar nerve block, and greater palatine nerve block. Each technique lists the nerves anesthetized, areas anesthetized, indications, contraindications, and steps for administration. Complications and alternatives are also noted for some techniques.

1. MAXILLARY ANESTHESIA
Seminar on -
Presented by –
Hemam Shankar Singh

2. A branch of trigeminal nerve
Purely sensory
Course foramen rotundum pterygopalatine fossa
inferior orbital fissure infraorbital foramen
Part of the maxillary nerve distal to the inferior orbital fissure is called
infraorbital nerve
Maxillary nerve:

4. A. Branch in middle cranial fossa:
before entering foramen rotundum gives off meningeal
branch to dura materof the middle cranial fossa
B. Branhes arising in pterygopalatine fossa:
i. Greater palatine n.:- emerges through the greater palatine
foramen & then runs forward on the inferior surface of
hard palate supplying mucous membrane & glands
ii. Lesser palatine n.:- emerge through lesser palatine
foramen, & runs backwards into the soft palate, supply
tonsil
iii. Nasopalatine n.:- runs downward & forward on the nasal
septum, pass through incisive foramen, supply ant. Part of
hard palate
Branches

5. iv. Posterior superior alveolar(PSA) n.:- runs down on the posterior surface of the
maxilla it lie in the wall of maxillary sinus where it supplies. It supply sensory
innervation to—
-buccal gingiva in maxillary molar region
-mucous membrane of the sinus
-alveoli, PDL, & pulpal tissue of the maxillary 3rd, 2nd & 1st molar with
exception (in 28%of patients) of mesiobuccal root of the 1st molar
C. Branch in infraorbital groove & canal
i. Middle superior alveolar (MSA) n.:- arise within the canal, provide sensory
innervation to two maxillary premolars & mesiobuccal root of maxillary 1st molar
(28%), periodontal tissues, buccal soft tissue, & bone of the premolar region
ii. Anterior superior alveolar (ASA) n.:- arise from infraorbital n. provide pulpal
innervation to C.I. & L.I., & canine, to periodontal tissue, buccal bone, & mucous
membrane of these teeth
Contd.

6. 1. Local Infiltration
2. Field Block
3. Nerve Block
Techniques of Maxillary Anesthesia

7. I. Supraperiosteal (infiltration)
II. Periodontal ligament (PDL, intraligamentary)
III. Intraseptal injection
IV. Posterior superior alveolar nerve block
V. Middle superior alveolar nerve block
VI. Anterior superior alveolar nerve block
VII. Greater (anterior) palatine nerve block
VIII. Nasopalatine nerve block
IX. Maxillary (second division) nerve block
X. Anterior meddle superior alveolar nerve block
XI. Palatal approach-anterior superior alveolar n block
Maxillary Injection Techniques

8. Nerves anesthetized– terminal branch of dental plexus
Areas anesthetized
Entire region innervated by the large terminal branches of this plexus
Indications
1. Pulpal anesthesia of maxillary teeth when treatment is limited to 1 or 2
teeth
2. Soft tissue anesthesia when indicated for surgical procedure
Contraindications
1. Infection or acute inflammation
2. Dense bone covering the apices of teeth
Supraperiosteal Injection

9. Advantages
1. High success rate (>95%)
2. Easy & usually entirely atraumatic
Disadvantages
Not recommended for larger areas because of multiple injection
Alternatives– PDL, IO, regional block
Anatomical landmark:
Mucobuccal fold
Crown of the tooth
Root contour of the tooth
Supraperiosteal Injection

10. Technique
1. Lift the lip, pulling the tissue taut
2. Hold the syringe parallel to the long axis of the tooth
3. Insert the needle at the height of the mucobuccal fold over the target tooth
4. Advance the needle until its bevel is at or above the apical region of the
tooth
5. Aspirate, if –ve , deposit 0.6 ml slowly over 20 seconds
Sighs & symptoms
1. Subjective: feeling of numbness in the area of administration
2. Objective: no pain during therapy
Supraperiosteal Injection

11. Safety features
1. Minimal risk of intravascular administration
2. Slowness of injection, aspiration
Precautions
should not be used for larger areas
Complications
pain on needle insertion with the tip against periosteum
Supraperiosteal Injection

12. Fig: PSA nerve

13. NervesAnesthetized-
Posterior superior alveolar and its branches
AreasAnesthetized-
1) Pulps of the maxillary 3rd , 2nd and 1st molars
2) Buccal periodontium and bone overlying these
teeth
Anatomical Landmarks-
1. Mucobuccal fold and its concavity
2. Zygomatic process of the maxilla
3. Infratemporal surface of the maxilla
4. Anterior border and coronoid process of the ramus
of the mandible
5. Maxillary tuberosity
Posterior superior alveolar(PSA) nerve block

14. Indications –
1. When treatment involves two or more maxillary molars
2. When supraperiosteal injection is contraindicated (e.g. with infection or
acute inflammation)
3. When supraperiosteal injection has proved ineffective
Contraindications-
When the risk of hematoma is too high ( as in hemophilic), in which case a
supraperiosteal or PDL is recommended.
Advantages-
1. Atraumatic
2. High success rate
3. Less number of injections
4. Minimize amount of local used
Posterior superior alveolar(PSA) nerve block

15. Disadvantages-
1. Risk of hematoma
2. Does not anesthetize first molar completely
3. No bony landmarks during insertion
4. Second injection necessary for 1st maxillary molar in 28% of patients
Positive Aspiration-
Approximately 3.1%
Posterior superior alveolar(PSA) nerve block

16. Needle pathway during insertion-
Needle penetrates the mucosa, alveolar tissue, and possibly the buccal pad
of fat. It penetrates the posterior fiber of buccinator muscle.
Approximating structures when needle is in position-
when needle is in final position, it should be as follow:
1. Posterior to the posterior surface of the maxilla
2. Anterior and lateral to the anterior margin of the external pterygoid muscle
3. Anterior to the pterygoid plexus of veins
Needle will be in proximity to the posterior superior alveolar canal
Posterior superior alveolar(PSA) nerve block

17. Technique For Right Side-
a) Operator stands on the right side of the patient
b) Patient is positioned so that maxillary occlusal plane is at 45º angle to the
floor
c) Move the left forefinger over the mucobuccal fold in a posterior direction
from bicuspid area until the zygomatic process of the maxilla is reached.
d) at its posterior surface fingertip will rest in a concavity in the mucobuccal fold
e) Rotate the finger so that the fingernail is adjacent to the mucosa and its
bulbous portion is still in contact with the posterior surface of the zygomatic
process.
f) Hand is lowered so that the finger is in a plane right angle to the maxillary
occlusal surface and 45º angle to patients sagittal plane
g) Area of insertion should be dried and painted with a suitable antiseptic
solution
Posterior superior alveolar(PSA) nerve block

18. Technique For Right Side(contd.)-
h) Previously loaded syringe, with a ¾ inch, 25-gauge, is held in a pen
grasp orienting the bevel towards the bone and inserted into the
tissue in a line parallel with the index finger and bisecting the
fingernail
i) Insert for a distance of about ½ to ¾ inch, going upward, inward and
backward
j) After aspirating and making certain that the needle is not within a
vessel, slowly, over 30-60 seconds about 0.9-1.8ml, inject the
solution maintaining the position of the needle throughout
Posterior superior alveolar(PSA) nerve block

20. Signs and symptoms-
1. Subjective : none
2. Objective : Instrumentation is necessary to demonstrate absence of pain
Safety Measures-
1. Slow injection, repeated aspiration
Precaution-
The depth of the needle penetration should be checked;
overinsertion increases the risk of hematoma
Posterior superior alveolar(PSA) nerve block

21. Failures of Anesthesia-
1. Needle too lateral
2. Needle too high
3. Needle too far posterior
Complications-
1. Hematoma
2. Mandibular anesthesia
Posterior superior alveolar(PSA) nerve block

22. Nerves anaesthetized
MSA & terminal branch
Areas anaesthetized
1. Pulps of maxillary 1st & 2nd premolar & mesiobuccal root of 1st
molar(28%)
2. Buccal periodontal tissues & bone of these teeth
Anatomical landmarks
Mucobuccal fold above the maxillary 2nd premolar
Advantages– minimizes no. of injection & volume of solution
Middle Superior Alveolar Nerve Block

23. Indications
1. When infraorbital n. block fails to provide pulpal anaesthesia distal to
maxillary canine
2. Dental procedures involving both maxillary premolars
Contraindications
-infection or inflammation in the area of injection
-where the MSA n. in absent
Alternatives
1. Local infiltration, PDL, IO injections
2. Infraorbital n. block
Middle Superior Alveolar Nerve Block

24. Technique
1. Chair position– 10 0’clock for right & 8 or 9 0’clock
for left handed
2. Stretch the upper lip to make the tissues taut & to
gain visibility
3. Insert the needle into the height of the mucobuccal
fold above the 2nd premolar
4. Aspirate, if –ve, slowly deposit 0.9 to 1.2 ml
Signs & symptoms
1. Subjective: upper lip numb
2. Objective: no pain
Safety features: relatively avascular area,
anatomically safety
Precaution– do not insert too rapidly & too close to
the periosteum
Middle Superior Alveolar Nerve Block

25. -- also called infraorbital n. block
Nerves anaesthetized
1. ASA nerve
2. MSA nerve
3. Infraorbital nerve – inferior palpebral
-- lateral nasal
-- superior labial
Areas anaesthetized
1. Pulps of maxillary C.I. through canine on the injected side
2. Pulps of maxillary premolars(72% of patients) & mesiobuccal root of the
molar
Anterior superior alveolar(ASA) nerve block

26. 3. Buccal(labial) periodontium and bone of these teeth
4. Lower eyelid, lateral aspect of the nose, upper lip
Anatomical landmarks
1. Infraorbotal notch
2. Infraorbital depression
3. Infraorbital ridge
4. Supraorbital notch
5. Anterior teeth
6. Pupils of eye
Anterior superior alveolar(ASA) nerve block

27. Needle pathway during insertion
1. Bicuspid approach: it passes through the mucosa & areolar tissue, and during
insertion should pass beneath & lateral to the external maxillary artery &
anterior facial vein
2. C.I. approach: it pass through mucosa & areolar tissue & beneath the
angular head of the levator labii superioris m., proceeds anteriorly to the
origin of levator anguli oris m. & beneath external maxillary artery &
anterior facial vein
Approximating structures when the needle is in position
When in final position at the orifice of infraorbital canal, it should be
a) Beneath infraorbital head of levator labii superioris m.
b) Above the origin of levator anguli oris m.
Anterior superior alveolar(ASA) nerve block

28. Technique
— Patient seated comfortably in the chair & tilted so that the maxillary plane is
at a 45º angle to the floor
— Patient is ask to look directly forward as the supraorbital & infraorbital
notchs are palpated
— Imaginary straight line drawn vertically through these landmarks will pass
through pupils of the eye, the infraorbital foramen, bicuspid teeth, mental
foramen
— Palpating finger should be moved downward about 0.5cm from th
infraorbital notch, where a shallow depression will be felt
— For block on right side– thumb of the operator left hand is placed over the
previously located infraorbital foramen, lip retracted with index finger
exposing the mucolabial fold
Anterior superior alveolar(ASA) nerve block

29. – A 1 5/8-inch, 25-gauge needle is inserted with either one of the two
direction, while for first– inserted in a line parallel with supraorbital notch,
pupil of eye, infraorbital notch, & 2nd bicuspid tooth
– insert about 5mm from the labial plate to pass over the canine fossa
– Thumb which is in placed should be used tto maneuver the needle into a
position so that it contacts the bone at the entrance to the foramen
– 2nd direction—insertion bisects the crown of the C.I. from the mesioincisal
angle to distogingival angle
– Needle inserted about 5mm from the mucobuccal fold
– Needle should gently contact the boundary of the foramen
– Approx. 2ml of solution is deposited & the thumb is held until the injection is
completed
– It is necessary to allow for midline or overlapping innervation by infiltration
over the apex of the oppositeC.I.
ASA nerve block

30. ASA nerve block

31. Indications
1. Dental procedures involving more than two maxillary teeth & their overlying
buccal tissue
2. Inflammation & infection (which C/I the supraperiosteal injection)
3. When supraperiosteal injections have been ineffective because of dense
cortical bone
Contraindications
1. Discrete treatment areas (supraperiosteal preferred)
2. Hemostasis of localized area (infiltration indicated)
Advantages
1. Comparatively simple technique
2. Coparatively safe, minimized volume of solution & number of needle
punctures necessary to achieved anaesthesia
ASA nerve block

32. Steps in atraumatic administration of palatal anesthesia
1. Provide adequate topical anesthesia at site of needle penetration--- by
allowing topical anesthetic to remain in contact with soft tissues for atleast
2 minutes
2. Use pressure anesthesia at site both before & during needle insertion &
deposition of solution--- by applying considerable pressure to the tissues
adjacent to the injection site with a firm object
3. Maintain control over the needle--- with a firm hand rest
4. Slow deposition--- density of the palatal soft tissues & firm adherence to the
underlying bone. Rapid deposition tears the palatal soft tissues & leads to
both pain on injection & localised soreness when anesthetic action is
terminated
Palatal anesthesia

33. Nerves anesthetized
Greater palatine nerve
Areas anesthetized
Posterior portion of the hard palate & its overlying tissues
Anteriorly as far as the 1st premolar & medially to the midline
Indications
1. When palatal soft tissue anesthesia is necessary for restorative therapy on
more than 2 teeth
2. Pain control during periodontal or oral surgical procedures involving the
palatal soft & hard tissues
Greater palatine nerve block

34. Contraindications
1. Inflammation or infection at the injection site
2. Smaller areas of therapy
Advantages
1. Minimizes needle penetration
2. Minimizes volume of solution
3. Minimizes patients discomfort
Disadvantage
1. No hemostasis except in the immediate area of injection
2. Potentially traumatic
Greater palatine nerve block

35. Alternatives
1. Local infiltration in specific regions
2. Maxillary n. block
Technique
1. Greater palatine n. emerge from greater palatine foramen & course forward
in a groove parallel to maxillary molar teeth
2. This foramen is situated between 2nd & 3rd maxillary molars about 1cm from
the palatal gingival margin towards the midline
3. Insertion is approach from the opposite side with an 1-inch, 27-gauge
needle, which is kept as near to a right angle as possible with the curvature
of the palatal bone
4. Needle should be inserted slowly
Greater palatine nerve block

36. 5. 0.25-0.5ml of anesthetic solution is injected slowly
6. When bicuspid has to be anesthetized, it is advantageous to insert the
needle & deposit the solution palatal curvature opposite the bicuspid
7. Procedure–
a) For right nerve block a right handed administrator should sit facing the patient at 7
or 8 o’clock position
b) For left nerve block a right handed administrator should sit facing the same
direction as the patient at 11 o’clock position
c) Then ask the patient to open wide, extend the neck & turn head left or right for
improved visibility
d) Then the foramen is located as follow:
Cotton swap is placed at the junction of the alveolar process & the hard palate starting
from 1st molar & palpate posteriorly by pressing firmly into the tissue till it falls into a
depression (foramen)
Greater palatine nerve block

37. e) Apply topical anesthesia for 2 min & apply considerable pressure at the area of
foramen with the swap in the left hand (if right handed), then note ischemia at
the injection site
f) Apply pressure for 30 seconds then direct the syringe
g) Continue to apply pressure anesthesia throughout the deposition
h) Slowly advance the needle until palatine bone is gently contacted
i) Depth of penetration is usually less than 10 mm
Signs & symptoms
1. Subjective: numbness in the posterior portion of the palate
2. Objective: no pain during dental therapy
Safety features
1. Contact with bone
2. Aspiration
Greater palatine nerve block

38. Greater palatine nerve block

39. Precautions
Do not enter the foramen
Failures of anesthesia
1. Not technically difficult
2. Deposited too far anterior to the foramen
3. Anesthesia in the area of 1st premolar may prove inadequate because of
overlapping from nasopalatine n.
Complications
1. Ischemia & necrosis of the soft tissue when highly concentrated
vasoconstricting solution used for hemostasis over a prolonged period
(norepinephrine)
2. Hematoma is possible, but rare because of density & firm adherence
Greater palatine nerve block

40. Nerves anesthetized
Nasopalatine n.
Areas anesthetized
Anterior portion of hard palate, hard & soft tissue, from the mesial of the
right 1st premolar to mesial of left 1st premolar
Indications
1. To supplement the block of ASA & MSA n.
2. To augment analgesia of six maxillary incisors
3. To complete anesthesia of the nasal septum
Anatomical landmark
Central incisor teeth & incisive papilla
Nasopalatine nerve block

41. Contraindications
1. Inflammation or infection at the injection site
2. Smaller area of therapy
Advantages
1. Minimized needle penetration & volume of solution
2. Minimal patient discomfort from multiple needle penetration
Disadvantages
1. No hemostasis except in the immediate area of injection
2. Potentially most traumatic intraoral injection
Alternatives
1. Local infiltration in specific regions
2. Maxillary n. block
Nasopalatine nerve block

42. Technique
Two types of technique– 1. single penetration
2. multiple penetration
Technique-1 (single)
1. Area of insertion– palatal mucosa just lateral to the
incisive papilla
2. Target area– incisive foramen beneath the papilla
3. Path– approach the injection site at 45 degree angle
toward the papilla
4. Chair position– 9 or 10 o’clock position facing in the same
direction as the patient
5. Slowly advance the needle towards the foramen until
bone is gently contacted (depth approx. 5 mm)
6. Slowly deposit 0.45 ml in 15-30 second minimum
Nasopalatine nerve block

43. Signs & symptoms
1. Subjective: numbness in anterior portion of the palate
2. Objective: no pain during procedure
Safety features
1. Contact with the bone
2. Aspiration
Precautions
1. Do not directly into the papilla
2. Do not deposit too rapidly
3. Do not deposit too much solution
4. If needle penetration is more than 5 mm then the floor of the nose is
entered & infection may result
Nasopalatine nerve block

44. Complications
1. Hematoma
2. Necrosis of soft tissue
Technique-2 (multiple)
1. Areas of insertion–
a) labial frenum in the midline between maxillary two C.I.
b) Interdental papilla between maxillary two C.I.
2. Path–
a) First injection: infiltration into the labial frenum
b) Second injection: needle held at a right angle to the interdental papilla
c) Third injection: needle held at a 45 degree angle to the incisive papilla
Nasopalatine nerve block

45. 3. Procedure
a) 1st injection: retract the upper lip to stretch tissues &
improve visibility. Gently insert in the frenum & deposit
0.3 ml in approx. 15 seconds
b) 2nd injection: at 11 or 12 o’clock position, tilting the
patients head in the right, & needle at right angle to
interdental papilla needle is inserted into the papilla just
above the level of crestal bone. Aspirate when ischemia is
noted in the incisive papilla or needle tip become visible
just beneath the tissue surface
c) 3rd injection: same as single penetration
Signs & symptoms
1. Subjective: numbness in the upper lip & anterior
portion of the hard palate
2. Objective: no pain therapy
Safety features
1. Aspiration
2. Contact with bone
Nasopalatine nerve block

46. Advantage– entirely or relatively atraumatic
Disadvantage
1. Requires multiple injection
2. Difficult to stabilized the syringe
Complications
1. Necrosis of soft tissue
2. Tender of interdental papilla for several days
Nasopalatine nerve block

47. Nerves anesthetized– maxillary division of the trigeminal nerve
Areas anesthetized
1. Pulpal anesthesia of maxillary teeth on the side of block
2. Buccal periodontium bone overlying these teeth
3. Soft tissues & bone of the hard palate & part of soft palate, medially to the
miidline
4. Skin of the lower eyelid, side of the nose, cheek & upper lip
Landmarks
Mucobuccal fold at the distal aspect of the maxillary 2nd molar
Maxillary tuberosity
Zygomatic process of maxilla
Greater palatine foramen, junction of maxillary alveolar process & palatine bone
Maxillary nerve block

48. Indications
1. Pain control before extensive oral surgical, periodontal, or restorative
procedures requiring anesthesia of the entire maxillary division
2. Inflammation or infection
3. Diagnostic or therapeutic procedures for neuralgia or tics of the 2nd division
of trigeminal nerve
Contraindication
1. Inexperience administrator
2. Pediatric patient
3. Uncooperative patients
4. Inflammation or infection
5. When hemorrhage is risky e.g. hemophilliac
Maxillary nerve block

49. Advantages
1. Atraumatic injection via high tuberosity approach
2. High success rate (>95%)
3. Minimize no. of needle penetration & volume of local anesthesia
4. Neither high tuberosity nor greater palatine canal approach usually is
traumatic
Disadvantage
1. Risk of hematoma
2. Lack of hemostasis
Maxillary nerve block

50. Alternatives
1. PSA nerve block
2. ASA nerve block
3. GP nerve block
4. Nasopalatine nerve block
Technique– 2-type: high tuberosity approach &
GP canal approach
High-tuberosity approach
1. Area of insertion– height of mucobuccal
fold above the distal aspect of 2nd molar
2. Target area– maxillary n. as it passes
through the pterygopalatine fossa
superior and medial to the target area of PSA n.
block
Maxillary nerve block

51. 3. Procedure: chair position 10 o’clock for left side & 8 o’clock for right side
--Place the needle into the height of mucobuccal fold over the maxillary 2nd
molar
--Advance the needle slowly in an upward, inward, & backward direction
also to the depth of 30 mm. At this depth the needle tip should lie in the
pterygopalatine fossa
--Aspirate. If –ve, deposit 1.8 ml slowly (>60 seconds)
Greater palatine canal approach
1. Area of insertion– palatal soft tissue directly over the GP foramen
2. Target area– maxillary n as it passes through the pterygopalatine fossa: the
needle passes through the GP canal to reach the pterygopalatine fossa
3. Chair position– 7 or 8 o’clock for right side & 10 or 11 o’clock for left side
Maxillary nerve block

52. 4. Locate the foramen as stated earlier
5. Direct the syringe into the mouth the opposite side with
the needle approaching injection site at a right angle
6. Very slowly advance the needle into the GP canal to a
depth of 30 mm.
7. Aspirate & if –ve slowly deposit 1.8 ml of solution
Signs & symptoms
1. Subjective: pressure behind the upper jaw on the side
being injected; this usually subsides rapidly, progressing
to tingling & numbness of the lower eyelid, side of the
nose, & upper lip
2. Subjective: sensation of numbness in the teeth & buccal
& palatal soft tissues on the side of injection
3. Objective: no pain
Maxillary nerve block

53. Precautions
1. Pain on insertion of injection; primarily GP approach
2. Overinsertion
3. Resistance to needle insertion in the GP approach
Complications
1. Hematoma develops rapidly if the maxillary artery is punctured
2. Penetration of the orbit may occur during a GP approach if the needle goes
too far
3. Complications produced by injection of LA
a. Volume displacement of the orbital structures, producing periorbital swelling &
proptosis
b. Diplopia (VI cranial n), Mydriasis,
c. Penetration nasal cavity complaining of anesthetic solution running down the
throat
Maxillary nerve block

54. Nerves anesthetized
1. ASA nerve
2. MSA nerve
3. Subdural dental nerve plexus of the ASA & MSA n
Areas anesthetized
1. Pulpal anesthesia of maxillary C.I. canines & premolars
2. Buccal attached gingiva of these same teeth
3. Attached palatal tissues from midline to free gingival margin on the
associated teeth
Anterior middle superior alveolar nerve block

55. Indications
1. Is easier to perform with a CCLAD system
2. Dental procedures involving the maxillary anterior teeth or soft tissues are
to be performed
3. Multiple maxillary teeth anesthesia
4. Scaling & root planing of anterior teeth
5. Facial approach supraperiosteal injection
Contraindications
1. Thin palatal tissues
2. Who cannot tolerate a 3-4 min administration time
3. Procedure requiring more than 90 min
Anterior middle superior alveolar nerve block

56. Advantages
1. Provides anesthesia of multiple teeth with single injection
2. Minimizes volume of anesthesia & no. of puncture
3. Allows effective soft tissue & pulpal anesthesia for periodontal scaling 7 root
planing
4. Allows accurate smile line assessment
5. Eliminates postoperative inconvenience of numbness to the upper lip &
muscle of facial expression
6. Can be perform comfortably with a CCLAD
Disadvantages
1. Requires a slow administration time ( 0.5 ml/min)
2. Can cause operator fatigue with a manual syringe
3. May need supplemental anesthesia for C.I. & L.I.
Anterior middle superior alveolar nerve block

57. 4. May cause excessive ischemia if administered rapidly
5. Use of LA containing epinephrine with a conc. of 1:50,000 is contraindicated
Alternatives
1. Multiple supraperiosteal or PDL injections
2. ASA & MSA n block
3. Maxillary n block
Technique
1. Area of insertion: on the hard palate about halfway along an imaginary line
connecting the midpalatal suture to free gingival margin; the location of the
line is at the contact point between the 2nd 1st premolars
2. Target area: palatal bone at injection site
3. Chair position: 9 or 10 o’clock, patient in supine position
Anterior middle superior alveolar nerve block

58. 4. Needle 45 degree angle with a tangent to the palate
5. A prepuncture technique can be utilized. Apply the bevel of the needle
toward the palatal tissue. Place a sterile cotton applicator on top of the
needle tip. Apply light pressure & initiate delivery of LA to the surface of the
epithelium.
6. An “anesthetic pathway technique” can be utilized. Very slowly advance the
needle tip into the tissue, rotation allows efficient penetration. Advance the
needle 1 to 2 mm every 4 to 6 seconds while administrating solution.
7. Ensure that the needle contact is maintained with bony surface of the bone
8. Aspirate. Solution is delivered at 0.5 ml of approx. 1.4 to 1.8 ml
9. Advice the patient that he/she will experience a sensation of firm pressure
Anterior middle superior alveolar nerve block

59. Anterior middle superior alveolar nerve block

60. Signs & symptoms
1. Subjective: (1) A sensation of firmness & numbness is immediately
experienced on the palatal tissues. (2) Numbness of the teeth & associated
soft tissues extends from C.I. to 2nd premolar on one side of injection
2. Objective: (1) blanching of soft tissues on palatal & facial attached gingiva
fromC.I. to premolar region. (2) no pain. (3) no anesthesia of the face &
upper lip.
Safety features
1. Contact with the bone
2. Aspiration
3. Slow insertion & administration
4. Less anesthetic than necessary for a traditional facial approach
Anterior middle superior alveolar nerve block

61. Precautions
1. Against pain– (i) extremely slow insertion, (ii) slow administration during
insertion with simultaneous administration
2. Against tissue damage– (i) when using 4% LA, reduce the volume (ii) avoid
excessive ischemia
Complications
1. Palatal ulcer at injection site
2. Unexpected contact with the nasopalatine n
3. Density of injection site causing squirk-back of anesthetic & bitter taste
Anterior middle superior alveolar nerve block

62. Nerves anesthetized
1. Nasopalatine n
2. Anterior branch of ASA
Areas anesthetized
1. Pulps of the maxillary C.I., L.I. & canines
2. Facial periodontal tissue associated with these same teeth
3. Palatal periodontal tissues associated with these same teeth
Alternatives
1. Supraperiosteal or PDL
2. ASA (bilateral) n block
3. Maxillary (bilateral) n block
Palatal approach-anterior superior alveolar

63. Indications
1. Procedures involving the maxillary anterior teeth & soft tissues are to be
performed
2. Bilateral anesthesia of maxillary anterior is desired in single injection
3. Scaling & root planing of anterior
4. Anterior cosmetic procedure
Cotraindications
1. With extremely long canine roots
2. Who cannot tolerate 3-4 min administration time
3. Procedures requiring more than 90 min
Palatal approach-anterior superior alveolar

64. Advantages
1. Provides bilateral maxillary anesthesia from a single injection
2. Minimizes no. of punctures & volume of solution
3. Eliminates postoperative inconvenience of numbness to the upper lip &
muscles of facial expression
Disadvantages
1. Requires slow administration
2. May need supplemental anesthesia for canine
3. May cause excessive ischemia if administered too rapidly
4. Use of LA containing epinephrine is contraindicated
Palatal approach-anterior superior alveolar

65. Technique
1. Area of insertion: just lateral to the incisive papilla
in the papillary groove
2. Target area: nasopalatine foramen
3. Chair position: 9 or 10 o’clock
4. Initial orientation of bevel is “face down” toward
the epithelium holding the needle at approx. a 45
degree angle with a tangent to the palate
5. A prepuncture technique and “anesthetic pathway
technique” can be utilized as in AMSA n block
6. Ensure that the needle is in contact with the inner
bony wall of the canal
7. Anesthetic is delivered at a rate of 0.5 ml during the
injection for a final dosage of approx. 1.4 to 1.8 ml
Palatal approach-anterior superior alveolar

66. Signs & symptoms
1. Subjective: (i) a sensation of firmness & anesthesia is immediately
experienced in the anterior palate. (ii) numbness of teeth associated soft
tissues extends from right to left canine
2. Objective: ischemia of soft tissues of the palatal & facial attach gingiva, no
pain, no anesthesia of the face & upper lip
Safety features
1. Contact with the bone
2. Aspiration
3. Slow insertion
4. Slow administration
5. Less anesthetic than necessary for a traditional facial approach
Palatal approach-anterior superior alveolar

67. Complications
1. Palatal ulcer at injection site developing 1 to 2 days postoperative
2. Unexpected nerve contact of the nasopalatine nerve
3. Density of injection site causing squirk-back of anesthetic and bitter taste.
Palatal approach-anterior superior alveolar