maxillary nerve block

CONTENTS…..
o TRIGEMINAL NERVE
o MAXILLARY NERVE
o COURSE OF MAXILLARY NERVE
o BRANCHES OF MAXILLARY NERVE
o LOCAL ANESTHESIA
o COMPOSITION OF LOCAL ANESTHESIA
o MAXILLARY INJECTION TECHNIQUE
o COMPLICATION OF LOCAL ANESTHESIA
o COMPLICATION OF NERVE BLOCK
o REFERENCE

TRIGEMINAL NERVE
It is the LARGEST CRANIAL NERVE, contains both
sensory and motor fibres. The trigeminal nerve is
attached to the lateral part of the pons by its 2
ROOTS, motor & sensory.
TRIGEMINAL

Ophthalmic

Maxillary Nerve
Mandibular Nerve

MAXILLARY NERVE
The maxillary nerve originates at the middle of the
semilunar ganglion and continues forward in the
lower part of the cavernous sinus.

It then passes from the foramen rotandum
leaving the
CRANIAL FOSSA

enters PTERYGOPALATINE FOSSA
In the pterygopalatine fossa, the nerve is intimately
related to the pterygopalatine ganglion, and gives
off the ZYGOMATIC & POSTERIOR SUPERIOR

ALVEOLAR NERVE.

. PSA Nerve enters the body of the maxilla, and
supplies the upper molar teeth and the adjoining
part of the gum

It further moves forward to the INFERIOR ORBITAL
FISSURE, to pass into the orbital cavity, then laterally
into

orbital groove k/a INFRA ORBITAL GROOVE
continuing forward,

the second division emerges on the anterior surface
of maxilla through the infra orbital foramen, where it
divides into anterior and middle superior alveolar
nerve, supplying the maxillary anterior teeth

.

PTERYGOPALATINE GANGLION
 It is the
ganglion.

largest parasympathetic peripheral

 It serves as a relay station for the secretomotor
fibres to the lacrimal gland & to the mucous glands

of the nose, the paranasal
pharynx

sinuses, palate &

 Topographically it is related to the maxillary nerve
but functionally it is related to the facial nerve
through its greater petrosal branch.

.

 The flattened ganglion lie in the pterygopalatine

fossa just below the maxillary nerve, in front of
the

pterygoid

canal

sphenopalatine foramen

&

lateral

to

the

BRANCHES OF MAXILLARY NERVE
 BRANCHES IN THE PTERYGOPALATINE
GANGLION
 ZYGOMATIC NERVE
 INFRA ORBITAL NERVE
 POSTERIOR SUPERIOR ALVEOLAR NERVE
 MIDDLE SUPERIOR ALVEOLAR NERVE
 ANTERIOR SUPERIOR ALVEOLAR NERVE

Branches of pterygopalatine
ganglion
 ORBITAL BRANCH- pass through the inferior

orbital fissure & supply the periosteum of the orbit,
& the obitalis muscle.
 PALATINE BRANCHES- the GREATER OR

ANTERIOR palatine nerve descends through the
greater palatine canal, & supplies the hard palate &

the lateral wall of the nose. The LESSER OR
MIDDLE & POSTERIOR PALATINE NERVES supply
the soft palate & the tonsil.

 NASAL BRANCHES- enters the nasal cavity through the

sphenopalatine foramen. The LATERAL POSTERIOR
SUPERIOR NASAL NERVES, supply the posterior part
of the superior & middle conchae.

 The MEDIAL POSTERIOR SUPERIOR NASAL

NERVES, supply the posterior part of the roof of the
nose & of the nasal septum. The largest nerve is known

as the NASOPALATINE NERVE, which descends upto
the anterior part of the hard palate through the incisive
foramen.

 PHARYNGEAL BRANCH- passes through the

palatinovaginal canal & supplies the part of the
nasopharynx behind the auditory tube.
 LACRIMAL BRANCH- to supply secretomotor

fibres to the lacrimal gland

ZYGOMATIC NERVE
 Zygomatico temporal

Zygomatico Facial

Arises from the temporal surface Emerges through zygomatico
of zygomatic bone
facial foramen
 Supply the skin of the temple. Supplies skin of cheek.

BRANCHES IN THE INFRAORBITAL
FORAMEN
the nerve passes through the infra orbital foramen giving
off its 3 branches –

Palpebral Branch- Supply lower eyelid
Nasal Branch- Skin on lateral side of nose
Superior Labial Branch- Upper lip & part of
of nose

POSTERIOR SUPERIOR ALVEOLAR
NERVE

 It arises from the trunk of the maxillary nerve,
just before it enters the infraorbital groove
 They descends on the tuberosity of the maxilla &
gives off several twigs to the gums &
neighboring parts of the mucous membrane of
the cheek
 They then enters the alveolar canal on the
infratemporal surface of the maxilla & passing
from behind forward in the substance of the
bone, communicate with the middle superior
alveolar nerve, & gives off branches to the lining
of the maxillary sinus & gingival and dental
branches to each molar tooth from a superior
dental plexus.

MIDDLE SUPERIOR ALVEOLAR NERVE
 This nerve arises from the infra orbital nerve

as it runs in the infra orbital groove, and runs
down and forwards in the lateral wall of the
maxillary sinus
 It supply the sinus mucosa, the roots of the
maxillary premolars, & the mesiobuccal root
of the 1st molar.

ANTERIOR SUPERIOR ALVEOLAR
NERVE
 It is given off from the maxillary nerve just
before its exit from the infraorbital foramen
 It descends in a canal in the anterior wall of

the maxillary sinus, & divides into branches
that supplies the3 incisors & canines.

Local anesthesia
It is defined as transient regional loss of sensation
to a painful or potentionally painful stimulus
resulting from a reversible interruption of a

peripheral conduction along a specific neural
pathway to its central integration & perception in
the brain. (laskin)

Composition of local
anaesthesia
 Lignocaine Hcl 2%- anesthetic solution
 Adrenaline- vasoconstrictor 1: 80000
 Methyl paraben- preservative ( 0.1%)

 Thymol- fungicide
 Sodium metabisulphite- reducing agent(0.5mg)
 Distilled water- diluting agent/ Vehicle

 Sodium chloride- to maintain the isotonicity of
the solution (6mg)

NERVE BLOCK
LA deposited close to the main nerve trunk usually at
distance from the site of operative intervention.

FIELD BLOCK
Local anaesthetic solution is deposited near the larger
terminal branch, so the anaesthetized area will be
circumscribed.Treatment is done in an area away from
the site of injection

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.

MAXILLARY INJECTION TECHNIQUES
SUPRA PERIOSTEAL INJECTION:

(

Local Infiltration )

INDICATIONS:
 Pulpal anesthesia of maxillary teeth when

treatment is limited to one or two tooth .
 Soft tissue anesthesia for surgical procedure
in a circumscribed area.

TECHNIQUE: needle is injected beneath the mucous
membrane & the solution is infiltrated slowly
throughout the area.
AMOUNT TO BE DEPOSITED- 0.6ml over 20 sec.

CONTRAINDICATION:
 Infection or acute inflammation in the area of injection.
DISADVANTAGES:
 Need for multiple needle insertions.
 Necessary to administer large volume of solution.

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.

LAND MARKS:





Mucobuccal fold.
Zygomatic process of maxilla.
Infra temporal surface of maxilla.
Anterior border & coronoid process of the ramus of
the mandible.
 Tuberosity of maxilla.

TECHNIQUE:

 PATIENT POSITION- pt is positioned such that
maxillary occlusal plane is 45 degree angle to the
floor.

 25 gauge short needle is used.
 Insertion- height of mucobuccal fold above the
maxillary II molar.

 The operators left forefinger over the muccobuccal
fold in a post direction from the bicuspid area until
the zygomatic process of maxilla is reached

 At its post surface finger will feel a concavity in the
mucobuccal fold. Then rotate the finger so that the
fingernail is adjacent to the mucosa, & its bulbous
portion still in contact with the posterior surface of
the zygomatic process.
 Now needle is held in pen grasp & inserted in a line
parallel with the index finger, going UPWARD

INWARD & BACKWARD ( this places the needle in
the immediate vicinity of the foramen through
which the nerves enter the maxilla).

 SYMPTOMSa) OBJECTIVE- instrumentation necessary to

demonstrate absence of pain.
b) SUBJECTIVE- None.

DEPTH OF NEEDLE PENETRATION-16 mm.
DEPOSIT:- 0.9 to 1.8 ml in 30 to 60 sec .

COMPLICATIONS:
 Hematoma

NERVE BLOCK
OTHER NAME:
 Infra orbital.
 Incisors, cuspids, bicuspids & mesiobuccal
root of 1st molar.
 Upper lip
 Lower eye lid.
 Portion of the nose of the
injected site.

ANATOMICAL LANDMARKS:








Infra orbital ridge.
Infra orbital depression.
Supra orbital notch.
Infra orbital notch.
Bicuspid teeth.
Mental foramen.
Pupil of the eyes.
An imaginary straight line drawn vertically through these
landmarks will pass through the pupil opf the eyee,
infraorbital foramen(when the infraorbital notch is located,
the palpatating finger should be moved downward about
0.5mm, where a shallow depression will be felt), bicuspids, &
mental foramen.

 Maxillary occlusal plane at 45degree to the floor
 NEEDLE PATHWAY
 BICUSPID APPROACH- The needle is inserted in

a line parallel with the supraorbital notch, the
pupil of the eye,infra orbital notch, & 2nd
biscuspid tooth
 CENTAL INCISOR APPROACH- The neeedle
bisects the crown of the central incisor from the
mesioincisal angle to the distogingival angle.
 In either situatin, the needle should not
penetrate more than ¾ inch, it prevents the
needle from entering the orbital cavity

TECHNIQUE:
 NEEDLE- 25 gauge needle.
 SOLUTION DEPOSITED- 0.9 to 1.5 ml.
SYMPTOMSSUBJECTIVE- Tingling & numbness of the upper
lip,side of the nose
OBJECTIVE- instrumentation necessary to
COMPLICATION:
 Hematoma.
 Facial nerve paralysis.

GREATER PALATINE NERVE BLOCK:
OTHER NAME:

 Anterior palatine nerve block

 Posterior portion of hard palate and its over lying soft

tissues.
 Anteriorly up to I premolar and medially up to midline.

ANATOMICAL LANDMARKS:





II and III maxillary molars.
Palatal gingival margin of II and III maxillary molar.
Midline of the palate.
Line approximating 1cm from the palatal gingival
margin towards midline of the palate.

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.

NASO PALATINE NERVE BLOCK:
OTHER NAMES:
 Incisive nerve block.
 Spheno palatine nerve block.
 Anterior portion of hard palate from mesial of Rt. I
premolar to mesial of the Lt.I premolar.
LANDMARKS:
 Central incisors
 Incisive papilla.

TECHNIQUE:
 INSERTION- At a 45 degree angle towards incisive
papilla.
 OPERATOR- In 9 or 10 o’ clock position.
 DEPOSIT- 0.45 ml of solution in 15 to 30 sec at a depth
of 6 to 10 mm.

COMPLICATIONS:
 Necrosis of soft tissue due to highly concentrated
vasoconstrictor solution.

MAXILLARY NERVE BLOCK
 For achieving profound anesthesia of hemi maxilla.
 2 approaches 1) Greater palatine canal approach
2) High tuberosity approaches
 OTHER NAMES:-

Second division block, V2 nerve block
 AREAS ANESTHETIZED:1) Maxillary teeth on the affected side
2) Alveolar bone & overlying structures
3) Hard palate,part of soft palate
4) Upper lip, cheek, side of the nose, lower eye lid

 ADVANTAGES:1) Minimizes the no. of needle penetrations
2) Minimizes the total volume of local
anesthetic solution 1.8ml versus 2.7ml
3) high success rates

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, situated
between the 2nd & 3rd molars about 1cm towards the
midline of the palate from the palatal gingival margin.
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

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

SYMPTOMS OBJECTIVE- instrumentation necessary to

demonstrate absence of pain sensation
 SUBJECTIVE- tingling & numbness of the
upper lip, side of the nose, & lower eyelid.

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
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

INTRALIGAMENTARY ANESTHESIA
This is achieved by injecting an analgesic solution
directly into the periodontal membrane of the
tooth.
USES:
 For extraction of teeth in hemophilic patients to

avoid bleeding.
 Useful in pedodontic patients.

 Indicated prior to immediate replacement dentures.

TECHNIQUE:

Finer needles of gauge 30 are inserted

in the periodontal membrane to a depth of 2mm.Needle is
inserted parallel with the long axis of the root of the tooth
until it contacts the alveloar bone. 0.2ml of solution is
injected over a period of 30secs.Maxillary Molars require 3
injections and mandibular molar 2 injections.
PERIOD OF ANESTHESIA: 30-45 mins

DISADVANTAGES:
Infection of the site.
Discomfort after the analgesia wears off.

Recommended volume of local anesthetic for
maxillary techniques
SUPRA PERIOSTEAL
PSA
ASA
GREATER PALATINE
NASOPALATINE
PALATAL INFILTRATION

0.6ML

0.9-1.8
0.9-1.2
0.45-0.6
0.45
0.2-0.3

1.8

EXTRA ORAL TECHNIQUES
INFRA ORBITAL BLOCK
Indications:

Infection, Trauma resulting in impossible intra oral
approach .
Anatomical Land marks:
 Pupil of the eye.
 Infra orbital ridge.
 Infra orbital notch.
 Infra orbital depression.

Technique:
 Using the available landmarks, the dentist

should locate the infra orbital foramen. The
skin & subcutaneous tissue is anesthesized by
local infiltration
 25 gauge needle used, and is directed slightly
upward & laterally which facilitates entrance
into the foramen, which open downward &
medially.
SYMPTOMS
 SUBJECTIVE- tingling & numbness of the upper
lip, side of the nose & lower eyelid
 OBJECTIVE- instrumentation necessary to

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
 For diagnostic and therapeutic purposes

Anatomical land marks:





Mid point of the zygomatic arch
Zygomatic notch
Coronoid process of the ramus of mandible
Lateral pterygoid plate

AREA ANAESTHETIZED Maxillary teeth on the affected side

 Alveolar bone & the overlying structure
 Hard palate & portion of soft palate
 Upper lip, cheek, side of the nose & lower

eyelid

Technique:
 The midpoint of the zygomatic process
is located & the depression in its inferior
surface is marked
 A skin wheal is raised just below this
mark, which the dentist identifies by
having the patient open & close the jaw
 The needle is inserted through the skin
wheal, until the needle point gently
contacts the lateral pterygoid plate.

 The needle is withdrawn , with only the point

left in the tissue, & re directed in a slight
forward & upward direction untill the needle
is inserted to the depth of the marker.
 After careful aspiration, 2-3ml of LA is
injected
 Care should be exercised to aspirate after
each 0.5ml of solution injected.

Complications of local
anesthesia
 LOCAL
 Needle breakage
 Paresthesia
 Facial nerve paralysis
 Trismus
 Hematoma
 Pain on injection
 Burning on injection
 Edema
 Sloughing of tissues
 Post anesthetic intra oral lesions

SYSTEMIC COMPLICATIONS Toxicity
 Idiosyncracy
 Allergy

 Anaphylactoid reaction

CLINICAL CONSIDERATION OF
BLOCKS

 Paraesthesia

 Needle breakage
 Haematoma

 Facial nerve paralysis

PARASTHESIA
It is defined as persistent anesthesia, (anesthesia
well beyond the expected duration )
HYPERESTHESIA(increased sensitivity to noxious
stimuli) & DYSESTHESIA(painful sensation
occuring to non noxious stimuli) , in both of these
patient experience PAIN & NUMBNESS.

CAUSE Trauma to any nerve.
 Haemorrhage into or around the neural sheath.

 Injection of a LA solution contaminated

by alcohol(alcohol are neurolytic &
sometimes can produce long term trauma
to the nerve) or sterilizing solution(
produces irritation, resulting in edema &
increased pressure in the region of the
nerve, leading to parasthesia)
 Trauma to the nerve sheath

PROBLEM
 May lead to self inflicted injury
 Biting or thermal or chemical insult can occur

without a patient awareness

PREVENTIONstrict adherence to injection protocol & proper
care & handling of dental cartridges
MANAGEMENT Reassure the patient, speak to the pt personally,
& explain is not uncommon after LA
adminstration
 Examine the patient- determine the degree &
extent of the paresthesia
 TINCTURE OF TIME- medicine
 Reschedule the pt for examination every 2
months
 Dental treatment may continue, but avoid
readminstration LA into the region of the
previously traumatized nerve.

NEEDLE BREAKAGE
CAUSES Weakening of the dental needle by bending it
 Sudden unexpected movement by the patient.
PREVENTION Use larger gauge needle (25gauge)
 Use long needles for injection requiring
penetration of significant depth of soft tissues
 Do not insert the needle into tissues to its hub
 Do not redirect a needle once it is inserted into
tissues.

MANAGEMENT
 Remain calm, do not panic
 Instruct the patient not to move, keep the pt
mouth open. If possible use a bite block
 If fragment is visible, try to remove it with a
SMALL HEMOSTAT OR A MAGILL
INTUBATION FORCEPS
 If the needle is lost, & cannot be retrieved
a) do not proceed with incision & probing
b) calmly inform the pt

• c) refer the patient to an oral & maxillofacial

surgeon for consultation, & not for removal of
the needle.

 Despite attempted removal, it is then

prudent to abandon the attempt & allow the
needle fragment to remain

HEMATOMA
The effusion of blood into extravascular spaces can,
result from inadvertently nicking a blood vessel
during the injection of local anesthetic. Injecting
the LA solution into the pterygoid plexus.
CAUSE- An arterial & venous puncture after PSA or
IAN block, the tissue surrounding these vessels
more readily accommodate significant volume of
blood until extravascular pressure exceeds
intravasular pressure.
HEMATOMA AFTER PSA ARE VISIBLE EXTRA
ORALLY, WHILE WITH IAN VISIBLE INTRA
ORALLY.

PROBLEM A hematoma rarely produces significant
problems, aside from the resulting bruise, which
may or may not be visible extraorally.
 Swelling & discoloration subsides within 7-14
days.
 Possible complication includes trismus & pain

PREVENTION
1. Knowledge of the normal anatomy

2. The depth of penetration for PSA may be
decreased in a patient with smaller facial
characteristics
3. Use shorter needle for PSA.
4. Minimize the no. of needle penetration into

tissue
5. Never use a needle as a probe in tissue.

MANAGEMENT
 IMMEDIATE- Direct pressure should be applied

to the site of bleeding.


PSA usually produces largest & unappealing

hematoma. Digital pressure can be applied in
the soft tissues in the mucobuccal fold as far
distally as can be tolerated by the patient.
 Apply pressure in a medial & superior direction
 Ice should be applied to increase pressure on the
site,& helps constricts the vessels.

NERVE BLOCK
 pressure is applied to the skin directly over the

infraorbital foramen
 Clinical manifestation is discoloration of the skin
below the lower eyelid
 Hematoma is unlikely to arise from ASA,
because the techniques described requires
application of pressure to the injection site
throughout drug administration & for a period of
2-3 min.

SUBSEQUENT Patient should be discharged once the bleeding

stops, advise the patient about possible
soreness and limitation of movement.
 For soreness, take an analgesic
 Do not apply heat for the next 4-6hrs, heat
produces VASODILATION thereby increasing
the size of hematoma.
 Heat may be applied beginning the next day,
that will increase the rate at which blood
elements are resorbed.

FACIAL NERVE PARALYSIS
CAUSEparalysis of some of the terminal branches of the 7th
cranial nerve, when infra orbital nerve block is
injected or when maxillary canine are infilterated.

PROBLEM Loss of motor functions to the muscles of facial

expression, there is usually minimal or no
sensory loss
 Inability to close the eyelid
 Drooping of lip on the affected side

 Winking and blinking becomes impossible
 Patients face appear lobsided.

MANAGEMENT Reassure the patient- situation is transitory
 Contact lenses must be removed until muscle

movement returns
 Eye patch should be applied, periodically
lubricate the eyes

REFERENCES
 HANDBOOK OF LOCAL ANESTHESIA- 5th

EDITION BY- STANLEY F. MALAMED
 MONHEIM’S LOCAL ANESTHESIA AND PAIN
CONTROL IN DENTAL PRACTICE BYC.RICHARD BENNETT
 B.D CHAURASIA

maxillary nerve block

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