psa nerve block, nasopalatine nerve blocks

1. YASH USHER-96
topic : maxillary nerve blocks

2. Maxillary nerve blocks
• maxillary nerve blocks include :
a) Posterior superior alveolar nerve block.
b) Nasopalatine nerve bock.
c) Anterior palatine nerve block.
d) Middle superior nerve block.
e) Anterior superior alveolar nerves.
f) Infraorbital nerve block.
g) Greater palatine nerve block.

3. Posterior superior alveolar nerve
block

4. NERVES ANESTHESIZED
• Posterior superior alveolar nerve

5. AREAS ANESTHESIZED
• The maxillary molars with the exception of the mesiobuccal root
of the 1st molar ; the buccal alveolar process of the maxillary
molars, including the overlying structures_ periosteum ,
connective tissue , and mucous membrane.
•

6. ANATOMICAL LANDMARKS
a) Mucobuccal fold and its concavity.
b) Zygomatic process of maxilla.
c) Infratemporal surface of the maxilla.
d) Tuberosity of maxilla.
e) Anterior border and coronoid process of the ramus of
mandible.

7. indications
• For operative procedures of the molar teeth and supporting
structures.This injection must be combined with palatal
injection for extractions or when instrumentation extends into
this area.

8. NEEDLE PATHWAY DURING INSERTION
• The needle penetrates the mucosa , areolar tissue, and possibly
the buccal pad of fat. It penetrates the posterior fibers of the
buccinator muscle.

9. APPROXIMATING STRUCTURESWHEN
NEEDLE IS IN POSITION.
When needle is in final position, it should be as follows:
a) posterior to the posterior surface of maxilla
b) anterior to pterygoid plexus of veins
c) anterior and lateral to anterior margin of external pterygoid
muscle.
The needle will be in proximity to the posterior superior alveolar
canal through which the posterior superior alveolar artery, vein
and nerve pass.

10. TECHNIQUE FOR RIGHT SIDE
a) The operator stands on the right side of patient.
b) The patient is positioned such that maxillary occlusal plane is
at 45-degree angle to the floor
c) The operator moves the left forefinger over the mucobuccal
fold in a posterior direction from the bicuspid area until the
zygomatic process of maxilla is reached. At its posterior
surface the fingertip will rest in a concavity in the mucobuccal
fold.
d) At this particular point the left forefinger is rotated so that the
fingernail is adjacent to the mucosa and its bulbous portion is
still in contact with the posterior surface of zygomatic process

11. a) Now after hand is lowered, with the finger keeping the bullous portion still in contact
with the zygomatic process so that the fingernail is adjacent to the mucosa and its
bullous portion is still in contact with the posterior surface of the zygomatic process.
b) Now the hand is lowered, with the finger keeping the bullous portion still in contact
with the zygomatic process so that the finger is in a plane at right angles to the
occlusal surfaces of the maxillary teeth and at a 45-degree angle to the patient sagittal
plane. One can best accomplish this by having the patient partially close the mouth so
that the lip and cheek can be extended laterally and posteriorly.
c) The index finger should be pointing in the exact direction the needle is to follow.
d) The area of insertion should be dried and painted with a suitable antiseptic solution. A
previously loaded syringe, with a 1^5/8-inch,25-guage needle, is held in pen grasp and
inserted into tissue in a line parallel with the index finger and bisecting the fingernail.
a. The insertion is made with a distance of about ½ to ¾ inch , going upward , inward
and backward .This should place the needle point in the immediate vicinity of the
foramina through which the nerves enter the maxilla.
b. After aspirating and making certain that the needle is not within a vessel , the operator
slowly injects the contents of the cartridge while maintaining the position of needle
throughout.

12. Analgesia of the 1st 2nd 3rd maxillary molars, including the buccal alveolar
process , periosteum and mucosa should be obtained.This however will not
include the mesiobuccal root if 1st molar , which is innervated by branches of
middle superior alveolar nerve.This root and supporting tissues can be
anesthetized by infiltrating buccally over involved root.

13. TECHNIQUE FOR LEFT SIDE
• For injection on the left side the operator stands on the right
side of patient, and the left arm is passed around the patient’s
head so that the area may be palpated with the left forefinger.
The technique for injection after palpation is the same as that for
the right side.

14. SYMPTOMS OF ANESTHESIA
a) Subjective symptoms :None
b) Objective symptoms : Instrumentation necessary to demonstrate
absence of pain sensation.

15. Nasopalatine nerve block

16. NERVES ANESTHESIZED
• Nasopalatine nerve block as it emerges from greater palatine
foramen.

17. AREAS ANESTHESIZED
• The anterior portion of the hard palate and overlying structures
back to the bicuspid area, where branches of the anterior
palatine nerve causing forward create a dual innervation.

18. ANATOMICAL LANDMARKS
a) Central incisor teeth.
b) Incisive papilla in the midline of palate

19. INDICATIONS
a) To supplement the block of the anterior and middle superior
alveolar nerves
b) To augment analgesia of the six maxillary incisors.
c) To complete analgesia of the nasal septum.

20. TECHNIQUE
• The nasopalatine nerve block is an extremely painful injection unless a
preparatory injection is made.The preparatory injection is made by
inserting a 1 inch 25-guage needle into the labial intraseptal tissue
between the maxillary central incisors.The needle is inserted at right
angle to the labial plate and passed into the tissues until resistance is
met; then 0.25 ml of anesthetic solution is deposited.

21. • The needle is then withdrawn and reinserted slowly into
the crest of the papilla, making certain that it is in line with
the labial alveolar plate
• The needle is then advanced slowly into the incisive
foramen, about 0.25 to 0.5 ml should be injected very
slowly to prevent distention of the surrounding tissues.
• For securing mucous membrane anesthesia before the
insertion of the needle into the incisive papilla, the jet-
injector can be used.This instrument will produce a small
area of surface anesthesia through which the needle can be
introduced painlessly to anesthetize the nasopalatine nerve

22. • The needle is inserted at right angle to the labial plate and passed into the
tissues until resistance is met; then 0.25 ml of anesthetic solution is
deposited.

23. • A property made nasopalatine nerve block will anesthetize the palatal tissues
of the six anterior teeth .some authors believe that if the needle is carried far
enough into the canal, the six anterior teeth can be anesthetized for operative
dentistry by any one injection alone.

24. SYMPTOMS OF ANESTHESIA
a) Subjective symptoms. Feeling of numbness in palate when contacted
with tongue.
b) Objective symptoms. Instrumentation necessary to demonstrate
absence of pain sensation.

25. Anterior palatine nerve block

26. NERVES ANESTHESIZED
•Anterior palatine nerve as it leaves the
greater palatine foramen.

27. AREAS ANESTHESIZED
Posterior portion of the hard palate and over lying
structures up to first bicuspid area on the side
injected the first bicuspid area, branches of the
nasopalatine nerve will be meet.

28. ANATOMICAL LANDNARKS
a) 2nd and 3rd maxillary molars.
b) Palatal gingival margin of 2nd and 3rd maxillary
molars.
c) Midline of palate.
d) A line approximately 1cm from the palatal gingival
margin toward the midline of palate

29. INDICATIONS
a) For palatal anesthesia to be used in conjunction
with the posterior superior alveolar block or
middle superior alveolar nerve block.
b) For surgery of the posterior portion of hard
palate.

30. TECHNIQUE
The anterior palatine nerve emerges onto the palate
through the greater palatine foramen and courses forward in
a groove parallel to the maxillary molar teeth.
The greater palatine foramen is situated between the
second and third molar teeth about 1cm from the palatal
gingival margin towards the midline.
The greater palatine foramen is approached from the
opposite side with a 1-inch,25 gauge needle, which is kept as
near to a right angle as possible with the curvature of the
palatal bone.

31. The needle should be inserted very slowly until the palatal bone is contacted.
The anesthetic solution, 0.25 to 0.5 ml, is injected very slowly. It will be
advantageous to insert the needle and deposit the solution so that the
anterior palatine nerve will be anesthetized anteriorly to the foramen.This
nerve may be blocked at any point along its anterior course after emergence
from the foramen. Anesthesia of the mucoperiosteum of the palate will be
obtained forward from the area of injection.

32. In many instances when the bicuspid area is to be
anesthesized, it is advantageous to insert the needle
and deposit the solution in the palatal curvature
opposite the bicuspids.This will ensure anesthetizing
the area that often receives dual innervation from the
anterior palatine nerve coursing forward and the
nasopalatine nerve extending posteriorly.

33. SYMPTOMS OF ANESTHESIA
a) Subjective symptoms. Feeling of numbness in posterior palate
when contacted with the tongue.
b) Objective symptoms. Instrumentation necessary to
demonstrate the absence of pain sensation.

34. ANTERIOR AND MIDDLE SUPERIOR ALVEOLAR
NERVE BLOCK

35. NERVES ANESTHETIZED
a) Infraorbital nerves.
b) Inferior palpebral, lateral nasal and superior nasal, and
superior labial nerves
c) Anterior and middle superior alveolar nerves
d) Sometimes posterior superior alveolar nerve

36. AREAS ANESTHETIZED
a) Incisors and bicuspids on the side injected.
b) Labial alveolar plate and overlying tissues.
c) Upper lip, portions of side of nose, and lower eyelid.
d) Sometimes maxillary molars and their buccal supporting structures.

37. ANATOMICAL LANDMARKS
• Pupil of eye
• Infraorbital ridge
• Infraorbital notch
• Infraorbital depression

38. INDICATIONS
a) When the anterior and middle superior alveolar nerves are to be anesthesized
and the infraorbital approach is not possible because of infection, trauma, or
other reasons.
b) When attempts to secure anesthesia by the intraoral methods have been
ineffective.

39. TECHNIQUE
a) Using the available landmarks, the dentist should locate and
mark the position of the infraorbital foramen.The skin and
subcutaneous tissues should be anesthesized by local
infiltration.
b) A 1½-inch, 25-guage needle attached to an aspirating
syringe is inserted through the marked and anesthesized
area. Directing the needle directly upward and laterally
facilitates its entrance into the foramen, which opens
downward and medially the foramen, which opens
downward and medially.

40. a) With a slight, gently probing motion the foramen is located and entered
to a depth not to exceed 1/8 inch. After careful aspiration, 1ml of
anesthetic solution is slowly injected.
When the infraorbital nerve block by means of the extra oral approach is
being performed, the needle passes through the following structures:
a) Skin
b) Subcutaneous tissue
c) Quadratus labii superioris muscle
When the needle is in position for this injection, the important structures near
it are the facial artery and vein, which since they are very tortuous, may lie on
either side of the needle.

41. SYMPTOMS OF ANESTHESIA
a) Subjective symptoms:Tingling and numbness of the upper lip, side of nose, and
lower eyelid.
b) Objective symptoms :Instrumentation necessary to demonstrate the absence of
pain sensation.