This document provides information on various maxillary nerve block techniques. It begins with the anatomy of the maxillary nerve and descriptions of local infiltration, field block, and nerve block injection techniques. It then describes specific maxillary nerve block techniques including supraperiosteal infiltration, intraligamentary injection, intraseptal injection, intraosseous injection, and posterior, middle, and anterior superior alveolar nerve blocks. For each technique, it provides details on the nerve anesthetized, area anesthetized, indications, contraindications, landmarks, procedures, advantages, and disadvantages. It concludes with notes on complications that may arise from some techniques.

1. PRESENTED BY – DR.SNEHA RATHEE
I MDS
1

2. Contents
• Anatomy of maxillary nerve
• Basic injection techniques
• Various maxillary nerve block techniques
Nerve anesthetized
Area anesthetized
Indication
Contraindication
Positive aspiration
Alternate
Technique
Advantage
Disadvantages
• References
2

3. Anatomy Of Maxillary Nerve
3

4. Local infiltration-
• small terminal nerve endings are flooded with local
anesthetic solution
• Incision is made in the same area of deposition
• Example – administration of local anesthetic into
interproximal papilla before root planning
4

5. Field block –
• local anesthetic is deposited near the larger terminal
nerve branches
• Incision is made away from the site of injection
• Example – maxillary injections administered above
the apex of the tooth to be treated
5

6. Nerve block-
• Local anesthetic is deposited close to the main nerve
trunk, usually away from the site of operative
intervention
• Affects a larger area
• Quadrant dentistry
• Example – posterior superior alveolar nerve block
6

7. Maxillary Injection Techniques
1. Supraperiosteal infiltration
2. Intraligamentary injection
3. Intraseptal injection
4. Intracrestal injection
5. Intraosseous injection
6. Posterior superior alveolar nerve
block
7. Middle superior alveolar nerve block
8. Anterior superior alveolar nerve
block
9. Maxillary nerve block
10. Greater palatine nerve block
11. Nasopalatine nerve block
12. Anterior middle superior alveolar
nerve block
13. Palatal approach ASA nerve block
7

8. Supraperiosteal Infiltration
8
Nerve anesthetized • Large terminal branches of the dental plexus
Area anesthetized
• Pulp and root area of the tooth
• Buccal periosteum
• Connective tissue and mucous membrane
Indication
• Pulpal anesthesia limited to one or two teeth
• Soft tissue anesthesia indicated for surgical procedures in
circumscribed area

9. Contraindication
• Infection or acute inflammation in the area of injection
• Dense bone covering the apices
Positive aspiration • Negligible, but possible (<1%)
Alternatives • Pdl injection, intraosseous injection, regional nerve block
9

10. Needle • 27 gauge short needle
Area of insertion
• Height of the mucobuccal fold above the apex of the
tooth
Target area • Apical region of the tooth
Landmark
• Mucobuccal fold
• Crown of the tooth
• Root contour of the tooth
10

11. Orientation of the
bevel
• Towards bone
Signs and symptoms
• Subjective- numbness in the area of administration
• Objective – no response from the tooth on EPT
• Absence of pain during treatment
Safety feature • Minimal risk of intravascular injection
Failure
• Needle tip lies below the apex
• Needle tip too far from the bone
11

12. Procedure-
• Prepare the tissue at the injection site with
topical antiseptic and analgesic
• Orient the needle so it faces the bone
• Parallel to the long axis of the tooth
• Insert the needle into the height of mucobuccal
fold and advance till the apical region of target
tooth
12

13. Procedure-
• Aspirate
• Deposit 0.6ml slowly over 20sec
• Slowly withdraw
• Make the needle safe
• Wait for 3-5 mins
13

14. Advantages -
1. High success rate (>95%)
2. Technically easy injection
3. Atraumatic
Disadvantages -
• Not recommended for large areas-
1. multiple needle insertion
2. Large total volume of local anesthetic
14

15. Intraseptal Injection
Nerve
anesthetized
• Terminal nerve endings at the site
of injection
Area
anesthetized
• Bone, soft tissue, root structure in
the area of injection
Indication
• Pain control and hemostasis are
desired for soft tissue and osseous
periodontal treatment
15

16. Contraindication
• Infection or severe
inflammation at the injection
site
Positive
aspiration
• Zero percent
Alternatives
• Pdl injection, intraosseous
anesthesia, regional nerve block
16

17. • Needle • 27 gauge short
• Area of insertion
• Center of the interdental papilla
adjacent to the tooth
• Target area • Center of the interdental papilla
17

18. • Signs and
symptoms
• No symptoms, ischemia of soft tissue
• Safety feature • Intravascular injection is unlikely
• Landmark
• Papillary triangle, 2mm below the tip,
equidistant from adjacent teeth
18

19. • Failure of
anesthesia
• Infected or inflamed tissues
• Precaution
• Do not inject solution into infected
tissue
• Do not inject solution rapidly
• Do not inject too much solution
(0.4ml/site)
19

20. Advantages
• Lack of lip and tongue anesthesia
• Minimum volumes of local anesthetic necessary
• Minimized bleeding during the surgical procedure
• Atraumatic
• Immediate onset of action (<30 seconds)
• Few postoperative complications
• Useful on periodontally involved teeth (avoids infected pockets)
20

21. Disadvantages
• Multiple tissue punctures may be necessary
• Bitter taste of the anesthetic drug (if leakage occurs).
• Relatively short duration of pulpal anesthesia; limited
• area of soft tissue anesthesia (may necessitate reinjection)
• Clinical experience necessary for success
21

22. Intraosseous Injection
Nerve anesthetized
• Terminal nerve endings at the site of injection and adjacent
hard and soft tissue
Area anesthetized
• Bone, soft tissue, and root structures in the area of
injection
Indication • Pain control for single or multiple teeth in quadrant
22

23. Contraindication • Infection or severe inflammation at the injection site
Positive aspiration • Minimal- 1% to 3%
Alternatives
• PDL injection, in the absence of infection or severe
periodontal involvement
• Intraseptal injection
• Supraperiosteal injection
• Regional nerve block
23

24. Signs and
symptoms
• Ischemia of soft tissue at the injection
site
• No response from the tooth with
maximal EPT output
Duration • Pulpal anesthesia 15-30min
Failure
• Infected or inflamed tissue
• Inability to perforate cortical bone
24

25. Precautions
• Do not inject into infected tissue
• Do not inject rapidly or too much
solution
• Do not use vasopressor containing LA
unless necessary
Complications
• Palpitations
• Post injection pain
• Fistula formation at the site of
perforation
• Perforation of lingual plate
25

26. Technique –
• Selection of site- lateral perforation,
vertical perforation
• Prepare the soft tissue
• Perforation of cortical plate
• Injection into cancellous bone
26

27. Advantages
• Lack of lip and tongue anesthesia
• Atraumatic
• Immediate onset of action (<30sec)
• Few post-op complications
27

28. Disadvantages
• Usually requires a special device (stabident system, X-Tip)
• Bitter taste of anesthetic
• Occasional difficulty in placing the needle in predrilled hole
• High incidence of palpitations when vasopressor containing local anesthetic is
used
28

29. Posterior Superior Alveolar Nerve Block
Nerve
anesthetized
• PSA nerve and branches
Area
anesthetized
• Pulp of maxillary third, second and
first molars
• Buccal periodontium and bone
Indication
• Treatment involving two or
maxillary molars
• Infection or acute inflammation
adjacent to operative site
• Supraperiosteal injection is
ineffective
29

30. Contraindication
• Risk of hemorrhage
(hemophiliac, patients on
coumadin or clopidogrel)
Positive
aspiration
• Approx; 3.1%
Alternatives
• Supraperiosteal or pdl injection
• Maxillary nerve block
30

31. Needle • 27 gauge, short needle
Area of insertion
• Height of the mucobuccal fold above the maxillary
second molar
Target area
• PSA nerve- posterior, superior and medial to the
posterior border of the maxilla
31

32. Landmark
• Mucobuccal fold
• Maxillary tuberosity
• Zygomatic process of maxilla
Orientation of the bevel • Towards the bone
Signs and symptoms
• Subjective- none
• Objective- painless procedure
32

33. Technique-
• Adjust the chair position
• Retract the tissue, insert the needle at the height of mucobuccal fold
• Advance the needle
I. upward
II. Inward
III. Backward
• Advance the needle to desired depth- Adult- 16mm
Children 10to 14mm
• Aspirate
• Deposit 0.9 to 1.8mL over 30 to 60 seconds
33

34. Advantages –
• Atraumatic
• High success rate (>95%)
• Minimizes the total volume of local anesthetic solution
Disadvantages -
• Risk of hematoma
• No bony landmark
• Second injection necessary for treatment of first molar
34

35. • Complications-
1. Hematoma formation- due to trauma to the pterygoid plexus of veins
2. Bells palsy- due to improper placement of needle into the inferior part of the
parotid gland, resulting in trauma to cervicofacial branch of facial nerve
3. Trismus- trauma to lateral or medial pterygoid muscle
4. Abducent nerve palsy- results in diplopia in lateral gaze due to paralysis of
lateral rectus muscle
• Inadverent injection into superior alveolar artery or forceful intra- venous
injection into pterygoid plexus of veins
35

36. Middle Superior Alveolar Nerve Block
36

37. Nerve anesthetized
• Middle superior alveolar nerve and branches
Area anesthetized
• Pulps of maxillary first and second premolar, mesiobuccal
root of the first molar
• Buccal periodontal tissues and bone
Indication
• When ASA nerve block fails to provide pulpal anesthesia
distal to canine
• Procedure involving only premolars
37

38. Contraindication
• Infection or inflammation
• MSA nerve is absent, premolar and mesiobuccal root of
molar anesthetized via ASA
Positive aspiration • Negligible (<3%)
Alternatives
• Local infiltration, PDL, intraosseous injection
• ASA block
38

39. Needle • 27 gauge short needle
Area of insertion
• Height of mucobuccal fold above the maxillary second
premolar
Target area
• Maxillary bone above the apex of the maxillary second
premolar
Landmark • Mucobuccal fold above the maxillary second premolar
39

40. Orientation of the
bevel
• Towards the bone
Signs and symptoms
• Subjective- upper lip numbness
• Objective- absence of pain during treatment
Safety feature • Anatomically safe
Failure
• Anesthetic solution not deposited high above the apex
of the second premolar
• Solution deposited too far from the maxillary bone
40

41. Procedure-
• Aseptic tissue preparation
• Insert the needle into the height of the
mucobuccal fold above the second premolar
• Aspirate
• Slowly deposit 0.9 to 1.2 mL of solution
• Withdraw and wait for 3 to 5mins
41

42. Advantages -
Minimizes the number of injections and the volume of solution
Complication- a hematoma may develop at the site of injection (rare)
42

43. Anterior Superior Alveolar Nerve Block
43

44. Nerve anesthetized
• Anterior superior alveolar nerve
• MSA nerve
• Infraorbital nerve – inferior palpebral, lateral nasal,
superior labial
Area anesthetized
• Pulps of maxillary central incisor through canine
• Pulps of maxillary premolars and mesiobuccal root of first
molar
• Buccal periodontium and bone
• Lower eyelid
• Lateral aspect of nose and upper lip
44

45. Indication
• Dental procedure involving two or more maxillary anterior
teeth and overlying buccal tissue
• Inflammation or infection
• Dense cortical bone- ineffective supraperiosteal injection
Contraindication • Hemostasis of the desired area cannot be achieved
Positive aspiration • 0.7%
Alternatives
• Supraperiosteal, PDL or intraosseous injection
• Maxillary nerve block
45

46. Needle • 25 or 27 gauge long needle
Area of insertion
• Height of the mucobuccal fold directly over first
premolar
Target area • Infraorbital foramen
Landmark
• Mucobuccal fold
• Infraorbital notch
• Infraorbital foramen
46

47. Orientation of the
bevel
• Towards the bone
Signs and symptoms
• Subjective- numbness of lower eyelid, side of the nose,
upper lip
• Objective- absence of pain during treatment
Safety feature
• Needle contact with the bone at the roof of infraorbital
foramen prevents inadvertent overinsertion
Failure
• Needle deviation medial or lateral to the infraorbital
foramen
• Soft tissue anesthesia without dental anesthesia
47

48. Procedure-
• Prepare the tissue under strict antiseptic
condition
• Locate the foramen and retract the lip
• Two techniques-
1. Premolar/bicuspid approach
2. Incisor approach
48

49. 1. Premolar approach
• Insert the needle into the height of mucobuccal
fold over the first premolar parallel to a line
passing through
olong axis of the tooth
oSupraorbital notch
oPupil of the eye
oInfraorbital notch
49

50. 2. Incisor approach
• Direction of insertion- bisect the crown
of central incisor from mesio-incisal angle
to disto-gingival angle
• Point of contact- upper rim of the
infraorbital foramen
• Depth of penetration is 16mm (adults)
• Aspirate and slowly deposit 0.9 to 1.2mL
solution
50

51. Advantages -
• Simple technique
• Safe, minimizes the volume of solution used and number of needle punctures
Disadvantages -
• Psychological- fear of injury to the eye
51

52. Greater Palatine Nerve Block
52

53. Nerve anesthetized • Anterior/greater palatine nerve
Area anesthetized
• Posterior portion of hard palate
• Anteriorly as far as premolar and medially till midline
Indication
• Palatal soft tissue anesthesia for surgical or restorative
procedure
53

54. Contraindication
• Inflammation or infection at the injection site
• Smaller area of therapy
Positive aspiration • Less than 1%
Alternatives
• Local infiltration into specific region
• Maxillary nerve block
54

55. Needle
• 27 gauge short needle
Area of insertion • Soft tissue slightly anterior to greater palatine foramen
Target area
• Greater palatine nerve as it passes anterior to greater
palatine foramen
Landmark
• Greater palatine foramen and junction of maxillary
alveolar process and palatine bone
55

56. Signs and symptoms
• Subjective – numbness in the posterior portion of the
palate
• Objective- painless procedure
Safety feature • Contact with the bone
Failure
• Anesthetic solution deposited far anteriorly
• Incomplete anesthesia of maxillary first premolar due to
over lap of nasopalatine nerve fibers
56

57. Complication-
• Ischemia and necrosis of soft tissue when highly concentrated vasoconstrictor
(1:50,000) used repeatedly
• Uncomfortable for some patients due to soft palate anesthesia
57

58. Nasopalatine Nerve Block
• Incisive nerve block
• Sphenopalatine nerve block
58

59. Nerve anesthetized • Nasopalatine nerve bilaterally
Area anesthetized
• Anterior portion of the hard palate from mesial aspect of
the right first premolar to he mesial aspect of the left first
premolar
Indication • Palatal soft tissue anesthesia
59

60. Contraindication
• Inflammation or infection at the site of injection
• Smaller area of therapy
Positive aspiration • Less than 1%
Alternatives
• Local infiltration
• Maxillary nerve block
• Intranasal local anesthetic mist
60

61. Needle • 27 gauge; short needle
Area of insertion • Palatal mucosa just lateral to the incisive papilla
Target area • Incisive foramen, beneath the incisive papilla
Landmark • Central incisors and incisive papilla
61

62. Orientation of the
bevel
• Towards the palatal soft tissue
Signs and symptoms
• Subjective- numbness in the anterior portion of the
palate
• Objective- no pain during procedure
Safety feature
• Contact with the bone
• aspiration
Failure • Unilateral or inadequate palatal anesthesia
62

63. Procedure-
• Single approach technique-
One tissue penetration lateral to the incisive papilla
on the palatal aspect of the maxillary central
incisors
63

64. Procedure-
• Three puncture technique-
Injection 1- labial soft tissue between central incisors
Injection 2- interproximal papilla and adjacent palatal mucosa
Injection 3- palatal soft tissue
64

65. Advantages -
• Minimizes needle penetration and volume of solution
• Minimal patient discomfort from multiple needle penetration
Disadvantages -
• No hemostasis except the immediate area of injection
• Most traumatic intraoral injection
65

66. Anterior Middle Superior Alveolar Nerve
Block
• First described by Friedman and
Hochman
• Field block of Anterior superior nerve
Subneural dental plexus
66

67. Nerve
anesthetized
• ASA and MSA nerve
• Subneural dental plexus of
ASA and MSA nerves
Area
anesthetized
• Maxillary incisors, canine and
premolar
• Buccal attached gingiva
• Attached palatal tissue
Indication
• Easily performed with C-CLAD
system
• Multiple teeth for dental
procedure
67

68. Contraindication
• Patients with unusally thin palatal tissue
• Procedure requiring longer than 90min
Positive aspiration • Less than 1%
Alternatives
• Multiple supra periosteal or PDL injections
• ASA and MSA nerve blocks
• Maxillary nerve block
68

69. Needle • 27 gauge short needle
Area of insertion
• On hard palate , halfway along an imaginary line
connecting midpalatal suture to the free gingival margin
• Contact point between first and second premolar
Target area • Palatal bone at injection site
69

70. Signs and symptoms
• Subjective- numbness in the palatal tissue
• Objective- absence of pain during treatment
Safety feature
• Contact with bone
• Low risk of positive aspiration
• Slow insertion of needle (1 to 2mm every 4 to 6sec)
• Slow administration of local anaesthetic (0.5mL/min)
Failure
• May need supplemental anesthesia for central and
lateral incisor
70

71. Procedure-
Anesthetic pathway technique
• slowly advance the needle tip with rotation of the needle into the tissue
• Advance the needle 1 to 2mm every 4 to 6 seconds until it hits the bone
• After initial blanching is observed pause for several seconds to allow the onset
of superficial anesthesia and advance till it hits the bone
• Anesthetic is delivered at a rate of 0.5mL
71

72. Advantages -
• Provides anesthesia of multiple maxillary teeth with single injection
• Simple technique
• Safe
• Eliminates post operative inconvenience of numbness to upper lip and muscles of
facial expression
Disadvantages –
• Requires slow administration (0.5mL/min)
• Uncomfortable for patient if administered improperly
72

73. Maxillary Nerve Block
• Second division nerve block
• Profound anesthesia of hemimaxilla
73

74. Nerve anesthetized • Maxillary division of trigeminal nerve
Area anesthetized
• Pulpal anesthesia of the maxillary teeth on the same side
• Overlying bone and buccal periodontium
• Soft tissue and bone of the hard palate and part of the
hard palate and part of soft palate
• Skin of the lower eyelid, side of the nose, cheek and upper
lip
Indication
• Pain control before extensive procedure
• Tissue inflammation or infection precludes use of other
regional block
• Diagnostic procedure – neuralgias of second division
74

75. Contraindication
• Inexperienced administrator
• Pediatric patient
• Uncooperative patients
• Inflammation or infection of tissue
Positive aspiration • <1%
Alternatives
• All of the
• PSA nerve block, ASA nerve block, Greater palatine nerve
block, Nasopalatine nerve block
75

76. Needle • 25 gauge long needle
Area of insertion
• Height of mucobuccal fold above distal aspect of the
maxillary second molar
Target area
• Maxillary nerve- at pterygomaxillary fissure
• Superior and medial to target of PSA
76

77. Landmark
• Mucobuccal fold at distal aspect of maxillary 2nd molar
• Maxillary tuberosity
• Zygomatic process of maxilla
Signs and symptoms
• Subjective- pressure behind the upper jaw on the side
being injected
• Numbness in the teeth and lower eyelid, side of the nose
and upper lip
• Objective- painless procedure
Failure • Partial anesthesia
77

78. Procedure-
High – tuberosity approach
• Position the patient supine and prepare the tissue
in the height of mucobuccal fold distal to
maxillary second molar
• Partially open the patients mouth and retract the
cheek
• Advance the needle – upward, inward, backward
• Depth- 30mm
• Aspirate in two plane; inject 1.8mL
78

79. Procedure –
Greater palatine canal approach
• Position the patient supine, prepare the tissue site
• Greater palatine foramen is located with applicator
tip
• Needle held at 45 deg to facilitate the entry into
greater palatine canal upto a depth of 30mm
• Never force needle against resistance, discontinue
attempt if redirected needle fails again
• Aspirate in two planes
• Deposit 1.8mL
79

80. Advantages -
Atraumatic injection via high tuberosity approach
High success rate
Minimized number of needle penetrations
Minimized number of total volume of anesthetic solution
Disadvantages
Risk of hematoma
High tuberosity is relatively arbitrary
Lack of hemostasis
80

81. Extraoral Techniques
Anterior Middle Superior Nerve Block
81
Nerve anesthetized
• Infraorbital nerve
• Inferior palpebral, lateral nasal and superior labial nerve
• Anterior and middle superior nerve block
Area anesthetized
• Incisors and bicuspid on the side injected
• Labial alveolar plate and overlying tissue
• Upper lip, side of nose and lower lid

82. Anatomical landmark
• Pupil of eye
• Infraorbital ridge
• Infraorbital notch
• Infraorbital depression
Indication
• When intraoral technique precludes its use due to
infection, trauma or other reasons
• When intraoral methods have been ineffective
Symptoms of
anesthesia
Subjective- tingling numbness of upper lip, side of nose
and lower lid
Objective- instrumentation necessary to demonstrate
absence of pain
82

83. • Procedure –
• Locate the infraorbital foramen using landmarks and
marked
• Skin and subcutaneous tissue is anesthetised with
local infiltration
• Insert the needle through the mark in and upward
and lateral direction to a depth of 1/8inch
• Aspirate
• Deposit- 1ml of solution
83

84. Extraoral Techniques
Maxillary Nerve Block
84
Nerve anesthetized • Maxillary nerve and its subdivision
Area anesthetized
• Anterior temporal and zygomatic region
• Lower lid, side of nose and upper lip
• Maxillary teeth and alveolar bone with overlying structures
• Hard and soft palate
• Tonsils
• Part of pharynx
• Nasal septum and floor of the nose
• Posterior lateral mucosa and turbinate bones

85. Anatomical landmark
• Midpoint of zygomatic arch
• Zygomatic arch
• Coronoid process of ramus of mandible
• Lateral pterygoid plate
Indication
• Anesthesia of entire maxillary division is required for
extensive surgery
• Block all the branches with one injection and minimal
solution
• Other terminal block difficult – local infection,
inflammation or trauma
• Diagnostic and therapeutic purpose
85

86. Symptoms of anesthesia
Subjective- tingling numbness of upper lip, side of nose
and lower lid
Objective- instrumentation necessary to demonstrate
absence of pain
86

87. References
• Stanley F Malamed handbook of local anesthesia- 7th ed
• Monheim’s local anesthetia and pain control in dental practice- 7th ed
• Google
87

88. 88