Maxillary Injection Techniques

1. Maxillary Injection Techniques

2. Anatomy

4. Anatomy

6. Atraumatic Injection Protocol

7. 3 Main Types of Maxillary Injections: 1) Local Infiltration 2) Field Block 3) Nerve Block

8. Local Infiltration • Incision (treatment) is done in the samearea in which the local anesthetic was deposited (interproximal papilla before Scaling and Root Planing)

9. Field Block • Local anesthetic is deposited toward largernerve terminal branches • Treatment is done away from the site of local anesthetic injection • Maxillary injections administered above the apex of the tooth to be treated are properly referred to as field blocks not local infiltrations

10. Nerve Block • Local anesthetic is deposited close to a main nerve trunk, usually at a site removed from the area of treatment (PSA, IANB, NPB)

11. Types of Injections 1) Supraperiosteal Injection 2) Intraligamentary (PDL) Injection 3) Intraseptal Injection 4) Intracrestal Injection 5) Intraosseous Injection 6) Posterior Superior Alveolar (PSA) Nerve Block 7) Middle Superior Alveolar (MSA) Nerve Block 8) Anterior Superior Alveolar (ASA) Nerve Block 9) Maxillary Nerve Block (2nd Division) 10) Greater Palatine Nerve Block 11) Nasopalatine Nerve Block 12) Anterior Middle Superior Alveolar (AMSA) Nerve Block 13) Palatal Approach Anterior Superior Alveolar (P-ASA) Nerve Block

12. Maxillary and Mandibular Injections The following are used in both arches: • Supraperiosteal Injection • Intraligamentary (PDL) Injection • Intraseptal Injection • Intraosseous Injection

13. Supraperiosteal Injection

14. 1) Supraperiosteal Injection • Used for pulpal anthesia in maxillary teeth • Anesthetizes large terminal branches of the dental plexus • Greater than 95% success rate • 1 or 2 teeth

15. Supraperiosteal Injection • Dense bone covering the apices of the teeth can lead to failure -maxillary molar of children (zygomatic bone obscures) -central incisor of adults (nasal spine obscures) • Negligible positive aspiration rate (less than 1%) • Should not be used for large areas (multiple sticks/large amount of local anesthetic solution must be used)

16. Technique  Supraperiosteal Injection 1) 25 or 27 gauge short needle is recommended 2) Insert needle at height of mucobuccal fold over apex of desired tooth 3) Apply topical anesthetic for at least one minute 4) Orient bevel toward bone; lift lip pulling tissues taut

17. 5) Hold syringe parallel to long axis of the tooth being anesthetized 6) No resistance to penetration should be felt and no patient discomfort 7) Aspirate twice 8) Deposit .6 ml (one-third of a cartridge) into tissue over 20 seconds 9) Do not allow tissues to balloon 10) Wait 3 to 5 minutes to begin dental treatment

18. Problems/Failures • If tooth does not anesthetize the needle tip could be below the apex of the tooth resulting in inadequate anesthesia • If the needle lies too far from the bone then anesthesia will be inadequate because the solution was deposited in the soft tissue (lip) • The needle must be oriented toward the periosteum but should be managed properly to avoid tearing the highly innervated periosteum

22. Supraperiosteal vs. Infiltration These two words are used incorrectly; what most practitioners refer to as an infiltration injection is actually a field block

23. Citing the ongoing economic crisis and growing competition from other insurers, Washington Dental Service will reduce reimbursement rates for all dental procedures by 15% starting June 1. Was it purely a business decision?

24. Posterior Superior Alveolar Nerve Block (PSA)

25. 2) Posterior Superior Alveolar Nerve Block • Highly successful nerve block with greater than 95% success • Effective for maxillary 1st, 2nd and 3rdmolars and buccal periodontium • Mesiobuccal root of the maxillary 1st molar is not consistently innervated by the PSA nerve

26. Short dental needle is used for all but the largest of patients • Average depth of soft tissue penetration is 16 mm (short needle is 20 mm in length) • 28% of maxillary 1st molars’ mesiobuccal roots are innervated by the middle superior alveolar nerve (MSA)

27. When the risk of hemorrhage is too great as with a hemophiliac, you should use the supraperiosteal or PDL injections • Patient should feel no pain with this injection because bone is not contacted and there is a large area of soft tissue into which the solution is deposited

28. Positive aspiration risk is 3.1% • Patient will often say that they do not feel numb; reason why is because they are accustomed to the intense feeling of anesthesia experienced by the IANB; reassure patient that you are going to make sure they are comfortable during the procedure

29. Technique PSA Nerve Block 1) 25 gauge short needle is recommended 2) Insert needle at the height of the mucobuccal fold above the maxillary 2nd molar 3) Target area is the PSA nerve which is posterior, superior and medial to the posterior border of the maxilla

30. 4) Apply topical anesthetic for at least one minute 5) Have patient open their mouth half way which makes more room 6) Retract the patient’s cheek with mirror 7) Pull the tissues taut 8) Orient bevel toward bone

31. 9) Insert needle at height of mucobuccal fold over the 2nd maxillary molar 10) Advance needle upward, inward and backward direction 11) Odd feeling of having no resistance whatsoever 12) Penetrating to an average depth of 10-14 mm is adequate 13) Aspirate in two planes by rotating bevel one quarter turn

32. 14) Deposit 0.9 ml of a cartridge (1/2 cartridge) 15) Wait 3 to 5 minutes to start treatment Advance the needle in one movement, not three separate movements; usually atraumatic to most patients

33. Problems/Failures (PSA) • Hematoma formation if needle is overinserted too far posteriorly • Pterygoid plexus of veins leads to this hematoma • Visible intraoral hematoma develops within minutes; bleeds until the pressure of the extravascular blood equals that of the intravascular blood which can result in a large, unsightly hematoma

34. Problems/Failures (PSA) • Patients will usually claim that they do not feel any anesthesia which is not uncommon because patients can not reach this area to gauge their own level of anesthesia • If using a long dental needle the maximum insertion should be one-half on its length or 16 mm

40. Middle Superior Alveolar Nerve Block (MSA)

41. 3) Middle Superior Alveolar Nerve Block • Middle Superior Alveolar Nerve is not present in 28% of the population • When the infraorbital nerve block fails to provide anesthesia to teeth distal to the maxillary canines, the MSA is indicated • MSA provides anesthesia to 1st and 2nd premolars and mesiobuccal root of maxillary 1st molar; anesthetizes buccal periodontium and bone

42. If MSA is absent the premolars and mesiobuccal root of maxillary 1st molar is innervated by the ASA • Positive aspiration risk is less than 3% (negligible) • Infraorbital nerve block can block 1st premolar, 2nd premolar and mesiobuccal root of the maxillary 1st molar if you need an alternative block when the MSA is not adequate

43. Technique MSA Nerve Block 1) 25 or 27 gauge long or short needle 2) Insert needle at the height of the mucobuccal fold above 2nd maxillary premolar 3) Target is the maxillary bone above the apex of the 2nd maxillary premolar

44. 4) Orient bevel toward bone to avoid tearing periosteum 5) Apply topical anesthetic for one minute 6) Pull tissues taut 7) Penetrate tissues placing bevel of needle well above the apex of the 2nd maxillary premolar

45. Technique- Middle Superior Alveolar Nerve Block 8) Aspirate 9) Slowly deposit 0.9-1.2 ml of solution 10) Wait 3 to 5 minutes before starting treatment

46. Problems/Failures MSA • Anesthetic not deposited above the apex of the 2nd premolar • Solution deposited into the soft tissue too far from the periosteum (lip) • Hematoma may develop; Dentist should apply pressure to the area with gauze for at least sixty (60) seconds; up to 2 to 3 minutes

48. Middle Superior Alveolar Nerve Block

50. Anterior Superior Alveolar Nerve Block (ASA)