1. Hesham El-Hawary
Anatomical Consideration for dental local
Anesthesia
The innervation of maxillary and mandibular teeth

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Middle meningeal nerve

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Twigs to the sphenopalatine ganglion

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Posterior superior alveolar nerve

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Zygomatic nerve

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Infra-Orbital Nerve

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Middle superior alveolar nerve

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Anterior superior alveolar nerve

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Terminal branches of ION

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Branches of Maxillary nerve
1. Middle meningeal nerve
2. Twiges to the sphenopalatine ganglion
3. Posterior superior alveolar nerve
4. Zygomatic nerve
5. Infra-Orbital Nerve
1. Middle superior alveolar nerve
2. Anterior superior alveolar nerve
3. Terminal branches
1. Inferior palpebral nerve
2. Lateral nasal nerve
3. Superior labial nerve

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The Posterior Superior Alveolar
Neve

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• It arises from the
maxillary nerve just
before it enter the
infraorbital groove

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• Generally , posterior
superior alveolar
nerve is two in
number
• One branch descends
on the post. Surface
of the maxilla &
gives off several
twigs to m.m. of the
cheek

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• Other branch enters
small foramen on the
post. Surface of the
maxilla to run in the
post. Sup. Alveolar
canal located in the
posterior & lateral
walls of the max.
sinus

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 It communicate freely
with the middle &
anterior superior alveolar
nerves to form a
superior dental plexus
from which small twigs
enter the apical foramina
of the maxillary teeth &
other twigs supply the
overlying buccal
mucoperiosteum

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Posterior superior alveolar nerve
 Specifically posterior superior alveolar nerve supplies
– The Pulp
– The Investing structures
– The buccal mucoperiosteum
of Upper Molars except MB root of 1st molar(6)

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The Zygomatic Nerve

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• Arises from the maxillary
nerve as it enters the orbital
cavity
• Divides into two branches:
– Zygomatico-Tempopral
– Zygomatico-Facial
The Zygomatic Nerve

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Infra-Orbital Nerve

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The Infra-Orbital Nerve
• The maxillary nerve enters the inferior orbital fissure
to pass into the orbital cavity
• It turns slightly laterally in the infra-orbital groove and
continues forward in the orbital canal
• In the middle of the course in the canal it gives off the
middle superior alveolar nerve
• Just before the exit of the maxillary nerve from the
infra-orbital foramen and still in the infra-orbital canal
it gives off the anterior superior alveolar nerve
• As it leaves the infra-orbital foramen it gives off the
terminal branches

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Middle superior alveolar nerve
• Approximately in the middle of the infraorbital canal it
gives off the middle superior alveolar nerve
• It runs downward and forwards in a canal in the
lateral wall of the maxillary sinus to form part of the
superior dental plexus
• It Supplies
– Pulp
– Investing structures
– buccal mucoperiosteum
of Premolars & MB root of 1st molar(6)

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Anterior superior alveolar nerve
• Just before the exit of the maxillary nerve from the
infraorbital foramen, and while still in infraorbital canal
• It gives off the anterior superior alveolar nerve which
runs in a canal in the anterior wall of the maxillary sinus
to form part of the superior dental plexus
• It supplies
– Pulp
– Investing structures
– labial mucoperiosteum
of anterior teeth(1,2,3).

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Terminal branches of the maxillary nerve
• As the maxillary nerve leaves the infraorbital
foramen, it gives off its three terminal
branches, which are:
– Inferior palpebral nerve
– External nasal nerve
– Superior labial nerve

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The Sphenopalatine Ganglion

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• Nature: parasympathetic ganglion
• Site: pterygopalatine fossa hangs from the
maxillary nerve
• Roots:
– Sensory root: twigs from the maxillary nerve
to the sphenopalatine ganglion
– Sympathetic root: deep petrosal nerve
– Parasympathetic root: great superficial
petrosal nerve of the 7th cranial nerve
(Vidian nerve of facial nerve)

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• Branches:
– Orbital nerve
– Nasal nerve
– Palatine nerve
– Pharyngeal nerve

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• Branches:
– Orbital nerve
– Nasal nerve
– Palatine nerve
– Pharyngeal nerve

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• Branches:
– Orbital nerve
– Nasal nerve
– Palatine nerve
– Pharyngeal nerve

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• Branches:
– Orbital nerve
– Nasal nerve
– Palatine nerve
– Pharyngeal nerve

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• Branches:
– Orbital nerve
– Nasal nerve
– Palatine nerve
– Pharyngeal nerve

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Palatine Branches
• Palatine Branches Divides into:
–Greater (anterior) palatine nerve
–Lesser (posterior) palatine nerve

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Palatine Branches
• The greater (anterior) palatine nerve
– Emerges from greater (anterior) palatine foramen
in the horizontal part of the palatine bone medial
to the upper third molar
– Supplies palatal mucoperiosteum of maxillary
molars & premolars

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Palatine Branches
• The lesser ( posterior ) palatine nerve
– Emerges from Lesser (Posterior) palatine foramen
in the horizontal part of the palatine bone medial
to the upper third molar
– supplies uvula, soft palate & posterior part of
the hard palate

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Nasal Branches
• Nasal Branches Divides into:
– Long sphenopalatine nerve (nasopalatine nerve)
– Short sphenopalatine nerve

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Nasal Branches
• The Long sphenopalatine nerve
(nasopalatine nerve)
– Emerges from the incisive foramen in the anterior
part of the median plane of the palate
– supplies palatal mucoperiosteum of maxillary
anterior teeth

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Nasal Branches
• At the palatal side of the canine region, there is
anastomosis between the nasopalatine nerve &
greater palatine nerve
• The origin of these two nerves (nasopalatine
nerve& greater palatine nerve ) comes from the
sensory root of the sphenopalatine
gangalion (twigs from the maxillary nerve)

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Summary

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Pulp , Investing structures & Labial (buccal)
mucoperiosteum
Anterior superior alveolar nerve
Anterior teeth
(1,2,3)
Middle superior alveolar nerve
Premolars
(4,5) &
MB root of 1st
molar(6)
Posterior superior alveolar nerve
Molars except
MB root of 1st
molar(6)
Nerve supply of Maxillary teeth

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Palatal mucoperiosteum
Nasopalatine nerve
Anterior
teeth
(1,2,3)
Greater ( Anterior) palatine nerve
Premolars
(4,5)
&
Molars
(678)
Nerve supply of Maxillary teeth

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The accessory innervations of the teeth
• The buccal mucoperiosteum, the pulp and
investing structures of upper anterior teeth cross
innervation may take place i.e. branch from the anterior
superior nerve of the other side
• The palatal mucoperiosteum of the upper canine is
supplied by interlacing fibers between the greater
palatine nerve and the nasopalatine nerve

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Main Trunk

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Nervous Spimosum

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Nerve to medial pterygoid

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N. to Temporalis msc.

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N. to Massetter msc.

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N. to Lateral Pterygoid msc.

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Long Buccal N.

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Long Buccal N.

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Lingual Nerve

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Nerve to Mylohyoid muscle

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Inferior Alveolar Nerve

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Mental Nerve

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Incisive Nerve

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Branches of Mandibular Nerve
1. Main Trunk
2. Nervous Spimosum
3. Nerve to medial pterygoid
4. Anterior Division
– N. to Temporalis msc.
– N. to Massetter msc.
– N. to Lateral Pterygoid msc.
– Long Buccal N.
5. Posterior Division
– Auriculo-temporal N.
– Lingual Nerve
– Nerve to mylohyoid muscle
– Inferior Alveolar N.

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The Auriculo-Temporal nerve

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• It arises by a medial & a lateral root that unite
below the foramen spinosum
• The united nerve passes deep to the lateral
pterygoid muscle
• It gives off :
– Parotid branch
– Articular branch
– Auricular branch
– Temporal branch
– Terminal branch

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The Long Buccal Nerve

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Long Buccal Nerve
• Purely sensory nerve
• Passes between two heads of the lateral
pterygoid muscles
• It emerges beneath the anterior border of the
masseter muscle
• It crosses the anterior border of the ramus at
the level of the occlusal plane of the lower 7 & 8

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Long Buccal Nerve Cont.
It sends fibers to:
• M.M. of the cheek
Except the postero-superior area which receive sensory
fibers from posterior superior alveolar nerve
• Skin of the cheek
• M.M. of the lower buccal vestibule
• Buccal mucoperiosteum

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The Lingual Nerve

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• Purely sensory nerve
• Passes between the medial pterygoid muscle and
the ramus of the mandible in the
pterygomandibular space
• In the pterygomandibular space, it lies parallel to
the inferior alveolar nerve, but anterior and
medial (lingual) to it
• Then , it passes below the mandibular attachment
of the superior constrictor muscle of the
pharynx to reach the side of the base of the
tongue a short distance below & behind the lower
third molar (8)

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It supplies:
• M.M. of the ant. 2/3 of the tongue
• M.M. of the floor of the mouth
• M.M. of the lateral lingual vestibule
• Lingual mucoperiosteum of the all lower teeth
(1, 2, 3, 4, 5, 6, 7, & 8)

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The Inferior Alveolar Nerve

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• Mixed nerve (Sensory & Motor)
• Passes in the pterygomandibular space
• Before it enters the mandibular foramen, it gives
off the mylohyoid nerve, which contains
sensory & motor fibers
The Inferior Alveolar nerve

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The Inferior Alveolar Nerve
• Mylohyoid nerve
– Motor Fibers supply the
• Mylohyoid muscle
• Anterior belly of digastric muscles
– Sensory fibers supply the Pulp and investing
structures of the lower molars

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The Inferior Alveolar Nerve
• Within the mandible , the inferior alveolar nerve
descends in the inferior alveolar canal
• In the region of the mental foramen, it divides
into two terminal branches
– The mental nerve
– The Incisive nerve

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The Inferior Alveolar Nerve
Mental nerve
• leaves the mandible through the mental foramen
• It supply:
– Skin of the chin
– Skin of the lower lip
– M.M. of the lower lip
– Buccal mucoperiosteum of the mandibular anterior
teeth and premolars

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The Inferior Alveolar Nerve
Incisive nerve
• Supplies
– pulp & investing structures of the lower anterior
teeth (1, 2,& 3)
• Main trunk of the inferior

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Summary

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Nerve supply to the mandibular teeth
Pulp , Investing structures
Incisive nerve
Anterior teeth
(1,2,3)
Inferior alveolar nerve
Premolars
(4,5) &
Molars (678)

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Nerve supply to the mandibular teeth
Labial (buccal) mucoperiosteum
Mental nerve
Cutaneous coli nerve
( branch of cervical plexus C2 & c3 )
gives additional sensory supply for premolars ( 4 , 5 )
in about 20 % of the pt.
Anterior teeth
(1,2,3)
&
Premolars (45)
Long buccal nerveMolars (678)

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Nerve supply to the mandibular teeth
Lingual mucoperiosteum
Lingual nerve
Anterior teeth
(1,2,3) Premolars
(4,5) & Molars
(678)

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The accessory innervations of the teeth
• The pulp and investing structures of the lower
anterior teeth cross innervation may take place i.e.
branch from the incisive nerve of the other side
• The buccal mucoperiosteum of the lower premolar
may receive additional nerve supply from the cutaneous
coli nerve (branch from the cervical plexus of nerves)
• The pulp and investing structures of the lower
molars may receive additional nerve supply from the
nerve to mylohyoid

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