MAXILLARY NERVE BLOCK

1. By
•Foram kamani
•Monali joshi

2. Transmission in nerve fibers of the second division that innervate the
oral cavity may be interrupted by the following approaches:
1. Intraoral techniques
A. Local infiltration of nerve endings
B. Block of the terminal branches
C. Anterior & middle superior alveolar nerve block
D. Posterior superior alveolar nerve block
E. Nasopalatine nerve block
F. Anterior palatine nerve block
G. maxillary nerve block
2. Extraoral techniques
A. anterior & middle superior alveolar nerve block
B. maxillary nerve block

3. 1. Intraoral technique
A. Local infiltration of nerve endings
1) AREAS ANESTHETIZED: only that area into which
the local anesthetic solution is infiltrated
2) NERVES ANESTHETIZED: terminal branches or free
nerve endings
3) ANATOMICAL LANDMARKS: no landmark
4) INDICATION: local infiltration techniques are
indicated when only mucous membrane &
underlying connective tissues are to be anesthetized.
This method can be use for incision in the mucous
membrane or before insertions of other needles.

4. 5. TECHNIQUE: in the oral cavity a 1-inch, 25-gauge needle is
inserted beneath the mucous membrane into the
connective tissue in the area to be anesthetized, and the
anesthetic solution is infiltrate slowly throughout the area.
Care should be exercised to the solution is not injected too
rapidly or in too large volume. To do so many cause injury
to the tissue resulting in postinjection pain & in more sever
cases, slough.
This technique require more then one needle insertion,
depending on the size of the area to be anesthetized.
When the incision or surgical procedure is within the
injection area, this method is referred to as local
infiltration.

5. B. Block of the terminal branchs
1) NERVES ANESTHETIZED: large terminal branches
2) AREAS ANESTHETIZED: all of the area innervated by the
larger terminal branches affected
3) ANATOMICAL LANDMARK: there will depend on the
areas to be anethetized
4) INDICATION: this technique is indicated for producing
analgesia of one or two maxillary teeth or of a limited
area of the maxilla. It is most commonly confined
because the maxilla’s prosity lends itself to this method.
Blocking the larger terminal branches in the mandible is
usually difficult because of its denseness.

6. 5) TECHNIQUES
a. Paraperiosteal technique: the paraperiosteal
technique is most commonly used for anesthetizing
the larger terminal branches within the oral cavity.
As previously stated, the term paraperiosteal is used
in preference to the term supraperiosteal because the
solution is deposited alongside & not above the
periosteam.
• The paraperiosteal injection is indicated & more
widely used in the porous maxilla than in the dense
mandible.

7.  It should be kept in mind that there is a variation in the
thickness of the body plate covering the root of the
maxillary teeth. the bony plate covering the roots of the
deciduous maxillary teeth.
 A 1-inch, 25-guage needle is inserted through the mucous
membrane & underlying connective tissue until it gentely
comes in contact with the periosteum. The solution should
be deposited slowly.
 When one or two teeth are to be anesthetized, the needle is
inserted into the mucobuccal & buccolabial fold so that it
makes contact with the periosteum opposite & just above
the apex of the root of the tooth.

8. b. intraosseous technique: a second technique for
blocking the large terminal branches in the
interosseus method.
 Interosseus means, as a term implies, injecting directly
in to the bone. This is not only a painful but also a
dangerous procedure because of the possibility of
needle breakage.
 This technique is indicated primarily for the maxillary
incisors, cuspids & bicuspids & should be used when
the anterior & middle superior alveolar nerve block or
parapariosteal method is ineffective.

9. An opening of the interosseous structure should then
be made, with a suitable bone burr or interseptal drill.
• A 1-inch, 23–gauge needle is inserted through the
tissue incision & into the previously made opening in
the bone. The solution is deposite in this area.
• This technique may at times be used in the mandible
with varying degrees of success. Its effectiveness will
depend largely on the age of patient & porosity of
mandible.

10. c. Interseptal technique. It is most effective in children &
young adults. A 23- or 25-gauge needle is pressed
gently into the thin porous interseptal bone on either
side of the tooth to be anesthetized.
• The anesthetic solution is then forced under pressure
into the cancellous bone.
• It is important that the superficial mucous membrane
be anesthetized before a large-gauge needle is inserted
into the bone.

11. d. Intraligamentary technique. recently a technique has been
described for effectively anesthetizing single teeth by
injecting the local anesthetic into the periodontal
ligament.
• Special syringes have been developed & the needle is
introduced through the gingival sulcus & into the
periodontal ligament.
• High pressure cause the solution to be forced, rather than
difused, through the ligament to the nerves in the area.
• It is advised that single-rooted teeth be injected on the
mesial & distal sides or buccal & lingual sides & that
multirooted teeth be injected over each root.

12. e. Intrapulpal technique. For those procedures that involve
direct instrumentation of pulp, anesthesia may be achived
with this injection technique.
• A 25-gauge needle may be introduced directly into the
operative site.
• Ideally the needle should be wedged firmly into the pulp
chamber or root canal. it is best achived by combination of
the pharmacological action of the anesthetic solution & the
pressure used to apply it.
• The needle is always visible & is only being inserted into
the pulp of the tooth, breakage is not likely to occur.

13. C. Block of anterior & middle superior alevolar nerves
1) NERVES ANESTHETIZED: infraorbital, anterior, &
middle superior alveolar nerves, inferior palpebral, lateral
nasal, & superior labial nerves.
2) AREAS ANESTHETIZED: incisors, cuspid, bicuspid, &
mesiobuccal root of first molar on the side injected,
including bony support & soft tissue; upper lip, lower
eyelid, & a portion of the nose on the same side.
3) ANATOMICAL LANDMARKS: infraorbital ridge,
infraorbital depression, supraorbital notch, infraorbital
notch, anterior teeth & pupils of eyes.

14. 4) INDICATIONS: when the anterior & middle superior
alveolar nerves are to be blocked Any procedures,
surgical or operative, may be performed on the five
anterior maxillary teeth on the same side of the
median line.
5) TECHNIQUE: the patient is placed comfortably in the
chair & tilted so that the maxillary occlusal plane is at
a 45- degree angle to the floor. an imaginary straight
line drawn will pass through the pupils of the eyes, the
infraorbital foramen, the bicuspid teeth, the mental
foramen.

15.  For an infraorbital block of the right side the dentist stands
on the right side of the chair partially facing the patient.
the thumb of the operator's left hand is placed over the
previously located infraorbital foramen,& the index finger
is used to retract the lip, exposing the mucolabial fold.
 25-gauge needle is taken inserted into the mucolabial fold
from either one or two directions. In using the first
direction, the dentist inserts the needle in a line parallel
with the supraorbital notch, the pupil of the eye,
infraorbital notch, & the second bicuspid tooth, if it is in
place.

16.  The needle should be inserted a sufficient distance from
the labial plate to pass over the canine fossa.
 The second direction of insertion bisects the crown of the
central incisor from the mesioincisal angle to the
distogingival angle. The needle is again inserted about
5mm from the mucobuccal fold & guided into position by
the thumb marking the location of the infraorbital
foramen.
 the anterior & middle superior alveolar nerves are blocked
on the left side with exactly the same technique as that
used on the right side,with the exception that the operator
stands slightly more to the front of the patient.

19. D. Posterior superior alveolar nerve block
1) NERVES ANESTHETIZED: posterior superior
alveolar nerve
2) AREAS ANESTHETIZED: the maxillary molars, with
the exception of the mesiobuccal root of the first
molar; the buccal alveolar process of the maxillary
molars, including the overling structure-periosteum,
connective tissue, & mucous membrane.

20. 3) ANATOMIACL LANDMARKS:
a. mucobuccal fold & its concavity
b. zygomatic process of maxilla
c. infratemporal surface of the maxilla
d. anterior border & coronoid process of the ramus of
the mandible
e. tuberosity of the maxilla
4) INDICATIONS: for oprative procedures of the molar teeth
& suporting structures. This injection must be combine
with palatal injection for extractions or when
instrumentation extends into this area.

21. 5) TECHNIQUE FOR RIGHT SIDE: the area of insertion
should be dried & painted with a suitable antiseptic
solution. A previously loaded syringe, with a 1 5/8
inch, 25-gauge needle, is held in a pen grasp & inserted
into the tissue in a line parallel with the index finger &
bisecting the fingernail. The insertion is made for a
distance of about ½ to ¾ inch, going upward, inward,
& backward. This should place the needle point in the
immediate vicinity of the foramina through which the
nerves enter the maxilla.

22. 6) TECHNIQUE FOR LEFT SIDE: for injection on the
left side the operator stands on the right side of the
patient, & 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.

24. E. Nasopalatine nerve block (incisive canal injection)
1) NERVES ANESTHETIZED: nasopalatine nerve as it
emerges from the anterior palatine foramen
2) AREAS ANESTHETIZED: the anterior portion of the hard
palate & overling structures back to the bicuspid area,
where branches of the anterior palatine nerve coursing
forward create a dual innervation.
3) ANATOMICAL LANDMARKS:
a. central incisor
b. incisive papilla in the midline of the palate.

25. 4) INDICATION: for palatal anesthesia.
a. to supplement the block of the anterior & middle
superior alveolar nerves.
b. to augment analgesia of six maxillary incisors.
c. to complet anasthesia of the nasal septum.
5) TECHNIQUE: the nasopalatine nerve block is
extremely painful injection unless a preparatory
injection is made. The preparatory injection is made
by a inserting a 1 inch, 25-gauge needle into the labial
interseptal tissue between the maxillary central
incisors.

26.  This needle is inserted at a right angle to the labial
plate & pass into the tissue until the resistance is met;
then 0.25 ml of anesthetic solution is deposited. The
needle is 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 0.5 cm into the canal. About 0.25 to 0.5
ml should be injected very slowly to prevent distention
of the surrounding tissues.

28. F. Anterior palatine nerve block
1) NERVES ANESTHETIZED: anterior palatine nerve as it
leaves the greater palatine foramen.
2) AREAS ANESTHETIZED: posterior portion of the hard
palate & overlying structure up to the first bicuspid area
on the side injected. At the first bicuspid area, branches
of the nasopalatine nerve will b met.
3) ANATOMICAL LANDMARKS:
a. second & third maxillary molars
b. palatal gingival margin of second & third maxillary
molars.
c. midline of the palate

29. d. a line approximately 1 cm from the palatal gingival margin
toward the midline of the palate
4) 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.
5) TECHNIQUE:the anterior palatine nerve emerges onto the
palate through the greater palatine nerve foramen. It is
situated between the second & third maxillary molars.
• The needle should be inserted very slowly until the palatal
bone is contacted.

30.  The anesthetic solution, 0.25 to 0.5 ml, is injected very
slowly. It will be advantageous to insert the needle &
deposit the solution so that the anterior palatine nerve
will be anesthetized anteriorly to the foramen.
 Anesthesia of the mucoperiosteum of the palate will
be obtained forward from the area of injection.

31. G. Maxillary nerve block
1) NERVES ANESTHETIZED: entire maxillary nerve &
all its subdivisions peripheral to the site of the
injection.
2) AREAS ANETHETIZED:
a. maxillary teeth on the affected side.
b. alveolar bone & overlying structures.
c. hard palate & portion of soft palate
d. upper lip, cheek, side of nose, & lower eyelid

32. 3) ANATOMICAL LANDMARKS: the landmarks will
differ according to the technique.
a. high tuberosity technique. Same landmarks as for
the posterior superior alveolar nerve block.
b. greater palatine canal technique. Same landmarks as
for the locating the greater palatine foramen to block
the anterior palatine nerve.
4) INDICATION:
a. when anesthesia of the entire distribution of the
maxillary nerve is required for extensive surgery.

33. b. when local infection or other conditions make blocks of
the main terminal branches unfeasible.
c. for diagnostic or therapeutic purposes such as tics or
neuralgias of the maxillary division of the fifth nerve.
5) TECHNIQUES:
a. High tuberosity technique. The high tuberosity is exactly
the same as that described for the posterior superior
alveolar nerve, with the exception that a 1 5/8-inch, 25-
gauge needle is inserted in an upward, inward, & backward
direction to a previously marked depth of 1 1/4-inches. Two
to 4 ml of solution are taken slowly injected.

34. b. Greater palatine canal technique. Both the left & right
greater palatine canals can b entered with the operator
standing in front of & to the right side of the patient.
• In performing the maxillary block by the greater
palatine canal approach, the operator must insert the
needle in the canal very slowly & against no resistance.
• Both of these methods of blocking the entire maxillary
nerve by the intraoral approach could be considered as
being technically difficult. They should be attempted
only when definitely indicted.

35. 2. EXTRAORAL TECHNIQUES
A. Anterior & middle superior alveolar nerve block
1) NERVES ANESTHETIZED:
a. infraorbital nerves
b. inferior palpebral, lateral nasal, & superior labial nerves
c. anterior & middle superior alveolar nerves
d. sometimes posterior superior alveolar nerve
2) AREAS ANETHETIZED:
a. incisors & bicuspids on the side injected
b. labial alveolar plate & overlying tissues
c. upper lip, portions of side of nose, & lower eyelid
d. sometimes maxillary molars & their buccal supporting
structures

36. 3) ANATOMICAL LANDMARKS:
a. pupil of eye
b. infraorbital ridge
c. infraorbital notch
d. infraorbital depression
4) INDICATIONS:
a. when the anterior & middle superior alveolar nerves are
to be anesthetized & the intraoral approach is not possible
because of infection, trauma, or other reasons.
b. when attempts to secure anesthesia by the intraoral
methods have been ineffective.

37. 5) TECHNIQUES:
a. Using the available landmarks, the dentist should
locate & mark the position of the infraorbital
foramen. The skin & subcutaneous tissues should be
anesthetized by local infiltration.
b. A 1 1/2-inch, 25-gauge needle attached to an
aspirating syringe is inserted through the marked &
anesthetized area. Directing the needle slightly
upward & laterally facilitates its entrance into the
foramen, which opens downward & medially.

38. c. With a slight, gently probing motion the foramen is
located & entered to a depth not to exceed 1/8 inch .
After careful aspiration, 1 ml of anesthetic solution is
slowly injected.

39. B. Maxillary nerve block
1) NERVES ANESTHETIZED:maxillary nerve & all its
subdivisions peripheral to the site of injection.
2) AREAS ANESTHETIZED:
a. anterior temporal & zygomatic regions
b. lower eyelid
c. side of nose
d, anterior cheek
e. upper lip
f. maxillary teeth
g. tonsil

40. h. maxillary alveolar bone & overlying structures
i. hard & soft palate
j. part of the pharynx
k. nasal septum & floor of the nose
l. posterior lateral mucosa & turbinate bones
3) ANATOMICAL LANDMARKS:
a. midpoint of the zygomatic arch
b. zygomatic notch
c. coronoid process of ramus of mandible located by
opening & closing the jaw
d. lateral pterygoid plate

41. 4) INDICATIONS:
a. when anesthesia of the entire distribution of the
maxillary nerve is required for extensive surgery.
b. when it is desirable to block all the subdivisions of the
maxillary nerve with only one needle insertion & a
minimum of anesthetic solution.
c. when local infection, trauma, or other conditions make
blocks of the more terminal branches difficult or
impossible.
d. for diagnostic or therapeutic purposes, such as tics or
neuralgias of the maxillary division of the fifth nerve.

42. 5) TECHNIQUE:
a. The midpoint of the zygomatic process is located & the
depression in its inferior surface is marked. With a 25-
gauge hypodermic needle, a skin wheal is raised just
below this mark in the depression, which the dentist
indentifies by having the patient open & close the jaw.
b. The needle is inserted through the skin wheal,
perpendicular to the median sagittal plane until the
needle point gently contacts the lateral pterygoid plate.
The needle should never be inserted beyond the depth of
the marker. The needle is withdrawn, with only the point
left in the tissue, & redirected in a slight forward &
upward direction until the needle is inserted to the depth
of the marker.

43.  The needle is withdrawn, with only the point left in
the tissue, & redirected in a slight forward & upward
direction until the needle is inserted to the depth of
the marker.
 After careful aspiration, 2 or 3 ml of a suitable
anesthetic solution is slowly injected. Care should be
exercised to aspirate after each o.5 ml of the solution is
injected.