All innervation for the maxilla is through the second division of the trigeminal nerve (V₂). The trigeminal nerve has two other trunks: the ophthalmic nerve (V₁) and the mandibular nerve (V₃).

V₂ is exclusively sensory, and passes through the foramen rotundum to reach the pterygopalatine fossa, where is has numerous branches. Two branches enter the sphenopalatine ganglion, and come to form the greater palatine nerve, the nasopalatine nerve, and posterior nasal nerve twigs. V₂ transmits sensation from the maxillary teeth, hard and soft palate, gingival, lower eyelid, upper lip and the side of the nose.

The posterior superior alveolar nerve supplies all of themolars and the buccal tissues, except the mesiobuccal root of the first molar. While in the canal, the middle superior alveolar nerve branches off, innervating the premolars and their associated buccal plate and tissues.

The anterior superior alveolar nerve branches off just prior to the nerve leaving the infra-orbital canal, supplying the incisiors and canines.

All other innervation to the maxilla is from the sphenopalatine ganglion, which supplies the palate and nasal cavity.

The anterior palatine nerve descends through the posterior (greater) palatine foramen to supply the hard palate and its tissues up to the canines.

The nasopalatine nerve emerges through the incisive (anterior palatine) foramen to supply the anterior palate, or the premaxilla.

 

Technique

 

Use a short or long needle, no less than 27g

have patient open mouth slightly

retract the lip with the thumb or first finger of left hand and tense the skin.

hold the needle parallel to the lateral incisior and angle slightly posterior towards root of tooth.

penetrate mucosa, advance ¼ inch, deposit ½ carpule 

the block should cover the intended tooth and the two bordering teeth.

very similar to the anterior superior nerve block except that injection site is between the premolars

it is important to keep the long axis of the syringe parallel with the buccal plate.

bevel should always face the bone.

area of anesthesia should be the premolars and the bordering teeth.

retract the lip and cheek

have the patient close their mouth slightly

insert the needle at the height of the maxillary buccal sulcus at distal aspect of 2^nd molar

with the needle bent 45 degrees, advance the needle posteriorly, superiorly and medially to a depth of 15mm.

aspirate and then slowly inject 1.5ml of solution.

area of anesthesia should be all of the molars

have the patient open mouth wide, and locate the greater palatine foramen

use a cotton-tip applicator to apply pressure to the foramen, this helps to mark the spot and provide some analgesia.

the needle will contact bone quickly in this location

back the needle up 1-2mm and inject until the tissue blanches

the area of anesthesia should be the ipsilateral palates and the molars (possibly premolars).

stablize needle with finger

advance needle into incisive papilla (posterior to central incisiors)

inject until tissue blanches

Nasopalatine and greater palatine blocks are both supplementary blocks for the palate. They are used in combination with other dental blocks for patient comfort. The nasopalatine would be appropriate for frontal/medial teeth, while the greater palatine block would block the molars.

Pterygomandibular Space

Medial: medial pterygoid muscle

Lateral: ramus of the mandible

Superior: lateral pterygoid muscle

Posterior: parotid gland

Anterior: oral mucosa, submucosal connective tissue, buccinator muscle

CONTENTS: inferior alveolar nerve, lingual nerve, inferior alveolar artery and vein, sphenomandibular ligament

Hard tissue landmarks: mandibular foramen and lingual

anterior/posterior borders of mandibular ramus

mandibular bicuspid teeth of contralateral side

Distribution: Inferior Alveolar and Lingual nerves split prior to entering the pterygomandibular space. Lingual nerve lies anterior and medial to the Inferior Alveolar nerve and follows a downward and lateral course. The inferior alveolar nerve passes laterally and downward in an S shape until it reaches the ramus just behind the lingula. The inferior alveolar artery and vein lie posterior and lateral to the nerve prior to entering the mandibular foramen

There are 3 techniques: direct, Gow-Gates, and Akinosi. -This block takes 3-5 minutes for onset despite the solution used. Most solutions work in approximately 2 minutes, give or take 15 seconds.

rest the thumb in a retromolar fossa, palpating the coronoid notch on the anterior border of the ramus

rest the first finger on posterior border of ramus at same height as the thumb.

ask the patient to open mouth widely

insert syringe into oral cavity across the mandibular bicuspids of opposite side, parallel to mandibular occlusal plane.

locate the point of penetration by visualizing a V-shape, composed of the anterior border of ramus of mandible of the lateral aspect, and the pterygomandibular raphe medially. The ramus is palpable and the raphe visible.

penetrate the imaginary V midway between a level halfway up the thumbnail

advance the needle through tissue until bony contact is made, usually at a depth of 20-30mm.

once the bone is reached, withdraw slightly and aspirate

if aspiration is negative, inject approximately 1.5cc of solution.

area of anesthesia is bony, periodontal and pulpal area of all mandibular molars, premolars, cuspid and incisiors on the side of the injection to the midline.

Akinosi

 

a "closed mouth technique", meaning no bony contact.

with teeth in gentle occlusion, the needle is advanced in the maxillary vestibule with the syringe axis parallel to the occlusal plane at the level of the mucogingival junction. The needle depth is approximately 2.5cm.

 

Gow-Gates

a "high mandibular" block

depth of block is approximately 25-27mm

injection point is the cusps of the maxillary second molar

using a line from the tragal notch to the corner of the mouth, guide the needle toward the condylar neck.

with the pts head tilted back and mouth open wide, palpate the internal oblique ridge with either finger or thumb.

angulation of the injection will parallel the junction of the two external landmarks

the puncture point will be between the pterygomandibular raphe and internal oblique ridge, approaching the anterior condylar neck from the contralateral premolars.

deposit the entire carpule of solution. The onset may be slower, but is profound for 2-3hrs.

 

Mandibular Buccal Soft Tissue Block

Distribution: crosses the deep tendon of the temporalis, retromolar triangle and the external oblique ridge at the level of the occlusal plane.

Supplies the cheek, vestibule, and alveolar mucosa in the molar region.

Technique: needle puncture is made lateral and distal to the last mandibular molar at the level of the occlusal plane. Insertion depth is 2-3mm until contact with the anterior border of the ramus of the mandible.

Questions