Download Supraperiosteal infiltrations Anterior superior alveolar nerve block

Supraperiosteal infiltrations A supraperiosteal infiltration anesthetizes individual teeth (see image below). Use this technique only with the maxillary incisors, canines, and premolars.
1. Landmarks: Locate the mucobuccal fold above the tooth to be anesthetized by grasping the membrane with gauze and pulling out and down for maxillary locations and out and up for mandibular locations. 2. Apply topical anesthetic as described in the Anesthesia section. 3. Approach: Insert needle into the mucobuccal fold with the bevel facing bone, aligned with the center of the tooth to be anesthetized, aimed toward the maxilla. Contact the maxilla, then withdraw the needle 1 mm. 4. Aspirate. 5. Slowly inject 1­2 mL of local anesthetic at the apex of the root tip. Anterior superior alveolar nerve block The anterior superior alveolar (ASA) nerve block anesthetizes the maxillary canine, the central and lateral incisors, and the mucosa above these teeth, with occasional crossover to the contralateral maxillary incisors. 1. Landmarks: Locate the mucobuccal fold where it intersects with the apex of the canine (cuspid) tooth by retracting the membrane with gauze and pulling out and down. 2. Apply topical anesthetic as described in the Anesthesia section. 3. Approach: While retracting the lip, insert the needle into the intersection of the mucobuccal fold and the apex/center of the canine at a 45­degree angle, advancing the needle approximately 1­1.5 cm. 4. Aspirate. 5. Slowly inject 2 mL of local anesthetic and massage for 10­20 seconds. 6. Middle superior alveolar nerve block The middle superior alveolar (MSA) nerve block anesthetizes the maxillary premolars with occasional overlap to the canine and first molar. 1. Landmarks: Locate the mucobuccal fold where it intersects with the junction of maxillary premolar 2 and molar 1. 2. Apply topical anesthetic as described in the Anesthesia section. 3. Approach: While retracting the cheek, insert the needle into the aforementioned intersection point at a 45­degree angle, and advance 1­1.5 cm. 4. Aspirate. 5. Slowly inject 2­3 mL of local anesthetic and massage for 10­20 seconds. Posterior superior alveolar nerve block The posterior superior alveolar (PSA) nerve block anesthetizes maxillary molar teeth (see image below). With the PSA nerve block, the first molar may not be completely anesthetized; in this case, the PSA nerve block can be used in conjunction with an MSA/supraperiosteal block. 1. Landmarks: Start with the jaw half open and swung toward the operator. Retract the cheek laterally and locate the intersection of the mucobuccal fold and the junction of molars 1 and 2. 2. Apply topical anesthetic as described in the Anesthesia section. 3. Approach: Insert the needle into the intersection and direct it toward the posterolateral maxillary tuberosity (up, back, and inward) along the curvature or the maxilla and to a depth of approximately 2­2.5 cm. If the needle contacts bone, withdraw and redirect more laterally. 4. Aspirate. 5. Slowly inject 2­3 mL of local anesthetic. Inferior alveolar nerve block An inferior alveolar nerve block anesthetizes all teeth on the ipsilateral side of mandible, as well as the ipsilateral lip and chin via the mental nerve.
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1. Landmarks: Start by standing contralateral to the side to be anesthetized. Place the thumb in the mouth, and place the index finger externally and posterior to the ramus (angle of the jaw). Retract cheek laterally and palpate the retromolar fossa to find the greatest depth of the anterior border of the ramus; this is the coronoid notch. 2. Apply topical anesthetic as described in the Anesthesia section. 3. Approach: With the patient’s jaw open, align the barrel of the syringe with occlusive surfaces of the teeth, angled between the first and second premolars on contralateral side (the syringe must be thus aligned for a successful nerve block). Insert the needle 1 cm above the occlusive surface of the teeth in the triangle at the lingula. The lingula is a bony projection on the medial surface of the ramus 1 cm above the occlusive plain. The goal is to insert the needle just superior and posterior to the lingula; if the needle is inserted too low, anesthesia does not occur. Stop insertion when the needle strikes the bone but not before. Withdraw the needle 1­2 mm. Aspirate. Inject 2­4 mL of local anesthetic. Because of its close proximity to the inferior alveolar nerve, the lingual nerve is usually also anesthetized with this technique. Mental nerve block A mental nerve block anesthetizes the ipsilateral lower lip and skin of the chin (not the teeth) 1. Landmarks: To locate the mental foramen, retract the cheek and lip and locate the junction of mandibular premolars 1 and 2 and down 1 cm inferior to the gum line (just medial to the midline pupil). Note that this is in the same line as the infraorbital foramen. 2. Apply topical anesthetic as described in the Anesthesia section. 3. Approach: Insert the needle 1 cm inferior to the second premolar at a 45­degree angle. Advance until the needle contacts the mandible. Withdraw the needle slightly. 4. Aspirate. 5. Inject 1­2 mL of anesthetic adjacent to the foramen and massage for 10­20 seconds. Infraorbital nerve block An infraorbital nerve block, which branches from the maxillary nerve, anesthetizes the lower eyelid, upper cheek, part of the nose, and upper lip (see image below). The ASA nerve, which innervates the maxillary canine, the central and lateral incisors, and the mucosa above these teeth, with occasional crossover to the contralateral maxillary incisors, also branches from the maxillary nerve, proximal to the infraorbital nerve. Because of this anatomy, anesthetizing the infraorbital nerve can result in some overlapping anesthesia of the ASA nerve or vice versa. However, anesthetizing one of these nerves does not guarantee anesthesia of the other. 1. Landmarks: Externally, the intraorbital foramen is just medial to the intersection of a vertical line from the pupil (when midline) to the inferior border of the infraorbital ridge. Internally, the intraorbital foramen is approached at the intersection of the mucobuccal fold and the junction of premolars 1 and 2. 2. Apply topical anesthetic as described in the Anesthesia section. 3. Approach: Place the index finger of the nondominant hand over the above the intersection mentioned above (ie, the infraorbital foramen) and retract the cheek with the thumb. Insert the needle into the mucobuccal fold at junction of premolars 1 and 2. Direct the needle parallel to the long axis of premolar 2, palpating its location as the needle is advanced until it is adjacent to the infraorbital foramen (approximately 1.5­2 cm). If the needle is directed at an angle that is too acute, it will hit the maxillary eminence; if directed at an angle that is too superior, the needle will enter the orbit. 4.
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Aspirate. Inject 2­3 mL of local anesthetic while holding firm pressure with the index finger over infraorbital ridge to prevent ballooning of lower eyelid. Massage for 10­20 seconds.