Maxillary Injection

Techniques

Anatomy

Anatomy

Atraumatic Injection Protocol

3 Main Types of Maxillary Injections:

1) Local Infiltration
2) Field Block
3) Nerve Block

Local Infiltration
Incision (treatment) is done in the same area in which the
local anesthetic was deposited (interproximal papilla
before Scaling and Root Planing)

Field Block
Local anesthetic is deposited toward larger nerve 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

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)

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

Maxillary and Mandibular

Injections
The following are used in both arches:
Supraperiosteal Injection
Intraligamentary (PDL) Injection
Intraseptal Injection
Intraosseous Injection

Supraperiosteal Injection

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

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)

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

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

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

Supraperiosteal vs. Infiltration

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

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?

Posterior Superior Alveolar

Nerve Block (PSA)

2) Posterior Superior Alveolar Nerve Block

Highly successful nerve block with greater than
95% success
Effective for maxillary 1st, 2nd and 3rd molars and
buccal periodontium
Mesiobuccal root of the maxillary 1st molar is not
consistently innervated by the PSA nerve

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)

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

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

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

4) Apply topical anesthetic for at least one minute

5) Have patient open their mouth half way which
makes more room
6) Retract the patients cheek with mirror
7) Pull the tissues taut
8) Orient bevel toward bone

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

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

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

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

Middle Superior Alveolar

Nerve Block (MSA)

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

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 1 st premolar, 2nd
premolar and mesiobuccal root of the maxillary 1 st
molar if you need an alternative block when the
MSA is not adequate

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

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

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

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

Middle Superior Alveolar Nerve

Block

Anterior Superior Alveolar

Nerve Block (ASA)

Highly successful extremely safe block that

causes hesitation in most clinicians
Provides profound pulpal and soft tissue
anesthesia from the maxillary central incisor
distal to the premolars in 72% of patients
Used in place of the supraperiosteal injection

Uses less anesthetic solution than the supraperiosteal

injection
Supraperiosteal 3.0 ml solution
ASA 1.0 ml solution
#1 fear is damage to the patients eye which is
unfounded
Also known as the Infraorbital Nerve Block which is
inaccurate
Failed ASA is just a supraperiosteal injection over the
1st premolar

Areas Anesthetized ASA Nerve Block

1) Pulp of the maxillary central incisor through the
canine
2) 72% of patients have premolars and mesiobuccal
root of 1st molar anesthetic
3) Buccal periodontium and bone of the above teeth
4) Lower eyelid, lateral aspects of the nose and upper
lip

When Do I Use This Block?

1) Dental procedures involving more than
one tooth, i.e., central and lateral incisor
2) Inflammation/Infection precluding the use
of the supraperiosteal injection
3) Ineffective supraperiosteal injections due
to dense cortical bone

Technique ASA Nerve Block

1) 25 gauge long needle is recommended
2) Insert needle at the height of the mucobuccal fold
over the 1st premolar
3) Target: Infraorbital Foramen
4) Landmarks: Infraorbital Notch, Mucobuccal fold,
Infraorbital Foramen
5) Apply topical anesthetic for at least one minute

6) Feel the infraorbital notch moving your finger

down the notch palpating the tissues gently; the
outward bulge is the lower border of the orbit
which is the roof of the infraorbital foramen;
continue the finger inferiorly until a depression
is felt which is the infraorbital foramen
7) Maintain pressure over the foramen while
inserting the needle down the long axis of the
1st premolar

8) Advance the needle slowly until bone is contacted

gently which is the upper rim of the infraorbital
foramen
9) 16 mm total advancement of needle;1/2 of long
needle length
10) Estimate the distance between the infraorbital
foramen and mucobuccal fold
11) Aspirate

12) Deposit 1.0 ml of anesthetic solution

13) Administrator can feel the anesthetic expanding
the tissue with finger tip
14) Maintain finger pressure over the foramen for
at least one minute to disperse the anesthetic
solution
15) Needle should not be palpable in most patients
16) Wait 3 to 5 minutes for anesthesia to result

Problems/Failures (ASA)
Failure is from the needle deviating to the medial or
lateral away from the infraorbital foramen
Failure to reach the infraorbital foramen will result
in anesthesia of the lateral side of the nose, upper
lip and lower eyelid but not the teeth
Hematoma formation can result although rarely;
apply pressure to area for 2 to 3 minutes; at least 60
seconds

Palatal Anesthesia

Palatal Anesthesia
Easily one of the most traumatic experiences
for dentists due to the pain that is sometimes
elicited from the patients
Palatal injections can be administered
atraumatically

STEPS- Results in painless palatal injections

1) Apply topical for two minutes
2) Apply pressure to site both before and
during deposition of the solution
3) Deposit solution slowly

5 PALATAL INJECTIONS
1) Anterior (Greater) Palatine Nerve Block:
no pulpal anesthesia
2) Nasopalatine Nerve Block: no pulpal anesthesia
3) Local Infiltration: no pulpal anesthesia
4) P-AMSA: pulpal and soft tissue
5) P-ASA: pulpal and soft tissue

Greater Palatine Nerve Block

GP Nerve Block (soft tissue and bone only)

Anesthetizes palatal soft tissue distal and
medially to the canine
(posterior portion of the palate)
Tissues around the Greater Palatine Foramen are
able to accommodate a larger volume of
solution than the tissue in the vicinity of the
Nasopalatine Foramen less patient
discomfort

Indications for palatal injections:

1) Scaling and root planing
2) Subgingival restorations
3) Deep placed matrix bands
4) Extractions (oral surgery)

Technique Greater Palatine Nerve Block

1) 27 gauge short needle
2) Insert needle in soft tissue slightly anterior
to the greater palatine foramen
3) Target is the greater palatine nerve as it
passes from the foramen between the soft
tissue and bone of the hard palate

Locate the Greater Palatine Foramen:

-use cotton swab/mirror handle
-place a cotton swab at the junction of the
maxillary alveolar process and the hard palate
-press firmly into tissues moving posteriorly
from the maxillary 1st molar
-swab falls into the depression of the
greater palatine foramen

4) Foramen is most often located distal to the

2nd maxillary molar
5) Apply considerable pressure to cotton swab
in area of foramen until a noticeable ischemia
occurs; hold pressure for 30 seconds before
injection

6) Continue to apply pressure throughout the

injection with the cotton swab
7) Slowly advance the needle until bone is
gently contacted
8) Depth of penetration is usually less than 10 mm
9) Aspirate
10) Deposit solution very slowly

Do not enter the greater palatine canal

There is no reason to have the needle
penetrate the canal
There is no negative repercussion except
post-operative pain

Nasopalatine Nerve Block

Nasopalatine Nerve Block (soft tissue and bone only)

Considered by many to be the most traumatic, painful
injection of all the dental injections
Most important injection to follow the protocol about to be
explained
Anesthetizes the anterior portion of the hard palate (soft and
hard tissues) from the mesial of the left premolar to the
mesial of the right premolar
Use this injection for the same reasons as Greater Palatine
Nerve Block
Target area is the incisive foramen beneath the incisive
papilla

Technique Nasopalatine Nerve Block

1) 27 gauge short needle is recommended
2) Insertion point: palatal mucosa just lateral to the
incisive papilla
3) Approach the injection site at a 45 degree angle
4) Apply topical anesthetic for two minutes
5) Apply considerable pressure to the incisive papilla
until ischemia

6) Continue to apply pressure to the cotton applicator

tip while injecting
7) Advance the needle until bone is gently contacted
8) Depth of needle penetration is usually 5 mm
9) Slowly deposit cartridge over a 30 second
interval
10) Wait 2-3 minutes for anesthesia

Other Than P-ASA and

Maxillary Nerve Blocks
There is no reason to enter the Greater
Palatine Foramen or the Nasopalatine
Foramen when providing these injections
do not advance needle more than 5 mm
into the incisive canal because it could
enter the floor of the nose causing infection

Back Spray
During palatal injections, the pressure
generated within the syringe will cause
the solution to spray into your mask/face;
always wear the appropriate safety
glasses and mask when giving any injection
regardless of how trivial it may seem
at the time

2nd Example of Nasopalatine Injection

Technique 2nd Example of Nasopalatine Injection
Insertion Points:
1) Labial frenum; midline of maxilla (0.3 ml over
15 seconds)
2) Interdental papilla of #8 and #9 (0.3 ml over
15 seconds)
3) Palatal soft tissues lateral to the incisal
papilla (contact bone)

2 Example of Nasopalatine Injection

nd

Important Points:
Topical and pressure anesthesia on the palate are not
necessary because the first injection anesthetized the palatal
tissues
Contact bone on the 3rd injection (incisive papilla) only
Interdental papilla between maxillary central incisors is sore
for a few days
Greater palatine nerve may overlap and lead to inadequate
anesthesia of the canine and 1st premolar

Local Infiltration of the Palate

Local Infiltration of the Palate

Anesthetizes the terminal branches of the Greater
Palatine Nerve and Nasopalatine Nerve
Anesthetizes the soft tissue in the immediate
vicinity of the injection

Indications for Palatal Anesthesia:

1) Hemostasis during procedures of a minimal
area of tissue
2) Palatogingival pain control for rubber dam
clamps, retraction cord placement and small
surgical procedures

Local Infiltration of the Palate

Important Points:
-Gate control method (inhibitory neuron prevents the
projection neuron from sending signals to the brain
(gate is closed)) of pain removal is used with
-these injections using a cotton swab for pressure
resulting in blanching tissue
-Target area is the palatal tissue 5 to 10 mm from the
free gingival margin
-Masticatory mucosa of the hard palate is only
3 to 5 mm thick
-Palatal Infiltrations are safe areas anatomically to
deposit anesthetic

P-ASA

P-ASA Palatal Approach Anterior Superior

Alveolar Nerve Block
Described in the 1990s by the inventors of the
CCLAD systems
Comparative to the Nasopalatine Nerve Block
Insertion: lateral point of the incisive papilla but the
big difference:
NEEDLE TIP IS POSITIONED IN THE
INCISIVE CANAL

 Deposit 1.4 1.8 ml of solution at

0.5 ml per minute
Primary method of achieving bilateral
pulpal anesthesia of the maxillary anterior
six teeth; anterior palatal 1/3rd
Provides profound soft tissue anesthesia
of the gingiva and mucoperiosteum

 Soft tissue of the facial attached gingiva

is achieved anterior to the maxillary
anterior six teeth
P-ASA is the 1st injection to produce
bilateral pulpal anesthesia of the
maxillary anterior six teeth from a single
injection

MAIN POINT OF THIS INJECTION:

P-ASA is designed to provide pulpal anesthesia of the
maxillary anterior six teeth in addition to the facial
gingival soft tissue and mucoperiosteum
it does not anesthetize the lip as with the regular
mucobuccal fold approach; esthetic Dentistry can
then be assessed without dealing with lip anesthesia
when smiling

 Palatal approach allows anesthesia to be limited to

the subneural plexus for the maxillary anterior teeth
and nasopalatine nerve
Minimum volume for injection is 1.8 ml (full
cartridge) over 0.5 ml/minute
Insert needle very slowly
4% anesthetics should have volume reduced by
(Prilocaine/Articaine)

 Do not use 1:50,000 epinephrine

May need supplemental mucobuccal fold
injections for canines because of their
very long roots
Palatal ulcers develop from ischemia
1-2 days after treatment and are selflimiting; healing occurs in 5-10 days

Technique P-ASA
1) 27 gauge short needle is recommended
2) Insert needle just lateral to the incisive
papilla in the papillary groove
3) Target is the nasopalatine foramen
4) Needle held at 45 degree angle to the palate
(same as central incisors)

5) Insert needle 6 to 10 mm; if resistance is found do

not force needle
6) Insert needle 1-2 mm every 4-6 seconds while
administering solution
7) Resistance means you have to reinsert the needle;
careful of nose floor
8) Aspirate
9) Deposit 1.8 ml of anesthetic solution very slowly
0.5 ml/minute
10) Patient may feel needle shock very disturbing
to
patient

Maxillary Nerve Block

1) Greater Palatine Approach
2) High Tuberosity Approach

Maxillary Nerve Block Facts

Also known as a 2nd Division block
Anesthetizes the maxillary division
of the trigeminal nerve

Areas Anesthetized:
1) Pulpal anesthesia of all teeth on the side of
injection (ipsalateral)
2) Buccal periodontium and bone on the side of
injection
3) Soft tissues and bone of the hard palate/soft palate
medial to midline
4) Skin of lower eyelid, side of the nose, cheek and
upper lip

Maxillary Nerve Block Approaches

It would require 4 other injections to get the
effect of the Maxillary Nerve Block i.e., PSA,
Infraorbital, Greater Palatine and Nasopalatine
2 Approaches:
1) Greater Palatine Approach
2) High Tuberosity Approach

1) Greater Palatine Approach Technique

25 gauge long needle recommended
Insert into palatal soft tissue over greater palatine
foramen
Target is the maxillary nerve as it passes through the
Pterygo-palatine Fossa; the needle passes through
the Greater Palatine Canal to reach the
Pterygopalatine Fossa

Find the foramen by using a cotton swab until

it falls into the foramen
Most often found at distal of the maxillary 2nd
molar
Topical anesthetic for at least two minutes
Inject into the area adjacent to the Greater
Palatine Foramen in order to block the nerve
before probing into the actual foramen itself

1) Greater Palatine Approach Technique

Remember to apply constant pressure into this area until the
tissue blanches which will lessen the discomfort of the
needle penetration
Probe gently for the foramen with the needle tip at a
45 degree angle
After finding the canal advance the needle 30 mm
5 to 15% of foramens have boney obstructions, so if you
encounter an obstruction do not force the needle, try again
then abort

Maxillary Nerve Block Complications

1) Greater Palatine Approach Complications
Penetration of the orbit leading to a myriad of
complications
periorbital swelling or proptosis (bulging eye)
block of 6th cranial nerve producing diplopia
(double vision)
Retrobulbar (behind the eye) hemorrhage, corneal
anesthesia
optic nerve anesthesia loss of vision

Maxillary Nerve Block Complications

Penetration of the nasal cavity (medial wall
of the pterygopalatine fossa is paper thin):
-patient complains of something draining
down their throat
-large amounts of air will be aspirated into
the cartridge

Maxillary Nerve Block 2nd Approach

2) High Tuberosity Approach
25 gauge long needle recommended
Insert to the height of the mucobuccal fold distal
to the 2nd molar
Target is maxillary nerve as it passes through the
pterygopalatine fossa
Superior and medial to the target site of the PSA

Again, advance the needle to a depth of 30 mm

Upward, inward and backward direction same as
PSA
Resistance should not be felt, if it is, the
angulation is too medial
At 30 mm the needle tip should lie within the
pterygopalatine fossa
Aspirate several times and inject 1.8 ml (one
cartridge) slowly

Maxillary Nerve Block 2nd Approach

2) High Tuberosity Approach Complications
Hematoma develops rapidly if the maxillary
artery is punctured with the needle tip

Thin, porous substance of the maxillary bone allows

for rapid diffusion of solutions into the cancellous
bone
Most Dentists rely solely on the supraperiosteal
injection to provide anesthesia in the maxilla
PSA and ASA combined can deliver safe anesthesia
to virtually all patients requiring maxillary
anesthesia

Universal:
-applying topical anesthetic for
one minute
-proper patient positioning
-aspiration
-making the needle safe after each
injection with the scoop technique

References
Malamed, Stanley: Handbook of Local Anesthesia. 5 th Edition. Mosby. 2003