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Anatomy of Maxillary and Mandibular Local Anesthesia

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Anatomy of Mandibular and Maxillary Local Anesthesia Patricia L. Blanton, Ph.D., D.D.S. Professor Emeritus, Department of Anatomy, Baylor College of Dentistry – TAMUS and Private Practice in Periodontics Dallas, Texas Anatomy of Mandibular and Maxillary Local Anesthesia I. Introduction A. The anatomical basis of local anesthesia 1. Infiltration anesthesia 2. Block or trunk anesthesia II. Review of the Trigeminal Nerve (Cranial n. V) – the major sensory nerve of the head A. Ophthalmic Division 1. Course a. Superior orbital fissure – root of orbit – supraorbital foramen 2. Branches – sensory B. Maxillary Division 1. Course a. Foramen rotundum – pterygopalatine fossa – inferior orbital fissure – floor of orbit – infraorbital 2. Branches - sensory a. Zygomatic nerve b. Pterygopalatine nerves [nasal (nasopalatine), orbital, palatal (greater and lesser palatine), pharyngeal] c. Posterior superior alveolar nerves d. Infraorbital nerve (middle superior alveolar nerve, anterior superior nerve) C. Mandibular Division 1. Course a. Foramen ovale – infratemporal fossa – mandibular foramen, Canal -> mental foramen 2. Branches a. Sensory (1) Long buccal nerve (2) Lingual nerve (3) Inferior alveolar nerve -> mental nerve (4) Auriculotemporal nerve b. Motor (1) Pterygoid nerves (2) Temporal nerves (3) Masseteric nerves (4) Nerve to tensor tympani (5) Nerve to tensor veli palatine (6) Nerve to mylohyoid (7) Nerve to anterior belly of digastric c. Both motor and sensory (1) Mylohyoid nerve III. Usual Routes of innervation A. Maxilla 1. Teeth a. Molars – Posterior superior alveolar nerve b. Premolars – Middle superior alveolar nerve c. Incisors and cuspids – Anterior superior alveolar nerve 2. Gingiva a. Facial/buccal – Superior alveolar nerves b. Palatal – Anterior – Nasopalatine nerve; Posterior – Greater palatine nerves B. Mandible 1. Teeth a. Molars, premolars, cuspids and incisors – Inferior alveolar nerve 2. Gingiva a. Facial – Mental nerve b. Buccal – Long buccal nerve c. Lingual – Lingual nerve IV. Aberrant and/or Supplemental Routes of Innervation A. Maxilla 1. Posterior superior alveolar nerve; tuberosity 2. Cross-over innervation in molar area 3. Absence of middle superior alveolar nerve 4. Anterior superior nerve; infraorbital nerve 5. Nasopalatine nerve; greater palatine; cross-over innervation in incisor area B. Mandible 1. Inferior alveolar nerve a. mylohyoid nerve b. supplemental innervation to 2nd and 3rd molars c. supplemental innervation to 1st and/or 3rd molars d. transverse cervical nerve: “cross-over” innervation 2. Lingual nerve 3. Long buccal nerve 4. Mental nerve 5. Mandibular (Third) Division: Gow-Gates; Akinosi V. Technique tips based on anatomical features A. Maxilla 1. PSA nerve block (tuberosity nerve block) 2. MSA nerve – zygomaticoalveolar crest 3. ASA nerve 4. Infraorbital nerve block 5. Nasopalatine nerve block 6. Greater palatine nerve block 7. Second Division nerve block (Pterygopalatine fossa) B. Mandible 1. Inferior alveolar nerve block – Halstead approach 2. Lingual nerve block 3. Long buccal nerve block 4. Gow-Gates (wide open mouth) approach 5. Akinosi (closed mouth) approach 6. Supplemental routes of mandibular innervation a. mylohyoid nerve b. branch of inferior alveolar nerve to 2nd and 3rd molars c. branch of inferior alveolar nerve to 1st and/or 3rd molars 7. Mental (incisive) nerve block VI. Complications of Local Anesthesia A. Facial paralysis 1. Parotid gland and facial nerve (Cranial n. VII) B. Muscle trismus 1. Medial pterygoid muscle and temporalis muscle C. Lingual nerve trauma D. Hemorrhage (venous versus arterial) 1. Pterygoid plexus of veins 2. Maxillary artery (proximal,distal) 3. Inferior alveolar artery 4. Internal carotid artery Dr. Patricia L. Blanton Anatomy of Mandibular and Maxillary Local Anesthesia REFERENCES Akinosi, J.O. 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Heritage Press, Dallas, Texas, 1980. Lacouture, C., Blanton, P.L., and Hairston, L.E. The anatomy of the maxillary artery in the infratemporal fossa in relationship to oral injections. Anat. Rec. 205(3):104A, 1983. Loetschor, C.A., Melton, D.C. and Walton, R.E. Injection regimen for anesthesia of the maxillary first molar. J.A.D.A. 117:337-340, 1988. Loizeaux, A.D. and Devos, B.J. Inferior alveolar nerve anomaly. J. Hawaii Dent. Assoc. 12:10- 11, 1981. McArdle, B. Limiting sensitivity after quadrant scaling and root planing. J.A.D.A. 131:221-222, 2000. McKissock, M., Meyer, R. Accessory innervation of the mandible: Identification and anesthesia options. General Dent. 662-669, Nov.-Dec. 2000. Madiera, M.C., Percinoto, C. and Silver, M.G.M. Clinical significance of supplementary innervation of the lower incisor teeth: A dissection study of the mylohyoid nerve. Oral Surg. 46:608-614, 1978. Malamed, S.F. Handbook of Local Anesthesia. 3rd ed. St. Louis: Mosby Year Book, 197-218, 1990. Malamed, S.F. The periodontal ligament (PDL) injection: an alternative to inferior alveolar nerve block. Oral Surg. 55:117-121, 1982. Matheson, B.R., Blanton, P.L., Rivera-Hidalgo, F., Rees, T.D., Bradley, R.E. and Dill, R. Utilization of an intraoral landmark to localize the mental foramen. AADR Abstract #977, J. Dent. Res. 63A:278, 1986. Matheson, B.R., Rivera-Hidalgo, F., Blanton, P.L., Rees, T.D., Bradley, R.E. and Dill, R. Reliability of radiographic location of the mental foramen. AADR Abstract #393, J. Dent. Res. 65A:213, 1986. Nicholson, M.L. A study of the position of the mandibular foramen in the adult human mandible. Anat. Rec. 212:110-112, 1985. Penarrocha-Diago, M., and Sanchis-Bielsa, J.M. Ophthalmologic complications after intraoral local anesthesia with articaine. Oral Surg. 90(1):21-24, 2000. Pogrel, M.A., and Thamby, S. Permanent nerve involvement resulting from inferior alveolar nerve blocks. J.A.D.A. 131:901-907, 2000. Ragan, Michael R. Dental Local Anesthesia. 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    Jemds.com Original Research Article Comparison of Greater Palatine Nerve Block with Intravenous Fentanyl for Postoperative Analgesia Following Palatoplasty in Children Amol Singam1, Saranya Rallabhandi2, Tapan Dhumey3 1Department of Anaesthesiology, JNMC, DMIMS, Sawangi Meghe, Wardha Maharashtra, India. 2Department of Anaesthesiology, JNMC, DMIMS, Sawangi Meghe, Wardha, Maharashtra, India. 3Department of Anaesthesiology, JNMC, DMIMS, Sawangi Meghe, Wardha, Maharashtra, India. ABSTRACT BACKGROUND Good pain relief after palatoplasty is important as inadequate analgesia with vigorous Corresponding Author: cry leads to wound dehiscence, removal of sutures and extra nursing care. Decrease Dr. Saranya Rallabhandi, in oxygen requirement and cardio-respiratory demand occur with good pain relief Assisstant Professor, and also promotes early recovery. Preoperative opioids have concerns like sedation, Department of Anesthesiology, AVBRH, DMIMS (DU), Sawangi Meghe, respiratory depression and airway compromise. Greater palatine nerve block with Wardha- 442001, Maharashtra, India. bupivacaine is safe and effective without the risk of respiratory depression. The study E-mail: [email protected] was done to compare pain relief postoperatively with intravenous fentanyl and greater palatine nerve block in children following palatoplasty. DOI: 10.14260/jemds/2020/549 METHODS How to Cite This Article: 80 children of ASA I & II, between 1 to 7 years were included and allocated into two Singam A, Rallabhandi S, Dhumey T. Comparison of greater palatine nerve block groups of 40 each. Analgesic medication was given preoperatively after induction of with intravenous fentanyl for postoperative general anaesthesia, children in Group B received greater palatine nerve block with analgesia following palatoplasty in -1 2 mL 0.25% inj. Bupivacaine (1 mL on each side) and Group F received 2 μg Kg I.V.
  • The Mandibular Nerve - Vc Or VIII by Prof

    The Mandibular Nerve - Vc Or VIII by Prof

    The Mandibular Nerve - Vc or VIII by Prof. Dr. Imran Qureshi The Mandibular nerve is the third and largest division of the trigeminal nerve. It is a mixed nerve. Its sensory root emerges from the posterior region of the semilunar ganglion and is joined by the motor root of the trigeminal nerve. These two nerve bundles leave the cranial cavity through the foramen ovale and unite immediately to form the trunk of the mixed mandibular nerve that passes into the infratemporal fossa. Here, it runs anterior to the middle meningeal artery and is sandwiched between the superior head of the lateral pterygoid and tensor veli palatini muscles. After a short course during which a meningeal branch to the dura mater, and the nerve to part of the medial pterygoid muscle (and the tensor tympani and tensor veli palatini muscles) are given off, the mandibular trunk divides into a smaller anterior and a larger posterior division. The anterior division receives most of the fibres from the motor root and distributes them to the other muscles of mastication i.e. the lateral pterygoid, medial pterygoid, temporalis and masseter muscles. The nerve to masseter and two deep temporal nerves (anterior and posterior) pass laterally above the medial pterygoid. The nerve to the masseter continues outward through the mandibular notch, while the deep temporal nerves turn upward deep to temporalis for its supply. The sensory fibres that it receives are distributed as the buccal nerve. The 1 | P a g e buccal nerve passes between the medial and lateral pterygoids and passes downward and forward to emerge from under cover of the masseter with the buccal artery.