Anatomy Of Oral Regional Nerve Blocks

Front 1

Infiltration

Back 1

1. Anesthetizes the terminal nerve branches in the area of treatment
a. Dental - pulp
b. Interradicular – PDL and buccal gingiva
c. Interdental – PDL and buccal gingiva
2. When used on maxillary teeth, it is referred to a plexus anesthesia because of the over-lapping of fibers of the posterior, middle and anterior alveolar nerves

Front 2

Nerve block

Back 2

1. Anesthesia is deposited along the trunk of the nerve, which will anesthetized a larger area
2. Generally used on mandibular teeth because the cortical bone is too thick for infiltration
3. May used when infections block the penetration of the anesthesia
4. Prevent multiple injections and less discomfort to the patient

Front 3

Fiber components of trigeminal nerve

Back 3

1. Motor (to muscles of pharyngeal arch origin)
2. Sensory (general sensation)

Front 4

Functions important to the dental profession of trigeminal nerve

Back 4

1. General sensation to the face, to the TMJ and to parts of the mucous membranes of the head
2. Motor and proprioceptive fibers to the muscles of mastication
3. Carries postganglionic parasympathetic fibers to target organs

Front 5

Ciliary ganglion

Back 5

Ophthalmic division of trigeminal

Front 6

Pterygopalatine ganglion

Back 6

Maxillary division of V

Front 7

Otic ganglion

Back 7

Mandibular division of V

Front 8

Submandibular ganglion

Back 8

Mandibular division of V

Front 9

Location of cell bodies of Trigeminal Nerve

Back 9

1. Motor nucleus of V
2. Mesencephalic nucleus of V – proprioception
3. Trigeminal ganglion – general sensory

Front 10

Ophthalmic Division – V1

Back 10

1. Sensory only
2. No branches associated with teeth or surrounding tissue

Front 11

Maxillary Division – V2

Back 11

1. Sensory only
2. Review of branches
a. Pterygopalatine branches
b. Greater & lesser palatine nn.
c. Pharyngeal nerve
d. Nasopalatine nerve
e. Zygomatic nerve
f. Posterior superior alveolar n.
h. nerve
(1) Middle superior alveolar n.
(2) Anterior superior alveolar n.
(3) Palpebral, labial, nasal nn.

Front 12

Branches for Intraoral Injection of Maxillary V2

Back 12

Infraorbital nerve
Anterior superior alveolar nerve
Middle superior alveolar n.
Posterior superior alveolar nerve
Nasopalatine nerve
Greater Palatine Nerve

Front 13

Infraorbital nerve
Anatomical considerations

Back 13

(a) Palpebral, labial, nasal nn.
(b) Infraorbital vessels
(c) Orbit

Front 14

Anterior superior alveolar nerve distribution

Back 14

(a) Roots of canines and incisors of ipsilateral side with some cross-over to the contralateral incisors
(b) Periodontal ligament and alveolar periosteum
(c) Buccal gingiva

Front 15

Middle superior alveolar n distribution

Back 15

(a) Mesiobuccal root of first molar and roots of both premolars
(b) Periodontal ligament and alveolar periosteum
(c) Buccal gingiva

Note: In absence of the MSA, the PSA supplies the premolars approximately 25% of the time; otherwise they are innervated by the ASA

Front 16

Posterior superior alveolar nerve distribution

Back 16

(a) Roots of all molars, with the exception of the mesiobuccal root of the first molar
(b) Periodontal ligament and alveolar periosteum
(c) Buccal gingival

Front 17

Posterior superior alveolar nerve anatomical considerations

Back 17

(a) Foramina
(b) Posterior superior alveolar a.
(c) Pterygomaxillary fissure
(d) Approach to the maxillary nerve

Front 18

Nasopalatine nerve
Distribution

Back 18

(a) Mucosa of primary palate
(b) Lingual alveolar periosteum of incisors and canines
(c) Lingual gingival of incisors and canines

Front 19

Nasopalatine nerve anatomical considerations

Back 19

(a) Greater palatine foramen
(b) Greater palatine artery

(c) Intraoral approach to the maxillary nerve through the pterygopalatine canal

Front 20

Mandibular Division – V3 Anterior division

Back 20

a. Motor to muscles of mastication
b. Sensory
(1) Long buccal nerve
(a) Skin of cheek wall
(b) Buccal mucosa
(c) Buccal gingiva of mandibular molars

Front 21

Mandibular Division – V3 Posterior Division Motor to

Back 21

(1) Mylohyoid muscle
(2) Anterior Belly of Digastric

Front 22

Mandibular Division – V3 Posterior Division Sensory to

Back 22

Lingual nerve
Inferior alveolar nerve
Auriculotemporal nerve

Front 23

(1) Lingual nerve

Back 23

Sensory to

(a) To anterior 2/3 of tongue
(b) Mucosa of floor of the mouth
(c) Lingual mandibular gingiva
(d) Submandibular & sublingual glands

Front 24

(2) Inferior alveolar nerve

Back 24

Sensory to

(a) Nerve to mylohyoid m.
(b) Dental branches to molar and premolars
(c) Mental n. to skin of lip
(d) Incisive n. - Overlap
[a] Dental branches to canines and incisors

Front 25

Auriculotemporal nerve

Back 25

sensory to

(a) TMJ
(b) Parotid gland
(c) Skin posterior to ear

Front 26

Otic ganglion attached to posterior division

Back 26

(1) Postganglionic parasympathetic neurons
(2) Fibers gains access to parotid gland via auriculotemporal nerve

Front 27

Lingual Nerve carries

Back 27

Carries taste fibers from the chorda tympani nerve that innervate the anterior 2/3 of the tongue

Front 28

Submandibular ganglion

Back 28

(1) Attached to lingual nerve
(2) Postganglionic parasympathetic neurons send fibers to submandibular and sublingual glands

Front 29

Branches for Intraoral Injection

Back 29

a. Inferior Alveolar Nerve
b. Lingual Nerve
c. Long Buccal Nerve
d. Mental Nerve
e. Incisive Nerve
f. Nerve to the mylohyoid muscle?

Front 30

Pterygomandibular Space

Back 30

(1) Subdivision of masticator space

Front 31

Pterygomandibular Space boundaries

Back 31

(a) Medial – medial pterygoid muscle
(b) Lateral – ramus of the mandible
(c) Superior – lateral pterygoid muscle
(d) Posterior – connective tissue sheath of parotid gland
(e) Anterior – open – no structures

Front 32

Pterygomandibular Space Medial boundary

Back 32

medial pterygoid muscle

Front 33

Pterygomandibular Space Lateral Boundary

Back 33

ramus of the mandible

Front 34

Pterygomandibular Space Superior Boundary

Back 34

lateral pterygoid muscle

Front 35

Pterygomandibular Space Posterior boundary

Back 35

connective tissue sheath of parotid gland

Front 36

Pterygomandibular Space Anterior boundary

Back 36

No structures-open

Front 37

Pterygomandibular Space contents

Back 37

(3) Pterygoid Plexus
(4) Inferior alveolar artery and vein
(5) Muscular branches of the alveolar artery
(6) Nerve and vessels to the mylohyoid muscle
(7) Nerve and vessels to the medial pterygoid muscle
(8) Sphenomandibular ligament

Front 38

Sphenomandibular ligament relationship to mylohyoid nerve

Back 38

[1] Can cover mylohyoid n.
[2] May have sensory component
[a] Incomplete anesthesia
[b] Nerve fibers enter bone and pulp

Front 39

Sphenomandibular ligament Relationship to the inferior alveolar nerve

Back 39

[1] Can block anesthetic to nerve
[2] Incomplete anesthesia

Front 40

Maxillary Dental Plexus Injections sites

Back 40

1. Supraperiosteal injections
a. Along the roots by injection into the mucobuccal fold at the apices of the roots
b. Anesthesia penetrates the thin cortical plate of the alveolar bone to reach the pulp
2. Intraligamentary or periodontal ligament injection
3. Intraseptal or interdental injection to anesthetize the buccal gingiva
4. Local palatal injection to anesthetize the palatal (lingual) gingiva

Front 41

Supraperiosteal injections

Back 41

a. Along the roots by injection into the mucobuccal fold at the apices of the roots
b. Anesthesia penetrates the thin cortical plate of the alveolar bone to reach the pulp

Front 42

Posterior Superior Alveolar Nerve Block injection site

Back 42

Over second molar directed posteriorly
Mucobuccal fold at level of second molar

Front 43

Posterior Superior Alveolar Nerve Block Avoid

Back 43

a. Posterior superior alveolar artery & tearing periosteum
(1) Injection into vessel could cause serious cardiac arrhythmia
(2) Shearing vessel could cause a hematoma – bleeding in the masticator space

Front 44

Middle Superior Alveolar Nerve Block injection site

Back 44

Above 2nd premolar
Mucobuccal fold above 2nd premolar

Front 45

Middle Superior Alveolar Nerve Block avoid

Back 45

tearing periosteum & blood vessels

Front 46

Anterior Superior Alveolar Nerve Block injection site

Back 46

Over lateral incisor
Mucobuccal fold above the lateral incisor

Front 47

Anterior Superior Alveolar Nerve Block avoid

Back 47

Avoid tearing periosteum & blood vessels

Front 48

Infraorbital Nerve Block injection site

Back 48

Above the first premolar
Mucobuccal fold of the 1st premolar directed toward infraorbital foramen

Front 49

Infraorbital Nerve Block

Back 49

(a) Avoid sticking needle into the infraorbital foramen and orbit
(b) Tearing periosteum & blood vessels

Front 50

Greater Palatine Nerve Block injection site

Back 50

Distal border of 2nd maxillary molar
Junction between hard palate and lateral edge of alveolar distal to the 2nd molar

Front 51

Greater Palatine Nerve Block avoid

Back 51

. Sticking needle in foramen and damaging nerve & blood vessels
b. Tearing the periosteum

Front 52

Nasopalatine Nerve Block injection site

Back 52

Lateral to the incisive canal
Incisive papilla

Front 53

Nasopalatine Nerve Block avoid

Back 53

a. Sticking needle in foramen and damaging nerve & blood vessels
b. Tearing the periosteum

Front 54

Posterior Superior Alveolar Nerve Block teeth

Back 54

All roots of 1st, 2nd, 3rd molar, except mesiobuccal root of 1st molar, and their facial gingivae

Front 55

Middle Superior Alveolar Nerve Block teeth

Back 55

Mesiobuccal root of 1st molar, premolars, and their facial gingivae

Front 56

Anterior Superior Alveolar Nerve Block teeth

Back 56

Canine, incisors, their labial gingivae, and lip

Front 57

Infraorbital nerve block teeth

Back 57

Canine, incisors, and labial gingivae, lower eyelid, side of the nose and lip.

Front 58

Greater palatine nerve block palpebral tissue

Back 58

Hard palate and palatal gingiva from molars up to canines

Front 59

Nasopalatine nerve block palpebral tissue

Back 59

Palatal alveolar periosteum of anterior teeth
Palatal mucosa
Palatal gingiva

Front 60

Inferior Alveolar Nerve, Lingual Nerve and Long Buccal Nerve Block injection site

Back 60

Pterygotemporal fossa (anterior to the pterygomandibular fold)
Mucosa lateral to the pterygomandibular fold

Front 61

Inferior Alveolar Nerve, Lingual Nerve and Long Buccal Nerve Block avoid

Back 61

Muscles, Inferior alveolar artery, branches of pterygoid plexus and sheath of parotid gland

Front 62

Gow-Gates injection site

Back 62

Mucosa medial to temporalis tendon below the occlusal plane of the second maxillary molar to the tragus

Front 63

Gow-Gates target

Back 63

Mandibular nerve near coronoid process

Front 64

Akinosi-Varian Closed Mouth Mandibular Block injection site

Back 64

Mucogingival junction of 2nd or 3rd maxillary molar lateral to the pterygomandibular fold

Front 65

Akinosi-Varian Closed Mouth Mandibular Block target site

Back 65

Lingula

Front 66

Mental Nerve block injection site

Back 66

Mental foramen
Between the roots of the first and second premolar

Front 67

Mental nerve block avoid

Back 67

Mental artery and damage to mental nerve by thrusting needle into the foramen

Front 68

Inferior alveolar nerve block injection site

Back 68

Mucosa lateral to the pterygomandibular fold

Front 69

Inferior alveolar nerve block teeth and soft tissue

Back 69

Mandibular teeth

Buccal gingiva of incisors, canines and premolars

Front 70

Lingual nerve block injection site

Back 70

Mucosa lateral to the pterygomandibular fold

Front 71

Lingual nerve block soft tissue

Back 71

Lingual gingiva of all teeth, floor of the mouth and tongue

Front 72

Long buccal nerve injection site

Back 72

Medial to the border of the ramus of the mandible at the occlusal plane of the maxillary molars

Front 73

Long buccal nerve block soft tissue

Back 73

Buccal gingiva and mucosa of the mandibular molars

Front 74

Incisive nerve block injection site

Back 74

Between the roots of the first and second premolar

Front 75

Incisive nerve block teeth and soft tissue

Back 75

Incisors, canines and premolars Buccal gingiva and lower lip in area of incisors, canines and premolars