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EXTRAORAL TECHNIQUES

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by

Joy David

on 29 September 2013

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Transcript of EXTRAORAL TECHNIQUES

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EXTRAORAL TECHNIQUES
Extraoral techniques

Anterior and Middle Superior Alveolar Nerve Block (infraorbital)

Anterior and Middle Superior Alveolar Nerve Block (infraorbital)

Technique:
When the infraorbital nerve block by means of the extraoral approach is being performed, the needle passes through the following structures:

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Nerves Anesthetized
Infraorbital nerve
Inferior palpebral, Lateral nasal and Superior labial nerves
Anterior and Middle superior alveolar nerves
Sometimes posterior superior alveolar nerve

Areas Anesthetized
Incisors and bicuspids on the side injected
Labial alveolar plate and overlying tissues
Upper lip, portions of side of nose, and lower eyelid
Sometimes maxillary molars and their buccal supporting structures

Anatomical Landmarks
Pupil of the eye
Infraorbital ridge
Infraorbital notch
Infraorbital depression

Indications

When the anterior and middle superior alveolar nerves are to be anesthetized and the intraoral approach is not possible because of infection, trauma, and other reasons.

When attempts to secure anesthesia by the intraoral methods have been ineffective.

Maxillary Nerve Block

This procedure should be carried out under aseptic conditions. This implies that the dentist should complete a surgical scrub, use sterile gloves, and surgically prepare the field.

a. Using the available landmarks, the dentist should locate and mark the position of the infraorbital foramen. The skin and subcutaneous tissues should be anesthetized by local infiltration.

b. A 1 1/2 – inch, 25 gauge needle attached to an aspirating syringe is inserted through the marked and anesthetized area. Directing the needle slightly upward and laterally facilitates its entrance into the foramen, which opens downward and medially.

c. With a slight, gently probing motion the foramen is located and entered to a depth not to exceed 1/8 inch. After careful aspiration, 1 ml of anesthetic solution is slowly injected.

Skin
Subcutaneous tissue
Quadratus labii superioris muscle

when the needle is in position for this injection, the important structures near it are the facial artery and vein, which, since they are very tortuous, may lie on either side of the needle
Symptoms of Anesthesia

a. Subjective Symptoms
Tingling and numbness of the upper lip, side of the nose, and lower eyelid

b. Objective Symptoms
- Instrumentation necessary to demonstrate the absence of pain sensation

Maxillary Nerve Block

Nerves Anesthetized
Maxillary nerve and all its subdivisions peripheral to the site of injection

Areas Anesthetized
Anterior temporal and zygomatic regions
Lower eyelid
Side of the nose
Anterior cheek
Upper lip
Maxillary teeth
Maxillary alveolar bone and overlying structures
Hard and soft palate
Tonsil
Part of the pharynx
Nasal septum and floor of the nose
Posterior lateral mucosa and turbinate bones

Anatomical Landmarks

Midpoint of the zygomatic arch
Zygomatic arch
Coronoid process of the ramus of the mandible located by opening and closing the lower jaw
Lateral pterygoid plate

Indications

When the anesthesia of the entire distribution of the maxillary nerve is required for extensive surgery
When it is desirable to block all the subdivisions of the maxillary nerve with only one needle insertion and a minimum of anesthetic solution.
When local infection, trauma, or other conditions make blocks of the more terminal branches difficult or impossible
For diagnostic or therapeutic purposes, such as tics or neuralgias of the maxillary division of the fifth nerve

Techniques

This procedure should also be carried out under aseptic conditions. This implies that the dentist should complete a surgical scrub, use sterile gloves, and surgically prepare the field.

The midpoint of the zygomatic process is located and the depression in its inferior surface is marked. With a 25-gauge hypodermic needle, a skin wheal is raised just below this mark in the depression, which the dentist identifies by having the patient open and close the jaw.
Using a 4-inch (8.8 cm), 22-gauge needle attached to a Luer-Lok type of syringe, one measures 4.5 cm and marks with a rubber marker.

Techniques

c. The needle is inserted through the skin wheal, perpendicular to the median sagittal plane (skin surface) until the needle point gently contacts the lateral pterygoid plate. The needle should never be inserted beyond the depth of the marker. The needle is withdrawn, with only the point left in the tissue, and redirected in a slight forward and upward direction until the needle is inserted to the depth of the marker.


After careful aspiration 2 or 3 ml of a suitable anesthetic solution is slowly injected. Care should be exercised to aspirate after each 0.5ml of the solution is injected.



When the maxillary nerve block is being executed by means of the extraoral approach, the needle passes through the following structures:

Skin
Subcutaneous muscle
Masseter muscle
Mandibular notch
External pterygoid muscle
When the needle is in contact with the lateral pterygoid plate, the following important structures are near it:

Superiorly, the base of the skull
The internal maxillary artery that crosses inferiorly and curves up anterior to it, entering the lower part of the pterygomaxillary fissure.
Temporal vessels from the internal maxillary artery that may lie on either side of it.
Superficially, the transverse facial artery that may lie above or below it
Posteriorly, the foramen ovale, through which passes the mandibular nerve, and posterior to that, the foramen spinosum, through which passes the middle pterygopalatine fossa.

Symptoms of Anesthesia

a. Subjective Symptoms
Tingling and numbness of the upper lip, side of the nose, and lower eyelid and in some instances, anesthesia of the soft palate and pharynx, with a gagging sensation

b. Objective Symptoms
Instrumentation necessary to demonstrate absence of pain sensation

Mandibular nerve block

Nerves anesthetized
Mandibular nerve and subdivisions
Inferior alveolar nerve
Buccinator nerve
Lingual nerve
Mental nerve
Incisive nerve

Areas anesthetized

All those areas innervated by the mandibular nerve and its subdivisions
Temporal region
Auricle of the ear
External auditory meatus
Temporomandibular joint
Salivary glands
Anterior 2/3 of the tongue
Floor of the mouth
Mandible
Lower teeth, gingiva, and buccal mucosa
Lower portion of the face (except at the angle of the jaw)

Indications

When it is desirable to anesthetize the entire mandibular nerve and its subdivisions with one needle insertion and a minimum of anesthetic solution
When infection or trauma makes anesthesia of the nerve’s subdivisions difficult or impossible
Diagnostic or therapeutic purposes


Technique

The technique is essentially the same as that used for the block of the maxillary nerve, with the exception that a marker is placed on the needle at a measured distance of 5 cm. after the needle contacts the lateral pterygoid plate, it is withdrawn exactly as in the maxillary block; however, when reinserted, the needle is directed upward and slightly posteriorly so that the needle will pass posterior to the lateral pterygoid plate. The needle should not be introduced to a depth greater than the measured 5 cm.
The structures through which the needle passes and the structures adjacent to the needle when it is in contact with the lateral pterygoid plate are given in the section on the maxillary nerve block.


Symptoms of Anesthesia

a. Subjective symptoms
Tingling and numbness of the lower lip and anterior 2/3 of the tongue

b. Objective symptoms
Opening of the mandible and tapping of the jaws shut will demonstrate a decided difference in the feeling of the lower teeth and the floor of the mouth. Instrumentation will also demonstrate the presence of anesthesia
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