Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

Surgical anatomy for injections of local anaesthesia

No description
by

ahmad dzulfikar samsudin

on 6 October 2013

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of Surgical anatomy for injections of local anaesthesia

To understand anatomy of maxillary and mandibular innervation

To learn techniques of giving local anesthesia
Functions

Sensory divisions
Ophthalmic div. V1
Maxillary div. V2
Mandibular div. V3

Motor divisions
Muscle of mastications
Mylohyoid
Anterior belly of the digastric
Tensor tympani
Tensor veli palatini
Largest branch of the trigeminal nerve
Composed of sensory and motor roots
Sensory root :
- Originates at inferior border of trigeminal ganglion
Motor root :
- Arises in motor cells located in the pons and medulla
- Lies medial to the sensory root
ANATOMY and
LOCAL ANESTHESIA TECHNIQUE

Ahmad Dzulfikar Samsudin
DDS,MClinDent,MFDSRCS

Mandibular Division (v3)
Learning outcome
THANK YOU
:)

Maxillary Division (V2)
Exits the cranium via foramen rotundum of the greater wing of the sphenoid into the pterygopalatine fossa.

Branches divided by location :
1. within the middle cranial fossa
2. within Pterygopalatine fossa
3. associated with the pterygopalatine g.
4. within the infraorbital canal
5. after infraorbital nerve emerges from the infraorbital foramen.
Maxillary Division (V2)
1. within the middle cranial fossa

Middle Meningeal Nerve
: providing sensory innervation to the meninges.
Maxillary Division (V2)
2. Within the pterygopalatine fossa

Zygomatic nerve :
zygomaticofacial nerve
- skin to cheek prominence
zygomaticotemporal nerve
- skin to lateral forehead

Pterygopalatine nerves :
Serves as communication for the pterygopalatine ganglion and the maxillary nerve
Carries postganglionic secremotor fibers through the zygomatic branch to the lacrimal gland
Maxillary Division (V2)


Pterygopalatine nerves
Orbital branches - supplies periosteum of the orbits

Nasal branches - supplies mucous membranes of superior and middle conchae, lining of posterior ethmoid sinuses, and posterior nasal septum

Nasopalatine nerve
- travels across the roof of nasal cavity giving branches off to the anterior nasal septum and floor of nose. Enters incisive foramen and provides palatal gingiva innervation to the premaxilla.
Maxillary Division (V2)

Pterygopalatine nerves
Palatine branches - greater (anterior) and lesser (middle or posterior) palatine nerves

Greater palatine
: travels through the pterygopalatine foramen. Innervates palatal tissue from premolars to soft palate. Lies 1 cm medial from 2nd molar region.

Lesser palatine
; emerges from lesser palatine foramen and innervates the mucous membranes of the soft palate and parts of the tonsillar region
Pharyngeal branch
: exits the pterygopalatine ganglion and travels through the pharyngeal canal. Innervates mucosa of the portions of the nasal pharynx.

Posterior superior alveolar nerve (PSA)
: branches from V2 prior to entrance into infraorbital groove. Innervates posterior maxillary alveolus, periodontal ligament, buccal gingiva, and pulpal tissue (only for 1st, 2nd and 3rd molars)
continue...
Maxillary Division (V2)
3. Infraorbital canal branches :

Middle superior alveolar (MSA)
:
Provides innervation to the maxillary alveolus, buccal gingiva, periodontal ligament, and pulpal tissue for the premolars only

Anterior superior alveolar (ASA)
:
Provides innervation to the maxillary alveolus, buccal gingiva, periodontal ligament, and pulpal tissue for the canines, lateral and central incisors
Branches 6-8 mm posterior to the infraorbital nerve exit from infraorbital foramen.
Maxillary Division (V2)
4. Facial branches

Emerges from the infraorbital foramen
Branches consist of :
Inferior palpebral - lower eyelid
External nasal - lateral skin of nose
Superior labial branch - upper lip skin and mucosa
Branches
The sensory and motor roots emerge from the foramen ovale of the greater wing of the sphenoid.

Initially merge outside of the skull and divide about 2-3mm inferiorly

Branches :
Branches of the undivided nerve
Branches of the anterior division
Branches of the posterior division
Mandibular division (V3)
Branches of the undivided nerve :

Nervus spinosus : innervates mastoirds and dura

Medial pterygoid - innervates medial pterygoid muscle
Branches into
- Tensor veli palatini
- Tensor tympani
Mandibular Division (V3)
Branches of the anterior division :

Buccal nerve (long buccal and buccinator)

Travels anteriorly and lateral to the lateral pterygoid muscle
Gives branches to the deep temporal (temporalis muscle), masseter, and lateral pterygoid muscle
continue...
Continues to travel in antero-lateral direction

At level of the mandibular 3rd molar, branches exit through the buccinator and provide innervation to the skin of the cheek

Branches also stay within the retromandibular triangle providing sensory innervation to the buccal gingiva of the mandibular molars and buccal vestibule
Branches of the posterior division :

Travels inferior and medial to the lateral pterygoid

Divisions :
- Auricotemporal
- Lingual
- Inferior alveolar
Mandibular Division (V3)
Mandibular Division (V3)
Branches of the posterior division :

Auricotemporal : all sensory
Transverses the upper part of the parotid gland and posterior portion of the zygomatic arch
Branches :
- Communicates with facial nerve to provide sensory innervation to the skin over areas of the zygomatic, buccal and mandibular.
- Communicates with the otic ganglion for sensor, secretory, and vasomotor fibers to the parotid.
Branches
Anterior auricular - skin over helix and tragus
External auditory meatus - skin over meatus and tympanic membrane
Articular - posterior TMJ
Superficial temporal - skin over temporal region
Mandibular Division (V3)
Branches of the posterior division :

Lingual :
Lies between ramus and medial pterygoid within the pterygomandibular raphe
Lies inferior and medial to the mandibular 3rd molar alveolus
Provides sensation to anterior 2/3rds of tongue, lingual gingiva, floor of mouth mucosa, and gustation (chorda tympani)
Mandibular Division (V3)
Branches of the posterior division :

Inferior alveolar :
Travels medial to the lateral pterygoid and latero-posterior to the lingual nerve
Enters mandible at the lingula
Accompanied by the inferior alveolar artery and vein (artery anterior to nerve)
Travels within the inferior alveolar canal until the mental foramen
Mylohyoid nerve - Motor branch prior to entry into lingula
continue...
Provides innervation to the mandibular alveolus, buccal gingiva fom premolar teeth anteriorly, and the pulpal tissue of all mandibular teeth on side blocked
Terminal branches
- Incisive nerve : remains within inferior alveolar canal from mental foramen to midline
- Mental nerve : exits mental foramen and divides into 3 branches to innervate the skin of the chin, lower lip and labial mucosa
Local Anesthetic Instruments
Anesthetic carpules
Syringe
Needle
Mouth props
Retractors
Maxillary Anesthesia
3 major types of injections can be performed in the maxilla for pain control

Local infiltration
Field block
Nerve block
Infiltration
Able to be performed in the maxilla due to the thin cortical nature of the bone.

Involves injecting to tissue immediately around surgical site
supraperiosteal injections
intraseptal injections
periodontal ligament injection
Field blocks
Local anesthetic deposited near a larger terminal branch of a nerve
Periapical injections
Nerve blocks
Local anesthetic deposited near main nerve trunk and is usually distant from operative site

Posterior superior alveolar N
Middle superior alveolar N
Anterior superior alveolar N
Infraorbital N
Greater palatine N
Nasopalatine N
Used to anesthetize the pulpal tissue, corresponding alveolar bone, and buccal gingival tissue to the maxillary 1st, 2nd and 3rd molars

Technique
Area of insertion - height of mucobuccal fold between 1st and 2nd molar
Angle at 45 degree superiorly and medially
No resistance should be felt (if bony contact angle is to medial, reposition laterally)
Insert about 15-20mm
Aspirate then inject if negative
Posterior Superior Alveolar Nerve block
Middle superior Alveolar nerve block
Used to anesthetize the maxillary premolars, corresponding alveolus, and buccal gingival tissue

Present in about 28% of the population
Used if the infraorbital block fails to anesthetize premolars

Technique
Area of insertion is height of mucobuccal fold in area of 1st/2nd premolars
Insert around 10-15 mm
Inject around 0.9-1.2 cc
Anterior Superior Alveolar nerve block
Used to anesthesize the maxillary canine, lateral incisor, central incisor, alveolus, and buccal gingiva

Technique
Area of insertion is height of mucobuccal fold in area of lateral incisor and canine
Insert around 10-15 mm
Insert around 0.9-1.2 cc
Infraorbital nerve block
Used to anesthetize the maxillary 1st and 2nd premolars, canine, lateral incisor, central incisor, corresponding alveolar bone, and buccal gingiva

Combines MSA and ASA blocks

Will also cause anesthesia to the lower eyelid, lateral eyelid, lateral aspect of nasal skin tissue, and skin of infraorbital region

Technique
Palpate infraorbital foramen extra-orally and place thumb or index finger on region
Retract the upper lip and buccal mucosa
Area of insertion is the mucobuccal fold of the 1st premolar/canine area
Contact bone in infraorbital region
Inject 0.9-1.2 cc of local anesthetic
Greater palatine nerve block
Can be used to anesthetize the palatal soft tissue of the teeth posterior to the maxillary canine and corresponding alveolus/hard palate

Technique
Area of insertion is ~ 1 cm medial from 1st/2nd maxillary molar on the hard palate
Palpate with needle to find greater palatine foramen
Depth is usually less than 10mm
Utilize pressure with elevator/mirror handle to desensitize region at time of injection
Inject 0.3 - 0.5cc of local anesthetic
Nasopalatine nerve block
Can be used to anesthetize the soft and hard tissue of the maxillary anterior plate from canine to canine

Technique
Area of insertion is incisive papilla into incisive foramen
Depth of penetration is less than 10 mm
Inject 0.3 - 0.5 cc of local anesthetic
Can use pressure over area at time of injection to decrease pain
Maxillary nerve block
Can be used to anesthetize maxillary teeth, alveolus, hard and soft tissue on the palate, gingiva, and skin of the lower eyelid, lateral aspect of nose, cheek, and upper lip skin and mucosa on side blocked.

Two techniques exist for blockade of V2
High tuberosity approach
Greater palatine canal approach
High tuberosity approach technique
Technique
Area of injection is height of mucobuccal fold of maxillary 2nd molar
Advance at 45 degree superior and medial same as in the PSA block
Insert needle ~ 30mm
Inject ~ 1.8 cc of local anesthetic
Greater palatine canal technique
Technique
Area of insertion is greater palatine canal
Target area is the maxillary nerve in the pterygopalatine fossa
Perform a greater palatine block and wait 3-5 mins
Then insert needle in previous area and walk into greater palatine foramen
Insert to depth of ~ 30mm
Inject 1.8cc of local anesthetic
Mandibular Anesthesia
Infiltration do not work in the adult mandible due to the dense cortical bone
Nerve blocks are utilized to anesthetize the inferior alveolar, lingual, and buccal nerves
Provides anesthesia to the pulpal, alveolar, lingual and buccal gingival tissue, and skin of lower lip and medial aspect of chin on side injected
Inferior alveolar nerve block (IAN)
Technique involves blocking the inferior alveolar nerve prior to entry into the mandibular lingula on the medial aspect of the mandibular ramus

Multiple techniques can be used for the IAN nerve block
IAN
Akinosi
Gow-gates
Inferior alveolar nerve block (IAN)
Technique

Area of insertion is the mucous membrane on the medial border of the mandibular ramus at the intersection of a horizontal line (height of injection) and vertical line (anteroposterior plane)
Heigh of injection 6-10 mm above the occlusal table of the mandibular teeth
Anteroposterior plane - just lateral to the pterygomandibular raphe
Mouth must be open for this technique, best utilize mouth prop
Depth of injection : 25mm
Approach area of injection from contralateral premolar region
Use the non-dominant hand to retract the buccal soft tissue (thumb in coronoid notch of mandible ; index finger on posterior border of extraoral mandible)
Inject ~0.5-1.0 cc of local anesthetic
Continue to inject ~ 0.5cc on removal from injection site to anesthetize the lingual branch
Inject remaining anesthetic into coronoid notch region of the mandible in the mucous membrane distal and buccal to most distal molar to perform a long buccal nerve block
Akinosi Closed-Mouth mandibular block
Area of insertion : soft tissue overlying the medial border of the mandibular ramus directly adjacent to maxillary tuberosity
Inject to depth of 25mm
Inject ~ 1.0 - 1.5 cc of local anesthetic as in the IAN
Inject remaining anesthetic in area of long buccal nerve
Mental Nerve Block
Mental and incisive nerves are the terminal branches for the inferior alveolar nerve.

Provides sensory input for the lower lip skin, mucous membrane, pulpal/alveolar tissue for the premolars, canine, and incisors on side blocked
Others lists to read
Gow gates technique
Intraligamentary injections
Intrapulpal
Technique

Area of injection mucobuccal fold at or anterior to the mental foramen. This lies between the mandibular premolars.
Depth of injection ~ 5-6mm
Inject 0.5-1.00 cc of local anesthesia
Message local anesthesia into tissue to manipulate into mental foramen to anesthesize the incisive branch
References
Evers.H and Haegerstam.G Handbook of Local Anesthesia
Schultz Medical Information, Mosby 1981
Malamed.S Handbook of Local Anaesthesia
3rd Edition, Mosby 1990
Netter.F Atlas of Human Anatomy
CIBA, 1989
TRIGEMINAL NERVES (V)
Ophthalmic Nerve (V1)
is the first branch of trigeminal nerve

passess anterior on the lateral wall of the cavernous sinus

exits through the superior orbital fissure

3 major branches
Lacrimal
Frontal
Nasociliary
Full transcript