Al-ameed University 3th stage
College of dentistry
Oral and maxillofascial surgery
[ maxillary nerve block technique]
Maxillary Nerve Block Technique
The following 3 techniques may be used to perform a maxillary nerve block:
1. High tuberosity approach
2. Greater palatine canal approach
3. Coronoid approach
High tuberosity approach
The high tuberosity approach blocks the nerve as it courses along the pterygopalatine fossa. It
anesthetizes the hemimaxilla on the side of the block, including the maxillary teeth; the buccal,
gingival, and periodontal tissues; and the soft and hard palate.
With the mouth open and a tongue depressor drawing the cheek outward, the highest point on
the mucobuccal fold just distal to the second maxillary molar teeth is identified. This area is
cleaned. A needle is inserted at this point at a 45° angle and directed posteriorly, superiorly, and
medially toward the bone (see the image below).
High tuberosity approach to blocking maxillary nerve.
The needle is then advanced 3 cm so that it lies within the fossa. Negative aspiration for blood is
confirmed in this plane, and, after the needle is rotated by a quadrant, 1.8 mL of local
anesthetic is slowly injected here. This technique is associated with a 95% success rate of nerve
block. However, injury of the maxillary artery by the needle tip may result in rapid hemorrhage.
Greater palatine canal approach
The greater palatine canal approach blocks the maxillary nerve as it travels through the
pterygopalatine fossa. This is the most frequently used approach and is associated with a higher
rate of success; however, it is contraindicated if the canal cannot be located or negotiated.
The greater palatine foramen is usually located on the palate, 1 cm medial and adjacent to the
second molar teeth. A cotton swab may be pressed on the palate to find the depression caused
by the foramen.
A greater palatine nerve block is performed with the patient in a semifallourous position. A 25-
gauge long needle 1-2 mm is inserted in front of the greater palatine foramen (see the image
below). The needle is inserted perpendicularly until the bone is contacted, and 0.5 mL of local
anesthetic may be deposited here. Alternatively, 0.5 mL of local anesthetic may be deposited
around the greater palatine foramen.
Greater palatine canal approach for maxillary nerve block.
After a 3- to 5-minute wait, and with adequate palatal anesthesia ensured, the greater palatine
foramen is probed for and walked in with the tip of a needle. Applying constant pressure to this
area reduces the discomfort. The needle is advanced 3 cm. If no resistance is met with, 1.8 mL
of local anesthetic is slowly injected after it is confirmed that no blood is aspirated in 2 planes. If
resistance is encountered, the needle is redirected and reinserted at a different angle. If
resistance is encountered earlier on or the canal cannot be negotiated, this approach is
abandoned.
Coronoid approach
The coronoid approach is better performed under imaging guidance. It differs from the other 2
approaches in that its access is external.
The coronoid notch of the mandible is identified by having the patient open and close the
mouth and palpating in front of and below the tragus. This area is cleaned with povidone-iodine
and prepared.
With the mouth in neutral position, a 22-gauge long needle is advanced perpendicular to the
skin at the center of the coronoid notch below the zygomatic arch. At a depth of 4-5 cm, the
lateral pterygoid plate is encountered.
The needle is then withdrawn slightly, redirected anteriorly and superiorly, and advanced to a
depth of 1 cm. At this point, paresthesias in the region of the maxillary nerve are usually
elicited, and after negative aspiration, about 5-10 mL of the drug is slowly deposited here. If the
needle is withdrawn by 2 mm, the block will include the mandibular nerve as well.
The following areas are anesthetized on the side of the block:
Pulpal area of all teeth
Buccal periosteum and bone
Soft tissue and bone of the palate
Skin of the lower eyelid, side of nose, cheek, and upper lip
Complications
Complications related to the local anesthetic include the following:
1. Toxicity: If a large volume of local anesthetic is administered or an inadvertent
intravascular injection has taken place, the systemic toxicity characteristic of the drug
used may develop; symptoms may be minimal to moderate (eg, anxiety, numbness,
dizziness, weakness, and tremors) but are sometimes severe (eg, central nervous system
or cardiovascular collapse).
2. Allergic reaction: This may occur in response to the preservatives added to the local
anesthetic (eg, methylparaben or sodium metabisulfite) or to an ester-group local
anesthetic.
3. Complications related to the technique itself include the following:
4. Persistent paresthesia and numbness: These may be due to maxillary nerve trauma or to
local hematoma formation.
5. Infection: Needle track infection is possible.
6. Blockade of nerves in the vicinity of the maxillary nerve block: This may involve facial
nerve block (typically transient), retrobulbar nerve block (rare), optic nerve block (rare
but capable of inducing temporary blindness), or sixth nerve block (capable of causing
diplopia).
7. Retrobulbar hematoma formation
8. Edema and sloughing of tissues (very rare)
9. Penetration of nasal cavity
Editor:سيف عايد هاشم
Email: [email protected]
