Oral and Maxillofacial Regional Anesthesia

Authors: Benaifer D. Dubash, DMD; Adam T. Hershkin, DMD; Paul J. Seider, DMD; Gregory M. Casey,
DMD

Affiliation: St. Luke's-Roosevelt Hospital Center, Department of Oral and Maxillofacial Surgery

Greater Palatine Nerve Block

The greater palatine nerve block is useful when treatment is necessary on the
palatal aspect of the maxillary premolar and molar dentition. This technique targets
the area just anterior to the greater palatine canal. The greater palatine nerve exits
the canal and travels forward between the bone and soft tissue of the palate.
Contraindications to this technique are acute inflammation and infection at the
injection site. A 25- or 27-gauge long needle is preferred for this technique.

Technique

The patient should be in the supine position with the chin tilted upward for
visibility of the area to be anesthetized. The right handed operator should stand at
the eight o’clock position whereas the left handed operator should stand at the four
o’clock position. Using a cotton swab, locate the greater palatine foramen by
placing it on the palatal tissue approximately one centimeter medial to the junction
of the 2nd and 3rd molar (Fig. 14, A and B). While this is the usual position for the
foramen, it may be located slightly anterior or posterior to this location. Gently
press the swab into the tissue until the depression created by the foramen is felt.
Malamed and Trieger found that the foramen is found medial to the anterior half of
the 3rd molar approximately 50% of the time, medial to the posterior half of the 2nd
molar approximately 39% of the time and medial to the posterior half of the 3rd
molar approximately 9% of the time.6 The area approximately one to two
millimeters anterior to the foramen is the target injection site. Using the cotton
swab, apply pressure to the area of the foramen until the tissue blanches. Aim the
syringe perpendicular to the injection site which is one to two millimeters anterior
to the foramen. While keeping pressure on the foramen, inject small volumes of
anesthetic solution as the needle is advanced through the tissue until bone is
contacted. The tissue will blanch in the area surrounding the injection site. Depth of
penetration is usually no more than a few millimeters. Once bone is contacted,
aspirate and inject approximately one fourth (0.45cc) of anesthetic solution.
Resistance to deposition of anesthetic solution is normally felt by the operator. This
technique provides anesthesia to the palatal mucosa and hard palate from the 1st
premolar anteriorly to the posterior aspect of the hard palate and to the midline
medially.1,6

Figure 14, A: Location of the greater palatine nerve. B: Area of insertion for the greater
palatine nerve block is one centimeter medial to the junction of the maxillary 2nd and 3rd
molars.

Nasopalatine Nerve Block

The nasopalatine nerve block, otherwise known as the incisive nerve block
and sphenopalatine nerve block, anesthetizes the nasopalatine nerves bilaterally. In
this technique anesthetic solution is deposited in the area of the incisive foramen.
This technique is indicated when treatment requires anesthesia of the lingual aspect
of multiple anterior teeth. A 25- or 27-gauge short needle is preferred for this
technique.
Technique

The patient should be in the supine position with the chin tilted upward for
visibility of the area to be anesthetized. The right handed operator should be at the
nine o’clock position whereas the left handed operator should be at the three
o’clock position. Identify the incisive papillae. The area directly lateral to the
incisive papilla is the injection site. With a cotton swab, hold pressure over the
incisive papilla. Insert the needle just lateral to the papilla with the bevel against the
tissue (Fig. 15, A and B). Advance the needle slowly toward the incisive foramen
while depositing small volumes of anesthetic and maintaining pressure on the
papilla. Once bone is contacted, retract the needle approximately one millimeter,
aspirate, and inject one fourth (0.45cc) of a cartridge of anesthetic solution over the
course of thirty seconds. Blanching of surrounding tissues and resistance to the
deposition of anesthetic solution is normal. Anesthesia will be provided to the soft
and hard tissue of the lingual aspect of the anterior teeth from the distal of the
canine on one side to the distal of the canine on the opposite side.1

Figure 15 A: Location of the nasopalatine nerve. B: Insertion of the needle just lateral to
the incisive papilla for the nasopalatine nerve block.