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Maxillary Anesthesia I: Pulpal Anesthesia
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262
3) Needle protrusion outside the greater palatine canal,
which also induces anesthetic failure for the following
reasons.
● The needle penetrates the greater palatine foramen
too far rearward, reaching the soft (nasal-
pharyngeal)
palate. The clinician’s perception is an overly smooth
injection and the patient’s a bitter taste in their throat
because the liquid drips behind the soft palate and
ultimately into the esophagus (Szerlip and
Morristown1950; Saborido1977; Sved etal.1992).
● The needle penetrates the anterior wall of the greater
palatine canal and the anesthetic solution is deposited in the maxillary sinus (Mercuri1979).
● The needle penetrates the posterior wall of the greater
palatine canal and the anesthetic solution is deposited in the infratemporal fossa (formerly zygomatic
fossa), to no anesthetic effect (Mercuri1979; Wong
and Sved1991).
● The needle penetrates the lateral/medial wall of the
canal and the tip enters the nasal-
pharynx and nasal
cavity. In such cases, aspiration prior to injection may
draw bubbles into the cartridge (a sign that the needle is
in the nasal pharynx) and the patient begins to cough,
with a bitter taste in their throat, and may bleed through
the nose on the side injected (epistaxis) when the needle penetrates the highly vascularized nasal mucosa
(Saborido1977; Mercuri1979; Wong and Sved1991).
Note: As the osseous walls of the greater palatine
canal tend to be very thin, they may be readily perforated if the clinician forces the needle (Malamed and
Trieger1983; Wong and Sved1991).
4) Visual and ocular alterations in the eye on the side
injected in around 10% of cases (Table14.5).
● The cause of these complications is the use of very
long needles and/or the injection of large amounts of
anesthetic solution, some of which reaches the upper
area of the pterygopalatine fossa and may seep across
the inferior orbital fissure, entering the eye socket
and anesthetizing ocular nerves and muscles
(Table14.5). For some authors these symptoms confirm that the anesthetic has reached the maxillary
nerve (V
● The possible complications are as follows.
⚪ Double vision (diplopia) due to ocular muscle anes-
) (Sved etal.1992).
2
thesia. This is the most common complication and
in 90% of cases appears alone or with strabismus or
a drooping eyelid (Sved etal.1992; Torres etal.2011).
⚪ Inability to coordinate and synchronize the move-
ments of the two eyes (strabismus) due to paralysis
of the eye muscles (the lateral rectus muscle is the
one most severely affected). It is usually attendant on
diplopia, seldom appearing alone (Sved etal.1992).
⚪ Drooping upper eyelid (ptosis) due to anesthesia of
the branches of the oculomotor nerve in the upper
eyelid. It is likewise usually attendant on diplopia,
seldom appearing alone (Sved etal.1992).
⚪ Other rare complications include dilated pupil
(mydriasis), corneal anesthesia, blurred vision
(Broering etal.2009), and, very exceptionally, temporary blindness due to optical nerve (cranial nerve
II) anesthesia.
● These complications generally disappear spontane-
ously with the effect of the anesthesia without any
sequelae (Dickson and Coates 1945; Saborido1977;
Mercuri1979).
● Treatment in such cases consists of the following:
1) Reassure the patient that the effect will disappear
spontaneously with the effect of the anesthesia.
2) Place a protective patch over the eye for the
duration.
3) Advise the patient that they may not drive nor
operate hazardous machinery while the effect lasts.
5) The side of the face affected may also be pale and exhibit
blanching (ischemic paling). This is usually because the
needle punctures or rubs against the internal maxillary
artery that transmits through the upper part of the
pterygopalatine fossa, causing spasm/contraction in all
its branches and paling in the entire area of the face covered by the artery. It is more readily visible in people
with lighter skin (Mercuri1979). The patient may occasionally also feel a sudden burning sensation in the
whole area. Note that the area covered by the internal
maxillary artery is nearly parallel to the facial area
innervated by the maxillary nerve (V
). Treatment in
2
these cases consists of reassuring the patient that the
effect is temporary and will disappear spontaneously in
a few minutes.
6) In 1% of cases the needle punctures the nerve inducing a
kind of electric shock, cramp, or intense burning sensation in the posterior and medial half of the palate on the
side injected, with no sequelae (Sved et al. 1992). No
chronic or long-
lasting lesions of this nature have been
reported in clinical practice, despite their theoretical
likelihood (Silverman 1923; Dickson and Coates1945;
Mercuri1979; Wong and Sved1991), perhaps because
the technique is seldom used.
7) With this technique:
● Pain is less severe, especially during needle travel,
than in the alternative high tuberosity approach
(Annex 23).
● Moderate to severe post- operative pain around the
injection site may last 1–3 days in only 2% of individuals (Broering et al. 2009), subsiding spontaneously
with no sequelae.
t.me/Dr_Mouayyad_AlbtousH
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Factors That Lead toSuccess
Three major factors determine the success of this technique (Wong and Sved1991).
1) The greater palatine foramen on the posterior palate
must be located, which is not always a simple task.
2) The needle must travel a long enough distance to reach
the pterygopalatine fossa. If the needle is too short, as is
often the case, the anesthetic solution fails to bathe the
maxillary nerve (V
Long needles measuring 42
), remaining rather in the canal.
2
mm are therefore needed.
3) A sufficient amount of anesthetic must be injected to
diffuse satisfactorily across the roof of the pterygopalatine fossa. Clinicians tend not to use enough
(Hofer1922b; Wong and Sved1991), despite the recommended two 1.8- ml cartridges or 3.6 ml.
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Ulusoy, Ö.I.A. and Alacam, T. (2014). Efficacy of single
buccal infiltrations for maxillary first molars in patients
with irreversible pulpitis: a randomized controlled trial.
Int. Endod. J. 47 (3): 222–227.
Viegas, A.R. and Hemphill, F.M. (1961). Predicting depth of
insertion of needle required to anesthetize the maxillary
nerve by way of the pterygopalatine canal. J. Oral Surg.
Anesth. Hosp. Dent. Serv. 19 (2): 105–109.
Weinand, F.S., Pavlovic, S., and Dick, B. (1997).
Endophthalmitis nach enoraler Blockade des Nervus
infraorbitalis. Klin. Monatsbl. Augenheilkd. 210 (5): 402–404.
Wong, J.D. and Sved, A.M. (1991). Maxillary nerve block
anaesthesia via the greater palatine canal: a modified
technique and case reports. Aust. Dent. J. 36 (1): 15–21.
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Maxillary Anesthesia II: Complementary Anesthesia ofthe Palate
267
Introduction
Clinical experience shows that the buccal infiltrative technique applied via the buccal area does not usually anesthetize the palate, therefore some interventions must be
completed with anesthesia of the palate, hence the concept
of complementary anesthesia of the palate. In any case it is
important to remember that the palate is innervated and
that the fibromucosa, periosteum, and bone are innervated
by two nerve trunks:
● The nasopalatine nerve, which emerges from the incisive
foramen, supplies the area of the palate at the incisive papilla
and the areas close to the central and lateral incisors.
● The greater palatine nerve, which emerges at the back
part of the palate via the greater palatine foramen, supplies the palate in the canine, premolar, and molar areas
on each side as far as the raphe.
This chapter reviews three techniques for anesthetizing
the nerve trunks of the palate:
● Nasopalatine nerve block and its intranasal variant.
● Greater palatine nerve block and its variant in the area of
innervation extending from the first premolar to
crossthe lateral incisor.
● Transpapillary technique for children.
Some of the characteristics of the techniques used to
anesthetize the palate are now reviewed.
The Nasopalatine Nerve Innervates Less than
Previously Thought
Many texts continue to attribute a much greater area of
innervation to the nasopalatine nerve than it actually has
(Bennett1984; Jastak etal.1995; Malamed2004). Clinical
research has shown that the area between the lateral incisor and the first premolar is an area of cross-
innervation
where the main supply is from the greater palatine nerve.
Thus, the greater palatine nerve supplies the first premolar
in 95% of cases, the canine in 75% of cases, and the lateral
incisor in 50% (see Table2.1, Chapter2).
The Potency ofthe Anesthetic is not Important
The potency of the anesthetic solution, according to the
type and concentration of the anesthetic and/or vasoconstrictor, is not important for ensuring anesthesia of these
nerves via the palate because they are superficial and not
covered by periosteum or cortical bone, therefore little
anesthetic is required to anesthetize the area.
Anesthesia ofthe Palate Without Complementary
Palatal Anesthesia
Clinical studies show that use of potent solutions such as
articaine 4% with epinephrine 1:100
000 (10 μg/ml) (A- 100)
in extractions in the area of the molars and premolars
principally is successful in 94% of cases with the buccal
infiltrative technique. This approach does not require
complementary palatal anesthetic, although patients may
complain of mild discomfort in the palate. However, when
the standard solution is used (lidocaine 2% with epinephrine 1:100 000) (L- 100), the success rate falls to 55%
(Table 15.1). Some authors recommend waiting longer
(7–9
minutes) for the solution to reach the palate. In addition, this approach is more effective in anterior teeth than
in posterior teeth (Kumaresan etal.2015).
Studies based on magnetic resonance imaging do not
reveal diffusion of the anesthetic solution from the buccal
area to the palate (Özec etal.2010); however, experimental
Local Anesthesia in Dentistry: A Locoregional Approach, First Edition. Jesús Calatayud and Mana Saraghi.
© 2024 John Wiley & Sons Ltd. Published 2024 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/Calatayud/local
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Table15.1 Success (%) ofextraction ofmaxillary molars (M) andpremolars (PM) after buccal infiltration witha potent anesthetic
solution (A-
Reference Sample size Tooth
No complementary anesthesia with A- 100
Uckan etal. (2006) 53 —
Fan etal. (2009) 71 —
LimaLimaSomuri etal. (2013) 30 PM 1.7/ADarawade etal. (2014) 50 PM 0.8/ASharma etal. (2014) 80 M, PM 0.9/AKandasamy etal. (2015) 116 —
Bataineh and AlMajid and Ahmed (2018) 28 M 1.8/ABataineh etal. (2019) 50 I, PM, M 1.3/A-
No complementary anesthesia with L- 100
Badcock etal. (2007) 51 3rdM 2.2/LLassemi etal. (2008) 30 IC 1.8/LDarawade etal. (2014) 50 PM 1.3/LKandasamy etal. (2015) 111 —
Kumaresan etal. (2015) 25 M 1.5/LMajid and Ahmed (2018) 28 M 3.6/LBataineh etal. (2019) 50 I, PM, M 1.3/L-
100) or standard solution (L- 100 or L- 80) andno complementary palatal anesthetic.
Solution Palatal anesthetic Success (%)
ml/LAS/time (min) ml/LAS (proportion)
2.0/A- 100/5′ No 96% (51/53)
1.7/A- 100/5′ No 90% (64/71)
Junior etal. (2009) 50 3rdM 1.8/A- 100/10′ No 94% (47/50)
Junior etal. (2013) 15 3rdM 1.8/A- 100/5′ No 100% (15/15)
100/−− No 90% (27/30)
100/— No 100% (50/50)
100/— No 94% (75/80)
1.7/A- 100/10′ No 93% (106/116)
Sabri (2017) 48 M, PM 1.8/A- 100/5′ No 92% (44/48)
100/10′ No 86% (24/28)
87/12′ No 94% (47/50)
Mean 94%
80/5′ No 86% (44/51)
80/6′ No 77% (23/30)
100/— No 2% (1/50)
1.7/L- 80/10′ No 1% (1/111)
80/7–9′ No 52% (13/25)
100/10′ No 86% (24/28)
75/10′ No 96% (48/50)
Mean 55%
N, sample size; ml, milliliters injected; LAS, local anesthetic solution; A- 100, articaine 4% + epinephrine 1:100 000 (10 μg/ml); A- 87, articaine
4% + epinephrine 1:87 000 (11.5 μg/ml); L- 100, lidocaine 2% + epinephrine 1:100 000 (10 μg/ml); L- 80, lidocaine 2% + epinephrine 1:80 000
(12.5 μg/ml); L- 75, lidocaine 2% + epinephrine 1:75 000 (13.3 μg/ml); 5 is 5 minutes waiting time after administering the anesthetic.
animal studies did find concentrations of anesthetic solution in the bone and the mucous membrane of the palate.
with complementary palatal anesthetic are more comfort-
able for the patient (Majid and Ahmed2018).
These are greater with A- 100 than with L- 100 (Al- Mahalawy
etal.2018). Reported findings are contradictory.
Nevertheless, when complementary palatal anesthetic is
Indications
used, irrespective of whether it is with A- 100 or L- 100, the
success rate is practically 100% (Table 15.2).These successes in the third maxillary molars may be due to the fact
that extraction at this level is relatively simple and rapid
These techniques are not aimed at achieving pulpal anes-
thesia (Hicks etal.1995), but rather at providing comple-
mentary anesthesia of the palate in the following cases:
(less than 1 minute in most cases) and that the depth of
anesthesia necessary for these extractions is lower than
that needed in other procedures, such as endodontic procedures (Badcock et al. 2007). However, extraction of first
molars may take longer (around 4 minutes) and be more
complicated, although it is also successful, and extractions
1) Dental surgery and extractions (Roberts and Sowray1987;
Evers and Haegerstam1981).
2) Reinforcing pulpal anesthesia after a buccal infiltra-
tion in healthy teeth (Guglielmo etal.2011) or in the
case of irreversible acute pulpitis (Aggarwal etal.2011;
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Table15.2 Success (%) ofextraction ofmaxillary molars (M) andpremolars (PM) after buccal infiltration, based ona potent
anesthetic (A-
Reference Sample size Tooth
Complementary anesthesia with L- 100
Uckan etal. (2006) 53 —
Lassemi etal. (2008) 30 IC —
Somuri etal. (2013) 30 PM 1.8/LSharma etal. (2014) 80 M, PM 1.8/LKumaresan etal. (2015) 25 M 1.5/LBataineh etal. (2019) 55 I, PM, M 0.9/L-
Complementary anesthesia with A-
Fan etal. (2009) 71 —
LimaMajid and Ahmed (2018) 28 M 1.8/A-
N, sample size; ml, milliliters injected; LAS, local anesthetic solution; A- 100, articaine 4% + epinephrine 1:100 000 (10 μg/ml); L- 100, lidocaine
2% + epinephrine 1:100 000 (10 μg/ml); L- 80, lidocaine 2% + epinephrine 1:80 000 (12.5 μg/ml); L- 75, lidocaine 2% + epinephrine 1:75 000
(13.3 μg/ml); 5 is 5 minutes waiting time after administering the anesthetic.
100) or thestandard solution (L- 100 or L- 80) withcomplementary palatal anesthesia.
Solution Palatal anesthetic Success (%)
ml/LAS/time (min) ml/LAS (proportion)
1.8/L- 100/5′ 0.5/L- 100 98% (52/53)
/L- 80/6′ — /L80 100% (30/30)
100/— 0.25/L- 100 100% (30/30)
100/— — /L- 100 100% (80/80)
80/2′ 0.3/L- 80 100% (25/25)
75/7′ 0.2/L- 75 100%(55/55)
Mean 99.6%
100
1.7/A- 100/5′ 0.4/A- 100 95% (67/71)
Junior etal. (2009) 100 3M 1.8/A- 100/5–10′ —/A- 100 100% (100/100)
100/10′ 0.2/A- 100 100% (28/28)
Mean 98.3
≈ 100%
≈ 100%
Ulusoy and Alacam 2014; Askari et al. 2016), given
that in teeth with palatal roots the percentage of
pulpal
anesthesia increases.
3) Scaling and root planing.
4) Subgingival preparations in the palate:
○ Restorations.
○ Restorations by cervical caries.
○ Placement of a retraction cord.
○ Gingival retraction in the palate.
5) Insertion of subgingival matrix bands at the level of the
palate (Malamed2004).
6) Placement of clamps for a dental dam that penetrate or
pinch the mucous membrane of the palate.
Methods forReducing Pain
inPalatal Techniques
Clinical observation tells us that injections into the palate
are the most painful (Kramp etal.1999; Wahl etal.2001;
Primosch and Brooks2002). Clinical studies confirm this
observation (Annexes 19 and 23). This is because the palatal fibromucosa is formed by dense fibers, with little subcutaneous tissue, and is firmly attached to the periosteum.
Consequently, elasticity is minimal, the ability to spread
after administration is limited, and the technique is painful
(Gill and Orr II 1979; Keller 1985; Kreider et al. 2001;
Bhalla etal.2009). In addition, the anterior part of the palate is known to be somewhat more painful than the posterior part, precisely because the fibromucosa is more firmly
attached (Meechan etal.2005; Özec etal.2010).
Several methods are used to prevent or at least minimize
the pain induced by injection into the palate. However, as
expected, when several methods are available and no consensus has been reached on which is best, this is because
neither is completely satisfactory.
Topical Anesthesia
Topical anesthesia is poorly effective in the palate, as
shown in clinical trials (Annex 19). These poor results are
due not only to previous comments (fibromucosa firmly
attached to the periosteum), but also to the fact that because
the mucous membrane of the palate is more keratinized, its
permeability is lower than that of the rest of the oral
mucous membrane (Lesch etal.1989), leading to reduced
penetration of topical anesthetic.
In any case, topical anesthesia reduces the average perception of pain compared with placebo, although the differences are not significant.
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Pressure Techniques
Conventional methods (Malamed2004)
These techniques involve applying firm and continuous
pressure with a cotton swab (e.g. those used for application
of topical anesthesia) on the surface of the mucous membrane of the palate to be injected for 20–30 seconds before
insertion. The pressure should be sufficiently firm for the
mucous membrane to change from its usual pink color to a
white or pale color owing to the blanching caused by the
pressure applied. The injection should be made very close
to the head of the swab, and pressure should be maintained
throughout the injection.
“Press and roll” technique (Kravitz2006)
Inform the patient that you are about to place topical
anesthetic on the palate (optional, although it does reassure the patient) and that he/she will feel considerable
pressure on the palate during the maneuver.
● Dry the mucous membrane with a gauze.
● Cover the area with topical anesthesia and leave it for
about 1–2
● Apply pressure on the area of the palate to be injected
minutes (optional).
with the end of the shaft of a dental mirror.
● Insert the needle while pressing it against the shaft of the
mirror, almost pushing it below the shaft and at the same
time press with the shaft.
● Inject a few drops of anesthetic and then turn the shaft of
the mirror toward the needle. Inject for only 3–5
seconds.
This maneuver leaves the mucous membrane white or pale
owing to the blanching induced by the pressure (Figure15.1).
● Remove the needle, remove the shaft of the mirror, and
wait a minute for the few drops of anesthetic solution to
take effect and the soft tissues at the injection site
tobecome anesthetized.
● After aspirating, reinsert the needle at the same site to
inject a larger quantity of anesthesia (±1/8 of a cartridge
or 0.25
ml) slowly (7–10 seconds) and wait a further
30
seconds. A small amount of anesthetic is preferred to
a large amount to reinforce the previous amount and
ensure that the palate starts to become anesthetized.
This technique is fairly fast without topical anesthetic.
Pressure maneuvers act by activating the gate control
system in the trigeminal nerve nuclei. This partially inhibits the passage of pain stimuli to higher pathways, thus
helping the stimulus to remain below the pain threshold
(Melzack and Wall1965; Dubner1978) (seeChapter11).
Topical Cooling
Cold reduces the velocity of nerve conduction, which
ceases when the temperature falls from 10 to 0
°C
(Harbert1989), thus inducing anesthesia. Topical cooling
techniques are used before injection of palatal local anesthesia to ensure that the procedure is as painless as possible. The only contraindication would be in patients who
cannot tolerate cold (Harbert1989).
There are three different approaches: (i) old cold aerosols, like ethyl chloride; (ii) refrigerants, only used on the
palate (Duncan etal.1992; Kosaraju and Vandewalle2009;
Wiswall etal.2014); and (iii) topical ice. All these methods
are explained in Chapter12.
Figure15.1 Needle inserted under the tip of the shaft. The
exact point at which a few drops are injected and the shaft turns
toward the needle while applying pressure. Redrawn
from Kravitz (2006).
Periodontal Ligament Technique
This technique was first proposed by Dr. Barry McArdle as
being almost painless (McArdle1997; Aslin2001).
● In the first stage, buccal infiltration is used to anesthetize
the buccal gingiva and the buccal part of the papillae of
the tooth at the point on the palate to be anesthetized.
This maneuver may take some time since, as the anes-
thesia begins to take effect, it is necessary to inject into
the attached gingiva while moving gradually toward the
interdental papilla.
● A high- pressure pistol- grip syringe for the periodontal
ligament technique is prepared with an extrashort nee-
dle (8–12 mm, 27 G or 30 G). In posterior teeth, it may
be necessary to deflect the needle halfway up the shaft,
but never at the hub, which is where the needle
can break.
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