MAXILLARY NERVE

DR. SANJANA MALL

D EPART M EN T O F P ED O D O N T I C S
 CONTENTS :
• INTRODUCTION
• ORIGIN
• SENSORY PATHWAY
• COURSE
• BRANCHES
• MAXILLARY ANESTHESIA TECHNIQUES
• CLINICAL IMPLICATIONS
• SUMMARY
 INTRODUCTION :
• Maxillary nerve is the second division of the
trigeminal nerve(Vth cranial nerve).

• Purely sensory nerve.

• Develops from the first pharangeal arch.

 ORIGIN:

MECKEL’S CAVE :
Formed by two layers of dura mater at the apex of petrous
part of temporal bone.
 TRIGEMINAL GANGLION
• Crescent shaped
containing unipolar
neurons.

• Forms 2 processes:
 Central- Sensory roots
of the nerve
 Peripheral- 3 divisions
 SENSORY PATHWAY:

Tactile - Touch, Pressure

Temperature

Nocioceptive- Pain

Propioceptive- Sense of
relative position of one’s
own parts of the body
Temperature, Pain , Touch Propioception
Light Touch Pressure

Trigeminal Ganglion
Bypass the
sensory root of the
trigeminal ganglion
General Somatic Afferent Fibres to reach the pons

Ascending fibres

Spinal Nucleus Principal Sensory Mesencephalic

Nucleus Nucleus
 COURSE
Convex anterior Lateral wall of Foramen
border of cavernous rotundum
trigeminal g. sinus

Infra orbital Inferior Orbital

groove and Pterygopalatine
Fissure fossa
canal

Infra orbital Terminal

foramen branches
 BRANCHES

Branches of the maxillary can be classified as:

• DIRECT- those which branch out from the main

trunk

• INDIRECT - those which relay to the ganglion

before going to the tissues.
 DIRECT BRANCHES
Middle Cranial Fossa:
• Meningeal branch- Duramater of middle cranial fossa.

Pterygopalatine Fossa:
• Ganglionic branches: Suspend the Pterygopalatine ganglion
giving it its sensory supply
• Zygomatic branch :
 Zygomaticofacial: Skin on prominence of cheek(zygomatic
bone)
 Zygomaticotemporal :Skin over the anterior temporal fossa
• Posterior Superior Alveolar Branch(PSA):
 Dental- Molars and Premolars
Alveolar- Alveolar periosteum and gingival mucosa.
Mucous- Mucosa of maxillary sinus
Bone- Maxillary bone

Orbit:
• Middle Superior Alveolar (MSA)- Premolars, Mesiobuccal root
of first molar and Mucosa of maxillary sinus.
• Anterior Superior Alveolar(ASA)-
 Nasal- Mucous membrane of lateral wall of the nose
Dental- Maxillary anterior teeth
FACE/ TERMINAL BRANCHES
• Nasal- Skin of the side of the nose and mobile part
of nasal septum
• Palpebral- Skin of lower eyelid and conjuctive
• Superior labial- Unites with facial nerve and forms
INFRA-ORBITAL PLEXUS:
 Skin of mucous membrane of upper lip
 Adjacent part of cheek and labial gland

PSA + MSA + ASA = SUPERIOR DENTAL PLEXUS/ SUPERIOR

ALVEOLAR PLEXUS

INFRA-ORBITAL NERVE: Orbital branches + terminal branches

 INDIRECT BRANCHES
• ORBITAL -Orbital periosteum, Ethmoidal air sinus, Lacrimal
gland.
• NASAL:
o Postero- superior lateral :Postero-superior lateral wall of nose
o Postero-superior medial : Roof of nose >incisive
foramen>NASOPALATINE

• PALATINE
o Greater palatine: Mucous membrane of hard palate and
adjoining gingiva.POST INF NASAL>POST INF QUAD OF NOSE
o Lesser palatine: Soft palate and tonsils (TASTE SENSATION
ALSO)
• PHARANGEAL- mucous membrane of naso pharynx.
MAXILLARY NERVE ANESTHESIA
• The cortical bone in the maxilla is much thinner and less
dense than in the mandible.
• In the maxilla, buccal cortical bone density of the alveolar bone
at the premolar area was the highest. Bone density at the
maxillary tuberosity was the lowest.
 FACTORS AFFECTING SELECTION OF THE
TECHNIQUE TO BE USED:
• Depending of type of bone: Maxilla is mainly made of
cancellous bone(more porous) with thin cortical layer thus
infiltration anesthesia reaches the nerve fibres inside the
bone faster.

• Extent of Surgical Procedure: Large operative field Nerve

Block preferable – anesthesia of entire operative area,
Prevent multiple needle penetrations, amount of solution
deposited

• Duration and depth: Nerve Block preferable

• Age: Older patients have dense bone, thus infiltration
anesthesia is difficult to penetrate

• Homeostasis: Vasoconstrictor present in the infiltration

anesthesia will act directly on the blood vessels and reduce
bleeding.

• Presence of infection:
 Local acidosis( decrease in pH) caused by tissue
inflammation>ion trapping of anesthetic molecule in ionised
form causing a decrease in the number of molecules crossing
the nerve membrane.
 Activation of nocioceptors by inflammatory mediators i.e. these
mediators reduce the threshold for activation of the
nocioceptive neurons.
 Infiltration anesthesia should be avoided during infection to
prevent the injection in the infected area which may lead to spread
of infection
SUBMUCOSAL ANELGESIA (Small terminal nerve endings)

SOFT TISSUE BONY

FIELD BLOCK (Large
terminal branches) PARAPERIOSTEAL INTRAOSSEOUS
INTRAPULPAL INTRASEPTAL
INTRALIGAMENTARY
NERVE BLOCK
(Main nerve trunk) INFRA ORBITAL GREATER PALATINE
NASOPALATINE POSTERIOR SUPERIOR ALVEOLAR
 SUBMUCOSAL ANALGESIA

• Only the mucous

membrane and
underlying
connective tissue
are anesthetized.

• Used for incisions

in mucous
membrane or
before insertion of
other needles.
 PARAPERIOSTEAL
BUCCAL INFILTRATION
PALATAL INFILTRATION
VARIATIONS
• Primary anteriors - Injection should be made
closer to the gingival margin.

• Central Incisors- Because nerve fibres may be

extending from opposite side , it may be necessary
to deposit the LA at the apex of the opposite
central.

• Buccal infiltration is adequate for all dental

procedure besides extraction in which palatal
infiltration should also be used.
INTRAPULPAL
 INTRALIGAMENTARY
• Supplemental anesthesia.

• Needle is placed in the gingival

sulcus usually on the mesial surface
and advanced to the root surface till
resistance is met.(0.2 ml deposited)

• Multi rooted teeth injection is made

on both mesial and distal.

• CONSIDERABLE PRESSURE IS
NECESSARY TO EXPRESS THE
SOLUTION.
 BONY ANESTHESIA
INTRAOSSEOUS INTRASEPTAL
• MORE EFFECTIVE IN
CHILDREN AND YOUNG
ADULTS AS THE
INTRASEPTAL BONE IS
POROUS
POSTERIOR SUPERIOR ALVEOLAR
 MANAGEMENT OF HEMATOMA
• Haematoma maybe characterized as a swollen
discolouration of the involved region, soreness or trismus
• Patient is advised:
Immediate application of ice pack(minimize the size by
inducing vasoconstriction and palliative effect)
Analgesics
Avoid heat application
Ice packs 30 minutes per hour for the first 24 hours after
surgery following which intermittent hot moist packs can be
used to resolve the condition
Transient diplopia following posterior superior
alveolar nerve block , Amaurosis (temporary
blindness), Epiphoria , Esotropia (medial rotation
of the orbit) Pupillary dilation and Ptosis
are among the other rare ocular complications
reported. The present article analysed 32 case
reports (1970 − 2016) of ophthalmologic
complications after intraoral posterior superior
alveolar nerve block in conjunction with or
without greater palatine nerve
block Mydriasis and ptosis (17.77%)
each, Horner’s syndrome in (8.88%) and
accommodation disturbance
was noted only in one case
INFRAORBITAL
NASOPALATINE
GREATER PALATINE
CLINICAL IMPLICATIONS
SUMMARY
 REFERENCES
• Books:
o Textbook of anatomy-head and neck- B. D. Chaurasia
o Essentials of human anatomy- A K Dutta
o Mcdonald and avery- 8th edition
o Moheim’s local anesthesia and pain control
o Malamed’s Local anesthesia- 4 th edition

American Journal of Orthodontics and Dentofacial Orthopedics Volume

133, Issue 1, January 2008, Density of the alveolar and basal bones of
the maxilla and the mandible

Journal of Oral and Maxillofacial Surgery Volume 75, Issue 1, January

2017 Extraction of Maxillary Teeth Using Articaine Without a Palatal
Injection: A Comparison Between the Anterior and Posterior Regions of
the Maxilla
Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology,& Endodontology
Volume 83, Issue 1, January 1997, Intrapulpal injection: Factors related to
effectiveness

Journal of Oral and Maxillofacial Surgery,Medicine, and Pathology , Am I seeing

double? – A rare complication following PSANB: Casereport & brief review of
literature
Diana Daniel ∗, Sahana Gopal, Sundaram R, Subrato Saha