Posterior Superior Alveolar Nerve Research Articles

Overcoming local anesthesia failure during routine dental treatments in children.

Local anesthesia (LA) during routine dental treatment in children fails in 5%-35% of first attempts. No data, however, are available on the success rates of subsequent attempts. To evaluate the effectiveness of primary, secondary, and tertiary LA attempts (P-LA, S-LA, and T-LA, respectively) for anesthetizing molars during routine dental treatments in children. We retrospectively analyzed dental records of all children (2-18 years) who had been administered LA for the treatment of primary or permanent molars by a single paediatric dentist, between 2011 and 2022. All LAs were delivered using a computer-controlled local anesthetic delivery (CCLAD) system. The failure rate of P-LA in 1312 molars was 13% and correlated with age (p < .001), type of tooth (p < .001), type of treatment (p < .001), and treated arch (p < .001). The effectiveness of S-LA for buccal infiltration, intrasulcular, inferior alveolar nerve block, greater palatine nerve block (GPNB), posterior superior alveolar nerve block (PSANB), or a combination of the last two was 50%, 87.2%, 66.7%, 63.6%, 33.3%, and 100%, respectively, and was not significantly associated with age or the type of tooth, treatment, or P-LA. The optimal choice of S-LA for anesthetizing maxillary molars was a combination of PSANB and GPNB, whereas for mandibular molars, it was IS-CCLAD system.

Considering Anatomic Features When Retrieving a Separated Needle: A Case Report Using CT Navigation Within the Infratemporal Fossa

Needle separation is an unfortunate complication encountered during local anesthetic administration in dentistry. Attributing factors have been thought to be related to needle gauge, pre-injection needle bending, needle deflection, redirection, and depth of penetration. Various methods have been described for FB identification and retrieval. We present a case of a separated hypodermic needle in the infratemporal fossa after a posterior superior alveolar (PSA) nerve block. We describe the use of computed tomography (CT) navigation system with an expanded armamentarium of guided instrumentation. Utilization of our method can efficiently aid in the localization and removal of foreign bodies in the maxillofacial region.

Comparison of posterior superior alveolar and greater palatine nerve block with local infiltration for extraction of maxillary molars in oral surgery – A randomized controlled trial

Administration of local anesthetic drug that prevents pain during dental treatment is of absolute importance. Act of injecting local anesthetic should be nonpainful and atraumatic. The maxilla is very porous and highly vascular. Therefore, anesthesia of maxillary teeth can be accomplished more easily than with mandibular teeth. The aim of this study is to determine the anesthetic efficacy of the conventional technique of posterior superior alveolar (PSA) and greater palatine nerve(GP) block anesthesia as compared to the buccal and palatal technique in terms of pain during injection, after extraction, after 15mins of the procedure and quality of anesthesia during the extraction procedure. The study also intends to determine the incidence of positive aspiration in the infiltration technique. This randomized clinical study was carried out on 154 patients who reported to the Department of Oral and Maxillofacial Surgery, Sri Rajiv Gandhi College of Dental Sciences &amp; Hospital Bangalore, requiring extraction of maxillary second and third molar teeth. The patients received anesthesia using the conventional nerve block technique and infiltration technique randomly on each side of the mouth. Patients were assessed for pain during the injection, after extraction, and after 15mins of the procedure with each technique using Visual Analog Scale (VAS). The patients were also assessed for pain using the Verbal Response Scale (VRS). The positive aspiration was assessed for each technique. During tooth extraction, quality of anesthesia was assessed using an eight-point category rating scale. The results obtained were analyzed using Chi-square test. It was concluded that the buccal infiltration technique is less painful for the patient as compared to the posterior superior alveolar nerve block. This technique has a lower frequency of positive aspiration as compared with the PSA nerve block. However, the PSA nerve block technique provides better-quality of anesthesia. It can be concluded that the infiltration technique appears to be a successful alternative with additional advantages, as compared to the nerve block technique.

DIPLOPIA FOLLOWING INTRA-ORAL LOCAL ANAESTHESIA- A CASE REPORT

Context There are several local and systemic complications associated with the administration of intra-oral local anaesthesia. Very few cases of ophthalmic complications following use of intra-oral local anaesthesia are reported till date. Diplopia is one of such very rare Case Description complications that follow a posterior superior alveolar nerve block. This article describes a very rare case report, the possible mechanisms and their management. The patient was administered PSA nerve block for the extraction of the upper left third molar tooth. After the extraction, the patient complained of double vision and not being able to abduct the left eye. The patient recovered completely after the anaesthetic effect wore of. Conclusion The clinician needs to be aware of such ophthalmic complications and their management.

Posterior superior alveolar nerve block alone in the extraction of upper third molars: a prospective clinical study.

Third molar extraction is the most commonly performed minor oral surgical procedure in outpatient settings and requires regional anesthesia for pain control. Extraction of the maxillary molars commonly requires both posterior superior alveolar nerve block (PSANB) and greater palatine nerve block (GPNB), depending on the nerve innervations of the subject teeth. We aimed to study the effectiveness of PSANB alone in maxillary third molar (MTM) extraction. A sample size comprising 100 erupted and semi-erupted MTM was selected and subjected to study for extraction. Under strict aseptic conditions, the patients were subjected to the classical local anesthesia technique of PSANB alone with 2% lignocaine hydrochloride and adrenaline 1:80,000. After a latency period of 10 min, objective assessment of the buccal and palatal mucosa was performed. A numerical rating scale and visual analog scale were used. In the post-latency period of 10 min, the depth of anesthesia obtained in our sample on the buccal side extended from the maxillary tuberosity posteriorly to the mesial of the first premolar (15%), second premolar (41%), and first molar (44%). This inferred that anesthesia was effectively high until the first molars and was less effective further anteriorly due to nerve innervation. The depth of anesthesia on the palatal aspect was up to the first molar (33%), second molar (67%), and lateromedially; 6% of the patients received anesthesia only to the alveolar region, whereas 66% received up to 1.5 cm to the mid-palatal raphe. In 5% of the cases, regional anesthesia was re-administered. An additional 1.8 ml PSANB was required in four patients, and another patient was administered a GPNB in addition to the PSANB during the time of extraction and elevation. The results of our study emphasize that PSANB alone is sufficient for the extraction of MTM in most cases, thereby obviating the need for poorly tolerated palatal injections.

The curious case of inability to open one eye after ipsilateral posterior superior alveolar nerve block

AbstractIntroductionDental patients are usually concerned about the side effects of extraction of upper teeth on their eyes, however rare but certain ophthalmic complications corresponding to dental anaesthesia are well reported in literature.Material and MethodsWe present a case of 50‐year‐old female who developed ophthalmic complications following Posterior Superior Alveolar Nerve Block administration during extraction of left maxillary second molar.ResultsA clinical diagnosis of transient oculomotor palsy was made. Constant assurance about the transient nature of the symptoms was given to the patient. The patient started recovering after 30 min and recovered fully in about 2 h.Clinical significanceClinicians should be well aware of the ophthalmic effects of dental anaesthesia, this should always be kept in the back of mind that such complications are mostly transient but permanent loss of vision has also been documented in literature.

Posterior superior alveolar nerves contribute to sensation in the anterior teeth

BackgroundThere is no available data on the occurrence rate of a converged alveolar canal, the detailed three-dimensional (3D) courses of alveolar canals/grooves (ACGs), or the contribution of each superior alveolar nerve to each area in the maxilla. This study aimed to clarify the 3D courses of ACGs, the relationship between ACGs and superior alveolar nerves, and the contribution of posterior superior alveolar nerves (PSANs) using computed tomography (CT) with histological analysis. MethodsDuring the gross anatomy course at Niigata University, we investigated nine human cadavers. ResultsAll anterior and posterior ACGs converged into the common alveolar canal, which contained blood vessels and several nerve bundles surrounded by perineurium, located at the nasal floor near the pyriform aperture. Histometrical analysis clarified that 16.3% of the nerve bundles in this canal were derived from PSANs, and 67% of the bundles were dispersed while they coursed down to the nasal floor. There seems to be no relationship between the density of nerve bundles in the canal and the number of remaining anterior teeth. ConclusionsData obtained from observing the detailed 3D courses of anterior and posterior ACGs, and their relationship with superior alveolar nerves, suggest that PSANs partially contribute to the nociception of the anterior teeth.

Diplopia due to local anesthesia. A very rare complication

Introduction: Local anesthesia for dental procedures is considered relatively safe since, apart of anaphylactic reactions, only rare complications are reported. Visual disturbances such as diplopia that is presented below account for 0.1% of all complications. Method: A 57 year old woman was administered a posterior superior alveolar nerve block for the dental filling of the first right molar tooth with the use of Articaine Hydrochloride 4% with Adrenaline 1:100,000 in a 30 gauze syringe. Soon after she complained of diplopia and dizziness and was referred for evaluation by a specialist. Psychiatric evaluation did not reveal any psychopathology other than the presence of great distress. Neurological examination revealed horizontal diplopia and limitation of the lateral rectus muscle to abduct the right eye. Pupil reaction was normal and no ptosis was present. It was diagnosed right abducent nerve palsy. The patient was reassured of the transient nature of symptoms and the eye was covered to minimize nausea. Symptoms resolved gradually after 90 min. Results: Literature suggests that diplopia occurs most frequently after maxillary injections (77.8% vs 57.1% for mandibular injections) and after posterior superior alveolar nerve block. Various mechanisms, other than improperly placed nerve block are proposed. The most possible hypothesis of retrograde flow of anesthetic solution into the venous system explains that the anesthetic solution, after an accidental entry into the venous system, will drain into the pterygoid venous plexus, and at last into the cavernous sinus, where the abducent nerve is sited. These complications may be related to anatomic variations Conclusion: Diplopia during local anesthesia is very rare and usually transient, however is very alarming and might lead to medicolegal issues. Generally is proposed to always aspirate before injection, stop any procedure and refer the patient if symptoms persist.

Clinical efficacy of 0.75% ropivacaine vs. 2% lignocaine hydrochloride with adrenaline (1:80,000) in patients undergoing removal of bilateral maxillary third molars: a randomized controlled trial.

BackgroundLignocaine with adrenaline is routinely used as a local anesthetic for dental procedures. Adrenaline was added to increase the duration of anesthesia. However, epinephrine containing a local anesthetic solution is not recommended in conditions such as advanced cardiovascular diseases and hyperthyroidism. Recently, ropivacaine has gained popularity as a long-acting anesthetic with superior outcomes. The goal of this study was to assess and compare the effectiveness of 0.75% ropivacaine alone and 2% lignocaine with adrenaline (1:80,000) in the removal of bilateral maxillary wisdom teeth using the posterior superior alveolar nerve block technique.MethodsThis was a single-blind, randomized, split-mouth, prospective study assessing 15 systemically sound outpatients who needed bilateral removal of maxillary third molars. We randomly allocated the sides and sequences of ropivacaine and lignocaine with adrenaline administration. We evaluated the efficacy of both anesthetics with regard to the onset of anesthesia, intensity of pain, variation in heart rate, and blood pressure.ResultsThe onset of anesthesia was faster with lignocaine (138 s) than with ropivacaine (168 s), with insignificant differences (p = 0.001). There was no need for additional local anesthetics in the ropivacaine group, while in the lignocaine with adrenaline group, 2 (13.3%) patients required additional anesthesia. Adequate intraoperative anesthesia was provided by ropivacaine and lignocaine solutions. No significant difference was observed in the perioperative variation in blood pressure and heart rate.ConclusionRopivacaine (0.75%) is a safe and an adrenaline-free local anesthetic option for posterior superior alveolar nerve block, which provides adequate intraoperative anesthesia and a stable hemodynamic profile for the removal of the maxillary third molar.

A comparative analysis between atraumatic and conventional anesthetic techniques in surgical removal of upper third molars

Pain control is essential in dental practice, and can be accomplished through various techniques. This study seeks to compare atraumatic and conventional anesthetic techniques, applied during surgeries to remove upper third molars. The endpoints evaluated were pain indices, patient satisfaction and anesthetic efficacy. A random parallel split-mouth clinical trial was conducted with 14 patients. Group A received atraumatic anesthesia without a needle (Comfort-in®) and group B received conventional anesthesia by blocking the posterior superior alveolar nerve (PSAN) and Greater Palatine Nerve (GPN). A Visual Analogue Scale (VAS) was used to assess pain. A significantly (p&lt;0.001) lower perception of pain was observed among individuals who received the atraumatic technique. In 71% of cases, it was necessary to supplement the anesthesia during the procedure. Even considering the need for additional anesthesia, the Comfort-in® technique was more accepted by patients with regard to pain perception than the conventional manual technique.

Pilot Randomized Clinical Trial Study: Comparative Study of 10% Lidocaine Hydrochloride Solution with Lidocaine Prilocaine Emulsion Prior to Local Anesthetic Injection

Background: The pain caused by the injection of local anesthetic has been reported as one of the main complaints of dental patients. Topical anesthetics are widely used drugs in dentistry, mainly to control pain associated with the needle penetration in the administration of local anesthesia. Objective: The present study aimed to evaluate (5%,7.5% and 10%) concentrations of lidocaine/prilocaine agent, compared to the common 10% lidocaine hydrochloride spray in the oral cavity. Materials and Methods: This was a split-mouth double-blind, randomized clinical trial pilot study. We randomized 15 patients, ages 35 to 64 years, with American Society of Anesthesiologists I and II with severe chronic periodontitis who were referred to the dental clinic for surgery, to receive 4 topical anesthetics (5%, 7.5%, and 10%) lidocaine prilocaine emulsion and 10% lidocaine hydrochloride topical anesthetic agent before local infiltration. Primary outcomes were assessing drug safety and pain level that measured by assessment of visual analog scale (VAS) scores of pain during LA injection in the first premolar and second molar in each maxillary quadrant in 15 patients corresponding to the posterior superior alveolar nerve (PSA) and secondary outcome was the relationship between age and gender regarding pain perception, and a total of 60 regions were analyzed. Results: Results revealed that there was no statistically significant difference between lidocaine hydrochloride and (5%,7.5% and 10%) lidocaine prilocaine in terms of pain reduction when the 4 different compounds were compared. According to Spearman's rank correlation coefficient and Friedman test, the age and gender of the patients had an insignificant correlation with the anesthetic effects of the four studied solutions. Conclusion: Based on these results, age and gender have insignificant effects on the pain scores and it can be said that the four solutions do not have significant differences regarding their anesthetic effects; also, we did not find any adverse reactions by using 7.5% and 10% lidocaine/prilocaine agent.

Effectiveness of the Greater Palatine Nerve Block for Anaesthetising Anterior Palate: A Prospective Study

Introduction: Local Anaesthesia (LA) is the mainstay of any routine dental extraction. Accomplishing optimum anaesthesia with least pain and anxiety to patients is a challenge. Hence, modification of technique and application of routine dental LA to enhance patient comfort is the need of the hour. In this pursuit, a prospective cohort study was carried out to evaluate the effectiveness of greater palatine nerve block as an alternative to nasopalatine nerve block in anaesthetising the anterior palatal mucosa and to achieve optimum palatal anaesthesia. Aim: The primary outcome variable is to assess the extent of the anaesthetic effect of greater palatine nerve block in maxillary anterior palatal region. Materials and Methods: A total of 100 patients scheduled for the extraction of ipsilateral anterior and posterior maxillary teeth were included in this prospective study between June 2017 to June 2019. Palatal anaesthesia for all the extractions done was achieved only with greater palatine nerve block. After an interval of five minutes, the extent of palatal anaesthesia from the posterior palatal tissue to the anterior region was evaluated for both subjective and objective symptoms. Pain on the palatal mucosa was assessed using Numerical rating scale of 0-10. Post-evaluation, depending on the proposed tooth of extraction, buccal anaesthesia was achieved with Posterior superior alveolar nerve block for posterior teeth and infraorbital nerve block for anterior teeth. Results: Of the 100 patients administered with greater palatine nerve block, it was observed that in 36 patients (36%) had effectiveness in anaesthesia till central incisor, 28 (28%) patients had effectiveness in anaesthesia till lateral incisor, 20 (20%) patients had effective in anaesthesia till the canine and 16 (16%) patients anaesthetic effects were limited to posterior teeth. Overall, 84% had varied degree of positive anterior anaesthesia with greater palatine nerve block alone. Conclusion: Greater palatine nerve block was effective in providing anaesthesia to the posterior region till the premolars, with the extended complete anaesthesia in the anterior region with similar action as the nasopalatine nerve block administered to anaesthetise the anterior palate for extraction of the anterior teeth.

Chlorhexidine Abuse – Case Report

We reported a case where 2% chlorhexidine gluconate (CHX) was mistaken for an anaesthetic solution and injected in the left buccal vestibule while administering the posterior superior alveolar nerve block during routine root canal treatment. Accidentally, 2% chlorhexidine gluconate solution was injected in the left upper buccal vestibule (26) of a 38 year old female during routine root canal treatment. The patient experienced pain and a burning sensation over the injected area shortly after injection. Swelling extraorally over the left cheek area was observed clinically. The patient was immediately injected with normal saline solution in the same region of infiltration and flushing of the region with normal saline solution was carried out. The patient was prescribed analgesics and anti-inflammatory drugs. The swelling increased within the next 24 hours, but was slowly reduced on the second day. the The patient did not experience any parasthesia/loss of sensation over the left cheek. Key words Accidental injection, root canal therapy, 2% chlorhexidine (CHX) gluconate, flushing with saline.

Reinforcing Teaching Strategies with Demonstrational Videos in Dental Education

Introduction: Blended learning is the trending concept in current educational system including the field of dentistry where traditional teachings are combined with online resources such as demonstrational videos etc. Aims and Objectives: To assess whether demonstrational videos help enhance dental student’s confidence, knowledge and technique during local anesthesia injection. Methods: Fifty dental students of year 3 (B.D.S.) of SEGi University were randomly allocated into two groups. Both groups were given live demonstration of the posterior superior alveolar (PSA) nerve injection technique. In addition, the test group received additional demonstrational video to watch. Then both the groups were made to inject on each other. Two oral surgeons assessed both the groups individually on some fixed criteria for injection technique. The data were collected and analyzed using SPSS version 22, mean values and percentages were compared between 2 groups using independent sample t-test and Chi-square test respectively. Results: The mean score for injection technique was 1.4038 in control group and 1.6957 in the test group with p=0.004. In other aspects of this study, there was no significant difference found. Conclusion: Demonstrational videos helped improve injection technique among dental undergraduates.

A Large Cheek Hematoma as a Complication of Local Anesthesia: Case Report.

Hematoma is among less frequent complications which occur following local anesthesia. The posterior superior alveolar nerve block and inferior alveolar nerve block are known to be accompanied with a higher incidence of positive aspiration compared to all infiltration and block anesthesia techniques in oral surgery. We present the case of an otherwise healthy 8-year-old boy who experienced a large cheek hematoma after a routine infiltration anesthesia in the maxilla. Firstly, he was mistakenly treated under the diagnosis of type1 allergic reaction. Subsequently, the topical therapy for an evident, large hematoma was unsuccessful. Ultimately, incision of the infected hematoma and antibiotic therapy were crucial for its resolution. Early recognition of clinical signs of hematoma is of utmost importance for the surgeon in order to treat the patient adequately.

Palatal Injection does not Block the Superior Alveolar Nerve Trunks: Correcting an Error Regarding the Innervation of the Maxillary Teeth.

The superior alveolar nerves course lateral to the maxillary sinus and the greater palatine nerve travels through the hard palate. This difficult three-dimensional anatomy has led some dentists and oral surgeons to a critical misunderstanding in developing the anterior and middle superior alveolar (AMSA) nerve block and the palatal approach anterior superior alveolar (P-ASA) nerve block. In this review, the anatomy of the posterior, middle and anterior superior alveolar nerves, greater palatine nerve, and nasopalatine nerve are revisited in order to clarify the anatomy of these blocks so that the perpetuated anatomical misunderstanding is rectified. We conclude that the AMSA and P-ASA nerve blockades, as currently described, are not based on accurate anatomy.

Cadaveric Study for Intraoral Needle Access to the Infratemporal Fossa: Application to Posterior Superior Alveolar Nerve Block Technique.

The posterior superior alveolar (PSA) nerve block is, from an anatomical perspective, challenging because the mandibular ramus and the zygomatic process of the maxilla can interfere with the course of the needle. Dentists empirically know that shifting the patient’s mandible to the ipsilateral side can improve visibility and accessibility for such blocks. This cadaveric study aimed to establish anatomical evidence for the ipsilateral mandible shifting used in the PSA. The distance between the lateral most bulging point of the alveolar part of the maxilla and ipsilateral anterior border of the ramus of the mandible ranged from 1.4 to 6.9 mm with a mean of 4.3 ± 1.6 mm. This result supports the empirical technique of shifting the mandible ipsilaterally for PSA nerve block.

The Efficacy of Buccal Infiltration of 4% Articaine and PSA Injection of 2% Lidocaine on Anesthesia of Maxillary Second Molars.

Introduction:During the early mixed dentition period, the location of the deciduous maxillary second molar results in ineffectiveness of the infiltration technique in this area. In such cases, administration of posterior superior alveolar (PSA) nerve block is recommended; however, such a technique has some complications. The present study was undertaken to compare the effects of buccal infiltration of 4% Articaine and PSA technique with 2% Lidocaine on the success of anesthesia of maxillary deciduous second molars in 6 to 9-year old children. Methods and Materials: In the present double-blind randomized clinical trial, 56 children aged 6-9 years requiring vital pulp therapy of deciduous maxillary second molar were included. In group 1, 4% Articaine was injected using a buccal infiltration technique. In group 2, 2% Lidocaine was injected using the PSA nerve block technique. After 10 min, the caries was removed and access cavity preparation was instituted. The patients were asked to report the presence or absence of pain during the procedure. Therefore, the existence of pain was measured by the patient's self-report. Data were analyzed with descriptive statistical methods and the chi-squared test. Results:Pain was reported by 6 (21.4%) and 9 (32.1%) subjects in the Articaine and Lidocaine groups, respectively. Chi-squared test did not reveal any significant differences between the two groups (P=0.54). Conclusion:Under the limitations of the present study, there was no significant differences between the results of Articaine buccal infiltration and Lidocaine PSA technique, so Articaine buccal infiltration can be used as a substitute for the PSA technique.

Anaesthesia Techniques for Maxillary Molars - A Questionnaire-Based Retrospective Field Survey of Dentist in Western India.

Clinicians use various anaesthesia techniques like Posterior Superior Alveolar (PSA) nerve block, buccal infiltration with or without supplemental anaesthesia like palatal and intraligamentary infiltrations for root canal treatment in maxillary molars. However there is no general consensus regarding which technique is enough for performing endodontic treatment in maxillary molars. The aim of this questionnaire-based survey is to compare and evaluate the various techniques used to anaesthetize the maxillary molars and its effect on postoperative pain. The data were obtained from 290 dental practitioners using a specially prepared questionnaire survey conducted anonymously. The questionnaire contained questions covering data such as years in dentistry, acquired specialty, techniques used for anaesthetizing maxillary molars, success of anaesthesia, and postoperative pain, etc. Buccal infilteration with supplemental anaesthesia in the form of palatal (82%) and intra-ligamentary infilteration (88%) show higher success rate compared to only buccal infilteration (69%). However, intra-ligamentary infilteration group showed highest rate (75%) of postoperative pain. General practitioners (62% of clinicians) prefer to give both buccal and palatal infilterations and specialists opt for only buccal infilteration (66-74% of specialists). Only buccal infilteration is sufficient during root canal treatment of maxillary molars. Routine use of supplemental anaesthesia in the form of palatal and intra-ligamentary infilteration is not necessary unless patient experiences discomfort during endodontic treatment. However, intra-ligamentary infilteration may lead to postoperative discomfort in the form of pain.

Complications in Maxillary Local Anesthesia

branch of the trigeminal nerve. Complications that may arise following local anesthesia are breakage of the needle, injection of the solution in vessels, mechanical damage to the nerve bundle and migration of the solution in different sites. In breakage of the needle this should be quicky removed or identified; the injection of solution in vessels may determine distant transient effect of the solution (the ephinephrine present should be considered, too), while mechanical damage to the nerve bundle is rare but may occurr. With regards to the migration of the solution in different sites, the most common procedure that may determine this complication is posterior superior alveolar block, as this technique provides the block of this nerve with a long distance of the needle inside the soft tissues. Most common symptom is diplopia that commonly recovering with the local anesthesia. Editorial One aspect of oral pathology and maxillofacial not to be overlooked in the anesthesiological approach to the patient are complications due to local anesthesia in maxillary bone. Main procedures of local anesthesiology involve the greater palatine nerve, the infra-orbitary nerve and the posterior superior alveolar nerve: all of these nerves derive from the second sensitive