The middle alveolar superior nerve (MSA) branches off the infraorbital nerve within the infraorbital canal.

This nerve
provides sensory innervation to the maxillary premolars, the mesiofacial root of the first molars, the periodontal tissues,
and bone in the premolar area. The MSA nerve is not present in approximately 60 % of individuals, in its absence, these
areas are innervated by the posterior superior alveolar nerve, or more commonly, the anterior superior alveolar nerve.

The anterior superior nerve (ASA) descends from the infraorbital nerve just before the latter’s exit from the infraorbital
foramen. The ASA nerve provides innervation to the central and lateral incisors, the canine, the periodontal tissues, and
facial soft tissue and bone over these teeth. In those individuals without an MSA nerve, the ASA nerve most often
provides innervation to the premolars and possibly the mesiofacial root of the first molar.

Mandibular Division (V₃)

The mandibular nerve, the third and largest division of the trigeminal nerve, both has a sensory root and carries the
motor root for the trigeminal nerve. The sensory root arises from the trigeminal ganglion, after which it is joined by the
motor root. Both roots emerge from the cranium via the foramen ovale, and at this point, they unite to form the main
trunk of the mandibular nerve. The trunk then divides into an anterior branch and a posterior branch. Those nerve arising
from these branches that relate to intraoral local anesthesia are the following:

BRANCHES OF THE ANTERIOR DIVISION, the anterior division is smaller than its posterior counterpart and contains
primarily motor component innervates the muscle of mastication : the masseter, the temporalis, and the lateral and
medial pterygoid. The sensory component of the anterior division is the buccal nerve. At the level of occlusal plane of the
mandibular molars, it crosses the anterior border of the ramus and branches to innervate the buccak gingiva of the
mandubular molars.

BRANCHES OF THE POSTERIOR DIVISION, The posterior division of the mandibular nerve is primarily sensory, but it also
has a small motor component. The branches of posterior division related to mandibular anesthesia are the lingual and
inferior alveolar nerves.

The lingual nerve emerges between the lower head of the lateral pterygoid and medial pterygoid muscles and lies
between the ramus and the medial pterygoid muscle in the pterygomandibular space. It turns anteriorly, two – thirds of
the tounge,the mucous membranes of the floor of the mouth, and the lingual gingiva of the mandible.

The inferior alveolar nerve runs posterior and parallel to the lingual nerve within the pterygomandibular space, where it
enters the mandibular foramen. Within the mandible the inferior alveolar nerve travels in the mandibular canal and
innervates the pulpal and osseous tissues of the mandibular teeth in the quadrant and facial soft tissues anterior to the
first molar. Throughout its course the inferior alveolar nerve is accompanied by the inferior alveolar artery and vein.

As the inferior alveolar nerve reaches the mental foramen, it devides into two terminal branches. The incisive
nerve is a direct extension of the inferior alveolarnerve, continuing anteriorly within the mandibular canal. It innervates
the pulpal and osseous tissues of the mandibular first premolar, canine, lateral and central incisors, and the facial
periodontal tissues of the teeth. The mental nerve branches from the inferior alveolar nerve and exits the mandible via
the mental foramen and provided sen sory innervation to the mucous membranes and skin of the lower lip and chin.
 The mylohyoid nerve branches from the inferior alveolar nerve before the latter enters into the mandibular
foramen. It advances downward and forward in the mylohyoid groove on the medial side of the ramus and provides
motor innervation to the mylohyoid and anterior digastric muscles. In some individuals the mylohyoid nerve may supply
accessory sensory innervation to the mandible in the premolar and molar area.

LOCAL ANESTHESIA TECHNIQUES

When choosing the appropriate injection to be administered, the dental hygienst needs to consider the area to be
treated, the procedure to be performed, the extent of anesthesia necessary, and the client’s needs and comfort. In oral
health care there are three major types of injections useed to obtain local anesthesia:

a. Local infiltration

b. Field block

c. Nerve block

These are differentiated by the of anesthetic solution deposition relative to the area to receive treatment.

Local Infiltration

A local infiltration injection refers to the placement to the anesthetic solution clise to the smaller terminal endings
of the nerve fibers in the immidiate area to be treated. An example would be the injection of anesthetic solution into an
approximal papilla before therapeutic scalling and root planing.

Field Block

This method of obtaining anesthesia refers to the deposition of solution near large terminal nerve branches. The
resulting anesthesia is more circvumscribed, most often involving one tooth and the tissues surrounding the tooth.
Treatment is away from the site of the injection. The deposition of anesthetic solution above the apex of a maxillary right
central incisors, is an example of a field block. In oral healthcare a field block is often incorrectly refferred to as a local
infiltration.

Nerve Block

The nerve block refers to the deposition of anesthetic solution close to a main nerve trunk, often at some distance
from the treatment area. This type of injection most often anesthetizes a larger area than that of a field block. Examples
include a posterior superior alveolar nerve block and inferior alveolar nerve block.

Thus, when providing dental hygiene care in a small, isolated area, infiltretion anesthesia may be the best choice,
whereasb a field block is the injection of choice when one or two teeth are to be treated. When the dental hygiene care
plan involves a sextant or quadrant, nerve block anesthesia is recommended.

The term anesthesia is often proceded by either the word local or regional. Either phrase is correct ; each
indicates that a specific area is concious, unlikegeneral; anesthesia, in which the client is unconscious. Thus the use of
either term is appropriate, and they can be used interchangeably altough local anesthesia appears to be more commonly
used.
PROCEDURES FOR A SUCCESSFUL INJECTION

The goal for each administration of local anesthetic is, of course, to give a safe, comfortable injection for control and
elimination of painful sensations during and after dental hygiene care. It is ironic, however, that a procedure meant to
control pain for clients is oftenreported to be the most dreaded. Altough the prospect of receiving an intraoral injection
provokes fear and apprehension for many individuals, local anesthetic agent administration need not be painful. The
dental hygienist strives to make all dental hygiene care free from pain and strees, especially when administering intraoral
local anesthetics. Such techniques as using a topical anesthetic before needle insertion, depositing a few drops of
anesthetic solution and waiting 5 seconds before cautiously advancing the needle, and slowly depositing the anesthetic
solution help minimize or eliminate discomfort.

Strategies used to minimize anxiety include communicating with the client about the progress of the procedure. Keeping
clients informed of the procedures in a calm manner and using nonthreatening language helps minimize apprehension
and promote trust and cooperation. For example, telling clients “ I’m applying the topical anesthetic to the tissues so the
remainder of the procedure is more comfortable ” or, “ I don’t expect you to feel this ” when inserting the needle into the
tissues place a positive idea in the clients’s mind regarding the injecyion and keeps the client informed of theimpending
procedure. Taking the extra time results in a more comfortable procedure for the client, thus meeting the humans needs
for freedom pain and stress.

Procedure 34 – 4 presents steps to ensure comfort, safety, and succes common to all injections. Altough each injection is
unique with regard to anatomic considerations, these steps should be employed regardless of injection being
administered. Not every injection is successful and totally free of discomfort because the reactions of clients and the skills
of hygienist vary, however, if the steps in procedure 34 – 4 are followed, the client and the dental hygienist will enjoy the
benefit of the safest and least traumatic injection possible.

INJECTION TECHNIQUES FOR THE MAXILLARY TEETH AND FACIAL HARD SOFT TISSUES
The injection techniques available to anasthetize the maxillary teeth and soft tissues include supraperiosteal injection,
antertior superior alveolar nerve block, and posterior superior alveolar nerve block (PSA).

SUPRAPEROSTEAL INJECTION (LOCAL INFILTRATION)

A supraperiosteal injection, more commonly reffered to as local infiltration, involves depositing anashetic solution near
the apex of a single tooth, thus providing anasthesia of the tooth and the immediate surrounding area.

Equipment

Health history form

Sphgygmomanometer

Stethoscope

Gauze

Topical anasthetic agent

Cotton tipped applicator

Syringe

Anasthetic catridge

Needle

Protective barriers

Steps

1. asses the health history data

2. take vital signs. Minimal examination should include blood pressure, heart rate (pulse), and respiratory rate.

3. confirm care plan

4. Check armamentarium

5. Load the syringe and determine the syringe window and needle bevel orientation

6. chech needle sharpness by pulling the needle tip across sterile gauze, and watching forsnags (optional)

7. check the flow of solution

8. place the client in a supine position

9. communicate with the client. Do not use word with a negative connotation, such as shot, injection, pain, or hurt.
Instead, speak in less threatening terms such as “ administer the local anasthetic.”

10. position self (clinician) appropriately

11. visualize or palpate to locate the penetration site

12. dry the penetration site with gauze

13. apply topical anasthetic to the penmetration site ( optional )

14. apply topical anasthetic to the penetration site for 1 – 2 minutes

15. in the case of paltal injections, when placing topical anasthetic on the injection site, apply considerable pressure with
the cotton swab for a minimum of 1 minute before the injection.

16. redry the penetration site

17. make the tissue taut at the penteration site by retracting it (except the palate), utilizing saterile gauze

RATIONALE
Assist the dental hygienist in determining if the client is physiologically and psychologically able to tolerate the proposed
treatment and local anasthetic administration, and in modeling approach to care, if necessary, to decrease risk and
prevent subsequent medical emergencies.

Following guidelines for dental management of clients according to blood pressure level, heart rate, and respiratory rate
minimizes medical complications.

Verifies with the client the dental hygiene care indicated. Ensures that all materials are properly assembled, prepared, and
functional so the procedure is efficient.

The large window of the syringe should face the operator so she or he is able to see the amount of anasthetic being
administered and detect apositive aspiration. The bevel of the needle should face the bone. Tus. If the needle contacts
bone, the bevel deflects over the periosteum, minimizing discomfort and trauma. If the bevel faces away from