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Block anesthesia for the maxilla
BIIOCK
ANESTHESIA
FOR THE
A
MAXILLA
BLOCK anesthesia for the maxilla similar to t,he one used commonly for the mandible is something that any practitioner in dentistry, especially those who are working in the fields of oral surgery and exodontia, should desire. Ijentists all know that it is common practice to make at least five injections to anesthetize the posterior, middle, and anterior superior alveolar nerves, and the ant,rrior palatine and nasopalatine nerves. These injections arc always a source of discomfort to the patieni., skillful and careful as the operator may bc, both at lhe time of injecting and also postoperatively. Why, then, has not Ihe maxillary block, or serond division injection, as it is commonly referred to, been put into more common usage? The commonest criticism that is presented among practitioners seems to be that we are encroaching upon unfamiliar and dangerous structures while making this injection; but who should be more familiar with anatomical structures than the dentist, who spends at least six years of college preparation culminating in a specialized practice of work in the oral cavity and its surrounding structures? When this criticism is voiced by a doctor of dental surgery, it would seem either that he is uncertain of the cranial anatomy or that he lacks self-confidence, which can be gained only by expcriclncc in this particular field. How many dentists cannot remember seeing for the first time the mandibular or inferior alveolar block being given, and at the same time marveling at the skill and knowledge of the operator whom they watched. This I believe to 1)~ somewhat t,he same feeling that most dentists experience when t,hey see or read of t,his second division injection being made. Yet I earnestly feel that, with the background that every member of the dental profession must have in order legally to practice his art, he is equipped to execute this seemingly difficult and dangerous injection with comparative ease and safety, at least without any more hazards and difficulties than the mandibular injection presents which so many dentists arc commonly using today in their practices. The anesthesia for this second division injection of the trigerninal nerve is obt,ained by depositin g a local anesthetic solution in the vicinity of the sphenopalatine ganglion. This is accomplished by entering the posterior palatine foramen which opens into the pterygopalatine canal and carrying a needle up this canal approximat,ely one and a half inches. A local anesthetic solution deposited in this canal with the needle at this depth will anesthetize the ganglion and its branches and also the maxillary nerve from which the sphenopalatine or Meckel’s ganglion is so closely suspended. These are the branches of the trigeminal nerve which innervate the maxilla and supply all the maxillary teeth on one side of the head and which, when influenced by novocain or some similar local anesthetic, produce a profound anesthesia of these parts. *Resident
in
oral
surgery,
Harper
Hospital. 683
664
R. Noble Pcckhawt
The technique which I employ for executing this injection follows: The patient’s head is tipped backward in the headrest allowing a clear view of the roof of the mouth and its surroundings. The mucous membrane under which lies the posterior palatine foramen is rubbed with a dry swab, re-
Fig.
Fig.
P.-Posterior
palatine
L-Posterior
foramen
palatine
located and ing Meckel’s
foramen
needle ganglion.
being
in
located.
pterygopalatine
canal
approximat-
moving any saliva or mucous secretion which may be present, and an antiseptic solution is applied to this area. I routinely use a 2 per cent iodine solution for this procedure, though there are others just as practical. The point where I have nearly always found the posterior palatine foramen to be lies on an imaginary line drawn from the middle of the maxillary second molar medially
Block Anesthesia
for
the
Ma&a
685
along the roof of the mouth to the midline (or fusion line) of the palate and slightly less than halfway from the crest of the alveolar ridge to the midline of the palate.
A
Fig. X-Diagram illustrating method of finding posterior palatine foramen. AB, Fusion CD, imaginary line drawn from middle of maxillary second molar medially line of palate; on this imaginary line slightly along roof of mouth to fusion line of palate; E, point less than halfway from crest of alveolar ridge to fusion line.
Fig. 4 .-Sagittal section of head showing position A, Sphenopalatine ganglion attached to maxillary nerve rotundurn; 33, maxillary division of Gasserian ganglion D, posterior palatine foramen. C, Gasserian ganglion:
of needle during maxillary block. after it has passed through foramen before entering foramen rotundum;
With the mucous membrane at this point having been thus prepared, a needle of 25 gauge and 17/s inches in length is quickly inserted beneath the soft
686
R. Noble Pockham
tissue under which the posterior palatine foramen lies; and a few drops of the anesthetic solution are deposited immediately, which will anesthetize the palatal soft tissue in this area, allowing the operator carefully to “step” the point of the needle about until he feels the tip of the needle slip into the foramen. This entrance point to the pterygopalatine canal can usually be found from this first puncture site, although additional punctures may be needed until the foramen can be found. This will, however, cause no discomfort to the patient because this entire area has been previously anesthetized wit,h the first few drops of the anesthetic. After the posterior palatine foramen is located, the needle is in position to be directed up the pterygopalatine canal and to approximate the sphenopalatine ganglion. Keeping a small amount of solution ahead of the needle point, the needle is carried through the foramen and directly upward in the pterygopalatine canal to a depth of one and one-half inches. Any resistance that, can be felt during this portion of the injection is an indication to the operator that he is not holding the needle parallel to the walls of this canal. The needle should immediately be withdrawn slightly, and the course of the insertion should be corrected and the injection then be continued. Now with the needle in the pterygopalatine canal at a depth of one and one-half inches, between 1 C.C. and 1.5 cc. of anesthetic solution are slowly deposited. The needle should then slowly be withdrawn. The patient can usually express symptoms of anesthesia five minutes after this injection has been given, although there are some patients who require a longer interval, as is the case sometimes with the familiar mandibular block. Symptoms which the patients describe that are indicative of anesthesia being present are : a sense of numbness of the upper lip on the side of the face the injection has been given, extending to the midline; also a numbness or ‘ ‘ prickly feeling ’ ’ on the corresponding side of the nose, and a numb sensation of the lower eyelid. The entire roof of the mouth will also have the characteristic ‘ (dead feeling. ’ ’ When these symptoms are evidenced by the patient, the operator can be assured that anesthesia is present, and the required operative work may be readily begun. Any operating to be done at the midline, such as the extraction of a central incisor, should be preceded by an infiltration extending to the opposite side of the midline to anesthetize any interlacing nerve fibers present. In a series of one hundred injections of this type done at Harper Hospital in a period of three months (November, 1937, to February, 1938)) no ill effects were evidenced by any of the patients, and a profound anesthesia lasting from two to six hours was secured in all cases. In the future we should see this block or conduction type of anesthesia being used for operations involving the maxilla as it is now being employed for the mandible. I am indebted Dr. Wm. A. Cook, specimen.
to Mr. Frank Chief of Staff,
N.
Ruslander Oral Surgery,
of
Harper Harper
Hospital Hospital,
for for
photography and to loan of anatomical
ANESTHESIA
FOR THE
A
MAXILLA
BLOCK anesthesia for the maxilla similar to t,he one used commonly for the mandible is something that any practitioner in dentistry, especially those who are working in the fields of oral surgery and exodontia, should desire. Ijentists all know that it is common practice to make at least five injections to anesthetize the posterior, middle, and anterior superior alveolar nerves, and the ant,rrior palatine and nasopalatine nerves. These injections arc always a source of discomfort to the patieni., skillful and careful as the operator may bc, both at lhe time of injecting and also postoperatively. Why, then, has not Ihe maxillary block, or serond division injection, as it is commonly referred to, been put into more common usage? The commonest criticism that is presented among practitioners seems to be that we are encroaching upon unfamiliar and dangerous structures while making this injection; but who should be more familiar with anatomical structures than the dentist, who spends at least six years of college preparation culminating in a specialized practice of work in the oral cavity and its surrounding structures? When this criticism is voiced by a doctor of dental surgery, it would seem either that he is uncertain of the cranial anatomy or that he lacks self-confidence, which can be gained only by expcriclncc in this particular field. How many dentists cannot remember seeing for the first time the mandibular or inferior alveolar block being given, and at the same time marveling at the skill and knowledge of the operator whom they watched. This I believe to 1)~ somewhat t,he same feeling that most dentists experience when t,hey see or read of t,his second division injection being made. Yet I earnestly feel that, with the background that every member of the dental profession must have in order legally to practice his art, he is equipped to execute this seemingly difficult and dangerous injection with comparative ease and safety, at least without any more hazards and difficulties than the mandibular injection presents which so many dentists arc commonly using today in their practices. The anesthesia for this second division injection of the trigerninal nerve is obt,ained by depositin g a local anesthetic solution in the vicinity of the sphenopalatine ganglion. This is accomplished by entering the posterior palatine foramen which opens into the pterygopalatine canal and carrying a needle up this canal approximat,ely one and a half inches. A local anesthetic solution deposited in this canal with the needle at this depth will anesthetize the ganglion and its branches and also the maxillary nerve from which the sphenopalatine or Meckel’s ganglion is so closely suspended. These are the branches of the trigeminal nerve which innervate the maxilla and supply all the maxillary teeth on one side of the head and which, when influenced by novocain or some similar local anesthetic, produce a profound anesthesia of these parts. *Resident
in
oral
surgery,
Harper
Hospital. 683
664
R. Noble Pcckhawt
The technique which I employ for executing this injection follows: The patient’s head is tipped backward in the headrest allowing a clear view of the roof of the mouth and its surroundings. The mucous membrane under which lies the posterior palatine foramen is rubbed with a dry swab, re-
Fig.
Fig.
P.-Posterior
palatine
L-Posterior
foramen
palatine
located and ing Meckel’s
foramen
needle ganglion.
being
in
located.
pterygopalatine
canal
approximat-
moving any saliva or mucous secretion which may be present, and an antiseptic solution is applied to this area. I routinely use a 2 per cent iodine solution for this procedure, though there are others just as practical. The point where I have nearly always found the posterior palatine foramen to be lies on an imaginary line drawn from the middle of the maxillary second molar medially
Block Anesthesia
for
the
Ma&a
685
along the roof of the mouth to the midline (or fusion line) of the palate and slightly less than halfway from the crest of the alveolar ridge to the midline of the palate.
A
Fig. X-Diagram illustrating method of finding posterior palatine foramen. AB, Fusion CD, imaginary line drawn from middle of maxillary second molar medially line of palate; on this imaginary line slightly along roof of mouth to fusion line of palate; E, point less than halfway from crest of alveolar ridge to fusion line.
Fig. 4 .-Sagittal section of head showing position A, Sphenopalatine ganglion attached to maxillary nerve rotundurn; 33, maxillary division of Gasserian ganglion D, posterior palatine foramen. C, Gasserian ganglion:
of needle during maxillary block. after it has passed through foramen before entering foramen rotundum;
With the mucous membrane at this point having been thus prepared, a needle of 25 gauge and 17/s inches in length is quickly inserted beneath the soft
686
R. Noble Pockham
tissue under which the posterior palatine foramen lies; and a few drops of the anesthetic solution are deposited immediately, which will anesthetize the palatal soft tissue in this area, allowing the operator carefully to “step” the point of the needle about until he feels the tip of the needle slip into the foramen. This entrance point to the pterygopalatine canal can usually be found from this first puncture site, although additional punctures may be needed until the foramen can be found. This will, however, cause no discomfort to the patient because this entire area has been previously anesthetized wit,h the first few drops of the anesthetic. After the posterior palatine foramen is located, the needle is in position to be directed up the pterygopalatine canal and to approximate the sphenopalatine ganglion. Keeping a small amount of solution ahead of the needle point, the needle is carried through the foramen and directly upward in the pterygopalatine canal to a depth of one and one-half inches. Any resistance that, can be felt during this portion of the injection is an indication to the operator that he is not holding the needle parallel to the walls of this canal. The needle should immediately be withdrawn slightly, and the course of the insertion should be corrected and the injection then be continued. Now with the needle in the pterygopalatine canal at a depth of one and one-half inches, between 1 C.C. and 1.5 cc. of anesthetic solution are slowly deposited. The needle should then slowly be withdrawn. The patient can usually express symptoms of anesthesia five minutes after this injection has been given, although there are some patients who require a longer interval, as is the case sometimes with the familiar mandibular block. Symptoms which the patients describe that are indicative of anesthesia being present are : a sense of numbness of the upper lip on the side of the face the injection has been given, extending to the midline; also a numbness or ‘ ‘ prickly feeling ’ ’ on the corresponding side of the nose, and a numb sensation of the lower eyelid. The entire roof of the mouth will also have the characteristic ‘ (dead feeling. ’ ’ When these symptoms are evidenced by the patient, the operator can be assured that anesthesia is present, and the required operative work may be readily begun. Any operating to be done at the midline, such as the extraction of a central incisor, should be preceded by an infiltration extending to the opposite side of the midline to anesthetize any interlacing nerve fibers present. In a series of one hundred injections of this type done at Harper Hospital in a period of three months (November, 1937, to February, 1938)) no ill effects were evidenced by any of the patients, and a profound anesthesia lasting from two to six hours was secured in all cases. In the future we should see this block or conduction type of anesthesia being used for operations involving the maxilla as it is now being employed for the mandible. I am indebted Dr. Wm. A. Cook, specimen.
to Mr. Frank Chief of Staff,
N.
Ruslander Oral Surgery,
of
Harper Harper
Hospital Hospital,
for for
photography and to loan of anatomical