INTRODUCTION

Old actions return again, furbished over with some new and different circumstances. Fuller 1902

ocal anaesthesia has been defined as loss of sensation in circumscribed area of the body caused by a depression of excitation in nerve endings or an inhibition of the

conduction process in peripheral nerves.1 Halsted is credited with being the first to block the inferior alveolar nerve2, 3,4. In a letter to Dr. C. Edmund Kells (October 26, 1920) Halsted credits Koller with the first injection of the infraorbital nerve5. Adrenaline was added to cocaine by E. Mayer6 in 1901 to promote vasoconstriction, prolong the duration and intensify the depth of anaesthesia. Procaine, less toxic than cocaine and non-addictive, was synthesized in 1905 by Alfred Einhorn and Heinrich Braun4. This established the routine use of local anaesthesia for pain control in medicine and dentistry. As a result, clinicians developed techniques for regional anaesthesia. Early literature on the subject is limited but it appears that intraoral maxillary nerve block via the palatal approach was described first in the English literature by Mendel Nevin in 19177. The buccal approach was described by A.E. Smith in his 1920 text: "Block Anaesthesia and Allied Subjects". Gaston Labat was a pioneer in regional anaesthesia and his innovative 1923 text contained various techniques for extraoral and intraoral approaches to the maxillary nerve. Although no bibliography was given, some techniques were obviously drawn from the European literature, e.g. lateral route of Schlosser, intranasal route of Sluder.8

INTRODUCTION
The anatomy of the maxilla is different as compared to that of mandible, in that a thinner cortical plate will allow infiltration anesthesia in most situations. Despite this fact, the ability to block the maxillary nerve has many advantages that include the ability to do quadrant dentistry without the need for multiple injections.9 Maxillary nerve block provides a much broader scope for surgery. Patients accept this approach better than other techniques which require multiple injections; a case in point is extensive maxillary dental extraction which necessitates painful palatal injections in addition to multiple buccal and labial infiltrations. When combined with effective intravenous conscious sedation, maxillary nerve block elicits little reaction from the patient. Compared to general anesthesia, apart from obviating the dangers of this technique in poor risk patients, maxillary nerve block offers other advantages. First, bleeding is minimized. This effect is enhanced by use of a controlled quantity of epinephrine than is possible with certain inhalation anesthetics. Second, the absence of an oral-endotracheal tube eliminates competition for the same field between surgeon and anaesthesiologist. Moreover, because the laryngeal reflexes are preserved, the airway is protected from blood, tissue fragments, and packs, both during the operation and in the early postoperative period. Third, with regional anesthesia, several of the procedures that have been discussed may be performed expeditiously and less expensively in the office rather than in the hospital.10 The maxillary nerve can be blocked after it exits the foramen rotundum as it enters the pterygopalatine fossa. Several techniques of approach to this nerve are described: Intraoral route, High tuberosity technique and through the greater palatine foramen and canal. Extraoral route: By way of the sigmoid notch of the mandible and anterior to the coronoid process of the mandible.10 The maxillary nerve may be blocked for surgical, therapeutic and diagnostic purposes.
2

INTRODUCTION
Surgical indications include, multiple maxillary extractions11,12,13,14,15, endodontic procedures12,16 multiple restorations7,16.15, , periodontal procedures.14,16 . Surgical Procedures include apical surgery15, impacted teeth17,
18,19,1

, alveolectomy19.Maxillary sinus procedures

including Caldwell-Luc antrostomy18, 19, and 13,20,21,14,16,1. Palatal surgery ligations. Fracture reduction18,19,14,22, Segmental osteotomy
1,15 20.13.16:

Intranasal procedures, septal reconstructions, polypectomy, arterial

, Excision of large neoplasms

23,11,7,12,15

18,19

,Soft

tissue surgery 13,14,16,Incision and drainage of abscesses

,An alternative to other

techniques in the presence of infection or pathology 24,25,18,7,8.12.16,1,15. Trismus/False ankylosis

23

, Poor risk general anaesthestic patients.19,

11,8,14

, General anaesthesia not available11, 8.

Useful adjunct to awake nasal intubation, to treat epistaxis (in conjunction with vasoconstrictor).Therapeutic Indications include pain relief especially with intractable pain. 26,
12, 13

. Diagnostic Indications includes Differentiation of neuralgias.17,

12, 13, 16,1,15,

Oral and

maxillofacial pain syndromes16 The basic concept of maxillary nerve block remains unaltered since the techniques were first described. Modifications have been introduced as a result of operator experience and research. In literature some conflicts still exists over which intraoral technique is better. Some researchers suggest high tuberosity technique over greater palatine canal technique and some suggest greater palatine technique. There are still no absolute guidelines about the amount of solution to be used and the adequate length of needle to be used in both techniques. To compare between two techniques over the issue of efficacy including both soft tissue and hard tissue anaesthesia a study was undertaken to assess which technique is more effective with respect to comfort to the patient, ease of administering, lesser long term complications and achieving hemimaxilla anaesthesia.