Head and Neck Anatomy in

Relation to Local Anaesthesia

Dr Heather Apthorpe
Bdent 2
A preparatory lecture of essential
knowledge prior to Local Anaesthesia
RCA

Knowing your anatomy is a

pre-requisite for administering LA

From :Abrahams, Boon, Spratt.2008. Mc Minns Clinical Atlas of Human Anatomy 6th Ed

From
:Abrahams,
Boon,
Spratt.2008
. Mc Minns
Clinical
Atlas of
Human
Anatomy
6th Ed

Blood supply to the head

Common carotid artery divides to
Internal carotid-supplies brain,
eye and carries sympathetic
plexus.
External carotid gives off
branchesSuperior thyroid a.
Lingual a. supplies tongue (2)
Facial a. supplies face (including
facial expression muscles) (3)
Occipital a.(runs posteriorly and
exits behind mastoid to supply
occipital area)
Maxillary a.(deep to neck of
condyle)
Superficial temporal a. (supplies
scalp) (4).

Venous drainage of the head and

neck
Be aware of the
position of the
veins and the
direction of venous
drainage.
Also position of the
Inferior Alveolar
Vein in mandible
and Pterygoid
plexus (in Pterygopalatine fossa)

Sensory Nerve supply

As dental clinicians you will be most
involved in anaesthesia of the teeth
and oral region.
The cranial nerve that you are about
to form a life long relationship with,
is the Trigemminal Nerve (CNV).
In order to deal with it effectively, it
is necessary to know it thoroughly.

Trigemminal Nerve CNV

Largest cranial nerve, made up of 3 divisions:
Ophthalmic,Maxillary,Mandibular

1.
2.
3.
1.

Sensory to the face, scalp, nose, mouth and

teeth (via Div 1,2&3)
Small motor component to muscles of
mastication (via Div 3 only)
Contains 4 nuclei in the brain:
Sensoryspinal nucleus in the medulla
mesencephalic nucleus in the midbrain
pontine (chief) sensory nucleus in the pons
Motormotor nucleus in the pons

Ophthalmic nerve CNV1

Smallest division
Supplies sensory innervation to orbit,
lacrimal gland, nose and skin of the
eyelids and forehead
Enters orbit through superior orbital
fissure
Divides into lacrimal, frontal,
nasociliary branches

Ophthalmic nerve (CNV1)

Haglund, Evers. Local anaesthesia in dentistry, 5th Ed, 1984, Astra

Lakemedel

Maxillary nerve (CNV2)

Divides into 4 branches:

infraorbital, zygomatic, superior alveolar, palatine.
Infraorbital n. enters infraorbital groove and exits at
infraorbital foramen on maxilla. Supplies skin of

lower eyelid, front of cheek, side of the nose.

Zygomatic n. has 2 branches:

zygomaticotemporal :
(supplies skin of the temple) and

zygomaticofacial
(supplies skin over cheekbones)

Dental and sinus branches

Superior alveolar n. has three
branches: posterior, middle and
anterior.
Supply the maxillary teeth and buccal
gingiva and buccal vestibule.
supply the maxillary sinus for sensory
innervation.
Explains tooth pain in sinusitis.

Palatine n. divides into:

greater and lessor palatine nerves
nasal branches
enters greater palatine canal in maxilla

nasal branches supply nasal mucosa

greater palatine supplies posterior hard
palate and gingiva (to level of canine teeth)
lessor palatine nerves supply soft palate
nasopalatine n. is terminal branch of one of
the nasal branches. It supplies soft tissue on
anterior part of hard palate (13-23)

Maxillary nerve- another view

Posterior, middle and anterior superior

alveolar branches of maxillary nerve.

Howe, Whitehead, Local anaesthesia in dentistry 1st Ed, 1972, John

Wright and Sons.

Anterior, middle and posterior superior

alveolar branches maxillary nerve

Haglund, Evers. Local anaesthesia in dentistry, 5th Ed, 1984, Astra

Lakemedel.

Maxillary Anterior teeth

The anterior superior alveolar nerve innervates

The incisors,
canines,
the buccal gingiva and
the periosteum

Important: The nerves anastomose over the midline

The medial spread of L.A. may be hindered by
the labial frenulum in the midline.
The nasopalatine nerve innervates

The palatal gingiva,

The palatal mucosa and
The palatal periosteum of the incisors and canine.
Emerges from the bone through the incisive or nasopalatine
foramen.

Maxillary anterior teeth

The anterior superior
alveolar nerve
innervates

The incisors,
canines,
the buccal gingiva and
the periosteum

Important:
The
nerves anastomose over
the midline
The medial
spread of L.A. may be
hindered by the labial
frenum in the midline.

Variations in depth of needle placement in infiltration

anaesthesia

Aim is to position the needle

horizontally adjacent to the
apex of the tooth root, to
allow the solution to reach the
nerve as it leaves the tooth
Deep buccal sulcus means
fairly superficial placement of
needle tip under mucosa
Shallow buccal sulcus means
the needle needs to penetrate
further in order to be placed
adjacent to the root apex

Authors own photo October 08

Maxillary pre-molar teeth

The middle superior
alveolar nerve
(The superior dental plexus
is formed by convergent
branches from the
posterior, middle and
anterior superior alveolar
nerves. The presence of
the middle superior
alveolar nerve is irregular)
Innervates:
The maxillary premolars
the buccal gingiva and
the periosteum of the
alveolar ridge

Howe, Whitehead, Local anaesthesia

in dentistry 1st Ed, 1972, John
Wright and Sons.

Authors own photo July 08

Maxillary molar teeth

The Posterior Superior
Alveolar Nerves:
branch off the maxillary
nerve down the posterior
surface of the maxilla,
which they enter to
innervate

the upper molars,

the buccal gingiva and
Periosteum over the
buccal surface of alveolar
ridge.

Howe, Whitehead, Local anaesthesia

in dentistry 1st Ed, 1972, John
Wright and Sons.

From: Howe and

Whitehead,
1972,Local
anaesthesia in
dentistry. Wright &
Sons, Bristol. Pg 46

Branches of the mandibular nerve in

relation to the mandible.

Mandibular nerve CNV3

Both sensory and motor
Motor to muscles of
mastication, mylohyoid,
anterior belly of digastric,
tensor tympani, tensor veli
palatini.
Sensory to anterior two
thirds of tongue, floor of
mouth, buccal mucosa,
mandibular teeth, skin of
temporal region, lateral
cheek, mandible (not at
angle-cervical plexus), chin
and lower lip.
Emerges from cranial
cavity through foramen
ovale into infratemporal
fossa, where it branches.

Mandibular incisor teeth

The incisive nerve

(a distal branch of the

inferior dental nerve)
innervates the
canine and
incisor teeth, and
the first premolar
the teeth from 33 to 43
can be anaesthetised by
infiltration or by
mandibular block.

From; Howe and Whitehead, Local

Anaesthesia in dentistry, 1972, Wright &
Sons Ltd p65

Mental nerve- branch of IAN

The mental nerve
innervates

the buccal gingiva , the lip

and
the periosteum of the
mandibular incisors and first
premolars

Not the lower

incisor teeth.

They are innervated by the

IAN.
The nerve exits through the
mental foramen.
The mental nerve will also be
blocked by the IAN injection.
It can be anaesthetised alone
by infiltration next to the
nerve as shown at left.

Mental Nerve
Innervates the
buccal and labial
mucosa from 33 to
midline and from 43
to midline. No
crossover at the
midline.
Innervates the lower
lip on that side to
the corner of the
mouth.
Can be
anaesthetised at the
mental foramen or
via IAN block.

You can also

anaesthetise the
mandibular premolar
teeth by mental
nerve block if the
anaesthetic solution
is placed close
enough to the
foramen.
This is very easy
when using
Septanest LA
(Articaine).

Inferior Alveolar Nerve Block

A nerve block that deposits
LA at the opening of the
mandibular canal on the
inside of the mandible in
order to anaesthetise the
inferior alveolar nerve.
Area of anaesthesia:
all mandibular teeth on that
side to the midline.
lower lip, labial mucosa (to
corner of mouth), labial
gingiva and periosteum
over teeth from 1st premolar
to central incisor..

Variations in the mandible topography

The level of the
mandibular foramen
varies depending on
age and degree of
edentulism.
For this reason it is
often useful to
palpate the anterior
and posterior borders
of the ascending
ramus because the
tip of the needle is
going to be aimed to
end up approximately
midway between the
finger and thumb
From;Howe and Whitehead, Local Anaesthesia in dentistry, 1972, Wright & Sons Ltd p63

Inferior Alveolar Nerve Block Horizontal

Angulation

The barrel of the

syringe should
usually lie over the
premolar teeth on
the opposite side.

Inferior Alveolar Nerve Block

Palpation of coronoid notch on anterior

border of mandible.

Insertion of long needle using safe

method with mirror to retract tissues.
Red line represents another possible
entry point for the needle.

Long Buccal Nerve

The long buccal nerve
(CNV3) innervates the
mucosa of the cheek,
vestibule and gingiva
adjacent to the
mandibular molar teeth
as far forward as the
second pre-molar tooth.
A separate injection is
required when
disturbing the buccal
vestibule mucosa eg
when extracting a lower
molar tooth. You can
either inject next to
tooth or do buccal nerve
block.

IAN
block
buccal
nerve
block

Lingual nerve
The Lingual nerve
innervates

the lingual gingiva and

periosteum of the
mandibular
teeth from 38 to 31 and 48
to 41

Coronal section showing

position for anaesthetising
the lingual nerve
Pterygomandibular
raphe

Uses of IAN Block for Local

Anaesthesia on mandibular teeth
Cavity Preparations and Pulp Surgery
(Endodontics)
The IAN block is used and no blocking of
the lingual nerve is necessary.
Surgical Procedures example: exodontia
The IAN block should be supplemented by a
deposition of solution at the lingual nerve.
The soft tissues surrounding the molars are
anesthetized by blocking the long buccal nerve.

Deep scaling and periodontal procedures

The IAN block should be supplemented by
solution deposition at the lingual and long buccal
nerves.

Thank you for your attention