PALATAL ANESTHESIA

The mucosa of the hard palate and the palatal gingiva are supplied by the nasopalatine and
greater palatine nerves. The boundary between the areas innervated by the two nerves
corresponds roughly to a line drawn between the maxillary canines; however, the two areas
are not so sharply delineated as such an imaginary line might suggest. By severing the
nasopalatine nerve, Langford showed that the greater palatine nerve may play a larger role in
the innervation of the anterior palate than had previously been thought. 1 Apart from
infiltration anesthesia, wo major blocks are recommended for palate,
Nasopalatine nerve block - Fibers of the superior alveolar plexus occasionally join the
nasopalatine nerve just below the nasal floor and travel with the nasopalatine nerve to reach
the central incisor on the side of the mouth being innervated. It may be necessary to
anesthetize the nasopalatine nerve to completely anesthetize the central incisors. This is best
accomplished by injecting immediately lateral to the incisive papilla, with the needle directed
upward, backward and slightly medially.2
Meyer TN, Lemos LL, Nascimento CNM, Lellis WRR (2007) 3
assessed the effectiveness of nasopalatine nerve block for anesthesia of maxillary central
incisors after failure of the anterior superior alveolar nerve (ASAN) block technique. Twentyseven healthy, young adult volunteers (age: 17-26 years; gender: 9 males and 18 females)
were enrolled in this study. All participants were undergraduate dental students of the
University of Vale do Rio Verde de Trs Coraes. The volunteers had the anterior superior
alveolar nerves anesthetized and a thermal sensitivity test (cold) was performed on the
maxillary central incisors. The volunteers that responded positively to cold stimulus received
a nasopalatine nerve block and the thermal sensitivity test was repeated. All participants were
anesthetized by a single operator. Three patients presented sensitivity after both types of
bilateral blocks and were excluded from the percentage calculations. In the remaining 24
patients, 16 had their maxillary central incisors anesthetized by the anterior superior alveolar
block and 8 remained with sensitivity after the ASAN block. All these 8 patients had their
maxillary central incisors successfully anesthetized by the nasopalatine block.
Greater palatine nerve block - .Most of the older literature place the greater palatine
foramen, which is accessed to administer a greater palatine nerve block or a second division
nerve block, palatally opposite the second molar. More recent studies, however, localize the
greater palatine foramen farther posteriorly than is traditionally depicted. One study showed

this foramen to be opposite or slightly distal to the third molar or its extraction site (57
percent). The foramen has been shown to lie 1.9 mm in front of the posterior border of the
hard palate and 15 mm from the palatal midline. These measurements are useful for more
easily locating the greater palatine foramen and enhancing the anesthetic injection technique
in the posterior palate.2
Sahar HN et al. (2014)4 gave a new technique of ultrasound-guided greater palatine nerve
block. They scanned and injected 16 undissected well-embalmed hemisectioned cadaveric
heads after excluding major anatomical malformations. The success rate of identification of
GPF, number of attempts, and number of successful injections were recorded. The technique
was evaluated clinically in 7 patients undergoing dental procedures. Five patients had USguided injections, and 2 patients received US-assisted greater palatine canal blocks. Clinical
evaluation reconfirmed successful identification of GPF by US in 6 of 7 patients (n = 6/7).
US-guided injections were successful in 6 of the 8 attempted blocks (n = 6/8) with median
number (range) of attempts being 2 (1-4) US-assisted injections were successful in 2 patients
(n = 2/2). Authors concluded that US has the potential to successfully locate and characterize
GPF in normal and edentulous maxilla as a defect in the bony palate.
Even after the invention of the modern injection
techniques, palatal injection still remains a painful experience for patients, and this pain is
attributed to the presence of rich nerve complement and displacement of palatal mucosa
during anesthesia. A number of techniques may be used to reduce the discomfort of intraoral
injections, including transcutaneous electronic nerve stimulation (TENS), topical anesthetic
application, topical cooling of the palate, computerized injection systems, pressure
administration, and eutectic mixture of local anesthetics (EMLA). Among local anesthetics,
it has been claimed that articaine, which belongs to the amide group is able to diffuse
through soft and hard tissues reliably. This property of articaine makes it possible to obviate
the need for a palatal injection when infiltrated buccally, if maxillary teeth are indicated
for extraction.3
Sekhar GR, Nagaraju T, Nandagopal V, Sudheer R, KolliGiri (2010) 5 conducted a study
to demonstrate if lidocaine HCl could provide palatal anesthesia if given buccally during
maxillary tooth removal without the need for a palatal injection. The study group consisted of
75 patients, and 25 were controls. All the patients in the study group had unilateral
extractions. In 75 patients, 2 ml of 2% lidocaine HCl with 1:80,000 epinephrine was injected

into the buccal vestibule of tooth indicated for extraction without palatal injection. After 8
min, the extraction of maxillary tooth was carried out. Twenty-five subjects in the control
group underwent same protocol with palatal injection. All the patients completed a faces pain
scale (FPS) and a 100 mm visual analog scale (VAS) after extraction. According to VAS and
FPS scores, when comparison was carried out between permanent maxillary tooth removal
with and without palatal injection, the difference in the pain levels were not statistically
significant (P>0.05). So, authors concluded that The extraction of permanent maxillary tooth
is possible by depositing 2 mL of lidocaine to the buccal vestibule of the tooth without the
need for palatal anesthesia.