Bachelor of Dentistry Year 2

NOTES IN ANATOMY
IN RELATION TO LOCAL ANAESTHESIA

February 2010

by Dr Michael Hornby BDS, GradDipClinDent (Sedation & Pain Control)

NB: Please refer to presentation for basic sites and techniques for local anaesthesia administration
MAXILLA
Features:
Horizontal process
Anterior nasal spine
Groove for the incisive canal
Orbital surface
Infraorbital groove and foramen
Tuberosity
Foramina for posterior superior alveolar arteries and nerves
Zygomatic buttress
Canine fossa and canine eminence; incisive fossa (on frontal surface)
Bony architecture: The maxilla commonly has a thin outer cortex (from anteriorly to posteriorly),
which allows for infiltration anaesthesia. The strength of this bone is in the thick zygomatic and
frontal processes for transmitting forces vertically.

MAXILLARY NERVE
The 2nd division of the 5th cranial nerve, it travels forward from the trigeminal ganglion in the
middle cranial fossa, enters foramen rotundum and thence into the pterygopalatine fossa where
the pterygopalatine ganglion is located. It is responsible for the sensory supply to the upper teeth
and gingivae, the mucosal lining of the nose, maxillary antrum and conchae; it also supplies the
lower eyelid and skin of the face from the upper lip, ala of the nose and to the temporal region
where its terminal fibres intermingle with those of the supraorbital (ophthalmic division) and
auriculotemporal (mandibular division) nerves. It also carries postganglionic secretomotor fibres
picked up from the pterygopalatine ganglion within the pterygopalatine fossa.

INFRAORBITAL NERVE
The continuation of the maxillary nerve from within the pterygopalatine fossa; it runs forward
along the floor of the orbit, from the inferior orbital fissure, usually within its own bony canal but
occasionally with only the periosteum of the orbit roofing its path, then exits the infraorbital
foramen to supply the soft tissues from the upper lip including the buccal gingivae and sulcus, to
the ala of the nose and to the lower eyelid inclusive.

from: Romanes G J, “Cunningham’s Manual of Practical Anatomy”, vol 3, 15th ed. Oxford Medical Publications, 1989. fig. 107, p 127

2
POSTERIOR SUPERIOR ALVEOLAR (PSA) NERVE
Three to four branches: one or two to soft tissues of the buccal sulcus, and two main bony
branches (superior and inferior): both pierce the thin maxilla high up and travel on the postero-
lateral wall of the antrum; the inferior branch gives supply to the molars except the mesio-buccal
root of the 1st molar; the superior division gives supply to the premolars and the mesio-buccal
root of 1st molar. PSA block: beware of the posterior superior alveolar arteries and (higher up) the
maxillary artery.

MIDDLE SUPERIOR ALVEOLAR (MSA) NERVE

Possibly not a main trunk proper, probably from the smaller superior PSA nerve or branching off
the ASA nerve after it has left the infraorbital nerve, when present (approx 30% of cases) MSA
gives supply to premolars and mesiobuccal root of 1st molar

ANTERIOR SUPERIOR ALVEOLAR (ASA) NERVE

The largest of the 2 superior alveolar nerves, it splits off laterally from the infraorbital nerve approx
15mm proximal from infraorbital foramen and runs down then along the lateral wall of the antrum
(anterior to zygomatic buttress) before turning on the anterior wall of the antrum and passing
medially towards the nose. It is located about 6mm below the infraorbital foramen. Before
reaching the nose the ASA nerve gives twigs to the anterior teeth (these twigs ramify with the
superior and inferior branches of the PSA nerve. The ASA nerve then continues to supply the
anterior lateral wall of nose and floor, and part of the anterior septum.
In giving an infraorbital block to anaesthetise the anterior teeth you are anaethetising the ASA
nerve by perfusion through the thin anterior maxilla, because blocking the infraorbital nerve at the
foramen will not block the ASA nerve (as the ASA nerve splits off the infraorbital nerve proximal to
the foramen).
Because the PSA and ASA nerves run on the antral wall, it can sometimes be difficult to achieve
anaesthesia if the patient has acute sinusitis or nasal congestion; even inflammation of the antral
lining can be a barrier to profound anaesthesia.
Arterial supply: from the maxillary, 3rd part (the part of the maxillary artery entering and within the
pterygopalatine fossa; the arteries run with the nerves.

PALATE
The hard palate is comprised of both maxillary and palatine bones. Greater palatine foramen is at
the junction of the maxilla and palatine bones. Lesser palatine foramina (2 to 3) found on root of
pyramidal process of palatine bone. Greater palatine canal is located on the lateral wall of the
nose approx. 70-80 degrees off the occlusal plane, and is thin-walled in bone. Quite often the
canal is not perfectly straight and curves slightly; coupled with the fact that it has nerves and
vessels traversing the length of the canal it can be extremely difficult to navigate with a needle
(non - patent), thus making a maxillary block though this route difficult to achieve. When you have
traversed the canal into the pterygopalatine fossa and deposit anaesthesic you may inadvertently
squirt it into the back of the nose (through sphenopalatine foramen) or because the medial wall of
the canal is so thin you may even be in the nose before you deposit solution!
The lesser palatine neurovascular bundle runs in a canal parallel to greater palatine canal.
The greater palatine foramen is usually located below the palatal roots of and between the 2nd
and 3rd molars.

LESSER PALATINE NERVES

Give supply to the hamular region and soft palate, thus in the removal of an upper 8 you are
anaesthetising lesser palatine fibres as well as greater palatine fibres; also innervates part of the
palatine tonsil.

GREATER PALATINE NERVE

Runs forward with the greater palatine vessels forward along the maxilla to give supply to the
palatal gingiva up to the canine region and midline, where its terminal branches interdigitate with
the terminal branches of the incisive nerve (from nasopalatine nerve).

GREATER PALATINE ARTERY

Runs forwards and up the incisive canal, to anastamose with the nasopalatine/sphenopalatine
arteryon the nasal septum near the floor of the nose.
3
NASOPALATINE OR SPHENOPALATINE ARTERY
Coming from the 3rd part of the maxillary artery, enters the nose with the nasopalatine of
sphenopalatine nerve through the sphenopalatine foramen, then runs over the back of the roof of
the nose medially to the septum, where it then runs forward to the incisive canal.

SPHENOID BONE
An important bone for local anaesthesia, as the greater wing houses foramen ovale, foramen
spinosum and the attachment for upper head of lateral pterygoid. The sphenoid also articulates
with the palatine bone and posterior aspect of the maxilla, forming the pterygopalatine fossa. The
sphenoid bone contains foramen rotundum for the maxillary nerve and the pterygoid canal for
parasympathetic and sympathetic connections in the pterygopalatine ganglion. The sphenoid
bone also has the lateral and medial pterygoid plates, with the pterygoid hamulus at the end of
the medial pterygoid plate.

PTERYGOPALATINE FOSSA
Located behind the maxilla and in front of the root of the pterygoid plates of the sphenoid, it
contains terminal branches of 3rd part of maxillary artery, maxillary nerve, pterygopalatine
ganglion.

PTERYGOPALATINE GANGLION
The pterygopalatine ganglion receives parasympthetic secretomotor fibres from the greater
superficial petrosal nerve. The superior salivatory and lacrimal nucleI sends fibres to the facial
nerve via nervus intermedius. These fibres leave the facial nerve at the external genu as the
greater superficial petrosal nerve, which leaves the temporal bone at the facial hiatus. It then
courses antero-medially towards foramen lacerum. As it runs forward into foramen lacerum the
greater superficial petrosal nerve picks up sympathetic fibres from the internal carotid plexus (the
deep petrosal nerve) and then enters the pterygoid canal on the anterior wall of foramen lacerum
as the nerve of the pterygoid canal. The pterygoid canal begins at the base of the medial
pterygoid plate. It runs parallel to the maxillary nerve and is located inferior and medial to
foramen rotundum.
Fibres from the ptergyopalatine ganglion go to:
Lacrimal gland via zygomatic and lacrimal nerves
Glands in the nose via the nasopalatine nerve
Glands on the palate via the greater palatine nerve
Glands in the nasopharynx via the pharyngeal nerve
Special sensory to taste receptors on the palate and nasopharynx

ZYGOMATIC NERVE
It comes off maxillary nerve (before the origin of the infraorbital nerve) and runs through the
inferior orbital fissure to the orbit, under the orbital periosteum where it sends a branch to the
lacrimal nerve, before dividing into its temporal and facial branches and leaving the orbit through
their respective foramina.

ANAESTHESIA OF THE MAXILLARY NERVE (intra- or extra-oral approach)

Everything in the pterygopalatine fossa, including the pterygopalatine ganglion will be
anaesthetised – thus preventing the lacrimal gland’s secretions: you must cover the eye and or
keep the eye moist with drops.

MANDIBLE
Features:
Condyle: note medial-lateral width is much greater then its anterior-posterior width;
attachment of capsule of TMJ
Condylar neck (attachment of lateral ligament of TMJ) and pterygoid fovea (attachment of
lateral pterygoid muscle, inferior head; target for Gow-Gates block)
Sigmoid or mandibular notch: masseteric nerve and artery
Coronoid process: medial side attachment of temporalis, the tendon attaches down as far
as retromolar region
Coronoid notch: depth indicates level of mandibular foramen

4
 External oblique ridge: landmark for third molar surgery; terminal branches of long buccal
nerve ramify over ridge with terminal branches of greater auricular nerve (cervical ventral
rami 2&3)
Angle of mandible and attachment of masseter muscle
Mental foramen(a)
Mental protruberance
Genial tubercles/mental spine: for attachment of genioglossus and geniohyoid muscles
Digastric fossa for attachment of anterior belly of digastric
Mandibular foramen: inferior alveolar vessels from anterior to posterior: nerve, artery then
vein
Lingula: attachment of sphenomandibular ligament
Mylohyoid groove: for mylohyoid artery, nerve and vein
Mylohyoid line: for mylohyoid muscle
Roughening on medial angle of mandible for medial pterygoid muscle
Fossa for submandibular gland
Flattened area for lingual nerve lingual to 3rd molar
Internal oblique ridge & attachment of pterygomandibular raphe
Retromolar area – the convergence of fibres from the tendon of temporalis, buccinator
muscles
Bony architecture
The mandible is comprised of basal bone and alveolar process. It has a thick buccal cortex of
bone which is thickest at the 3rd molar region (often a buccal shelf) and progressively thins out
towards the incisor region, to the point where fenestrations and dehiscences are often present.
The lingual cortex of the alveolar process is fairly uniform in thickness (from incisor to 3rd molar
region), but is thin in relation to the buccal cortex.
One of the thinnest regions in the mandible is posterior and inferior to the 3rd molars, where the
mylohyiod neurovascular bundle runs. Occasionally a buccally tilted 3rd molar will have little or no
bone overlying the roots, and can be innervated additionally by the mylohyiod nerve, the
glossopharyngeal or the great auricular nerve.

INFRATEMPORAL FOSSA
A space bound superiorly by the greater wing of sphenoid, medially by the lateral surface of the
lateral pterygoid plate, anteriorly by the posterior portion of the maxilla and tuberosity, laterally by
the coronoid process and temporalis fascia, postero-medially by the tensor and levator veli
palatini, the pharyngotympanic tube [the styloid process and the investing layer of deep cervical
fascia] and carotid sheath, inferiorly it is not bounded; the infratemporal fossa communicates with
the temporal fossa which is deep to the zygomatic arch. The division between infratemporal and
temporal fossa is the infratemporal crest (of greater wing of sphenoid) which is the limit of
attachment of temporalis and lateral pterygoid (sup. head) muscles.
Contents:
The greater wing of the sphenoid (infratemporal surface) contains foramen ovale, and,
postero-laterally, foramen spinosum, so named because of its relation to the sphenoid
spine (postero-lateral to f. spinosum)
The 3rd division of trigeminal plus the motor root and the otic ganglion.
PSA nerves
Chorda tympani nerve
Maxillary artery (except: all of 3rd part excluding the PSA arteries) and its branches
including the middle meningeal
Pterygoid venous plexus
Pterygoid muscles
Sphenomandibular ligament

SPHENOMANDIBULAR LIGAMENT
Attached to the lingula on the mandible and to the spine of the sphenoid on its greater wing, it is
the embryological remnant of Meckel’s cartilage. It may act as a diffusion barrier during an inferior
alveolar nerve block.

5
MANDIBULAR NERVE
Out from foramen ovale passes the motor root and the mandibular division of the largest cranial
nerve (V, trigeminal), very quickly uniting at the otic ganglion. The mandibular nerve then divides
into posterior and anterior divisions; the anterior being mostly motor, and the posterior division
being mostly sensory.
Anterior division: ! motor to! Tensor tympani
! ! ! ! ! Tensor veli palatini
! ! ! ! ! Temporalis (via deep temporal nerves)
! ! ! ! ! Lateral pterygoid
! ! ! ! ! Masseter
! ! ! ! ! Medial pterygoid muscle
sensory ! Via the long buccal nerve, which passes between the 2
heads of lat. pterygoid
Posterior division: ! sensory! Auriculotemporal nerve
! ! ! ! Lingual nerve
! ! ! ! Inferior alveolar nerve (IAN)
! ! ! ! Meninges
motor to! Mylohyoid and anterior belly of digastric muscles (comes off
the IAN before it enters the mandibular canal)
Otic ganglion:! parasympathetic secretomotor to the parotid gland (via auriculotemporal
nerve)
Relationships:
Thee deep temporal and masseteric nerves run superiorly over the superior head of lateral
pterygoid
The long buccal nerve runs between the two heads of the lateral pterygoid muscles
The lingual nerve runs anterior to the inferior alveolar nerve
The auriculotemporal nerve passes directly posterior, its two roots enclosing the middle
meningeal artery

MAXILLARY ARTERY
The external carotid artery enters the substance of the parotid gland and then divides into its two
terminal branches – the superficial temporal which continues to ascend vertically, and the
maxillary artery which branches off and enters the infratemporal fossa from behind and just below
the neck of the condyle. This then becomes the 1st part of the maxillary artery (horizontal portion)
which sends off five branches into bone:
Deep auricular: into the external acoustic meatus between bone and cartilage
Anterior tympanic: into the petrotympanic fissure
Middle meningeal: foramen spinosum
Accessory meningeal: foramen ovale
inferior alveolar: mandibular foramen
This then runs horizontally between the neck of the mandible and the sphenomandibular ligament,
at the level of the inferior border of the inferior head of lateral pterygoid.
The 2nd part turns upward at an angle to eventually enter the pterygomaxillary fissure. This part
lies on the lateral surface of the lateral pterygoid muscle. It also gives off five branches, into soft
tissue:
To medial pterygoid muscle
To lateral pterygoid muscle
Deep temporal arteries (to temporalis muscle)
A branch which accompanies the lingual nerve (not the lingual artery!)
A branch which accompanies the long buccal nerve
The maxillary artery then enters the pterygopalatine fossa through the pterygomaxillary fissure,
becoming the 3rd part. Branches are seven:
Posterior superior alveolar arteries
Infraorbital
Sphenopalatine (or nasopalatine): through sphenopalatine foramen
Greater palatine
Lesser palatine
A small pharyngeal artery (through palatovaginal canal)
Artery of pterygoid canal

6
VENOUS DRAINAGE IN THE INFRATEMPORAL FOSSA (PTERYGOID VENOUS PLEXUS)
The pterygoid venous plexus consists of a meshwork of small veins lying between the temporalis
and lateral pterygoid muscle and partly between both pterygoid muscles. The veins receive
branches from the corresponding maxillary artery branches, which are: middle meningeal, deep
temporal, pterygoid, masseteric, buccal, superior alveolar, some palatine and inferior alveolar.
This plexus communicates very freely with the facial vein and the cavernous sinus by branches
through the foramen of Vesalius (not always present, anterior and medial to f. ovale), fa. ovale and
lacerum.

MUSCLES
Lateral pterygoid – comprised of two heads, superior and inferior. The inferior head attaches to
the pterygoid fovea on the medial side of the neck of the condyle, just below the condylar head,
and its fibres pass forward, down and medially to attach onto the lateral surface of the lateral
pterygoid plate. The superior head inserts its muscular fibres into the capsule of the TMJ and
also into the articular disc. Its fibres then run forward in a medial and horizontal direction to
attach to the infratemporal surface of the greater wing of the sphenoid bone. This head is broad
and flat. Both heads are quite fleshy with little or no tendinous structure.
The infratemporal crest on the greater wing of the sphenoid bone delineates the attachment of
superior head of lateral pterygoid and the temporalis muscle attachments, thus dividing the
temporal fossa from the infratemporal fossa.
Masseter – a thick fleshy muscle arising from the angle of mandible and lateral ramus; having
three heads and passing upwards and forwards to insert into the medial surface of the zygomatic
arch. Its blood supply is mainly from the transverse facial artery (from the superficial temporal). It
has the facial artery related to its anterior border on the inferior edge of the ramus.
Medial pterygoid – a thick fleshy muscle arising from the angle and medial ramus; has two heads;
the fibres from the deep (and larger) head pass into the medial surface of the lateral pterygoid
plate in the same direction as masseter. The small superficial head inserts its fibres into part of
the maxillary tuberosity.
Temporalis – a thick muscle which inserts into the medial side of the coronoid process of the
mandible, with its tendinous insertion going inferiorly as far as the retromolar region. In this area
the long buccal nerve may pierce the fascia of temporalis, but finally emerges to innervate the
retromolar area and buccal sulcus up to the distal of the lower 1st or 2nd premolar

PAROTID GLAND
The facial or seventh cranial nerve exits the skull base at the stylomastoid foramen, gives off
branches for the stylohyoid, the posterior belly of digastric, and the auricular muscles, then enters
the substance of the parotid gland. It then divides into its five branches – zygomatic, temporal,
buccal, marginal mandibular and cervical branches. It divides in the same plane, creating
‘superficial’ and ‘deep’ portions of the parotid gland. The ‘deep’ portion or medial pole of the
gland lies behind the ramus and then hooks around medial to the ascending ramus and medial
pterygoid muscle. It contains the external carotid artery (more medial, becoming maxillary and
superficial temporal arteries) and the retromandibular vein (lateral in relation to external carotid
artery). The facial nerve lies more superficial to the external carotid artery and retromandibular
vein. Therefore passing a needle into the substance of the parotid gland not only has implications
for facial nerve anaesthesia but also for positive aspirations.
Over the face the facial nerve’s branches communicate with terminal branches of the trigeminal
nerve. For example, the (marginal) mandibular branch of the facial nerve communicates freely
with the inferior alveolar nerve through the mental foramen.

OTIC GANGLION
This ganglion lies on the medial side of the trunk of the mandibular nerve. The otic ganglion
receives preganglionic parasympathetic fibres from the lesser superficial petrosal nerve. The
lesser superficial petrosal nerve originates from the tympanic plexus. The inferior salivatory
nucleus in the brainstem sends fibres to the tympanic plexus via the glossopharyngeal nerve (after
CN IX exits through the jugular foramen in its own dural fold, it sends a nerve up through the
temporal bone through a canal on the anterior part of the jugular fossa, also called Jacobson’s

7
nerve. The lesser superficial petrosal nerve, after leaving the petrous temporal bone lateral to the
facial hiatus, courses medially, below the dura mater, to enter foramen ovale beneath the
mandibular nerve, or through its own foramen.

TEMPOROMANDIBULAR JOINT INNERVATION

The capsule, posterior 2/3s of the disc, and posterior attachment tissues are heavily innervated by
the auriculotemporal nerve. The anterior 1/3 of the TMJ receives some fibres from the masseteric
and deep temporal nerves.

DEEP RELATIONS OF NEEDLE WHEN ADMINISTERING AN IAN BLOCK

The needle passes laterally to the pterygomandibular raphe (in the pterygotemporal depression –
which is through buccinator, not superior constrictor). The needle is then medial to the ascending
ramus, lateral to the medial pterygoid muscle. At the target point (bone, just above the
mandibular foramen and lingula), the needle is just anterior and lateral to the IAN.
From anterior to posterior, the order the inferior alveolar neurovascular bundle is: nerve, artery,
then vein. Therefore the first structure in the neurovascular bundle you are likely to hit with your
needle is the nerve.
The deep part of the parotid gland is posterior and medial to the target site; so if no bone is
contacted the needle may pass into the substance of the parotid gland.
The sphenomandibular ligament attaches to the lingula, therefore being anterior and slightly
medial to the inferior alveolar neurovascular bundle.
The medial pterygoid muscle attaches to the angle inferior to the mandibular foramen, so if the
needle is too low the clinician may feel resistance as it penetrates the muscle.

8
VARIATIONS OF NORMAL ANATOMICAL INNERVATION OF TEETH

The division of IAN before entering the mandible producing 2 mandibular foramina, possibly
lowering the success of IAN blocks if not enough volume of local anaesthetic solution is used

The presence of accessory mental foramina

The existence of MSA nerve

ACCESSORY INNERVATION
Mylohyoid and glossopharyngeal nerves may enter the mandible lingual to the lower molars

Cervical plexus:
! Great auricular nerve innervation of buccal sulcus/periodontium of lower molars;
! Transverse nerve of the neck may innervate lower anterior teeth

from: Romanes G J, “Cunningham’s Manual of Practical Anatomy”, vol 3, 15th ed. Oxford Medical Publications, 1989. fig. 22, p 23

9
ANATOMICAL REASONS FOR COMPLICATIONS

Blanching of tissues after an IAN block

After an inferior alveolar nerve block, you may notice blanching on the side of the face (and
intraorally too) - you have brushed the maxillary artery (or a branch of) with the needle, and
caused vasospasm, due to the meshwork of sympathetic fibres over the artery.

Reassure the patient that the affect is only transient. By the time the inferior alveolar nerve is
anaesthetised, the effects would have largely disappeared.

If the patient reports tachycardia or an increased force of the heartbeat, you have injected
adrenaline intravascularly. The most likely route of intravenous administration of local anaesthetic
is via the pterygoid plexus of veins. With no valves, the pterygoid venous plexus communicates
freely with the cavernous sinus through either through the deep facial vein (then facial, angular
and ophthalmic veins – long route) or directly via emissary branches through foramina ovale,
Vesalius and lacerum. The solution also has of course the more likely chance of going to the heart
via the retromandibular and internal or external jugular vein.

There have been reports of visual and auditory disturbances following the administration of a
solution of local anaesthetic. A possible route to the orbit is deposition of solution into the
maxillary artery via the inferior alveolar or posterior superior alveolar arteries, then to the middle
meningeal artery. The middle meningeal artery then communicates with the lacrimal artery (which
sometimes replaces the middle meningeal in its function to supply the dura mater). The lacrimal
artery will then transfer the anaesthetic into the orbit via the ophthalmic artery.

A possible route for auditory disturbances is via the maxillary artery, with retrograde flow to the
arteries which supply the tympanic part of the temporal bone, namely the posterior auricular and
anterior tympanic branches (1st part of maxillary artery).

Facial paralysis
The injection of local anaesthetic solution into the parotid gland will usually anaesthetises some
branches of the facial nerve (often only the temporal and zygomatic, because the part of the
parotid containing the other branches is usually inferior to the target site), thus paralysing those
affected muscles – often orbicularis oculi is the only one seen.

Saying that, there are variations in anatomy, such as a wide-flaring ascending mandibular ramus,
which permits a larger deep pole of the parotid, and in such a case, the facial nerve may be easier
to anaesthetise, especially if the person in small and thin.

Variations

As a final note, there is the general relationship of anatomical structures, and there are variations
in the size, angle and location of these structures. The relationship between these structures still
hold, so if you understand the relationship, you will be able to manage situations where the
anatomy is different.

10