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The nasopalatine nerve block is a very useful technique for palatal pain control because with minimum volume of anesthetic solution (maximally, 1/4 of a cartridge), a wide area of palatal soft tissue anesthesia is achieved, thereby minimizing the need for multiple palatal injections.  Unfortunately, the nasopalatine nerve block has the distinction of being a potentially highly traumatic (painful) injection.  Strict adherence to the protocol will assist in atraumatic injections. 

The nerve that is anesthetized are the bilateral nasopalatine nerves.  The areas that are anesthetized are the bilateral anterior portions of the hard palate (soft and hard tissues) from the mesial of the right first premolar to the mesial of the left first premolar.  There are two approaches to this injection, and clinicians should become familiar with both techniques and then should use the one with which they feel more comfortable.

The first approach involves only one tissue penetration, lateral to the incisive papilla on the palatal aspect of the maxillary central incisors.  The soft tissue in this area is dense, firmly adherent to underlying bone, and quite sensitive.  These three factors combine to increase patient discomfort during the injection.

Proper technique:

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  1. 27-gauge short needle is recommended 

  2. Area of insertion: palatal mucosa just lateral to the incisive papilla (located in the midline behind the central incisors); tissue in this area is more sensitive than other palatal mucosa

  3. Target area: incisive foramen, beneath the incisive papilla 

  4. Landmarks

    • Central incisors 

    • Incisive papilla

  5. Path of insertion: approach the injection site at a 45-degree angle toward the incisive papilla 

  6. Orientation of the bevel: toward the palatal soft tissues

The second approach involves three needle punctures, but when carried out properly, is significantly less traumatic than the more direct one-puncture technique.  The labial soft tissues between maxillary central incisors are anesthetized (injection #1), then the needle is directed from the labial aspect through the interproximal papilla between the central incisors towards the incisive papilla on the palate to anesthetize the superficial tissues in this area (injection #2).  A third injection, directly into the now partially anesthetized palatal soft tissues overlying the nasopalatine nerve is necessary.  Although the single-needle puncture technique may be preferred whenever possible, the second approach can produce effective nasopalatine anesthesia with a minimum of discomfort.

Procedures:

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  1. Correct patient & clinician positioning

    • Right-handed clinician sit at 9:00 or 10:00 facing in the same direction as the patient / left-handed clinician sit at 2:00 or 3:00 facing in the same direction as the patient

  2. Ask the patient, who is in a supine position, to do the following: ​

    • Open wide​

    • Extend their neck

    • Turn their head to the left or right (for improved visibility)

  3. Prepare tissue just lateral to the incisive papilla

    • Dry with gauze or blow air with air/water syringe​

    • Apply topical anesthetic for 2 minutes 

  4. After 2 minutes of topical anesthetic application, move the swab directly onto the incisive papilla and apply pressure (blanching should be visible)

  5. With the bevel lying against the tissue:

    • Apply enough pressure to bow the needle slightly ​

    • Deposit a small volume of anesthetic (the solution will be forced against the mucous membrane)

  6. Straighten the needle and permit the bevel to penetrate the mucosa

    • Continue to deposit small volumes of anesthetic throughout the procedure​

    • Observe blanching spreading into adjacent tissues as solution is deposited

  7. Continue to apply pressure with the cotton applicator stick throughout the deposition of the anesthetic solution

  8. Slowly advance the needle toward the incisive foramen until bone is contacted

    • The depth of penetration normally is about 1-2mm, no greater than 5mm​

    • Deposit small volumes of anesthetic while advancing the needle.  As the tissue is entered, resistance to the deposition of solution is significantly increased; this is normal with the nasopalatine nerve block

  9. Aspirate in two planes

  10. If negative, slowly deposit (15-30 seconds minimum) not more than 0.45mL (1/4 of a cartridge) 

  11. Slowly withdraw needle and safely recap

  12. Wait 2-3 minutes before starting dental procedure​

Procedures (Multiple Needle Penetrations):

  1. First injection: infiltration of 0.3mL into the labial frenum - The aim for this first injection is to anesthetize the inderdental papilla between the two central incisors.

    • Dry with gauze of blow air with air/water syring​

    • Apply topical anesthetic for at least 1 minute 

    • Retract the upper lip to stretch tissues and improve visibility (be careful not to overstretch the frenum)

    • Gently insert the needle into the frenum 0.3mL of anesthetic in approximately 12 seconds (the tissue may balloon as solution is injected)

    • Anesthesia of soft tissue develops immediately

  2. Second injection: penetration through the labial aspect of the papilla between the maxillary central incisors toward the incisive papilla

    • Retract the upper lip gently to increase visibility (be careful not to overstretch the frenum)​

    • Right-handed clinician sit at 11:00 or 12:00 facing in the same direction as the patient with head tilt to the right/ left-handed clinician sit at 12:00 or 1:00 facing in the same direction as the patient with head tilt to the left (the tilt of the patient's head will provide a proper angle for needle penetration)

    • Holding the needle at a right angle to the interdental papilla, insert it into the papilla just above the level of crestal bone

      • Direct it toward the incisive papilla (on the palatal side of the interdental papilla)

      • Soft tissues on the labial ​surface have been anesthetized by the first injection, so there is no discomfort.  However, as the needle penetrates toward the unanesthetized palatal side, it becomes necessary to administer minute amounts of local anesthetic to prevent discomfort.

      • With the patient's head extended backward, you can see the blanching produced by the local anesthetic and (on occasion) can see the needle tip as it nears the palatal aspect of the incisive papilla.  Careful not to puncture through the papilla into the oral cavity on the palatal side​.

    • ​Aspirate in two planes
    • If negative, administer no more than 0.3mL of anesthetic solution in approximately 15 seconds (there is considerable resistance to the deposition of solution but no patient discomfort)
    • Stabilization of the syringe in this second injection is critical.  Use of a finger from the other hand to stabilize the needle is recommended.  However, the syringe barrel must be held such that is remains within the patient's line of sight
    • Slowly withdraw needle and safely recap
    • Anesthesia usually develops in a minimum of 2-3 minutes​​
    • If the area is less than adequately anesthetized, proceed to the third injection
  3. Third injection: 

    Wait a minimum of 2-3 minutes before starting dental treatment

    • Dry the tissue just lateral to the incisive papilla​
    • Ask the patient to open wide
    • Extend the patient's neck
    • Place the needle into soft tissue adjacent to the incisive papilla, aiming toward the most distal portion of the papilla
    • Advance the needle until contact is made with bone
    • Withdraw the needle 1mm to avoid superiosteal injection
    • Aspirate in two planes
    • If negative, slowly deposit not more than 0.3mL of anesthetic in approximately 15 seconds
    • Slowly withdraw needle and safely recap

Proper technique (Multiple Needle Penetrations):

​

  1. 27-gauge short needle is recommended 

  2. Area of insertion:

    • First injection: Labial frenum in the midline between the maxillary central incisors 

    • Second injection: Interdental papilla between the maxillary central incisors

    • Third injection: If needed, palatal soft tissues lateral to the incisive papilla

  3. Target area: incisive foramen, beneath the incisive papilla 

  4. Landmarks

    • Central incisors 

    • Incisive papilla

  5. Path of insertion:

    • First injection: infiltration into the labial frenum 

    • Second injection: needle held at a right angle to the interdental papilla

    • Third injection: needle help at a 45-degree angle to the incisive papilla

  6. Orientation of the bevel: toward the palatal soft tissues

    • First injection: bevel toward bone​

    • Second injection: not relevant

    • Third injection: not relevant

N A S O P A L A T I N E   ( N P ) 

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