 Hello everyone, welcome back to another session on dentistry and more Today we have a nerve block that is intra orbital nerve block So it is a maxillary nerve block, which is given just below the orbit. That is why it has got this name intra orbital Before moving on we need to understand a little bit about the Nerve Anatomy so we have the fifth cranial nerve that is trigeminal nerve has got three divisions the Ophthalmic Maxillary and mandibular so this intra orbital is a part of maxillary No, so you can see the maxillary nerve here so it has got many branches so I can see the Posterior superior alveolar nerve anterior superior alveolar now the middle superior alveolar now then the Intra orbital nerve and which has got the terminal branches which is emerging from the intra orbital foramen That is palpebral branches nasal branches superior label branches and you can see towards the posterior side It is going to the temporal region and that is a zygomatico temporal and zygomatico facial nerve So this is just the anatomy and the distribution of the nerve So understanding this will help you to get the idea about the Anesthetized area because we are going to apply the anesthetic solution here. That is the intra orbital region So it will definitely anesthetize these three parts. That is the terminal branches then the anterior superior Alveolar nerve and then the middle superior alveolar nerve because these three are the main branches which is after the intra orbital Foramen so this anterior teeth so we have One two three that is a central incisor canine and the lateral incisor which is supplied by anterior superior alveolar nerve whereas the premolars 4 5 and the meso buckle root of six supplied by middle superior alveolar nerve and And the other molars that is seven and eight that is second molar and third molar also the roots which is accepted that is a disturb buckle and palatal root of Six that is the first molar supplied by posterior superior Alveolar nerve, okay so this is how The nerve supplies teeth pulp and pyridontium Central lateral canine is supplied by anterior superior alveolar nerve Which is anterior most branch then the middle superior alveolar nerve which is supplying two premolars and the Meso buckle which is near to the premolar Meso buckle root of first molar the remaining That is second and third molar along with the other roots other than meso buckle that is a disturb buckle and palatal roots so when we apply Local anaesthetic intraction So we are going to Anacetize these many teeth so it will anacetize definitely anterior superior alveolar nerve, so Infra orbital sometimes known as anterior superior alveolar nerve, but most of the cases Middle superior alveolar nerve also will be anacetized, but in 20 percentage cases It will not be anacetized in those cases. We need to give a separate Middle superior alveolar injection for the procedure So moving on intra orbital nerve block So the aim is to deposit anaesthetic solution into the intra orbital canals through the intra orbital Foramen, okay, so in this technique as I said it will anacetize anterior superior alveolar nerve and also middle superior alveolar nerve and along with The branches, okay, so the terminal branches of intra orbital nerve They are inferior palpable the lateral nasal and superior labial terminal branches they are Lateral nasal So you can see the picture here superior labial that is above the lip then inferior palpibril Just below the eyelids So these are the nerves Anacetized when we apply intra orbital Nerve block, so what are the areas to be anacetized so the areas As as we can imagine This is being deposited just side of the nose below the eyes on one side so this will Anacetize upper lip not bilaterally only on one side the lateral aspect of nose on the injection side that is a lateral part and the lower eyelid and Also the Bacchal mucosa of the upper anterior teeth and trimolars and the pulpan Investing structures of these upper anterior teeth and primolars and mostly the meso Bacchal root of first molar So these are the areas Anacetized These are the nerves Anacetized, okay So now what is the position of the patient and dentist so patient position? As you see the picture here head neck and trunk on the same straight line Okay, and the back of the chair is tilted so that the patient is in a supine position The occlusion plane of the maxillary teeth and at a 45 degree angle to the floor So it should be a supine position the maxillary occlusion plane should be 45 degree angle to the floor and we can Start giving the procedure whereas a dentist position stands on the right side in front of the patient for a right side injection and alongside the patient for a left side injection and Mostly the armamentarium or needle commonly used is 25 to 27 gauge and it will be definitely a long needle Armamentarium 25 to 27 gauge long needle No, what are the landmarks so landmarks will guide us to give the injection at exactly The intra-orbital region or exactly where it is intended to so anatomical landmarks are The supra orbital notch can see the picture here and The intra-orbital notch then the intra-orbital depression intra-orbital depression Then the anterior teeth and Pupils of eye So we need to Visualize a imaginary straight line which is passing through the supra-orbital foramen Intra-orbital foramen and mental foramen Okay, so these three will be passing through a straight line and we need to visualize The area which is near to just below the orbit lateral to the nose at that depression, okay so First thing is we need to start Using our thumb we need to feel the depression, which is the intra-orbital depression and The line we need to visualize imagine a visualization and we need to visualize the we need to feel the Intra-orbital depression where the intra-orbital foramen is located Next a needle pathway so needle pathway of insertion So how we are going to insert the needle into the mucosa approaching the Infra-orbital foramen. So we have got two methods one is a bicuspid method and the next one is central incisor Method so bicuspid method is a commonly used one because it is Going just above the primolars that is a straight line We are keeping our needle in a straight line and we are Approaching the infra-orbital foramen We'll deposit around two ml of solution by inserting the needle five mm into the Mucosa, but we should never Go more than three fourth of the needle length Where as a central incisor approach it passes through the mucosa and a ariola tissue Okay, it is like we have the central incisor here will this is a Ankle we have two central incisor Okay, this is a lateral incisor and this is canine So we aim from the meso incisor angle to the Disto cervical ankle and we aim the sorry so we aim the needle at a 45 degree or at a Ankle towards the This is our target area Infra-orbital region Okay, so you can see the picture here This is a central incisor approach. This is two ways of approaching Sorry Next one is a parallel approach that is Through the primolars. Okay, so through through the primolars. Let it be here through the primolars It is going almost parallel without any angulation almost parallel to the primolars. This is making an angulation And approaching the infra-orbital foramen So, what are the indications of Infra-orbital nerve block that is a dental procedure involving more than two maxillarities and other buccal tissues that is central canine even primolars We can do using infra-orbital or any other inflammation or infection procedures or Or when supraperiosteal injections have been ineffective because of this dense cortical bone So the residence cortical bone is present. So this supraperiosteal injections might not be effective at times So in those times we can directly go for the block contra-indications Some procedures it requires just supraperiosteal injection in those cases. We don't need to go for intra-orbital and Any localized Indication also we can avoid intra-orbital instead. We can give for a infiltration Now we have the Symptoms so the symptoms subjective symptoms what the patient tells you patient There's tingling and numbness of the upper lip side of the nose and one part of the the inferior Eyelid area whereas objective Symptoms our patient might not feel any pain during the instrumentation. Okay, so complications involve the hematoma and Facial now paralysis So these are the complications associated with intra-orbital numb block so it's a very commonly asked essay question and oral surgery paper So we need to write about its indication contra-indication its side effect two methods of pathway of insertion that is a central incisor and bicuspid approach The amount of Solution injected and the needle The length of the needle to be inserted It should not go beyond three-fourth of the length than the landmarks Supra-orbital notch, intra-orbital notch, intra-orbital depression, anterior teeth and pupils of the eye and In the beginning part we need to explain a little bit about the intra-orbital foraminamid spranches that is anterior, middle, supia diurnal and all those things So you need to draw pictures and explain the intra-orbital nerve block So along with that you need to explain about the area and it's the taste and the nerve and it's the taste So i'll come up with the middle, supia diurnal in my next session. Thank you