Innervation of the Maxillary Teeth: Integrating Classical Anatomy With the Dual Innervation Model

A precise understanding of maxillary tooth innervation is paramount for all dental and oral surgical procedures, from routine local anesthesia to complex interventions. The three superior alveolar nerves-posterior, middle, and anterior-arise from the maxillary division of the trigeminal nerve, forming the superior dental plexus that classically innervates the maxillary teeth. However, this conventional anatomical paradigm has often failed to fully explain common clinical phenomena, such as the inconsistent efficacy of specific anesthetic techniques or the unpredictable outcomes observed in practice. Recent groundbreaking advancements in diagnostic imaging and microanatomical research have provided critical insights, addressing these long-standing clinical questions. This review comprehensively synthesizes classical anatomical knowledge with these contemporary findings. It establishes a dual innervation model that reveals a significant neurovascular supply originating from the palatal aspect, a pathway previously unhighlighted yet complementary to the well-known buccal pathways. Furthermore, it necessitates a reassessment of established palatal anesthetic techniques, such as the anterior and middle superior alveolar (AMSA) and the palatal approach anterior superior alveolar (P-ASA) nerve blocks, identifying them as localized palatal infiltrations rather than true nerve blocks. This new anatomical perspective has led to the proposal of evidence-based techniques, such as the palatal alveolar foramen injection (PAFI). Integrating this comprehensive dual innervation concept into future anatomical education and clinical training is essential to enhance surgical precision and ultimately bring greater benefits to patients.