Mandibular nerve block techniques in short for Dental Surgeons. Mandibular nerve blocks are very important for all dental surgeons as it becomes a part and parcel of all dental and oral surgeons. This presentation will be useful for students of dentistry and doctors.

1. Types and Techniques of
Mandibular nerve block
By
Dr. Saikat Saha
MDS (Oral And Maxillofacial Surgery)
Consultant Oral & Maxillofacial Surgery

2. Types of Mandibular Regional Anesthesia
* Inferior Alveolar Nerve Block
Mandibular teeth on side of injection, buccal and lingual hard and soft tissue, lower lip
* Buccal Nerve Block
Buccal soft tissue of molar region
*Gow-Gates Mandibular Nerve Block
Mandibular teeth to midline, hard and soft tissue of buccal and lingual aspect, anterior 2/3 of
tongue, FOM, skin over zygoma, posterior aspect of cheek, and temporal region on side of
injection
*Vazirani-Akinosi Closed Mouth
Mandibular teeth to midline, hard and soft tissue of buccal aspect, anterior 2/3 of tongue,
FOM
*Mental Nerve Block
Buccal soft tissue anterior to mental foramen, lower lip, chin
Incisive Nerve Block
Premolars, canine and incisors, lower lip, skin over the chin, buccal soft tissue anterior to the
mental foramen

3. Types of Mandibular Regional Anesthesia
* Inferior Alveolar Nerve Block
Mandibular teeth on side of injection, buccal and lingual hard and soft tissue, lower lip
* Buccal Nerve Block
Buccal soft tissue of molar region
*Gow-Gates Mandibular Nerve Block
Mandibular teeth to midline, hard and soft tissue of buccal and lingual aspect, anterior 2/3 of
tongue, FOM, skin over zygoma, posterior aspect of cheek, and temporal region on side of
injection
*Vazirani-Akinosi Closed Mouth
Mandibular teeth to midline, hard and soft tissue of buccal aspect, anterior 2/3 of tongue,
FOM
*Mental Nerve Block
Buccal soft tissue anterior to mental foramen, lower lip, chin
Incisive Nerve Block
Premolars, canine and incisors, lower lip, skin over the chin, buccal soft tissue anterior to the
mental foramen

4. Techniques of Mandibular
Regional Anesthesia
•
Techniques used in clinical practice for the anesthesia of the hard and soft
tissues of the mandible include the supraperiosteal technique, PDL
injection, intrapulpal anesthesia, intraseptal injection, inferior alveolar
nerve block, long buccal nerve block, Gow-Gates technique, Vazirani-
Akinosi closed mouth mandibular block, mental nerve block, and incisive
nerve block.
•
The supraperiosteal, PDL, intrapulpal, and intraseptal techniques are
executed in the same manner as described above for maxillary anesthesia.
When anesthetizing the mandible the patient should be in the semisupine
or reclined position. The right handed operator should stand at the nine
o’clock to ten o’clock position whereas the left handed operator should
stand at the three o’clock to four o’ clock position.

5. Inferior Alveolar Nerve Block
•
The inferior alveolar nerve block is one of the most commonly
employed techniques in mandibular regional anesthesia.
•
It is extremely useful when multiple teeth in one quadrant require
treatment. While effective, this technique carries a high failure rate
even when strict adherence to protocol is maintained.
•
The target for this technique is the mandibular nerve as it travels
on the medial aspect of the ramus, prior to its entry into the
mandibular foramen. The lingual, mental, and incisive nerves are
also anesthetized.
•
A 25 gauge long needle is preferred for this technique.

6. •
Technique :
•
The patient should be in the semisupine position. The right handed
operator should be in the eight o’clock position whereas the left handed
operator should be in the four o’clock position.
•
With the mouth open maximally, identify the coronoid notch and the
pterygomandibular raphae.
•
Three quarters of the anteroposterior distance between these two
landmarks, and approximately six to ten millimeters above the occlusal
plane is the injection site.
•
Use a retraction instrument to retract the cheek and bring the needle to
the injection site from the contralateral premolar region.
•
As the needle passes through the soft tissue, deposit one or two drops of
anesthetic solution.

7. •
Advance the needle until bone is contacted. Once bone is
contacted, withdraw the needle one millimeter and redirect the
needle posteriorly by bringing the barrel of the syringe towards the
occlusal plane (Fig. 18, A and B).
•
Advance the needle to three quarters of its depth, aspirate, and
inject three quarters of a cartridge of anesthetic solution slowly
over the course of one minute.
•
As the needle is withdrawn, continue to deposit the remaining one
quarter of anesthetic solution so as to anesthetize the lingual nerve
(Fig. 18, C).
•
Successful execution of this technique results in anesthesia of the
mandibular teeth on the ipsilateral side to the midline, associated
with buccal mucosa anterior to the mental foramen, lingual soft
tissue, lateral aspect of the tongue on the ipsilateral side, and lower
lip on the ipsilateral side.

10. Figure 18 A: Location of the inferior alveolar nerve. B: After contacting
bone, the needle is redirected posteriorly by bringing the barrel of the
syringe towards the occlusal plane. The needle is then advanced to three
quarters of its depth

11. Figure 18 C: Location of the lingual nerve which is anesthetized
during the administration of an inferior alveolar nerve block

13. Buccal Nerve Block
•
The buccal nerve block, otherwise known as the long buccal or
buccinator block, is a useful adjunct to the inferior alveolar nerve
block when manipulation of the buccal soft tissue in the mandibular
molar region is indicated.
•
The target for this technique is the buccal nerve as it passes over
the anterior aspect of the ramus.
•
Contraindications to the procedure include acute inflammation and
infection over the site of injection.
•
A 25 gauge long needle is preferred for this technique.

14. •
Technique-
•
The patient should be in the semisupine position. The right
handed operator should be in the eight o’clock position
whereas the left handed operator should be in the four
o’clock position.
•
Identify the most distal molar tooth on the side to be treated.
The tissue just distal and buccal to the last molar tooth is the
target area for injection (Fig. 19, A and B).
•
Use a retraction instrument to retract the cheek.
•
The bevel of the needle should be toward bone and the
syringe should be held parallel to the occlusal plane on the
side of the injection.
•

15. •
The needle is inserted into the soft tissue and a few
drops of anesthetic solution are administered.
•
The needle is advanced approximately one or two
millimeters until bone is contacted. Once bone is
contacted and aspiration is negative, 0.2cc of local
anesthetic solution is deposited.
•
The needle is withdrawn and recapped. Successful
execution of this technique results in anesthesia of
the buccal soft tissue of the mandibular molar
region.

16. Figure 19 A:Location of the buccal nerve. B: The tissue just distal and buccal
to the last molar tooth is the target area for
injection.

17. Gow-Gates Technique
•
The Gow-Gates technique or third division nerve block is useful
alternative to the inferior alveolar nerve block
•
it is often used when the latter fails to provide adequate
anesthesia.
•
Advantages of this technique versus the inferior alveolar technique
are its low failure rate and low incidence of positive aspiration.
•
The Gow-Gates technique anesthetizes the auriculotemporal,
inferior alveolar, buccal, mental, incisive, mylohyoid and lingual
nerves. Contraindications to this procedure include acute
inflammation and infection over the site of injection and trismatic
patients. A 25 gauge long needle is preferred for this technique.

18. •
Technique-
•
The patient should be in the semisupine position. The right handed operator
should be in the eight o’clock position whereas the left handed operator should be
in the four o’clock position.
•
The target area for this technique is the neck of the condyle below the area of
insertion of the lateral pterygoid muscle. A retraction instrument is used to retract
the cheek.
•
The patient is asked to open maximally and the mesiolingual cusp of the maxillary
2nd molar on the side of desired anesthesia is identified.
•
The insertion site of the needle will be just distal to the maxillary 2nd molar at the
level of the mesiolingual cusp.
•
Bring the needle to the insertion site in a plane that is parallel to an imaginary line
drawn from the intertragic notch to the corner of the mouth on the same side as
the injection (Fig. 20, A and B).

19. •
The orientation of the bevel of the needle is not important in this
technique.
Advance the needle through soft tissue approximately 25mm until
bone is contacted. This is the neck of the condyle.
Once bone is contacted, withdraw the needle one millimeter and
aspirate.
Redirect the needle superiorly and reaspirate.
If aspiration in two planes is negative, slowly inject one cartridge of
local anesthetic solution over the course of one minute.
Area Anesthetized :-
Ipsilateral mandibular teeth up to the midline, and associated
buccal and lingual hard and soft tissue. The anterior two thirds of
the tongue, floor of the mouth, skin over the zygoma, posterior
aspect of the cheek and temporal region on the ipsilateral side of
injection are also anesthetized.

20. Gow Gates Technique
Area Anesthetized :-
@ Ipsilateral mandibular teeth up to the mid-line, and
associated buccal and lingual hard and soft tissue.
@ The anterior two thirds of the tongue,
@ floor of the mouth,
@ skin over the zygoma,
@ posterior aspect of the cheek
@ temporal region

21. Figure 20 A:
The patient is asked to open mouth maximally. The mesiolingual cusp of the
maxillary 2nd molar is the reference point for the height of the injection. B: The
needle is then moved distally and is held parallel to an imaginary line drawn
from the intertragic notch to the corner of the mouth

23. Vazirani-Akinosi Closed Mouth Mandibular Block
•
Advantages Of This Closed Mouth Technique
•
@ limited opening due to trismus
•
@ ankylosis of the temporomandibular joint.
•
@ minimal risk of trauma to the inferior alveolar nerve, artery, vein, and
pterygoid muscle,
@ low complication rate and minimal discomfort upon injection.
•
Contraindications
@ acute inflammation and infection in the pterygomandibular space,
@ deformity or tumor in the maxillary tuberosity region
@ any inability to visualize the medial aspect of the ramus.
•
A 25 gauge long needle is preferred for this technique.

24. •
Technique-
•
The patient should be in the semisupine position. The right handed operator
should be in the eight o’clock position whereas the left handed operator should be
in the four o’clock position.
•
The gingival margin above the maxillary 2nd and 3rd molars and the
pterygomandibular raphae serve as landmarks for this technique.
•
A retraction instrument is used to stretch the cheek laterally.
•
The patient should occlude gently on the posterior teeth. The needle is held
parallel to the occlusal plane at the level of the gingival margin of the maxillary
2nd and 3rd molars.
•
The bevel is directed away from the bone facing the midline.
•
The needle is advanced through the mucous membrane and buccinator muscle to
enter the pterygomandibular space.

25. •
The needle is inserted to approximately one half to three quarters of its
length.
•
At this point the needle will be in the midsection of the
ptyerygomandibular space.
•
Aspirate and if negative, one cartridge of local anesthetic solution is
deposited over the course of one minute.
•
Diffusion and gravitation of the local anesthetic solution will anesthetize
the lingual and long buccal nerves in addition to the inferior alveolar
nerve.
•
Successful execution of this technique provides anesthesia of the
ipsilateral mandibular teeth up to the midline, and associated buccal and
lingual hard and soft tissue. The anterior two thirds of the tongue and
floor of the mouth are also anesthetized.9,10

28. Mental Nerve Block
•
The mental nerve block is indicated for procedures where
manipulation of buccal soft tissue anterior to the mental
foramen is necessary.
•
Contraindications to this technique are acute inflammation
and infection over the injection site.
•
A 25 or 27 gauge short needle is preferred for this technique.

29. •
Technique-
•
The patient should be in the semisupine position. The right
handed operator should be in the eight o’clock position
whereas the left handed operator should be in the four
o’clock position.
•
The target area is the height of the mucobuccal fold over the
mental foramen (Fig. 21, A and B).
•
The foramen can be manually palpated by applying gentle
finger pressure to the body of the mandible in the area of the
premolar apicies.
•
The patient will feel slight discomfort upon palpation of the
foramen.
•

30. •
Use a retraction instrument to retract the soft tissue.
•
The needle is directed toward the mental foramen with the
bevel facing the bone.
•
Penetrate the soft tissue to a depth of five millimeters,
aspirate and inject approximately 0.6cc of anesthetic solution.
•
Successful execution of this technique results in anesthesia of
the buccal soft tissue anterior to the foramen, lower lip and
chin on the side of the injection.1

31. Figure 21, A: Location of the mental and incisive nerves.
Figure 21, B: Block of the mental and incisive nerves: The needle is
inserted at the height of the mucobuccal fold over the mental foramen
for both the mental nerve block and incisive nerve block.

32. Incisive Nerve Block
•
The incisive nerve block is not as frequently employed in
clinical practice however it proves very useful when
treatment is limited to mandibular anterior teeth and full
quadrant anesthesia is not necessary.
•
The technique is almost identical to the mental nerve block
with one additional step. Both the mental and incisive nerves
are anesthetized using this technique.
•
Contraindications to this technique are acute inflammation
and infection at the site of injection.
•
A 25 or 27 gauge short needle is preferred for this technique.

33. •
Technique-
•
The patient should be in the semisupine position. The right handed operator
should be in the eight o’clock position whereas the left handed operator should be
in the four o’clock position.
•
The target area is the height of the mucobuccal fold over the mental foramen (See
Fig. 21, B).
•
Identify the mental foramen as previously described. Give the patient a mental
nerve block as described above and apply digital pressure at the site of injection
during administration of anesthetic solution.
•
Continue to apply digital pressure at the site of injection two to three minutes
after the injection is complete to aid the anesthetic in diffusing into the foramen.
•
Successful implementation of this technique provides anesthesia to the
premolars, canine, incisor teeth, lower lip, skin of the chin, and buccal soft tissue
anterior to the mental foramen.

34. Figure 21, B: Block of the mental and incisive nerves: The
needle is inserted at the height of the mucobuccal fold over
the mental foramen for both the mental nerve block and
incisive nerve block.