Mandibular Anesthesia Techniques

TECHNIQUES OF MANDIBULAR
ANESTHESIA
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com


L A SUCCESS RATE
MAXILLA VS MANDIBLE


TECHNIQUES
 INFERIOR ALVEOLAR NERVE BLOCK
 BUCCAL NERVE BLOCK
 THE GOW GATES TECHNIQUE
 EXTRA ORAL
 VAZIRANI-AKINOSI CLOSED MOUTH
 MENTAL NERVE BLOCK
 INCISIVE NERVE BLOCK


INFERIOR ALVEOLAR NERVE
BLOCK
 Most frequently used
 Commonly called MANDIBULAR NERVE BLOCK

Nerves anesthetized
1. Inferior alveolar,
2. Incisive
3. Mental
4. Lingual


 Areas anesthetized
1. Mandibular teeth to the midline

2. Body of the mandible, inferior portion of
the ramus
3. Buccal mucoperiosteum, mucous
membrane anterior to the mandibular first
molar
4. Anterior two thirds of the tongue and
floor of the oral cavity
5. Lingual soft tissues and periosteum

Indications
1. Procedures on multiple mandibular teeth in one quadrant
2. When buccal soft tissue anesthesia (anterior to the first
molar) is required
3. When lingual soft tissue anesthesia is required

Contraindications
1. Infection or acute inflammation in the area of injection
2. Patients who might bite either the lip or the tongue


Advantages
One injection provides a wide area of anesthesia
Disadvantages
1. Wide area of anesthesia (not necessary for localized
procedures)
2. Rate of inadequate anesthesia (15% to 20%)
3. Intraoral landmarks not consistently reliable
4. Positive aspiration -10%
5. Lingual and lower lip anesthesia,


 It has a significantly lower success rate because

of
(1) anatomical variation in the height of the
mandibular foramen.
(2) the greater depth of soft tissue penetration
required


Methods
 Direct
 In Direct


 Technique
1. A 25-gauge long needle recommended

2. Area of insertion: mucous membrane on the medial side
of the mandibular ramus, at the intersection of two
lines—
horizontal-height of injection,
vertical- anteroposterior plane of injection

3. Target area: inferior alveolar nerve as it passes
downward toward the mandibular foramen but before it
enters into the foramen

 The needle is located too far anteriorly (laterally)
 Overinsertion with no contact of bone.
 The needle is usually posterior (medial)
 Early contact of bone


 Insert the needle. When bone is contacted,

withdraw approximately I mm to prevent
subperiosteal injection.
 Aspirate. If negative, slowly deposit 1.5 ml of
anesthetic over a minimum of 60 seconds.
 Slowly withdraw the syringe.
 If negative, deposit a portion of the remaining
solution (0.1 ml) to anesthetize the lingual nerve.


 Signs and symptoms
1. Tingling or numbness of the lower lip

indicates anesthesia of the mental nerve,. It
is a good indication that the inferior
alveolar nerve is anesthetized,
2. Tingling or numbness of the tongue
indicates anesthesia of the lingual nerve,
3. 3. No pain is felt during dental therapy.


 Precautions

1. Do not deposit local anesthetic if bone is not
contacted.
2. Avoid pain by not contacting bone too forcefully.
Failures of anesthesia
 The most common causes of absent or incomplete
inferior alveolar nerve block follow:
1. Deposition of anesthetic too low (below the
mandibular foramen). To correct: Reinject at a higher
site.
2. Deposition of anesthetic too far anteriorly) on the
ramus
3. Accessory innervation to the mandibular teeth

BUCCAL NERVE BLOCK
 The buccal nerve is a branch of the anterior

division of V3
 The sole indication for administration of a buccal
nerve block, therefore, is when manipulation of
these tissues is contemplated


 Area of insertion: mucous membrane distal

and buccal to the most distal molar tooth in
the arch
3. Target area: buccal nerve as it passes over
the anterior border of the ramus
4. Landmarks: mandibular molars, mucobuccal
fold
5. Orientation of the bevel: toward bone If
negative, slowly deposit 0.3 ml over 10
seconds

The Gow-Gates technique
 The Gow-Gates technique is a true mandibular nerve

block since it provides sensory anesthesia to virtually
the entire distribution of V3.
 Significant advantages of the Gow-Gates technique
over the inferior alveolar nerve block include
 its higher success rate,
 Its lower incidence of positive aspiration
(approximately 2% versus 10% to 15% with the
inferior alveolar nerve block), and
 the absence of problems with accessory sensory
innervation to the mandibular teeth.

 Nerves anesthetized

1. Inferior alveolar
2. Mental
3. Incisive
4. Lingual
5. Mylohyoid
6. Auriculotemporal
7 Buccal (in 75% of patients)


 Areas anesthetized (Fig. 14-15)

1. Mandibular teeth to the midline
2. Buccal mucoperiosteum and mucous
membranes on
the side of injection
3. Anterior two thirds of the tongue and floor of the
oral cavity
4. Lingual soft tissues and periosteum
5. Body of the mandible, inferior portion of the
ramus
6. Skin over the zygoma, posterior portion of the
cheek, and temporal regions

 Indications

1. Multiple procedures on mandibular teeth
2. When buccal soft tissue anesthesia, from the
third molar to the midline, is required
3. When lingual soft tissue anesthesia is
required
4. When a conventional inferior alveolar nerve
block isunsuccessful


Contraindications
 Patients who are unable to open their mouth
wide
Advantages
1. Requires only one injection;
2. High success rate (> 95%), with experience
3. Minimum aspiration rate
4. Few postinjection complications (i.e., trismus)
5. Provides successful anesthesia where a bifid
inferior alveolar nerve and bifid mandibular canals
are present

Technique
1. 25-gauge long needle
recommended
2. Area of insertion: mucous
membrane on the mesial of
the mandibular ramus, on a
line from the intertragic
notch to the corner of the
mouth, just distal to the
maxillary second molar
3- Target area: lateral side of
the condylar neck, just
below the insertion of the
lateral pterygoid muscle

Failures of anesthesia
 Rare with the Gow-Gates mandibular block,

once the administrator becomes familiar with the
technique
1. Too little volume. The greater diameter of the
mandibular nerve may require a larger volume of
anesthetic solution. Deposit up to 1.2 ml in the
second injection if the depth of anesthesia is
inadequate following the initial 1.8 ml.
2. Anatomical difficulties. Do not deposit
anesthetic unless bone is contacted.

 The technique has a very high success rate,

has minimal toxic effects, shows very low
positive blood aspiration, Unlike the
conventional inferior alveolar technique,
 provided the mouth is fully opened, the Gow-

Gates Technique allows for the deposition of
the anesthetic solution in the relatively
avascular region at the neck ofthe condyle.

Anesth Prog 34:142-149 1987

Vazirani-Akinosi technique.
 Its primary indication remains those situations in

which limited mandibular opening precludes the use
of other mandibular injection techniques


 Technique
 Area of insertion: soft tissue

overlying the medial (lingual)
border of the mandibular
ramus directly
 adjacent to the maxillary
tuberosity
 at the height of the
mucogingival junction
adjacent to the maxillary third
molar

 Target area: soft tissue on the medial (lingual)

border of the ramus in the region of the inferior
alveolar, lingual, and mylohyoid nerves as they
run inferiorly from the foramen ovale toward the
mandibular foramen
 The height of injection -below that with the

Gow-Gates but above that with the inferior
alveolar nerve block
 Orientation of the bevel (bevel orientation in

theclosed-mouth mandibular block is very
significant):
 the bevel must be oriented away from the bone

Landmarks
a. Mucogingival junction of the maxillary third (or
second) molar
b. Maxillary tuberosity
c. Coronoid notch on the mandibular ramus


EXTRA ORAL


Comparison of the Anesthetic
Efficacy


JOE—Volume 34, Number 11, November 2008


JOE—Volume 34, Number 11, November 2008

Speed of Injection Influences Efficacy
of Inferior Alveolar
Nerve Blocks


JOE — Volume 32, Number 10, October 2006

MENTAL NERVE BLOCK
Areas anesthetized
 Buccal mucous membranes anterior to the mental
foramen (around the second premolar)to the midline
and skin of the lower lip and chin
Indication
When buccal soft tissue anesthesia is required for
proceduresin the mandible anterior to the mental
foramen, such as
1. Soft tissue biopsies
2. Suturing of soft tissues
Contraindication
Infection or acute inflammation in the area of
injection

 Technique

1. A 25- or 27-gauge short needle recommended
2. Area of insertion: mucobuccal fold at or just
anterior to the mental foramen
3. Target area: mental nerve as it exits the mental
foramen (usually located between the apices of
the first and second premolars)
4. Landmarks: mandibular premolars and
mucobuccal fold


INCISIVE NERVE BLOCK
 Areas anesthetized

1. Buccal mucous membrane anterior to the mental
foramen, usually from the second premolar to the
midline
2. Lower lip and skin of the chin
3- Pulpal nerve fibers to the premolars, canine, and
incisors
 Indications

1. pulpal anesthesia on mandibular teeth anterior to the
mental foramen
2. When inferior alveolar nerve block is not indicated
a. When six or eight anterior teeth

THANK YOU


Mandibular Anesthesia Techniques

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