Mandibular anesthetic techniques

Mandibular Anesthetic Techniques


Hesham El-Hawary
Lecturer OMFS
Cairo University
www.elhawarydentalclinic.com

ELHAWARY


Types of mandibular injections
Anterior labial
infl anesth

Infiltration Anterior lingual
anesthesia inf anesth

Long buccal inf
anesth
Mandibular
anethesia
IA and L NB

Nerve block
Mental NB
anesthesia

Long Buccal
NB

ELHAWARY


The mandibular nerve
1. Main Trunk
2. Nervous Spimosum
3. Nerve to medial pterygoid
4. Anterior Division
1. N. to Temporalis msc.
2. N. to Massetter msc.
3. N. to Lateral Pterygoid
msc.
4. Long Buccal N.
5. Posterior Division
1. Auriculo-temporal N.
2. Lingual Nerve
3. Inferior Alveolar N.
ELHAWARY


Nerve supply to mandibular teeth

Pulp , Investing structures
Anterior teeth
(1,2,3) Incisive nerve

Premolars (4,5)
& Inferior alveolar nerve
Molars (678)

ELHAWARY


Cont.
Labial (buccal) mucoperiosteum
Mental nerve
Anterior teeth
(1,2,3) Cutaneous coli nerve
& ( branch of cervical plexus C2 &
c3 ) gives additional sensory supply
Premolars
for premolars ( 4 , 5 ) in about 20 %
(45)
pt.
Molars (678) Long buccal nerve

ELHAWARY


Cont.

Lingual mucoperiosteum

Anterior teeth
(1,2,3) Premolars
Lingual nerve
(4,5) & Molars
(678)

ELHAWARY


The accessory innervation of Mandibular teeth

• The lower anterior teeth cross innervation
may take place i.e. branch from the
incisive nerve of the other side
• The lower premolar may receive additional
nerve supply from the cutaneous coli
nerve (branch from the cervical plexus of
nerves)
• The lower molars may receive additional
nerve supply from the nerve to mylohyoid
ELHAWARY



Infiltration Anesthesia

Anteriors’ Labial Infiltration
anesthesia

ELHAWARY


Anteriors’ Labial infiltration anesthesia
• Nerve to be anesthetized
– Incisive Nerve
– Inferior dental plexus

ELHAWARY


Anterior’s Labial infiltration anesthesia
Patient position Dentist position
• Head , neck and trunk on the • From infront and to the
same straight line right
• The back of the chair is tilted so
that it make a 45 degree angle
with the floor
• So that when the patient open his
mouth the occlusal plane of the
mandibular teeth becomes
parallel to the floor
• The occlusal plan of mandibular
teeth near to the operator’s
elbow

ELHAWARY


Anteriors’ Labial infiltration anesthesia
Cont.
• Needle:
– 25-27 gauge
– Short needle
• Syringe
– Non-Aspirating syringe
• The target area
– The apical region of the tooth to be anesthetized

ELHAWARY


Anteriors’ labial Infiltration Anesthesia
Cont.

The point of needle insertion
The point of intersection of 2
imaginary lines
• 1st line is a vertical line
parallel to the long axis of
the tooth
• 2nd line is a horizontal line
along the mucobuccal fold

ELHAWARY


Anteriors’ Labial Infiltration Anesthesia
Cont.

Direction of needle insertion
• 45° with the buccal cortical
plate of bone

ELHAWARY


Steps for Labial infiltration
 The lip/cheek is retracted using dental mirror or your
finger to make almost a right angle with the
labial/buccal aspect of the jaw
 The point of insertion is determined as mentioned
 The needle is inserted with its bevel toward the bone
and making an angle of 45° with the buccal aspect
 The needle is pushed through the soft tissue until
the bone is reached (within 2mm)

ELHAWARY


Steps for Labial infiltration Cont.
 The needle is held firmly and 1.5cc of the solution is
slowly deposited for buccal/labial injection, and 0.3
cc for lingual anesthesia
 The needle is then withdrawn gently and recap it

 Wait 2-3 minutes before starting your dental
procedure

 Check your anesthesia using the dental probe
(objective finding)
ELHAWARY


Confirming the Anesthesia
• Subjective findings
– Numbness of the lower lip
• Objective findings
– Probing does not lead to pain

ELHAWARY




Anteriors’ lingual Infiltration Anesthesia

ELHAWARY


Lingual Infiltration Anesthesia
– Terminal branches of the lingual nerve

ELHAWARY


Anteriors’ Lingual infiltration
anesthesia
same straight line right except when
• The back of the chair is tilted so anesthetizing the lower left
with the floor
anterior teeeh the operator
stands in the right rear
mouth the occlusal plane of the position
elbow

ELHAWARY


Anteriors’
Anteriors’ Lingual infiltration anesthesia
Cont.

• Needle:
– 25-27 gauge
– Short needle
• Syringe
• The target area
– Apical to the tooth to be anesthetized lingually

ELHAWARY


Anteriors’ Lingual Infiltration Technique
Cont.


Above the The point of intersection of 2 imaginary lines
• 1st line is a vertical line parallel to the long axis of the tooth
• 2nd line is a horizontal line above the floor of the mouth
(mucolingual fold)
– By 2-3 mm
– i.e. 3-5 mm cervical to the free gingival margin along the long axis of
the tooth

ELHAWARY


Anteriors’ lingual Infiltration Technique
Cont.

Direction of needle insertion Direction of needle insertion
in left side in right side

• DIRECT VISION TECHNIQUE: •INDIRECT VISION TECHNIQUE:

• The syringe is directed from The syringe is directed from the
the corner of the mouth of the corner of the mouth from the left
rt. Side side

• The bevel towards the bone Bevel towards bone

ELHAWARY


Steps for Anteriors’ Lingual
Anteriors’
infiltration
 The tongue is retracted and the light is reflected using dental
mirror held in the left hand
 Direction: As mentioned before in Left/Right sides
 The needle is pushed through the soft tissue until the bone is
reached (within 2mm)
 Administer 0.2-0.3ml of anesthetic sol

ELHAWARY


Steps for Lingual infiltiration
Cont.

procedure

(objective finding)

ELHAWARY


– No Subjective findings

ELHAWARY




Long Buccal Infiltration anesthesia

ELHAWARY


Long buccal infltration anesthesia
– Terminal parts of the long buccal nerve

ELHAWARY


Long Buccal infiltration anesthesia
same straight line right
with the floor
elbow

ELHAWARY


Long Buccal infiltration anesthesia Cont.
• Needle:
– 25-27 gauge
– Long needle
• Syringe
• Except when injecting long buccal infiltration following Inferior
alveolar nerve block)

• The target area
– Distal to The apical region of the tooth to be
anesthetized
ELHAWARY


Long Buccal Infiltration Anesthesia Cont.
The point of intersection of 2 imaginary lines
• 1st line is a vertical line parallel to the long axis of
the DISTAL root of the molar
• 2nd line is a horizontal line along the mucobuccal
fold
• 45° with the buccal cortical plate of bone

ELHAWARY


Steps for Long Buccal infiltration
 The cheek is retracted using dental mirror or your
finger to make almost a right angle with the
labial/buccal aspect of the jaw
and making an angle of 45° with the buccal aspect
 The needle is pushed through the soft tissue until
the bone is reached (within 2mm)

ELHAWARY


Steps for Long buccal infiltiration
Cont.
 The needle is held firmly and 0.2-0.3 cc of the
solution is slowly deposited

procedure

(objective finding)

ELHAWARY


– No subjective findings

ELHAWARY



Nerve Block Anesthesia

Inferior Alveolar & Lingual Nerve Block

ELHAWARY


IA & Lingual Nerve Block Anesthesia
• Aim
– To deposit the anesthetic solution in close
vicinity to the Inferior alveolar nerve just before
its entry to the mandibular foramen
– To deposit the anesthetic solution in close
vicinity to the lingual nerve as it pass anterior
and medial to the IAN

ELHAWARY


Methods for anesthesia the inf.alv.nerve
• Intra oral • Extraoral techniques
– Inf. Alv N. block – Inf. Alv N. block
technique – Mental N.block
– Gow gates technique
– Vazironi-akeinosi
technique

ELHAWARY


– Incisive Nerve
– Mental nerve
– Inferior alveolar nerve
– Lingual nerve

ELHAWARY


• Areas to be anesthetized
– All lower posterior teeth in the side of
anesthesia
• Pulp
• Investing structures
– Buccal mucoperiosteum of the anterior teeth
and premolars
– The lingual mucoperiosteum of the same side
– Floor of the mouth of the same side
– Half the tongue of the same side
ELHAWARY


• Indications
– Analgesia for all restorative procedures on the
mandibular teeth
– Surgical procedures on mandibular teeth and
supporting structures
– Diagnostic or therapeutic purposes, for
neuralgias of the mandibular nerve

ELHAWARY


• Contraindications
– Patients who might bite either the lip or
tongue (physically or mentally handicapped
patients, or very young children)
– Infection or acute inflammation in the area of
injection

ELHAWARY


• Advantages
– one injection provides wide area of anesthesia

• Disadvantages
– Wide area of anesthesia

– Rate of inadequate anesthesia is 15-20% which will need a
second injection

– Anatomical variations

– Lower lip anesthesia is discomforting to many patients while
possibly dangerous in children
ELHAWARY


• Head , neck and trunk on the • Right side:
same straight line – From infront and to the right
• The back of the chair is tilted so • Left side:
with the floor – From infront and to the right
using
• So that when the patient open his • Cross hand technique
mouth the occlusal plane of the • Using left hand
– From right rear position using
• From behind technique
elbow

ELHAWARY


Cont.
• Needle:
– 25-27 gauge
– Long needle
• Syringe
– Aspirating syringe
• The target area
– The point of entry of the IAN into the mandibular
canal

ELHAWARY


Cont.

• Landmarks: • Landmarks:
– Soft tissue landmarks: – Bony landmarks:
• Muccobuccal fold • External oblique ridge
• Buccal pad of fat • Internal oblique ridge
• Retromolar area – triangle • Anterior border of the
• Pterygomandibular raphe ramus
• Cronid process
• Cronoid notch

ELHAWARY


Steps for right mandibular injection
• Right handed operator
• The operator is positioned on the right
front of the patient

ELHAWARY


• The operator uses his left index finger to
determine the landmarks.

• He first puts his index finger in the muco-
buccal fold opposite to the premolar area.
(nail upwards)

ELHAWARY


• Gently slide the index finger posteriorly to
encounter the ext. oblique ridge, then
ascending ramus till the coronoid process
.(highest convexity)

• Then slide the finger down the ascending
ramus untill it reaches the point of greatest
depth.
ELHAWARY


• At this point rotate your finger medially so
the finger nail faces the tongue. (sagittal
plane)

• There you will feel a bony depression
under your finger tip.

ELHAWARY


• The point of needle insertion is 5mm along
an imaginary line bissecting the finger nail.

• Ask the pt. to open wide, dry the area and
apply topical antiseptic and then topical
anesthetic.

ELHAWARY


• With finger in place pull the underlying tissues
laterally, stretching the tissue over injection site
making the needle insertion less traumatic.

• Using a 25 gauge long needle, we approach the
target area from the opposite side (premolar
area) on the level of the occlusal plane.

ELHAWARY


• Advance the needle slowly untill it touches bone
. (about 2/3 of its length)

• Aspirate, if negative then rotate slightly and
aspirate again (why), if still negative then
administer 1.5ml slowly .

• This amount is to anesthetize the inf. Alv. Nerve
and the lingual nerve (how).
ELHAWARY


• After the subjective symptoms start then the long
buccal inj. is performed administering the
remaining 0.3ml distal to the tooth to be
extracted.

• Now you can proceed with your extraction
procedure.

ELHAWARY


Steps for left mandibular injection
• Right handed operator
The operator is positioned on the right front of
the patient
– From infront and to the right
• Cross hand technique
• Left hand technique
– Right rear position
• From behind technique

ELHAWARY


Errors during injection
• Too high injection
– Anesthesia of the auriclotemporal nerve : Numbness of the ear
– Injection into lateral pterygoid muscle : Soreness and trismus
• Too low injection:
– Deposited in parotid gland
• Temporary facial nerve paralysis
• Parotitis
– Deposited into medial pterygoid muscle,
• Pain
• Trismus
– Deposited into the posterior facial vein :
• Toxicity

• Too medial injection
– Deposited into the constrictor muscle of pharynx : disphagya
ELHAWARY


Gow-gates technique

• This technique was introduced in 1973 by the
Australian operator Dr. George Gow-gates

• It provides sensory anesthesia to all branches of
the Posterior Division and Buccal nerve

ELHAWARY


Vazirani -Akinosi Technique

• This technique was reported in 1977 by
Dr. Joseph Akinosi

• The main advantage is that it could be
administrated to patients with very limited
mouth opening

ELHAWARY




Mental Nerve Block

ELHAWARY


Mental Nerve Block
• Aim • Inject the anesthetic
solution in the vicinity
of the mental foramen

• Nerves to be • Mental nerve
anesthetized • Incisive nerve
• Part of the inferior
alveolar nerve

ELHAWARY


Mental Nerve Block
• Needle • 25-27 gauge
• Short needle

• Syringe • Aspirating syringe

ELHAWARY


Mental Nerve Block anesthesia
• Head , neck and trunk on the • Right rear position
same straight line
with the floor
elbow

ELHAWARY


Mental Nerve Block Anesthesia Cont.
The point of intersection of 2
imaginary lines
• 1st line is a vertical line
parallel to the long axis of
both premolars and
between them
• 2nd line is a horizontal line
along the mucobuccal fold

ELHAWARY


Anterior Labial Infiltration Anesthesia
Cont.

• 45° with the buccal cortical
plate of bone

ELHAWARY


Steps of injection
• Palpate the mental foramen with your
index finger
– It lies in between the apices of the first and
second premolars
– The bone anterior and posterior to the
foramen is smooth
– The bone immediately around it is rough
– The mental foramen opening is directed
posteriorly

ELHAWARY


Steps of injection Cont.
• Insert the needle in the mucobuccal fold between
the two bicuspids directing the syringe towards
the mental foramen
• Advance the needle till the foramen is reached
– The depth of penetration is usually 5-6 mm
• Aspirate, if negative deposit the local anesthetic
solution
• withdraw syringe and recap needle
• Wait 3 minutes before commencing dental
procedure
ELHAWARY




Long Buccal Nerve Block

ELHAWARY


Long buccal nerve block
– Long buccal nerve
• Needle
– 25-27 gauge
– Long needle
• Syringe
– Aspirating Syringe
• Leads to the anesthetization of the buccal
mucosa of the molar teeth
ELHAWARY


• 0.2 ml of anesthetic solution is deposited at the
apex of the retromolar triangle between the
external and internal oblique ridges
• Point of insertion
– apex of the retromolar triangle between the external
and internal oblique ridges
• Direction of injection
– Parallel to the occlusal plane from the same side

ELHAWARY


• Technique
– The same technique as the inferior alveolar
nerve is followed except that the point of
insertion is just anterior to the index finger or
the area palpated with the syringe oriented
over the teeth of the same side to be injected
and parallel to the occlusal plane.

ELHAWARY


ELHAWARY


– Numbness of the mucosa of the cheek
opposite to the lower molars

N.B. This long buccal infiltration or block should
be administered after the onset of subjective
symptoms of the inf. Alv.N.block
ELHAWARY


Mandibular anesthetic techniques
Supplementary Anesthesia

Intraosseous anesthesia
Interseptal anesthesia
Intrapulpal anesthesia
Intraligamentry anesthesia
ELHAWARY




ELHAWARY


(Inter dental)
• Indications:
– It anesthetizes the terminal nerve endings of
the soft and hard tissues at the site of
injection
– Obtaining hemostasis at the surgical site

ELHAWARY


(Inter dental)
• Point of insertion:
– At the center of the Base of the inter dental
papillae
• Direction of injection:
– 45 degrees with the buccal plate of bone
– Bevel directed to the bone
• Amount of injection:
– 0.2-0.4ml

ELHAWARY


(Inter dental)

• Type of syringe
– Non-aspirating syringe

– Pressure syringe

• Type of needle
– Short needle

– Gauge 25-27

ELHAWARY


(Inter dental)

• Advantages:

– Very quick onset

• Disadvantages:

– Causes blanching of the gingiva

– Resistance during administration

ELHAWARY



Intrapulpal anesthesia

ELHAWARY


Intrapulpal injection
• Administration of anesthesia directly into pulp
• Indications
– Acute pulpitis
– Endodontic treatment
• Needle
– 25-27 gauge
– Long needle
• Syringe

ELHAWARY


• Technique:
– The needle is inserted into the pulp chamber
– Wedged firmly in the pulp chamber or the root canal
– Deposit the anesthetic solution under pressure
N.B. Bend the needle if necessary to gain access to the pulp
chamber or canal
• Amount administered:
– About 0.2-0.3 ml

ELHAWARY


• Advantages:
– Profound
– Fast
– Allows painless pulp exterpation
• Disadvantages:
– Painful
– Needs pressure
– Variable duration

ELHAWARY



Intraligamentary anesthesia

ELHAWARY


Intraligamentry Anesthesia
• Delivering the anesthetic sol. through the
periodontal ligament to reach the periapical area
• Needle
– 25-27 gauge
– Short needle
• Syringe
– Non-Aspirating

ELHAWARY


• Indications / advantages:
– Pulpal and soft tissue anesthesia in a localized area
(one tooth)
– Avoids extensive anesthesia of the soft tissues that is
achieved through block anesthesia
• Contraindications / Disadvantages:
– Infection or inflammation at the site of injection
– Use in primary teeth
• Enamel hypoplasia
• Enamel hypomineralization

ELHAWARY


• Technique:
– The needle is inserted mesial or
distal to the tooth in the
inteproximal area at the depth of
the gingival sulcus
– The bevel facing towards the root
of the tooth
– Advance the needle apically until
resistance is encountered
– Deposit 0.2 ml of the anesthetic
solution in about 20 seconds
ELHAWARY


• Its main advantage is that it does not lead to
numbness of the whole segment, but just the
tooth involved

• While its disadvantages are:-

• Doesn’t work for all patients.

• Contraindicated in cases of infection.

• Contraindicated in children with primary
dentition. ELHAWARY


Thank you
www.elhawarydentalclinic.com

ELHAWARY

Mandibular anesthetic techniques

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