1.
Techniques of Mandibular
Anesthesia

2.
Mandibular Anesthesia
Lower success rate than Maxillary anesthesia -
approx. 80-85 %
Related to bone density
Less access to nerve trunks

3.
Indication For Special Technique
Anatomic variation
Complete nerve trunk
Selective pulpal / soft tissue anesthesia

4.
Mandibular Nerve Blocks
Inferior alveolar
Mental - Incisive
Buccal
Lingual
Gow-Gates
Akinosi

5.
Mandibular Anesthesia
Most commonly performed technique
Has highest failure rate (15-20%)
Success depends on depositing solution within 1 mm of
nerve trunk

6.
Inferior Alveolar Nerve Block
Not a complete mandibular nerve block.
Requires supplemental buccal nerve block
May require infiltration of incisors or mesial root
of first molar

7.
Inferior Alveolar Nerve Block
Nerves anesthetized
Inferior Alveolar
Mental
Incisive
Lingual

8.
Inferior Alveolar Nerve Block
Areas Anesthetized
Mandibular teeth to midline
Body of mandible, inferior ramus
Buccal mucosa anterior to mental foramen
Anterior 2/3 tongue & floor of mouth
Lingual soft tissue and periosteum

9.
Inferior Alveolar Nerve Block
Indications
Multiple mandibular teeth
Buccal anterior soft tissue
Lingual anesthesia

10.
Inferior Alveolar Nerve Block
Contraindications
Infection/inflammation at injection site
Patients at risk for self injury (eg. children)

11.
Inferior Alveolar Nerve Block
10%-15% positive aspiration

12.
Inferior Alveolar Nerve Block
Alternatives
Mental nerve block
Incisive nerve block
Anterior infiltration

13.
Inferior Alveolar Nerve Block
Alternatives (cont.)
Periodontal ligament injection (PDL)
Gow-Gates
Akinosi
Intraseptal

14.
Inferior Alveolar Nerve Block
Technique
Apply topical
Area of insertion:
medial ramus, mid-coronoid notch,
level with occlusal plane (1 cm above),
3/4 posterior from coronoid notch to
pterygomandibular raphe
advance to bone (20-25 mm)

15.
Inferior Alveolar Nerve Block
Target Area
Inferior alveolar nerve, near mandibular
foramen
Landmarks
Coronoid notch
Pterygomandibular raphe
Occlusal plane of mandibular posteriors

16.
Inferior Alveolar Nerve Block
Precautions
Do not inject if bone not contacted
Avoid forceful bone contact

17.
Inferior Alveolar Nerve Block
Failure of Anesthesia
Injection too low
Injection too anterior
Accessory innervation
-Mylohyoid nerve
-contralateral Incisive nerve innervation

18.
Inferior Alveolar Nerve Block
Complications
Hematoma
Trismus
Facial paralysis

19.
Long Buccal Nerve Block
Anterior branch of Mandibular nerve (V3)
Provides buccal soft tissue anesthesia adjacent to
mandibular molars
Not required for most restorative procedures

20.
Buccal Nerve Block
Indications
Anesthesia required - mucoperiosteum buccal to
mandibular molars
Contraindications
Infection/inflammation at injection site

21.
Buccal Nerve Block
Advantages
Technically easy
High success rate
Disadvantages
Discomfort

22.
Buccal Nerve Block
Alternatives
Buccal infiltration
Gow-Gates
PDL
Intraseptal

23.
Buccal Nerve Block
Technique
Apply topical
Insertion distil and buccal to last molar
Target
- Long Buccal nerve as it passes anterior border of ramus
Insert approx. 2 mm, aspirate
Inject 0.3 ml of solution, slowly
- 25-27 gauge needle
Area of insertion:
- Mucosa adjacent to most distal

24.
Buccal Nerve Block
Landmarks
Mandibular molars
Mucobuccal fold

25.
Buccal Nerve Block
Complications
Hematoma (unusual)
Positive aspiration
0.7 %

26.
Mental Nerve Block
Terminal branch of IAN as it exits mental foramen
Provides sensory innervation to buccal soft tissue
anterior to mental foramen, lip and chin

27.
Mental Nerve Block
Indication
Need for anesthesia in innervated area
Contraindication
Infection/inflammation at injection site

28.
Mental Nerve Block
Advantages
Easy, high success rate
Usually atraumatic
Disadvantage
Hematoma

29.
Mental Nerve Block
Alternatives
Local infiltration
PDL
Intraseptal
Inferior alveolar nerve block
Gow Gates

30.
Mental Nerve Block
Complications
Few
Hematoma
Positive aspiration
5.7 %

31.
Incisive Nerve Block
Terminal branch of IAN
Originates in mental foramen and proceeds
anteriorly
Good for bilateral anterior anesthesia
Not effective for anterior lingual anesthesia

32.
Incisive Nerve Block
Nerves anesthetized
Incisive
Mental

33.
Incisive Nerve Block
Areas Anesthetized
Mandibular labial mucous membranes
Lower lip / skin of chin
Incisor, cuspid and bicuspid teeth

34.
Incisive Nerve Block
Indication
Anesthesia of pulp or tissue required anterior to mental
foramen
Contraindication
Infection/inflammation at injection site

35.
Incisive Nerve Block
Advantages
High success rate
Pulpal anesthesia w/o lingual anesthesia
Disadvantages
Lack of lingual or midline anesthesia

36.
Incisive Nerve Block
Complications
Hematoma
Positive aspiration
5.7 %

37.
Gow-Gates Mandibular Block
Developed to improve success rate.
True mandibular nerve block.
Has a lower rate of positive aspiration
(2% vs. 10%-15% for IAN).
Technique dependent.

38.
Gow-Gates Mandibular Block
Target Area
Neck of condyle,
below insertion of
lateral pterygoid muscle

39.
Gow-Gates Mandibular Block
Landmarks
Mesiolingual cusp of maxillary 2nd molar
Intertragic notch
Corner of the mouth

40.
Gow-Gates Mandibular Block
Technique
Coordinate intraoral & extraoral landmarks
Align barrel of syringe over premolars and with
extraoral landmarks

41.
Gow-Gates Mandibular Block
Technique (cont.)
Penetrate mucosa distil to 2nd molar
Advance needle to bone (avg. 25 mm)
Aspirate, deposit 1.8 ml of solution slowly

42.
Gow-Gates Mandibular Block
Technique (cont.)
Patient’s mouth must be fully open during
injection and for 1-2 mins afterward
May require reinforcement with second
injection

43.
Gow-Gates Mandibular Block
Complications
Hematoma (< 2%)
Trismus

44.
Akinosi Closed Mouth Mandibular
Block
Alternative for mandibular
block when limited opening
is present
( eg. trismus, closed lock, etc..)

45.
Akinosi Closed Mouth Mandibular
Block
Advantages
Not necessary to open widely
High success rate
Relatively atraumatic
Few complications, few positive aspirations

46.
Akinosi Closed Mouth Mandibular
Block
Disadvantages
Visualization of path and depth of insertion is
difficult
No bony contact
Traumatic if needle hits periosteum

47.
Akinosi Closed Mouth Mandibular
Block
Target Area
Soft tissue medial to ramus
Above foramen, below condyle
Landmarks
Mucogingival junction of maxillary 2nd or 3rd
molar
Maxillary tuberosity

48.
Akinosi Closed Mouth Mandibular
Block
Area of insertion
Soft tissue overlying medial ramus, adjacent to
tuberosity
At height of mucogingival junction of maxillary
2nd or 3rd molar

49.
Akinosi Closed Mouth Mandibular
Block
Technique
Retract soft tissues, have patient occlude
Apply topical
Penetrate to 25 mm, parallel to maxillary
occlusal plane, in a posterior and lateral
direction

50.
Akinosi Closed Mouth Mandibular
Block
Technique (cont.)
Aspirate, deposit 1.8 ml slowly
Motor paralysis will develop first, allowing
patient to open more widely

51.
Akinosi Closed Mouth Mandibular
Block
Complications
Hematoma (<10%)
Facial nerve paralysis (Bell’s Palsy)
Trismus (rare)

52.
Akinosi Closed Mouth Mandibular
Block
Failures of anesthesia
Lateral flaring of mandible
Insertion too low
Penetration too deep or shallow (adjust for patient
size)

53.
Done By :
Ghadah Sidqi
G (3) , L(5) .