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Mandibular Local Anesthesia
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Mandibular Local Anesthesia

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Anaesthesia & Exodontia

Anaesthesia & Exodontia
Third Year

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Mandibular Local Anesthesia Presentation Transcript

  • 1. LOCAL ANAESTHESIA Techniques of regional analgesia for the mandibular nerve and its subdivisions Dr. Adel I. Abdelhady BDS, MSC, (Egypt) PhD. (Egypt,USA) Oral and Maxillofacial Surgery Dept. College of Dentistry, King Faisal University, KSA.
  • 2. Techniques of regional analgesia for the mandibular nerve and its subdivisions
  • 3. A- Intraoral techniques: 1- Inferior alveolar nerve block: a) Standard (direct) technique. b) Indirect technique. c) Closed mouth (VaziraniAkinosi) technique. d) Mandibular nerve block (Gow-Gates).
  • 4. A- Intraoral techniques: 23456- Lingual nerve block. Buccinator (long buccal) nerve block. Mental nerve block. Incisive nerve block. Block of the terminal branches (infiltration anesthesia). 7- Local infiltration of nerve endings (Submucosal analgesia).
  • 5. B- Extra oral techniques: 1- Mandibular nerve block. 2- Mental and incisive nerve block. 3- Infraorbital nerve block 4- Inferior alveolar nerve block.
  • 6. A. Mandibular anaesthesia I. Nerve block techniques:      II. infiltration techniques:  Lingual infiltration Inferior alveolar nerve block:  Long Buccal N. infiltration  Direct standard technique  Mylohyoid N.  Indirect technique  Infiltration in young  Akinosi-Vazerani technique  Gow-Gate technique children Mental & incisive NB technique Lingual NB technique Long buccal NB technique Mandibular NB technique:   Intraoral: Gow-Gate technique Extraoral technique
  • 7. B. Supplementary anaesthesia
  • 8. Mandibular nerve
  • 9. Mandibular Anesthesia Lower success rate than Maxillary anesthesia - approx. 80-85 %  Related to bone density  Less access to nerve trunks 
  • 10. Mandibular Anesthesia    Most commonly performed technique Has highest failure rate (15-20%) Success depends on depositing solution within 1 mm of nerve trunk    Not a complete mandibular nerve block. Requires supplemental buccal nerve block May require infiltration of incisors or mesial root of first molar
  • 11. Inferior Alveolar Nerve Block Areas Anesthetized Nerves anesthetized  Mandibular teeth to midline  Inferior Alveolar  Body of mandible, inferior  Mental ramus  Incisive  Buccal mucosa anterior to  Lingual mental foramen  Anterior 2/3 tongue & floor of mouth  Lingual soft tissue and periosteum
  • 12. Inferior Alveolar Nerve Block Indications  Multiple mandibular teeth  Buccal anterior soft tissue  Lingual anesthesia Contraindications  Infection/inflammation at injection site  Patients at risk for self injury (eg. children)
  • 13. Inferior Alveolar Nerve Block Advantages  Practitioner acceptance  Faster onset than higher blocks  Bony landmark Disadvantages     Area of injection is vascular; 10 -15% chance of positive aspiration Unlikely to anaesthetize accessory nerves Unlikely to anaesthetize long buccal nerve Difficult to see landmarks in some patients (e.g., macroglossia)
  • 14. Inferior Alveolar Nerve Block Alternatives  Mental nerve block  Incisive nerve block  Anterior infiltration  10%-15% positive aspiration     Periodontal ligament injection (PDL) Gow-Gates Akinosi Intraseptal
  • 15. Inferior Alveolar Nerve Block Target Area  Inferior alveolar nerve, near mandibular foramen Landmarks  Coronoid notch (the greatest depression on the anterior border of the ramus), also called the external oblique ridge  The contralateral mandibular bicuspids  Pterygomandibular raphe  Occlusal plane of mandibular posteriors  Internal oblique ridge
  • 16. Inferior Alveolar Nerve Block Technique:    Dry the area Apply antiseptic Apply topical anesthetic Area of insertion:      Palpate the deepest concavity at the anterior ramus border at the coronoid notch . 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)
  • 17. Inferior Alveolar Nerve Block Tech. con’s     Insert the needle into soft tissue in the halfway between the palpating finger or thumb and the pterygomandibular raphe about 5 mm opposite to the palpating finger. Approximate the height of the injection by the middle of the palpating fingernail or thumbnail. Ensure that the barrel of the syringe is located over the contralateral mandibular bicuspids. Insert until bone is contacted, and then withdraw ~1 mm. The depth of insertion for the averagesized adult is approximately 25 mm
  • 18. 1- Inferior alveolar nerve block:
  • 19. .a) Standard (direct) technique
  • 20. .b) Indirect technique
  • 21. Inferior Alveolar Nerve Block Precautions  Do not inject if bone not contacted  Avoid forceful bone contact Onset and duration   Onset for hard tissue anaesthesia is 3 to 4 minutes. Duration for hard tissue anaesthesia is 40 minutes to 4 hours, depending on the type of local anaesthetic used and whether a vasoconstrictor is used
  • 22. Inferior Alveolar Nerve Block Signs and Symptoms of anesthesia: a) Subjective symptoms numbness of the lower lip . b) Objective symptoms no pain by propping at the mental N. region . Failure of Anesthesia  Injection too low  Injection too anterior Accessory innervation  Mylohyoid nerve  -contralateral Incisive nerve innervation
  • 23. Pterygo-mandibular space
  • 24. Bony landmarks for IANB
  • 25. Mandibular anesthesia:
  • 26. Direct inferior alveolar nerve block and Lingual NB
  • 27. Areas anaesthetized
  • 28. Indirect IANB Same side technique
  • 29. Vazirani - Akinosi Closed Mouth Mandibular Block Advantages  Not necessary to open widely  High success rate  Relatively atraumatic  Few complications, few positive aspirationsCan be used for patients with trismus  Can be used for patients with a strong gag reflex  Mouth is closed, so injection may be less threatening to patient  Possibly less pain, because tissues are relaxed  Good for macroglossic patients Disadvantages      Visualization of path and depth of insertion is difficult No bony contact Traumatic if needle hits periosteum Difficult in patients with widely flaring ramus Difficult in patients with pronounced zygomatic buttress or internal oblique ridge
  • 30. Vazirani - Akinosi Closed Mouth Mandibular Block      Target Area Area of insertion Soft tissue medial to  Soft tissue overlying ramus medial ramus, adjacent to tuberosity Above the mandibular foramen, below the  At height of mucocondyle gingival junction of maxillary 2nd or 3rd Landmarks molar Mucogingival junction of maxillary 2nd or 3rd molar  Maxillary tuberosity
  • 31. Vazirani - Akinosi Closed Mouth Mandibular Block Technique  Retract soft tissues, have patient occlude  Dry area ,apply antiseptic and apply topical anesthetic  Penetrate to 25 mm, parallel to maxillary occlusal plane, in a posterior and lateral direction  Aspirate, deposit 1.8 ml slowly  Motor paralysis will develop first, allowing patient to open more widely
  • 32. Vazirani- Akinosi Closed Mouth Mandibular Block  Alternative for mandibular block when limited opening is present ( eg. trismus, closed lock )
  • 33. Vazirani - Akinosi technique
  • 34. Closed mouth (Vazirani-Akinosi) technique:
  • 35. Vazirani - Akinosi Closed Mouth Mandibular Block Complications  Hematoma (<10%)   Facial nerve paralysis (Bell’s Palsy) Trismus (rare) Failures of anesthesia  Lateral flaring of mandible  Insertion too low  Penetration too deep or shallow (adjust for patient size)
  • 36. 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   Target Area Neck of condyle, below insertion of lateral ptreygoid muscle
  • 37. Gow-Gates Mandibular Block Landmarks       Mesiolingual cusp of maxillary 2nd molar Intertragic notch Corner of the mouth the pterygomandibular raphe the neck of the condyle the contralateral mandibular bicuspids an imaginary line from the corner of the mouth to the tragal notch of the ear (extraorally).
  • 38. Mandibular Nerve Block (Gow-Gates).
  • 39. Gow-Gates Mandibular Block Technique  Coordinate intraoral & extraoral landmarks  Align barrel of syringe over premolars and with extraoral landmarks     Penetrate mucosa distal to 2nd molar Advance needle to bone (avg. 25 mm) Height of insertion above mand. Occlusal plane from 10-25 mm. Aspirate, deposit 1.8-3 ml of solution slowly
  • 40. 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 Complications  Hematoma (< 2%)  Trismus  Temporary paralysis of cranial nerve III,IV,VI
  • 41. Gow-Gates Mandibular Block Advantages      Perceptible end point (bone) Fewer blood vessels at this level, therefore less chance of positive aspiration Long buccal nerve anaesthesia likely Possible longer duration of anaesthesia Less chance of anaesthetizing accessory nerves Disadvantages Mouth wide open  Must use extraoral landmarks, which may increase the difficulty of this procedure 
  • 42. Mandibular NB, Gow-Gate tech. 1
  • 43. Gow-Gate tech. 2
  • 44. Lingual nerve block.
  • 45. Block of the terminal branches (infiltration anesthesia): Local infiltration of nerve endings (submucosal analgesia):
  • 46. SPECIAL TECHNIQUES
  • 47. Supplementary Techniques
  • 48. Supplemental Injection Techniques .Periodontal ligament injection- 1 .Intraseptal injection- 2 .Intraosseous injection- 3 .Intrapulpal injection- 4
  • 49. Intraligamentary Injection     Special syringe Short needle Blanching gingiva Hazards
  • 50. Periodontal Ligament Injection Indications  Anesthesia for 1-2 teeth  Bilateral mandibular treatment needed  Isolated treatment in children  Nerve blocks contraindicated (hemophiliacs)  Aid diagnosis of mandibular pain Contraindications  Primary teeth  Infection/inflammation  Psychological need for “feeling numb”
  • 51. Periodontal Ligament Injection Advantages Disadvantages  Avoid unnecessary  Administration difficult in areas of anesthesia some areas  Minimizes dosage of  May cause post-op anesthetic discomfort, tooth extrusion, &/or tissue  Supplements partially necrosis effective block  Excess pressure may break cartridge
  • 52. Periodontal Ligament Injection Technique  Insert needle on long axis of tooth  Deposit 0.2 ml slowly (30 secs)  Should feel resistance to deposition
  • 53. 1- Periodontal ligament injection.
  • 54. 2-Interseptal infiltration
  • 55. 2- Intraseptal injection.
  • 56. 3-Intra-pulpal infiltration
  • 57. 4- Intrapulpal injection.
  • 58. 4-Intra-osseous
  • 59. 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 
  • 60. Long Buccal Nerve Block      Advantages Technically easy High success rate Disadvantages Discomfort Indications  Anesthesia required - mucoperiosteum distal to mandibular molars Contraindications  Infection/inflammation at injection site
  • 61. Long 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 Landmarks  Mandibular molars  Mucobuccal fold Alternatives Buccal infiltration Gow-Gates PDL Intraseptal
  • 62. Buccinator (long buccal) nerve block:
  • 63. Long buccal nerve block
  • 64. Mental Nerve Block  Terminal branch of IAN as it exits mental foramen  Provides sensory innervations to buccal soft tissue anterior to mental foramen, lip and chin
  • 65. Mental Nerve Block     Indication Need for anesthesia in innervated area Contraindication Infection/inflammation at injection site      Advantages Easy, high success rate Usually atraumatic Disadvantage Hematoma
  • 66. Mental Nerve Block       Alternatives Local infiltration PDL Intraseptal Inferior alveolar nerve block Gow Gates     Complications Few Hematoma Positive aspiration 5.7 %
  • 67. Mental nerve block: Incisive nerve block:
  • 68. Mental and incisive nerve block
  • 69. Nerve block summary
  • 70. B- Extra oral techniques: Mandibular nerve block.
  • 71. Extraoral Nerve Blocks Indications  Infection  Inability to open mouth  Presence of pathology  Trauma  Diagnostic or therapeutic reasons    Maxillary nerve Infraorbital nerve Mandibular nerve
  • 72. Extraoral Maxillary/Mandibular Nerve Block Target area  Foramen Rotundum / Foramen Ovale  Penetration Point  Skin overlying sigmoid notch  Landmarks  Pterygoid plates Armamentarium  20-22 gauge spinal needle (3-5 inch)  3 ml syringe  Alcohol skin prep
  • 73. Extraoral Maxillary/ Mandibular Nerve Blocks Technique  Prep skin overlying sigmoid notch,  Anesthetize skin and masseter muscle  Pass spinal needle through sigmoid notch until the pterygoid plate is contacted
  • 74. Extraoral Maxillary/Mandibular Nerve Blocks Technique  Withdraw, then re-direct anterior/superior to 4.5 cm for maxillary block  Re-direct posterior/superior toward Foramen Oval for mandibular block
  • 75. Extraoral Maxillary/Mandibular Nerve Blocks Technique  Remove stylette  Place filled syringe on spinal needle  Aspirate and deposit 3 ml of anesthetic solution
  • 76. LA injection
  • 77. Spinal needle inserted
  • 78. Extraoral Infraorbital Nerve Block Landmarks  Infraorbital rim  Infraorbital foramen  Pupil Technique      Palpate foramen- 6 mm below rim on pupillary line Prep skin Penetrate skin and contact bone Redirect until foramen entered Advance 2-3 mm and deposit solution