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Mandibular anesthetic techniques
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  • 1. Mandibular Anesthetic TechniquesMandibular Anesthetic Techniques Hesham El-Hawary Lecturer OMFS Cairo University www.elhawarydentalclinic.com ELHAWARY
  • 2. Mandibular Anesthetic TechniquesTypes 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
  • 3. Mandibular Anesthetic Techniques The mandibular nerve1. Main Trunk2. Nervous Spimosum3. Nerve to medial pterygoid4. 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
  • 4. Mandibular Anesthetic TechniquesNerve supply to mandibular teeth Pulp , Investing structuresAnterior teeth (1,2,3) Incisive nervePremolars (4,5) & Inferior alveolar nerve Molars (678) ELHAWARY
  • 5. Mandibular Anesthetic TechniquesNerve supply to mandibular teeth Cont. Labial (buccal) mucoperiosteum Mental nerveAnterior 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
  • 6. Mandibular Anesthetic TechniquesNerve supply to mandibular teeth Cont. Lingual mucoperiosteum Anterior teeth(1,2,3) Premolars Lingual nerve (4,5) & Molars (678) ELHAWARY
  • 7. Mandibular Anesthetic TechniquesThe 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
  • 8. Mandibular Anesthetic TechniquesMandibular Anesthetic TechniquesInfiltration Anesthesia Anteriors’ Labial Infiltration anesthesia ELHAWARY
  • 9. Mandibular Anesthetic TechniquesAnteriors’ Labial infiltration anesthesia • Nerve to be anesthetized – Incisive Nerve – Inferior dental plexus ELHAWARY
  • 10. Mandibular Anesthetic TechniquesAnterior’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
  • 11. Mandibular Anesthetic TechniquesAnteriors’ 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
  • 12. Mandibular Anesthetic TechniquesAnteriors’ 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
  • 13. Mandibular Anesthetic TechniquesAnteriors’ Labial Infiltration Anesthesia Cont. Direction of needle insertion • 45° with the buccal cortical plate of bone ELHAWARY
  • 14. Mandibular Anesthetic Techniques 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
  • 15. Mandibular Anesthetic TechniquesSteps 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
  • 16. Mandibular Anesthetic Techniques Confirming the Anesthesia• Subjective findings – Numbness of the lower lip• Objective findings – Probing does not lead to pain ELHAWARY
  • 17. Mandibular Anesthetic TechniquesMandibular Anesthetic TechniquesInfiltration Anesthesia Anteriors’ lingual Infiltration Anesthesia ELHAWARY
  • 18. Mandibular Anesthetic Techniques Lingual Infiltration Anesthesia• Nerve to be anesthetized – Terminal branches of the lingual nerve ELHAWARY
  • 19. Mandibular Anesthetic Techniques Anteriors’ Lingual infiltration anesthesiaPatient position Dentist position• Head , neck and trunk on the • From infront and to the same straight line right except when• The back of the chair is tilted so anesthetizing the lower left that it make a 45 degree angle with the floor anterior teeeh the operator• So that when the patient open his stands in the right rear mouth the occlusal plane of the position mandibular teeth becomes parallel to the floor• The occlusal plan of mandibular teeth near to the operator’s elbow ELHAWARY
  • 20. Mandibular Anesthetic TechniquesAnteriors’Anteriors’ Lingual infiltration anesthesia Cont. • Needle: – 25-27 gauge – Short needle • Syringe – Non-Aspirating syringe • The target area – Apical to the tooth to be anesthetized lingually ELHAWARY
  • 21. Mandibular Anesthetic TechniquesAnteriors’ Lingual Infiltration Technique Cont. The point of needle insertion 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
  • 22. Mandibular Anesthetic TechniquesAnteriors’ 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
  • 23. Mandibular Anesthetic Techniques Steps for Anteriors’ Lingual Anteriors’ infiltration The tongue is retracted and the light is reflected using dental mirror held in the left hand The point of insertion is determined as mentioned The needle is inserted with its bevel toward the bone 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
  • 24. Mandibular Anesthetic Techniques Steps for Lingual infiltiration Cont. 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
  • 25. Mandibular Anesthetic Techniques Confirming the Anesthesia• Subjective findings – No Subjective findings• Objective findings – Probing does not lead to pain ELHAWARY
  • 26. Mandibular Anesthetic TechniquesMandibular Anesthetic TechniquesInfiltration Anesthesia Long Buccal Infiltration anesthesia ELHAWARY
  • 27. Mandibular Anesthetic TechniquesLong buccal infltration anesthesia• Nerve to be anesthetized – Terminal parts of the long buccal nerve ELHAWARY
  • 28. Mandibular Anesthetic Techniques Long Buccal infiltration anesthesiaPatient 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
  • 29. Mandibular Anesthetic TechniquesLong Buccal infiltration anesthesia Cont. • Needle: – 25-27 gauge – Long needle • Syringe – Non-Aspirating 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
  • 30. Mandibular Anesthetic TechniquesLong Buccal 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 DISTAL root of the molar • 2nd line is a horizontal line along the mucobuccal fold Direction of needle insertion • 45° with the buccal cortical plate of bone ELHAWARY
  • 31. Mandibular Anesthetic TechniquesSteps 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  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
  • 32. Mandibular Anesthetic TechniquesSteps for Long buccal infiltiration Cont.  The needle is held firmly and 0.2-0.3 cc of the solution is slowly deposited  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
  • 33. Mandibular Anesthetic Techniques Confirming the Anesthesia• Subjective findings – No subjective findings• Objective findings – Probing does not lead to pain ELHAWARY
  • 34. Mandibular Anesthetic TechniquesMandibular Anesthetic TechniquesNerve Block Anesthesia Inferior Alveolar & Lingual Nerve Block ELHAWARY
  • 35. Mandibular Anesthetic TechniquesIA & 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
  • 36. Mandibular Anesthetic Techniques 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
  • 37. Mandibular Anesthetic TechniquesIA & Lingual Nerve Block Anesthesia• Nerve to be anesthetized – Incisive Nerve – Mental nerve – Inferior alveolar nerve – Lingual nerve ELHAWARY
  • 38. Mandibular Anesthetic TechniquesIA & Lingual Nerve Block Anesthesia• 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
  • 39. Mandibular Anesthetic Techniques• 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
  • 40. Mandibular Anesthetic Techniques• 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
  • 41. Mandibular Anesthetic Techniques• 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
  • 42. Mandibular Anesthetic TechniquesIA & Lingual Nerve Block AnesthesiaPatient position Dentist position• 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: that it make a 45 degree angle 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 mandibular teeth becomes – From right rear position using parallel to the floor • From behind technique• The occlusal plan of mandibular teeth near to the operator’s elbow ELHAWARY
  • 43. Mandibular Anesthetic TechniquesIA & Lingual Nerve Block Anesthesia 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
  • 44. Mandibular Anesthetic Techniques IA & Lingual Nerve Block Anesthesia 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
  • 45. Mandibular Anesthetic TechniquesSteps for right mandibular injection• Right handed operator• The operator is positioned on the right front of the patient ELHAWARY
  • 46. Mandibular Anesthetic Techniques• 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
  • 47. Mandibular Anesthetic Techniques• 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
  • 48. Mandibular Anesthetic Techniques• 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
  • 49. Mandibular Anesthetic Techniques• 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
  • 50. Mandibular Anesthetic Techniques• 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
  • 51. Mandibular Anesthetic Techniques• 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
  • 52. Mandibular Anesthetic Techniques• 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
  • 53. Mandibular Anesthetic Techniques Confirming the Anesthesia• Subjective findings – Numbness of the lower lip• Objective findings – Probing does not lead to pain ELHAWARY
  • 54. Mandibular Anesthetic Techniques 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
  • 55. Mandibular Anesthetic Techniques 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
  • 56. Mandibular Anesthetic Techniques 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
  • 57. Mandibular Anesthetic Techniques 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
  • 58. Mandibular Anesthetic TechniquesMandibular Anesthetic TechniquesNerve Block Anesthesia Mental Nerve Block ELHAWARY
  • 59. Mandibular Anesthetic Techniques 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
  • 60. Mandibular Anesthetic Techniques Mental Nerve Block• Needle • 25-27 gauge • Short needle• Syringe • Aspirating syringe ELHAWARY
  • 61. Mandibular Anesthetic Techniques Mental Nerve Block anesthesiaPatient position Dentist position• Head , neck and trunk on the • Right rear position same straight line• 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
  • 62. Mandibular Anesthetic Techniques Mental Nerve Block Anesthesia Cont.The point of needle insertionThe 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
  • 63. Mandibular Anesthetic TechniquesAnterior Labial Infiltration Anesthesia Cont.Direction of needle insertion• 45° with the buccal cortical plate of bone ELHAWARY
  • 64. Mandibular Anesthetic Techniques 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
  • 65. Mandibular Anesthetic Techniques 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
  • 66. Mandibular Anesthetic Techniques Confirming the Anesthesia• Subjective findings – Numbness of the lower lip• Objective findings – Probing does not lead to pain ELHAWARY
  • 67. Mandibular Anesthetic TechniquesMandibular Anesthetic TechniquesNerve Block Anesthesia Long Buccal Nerve Block ELHAWARY
  • 68. Mandibular Anesthetic Techniques Long buccal nerve block• Nerve to be anesthetized – 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
  • 69. Mandibular Anesthetic Techniques Long buccal nerve block• 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
  • 70. Mandibular Anesthetic Techniques Long buccal nerve block• 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
  • 71. Mandibular Anesthetic Techniques ELHAWARY
  • 72. Mandibular Anesthetic Techniques Confirming the Anesthesia• Subjective findings – Numbness of the mucosa of the cheek opposite to the lower molars• Objective findings – Probing does not lead to pain N.B. This long buccal infiltration or block should be administered after the onset of subjective symptoms of the inf. Alv.N.block ELHAWARY
  • 73. Mandibular Anesthetic TechniquesMandibular anesthetic techniquesSupplementary Anesthesia Intraosseous anesthesia Interseptal anesthesia Intrapulpal anesthesia Intraligamentry anesthesia ELHAWARY
  • 74. Mandibular Anesthetic TechniquesMandibular anesthetic techniquesSupplementary Anesthesia Interseptal anesthesia ELHAWARY
  • 75. Mandibular Anesthetic Techniques Interseptal anesthesia (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
  • 76. Mandibular Anesthetic Techniques Interseptal anesthesia (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
  • 77. Mandibular Anesthetic Techniques Interseptal anesthesia (Inter dental)• Type of syringe – Non-aspirating syringe – Pressure syringe• Type of needle – Short needle – Gauge 25-27 ELHAWARY
  • 78. Mandibular Anesthetic Techniques Interseptal anesthesia (Inter dental)• Advantages: – Very quick onset• Disadvantages: – Causes blanching of the gingiva – Resistance during administration ELHAWARY
  • 79. Mandibular Anesthetic TechniquesMandibular anesthetic techniquesSupplementary Anesthesia Intrapulpal anesthesia ELHAWARY
  • 80. Mandibular Anesthetic Techniques Intrapulpal injection• Administration of anesthesia directly into pulp• Indications – Acute pulpitis – Endodontic treatment• Needle – 25-27 gauge – Long needle• Syringe – Pressure syringe – Non-Aspirating syringe ELHAWARY
  • 81. Mandibular Anesthetic Techniques Intrapulpal injection• 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
  • 82. Mandibular Anesthetic Techniques Intrapulpal injection• Advantages: – Profound – Fast – Allows painless pulp exterpation• Disadvantages: – Painful – Needs pressure – Variable duration ELHAWARY
  • 83. Mandibular Anesthetic TechniquesMandibular anesthetic techniquesSupplementary Anesthesia Intraligamentary anesthesia ELHAWARY
  • 84. Mandibular Anesthetic Techniques Intraligamentry Anesthesia• Delivering the anesthetic sol. through the periodontal ligament to reach the periapical area• Needle – 25-27 gauge – Short needle• Syringe – Non-Aspirating – Pressure syringe ELHAWARY
  • 85. Mandibular Anesthetic Techniques Intraligamentry Anesthesia• 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
  • 86. Mandibular Anesthetic Techniques Intraligamentry Anesthesia• 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
  • 87. Mandibular Anesthetic Techniques• 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
  • 88. Mandibular Anesthetic Techniques Thank you www.elhawarydentalclinic.com ELHAWARY