Local anesthesia techniques in mandible

1. 10. Mandibular anesthesia

2. objectives
 At the end of the lecture you are expected to know the techniques of
true mandibular nerve block, vazirani akinosi, IAN, long buccal, lingual,
mental, incisive nerve blocks

3. IANB (INFERIOR ALVEOLAR
NERVE BLOCK)
• Also called mandibular nerve block.
• Second most frequently used after
infiltration.
• For quadrant dentistry.
NERVES ANESTHETIZED –
• Inferior alveolar nerve.
• Incisive, Mental and Lingual nerves.

4. • TECHNIQUE – 25 gauge long needle is preferred
• AREA OF THE INSERTION –
• mucous membrane on the medial side of the ramus
• Target area – inferior alveolar nerve as it passes
downward before entering the mandibular foramen.
• LANDMARKS –
• Coronoid notch
• Pterygomandibular raphe
• Occlusal plane of mandibular teeth

6. Traditionally, the IA injection is described with an
insertion point 1.0 cm above the
mandibular occlusal plane.
IA
NB

7. • SIGNS AND SYMPTOMS –
• Tingling or numbness –
• Of the lower lip indicates anesthesia of the mental nerve.
• Of the tongue indicates anesthesia of the lingual nerve.
• PRECAUTIONS –
• Do not deposit anesthesia when no bone contact
• Do not contact bone forcefully
• COMPLICATIONS –
• Hematoma
• Trismus
• Transient facial paralysis

8. Incisive nerve block:
• TECHNIQUES – 27 gauge short needle
• Area of insertion – mucobuccal fold at or just anterior
to the mental foramen
• Target area – mental foramen through which the mental nerve exits and inside of which
incisive nerve is located.
• Landmarks – mandibular premolars and mucobuccal fold.
• FAILURES OF ANESTHESIA –
• Inadequate volume of anesthetic solution
• Failure to achieve anesthesia of second premolar
• COMPLICATIONS –
• Hematoma
• Paresthesia of lip and chin

9. Gow-Gates Mandibular (Open-Mouth) Nerve
Block
• George A. E. Gow-Gates first published this technique in 1973.
• True mandibular nerve block
• Significant advantages of the Gow-Gates technique over the IA nerve
block include its higher success rate, it slower incidence of positive
aspiration, and the absence of problems with accessory sensory
innervation to the mandibular teeth.
• The Gow Gates injection anesthetizes the inferior alveolar, lingual,
auriculotemporal, buccal (75% of the time), and mylohyoid nerves.
• The injection blocks the nerves at a point that is proximal to their
division into inferior alveolar, buccal, and lingual nerves.

10. Bennett C.R, Trigeminal Nerve. In: Monheim’s Local anaesthesia
and pain control in dental
practise.7:CBS;2010:26-53

12. The needle endpoint is the lateral aspect of the anterior portion of the condyle, just
inferior to the insertion of the lateral pterygoid muscle.
A 25-gauge long needle is inserted slowly to a depth of 25 to
30mm;
the end point is inferior and lateral to the condylar head.

13. Gow Gates Mandibular
anesthesia technique

14. Vazirani-Akinosi (Closed-
Mouth) Nerve Block
• In 1977, Dr. Sunder J. Vazirani and Dr. Joseph Akinosi reported on
a closed mouth approach to mandibular anesthesia.
• It is an intraoral approach to provide both anesthesia and motor
blockade in cases of severe unilateral trismus. This injection is useful
for patients with trismus because it is performed while the jaw is in
the physiologic rest position
• Other common names – Tuberosity technique.

15. This form of injection, also known as the closed mouth mandibular block,
anesthetizes the inferior alveolar, lingual, buccal, and mylohyoid
nerves.
A 25-gauge long needle is inserted parallel to the maxillary occlusal plane
at the height of the maxillary buccal vestibule.
AREAS OF INSERTION – soft tissue in the lingual border of the mandibular
ramus directly adjacent to the maxillary tuberosity at the height of the
mucogingival injection adjacent to the maxillary third molar.

16. • TARGET AREA – soft tissue of the medial border of the ramus where they run towards
the mandibular foramen.
• The depth of insertion will vary with the anteroposterior size of the patient’s ramus.
• TheVazirani-Akinosi injection is performed ‘‘blindly’’ because no bony endpoint exists.
• However, in adult patients, a rule of thumb is that the hub of the needle should be
opposite the mesial aspect of the maxillary second molar.
• COMPLICATION – hematoma, trismus, facial nerve paralysis

18. Regional Anesthesia to
Soft Tissue
Mental Nerve Block :
• this injection technique can be useful when bilateral
anesthesia is desired for procedures on premolars and
anterior teeth.
• A 25- or 27-gauge short needle is inserted at the
mucobuccal fold at or just anterior to the mental
foramen, which is typically located between the apices
of the 2 premolars
• The difference between the mental nerve block and the
incisive nerve block is that the incisive nerve block
requires pressure to direct local anesthetic solution into
the mental foramen.

19. • INDICATIONS –
• soft tissue biopsies and suturing of
soft tissues.
• COMPLICATIONS –
• Hematoma.
• Paresthesia of lip/chin.

20. Buccal Nerve
Block :
• Also called long buccal nerve block and buccinator nerve
block.
• The buccal injection will anesthetize the buccal soft
tissue lateral to the mandibular molars.
• The needle is inserted into the tissue in the distobuccal
vestibule opposite the second or third mandibular molar
just medial to the coronoid notch until bone is contacted
(approximately1to 3 mm), and 0.25 mL of anesthetic is
deposited.
• A 25 gauge long needle is recommended (because the

21. • TECHNIQUES – 25 Gauge Needle
• AREAS OF INSERTION – mucous membrane distal and
buccal to the most distal molar tooth in the arch.
• TARGET AREA – buccal nerve as it passes over the anterior
border of the ramus.
• LANDMARKS – mandibular molars, mucobuccal fold

22. • Direct the syringe, facing downward towards bone and
parallel to the occlusal
plane.
• Penetrate the mucous membrane at the injection site,
distal and buccal to the last molar.
• INDICATIONS –
• Scaling and curettage.
• Placement of a rubber dam clamp on soft tissues.
• Removal of subgingival caries.
• Subgingival tooth preparation.
• Placement of gingival retraction cord.
• Placement of matrix bands.
• DISADVANTAGES – painful if contacts the periosteum
• COMPLICATIONS – Hematoma.

23. Lingual
nerve block
• The lingual nerve block will
anesthetize the lingual gingiva,
floor of the mouth, and tongue
from the third molar anteriorly
to the midline. This nerve may
be anesthetized directly, by
inserting the needle as in the
IA to approximately 10mm and
injecting.

24. Recommended volumes of local anesthetic
solution for mandibular injection
technique
TECHNIQUE VOLUME,ml
Inferior alveolar 1.5ml
Buccal 0.3ml
Mental 0.6ml
Incisive 0.6 - 0.9ml
Gow – Gates 1.8 - 3.0ml
Vazirani – Akinosi 1.5 – 1.8ml

25. Thank You