injection techniques

1. {{
Mandibular blockMandibular block
techniquestechniques
Presented by:Dr. Mohana Priya.UPresented by:Dr. Mohana Priya.U
I year mds(OMFS)I year mds(OMFS)

2. Basic injection technique:Basic injection technique:
1)1) Use a sterilized sharp needleUse a sterilized sharp needle
2)2) Check the flow of local anesthesia.Check the flow of local anesthesia.
3)3) Determine whether to warm the anesthetic syringe.Determine whether to warm the anesthetic syringe.
4)4) Position of the patient.Position of the patient.
5)5) Dry the tissue.Dry the tissue.
6)6) Apply topical antiseptic.Apply topical antiseptic.
7)7) A: Apply topical anesthetic.A: Apply topical anesthetic.
8)8) Establish a firm hand rest.Establish a firm hand rest.
9)9) Make the tissue taut.Make the tissue taut.
10)10) Keep the syringe out of patient sight.Keep the syringe out of patient sight.
11)11) Insert needle into the mucosa.Insert needle into the mucosa.
12)12) Watch and communicate with the patient.Watch and communicate with the patient.
13)13) Inject several drops of l.aInject several drops of l.a
14)14) Slowly advance the needle towards the target.Slowly advance the needle towards the target.

3. 15) Deposit several drops of l.a before touching periosteum.
16) Aspirate.
17) Slowly deposit the local anesthetic solution.
18) Communicate with the patient.
19) Slowly with draw the needle. Cap the needle and discard.
20) Observe patient after injection.
21) Record the injection on the patients chart.

5. Branches:Branches:
1)Undivided nerve:1)Undivided nerve:
a)a)Nervus spinousNervus spinous
b)b)Nerve to the medial pterygoid muscle.Nerve to the medial pterygoid muscle.
2)Divided nerve:2)Divided nerve:
a)a)Anterior divisionAnterior division
Nerve to the lateral pterygoid muscleNerve to the lateral pterygoid muscle
Nerve to the masseter muscleNerve to the masseter muscle
Nerve to the temporal muscleNerve to the temporal muscle
Buccal nerve.Buccal nerve.
B)B)Posterior divisionPosterior division
Aurical temporal nerveAurical temporal nerve
Lingual nerveLingual nerve
Mylohoid nerveMylohoid nerve
Inferior alvelor nerveInferior alvelor nerve
Incisive branchIncisive branch
Mental nerveMental nerve
Branches of mandibular nerve:Branches of mandibular nerve:

7.  Local infiltration.Local infiltration.
 Field block.Field block.
 Nerve block.Nerve block.
Three major types of localThree major types of local
anesthetic injections:anesthetic injections:

8. {{ {{1) Direct technique:1) Direct technique:
 Inferior alveolar nerveInferior alveolar nerve
block.block.
 Buccal nerve block.Buccal nerve block.
 Gow gates technique.Gow gates technique.
 Vazirani-AkinosiVazirani-Akinosi
technique.technique.
 Mental nerve block.Mental nerve block.
 Incisive nerve block.Incisive nerve block.
 Extra oral technique.Extra oral technique.
2) Indirect technique:2) Indirect technique:
 Fischer 123 technique.Fischer 123 technique.
 Kurt- Thoma technique.Kurt- Thoma technique.
3) Supplemental:3) Supplemental:
a)Intraosseous anesthesiaa)Intraosseous anesthesia
*Periodontal ligament*Periodontal ligament
*Intraseptal*Intraseptal
*Intraosseous*Intraosseous
b)Intrapulpal injection.b)Intrapulpal injection.
Types of mandibular techniques:Types of mandibular techniques:

9. Inferior alveolar nerve block:Inferior alveolar nerve block:

10. {{ {{Nerves anesthetized:Nerves anesthetized: Area anesthetized:Area anesthetized:

11. {{ {{Indications:Indications: Contra-indications:Contra-indications:
 Multiple mandibularMultiple mandibular
teeth in one quadrant.teeth in one quadrant.
 Buccal soft tissueBuccal soft tissue
anesthesia.anesthesia.
 Lingual soft tissue.Lingual soft tissue.

12. Disadvantages:Disadvantages:
*inadequate anesthesia( 15 to 20%)*inadequate anesthesia( 15 to 20%)
*landmarks not reliable.*landmarks not reliable.
*positive aspiration.*positive aspiration.
*lingual and lip anesthesia, uncomfortable.*lingual and lip anesthesia, uncomfortable.
*partial anesthesia, in bifid mandibular canal or bifid*partial anesthesia, in bifid mandibular canal or bifid
IANIAN
Advantages:Advantages:
* Provides wide area of anesthesia.* Provides wide area of anesthesia.

13. Technique:
Needle: 25gauge.
Target area: inferior alveolar nerve-passes
downwards towards mandible foramen but before it
enters the foramen.
Position of patient: semi-supine- mouth open,
mandibular molar occlusal plain parallel to floor.
Position of operator: right- 8 ‘o’ clock
left- 10 ‘o’ clock. In sitting
position.

15.  1) height of injection1) height of injection
*6 mm above occlusal plain.*6 mm above occlusal plain.
*3/4 of the anteroposterior distance.*3/4 of the anteroposterior distance.
*pterygomandibular raphe.*pterygomandibular raphe.
There are three parameters that must beThere are three parameters that must be
considered during administration of IANB.considered during administration of IANB.

16.  2) Anteroposterior site of injection:2) Anteroposterior site of injection:
a. point 1 falls along the horizontal line from the coronoida. point 1 falls along the horizontal line from the coronoid
notch to the deepest point of pterygomandibular raphenotch to the deepest point of pterygomandibular raphe
b. point 2 is on vertical line through point 1 about 3/4b. point 2 is on vertical line through point 1 about 3/4thth
ofof
the distance from the anterior border of ramus.the distance from the anterior border of ramus.
3) Penetration depth:3) Penetration depth:
20-25mm or 2/320-25mm or 2/3rdrd
of the needle shouldof the needle should
be penetrated.be penetrated.

17.  1.5 ml 60 seconds, inferior alveolar nerve.1.5 ml 60 seconds, inferior alveolar nerve.
 0.1 ml, lingual nerve.0.1 ml, lingual nerve.
 0.6 ml 20 seconds, lingual side if necessary.0.6 ml 20 seconds, lingual side if necessary.
 0.6 ml 20 seconds, incisive nerve if necessary.0.6 ml 20 seconds, incisive nerve if necessary.
Amount of local anesthesia to be deposited:Amount of local anesthesia to be deposited:

18. Signs and symptoms:Signs and symptoms:

19. Complications:Complications:

20.  Deposition of anesthesia too low.Deposition of anesthesia too low.
 Deposition of anesthesia too far anteriorly.Deposition of anesthesia too far anteriorly.
 Accessary innervation to the mandibular teeth.Accessary innervation to the mandibular teeth.
 When bifid inferior alveolar nerve.When bifid inferior alveolar nerve.
 Incomplete anesthesia of the central or lateral incisors.Incomplete anesthesia of the central or lateral incisors.
Failures of anesthesia:Failures of anesthesia:

21. Buccal nerve block:Buccal nerve block:

22. {{ {{
Nerve anesthetized:Nerve anesthetized:
 Buccal nerve.Buccal nerve.
Indications:Indications:
*Soft tissue anesthesia in the*Soft tissue anesthesia in the
buccal region.buccal region.
Advantage:Advantage:
*High success rate.*High success rate.
*technically easy.*technically easy.
AreaArea anesthetizedanesthetized::
Contraindication:Contraindication:
*Infection or acute*Infection or acute
inflammation.inflammation.
Disadvantage:Disadvantage:
*potential for pain if needle*potential for pain if needle
contacts periosteum.contacts periosteum.

23. Technique:Technique:
Area of insertion: mucous membrane distal and buccal to the
distal tooth or last molar.
Target area: long buccal nerve- anterior border of ramus.
Needle 25 gauge.
Deposition: 0.25- 0.5 ml.

24. Complication:

25. Gow-Gates technique:Gow-Gates technique:

26. {{ {{
Nerve anesthetizedNerve anesthetized Area anesthetizedArea anesthetized

27. {{ {{Indications:Indications:
 Multiple procedures.Multiple procedures.
 When anesthesia of buccalWhen anesthesia of buccal
soft tissue from 3soft tissue from 3rdrd
molarmolar
to midline.to midline.
 Lingual soft tissueLingual soft tissue
anesthesiaanesthesia
 When inferior alveolarWhen inferior alveolar
nerve block isnerve block is
unsuccessful.unsuccessful.
Contra ndicatons:Contra ndicatons:
 Infection or acute infectons.Infection or acute infectons.
 Patient having habit of lipPatient having habit of lip
and tongue biting.and tongue biting.
 Patients who are unable toPatients who are unable to
open the mouth.open the mouth.

28. {{ {{Advantages:Advantages:
 Requires only one inj.Requires only one inj.
 High success rate.High success rate.
 Minimum aspirating rate.Minimum aspirating rate.
 Minimal post injectionMinimal post injection
complications.complications.
 Successful anesthesia inSuccessful anesthesia in
case of bifid inferiorcase of bifid inferior
alvelor nerve and canalalvelor nerve and canal
Disadvantages:Disadvantages:
 Lingual and lower lipLingual and lower lip
anesthesia uncomfortableanesthesia uncomfortable
 Onset time is longer.Onset time is longer.
 Clinical experience isClinical experience is
necessary to learn thenecessary to learn the
curve of gow gatescurve of gow gates
technique.technique.

29. Technique:Technique:

30. Target area: lateral side of the condylar neck- just below insertion
of lateral pterygoid muscle
Position of patient: semi-supine.
Position of operator: right 8’o’ clock, left 10’o’ clock.
Land marks:
a)imaginery line drawn from corner of the mouth to intertragic
notch.
b)Anterior border of ramus and the coronoid process is palpated
with the help of thumb of left hand. This helps to retract tissue and
determine the site of nerve penetration.
Needle: 25gauge.
Site and height of penetration:
needle slowly advanced until bone is contacted in NECK OF
CONDYLE.
Depth of penetration: 25mm.

32.  3ml is recommended- 60 to 90 seconds.3ml is recommended- 60 to 90 seconds.
 1.8ml initially, 1.2ml secondary1.8ml initially, 1.2ml secondary
Signs and symptoms:Signs and symptoms:
*tingling in the lower lip*tingling in the lower lip
*tingling in the tongue*tingling in the tongue
*no pain felt during dental therapy.*no pain felt during dental therapy.
Amount of local anesthesia to beAmount of local anesthesia to be
deposited:deposited:

33. Complications

34.  Too little volume of l.aToo little volume of l.a
 Anatomical difficulties.Anatomical difficulties.
Failures:Failures:

35. Mental nerve block:Mental nerve block:

36. {{ {{
Nerve anesthetized:Nerve anesthetized:
 Mental nerve.Mental nerve.
Indications:Indications:
a)a) Soft tissue biopsy.Soft tissue biopsy.
b)b) Suturing of soft tissueSuturing of soft tissue
Advantage: high successAdvantage: high success
rate,technically easy,rate,technically easy,
atraumatic.atraumatic.
Area anesthetized:Area anesthetized:
 Buccal mucosa anterior toBuccal mucosa anterior to
mental foramen( secondmental foramen( second
premolar) to midlinepremolar) to midline
 Skin of lower lip andSkin of lower lip and
chin.chin.
Contraindications:Contraindications:
a)a) Acute inflammation.Acute inflammation.
b)b) Infection.Infection.
Disadvantage: hematoma.Disadvantage: hematoma.

37. 25-27 gauge
Target area: mental nerve
Area of insertion: mucobuccal
fold at or just anterior to
mental foramen.
Land marks: mandibular
premolar and mucobuccal fold
Location of mental foramen:
1)Place your index finger in the mucobuccal fold and press against the body of
the mandible in 1st
molar area.
2)Move your finger anteriorly until the bone beneath your finger feels irregular
and somewhat concave.
3)Usually found around the apex of the second premolar.
4)Soreness will be produced as the mental nerve is compressed.
Radiographically can be located easily.

38. Depth of penetration: 5 to 6mm
Amount of Deposition: 0.6ml, 20 seconds.
Signs and symptoms:
Tingling and numbness of lower lip.
No pain during treatment.
Complications:
Hematoma.

39.  It is also otherwise called as MENTAL NERVEIt is also otherwise called as MENTAL NERVE
BLOCK.BLOCK.
Incisive nerve block:Incisive nerve block:

40. Vazirani- Akinosi closedVazirani- Akinosi closed
mouth technique:mouth technique:

41. In 1977 Dr.Joseph Akinosi reported on a closed mouth
approach to mandibular nerve.
Initially in 1960 tis method was described by varirani
and hence as a tribute , it is named as vazirani akinosi
closed mouth technique.
In 1992 Wolfe describe a modificaton of original
vazirani akinosi technique, where all the tecnique are
similar except 45’degree angulation of needle is given
This enable it to remain in close proximity to the
medial side of mandibular ramus.

43. {{ {{
Nerves anesthetized:Nerves anesthetized:
 Inferior alveolar nerveInferior alveolar nerve
 Incisive nerve.Incisive nerve.
 Mental nerve.Mental nerve.
 Lingual nerve.Lingual nerve.
 Mylohyoid nerveMylohyoid nerve
Area anesthetized:Area anesthetized:
 Mandibular teeth toMandibular teeth to
midline.midline.
 Body of mandible andBody of mandible and
inferior portion ofinferior portion of
ramus.ramus.
 Buccal mucoperiosteumBuccal mucoperiosteum
and mucous membraneand mucous membrane
infront of mentalinfront of mental
foramen.foramen.
 Anterior 2/3Anterior 2/3rdrd
of tongueof tongue
and floor of mouth.and floor of mouth.
 Lingual soft tissue.Lingual soft tissue.

44. {{ {{
Indications:Indications:
 Limited mouth opening.Limited mouth opening.
 Multiple procedures inMultiple procedures in
mandibular teeth.mandibular teeth.
 Inability to visualizeInability to visualize
landmark for IANB.landmark for IANB.
Advantage:Advantage:
*atraumatic.*atraumatic.
*not able to open mouth.*not able to open mouth.
*fewer complications.*fewer complications.
*successful anesthesia in*successful anesthesia in
bifid IAN and bifid canal.bifid IAN and bifid canal.
ContraindicationsContraindications
 Infection or acuteInfection or acute
inflammation.inflammation.
 Patient with habit of lipPatient with habit of lip
and tongue biting.and tongue biting.
 Inability to visualize orInability to visualize or
gain access to lingual side.gain access to lingual side.
Disadvantage:Disadvantage:
*difficult to visualize path of*difficult to visualize path of
insertion.insertion.
*No bony contact.*No bony contact.
* Potentially traumatic if* Potentially traumatic if
needle close toneedle close to
periosteum.periosteum.

45.  25 gauge recommended.25 gauge recommended.
 Area of insertion: osft tissue over lying the medial border ofArea of insertion: osft tissue over lying the medial border of
the mandibular ramus directly adjust to themaxillarythe mandibular ramus directly adjust to themaxillary
tuberosity at the height of mucogingival junction adjacenttuberosity at the height of mucogingival junction adjacent
to maxillary third molar.to maxillary third molar.
 Target area: soft tissue on medial border of ramus in regionTarget area: soft tissue on medial border of ramus in region
of IAN lingual nerve and mylohyoid nerve.of IAN lingual nerve and mylohyoid nerve.
 Land mark:a)mucogingival junction of maxillary thirdLand mark:a)mucogingival junction of maxillary third
molar, (b)maxillary tuberosity.(c)coronoid notch.molar, (b)maxillary tuberosity.(c)coronoid notch.
Techniques:Techniques:

46. Procedures:Procedures:
 Position of patient: supinePosition of patient: supine
 Position of operator: 8’o’ clock.Position of operator: 8’o’ clock.
 Ask the patient to occlude with muscles relaxedAsk the patient to occlude with muscles relaxed
 Soft tissue in the medial border of ramus is reflected.Soft tissue in the medial border of ramus is reflected.
 Needle held parallel to the occlusal plain at level of mucoNeedle held parallel to the occlusal plain at level of muco
gingival junction of 3gingival junction of 3rdrd
or 2or 2ndnd
molar.molar.
 Bevel away from ramusBevel away from ramus
 Direct needle posteriorly and slightly lateralDirect needle posteriorly and slightly lateral
 Deposition: 1.6- 1.8ml, 60 seconds.Deposition: 1.6- 1.8ml, 60 seconds.

48. Signs and symptoms:
*tingling and numbness of tongue and lip
Safety feature: decreased positive aspiration.
Precaution:

49.  HematomaHematoma
 Trismus.Trismus.
 Facial nerve paralysis.Facial nerve paralysis.
Complications:Complications:

50.  Flaring nature of ramus.Flaring nature of ramus.
 Needle insertion point too low.Needle insertion point too low.
 Under insertion or over insertion of needle.Under insertion or over insertion of needle.
Failures:Failures:

51.  This is the type of inferior nerve block technique.This is the type of inferior nerve block technique.
 This technique of anesthetizing the branches of mandibularThis technique of anesthetizing the branches of mandibular
nerve is also known as ‘ three positional nerve blocknerve is also known as ‘ three positional nerve block
technique.technique.
 It can also be mentioned as Fischer 123 technique.It can also be mentioned as Fischer 123 technique.
Indirect technique:Indirect technique:
1st
position: the direction is from the opposite side- to
inject between the external and internal oblique ridges-
for long buccal nerve
2nd
position: the direction is from same side –for lingual
nerve.
3rd
position: the direction is from opposite side- for
inferior nerve.

52. Nerve anesthetized: mandibular nerve and subdivision.Nerve anesthetized: mandibular nerve and subdivision.
Area anesthetized: a) temporal region.Area anesthetized: a) temporal region.
b) auricle of the ear.b) auricle of the ear.
c) external auditory meatus.c) external auditory meatus.
d) temporal mandibular joint.d) temporal mandibular joint.
e) salivary glands.e) salivary glands.
f) anterior 2/3f) anterior 2/3rdrd
of the tongue.of the tongue.
g)floor of the mouth.g)floor of the mouth.
h) mandibular teeth.h) mandibular teeth.
i) gingiva.i) gingiva.
j)buccal mucosa.j)buccal mucosa.
k) lower portion of the face(except angle ofk) lower portion of the face(except angle of
jaw)jaw)
Extra-oral technique forExtra-oral technique for
anesthesia:anesthesia:

53.  Infection and acute inflammation.Infection and acute inflammation.
 Presence of trauma, where that would contraindicate orPresence of trauma, where that would contraindicate or
difficult or impossible to anesthetize the mandibulardifficult or impossible to anesthetize the mandibular
nerve.nerve.
 When there is need to anesthetize the entire mandibularWhen there is need to anesthetize the entire mandibular
nerve and sub divisions.nerve and sub divisions.
 Diagnostic and therapeutic purpose.Diagnostic and therapeutic purpose.
 Extensive surgical procedure with single penetration andExtensive surgical procedure with single penetration and
minimum of l.a.minimum of l.a.
Indications:Indications:

54. Anatomical landmarks:
1)mid point of zygomatic bone.
2)Coronoid process of ramus of the mandible; and prominence
of the lateral pole of the condyle; which is located by having
the patient open and close the mouth.
3)Lateral pterygoid plate.
Technique:
*the needle contacts the lateral pterygoid plate, then with
drawn ,with only the point left in the tissues, and redirected in
a slight forward and upward direction posteriorly.
*In order for the needle to pass posterior to lateral pterygoid
plate.
*needle depth: not more than 5 mm.

55. Signs an symptoms:
1) Tingling sensation in tongue and lip.
2)Absence of pain during procedures
Complications:
1)Trismus
2) Failure of anesthesia.

56.  This type of technique is indicated in patients with limitedThis type of technique is indicated in patients with limited
mouth opening like TRISMUS, ANKYLOSIS.mouth opening like TRISMUS, ANKYLOSIS.
 The needle is inserted through the skin from below theThe needle is inserted through the skin from below the
lower border of the angle of the mandible close to the innerlower border of the angle of the mandible close to the inner
surface of the ramus so that the needle finally comes to liesurface of the ramus so that the needle finally comes to lie
medial to the mandibular foramen.medial to the mandibular foramen.
 Aspiration is done and solution deposited.Aspiration is done and solution deposited.
Kurt- thoma technique:Kurt- thoma technique:

57.  Handbook of local anesthesia-Handbook of local anesthesia-
Stanley F. Malamed.Stanley F. Malamed.
 Manual of local anesthesia in dentistry-Manual of local anesthesia in dentistry-
AP ChitreAP Chitre
Reference:Reference: