The document discusses various techniques for mandibular nerve anesthesia, including both intraoral and extraoral approaches. Intraoral techniques covered include the inferior alveolar nerve block (both direct and indirect techniques), lingual nerve block, buccinator nerve block, mental nerve block, incisive nerve block, infiltration of terminal branches, and submucosal infiltration. Extraoral techniques discussed are the mandibular nerve block, mental nerve block, infraorbital nerve block, and inferior alveolar nerve block. The document then provides more detailed descriptions and illustrations of specific techniques such as the inferior alveolar nerve block, Vazirani-Akinosi closed mouth technique, Gow-Gates mandibular

2. 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.

3. Techniques of regional analgesia
for the mandibular nerve and its
subdivisions

6. 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).

7. 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).

8. B- Extra oral techniques:
1- Mandibular nerve block.
2- Mental and incisive
nerve
block.
3- Infraorbital nerve block
4- Inferior alveolar nerve
block.

9. 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

10. B. Supplementary anaesthesia

12. Mandibular nerve

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

14. 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

15. 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

16. 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)

17. 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)

18. 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

19. 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

20. 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)

21. 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

22. 1- Inferior alveolar nerve block:

23. .a) Standard (direct) technique

25. .b) Indirect technique

26. 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

27. 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

34. Pterygo-mandibular space

35. Bony landmarks for IANB

36. Mandibular anesthesia:

37. Direct inferior alveolar nerve block
and Lingual NB

38. Areas anaesthetized

39. Indirect IANB
Same side technique

40. 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

41. 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

42. 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

43. Vazirani- Akinosi Closed Mouth
Mandibular Block
 Alternative
for mandibular block when
limited opening is present ( eg. trismus, closed lock )

45. Vazirani - Akinosi technique

46. Closed mouth (Vazirani-Akinosi) technique:

47. 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)

57. 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

58. 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).

59. Mandibular Nerve Block (Gow-Gates).

60. 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

61. 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

62. 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


69. Mandibular NB, Gow-Gate tech. 1

70. Gow-Gate tech. 2

72. Lingual nerve block.

73. Block of the terminal branches
(infiltration anesthesia):
Local infiltration of nerve endings (submucosal
analgesia):

75. SPECIAL
TECHNIQUES

76. Supplementary Techniques

77. Supplemental Injection
Techniques
.Periodontal ligament injection- 1
.Intraseptal injection- 2
.Intraosseous injection- 3
.Intrapulpal injection- 4

78. Intraligamentary Injection




Special syringe
Short needle
Blanching gingiva
Hazards

79. 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”

80. 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

81. Periodontal Ligament Injection
Technique

Insert needle on long axis of tooth

Deposit 0.2 ml slowly (30 secs)

Should feel resistance to deposition

82. 1- Periodontal ligament injection.

83. 2-Interseptal infiltration

84. 2- Intraseptal injection.

85. 3-Intra-pulpal infiltration

86. 4- Intrapulpal injection.

87. 4-Intra-osseous

90. 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


91. 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

92. 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

93. Buccinator (long buccal) nerve block:

94. Long buccal nerve block

95. 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

96. 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

97. Mental Nerve Block






Alternatives
Local infiltration
PDL
Intraseptal
Inferior alveolar nerve
block
Gow Gates




Complications
Few
Hematoma
Positive aspiration
5.7 %

98. Mental nerve block:
Incisive nerve block:

103. Mental and incisive nerve block

104. Nerve block summary

105. B- Extra oral techniques:
Mandibular nerve block.

106. Extraoral Nerve Blocks
Indications
 Infection
 Inability to open mouth
 Presence of pathology
 Trauma
 Diagnostic or therapeutic
reasons



Maxillary nerve
Infraorbital nerve
Mandibular nerve

107. 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

109. 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

110. 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

111. Extraoral Maxillary/Mandibular Nerve Blocks
Technique
 Remove stylette
 Place filled syringe on spinal needle
 Aspirate and deposit 3 ml of anesthetic
solution

116. LA injection

117. Spinal needle inserted

120. 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