Mandibular nerve blocks techniques

2. COURSE OF MANDIBULAR NERVE

5. NERVE SUPPLY FOR MANDIBULAR TEETH
•INCISIVE NERVE :
The Pulp &
Investing structure Of the lower anterior teeth ( 1 , 2 , 3 )
•INFERIOR ALVEOLAR NERVE :
The Pulp &Investing structure of the lower premolars (4 ,5 )
& molar teeth (6 ,7 ,8 )
•LONG BUCCAL NERVE :
Buccal mucoperiosteum of the lower molars ( 6 ,7 , 8 ) .
•LINGUAL NERVE :
Lingual mucoperiosteum of the all lower teeth ( 1 , 2 , 3 , 4 , 5 , 6 , 7 ,8 ) .

6. Closed mouth Open mouth
Vazirani-
Akinosi
block
Direct Indirect Kurt
thoma
technique
Mandibular
nerve block
Extraoral TechniquesIntraoral Techniques
Mental &
incisive
nerve
block
Fissure 1,2,3
technique
Block
of terminal
branch
Mental &
incisive nerve
block
Buccal nerve
block
Lingual nerve
block
Classical
inferior alveolar
nerve
block
Clark
&
holmes
Gow-
gates block
Angelo
sargenti
Direct thrust
technique by
Charles
Hopkins
Modified direct
thrust technique
Brownlees direct
thrust technique
Curved
needle
technique

7. INTRAORAL NERVE BLOCK TECHNIQUES

8. Nerve anesthetized: terminal branches
Area anesthetised: area innervated by terminal branches
Indication :successful for 6 anterior teeth
Techinque: paraperiosteal or interosseous techniques used with
1 5/8 ” needle
Symptoms : instrumentation needed
BLOCK OF TERMINAL BRANCHES

9. MENTAL NERVE BLOCK
Nerve anesthetized: Mental nerve
Area anesthetised:lower lip
Mucolabial fold anterior to the mental foramen
Anatomical landmarks: mandibular bicuspids
Indication : procedures where manipulation of buccal soft tissue
anterior to the mental foramen is necessary.
Contraindications : acute inflammation and infection over the
injection site.

10. AREAS ANAESTHETIZED

11. Technique:
•Mental foramen lies below the apex of the 2nd premolar or
between the the two premolars.
•It faces posteriorly & thus when making an injection the
approach should be from behind
•Mental foramen palpated.
Symptoms : Tingling & Numbness of lower lip
Adv : No loss of lingual sensation –better for children
Complication: Hematoma,partial anesthesia of central & lateral
incisors

14. INCISIVE NERVE BLOCK
 Nerve anesthetized: Incisive & Mental nerve
 Area anesthetised:Lower lip,Mandible &Overlying structures
anterior to mental foramen,Bicuspids,Cuspids& Incisors
 Anatomical landmarks: Mandibular bicuspids
 Indication : Structures anterior to mental foramen,
cases where IANB is contraindicated

15. INCISIVE NERVE BLOCK

16.  Contraindications : acute inflammation & infection over the
injection site.
 Techinque: same as mental nerve block.
anaesthetic solution to be penetrated into mental foramen
 Symptoms : Sub:Numbness & tingling
Obj:Anesthesia of anterior teeth & structures
on instrumentation
 Failure: 1.Inadequate volume of anesthetic solution
2.Inadequate duration of pressure.
 Complication:hematoma

17. LONG BUCCAL NERVE BLOCK
 Nerve anesthetised:Buccal branch of anterior division of V3
 Area anesthetised:buccal mucous membrane&
mucoperiosteum of mandibular molars
 Indication : surgery of mandibular buccal mucosa & adjunct
to IANB
 Techinque:Inserted into buccal mucosa distal to 3rd molar.
alternative : into retromolar triangle
 Symptoms : instrumentation

18. Infiltration in the buccal sulcus distal
to permanent molar tooth
Amount deposited-0.2-0.5 ml
LONG BUCCAL NERVE BLOCK

19. LINGUAL NERVE BLOCK
 Nerve anesthetised:Lingual nerve
 Area anesthetised: Anterior 2/3rd of tongue, floor of oral
cavity & mucoperiosteum on lingual side of mandible
 Indication : surgery of anterior 2/3rd of tongue, floor of
oral cavity & mucoperiosteum on lingual side of mandible
 Techinque: same as IANB
 Symptoms : sub:numbness & tingling
obj:anesthesia of anterior teeth & structures
on instrumentation

20. 3 TECHNIQUES TO BLOCK LINGUAL NERVE
 Blocking lingual nerve at the same time as an intraoral
inferior dental injection by depositing 0.5ml of solution
after the needle has been inserted for approx. 1cm
 By giving submcosal infiltration of 0.5 ml few
millimeteres below and behind the region of the lower 3rd
molar on its lingual aspect.
 Infiltration immediately lingual to the gingiva or mucosa to
be treated.

21. CLASSICAL INFERIOR ALVEOLAR NERVE
BLOCK

22. Mental
nerve
Incisive
nerve
NERVES
ANAESTHETIZED

23.  Body of mandible
 Mandibular teeth
 Mucous membrane and underlying tissue anterior to molar

24. Factors affecting the relative position of the mandibular
foramen
 Width of ascending ramus
 Width of arch of the mandible
 Obliquity of the angle of the mandible.

25. ANATOMIC VARIATIONS
 Mandible
- Mandibular foramen in children 4 years old and less is below the
plane of occlusion.
- The foramen moves superiorly in the ramus with the eruption of
6’s
Adults
Children

26. Correction for anatomical variation
 If bone is struck soon after insertion
 If bone is not reached after insertion of the needle for a
reasonable distance.

27.  Nerve anesthetised:Inferior alveolar nerve ,Mental.N ,Incisive.N,
Lingual & Buccinator.N
 Area anesthetised: body of mandible& inferior portion of ramus,
mandibular teeth, mucous membrane &structures anterior
to mand 1st molar
 Anatomical landmarks:
Mucobuccal fold
Anterior border of ramus of the mandible
External oblique ridge
Retromolar triangle
Internal oblique ridge
Pterygomandibular ligament
Buccal sucking pad
Pteygomandibular space.

28.  Indication : Analgesia for surgical & operative dentistry on
mandibular teeth & supporting structures,Diagnostic &
Therapeutic purposes
 Approximating strucutres when needle is in position:
The inferior dental nerve is blocked by the deposition of analgesic
solution around it just before it enters the mandibular foramen and
when it is in the pterygomandibular space.
This is bounded
Anteriorly :pterygomandibulr raphe
Posteriorly : parotid gland
Laterally:ascending ramus of the mandible
Medially : medial pterygoid muscle
Superiorly: 2 heads of lateral pterygoid
Inferiorly : attachment of medial pterygoid

31. ADVANTAGES:
 Wide area of Anesthesia
DISADVANTAGES:
 Wide area of anesthesia
 Inadequate anesthesia
 +ve aspiration(10% to 15%)
 Intra oral landmarks
 Lingual & lower lip anesthesia
 Partial anesthesia-bifid mand canals

32.  For rt IANB 8 o’clk position
 For lt IANB 10 o’clk position
 3 parameters:
 height of the injection
 anteroposterior site of injection
 penetration depth

33.  Technique:
• Mouth open,body of mandible parallel to floor
• Operator right side of patient
• Thumb palpates mucobuccal fold
• Thumb moves posteriorly to contact external oblique ridge on anterior
border of ramus
• Greatest depth is identified-coronoid notch-height of mand sulcus
• Thumb-ligually moved-across retromolar triangle-onto internal oblique
ridge.
• Thumb moved buccally along with buccal sucking pad-exposure to
internal oblique ridge,pterygomandibular raphe & pterygopharygeal
depression.
• Index finger-extraorally –behind –ramus of mandible.
• Syringe-parallel to occlusal plane-opp side of mouth-bisecting finger
• Moved until gently bone contacted
• Needle withdrawn 1mm,Solution deposited.

34.  Symptoms : sub:numbness & tingling of lower lip
obj:on instrumentation

35. FAILURES OF ANESTHESIA:
 Deposition of anesthetic too low.
 Deposition of anesthetic too far anteriorly on ramus.
 Accessory innervation to the mandibular teeth
 1o symptom-Incomplete pulpal anesthesia.
 Accessory sensory innervation (cervical accessory &
mylohyoid.N)
 To correct
Technique #1
 25 gauge long needle.
 Retract the tongue toward midline
 Place the syringe in corner of mouth on opp side & direct the
needle tip to apical portion of tooth immediately posterior to
tooth of interest
 Depth of penetration to bone:3-5mm.
 Aspirate:0.6ml in 20sec
Technique #2

36.  Bifid inferior alveolar nerve
to correct-deposit solution inferiorly
 Incomplete anesthesia to central & lateral incisors
 Due to innervation of mylohyoid
To correct:
 Supraperiosteal infiltration
 27gauge short needle
 Direction of needle tip
 Aspirate:0.6ml in 20secs
 After 2-3mins start dental procedure

37. COMPLICATIONS:
 High injection-Numbness of ear- when auriculotmporl.N
is anesthetised.
 High injection-trismus-injection into lateral pterygoid
 High injection-toxicity-injection into pterygoid plexus of
veins
 Low injection-Trismus-injection into medial pterygoid
 Low injection-toxicity-injection into posterior facial vein
 High & deep injection-paralysis-injection into substances
of parotid gland(facial nerve)
 HEMATOMA
 TRANSIENT FACIAL PARALYSIS-inj into medial
pterygoid

38. METHOD OF CLARKE AND HOLMES(1959)
 This involves depositing the of the solution at a higher
level than usual.
 It’s a modification of indirect technique.
 Occlusal plane is parallel to the floor.
 External oblique ridge is palpated
 Finger is rotated inwards so that the tip lies in the
retromolar fossa and the fingernail overlies the internal
oblique ridge.

39.  The needle is advanced from between the premoalrs on the
opp.side ,the point passing into the tissue just above the
fingernail of the index finger and not at the midpoint as with
the standard indirect technique.
 Bone is encountered
 Syringe is then gently swung round until it lies over the lower
central incisors.
 The needle is passed another 2cms deeper into the tissue and
1.5ml of the solution is deposited.
 If lingual analgesia required,then solution is deposited when
needle is being withdrawn

40. METHOD OF CLARK & HOLMES 1959

41. GOW GATES TECHNIQUE 1973
 Nerve anesthetised: inferior
alveolar,mental,incisive,lingual,mylohyoid,auriculotemporal,bucca
l.
 Area anesthetised:mand teeth to midline, buccal & lingual
mucoperiosteum & mucous membrane,ant 2/3rd of tongue, floor of
oral cavity, skin over the zygoma, posterior portion of cheek&
temporal region.
 Indication: multiple procedure on mandible, buccal soft
procedures from third molar to midline, lingual soft tissue
anesthesia, IANB unsuccessful.Diagnosis of facial pain
 Cotraindication
Infection & acute inflammation@ site,young patients, trismus
Intraoral approach for mandibular nerve block

42.  ADV:
only 1 inj needed, success rate, aspration
rate
post injection complication.
 DISADV :
time of onset than IANB

43. LANDMARKS
Extraoral
External ear.
Intertragic notch
Corner of the mouth
Intraoral
Tendon of temporal muscle
Anterior border of the ramus,
Mesiolingual cusp of maxillary 2nd molar

44. The patient mouth should be wide open,supine position
Needle is inserted at a point lateral to the pterygomandibular
depression but medial to the temporal tendon on a plane from the
corner of the mouth to intertragic notch.
Approximating srtuctures:
It should be just inferior to the condyle
Inferior to the attacthement of lateral pterygoid muscle.

45. TECHNIQUES:
 Position the patient
 Locate extra oral landmarks
 Visualize intraoral landmarks
 Prepare tissues at site of penetration
 Direct the syringe
 Insert the needle
 Align the needle with the plane
 Slowly advance the needle
 Depth of penetration:25mm
 Withdraw the needle 1mm
 Aspirate:
if –ve slowly deposit 1.8ml in 60-90 secs
 Withdraw the syringe
 Request the pt to keep mouth open for 1-2mins
 Upright position
 Wait for 3-5mins before starting dental procedure

47. METHOD OF ANGELO SARGENTI(1966)
 Its a modification of the direct technique.
 The prinicipal difference is that the nerve is approached from a
higher level than usual.
 Index finger placed at retromolar fossa with the nail facing
lingually.
 The needle is then inserted opp.the midpoint of the fingernail
and a little beyond its tip.
 The barrel is placed between and in contact with the upper
premolars of opp.side.

48.  It is kept in this position while the needle is slowly inserted
in a downward and backward direction until it touches
bone, which is usually at a depth of 1cm.

49. METHOD OF ANGELO & SARGENTI 1966

50. DR.MENDEL NEVIN
Guide finger- Coronoid Notch
Pterygotemporal depression in Pterygomandibular space
Bone is encountered
Syringe is brought in line with the lower teeth on the same
side for lingual block
DIRECT THRUST TECHNIQUE

51. Advantages:
One injection provides a wide area of anaesthesia, useful for quadrant
surgery.
Disadvantages:
•Rate of inadequate anesthesia (15 to 20%).
•Intraoral landmarks not consistently reliable.
•Positive aspiration is high (10 to 15%).
•Lingual & lower lip anesthesia is discomfort & possibly dangerous.
•Partial anesthesia possible if bifid inferior alveolar nerve or
bifid mandibular canals are present.

52. Dr.Charles B Hopkins
Perpendicular to ramus with barrel in respect to Opposite
side 1st & 2nd Molar
Height- Above the finger nail
Inserted Directly in the mandibular sulcus.
DIRECT TECHNIQUE OF CHARLES HOPKINS

53. Dr.Brownlee
Importance of Posterior border of ramus as landmark
Thumb-Coronoid notch
Index-Posterior border of ramus
Third finger-Angle of mandible
Advantages:
No unreliable landmarks.
Same for all the patients.
BROWNLEE’S DIRECT THRUST
TECHNIQUE

54. Dr.Boris Levitt
Modification of Mendel’s technique
Midway between the occlusal surface of upper and lower molar teeth
Depth not greater than 1 inch
Withdraw the needle halfway for Lingual block
Deposit solution even without bone contact
MODIFIED DIRECT THRUST TECHNIQUE

55. ARCHED/CURVED NEEDLE TECHNIQUE
 In the arched needle technique the flexibility of the fine bore needle is
utilized to change the approach angle of the needle tip
 Inserted at an acute angle, the subsequent arching changes the path &
the needle approaches the medial surface of the ramus almost
perpendicularly, which is otherwise impossible to achieve with an
unarched or unbent needle.

56. METHOD OF SUNDER J. VAZIRANI 1960

57. VAZIRANI- AKINOSI TECHNIQUE CLOSED MOUTH
MANDIBULAR BLOCK
 Indication: Patient unable to open mouth.
 Contraindication:Where trismus is present due to infection in
the tissues through which a needle would have to passs.

59. Landmarks
 Occlusal plane of occluding teeth
 mucogingival Junction of the maxillary molar teeth
 Anterior border of the ramus.

60.  The needle is placed parallel to the gingival margins of
the maxillary teeth or to the alveolar ridge in the
edentulous patient.
 The point of insertion is the mucosa, pterygomandibular
fold,buccinator and buccal aponeurosis on the inner
aspect of the ascending ramus to reach the
pterygomandibular space.

62. INDIRECT METHOD-FISCHER 1-2-3
TECHNIQUE
Step 1:
 Barrel of the syringe rests on occlusal surface of the
opp. Premolars.
 Tip of the needle rests on the external oblique ridge at
the midpoint of thumbnail.
 Needle is advanced 6mm and few drops of solution is
deposited to block the long buccal nerve.

63. Step 2:
 Barrel of the syringe is withdrawn slightly and shifted
to the same side so that ,needle glides over temporalis
tendon onto the internal oblique ridge.
 Needle is further advanced for about 8mm,keeping the
barrel of the syringe parallel to mandibular occlusal
plane.
 This is to block the lingual nerve.

64. Step3:
 The barrel is returned to opp.Side , near the 1st
premolar and the needle is advanced further for a
distance of 12-15mm, until the bony resistance is felt
by the tip of the needle.
 This is to block the inferior dental nerve.

65. INDIRECT METHOD

67. EXTRAORAL TECHNIQUES

68. KURT THOMA TECHNIQUE
•Anterior border of masseter is located & its lowest border palpated (A).
•This point is marked and line drawn connecting it with tragus of the ear
(B).
•The mid point of this line is located.(C).
•Parallel line drawn with posterior border of ramus (D).
•Skin is prepared
•Long needle is inserted on the inner aspect of lower border of mandible
keeping close to bone throughout & parallel to the line drawn
•21 Gauge needle with stopper of 7-8 cms length

69. EXTERNAL APPORACH BY – KURT THOMA
B
C
A
D

71. INDICATION FOR KURT THOMA APPROACH
 Severe limitation of opening of the jaws
 TMJ ankylosis

72. EXTRAORAL MANDIBULAR NERVE
BLOCK TECHNIQUE

73. The zygomatic process is palpated and midpoint of the depression on
its lower border is marked.
Local infiltration should be given
A heavy gauge needle min. of 3 1/8 inch(8cm) is used for injection
,incorporating a marker to indicate a depth of 4cm.
Needle is inserted little below the zygomatic process and at
right angle to the skin, until the lateral pterygoid is reached , which
should be at a depth of approx.4cm.
The needle is now withdrawn and reinserted a few degrees father
distally so as to pass just behind the posterior border of the lateral
pterygoid plate.
It should never be penetrated more than 5cm.
EXTRAORAL MANDIBULAR NERVE BLOCK TECHNIQUE

74. Landmarks –
- midppoint of zygomatic arch
- Zygomatic notch
- Coronoid process of ramus
- Lateral pterygoid plate
Depth – 4.5 cm

76. EXTRAORAL MENTAL NERVE BLOCK
 The mental foramen is palpated externally in the region
below the apex of second premolar.
 This normally equidistant between the upper and lower
borders of the mandible when the teeth are present.
 25 gauge(2.5 cms) needle is passed downwards at an angle
of 30 and forwards at angle of 45 to the body of the
mandible until bone is reached.

79. ADVANTAGE
 Avoids the unpleasant loss of lingual sensation, which
generally occurs with an inferior dental injection.
COMPLICATION & CONTRAINDICATION
 It should be remembered that the lower central incisors
and to a lesser degree the lateral incisors derive some
inervation from the incisive nerve of the opposite side.
 So to achive analgesia a supraperiosteal injection
should be used

80. •Inferior alveolar nerve block by injection into mandibular foramen in
the direction of 1st molar to lateral of pterygomandibular space.
•Adv : No danger of injecting the needle and depositing the local
anaesthetic contents into the maxillary artery and vein, the middle
meningeal artery and vein or the T-M joint capsule, thus avoiding
all of the unnecesary complications therein.
ANTERIOR RAMUS TECHNIQUE
(A.R.T)
Dr.Lawrence Gaum &Dr.Allan C Moon
Same as that explained by Fischer in 1900

84. MASSETERIC & DEEP TEMPORALBLOCKS
USEFUL IN MANDIBULAR DISLOCATION
ANESTH ESIA PROGRESS. 2009 SPRING; 56(1):

85. ANESTHETIC TECHNIQUE FOR INFERIOR
ALVEOLAR NERVE BLOCK: A NEW
APPROACH.
JOURNAL OF APPLIED ORAL SCIENCE.
2011 Jan-Feb; 19(1): 11–15.
Potentially effective for inferior
alveolar nerve block, especially in
pediatric dentistry.

86.  Insufficient knowledge of local anatomy
 Individual variations in anatomy
 Variation due to age
 Faulty technique
injecting too far posteriorly
injecting too low down

87. AGE CHANGES IN MANDIBLE
BIRTH
3 YEARS
6 YEARS
ADULT
EDENTULOUS OLD
AGE
Mental
foramen
Mandibuar
foramen

88. THANKYOU