The document discusses various mandibular anesthetic techniques including infiltration anesthesia of the anterior labial, anterior lingual, and long buccal regions as well as inferior alveolar and lingual nerve block. It describes the relevant anatomy, patient positioning, needle selection, injection sites, and steps for each technique. The goal is to effectively anesthetize the nerves supplying sensation to the mandibular teeth and surrounding tissues.
2. Mandibular Anesthetic Techniques
Types 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 nerve
1. Main Trunk
2. Nervous Spimosum
3. Nerve to medial pterygoid
4. 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
7. Mandibular Anesthetic Techniques
The 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
10. Mandibular Anesthetic Techniques
Anterior’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 Techniques
Anteriors’ 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 Techniques
Anteriors’ 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
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 Techniques
Steps 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
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
anesthesia
Patient 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 Techniques
Anteriors’
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 Techniques
Anteriors’ 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 Techniques
Anteriors’ 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
28. Mandibular Anesthetic Techniques
Long Buccal 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
29. Mandibular Anesthetic Techniques
Long 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 Techniques
Long 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 Techniques
Steps 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 Techniques
Steps 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
35. Mandibular Anesthetic Techniques
IA & 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 Techniques
IA & Lingual Nerve Block Anesthesia
• Nerve to be anesthetized
– Incisive Nerve
– Mental nerve
– Inferior alveolar nerve
– Lingual nerve
ELHAWARY
38. Mandibular Anesthetic Techniques
IA & 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 Techniques
IA & Lingual Nerve Block Anesthesia
Patient 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 Techniques
IA & 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 Techniques
Steps 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
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
61. Mandibular Anesthetic Techniques
Mental Nerve Block anesthesia
Patient 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 insertion
The 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
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
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
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
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
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
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