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Mandibular anesthesia
- 2. Introduction • Mandibular nerve (V3) is a branch of trigeminal nerve. • It divides mainly in 2 branches after coming out from cranium through foramen ovale • Undivided nerve – Nervus spinosus – Nerve to the medial pterygoid muscle • Divided nerve – Anterior division • Nerve to the lateral pterygoid muscle • Nerve to the masseter muscle • Nerve to the temporal muscle • Buccal nerve – Posteriordivision • Auriculotemporal nerve • Lingual nerve • Mylohyoid nerve • Inferior alveolar nerve: dental branches • Incisive branch: dental branches • Mental nerve
- 4. Mandibular Blocks • Six nerve blocks have been described here • Inferior alveolar nerve block • Gow-Gates mandibular nerve block • Vazirani-Akinosi (closed-mouth) • Incisive nerve block • Mental nerve block • Buccal nerves block
- 5. INFERIOR ALVEOLAR NERVE BLOCK (IANB) • Mostly refered as mandibular nerve block. • Most frequently used (after infiltration). • highest percentage of clinical failures even when properly administered.(due to the position of mandibular foramen)
- 6. INFERIOR ALVEOLAR NERVE BLOCK (IANB)
- 7. INFERIOR ALVEOLAR NERVE BLOCK (IANB) • Nerves Anesthetized – Inferior alveolar, – Incisive – Mental – Lingual (commonly) • Areas Anesthetized • Mandibular teeth to the midline • Body of the mandible, inferior portion of the ramus • Buccal mucoperiosteum, mucous membrane anterior to the mental foramen (mental nerve) • Anterior two thirds of the tongue and floor of the oral cavity (lingual nerve) • Lingual soft tissues and periosteum (lingual nerve)
- 8. INFERIOR ALVEOLAR NERVE BLOCK (IANB) • Indications – Procedures on multiple mandibular teeth in one quadrant – When buccal soft tissue anesthesia (anterior to the mental foramen) is necessary – When lingual soft tissue anesthesia is necessary • Contraindications – Infection or acute inflammation in the area of injection – Physically challenged pt. and children
- 9. Technique • A long dental needle is recommended for the adult patient. – A 25-gauge long needle is preferred Area of insertion: Mucous membrane on the medial (lingual) side of the mandibular ramus, at the intersection of two lines • Target area: Inferior alveolar nerve as it passes downward toward the mandibular foramen but before it enters into the foramen.
- 10. INFERIOR ALVEOLAR NERVE BLOCK (IANB) • Landmarks – Coronoid notch (greatest concavity on the anterior border of the ramus) – Pterygomandibular raphe (vertical portion) – Occlusal plane of the mandibular posterior teeth
- 11. Procedure 1. Operator position. – right IANB (right-handed) - 8 o'clock position – left IANB (right-handed) - at the 10 o'clock – Position the patient supine or semisupine 2. Locate the needle penetration (injection) site.
- 12. INFERIOR ALVEOLAR NERVE BLOCK (IANB) 3.Three parameters must be considered during administration of IANB: – the height of the injection(6-10mm from occlusal plane), – the anteroposterior site (medial to ramus lateral to deepest part of pterygo mand.raphe from the coronoid notch) – the depth of penetration (20-25mm till bone contacts)
- 13. Procedure • When bone is contacted, – withdraw approximately 1 mm to prevent subperiosteal injection – Aspirate in two planes – If negative, slowly deposit 1.5 mL of anesthetic over a minimum of 60 seconds 8. Slowly withdraw the syringe, and when approximately half its length remains within tissues, reaspirate. – If negative, deposit a portion of the remaining solution (0.2 mL) to anesthetize the lingual nerve
- 14. Failures of Anesthesia • Deposition of anesthetic too low (below the mandibular foramen). • Deposition of the anesthetic too far anteriorly (laterally) on the ramus. • Accessory innervation to the mandibular teeth - Incomplete anesthesia of the central or lateral incisors
- 15. Complications • Hematoma (rare) - Pressure and cold (e.g., ice) to the area for a minimum of 3 to 5 minutes • Trismus a Muscle soreness or limited movement • Transient facial paralysis (facial nerve anesthesia)
- 16. Buccal Nerve Block • commonly referred to as the long buccal nerve block. • Readily accessible to the local anesthetic as it lies immediately beneath the mucous membrane, not buried within bone. • Nerve Anesthetized: Buccal (a branch of the anterior division of the V3)
- 17. Buccal Nerve Block • Area Anesthetized – Soft tissues and periosteum buccal to the mandibular molar teeth
- 18. Buccal Nerve Block • Indication – When buccal soft tissue anesthesia is necessary for dental procedures - mandibular molar region • Contraindication • Infection or acute inflammation in the area of injection • Advantages – High success rate – Technically easy • Disadvantages – Potential for pain if the needle contacts the periosteum during injection.
- 19. Technique 1. Apply topical 2. Insertion distal to molar 3. Target - Long Buccal nerve as it passes anterior border of ramus 4. Insert approx. 2 mm, aspirate 5. Inject 0.3 ml of solution, slowly Landmarks –Mandibular molars –Mucobuccal fold
- 20. Complications • Hematoma (bluish discoloration and tissue swelling at the injection site). • Blood may exit the needle puncture point into the buccal vestibule. – Apply pressure with gauze directly to the area of bleeding for a minimum of 3 to 5 minutes.
- 21. Gow-Gates Technique • George Albert Edwards Gow Gates • high success rate: approximately 99% • true mandibular nerve block because it provides sensory anesthesia to virtually the entire distribution of V3 – inferior alveolar, – lingual, – mylohyoid, – mental, – incisive, – Auriculotemporal – buccal nerves
- 22. Areas Anesthetized • Mandibular teeth to the midline • Buccal mucoperiosteum and mucous membranes on the side of injection • Anterior two thirds of the tongue and floor of the oral cavity • Lingual soft tissues and periosteum • Body of the mandible, inferior portion of the ramus • Skin over the zygoma, posterior portion of the cheek, and temporal regions
- 23. Advantages • Requires only one injection; • High success rate (>95%) • Minimum aspiration rate • Few postinjection complications (e.g., trismus) • Provides successful anesthesia where a bifid inferior alveolar nerve and bifid mandibular canals are present
- 24. Disadvantages • Lingual and lower lip anesthesia is uncomfortable for certain individuals. • The time to onset of anesthesia is longer (5 minutes) than with an IANB , because of the size of the nerve trunk being anesthetized and the distance of the nerve trunk from the deposition site .
- 25. Technique • The mouth is opened as wide as possible • Insert the needle high into the mucosa at the level of the 2nd maxillary molar just distal to the mesiolingual cusp • extraoral landmark -Use the intertragic notch to help reach the neck of the mandibular condyle
- 26. Technique 1. Apply topical 2. Insertion distal to max.second molar 3. Target – Lateral side of condylar neck 4. Insert approx. 25 mm, aspirate 5. Inject 1.8ml of solution, slowly Landmarks –Mesiopalatal cusp of max. molars –Intertragic notch
- 27. Technique • Advance the needle in a plane from the corner of the mouth to the intertragic notch from the contralateral premolars until it contacts the condylar neck • Withdraw the needle slightly and perform aspiration to observe whether the needle is in a blood vessel • After a negative result on aspiration, slowly inject the anesthetic • Have the patient keep the mouth open for a few minutes after injection, to allow the anesthetic to diffuse around the nerves
- 28. Vazirani-Akinosi Closed-Mouth Mandibular Block facebook.com/notesdental • Also known as tuberosity technique • primary indication remains those situations where limited mandibular opening. • Nerves Anesthetized – Inferior alveolar – Incisive – Mental – Lingual – Mylohyoid
- 29. Areas Anesthetized • Mandibular teeth to the midline • Body of the mandible and inferior portion of the ramus • Buccal mucoperiosteum and mucous membrane anterior to the mental foramen • Anterior two thirds of the tongue and floor of the oral cavity (lingual nerve) • Lingual soft tissues and periosteum (lingual nerve)
- 30. Indications and Contraindications • Indications – Limited mandibular opening – Multiple procedures on mandibular teeth • Contraindications – Infection or acute inflammation in the area of injection – young children and physically or mentally handicapped adults – Inability to visualize or gain access to the lingual aspect of the ramus
- 31. Advantage and Disadvantage • Advantages – Relatively atraumatic – Patient need not be able to open the mouth. – Fewer postoperative complications (e.g., trismus) – Lower aspiration rate (<10%) than with the inferior alveolar nerve block – Provides successful anesthesia where a bifid inferior alveolar nerve and bifid mandibular canals are present • Disadvantages – Difficult to visualize the path of the needle and the depth of insertion – No bony contact; depth of penetration is difficult – Potentially traumatic if the needle is too close to the periosteum
- 32. Technique 1. Apply topical 2. Insertion medial border of ramus adjacent to max tuberosity at height of mucogingival junction 3. Target – Inf.alveolar nerve before entering mandibular foramen 4. Insert approx. 25 mm, aspirate 5. Inject 1.8ml of solution, slowly Landmarks –Mucogingival junction of max third molars –Max . tuberosity
- 33. Technique • Have the patient close the mouth • Insert the needle into the mucosa between the medial border of the mandibular ramus and the maxillary tuberosity at the level of the cervical margin of the maxillary molars
- 34. Technique • Advance the needle parallel to the maxillary occlusal plane • Once the needle is advanced approximately 23 to 25mm, it should be located in the middle of the pterygomandibular space near the inferior alveolar and lingual nerves • no bone will be contacted • After a negative result on aspiration, slowly inject the anesthetic
- 35. Mental Nerve Block facebook.com/notesdental • Terminal branch of IAN as it exits mental foramen • Provides sensory innervation to buccal soft tissue anterior to mental foramen, lip and chin
- 36. Areas Anesthetized • Buccal mucous membranes anterior to the mental foramen (around the second premolar) to the midline and skin of the lower lip and chin
- 37. Mental Nerve Block Indication •Soft tissue biopsies •Suturing of soft tissues Contraindication • Infection/inflammation at injection site Advantages • Easy, high success rate •Usually atraumatic Disadvantage • Hematoma
- 38. Technique • Locate the mental foramen via palpation • Insert the needle into the mucosa at the mucobuccal fold around the 2nd mandibular premolar • Perform aspiration; after a negative result, slowly inject the anesthetic
- 39. Incisive Nerve Block • Terminal branch of IAN • Originates in mental foramen and proceeds anteriorly • Good anterior anesthesia • Not effective for anterior lingual anesthesia • Nerves anesthetized – Incisive – Mental
- 40. Areas Anesthetized • Mandibular labial mucous membranes • Lower lip / skin of chin • Incisor, cuspid and bicuspid teeth
- 41. Incisive Nerve Block Indication • Anesthesia of pulp or tissue required anterior to mental foramen Contraindication • Infection/inflammation at injection site Advantages • High success rate • Pulpal anesthesia w/o lingual anesthesia Disadvantages • Lack of lingual or midline anesthesia
- 42. Technique • Locate the mental foramen via palpation • Insert the needle into the mental foramen to anaesthetize incisive nerve around the 2nd mandibular premolar • Perform aspiration; after a negative result, slowly inject the anesthetic
- 43. THANK YOU