Mandibular Anesthesia Part 2

what are the 3 techniques that can be used to administer inferior alveolar nerve blocks?

• Standard “classic” technique

• Gow-Gates Mandibular technique

• Akinosi “closed mouth” technique

what are 4 technique/reasons inferior alveolar nerve block might fail?

1. deposited too low (below mandibular foramen)

2. deposited too anteriorly to ramus

3. deposited too posteriorly on ramus

4. accessory innervation (mylohyoid n.)

target site for which injection?

standard inferior alveolar nerve block AND lingual nerve block (can anesthetize both nerves using single injection at this site)

during inferior alveolar nerve block, if anesthetic is deposited too low (below mandibular foramen), you can correct it by reinjecting ____ mm above the previous site.

5-10 mm

what are some anatomical reasons an inferior alveolar nerve block might fail?

Bifid inferior alveolar nerve/canal (A second mandibular foramen may exist)

if a patient has a bifid inferior alveolar nerve/canal, the nerve block might fail. how can you correct this?

second injection inferior to the normal anatomical landmark

what nerve block is indicated when lingual soft tissue anesthesia is required?

lingual nerve block

what nerve is indicated here?

lingual n.

lingual nerve block

what contraindications occur for lingual nerve block?

infection/acute inflammation in area of injection

what areas are anesthetized with ›lingual nerve block?

• Lingual soft tissue

• Floor of the mouth

• Anterior two thirds of the tongue to midline

is a separate injection usually necessary for lingual nerve block?

no (it is part of inferior alveolar nerve block)

if lingual nerve block is administered as a separate injection from IAN block, what is the proper technique?

may use a long needle but only need to advance half way

what is the proper injection/needle target site for lingual nerve block?

• Same for inferior alveolar nerve block

• Withdraw needle halfway after inferior alveolar nerve block and deposit local anesthetic solution

what is the proper depth of penetration for lingual nerve?

about 1/3-1/2 the length of a long needle

what is the proper depth of penetration for inferior alveolar nerve?

2/3-3/4 the length of a long needle

what is the proper operator position for lingual nerve block technique?

7 o’clock right side, 11 o’clock left

what is the proper needle size for lingual nerve block technique?

25 or 27 gauge long

what is the proper needle target for lingual nerve block technique?

Same as inferior alveolar nerve block

what is the proper bevel orientation for lingual nerve block technique?

not significant

what is the proper insertion point for lingual nerve block technique?

Same as inferior alveolar nerve block

what is the proper insertion pathj for lingual nerve block technique?

Through the mucosa and buccinator muscle, from the opposite premolars, parallel to occlusal plane and towards the mandibular sulcus

what is the proper insertion depth for lingual nerve block technique?

10-13 mm (1/3- 1/2 of a long needle)

what is the proper anesthetic volume for lingual nerve block technique?

0.3 to 0.5 mL

what nerve block is indicated when mandibular posterior buccal soft tissue is required for dental procedure?

long buccal nerve block

what is a contraindication for long buccal nerve block?

infection/acute inflammation

what areas are anesthetized with long buccal nerve block?

Soft tissue and periosteum buccal to the mandibular molar teeth

long buccal nerve block

target area of which nerve block?

long buccal nerve block

long buccal nerve block

what is the proper injection site for long buccal nerve block?

buccal side of 2nd or 3rd molar (injection depth is very shallow)

what is the proper operator position for long buccal nerve block?

7 o’clock right side, 11 o’clock left

what is the proper needle size for long buccal nerve block?

25 or 27 gauge long (usually administered together with IANB)

what is the proper needle target for long buccal nerve block?

Buccal nerve as it crosses the anterior border of the ramus at the level of the occlusal plane

what is the proper bevel orientation for long buccal nerve block?

toward bone

what is the proper insertion point for long buccal nerve block?

Just medial to the external oblique ridge at the level of the occlusal plane

what is the proper insertion path for long buccal nerve block?

Through the mucosa and buccinator muscle until bone in gently contacted on the anterior ramus

what is the proper insertion depth for long buccal nerve block?

2 – 3 mm (very superficial)

what is the proper anesthetic volume for long buccal nerve block?

0.3-0.5 mL

what is the proper area of anesthesia for long buccal nerve block?

Buccal mucosa and cheek adjacent to the mandibular molars; variable extent of effect

mylohyoid nerve can provide portion of pulpal innervation to which mandibular teeth?

most commonly in the mesial portion of the mandibular 1st molar or premolars

______ nerve block can be a useful supplement to inferior alveolar block when it appears to be inadequate

Mylohyoid

what is the proper technique for mylohyoid nerve block?

1. Use 25 gauge long needle

2. Retract the tongue

3. Direct the syringe from the opposite side

4. Direct needle tip to the apical region of the tooth immediately posterior to the tooth in question, until bone is contacted

5. Aspirate and deposit ~0.6 ml of solution

Gow Gates Approach and Akinosi Approach

what nerves are anesthetized with gow gates technique?

• Inferior alveolar nerve

• Mental/incisive nerve

• Lingual nerve

• Mylohyoid nerve

• Auriculotemporal nerve

• Buccal nerve (in most cases)

why is gow gates technique considered a “true” manidbular nerve block?

because the injection site is a lot higher up on the mandibular nerve, it is able to anesthetize more branches/more of the mandibular nerve than your standard with a singular injection

target area of which technique?

gow gates technique

gow gates technique (IAN)

the following areas are anesthetized with which nerve block?

• All mandibular teeth on the side of injection

• Surrounding periodontium and alveolar

• Buccal and lingual soft tissue

• Anterior two thirds of the tongue and floor of oral cavity

• Floor of the mouth

• Body of the mandible, inferior portion of the ramus

• Skin over the zygoma, posterior portion of cheek, and the temporal regions

gow gates mandibular nerve block

which nerve block is inidcated for multiple procedures on mandibular teeth?

GOW-GATES MANDIBULAR NERVE BLOCK

which nerve block is inidcated when buccal and lingual soft tissue anesthesia is required?

GOW-GATES MANDIBULAR NERVE BLOCK

which nerve block is inidcated when a classic IAN block is unsuccessful?

GOW-GATES MANDIBULAR NERVE BLOCK

what are some contraindications for GOW-GATES MANDIBULAR NERVE BLOCK?

• infection/acute inflammation of injection area (rare)

• pts who might bite/lacerate lip/tongue

• pts unable to open mouth wide (trismus)

what are some advantages to GOW-GATES MANDIBULAR NERVE BLOCK?

• singular injection for total mandibular anesthesia

• higher success rate than standard

• less positive aspiration than standard

• fewer post-injection complications

• no problems with accessory innervation

• bony contact

what is the success rate with GOW-GATES MANDIBULAR NERVE BLOCK?

>95%

what are some disadvantages to GOW-GATES MANDIBULAR NERVE BLOCK?

• lingual/lower lip anesthesia uncomfortblae

• onset time is longer (5 min)

• learning curve for high success

what is the proper insertion point for GOW-GATES MANDIBULAR NERVE BLOCK?

At the height of the ML cusp of maxillary 2nd molar, penetrate just distal to the maxillary 2nd molar

what is the target point for GOW-GATES MANDIBULAR NERVE BLOCK?

• Lateral aspect of condylar neck

• Use both intra-oral and extra-oral landmarks to establish the path of insertion

what extra oral landmarks are used for GOW-GATES MANDIBULAR NERVE BLOCK?

what intra oral landmarks are used for GOW-GATES MANDIBULAR NERVE BLOCK?

• barrel of syringe in corner of mouth on opposite side

• height of insertion = maxillary occlusal plane

• needle tip just below ML cusp of maxillary 2nd molar + just distal to maxillary 2nd molar

GOW-GATES MANDIBULAR NERVE BLOCK

t/f: it is very important for patients ot open their mouth as widely as possible during GOW-GATES MANDIBULAR NERVE BLOCK

true

what is the proper technique for establishing path of insertion during GOW-GATES MANDIBULAR NERVE BLOCK?

1. thumb palpating anterior border of ramus

2. index finger over intetragic notch of ear

3. advance needle slowly until bone is contacted (neck of condyle)

what is the average depth of needle insertion with GOW-GATES MANDIBULAR NERVE BLOCK?

25 mm

the boney contact in GOW-GATES MANDIBULAR NERVE BLOCK is the neck of the ______

condyle

what is the proper operator position for GOW-GATES MANDIBULAR NERVE BLOCK?

7 o’clock right side, 10 o’clock left

what is the proper needle size for GOW-GATES MANDIBULAR NERVE BLOCK?

25 or 27 gauge long needle

what is the proper needle target for GOW-GATES MANDIBULAR NERVE BLOCK?

Neck of the mandibular condyle, just below the insertion of the lateral pterygoid muscle when mouth is wide open

what is the proper bevel orientation for GOW-GATES MANDIBULAR NERVE BLOCK?

Not as significant

what is the proper insertion point for GOW-GATES MANDIBULAR NERVE BLOCK?

Medial to deep tendon of the temporalis muscle at the height of the mesiolingual cusp of the maxillary second molar and slightly distal to the maxillary second molar

what is the proper insertion pathj for GOW-GATES MANDIBULAR NERVE BLOCK?

Through the mucosa and buccinator muscle, usually from the opposite canine or premolars (paralleling the divergence of the tragus), in the plane established by the intertragic notch and the angles of the wide-open mouth, toward the neck of the condyle

what is the proper anesthetic volume for GOW-GATES MANDIBULAR NERVE BLOCK?

1.8-3 ml

which nerves are anesthetized with AKINOSI CLOSED MOUTH TECHNIQUE?

• Inferior alveolar nerve

• Mental/Incisive nerve

• Lingual nerve

• Mylohyoid nerve

which technique anesthetizes the following areas?

• Mandibular teeth to the midline

• Body of the mandible

• Buccal soft tissue served by mental nerve

• Anterior two thirds of tongue

• Floor of oral cavity

• Lingual soft tissue

AKINOSI CLOSED MOUTH TECHNIQUE

what are advantages of AKINOSI CLOSED MOUTH TECHNIQUE?

Relatively atraumatic Patient does not need to open the mouth Less post injection complications Lower aspiration rate (<10%)

t/f: it is thought to be more effective if the patient keeps their mouth open for about 30 seconds after administering GOW-GATES MANDIBULAR NERVE BLOCK

true. keeps nerve closer to where LA was administered

what are disadvantages of AKINOSI CLOSED MOUTH TECHNIQUE?

• Difficult to visualize path of insertion/depth of insertion

• No bony contact

target areas for which technqieu?

AKINOSI CLOSED MOUTH TECHNIQUE

AKINOSI CLOSED MOUTH TECHNIQUE

what is the proper height of insertion with AKINOSI CLOSED MOUTH TECHNIQUE?

mucogingival junction of maxillary 2nd or 3rd molar

what is the proper insertion depth with AKINOSI CLOSED MOUTH TECHNIQUE?

25 mm (measured from maxillary tuberosity)

AKINOSI CLOSED MOUTH TECHNIQUE

which target site is associated with each of the 3 IAN block techniques?

• IAN block standard

• akinosi closed mouth

• gow gates

what areas are anesthetized with MENTAL/INCISIVE NERVE BLOCK?

• Buccal soft tissue anterior to the mental foramen (around the 2nd premolar to the midline)

• Skin of lower lip

• Pulps of premolars, canines, and incisors

MENTAL/INCISIVE NERVE BLOCK

what are advantages of MENTAL/INCISIVE NERVE BLOCK?

• If treatment on mandibular anterior teeth, this block negates the need for bilateral inferior alveolar blocks

• Does not block lingual nerve. No tongue numbness

• High success rate

what are disadvantages of MENTAL/INCISIVE NERVE BLOCK?

Midline difficulty, may require a supplemental injections

target site for which nerve block?

MENTAL/INCISIVE NERVE BLOCK

what is the proper target site for MENTAL/INCISIVE NERVE BLOCK?

Mental nerve as it exits mental foramen (between apices of the 1st and 2nd premolar)

MENTAL/INCISIVE NERVE BLOCK

when doing MENTAL/INCISIVE NERVE BLOCK, locate the mental foramen with the aid of…?

radiographs and gentle palpation

what nerve is indicated here?

mental/incisive nerve

what is the proper operator position for akiosi closed mouth technique?

7 o’clock right side, 11 o’clock left

what is the proper needle size for akiosi closed mouth technique?

25 or 27 gauge long, may bend needle 15 – 30 degrees near hub

what is the proper needle target for akiosi closed mouth technique?

Midway anteroposteriorly in the superior portion of the ptergygomandibular space several mm medial and inferior to union of the mandibular ramus and condylar neck

what is the proper bevel orientation for akiosi closed mouth technique?

Not as significant

what is the proper insertion point for akiosi closed mouth technique?

Retromolar mucosa midway mediolaterallly between the maxilla and ramus of the closed mouth at the height of the maxilliary posterior and mucogingival junction

what is the proper insertion point for akiosi closed mouth technique?

Through the mucosa and buccinator muscle posteriorly in the sagittal plane between and the posterior maxilla and parallel to the occlusal plane until the needle tip is halfway between the anterior and posterior plane of the ramus

what is the proper insertion depth for akiosi closed mouth technique?

25 (23-27 mm)

what is the proper anesthetic volume for akiosi closed mouth technique?

1.5-1.8 ml