mandibular anesthesia part 2

standard IAN block, lingual nerve

failures of IAN block

• Deposit the anesthetic too low (below the mandibular foramen)

  • To correct: reinject 5-10 mm above the previous site

• Deposit the anesthetic too anteriorly on the ramus

• Deposit the anesthetic too posteriorly on the ramus

• Accessory innervation (Mylohyoid nerve)

describe failure of IAN block and relationship to bifid inferior alveolar nerve/canal

• A second mandibular foramen may exist

• To correct: second injection inferior to the normal anatomical landmark

• Indication: When lingual soft tissue anesthesia is required

• Contraindication: Infection/acute inflammation in the area of injection

lingual nerve block

Area Anesthetized:

• Lingual soft tissue

• Floor of the mouth

• Anterior two thirds of the tongue to midline

lingual nerve block

separate injection usually necessary for lingual nerve block

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Technique Factor

• A separate injection is usually not necessary (part of inferior alveolar nerve block)

• If administered as a separate injection, may use a long needle but only need to advance halfway

lingual nerve block

Injection/Needle Target Site

• Same for inferior alveolar nerve block

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

lingual nerve block

lingual nerve block

lingual nerve block

• Indication: When mandibular posterior buccal soft tissue is required for dental procedure

• Contraindication: Infection/acute inflammation

(long) buccal nerve block

Area Anesthetized: soft tissue and periosteum buccal to the mandibular molar teeth

(long) buccal nerve block

(long) buccal nerve block

(long) buccal nerve block

(long) buccal nerve block

Accessory innervation

• Can provide portion of pulpal innervation to mandibular teeth (most commonly in the mesial portion of the mandibular 1st molar or premolars)

• (BLANK) block can be a useful supplement to inferior alveolar block when it appears to be inadequate

mylohyoid nerve block

• Use 25 gauge long needle

• Retract the tongue

• Direct the syringe from the opposite side

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

• Aspirate and deposit ~0.6 ml of solution

mylohyoid nerve block

A “true” mandibular nerve block

Nerves Anesthetized:

• Inferior alveolar nerve

• Mental/incisive nerve

• Lingual nerve

• Mylohyoid nerve

• Auriculotemporal nerve

• Buccal nerve (in most cases)

Gow-gates mandibular technique

Area of Anesthesia:

• 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 technique

Indication

• Multiple procedures on mandibular teeth

• When buccal and lingual soft tissue anesthesia is required

• When a classic inferior alveolar nerve block is unsuccessful

Contraindication

• Infection/acute inflammation in the area of injection (rare)

• Patient who might bite/lacerate lip or tongue (ex: pediatric or special needs patients)

• Patient who are unable to open their mouth wide (ex: trismus)

Gow-gates mandibular technique

Advantage

• Requires only one injection for total mandibular anesthesia

• Higher success rate (>95%) than standard technique

• Less positive aspiration (2%) than standard technique (10-15%)

• Fewer post injection complication (trismus)

• Absence of problems with accessory innervation Bony contact

Disadvantage

• Lingual and lower lip anesthesia is uncomfortable for many patients

• The time to onset of anesthesia is longer (5 minutes) than standard technique

• Learning curve to achieve high success

Gow-gates mandibular technique

Insertion Point:

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

Target Point:

• Lateral aspect of condylar neck

• Use both intraoral and extraoral landmarks to

• establish the path of insertion

Gow-gates mandibular technique

Gow-gates mandibular technique

Gow-gates mandibular technique

• Thumb palpating the anterior border of the ramus Index finger over the intertragic notch of the ear

• This line forms the path of insertion

• Advance the needle slowly until bone is contacted

• Target: The bone contacted is the neck of the condyle

• Average depth of needle insertion is about 25 mm

Gow-gates mandibular technique

Gow-gates mandibular technique

Nerves anesthetized:

• Inferior alveolar nerve

• Mental/Incisive nerve

• Lingual nerve

• Mylohyoid nerve

akinosi closed mouth mandibular technique

Areas Anesthetized:

• 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 mandibular technique

Advantage

• Relatively atraumatic

• Patient does not need to open the mouth

• Less post injection complications

• Lower aspiration rate (<10%)

Disadvantage

• Difficult to visualize path of insertion/depth of insertion

• No bony contact

akinosi closed mouth mandibular technique

akinosi closed mouth mandibular technique

Height of Insertion: Mucogingival Junction of Maxillary 2nd or 3rd Molar Insertion depth: ~25 mm (measured from the maxillary tuberosity)

akinosi closed mouth mandibular technique

akinosi closed mouth mandibular technique

• 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

Advantage

• 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

Disadvantage

• Midline difficulty, may require a supplemental injections

mental/incisive nerve block

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

1 injection 1 technique mental and incisive soft tissue and anteriors

mental/incisive nerve block

mental foramen

mental/incisive nerve block

mental/incisive nerve block

mental/incisive nerve block

mental/incisive nerve block