Mandibular injections

Techniques of Mandibular Anesthesia

Mandibular AnesthesiaLower success rate than Maxillary anesthesia -

approx. 80-85 %

Related to bone density

Less access to nerve trunks  

Indication For Special TechniqueAnatomic variation Complete nerve trunk

Selective pulpal / soft tissue anesthesia

Mandibular Nerve BlocksInferior alveolarMental - Incisive BuccalLingualGow-GatesAkinosi

Mandibular AnesthesiaMost commonly performed technique

Has highest failure rate (15-20%)

Success depends on depositing solution within 1 mm of nerve trunk

Inferior Alveolar Nerve BlockNot a complete mandibular nerve block.

Requires supplemental buccal nerve block

May require infiltration of incisors or mesial root of first molar

Inferior Alveolar Nerve Block

Nerves anesthetized Inferior Alveolar Mental Incisive Lingual

Inferior Alveolar Nerve Block

Areas Anesthetized Mandibular teeth to midline Body of mandible, inferior ramus Buccal mucosa anterior to mental foramen Anterior 2/3 tongue & floor of mouth Lingual soft tissue and periosteum

Inferior Alveolar Nerve Block

Indications Multiple mandibular teeth

Buccal anterior soft tissue

Lingual anesthesia

Inferior Alveolar Nerve Block

Contraindications Infection/inflammation at injection site

Patients at risk for self injury (eg. children)

Inferior Alveolar Nerve Block

10%-15% positive aspiration

Inferior Alveolar Nerve BlockAlternatives

Mental nerve block

Incisive nerve block

Anterior infiltration

Inferior Alveolar Nerve BlockAlternatives (cont.)

Periodontal ligament injection (PDL)

Gow-Gates

Akinosi

Intraseptal

Inferior Alveolar Nerve BlockTechnique Apply topical Area of insertion: medial ramus, mid-coronoid notch, level with occlusal plane (1 cm above), 3/4 posterior from coronoid notch to

pterygomandibular raphe advance to bone (20-25 mm)

Inferior Alveolar Nerve Block Target Area Inferior alveolar nerve, near mandibular

foramen Landmarks Coronoid notch Pterygomandibular raphe Occlusal plane of mandibular posteriors

Inferior Alveolar Nerve BlockPrecautions Do not inject if bone not contacted

Avoid forceful bone contact

Inferior Alveolar Nerve BlockFailure of Anesthesia Injection too low Injection too anterior Accessory innervation -Mylohyoid nerve -contralateral Incisive nerve innervation

Inferior Alveolar Nerve BlockComplications Hematoma

Trismus

Facial paralysis

Long Buccal Nerve BlockAnterior branch of Mandibular nerve (V3)

Provides buccal soft tissue anesthesia adjacent to mandibular molars

Not required for most restorative procedures

Buccal Nerve BlockIndications Anesthesia required - mucoperiosteum buccal to

mandibular molars

Contraindications Infection/inflammation at injection site

Buccal Nerve BlockAdvantages Technically easy High success rate

Disadvantages Discomfort

Buccal Nerve BlockAlternatives Buccal infiltration Gow-Gates PDL Intraseptal

Buccal Nerve BlockTechnique Apply topical Insertion distil and buccal to last molar Target - Long Buccal nerve as it passes anterior border of ramus Insert approx. 2 mm, aspirate Inject 0.3 ml of solution, slowly - 25-27 gauge needle

Area of insertion:

- Mucosa adjacent to most distal

Buccal Nerve BlockLandmarks Mandibular molars

Mucobuccal fold

Buccal Nerve BlockComplications Hematoma (unusual)

Positive aspiration 0.7 %

Mental Nerve BlockTerminal branch of IAN as it exits mental foramen

Provides sensory innervation to buccal soft tissue anterior to mental foramen, lip and chin

Mental Nerve BlockIndication Need for anesthesia in innervated area

Contraindication Infection/inflammation at injection site

Mental Nerve BlockAdvantages Easy, high success rate Usually atraumatic

Disadvantage Hematoma

Mental Nerve BlockAlternatives Local infiltration PDL Intraseptal Inferior alveolar nerve block Gow Gates

Mental Nerve BlockComplications Few Hematoma

Positive aspiration 5.7 %

Incisive Nerve BlockTerminal branch of IAN      Originates in mental foramen and proceeds

anteriorly

Good for bilateral anterior anesthesia           Not effective for anterior lingual anesthesia  

Incisive Nerve BlockNerves anesthetized Incisive

Mental

Incisive Nerve BlockAreas Anesthetized Mandibular labial mucous membranes

Lower lip / skin of chin

Incisor, cuspid and bicuspid teeth

Incisive Nerve BlockIndication Anesthesia of pulp or tissue required anterior to mental

foramen

Contraindication Infection/inflammation at injection site

Incisive Nerve BlockAdvantages High success rate Pulpal anesthesia w/o lingual anesthesia

Disadvantages Lack of lingual or midline anesthesia

Incisive Nerve BlockComplications Hematoma

Positive aspiration 5.7 %

Gow-Gates Mandibular Block

Developed to improve success rate.

True mandibular nerve block.

Has a lower rate of positive aspiration (2% vs. 10%-15% for IAN).

Technique dependent.

Gow-Gates Mandibular BlockTarget Area

Neck of condyle, below insertion of lateral pterygoid muscle

Gow-Gates Mandibular BlockLandmarks Mesiolingual cusp of maxillary 2nd molar

Intertragic notch

Corner of the mouth

Gow-Gates Mandibular BlockTechnique Coordinate intraoral & extraoral landmarks

Align barrel of syringe over premolars and with extraoral landmarks

Gow-Gates Mandibular BlockTechnique (cont.) Penetrate mucosa distil to 2nd molar

Advance needle to bone (avg. 25 mm)

Aspirate, deposit 1.8 ml of solution slowly

Gow-Gates Mandibular BlockTechnique (cont.) Patient’s mouth must be fully open during

injection and for 1-2 mins afterward

May require reinforcement with second injection

Gow-Gates Mandibular BlockComplications Hematoma (< 2%)

Trismus

Akinosi Closed Mouth Mandibular Block

Alternative for mandibularblock when limited openingis present

( eg. trismus, closed lock, etc..)

Akinosi Closed Mouth Mandibular Block

Advantages Not necessary to open widely High success rate Relatively atraumatic Few complications, few positive aspirations

Akinosi Closed Mouth Mandibular Block

Disadvantages Visualization of path and depth of insertion is

difficult

No bony contact

Traumatic if needle hits periosteum

Akinosi Closed Mouth Mandibular Block

Target Area Soft tissue medial to ramus Above foramen, below condyle

Landmarks Mucogingival junction of maxillary 2nd or 3rd

molar Maxillary tuberosity

Akinosi Closed Mouth Mandibular Block

Area of insertion Soft tissue overlying medial ramus, adjacent to

tuberosity

At height of mucogingival junction of maxillary 2nd or 3rd molar

Akinosi Closed Mouth Mandibular Block

Technique Retract soft tissues, have patient occlude

Apply topical

Penetrate to 25 mm, parallel to maxillary occlusal plane, in a posterior and lateral direction

Akinosi Closed Mouth Mandibular Block

Technique (cont.) Aspirate, deposit 1.8 ml slowly

Motor paralysis will develop first, allowing patient to open more widely

Akinosi Closed Mouth Mandibular Block

Complications Hematoma (<10%)

Facial nerve paralysis (Bell’s Palsy)

Trismus (rare)

Akinosi Closed Mouth Mandibular Block

Failures of anesthesia Lateral flaring of mandible

Insertion too low

Penetration too deep or shallow (adjust for patient size)

Done By :

Ghadah SidqiG (3) , L(5) .