the inferior alveolar
nerve(mixed sensory and
motor) –gives off:
-Mylohyoid branch for
Mylohyoid muscule and
for the anterior belly of
the digastric muscule.
- the inferior alveolar
plexus,from which little
branches are sent to the
teeth and gingiva
-Mental nerve –innervates
the skin of the chin,the
skin and mucosa of the
lower lip .
-Incisive nerve -inervates
canine and incisors and
the corresponding bucal
gingiva
For work in the maxilla, LAs can usually be administered adjacent to
the teeth to be worked on, by means of a paraperiosteal field block or
infiltration. This is due to the relatively porous alveolar bone so that the
LA can penetrate more easily and reach its sites of action on nerves
that provide sensation to the pulps of the teeth and the gingiva in that
area.
The mandible is quite different. The outer layer of cortical bone is thick
and non-porous, normally requiring the use of a nerve block.Only the
anerior part of mandible presents sufficient porosity which is favorable
for infiltration techniques.
There are different approaches to achieving anaesthesia the mandible:
1.The inferior alveolar nerve block, also known as standard mandibular
block or the Halstead approach, or the conventional IANB
2.The Gow-Gates technique;
3.The Vazirani-Akinosi closed mouth block.
4. Fischer 1.2.3 IANB;
5. Torusal anaesthesia , Toruso-mandibular anaesthesia
Each technique has its advantages and disadvantages and dentists
need to become familiar with all of them.
For the administration of any LA, it is best to have the patient lying in
a supine position in order to reduce the likelihood of syncope. Patient
anxiety regarding an intraoral injection is common, and an anxious
patient who is sitting upright will be predisposed to fainting. Topical
anaesthetic may be placed prior to any injection. It should remove the
initial sensation of needle penetration, and therefore may be of value.
If used, you should allow a few minutes for onset of action.
With all of the mandibular techniques it is preferable to use a 25
gauge long needle. The 25 gauge is preferable to the smaller gauges
for two reasons. First, we must always aspirate prior to a mandibular
block in order to avoid injecting into a blood vessel, and aspiration
results are most reliable with this gauge. Secondly, there is less
deflection, an important characteristic for a deep block.
• The primary goal of each of the mandibular blocks is anaesthesia of the inferior alveolar
nerve, which innervates the pulps of the mandibular teeth on that side, as well as the
buccal periodontium anterior to the first molar. For each of these techniques, this goal is
accomplished by depositing anaesthetic within the pterygomandibular space. This
anatomical space contains the inferior alveolar nerve as well as the lingual nerve, which
is usually also anaesthetized by these techniques. It also contains the inferior alveolar
artery and vein, and the sphenomandibular ligament. This space is bounded laterally by
the ramus of the mandible, medially and inferiorly by the medial pterygoid muscle,
superiorly by the lateral pterygoid muscle, posteriorly by the parotid gland, and anteriorly
by the thin buccinator muscle.
The most commonly used technique for mandibular anaesthesia is the
inferior alveolar nerve block. This is also known as the standard
mandibular block or the Halstead approach. It is indicated when we are
carrying out procedures on either one or multiple mandibular teeth in
one quadrant. As well, it is indicated for procedures on the lingual soft
tissue or the buccal soft tissue anterior to the first molar. For surgery on
the molars, a separate buccal nerve block is required.
The objectives of this technique is to place the needle tip above the mandibular foramen,
into the sulcus just behind the lingula. This is where the inferior alveolar nerve inserts
into the mandibular canal. The lingual nerve lies just anteriorly and medially, and is
therefore often anaesthetized along with the inferior alveolar nerve .
Landmarks( bony and soft
tissue)
•External oblique ridge
•Coronoid notch
•Internal oblique ridge
•Pterygomandibular raphe
•Prerygotemporal
depression
inferior alveolar nerve block
Halstead technique
For this technique ask the patient to open
his/her mouth as wide as possible.
•The thumb of the free hand is placed on
the coronoid notch.The syringe approaches
from the opposite side,over the
contralateral first bicuspid.
•The Needle is inserted into the
pterygotemporal depression between the
pterygomandibular raphe and the
coronoin notch ,1cm above the
mandibular occlusal plane
•The needle is penetrated until bone.The
depth is approx. 25mm. Once bone is
contacted, you should withdraw ~1mm. At
this point aspirate and after negative
aspiration inject a full cartridge of local
anaesthetic, unless you are following with a
buccal nerve block, in which case you should
inject 3/4 of the cartridge. LA solution is
depositid slowly.
• If you contact bone too soon, significantly less than 25mm, you need
withdrawing the syringe slightly, moving the barrel more medially over
contralateral canine or incisors, and advancing again until bone is
contacted.
• If you do not contact bone after 25mm, and the needle is almost buried,
you should redirect by withdrawing somewhat, but not completely, and
move the barrel of the syringe more laterally and advancing again until
bone is contacted.
Successful Anaesthesia: Standard Block
The symptoms of successful anaesthesia include tingling and
numbness of the lower lip up to its midline. Tingling and numbness of
the tongue on that side indicates lingual nerve anaesthesia.
Objectively, you should confirm the signs of successful anaesthesia by
probing the gingiva adjacent to the canine area. The onset of
anaesthesia usually occurs within 3 to 5 minutes.
Anaesthetized area after inferior alveolar nerve block
• Mandibular teeth to midline
• Body of mandible
• Inferior portion of ramus
• Buccal mucoperiosteum and
mucous membrane anterior to
mandibular first Molar
• Lingual soft tissues and
mucoperiosteum of the same
side
• Anterior two-thirds of tongue and
floor of oral cavity of the same
side
For surgery on molars a separate buccal nerve block(or buccal infiltration) is required.
For the buccal nerve block needle is injected into the mucosa just distal and buccal to the
last molar tooth between the external and internal ridges and 0.25-0.5ml of LA solution is
deposited in this area.
FISCHER technique
Needle position
1st position-long buccal nerve
is anaesthetized from the
opposite side
2nd position-lingual nerve is
anaesthetized from the same
side
3rd position-inf. Alv. Nerve is
anaesthetized from the
opposite side
• FISCHER 1-2-3 TECHNIQUE:
Step 1:The tip of the finger is placed on retromolar fossa. Barrel of the syringe
rests on the occlusal surfaces of the opposite premolars. The needle is inserted
into the mucous membrane at the midpoint of the thumbnail. Needle is
inserted about 6 mm in the tissues and few drops are injected to anesthetize
the long buccal nerve.
•
Step 2: barrel of the syringe is withdrawn slightly and shifted to the same side
so that the needle glides over the temporalis tendon onto the internal oblique
ridge. The needle is further advanced about 6 mm, keeping the barrel of the
syringe parallel to the mandibular occlusal plane. Here, 0.5 ml of solution is
injected to anesthetize the lingual nerve.
•
Step 3: the barrel is returned to the opposite 1st premolar and needle further
advanced for a distance of 12-15 mm, until bony resistance is felt by the tip of
the needle. After withdrawing slightly and aspirating, 1 ml is injected slowly to
anesthetize the inferior alveolar nerve.
• A tingling sensationin the lower lip and one half of the tongue indicates the
effect of the anaesthesia
Torusal anaesthesia
Torusal anaesthesia
The Torusal anesthesia was proposed by Weisbrem in 1948. With this method, it is possible
to block inferior alveolar, lingual and buccal nerves. The objectives of this technique is to
place the needle tip above and in front of the mandibular foramen, into the mandibular
torus.
The mandibular torus is located on the inner surface of the mandibular ramus, above and
in front the mandibular lingula. It is formed by the junction of two ridges: the crista
temporalis and the crista colli mandible.
For this technique the patient should open his/her mouth as wide as possible. The barrel of
the syringe is rest on mandibular molar in the opposite side.
The needle is inserted into the lateral edge of the pterygomandibular fold 0.5 cm below
the occlusal plane of the maxillary third molar ( or below the second molar if there is no
third molar).
The needle is inserted until bone.The depth is approx. 0.25-2cm. Once bone is contacted,
you should withdraw ~1mm. At this point aspirate and after negative aspiration inject 2-
3ml of 2% Lidocaine. As a result, inferior alveolar and buccal nerves are blocked. During
the needle removal , 1 ml of local anesthetic solution is injected again to block the lingual
nerve. Sometimes the buccal nerve remains sensitive and in this case, infiltration is
required.
Mental nerve block
The target area is the height of the mucobuccal fold over the mental foramen.The
injection is administered between 1st and 2nd premolars, or distal to the 2nd premolar.
The needle is directed toward the mental foramen with the bevel facing the bone.
Penetrate the soft tissue to a depth of 5 mm, aspirate, and inject approximately 0.6 mL
of anesthetic solution
• A mental nerve block anesthetizes the ipsilateral lower lip and skin
of the chin (not the teeth). Needle entry into the mental foramen is
not necessary for successful anesthesia of the mental nerve .Extra-
foraminal injection is safest and still provides complete anesthesia
to the skin and soft tissues anterior to the nerve.
• Incisive Nerve Block is almost identical to the mental nerve block
but with one additional step. Technique: Give the patient a mental
nerve block as described above, and apply pressure at the site of
injection during 2–3 minutes after the injection. Successful
implementation of this technique provides anesthesia to the
premolars, canine, incisor teeth, lower lip, skin of the chin, and
buccal soft tissue anterior to the mental foramen.
