This document discusses various techniques for mandibular anesthesia. It begins by outlining the main techniques, including the inferior alveolar nerve block, buccal nerve block, Gow Gates technique, Vazirani-Akinosi closed mouth technique, mental nerve block, and incisive nerve block. For each technique, it provides details on the areas anesthetized, indications, contraindications, landmarks, and administration methods. It finds that the Gow Gates technique has a higher success rate than the inferior alveolar nerve block and discusses factors that can contribute to inadequate anesthesia.
4. INFERIOR ALVEOLAR NERVE
BLOCK
Most frequently used
Commonly called MANDIBULAR NERVE BLOCK
Nerves anesthetized
1. Inferior alveolar,
2. Incisive
3. Mental
4. Lingual
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5. Areas anesthetized
1. Mandibular teeth to the midline
2. Body of the mandible, inferior portion of
the ramus
3. Buccal mucoperiosteum, mucous
membrane anterior to the mandibular first
molar
4. Anterior two thirds of the tongue and
floor of the oral cavity
5. Lingual soft tissues and periosteum
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6. Indications
1. Procedures on multiple mandibular teeth in one quadrant
2. When buccal soft tissue anesthesia (anterior to the first
molar) is required
3. When lingual soft tissue anesthesia is required
Contraindications
1. Infection or acute inflammation in the area of injection
2. Patients who might bite either the lip or the tongue
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7. Advantages
One injection provides a wide area of anesthesia
Disadvantages
1. Wide area of anesthesia (not necessary for localized
procedures)
2. Rate of inadequate anesthesia (15% to 20%)
3. Intraoral landmarks not consistently reliable
4. Positive aspiration -10%
5. Lingual and lower lip anesthesia,
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8. It has a significantly lower success rate because
of
(1) anatomical variation in the height of the
mandibular foramen.
(2) the greater depth of soft tissue penetration
required
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10. Technique
1. A 25-gauge long needle recommended
2. Area of insertion: mucous membrane on the medial side
of the mandibular ramus, at the intersection of two
lines—
horizontal-height of injection,
vertical- anteroposterior plane of injection
3. Target area: inferior alveolar nerve as it passes
downward toward the mandibular foramen but before it
enters into the foramen
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11. The needle is located too far anteriorly (laterally)
Overinsertion with no contact of bone.
The needle is usually posterior (medial)
Early contact of bone
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13. Insert the needle. When bone is contacted,
withdraw approximately I mm to prevent
subperiosteal injection.
Aspirate. If negative, slowly deposit 1.5 ml of
anesthetic over a minimum of 60 seconds.
Slowly withdraw the syringe.
If negative, deposit a portion of the remaining
solution (0.1 ml) to anesthetize the lingual nerve.
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14. Signs and symptoms
1. Tingling or numbness of the lower lip
indicates anesthesia of the mental nerve,. It
is a good indication that the inferior
alveolar nerve is anesthetized,
2. Tingling or numbness of the tongue
indicates anesthesia of the lingual nerve,
3. 3. No pain is felt during dental therapy.
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15. Precautions
1. Do not deposit local anesthetic if bone is not
contacted.
2. Avoid pain by not contacting bone too forcefully.
Failures of anesthesia
The most common causes of absent or incomplete
inferior alveolar nerve block follow:
1. Deposition of anesthetic too low (below the
mandibular foramen). To correct: Reinject at a higher
site.
2. Deposition of anesthetic too far anteriorly) on the
ramus
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3. Accessory innervation to the mandibular teeth
16. BUCCAL NERVE BLOCK
The buccal nerve is a branch of the anterior
division of V3
The sole indication for administration of a buccal
nerve block, therefore, is when manipulation of
these tissues is contemplated
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17. Area of insertion: mucous membrane distal
and buccal to the most distal molar tooth in
the arch
3. Target area: buccal nerve as it passes over
the anterior border of the ramus
4. Landmarks: mandibular molars, mucobuccal
fold
5. Orientation of the bevel: toward bone If
negative, slowly deposit 0.3 ml over 10
seconds
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19. The Gow-Gates technique
The Gow-Gates technique is a true mandibular nerve
block since it provides sensory anesthesia to virtually
the entire distribution of V3.
Significant advantages of the Gow-Gates technique
over the inferior alveolar nerve block include
its higher success rate,
Its lower incidence of positive aspiration
(approximately 2% versus 10% to 15% with the
inferior alveolar nerve block), and
the absence of problems with accessory sensory
innervation to the mandibular teeth.
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21. Areas anesthetized (Fig. 14-15)
1. Mandibular teeth to the midline
2. Buccal mucoperiosteum and mucous
membranes on
the side of injection
3. Anterior two thirds of the tongue and floor of the
oral cavity
4. Lingual soft tissues and periosteum
5. Body of the mandible, inferior portion of the
ramus
6. Skin over the zygoma, posterior portion of the
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cheek, and temporal regions
22. Indications
1. Multiple procedures on mandibular teeth
2. When buccal soft tissue anesthesia, from the
third molar to the midline, is required
3. When lingual soft tissue anesthesia is
required
4. When a conventional inferior alveolar nerve
block isunsuccessful
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23. Contraindications
Patients who are unable to open their mouth
wide
Advantages
1. Requires only one injection;
2. High success rate (> 95%), with experience
3. Minimum aspiration rate
4. Few postinjection complications (i.e., trismus)
5. Provides successful anesthesia where a bifid
inferior alveolar nerve and bifid mandibular canals
are present
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24. Technique
1. 25-gauge long needle
recommended
2. Area of insertion: mucous
membrane on the mesial of
the mandibular ramus, on a
line from the intertragic
notch to the corner of the
mouth, just distal to the
maxillary second molar
3- Target area: lateral side of
the condylar neck, just
below the insertion of the
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lateral pterygoid muscle
25. Failures of anesthesia
Rare with the Gow-Gates mandibular block,
once the administrator becomes familiar with the
technique
1. Too little volume. The greater diameter of the
mandibular nerve may require a larger volume of
anesthetic solution. Deposit up to 1.2 ml in the
second injection if the depth of anesthesia is
inadequate following the initial 1.8 ml.
2. Anatomical difficulties. Do not deposit
anesthetic unless bone is contacted.
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26. The technique has a very high success rate,
has minimal toxic effects, shows very low
positive blood aspiration, Unlike the
conventional inferior alveolar technique,
provided the mouth is fully opened, the Gow-
Gates Technique allows for the deposition of
the anesthetic solution in the relatively
avascular region at the neck ofthe condyle.
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Anesth Prog 34:142-149 1987
27. Vazirani-Akinosi technique.
Its primary indication remains those situations in
which limited mandibular opening precludes the use
of other mandibular injection techniques
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28. Technique
Area of insertion: soft tissue
overlying the medial (lingual)
border of the mandibular
ramus directly
adjacent to the maxillary
tuberosity
at the height of the
mucogingival junction
adjacent to the maxillary third
molar
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29. Target area: soft tissue on the medial (lingual)
border of the ramus in the region of the inferior
alveolar, lingual, and mylohyoid nerves as they
run inferiorly from the foramen ovale toward the
mandibular foramen
The height of injection -below that with the
Gow-Gates but above that with the inferior
alveolar nerve block
Orientation of the bevel (bevel orientation in
theclosed-mouth mandibular block is very
significant):
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the bevel must be oriented away from the bone
30. Landmarks
a. Mucogingival junction of the maxillary third (or
second) molar
b. Maxillary tuberosity
c. Coronoid notch on the mandibular ramus
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34. Speed of Injection Influences Efficacy
of Inferior Alveolar
Nerve Blocks
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JOE — Volume 32, Number 10, October 2006
35. MENTAL NERVE BLOCK
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
Indication
When buccal soft tissue anesthesia is required for
proceduresin the mandible anterior to the mental
foramen, such as
1. Soft tissue biopsies
2. Suturing of soft tissues
Contraindication
Infection or acute inflammation in the area of
injection
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37. Technique
1. A 25- or 27-gauge short needle recommended
2. Area of insertion: mucobuccal fold at or just
anterior to the mental foramen
3. Target area: mental nerve as it exits the mental
foramen (usually located between the apices of
the first and second premolars)
4. Landmarks: mandibular premolars and
mucobuccal fold
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38. INCISIVE NERVE BLOCK
Areas anesthetized
1. Buccal mucous membrane anterior to the mental
foramen, usually from the second premolar to the
midline
2. Lower lip and skin of the chin
3- Pulpal nerve fibers to the premolars, canine, and
incisors
Indications
1. pulpal anesthesia on mandibular teeth anterior to the
mental foramen
2. When inferior alveolar nerve block is not indicated
a. When six or eight anterior teeth
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There is a significant relationship between the rate ofinjection and pressure rise when depositing the anestheticsolution, consequently affecfing its retention within theregion. It is claimed that depositing 2 ml of an anestheticsolution at the lingula in 18.3 sec increases hydrostaticpressure from 14.5 to 469 mm Hg.18 Such a greatimbalance between intra- and extravascular pressure andthe resulting loss of the anesthetic through the pores ofthe capillary walls affects its concentration at the nervemembrane and may result in a partial or complete failureof the block.The inject