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Types and Techniques of

Mandibular nerve block

ByDr. Said Ahmed Mohamed

B.D.S. , FDSRCS Edin.

Consultant Oral & Maxillofacial

Surgery

Saqr Hospital



Types of Mandibular Regional

Anesthesia • Inferior Alveolar Nerve Block

Mandibular teeth on side of injection, buccal and lingual hard and soft tissue, lower lip

• Buccal Nerve Block

Buccal soft tissue of molar region

• Gow-Gates Mandibular Nerve Block

Mandibular teeth to midline, hard and soft tissue of buccal and lingual aspect,anterior 2/3 of tongue, FOM, skin over zygoma, posterior aspect of cheek, andtemporal region on side of injection

• Vazirani-Akinosi Closed Mouth

Mandibular teeth to midline, hard and soft tissue of buccal aspect, anterior 2/3 of tongue, FOM

• Mental Nerve Block

Buccal soft tissue anterior to mental foramen, lower lip, chin• Incisive Nerve Block

Premolars, canine and incisors, lower lip, skin over the chin, buccal soft tissue anteriorto the mental foramen



Techniques of Mandibular Regional

Anesthesia • Techniques used in clinical practice for the anesthesia of the hard

and soft tissues of the mandible include the supraperiostealtechnique, PDL injection, intrapulpal anesthesia, intraseptalinjection, inferior alveolar nerve block, long buccal nerve block,Gow-Gates technique, Vazirani-Akinosi closed mouth mandibular

block, mental nerve block, and incisive nerve block.• The supraperiosteal, PDL, intrapulpal, and intraseptal techniques

are executed in the same manner as described above for maxillaryanesthesia. When anesthetizing the mandible the patient should bein the semisupine or reclined position. The right handed operatorshould stand at the nine o’clock to ten o’clock position whereas the

left handed operator should stand at the three o’clock to four o’clock position.



Inferior Alveolar Nerve Block

• The inferior alveolar nerve block is one of the mostcommonly employed techniques in mandibularregional anesthesia.

• It is extremely useful when multiple teeth in one

quadrant require treatment. While effective, thistechnique carries a high failure rate even when strictadherence to protocol is maintained.

• The target for this technique is the mandibular nerveas it travels on the medial aspect of the ramus, prior toits entry into the mandibular foramen. The lingual,mental, and incisive nerves are also anesthetized.

• A 25 gauge long needle is preferred for this technique.



• Technique :

• The patient should be in the semisupine position. The right handedoperator should be in the eight o’clock position whereas the lefthanded operator should be in the four o’clock position.

• With the mouth open maximally, identify the coronoid notch and

the pterygomandibular raphae.• Three quarters of the anteroposterior distance between these two

landmarks, and approximately six to ten millimeters above theocclusal plane is the injection site.

• Use a retraction instrument to retract the cheek and bring the

needle to the injection site from the contralateral premolar region.• As the needle passes through the soft tissue, deposit one or two

drops of anesthetic solution.



• Advance the needle until bone is contacted. Once bone iscontacted, withdraw the needle one millimeter and redirect theneedle posteriorly by bringing the barrel of the syringe towards theocclusal plane (Fig. 18, A and B).

• Advance the needle to three quarters of its depth, aspirate, and

inject three quarters of a cartridge of anesthetic solution slowlyover the course of one minute.

• As the needle is withdrawn, continue to deposit the remaining onequarter of anesthetic solution so as to anesthetize the lingual nerve(Fig. 18, C).

• Successful execution of this technique results in anesthesia of themandibular teeth on the ipsilateral side to the midline, associatedwith buccal mucosa anterior to the mental foramen, lingual softtissue, lateral aspect of the tongue on the ipsilateral side, and lowerlip on the ipsilateral side.



Figure 18 A: Location of the inferior alveolar nerve. B: After contacting bone,

the needle is redirected posteriorly by bringing the barrel of the syringe

towards the occlusal plane. The needle is then advanced to three quarters of

its depth



Figure 18 C: Location of the lingual nerve which is anesthetized

during the administration of an inferior alveolar nerve block



• Technique-

• The patient should be in the semisupine position. The righthanded operator should be in the eight o’clock positionwhereas the left handed operator should be in the fouro’clock position.

• Identify the most distal molar tooth on the side to betreated. The tissue just distal and buccal to the last molartooth is the target area for injection (Fig. 19, A and B).

• Use a retraction instrument to retract the cheek.

• The bevel of the needle should be toward bone and thesyringe should be held parallel to the occlusal plane on theside of the injection.

•



• The needle is inserted into the soft tissue and afew drops of anesthetic solution areadministered.

• The needle is advanced approximately one ortwo millimeters until bone is contacted. Oncebone is contacted and aspiration is negative,0.2cc of local anesthetic solution is deposited.

• The needle is withdrawn and recapped.

Successful execution of this technique results inanesthesia of the buccal soft tissue of themandibular molar region.



Figure 19 A:Location of the buccal nerve. B: The tissue just distal

and buccal to the last molar tooth is the target area for injection.



Gow-Gates Technique

• The Gow-Gates technique or third division nerve block is usefulalternative to the inferior alveolar nerve block

• it is often used when the latter fails to provide adequateanesthesia.

• Advantages of this technique versus the inferior alveolar technique

are its low failure rate and low incidence of positive aspiration.• The Gow-Gates technique anesthetizes the auriculotemporal,

inferior alveolar, buccal, mental, incisive, mylohyoid and lingualnerves. Contraindications to this procedure include acuteinflammation and infection over the site of injection and trismaticpatients. A 25 gauge long needle is preferred for this technique.



• Technique-

• The patient should be in the semisupine position. The righthanded operator should be in the eight o’clock position

whereas the left handed operator should be in the fouro’clock position.

• The target area for this technique is the neck of the condylebelow the area of insertion of the lateral pterygoid muscle.A retraction instrument is used to retract the cheek.

• The patient is asked to open maximally and themesiolingual cusp of the maxillary 2nd molar on the side of desired anesthesia is identified.

• The insertion site of the needle will be just distal to themaxillary 2nd molar at the level of the mesiolingual cusp.

• Bring the needle to the insertion site in a plane that isparallel to an imaginary line drawn from the intertragicnotch to the corner of the mouth on the same side as theinjection (Fig. 20, A and B).



• The orientation of the bevel of the needle is not important in thistechnique. Advance the needle through soft tissue approximately25mm until bone is contacted. This is the neck of the condyle. Oncebone is contacted, withdraw the needle one millimeter andaspirate. Redirect the needle superiorly and reaspirate. If aspirationin two planes is negative, slowly inject one cartridge of localanesthetic solution over the course of one minute. Successfulexecution of this technique provides anesthesia to the ipsilateralmandibular teeth up to the midline, and associated buccal andlingual hard and soft tissue. The anterior two thirds of the tongue,floor of the mouth, skin over the zygoma, posterior aspect of thecheek and temporal region on the ipsilateral side of injection arealso anesthetized.1,8



Figure 20 A: The patient is asked to open mouth maximally. The mesiolingual

cusp of the maxillary 2nd molar is the reference point for the height of the

injection. B: The needle is then moved distally and is held parallel to an

imaginary line drawn from the intertragic notch to the corner of the mouth



Vazirani-Akinosi Closed Mouth

Mandibular Block • The Vazirani-Akinosi closed mouth mandibular block is a useful

technique for patients with limited opening due trismus orankylosis of the temporomandibular joint.

• Limited mandibular opening precludes the administration of theinferior alveolar nerve block or use of the Gow-Gates technique

both of which require the patient to be open maximally.• Other advantages to this technique are the minimal risk of trauma

to the inferior alveolar nerve, artery, vein, and pterygoid muscle,low complication rate and minimal discomfort upon injection.

• Contraindications to this technique are acute inflammation andinfection in the pterygomandibular space, deformity or tumor in the

maxillary tuberosity region or an inability to visualize the medialaspect of the ramus.

• A 25 gauge long needle is preferred for this technique.



• Technique-


• The gingival margin above the maxillary 2nd and 3rd molars andthe pterygomandibular raphae serve as landmarks for thistechnique.

• A retraction instrument is used to stretch the cheek laterally.

• The patient should occlude gently on the posterior teeth. Theneedle is held parallel to the occlusal plane at the level of thegingival margin of the maxillary 2nd and 3rd molars.

• The bevel is directed away from the bone facing the midline.

• The needle is advanced through the mucous membrane andbuccinator muscle to enter the pterygomandibular space.



• The needle is inserted to approximately one half to three quartersof its length.

• At this point the needle will be in the midsection of theptyerygomandibular space.

• Aspirate and if negative, one cartridge of local anesthetic solution

is deposited over the course of one minute.• Diffusion and gravitation of the local anesthetic solution will

anesthetize the lingual and long buccal nerves in addition to theinferior alveolar nerve.

• Successful execution of this technique provides anesthesia of theipsilateral mandibular teeth up to the midline, and associatedbuccal and lingual hard and soft tissue. The anterior two thirds of the tongue and floor of the mouth are also anesthetized.9,10



Mental Nerve Block

• The mental nerve block is indicated forprocedures where manipulation of buccal softtissue anterior to the mental foramen is

necessary.• Contraindications to this technique are acute

inflammation and infection over the injectionsite.

• A 25 or 27 gauge short needle is preferred for thistechnique.



• Technique-

• The patient should be in the semisupine position. The

right handed operator should be in the eight o’clockposition whereas the left handed operator should be inthe four o’clock position.

• The target area is the height of the mucobuccal fold

over the mental foramen (Fig. 21, A and B).• The foramen can be manually palpated by applying

gentle finger pressure to the body of the mandible inthe area of the premolar apicies.

•

The patient will feel slight discomfort upon palpation of the foramen.

•



• Use a retraction instrument to retract the softtissue.

• The needle is directed toward the mentalforamen with the bevel facing the bone.

• Penetrate the soft tissue to a depth of fivemillimeters, aspirate and inject approximately0.6cc of anesthetic solution.

• Successful execution of this technique results inanesthesia of the buccal soft tissue anterior tothe foramen, lower lip and chin on the side of theinjection.1



Figure 21, A: Location of the mental and incisive nerves.

Figure 21, B: Block of the mental and incisive nerves: The needle is inserted at

the height of the mucobuccal fold over the mental foramen for both the

mental nerve block and incisive nerve block.



Incisive Nerve Block

• The incisive nerve block is not as frequently employedin clinical practice however it proves very useful whentreatment is limited to mandibular anterior teeth andfull quadrant anesthesia is not necessary.

•

The technique is almost identical to the mental nerveblock with one additional step. Both the mental andincisive nerves are anesthetized using this technique.

• Contraindications to this technique are acuteinflammation and infection at the site of injection.

• A 25 or 27 gauge short needle is preferred for thistechnique.



• Technique-


• The target area is the height of the mucobuccal fold over themental foramen (See Fig. 21, B).

• Identify the mental foramen as previously described. Give thepatient a mental nerve block as described above and apply digitalpressure at the site of injection during administration of anesthetic

solution.• Continue to apply digital pressure at the site of injection two to

three minutes after the injection is complete to aid the anestheticin diffusing into the foramen.

• Successful implementation of this technique provides anesthesia tothe premolars, canine, incisor teeth, lower lip, skin of the chin, andbuccal soft tissue anterior to the mental foramen.



Figure 21, B: Block of the mental and incisive nerves: The needle

is inserted at the height of the mucobuccal fold over the mental

foramen for both the mental nerve block and incisive nerve

block.

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