1. Mandibular block techniques
Presented by:Dr. Mohana Priya.U
I year mds(OMFS)
Guided by: Prof.Dr.Jayavelu,(HOD)

2. Basic injection technique:
Use a sterilized sharp needle
Check the flow of local anesthesia.
Determine whether to warm the anesthetic syringe.
Position of the patient.
Dry the tissue.
Apply topical antiseptic.
A: Apply topical anesthetic.
Establish a firm hand rest.
Make the tissue taut.
Keep the syringe out of patient sight.
Insert needle into the mucosa.
Watch and communicate with the patient.
Inject several drops of l.a
Slowly advance the needle towards the target.
Basic injection technique:

3. 15) Deposit several drops of l.a before touching periosteum.
16) Aspirate.
17) Slowly deposit the local anesthetic solution.
18) Communicate with the patient.
19) Slowly with draw the needle. Cap the needle and discard.
20) Observe patient after injection.
21) Record the injection on the patients chart.

5. Branches of mandibular nerve:
1)Undivided nerve:
Nervus spinous
Nerve to the medial pterygoid muscle.
2)Divided nerve:
Anterior division
Nerve to the lateral pterygoid muscle
Nerve to the masseter muscle
Nerve to the temporal muscle
Buccal nerve.
Posterior division
Aurical temporal nerve
Lingual nerve
Mylohoid nerve
Inferior alvelor nerve
Incisive branch
Mental nerve

7. Three major types of local anesthetic injections:
Local infiltration.
Field block.
Nerve block.

8. Types of mandibular techniques:
1) Direct technique:
2) Indirect technique:
Inferior alveolar nerve block.
Buccal nerve block.
Gow gates technique.
Vazirani-Akinosi technique.
Mental nerve block.
Incisive nerve block.
Extra oral technique.
Fischer 123 technique.
Kurt- Thoma technique.
3) Supplemental:
a)Intraosseous anesthesia
*Periodontal ligament
*Intraseptal
*Intraosseous
b)Intrapulpal injection.

9. Inferior alveolar nerve block:

10. Area anesthetized:
Nerves anesthetized:

11. Multiple mandibular teeth in one quadrant.
Indications:
Contra-indications:
Multiple mandibular teeth in one quadrant.
Buccal soft tissue anesthesia.
Lingual soft tissue.

12. Advantages: * Provides wide area of anesthesia.
Disadvantages: *inadequate anesthesia( 15 to 20%) *landmarks not reliable. *positive aspiration. *lingual and lip anesthesia, uncomfortable. *partial anesthesia, in bifid mandibular canal or bifid IAN

13. Technique:
Needle: 25gauge.
Target area: inferior alveolar nerve-passes downwards towards mandible foramen but before it enters the foramen.
Position of patient: semi-supine- mouth open, mandibular molar occlusal plain parallel to floor.
Position of operator: right- 8 ‘o’ clock
left- 10 ‘o’ clock. In sitting
position.

15. There are three parameters that must be considered during administration of IANB.
1) height of injection
*6 mm above occlusal plain.
*3/4 of the anteroposterior distance.
*pterygomandibular raphe.

16. 2) Anteroposterior site of injection:
a. point 1 falls along the horizontal line from the coronoid notch to the deepest point of pterygomandibular raphe
b. point 2 is on vertical line through point 1 about 3/4th of the distance from the anterior border of ramus.
3) Penetration depth:
20-25mm or 2/3rd of the needle should
be penetrated.

17. Amount of local anesthesia to be deposited:
1.5 ml 60 seconds, inferior alveolar nerve.
0.1 ml, lingual nerve.
0.6 ml 20 seconds, lingual side if necessary.
0.6 ml 20 seconds, incisive nerve if necessary.

18. Signs and symptoms:

19. Complications:

20. Failures of anesthesia:
Deposition of anesthesia too low.
Deposition of anesthesia too far anteriorly.
Accessary innervation to the mandibular teeth.
When bifid inferior alveolar nerve.
Incomplete anesthesia of the central or lateral incisors.

21. Buccal nerve block:

22. *Soft tissue anesthesia in the buccal region.
Nerve anesthetized:
Area anesthetized:
Buccal nerve.
Indications:
*Soft tissue anesthesia in the buccal region.
Advantage:
*High success rate.
*technically easy.
Contraindication: *Infection or acute inflammation. Disadvantage: *potential for pain if needle contacts periosteum.

23. Technique:
Area of insertion: mucous membrane distal and buccal to the distal tooth or last molar.
Target area: long buccal nerve- anterior border of ramus.
Needle 25 gauge.
Deposition: ml.

24. Complication:

25. Gow-Gates technique:

26. Nerve anesthetized
Area anesthetized

27. When anesthesia of buccal soft tissue from 3rd molar to midline.
Indications:
Contra ndicatons:
Multiple procedures.
When anesthesia of buccal soft tissue from 3rd molar to midline.
Lingual soft tissue anesthesia
When inferior alveolar nerve block is unsuccessful.
Infection or acute infectons.
Patient having habit of lip and tongue biting.
Patients who are unable to open the mouth.

28. Minimum aspirating rate. Minimal post injection complications.
Advantages:
Disadvantages:
Requires only one inj.
High success rate.
Minimum aspirating rate.
Minimal post injection complications.
Successful anesthesia in case of bifid inferior alvelor nerve and canal
Lingual and lower lip anesthesia uncomfortable
Onset time is longer.
Clinical experience is necessary to learn the curve of gow gates technique.

29. Technique:

30. Target area: lateral side of the condylar neck- just below insertion of lateral pterygoid muscle
Position of patient: semi-supine.
Position of operator: right 8’o’ clock, left 10’o’ clock.
Land marks:
imaginery line drawn from corner of the mouth to intertragic notch.
Anterior border of ramus and the coronoid process is palpated with the help of thumb of left hand. This helps to retract tissue and determine the site of nerve penetration.
Needle: 25gauge.
Site and height of penetration:
needle slowly advanced until bone is contacted in NECK OF CONDYLE.
Depth of penetration: 25mm.

32. Amount of local anesthesia to be deposited:
3ml is recommended- 60 to 90 seconds.
1.8ml initially, 1.2ml secondary
Signs and symptoms:
*tingling in the lower lip
*tingling in the tongue
*no pain felt during dental therapy.

33. Complications

34. Too little volume of l.a
Anatomical difficulties.
Failures:

35. Mental nerve block:

36. Suturing of soft tissue
Nerve anesthetized:
Area anesthetized:
Mental nerve.
Indications:
Soft tissue biopsy.
Suturing of soft tissue
Advantage: high success rate,technically easy, atraumatic.
Buccal mucosa anterior to mental foramen( second premolar) to midline
Skin of lower lip and chin.
Contraindications:
Acute inflammation.
Infection.
Disadvantage: hematoma.

37. 25-27 gauge
Target area: mental nerve
Area of insertion: mucobuccal fold at or just anterior to mental foramen.
Land marks: mandibular premolar and mucobuccal fold
Location of mental foramen:
Place your index finger in the mucobuccal fold and press against the body of the mandible in 1st molar area.
Move your finger anteriorly until the bone beneath your finger feels irregular and somewhat concave.
Usually found around the apex of the second premolar.
Soreness will be produced as the mental nerve is compressed.
Radiographically can be located easily.

38. Signs and symptoms: Complications: Tingling and numbness of lower lip.
Depth of penetration: 5 to 6mm
Amount of Deposition: 0.6ml, 20 seconds.
Signs and symptoms:
Tingling and numbness of lower lip.
No pain during treatment.
Complications:
Hematoma.

39. It is also otherwise called as MENTAL NERVE BLOCK.
Incisive nerve block:

40. Vazirani- Akinosi closed mouth technique:

41. In 1977 Dr.Joseph Akinosi reported on a closed mouth approach to mandibular nerve.
Initially in 1960 tis method was described by varirani and hence as a tribute , it is named as vazirani akinosi closed mouth technique.
In 1992 Wolfe describe a modificaton of original vazirani akinosi technique, where all the tecnique are similar except 45’degree angulation of needle is given
This enable it to remain in close proximity to the medial side of mandibular ramus.

43. Inferior alveolar nerve Incisive nerve. Mental nerve. Lingual nerve.
Nerves anesthetized:
Area anesthetized:
Inferior alveolar nerve
Incisive nerve.
Mental nerve.
Lingual nerve.
Mylohyoid nerve
Mandibular teeth to midline.
Body of mandible and inferior portion of ramus.
Buccal mucoperiosteum and mucous membrane infront of mental foramen.
Anterior 2/3rd of tongue and floor of mouth.
Lingual soft tissue.

44. Multiple procedures in mandibular teeth.
Indications:
Contraindications
Limited mouth opening.
Multiple procedures in mandibular teeth.
Inability to visualize landmark for IANB.
Advantage:
*atraumatic.
*not able to open mouth.
*fewer complications.
*successful anesthesia in bifid IAN and bifid canal.
Infection or acute inflammation.
Patient with habit of lip and tongue biting.
Inability to visualize or gain access to lingual side.
Disadvantage:
*difficult to visualize path of insertion.
*No bony contact.
* Potentially traumatic if needle close to periosteum.

45. Techniques: 25 gauge recommended.
Area of insertion: osft tissue over lying the medial border of the mandibular ramus directly adjust to themaxillary tuberosity at the height of mucogingival junction adjacent to maxillary third molar.
Target area: soft tissue on medial border of ramus in region of IAN lingual nerve and mylohyoid nerve.
Land mark:a)mucogingival junction of maxillary third molar, (b)maxillary tuberosity.(c)coronoid notch.

46. Procedures: Deposition: 1.6- 1.8ml, 60 seconds.
Position of patient: supine
Position of operator: 8’o’ clock.
Ask the patient to occlude with muscles relaxed
Soft tissue in the medial border of ramus is reflected.
Needle held parallel to the occlusal plain at level of muco gingival junction of 3rd or 2nd molar.
Bevel away from ramus
Direct needle posteriorly and slightly lateral
Deposition: ml, 60 seconds.

48. Signs and symptoms: *tingling and numbness of tongue and lip
Safety feature: decreased positive aspiration.
Precaution:

49. Complications:
Hematoma
Trismus.
Facial nerve paralysis.

50. Failures: Flaring nature of ramus. Needle insertion point too low.
Under insertion or over insertion of needle.

51. This is the type of inferior nerve block technique.
This technique of anesthetizing the branches of mandibular nerve is also known as ‘ three positional nerve block technique.
It can also be mentioned as Fischer 123 technique.
Indirect technique:
1st position: the direction is from the opposite side- to inject between the external and internal oblique ridges- for long buccal nerve
2nd position: the direction is from same side –for lingual nerve.
3rd position: the direction is from opposite side- for inferior nerve.

52. Extra-oral technique for anesthesia:
Nerve anesthetized: mandibular nerve and subdivision. Area anesthetized: a) temporal region. b) auricle of the ear. c) external auditory meatus. d) temporal mandibular joint. e) salivary glands. f) anterior 2/3rd of the tongue. g)floor of the mouth. h) mandibular teeth. i) gingiva. j)buccal mucosa. k) lower portion of the face(except angle of jaw)

53. Indications: Infection and acute inflammation.
Presence of trauma, where that would contraindicate or difficult or impossible to anesthetize the mandibular nerve.
When there is need to anesthetize the entire mandibular nerve and sub divisions.
Diagnostic and therapeutic purpose.
Extensive surgical procedure with single penetration and minimum of l.a.

54. Anatomical landmarks:
mid point of zygomatic bone.
Coronoid process of ramus of the mandible; and prominence of the lateral pole of the condyle; which is located by having the patient open and close the mouth.
Lateral pterygoid plate.
Technique:
*the needle contacts the lateral pterygoid plate, then with drawn ,with only the point left in the tissues, and redirected in a slight forward and upward direction posteriorly.
*In order for the needle to pass posterior to lateral pterygoid plate.
*needle depth: not more than 5 mm.

55. Signs an symptoms:
1) Tingling sensation in tongue and lip.
2)Absence of pain during procedures
Complications:
1)Trismus
2) Failure of anesthesia.

56. Kurt- thoma technique:
This type of technique is indicated in patients with limited mouth opening like TRISMUS, ANKYLOSIS.
The needle is inserted through the skin from below the lower border of the angle of the mandible close to the inner surface of the ramus so that the needle finally comes to lie medial to the mandibular foramen.
Aspiration is done and solution deposited.

57. Reference: Handbook of local anesthesia- Stanley F. Malamed.
Manual of local anesthesia in dentistry-
AP Chitre

58. Thank you