1. Clinical notes (V)
Local Anesthetic for Inferior Alveolar Nerve Block (IANB)
Negligent Implant Placement
Negligent Fracture Of The Mandible
Negligent Surgical Extraction of Lower Molars

4. Applied anatomy of the pterygomandibular space: improving the success of inferior alveolar nerve blocks
 Diagrammatic representation of a transverse section of the right mandibular ramus at the level at which an IANB would be given. (M = masseter; R = ramus; IAN = inferior alveolar nerve; IAV = inferior alveolar vein; IAA = inferior alveolar artery; SML = sphenomandibular ligament; MP = medial pterygoid muscle; LN = lingual nerve; B = buccinator; PMR = pterygomandibular raphe; SCM = superior constrictor muscle; P = parotid gland; TT = tendon of temporalis; L = lingula). The needle is shown passing through the buccinator muscle, B, and into the pterygomandibular space where it is directed to an area of bone just superior to the lingula, L. The IAN, IAV and IAA are wrapped together by a fibrous sheath, in a neurovascular bundle, which occupies a spooned‐out depression on the medial surface of the ramus. The LN is located anterior and medial to the IAN.
© IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSION' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.
Australian Dental Journal Volume 56, Issue 2, pages , 30 MAY 2011 DOI: /j x

5. Photograph of a skull with simulated maximum opening of the mouth
 Photograph of a skull with simulated maximum opening of the mouth. A string has been attached to indicate where the pterygomandibular raphe would normally be located. This structure attaches to the pterygoid hamulus superiorly and descends to the inner aspect of the mandible near the most posterior molar. The pterygomandibular fold refers to the fold of mucosal tissue that overlies the pterygomandibular raphe and the needle should always be inserted lateral to the fold. The barrel of the syringe usually needs to be positioned over the contralateral premolars so that the needle tip can contact bone just superior to the lingula at the appropriate depth of needle insertion, approximately 20–25 mm in adults. The thumb or another finger can be used to palpate the coronoid notch, as seen in the photograph, to assist in establishing the correct height of needle insertion. (L = lingula; PMR = pterygomandibular raphe; H = pterygoid hamulus; CN = coronoid notch.)
© IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSION' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.
Australian Dental Journal Volume 56, Issue 2, pages , 30 MAY 2011 DOI: /j x

6.  Medial surface of the right mandibular ramus showing some landmarks relevant to IANBs. A crest of thickened bone lies slightly superior to the lingula and it represents the area where needle contact should be made on insertion, as it lies close to the inferior alveolar neurovascular bundle but minimizes the risk of damage to structures in the bundle. Although needle contact with the lingula may produce satisfactory anaesthesia, it is likely that needle withdrawal after initial bony contact will cause local anaesthetic solution to be deposited medial to the sphenomandibular ligament and, hence, reduce its effectiveness. (CN = coronoid notch; Li = lingula; SC = sulcus colli; GNM = groove for nerve to mylohyoid; CB = crest of thickened bone; MN = mandibular notch.)
© IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSION' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.
Australian Dental Journal Volume 56, Issue 2, pages , 30 MAY 2011 DOI: /j x

7. Intraoral photograph of the left side of the oral cavity showing the injection sites for different mandibular block techniques. The pterygotemporal depression exists between the pterygomandibular fold and coronoid notch and represents the area where a direct or indirect IANB is administered in the mediolateral plane. The height at which this block is given is approximately the level of the coronoid notch. In contrast, the Gow-Gates mandibular block is administered at a much higher level. The mesiopalatal cusp of the upper second molar determines the height of the injection while the site in the mediolateral plane is the area of tissue just posterior to the upper second or third molar (PTD: pterygotemporal depression, PMF: pterygomandibular fold, CN: coronoid notch, 1: area where a direct/indirect IANB would be administered, 2: area where a Gow-Gates mandibular block would be administered).

8.  Intraoral photograph of the right side of the oral cavity showing key anatomical landmarks observed when giving an IANB. The site for needle penetration is the pterygotemporal depression, which is outlined. The needle travels through the oral mucosa and underlying buccinator muscle before entering the pterygomandibular space. The height is at the level of the coronoid notch, the most concave region on the anterior border of the mandibular ramus. Approximate depth of needle penetration required in most adult patients is about 20–25 mm. (CN = coronoid notch; PTD = pterygotemporal depression; PMF = pterygomandibular fold.)
© IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSION' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.
Australian Dental Journal Volume 56, Issue 2, pages , 30 MAY 2011 DOI: /j x

9. Applied anatomy of the pterygomandibular space: improving the success of inferior alveolar nerve blocks
 Four representative intraoral photographs of the right side of the oral cavity showing the key intraoral landmarks observed and palpated when administering an IANB. (CN = coronoid notch; PTD = pterygotemporal depression; PMF = pterygomandibular fold.) The dotted line indicates the location of the PTD and the curved outline represents the level of the CN, which is the most concave area on the anterior border of the ramus. CN can be palpated to assist in establishing correct height of needle penetration.
© IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSION' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.
Australian Dental Journal Volume 56, Issue 2, pages , 30 MAY 2011 DOI: /j x

10.  Transverse section of the right mandibular ramus at the level of the lingula showing the IAN located just behind the tip of the lingula, anterior to the veins and artery. The thickening of the fibrous tissue medial to the neurovascular bundle represents the sphenomandibular ligament. During an IANB, the ideal position to deposit local anaesthetic solution is just above the tip of the lingula, as it allows the needle tip to be in close proximity to the nerve, without directly contacting it and risking damage. (SML = sphenomandibular ligament; IAN = inferior alveolar nerve; IAA = inferior alveolar artery; IAV = inferior alveolar vein; L = lingula; IPF = interpterygoid fascia.)
© IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSION' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.
Australian Dental Journal Volume 56, Issue 2, pages , 30 MAY 2011 DOI: /j x

11. If the needle hits the nerve, making the patient jump, or if blood shows during aspiration (the dentist is required to pull back on the syringe plunger to make sure he/she is not in an artery) before injecting the local anesthetic, the needle should have been backed off slightly before injecting the anesthetic.
These injuries usually resolve, but on rare occasions can develop into a sustained neuropathic pain. The dentist does have an obligation to chart your nerve injury and to map it in the chart, so as to follow it accurately for healing. If the symptoms are improving with respect to intensity and distribution, the dentist may not need to refer the patient to an oro-facial pain specialist. If there is significant paresthesia/dysesthesia and it is not resolving, the patient should be referred to an oral surgeon who specializes in microsurgery and/or an oro-facial pain specialist before the  fourth month of the injury.

12. Trigeminal Neuralgia

13. Implant Placement

15. Cone beam computed tomography (CBCT)
Cone Beam CT scan of the missing second molar and the inferior alveolar nerve. Simplant software allows the dentist to manipulate the teeth, inferior alveolar nerve and mandible in all directions. Here the three dimensional Simplant view is compare with the panorex view, both of which are obtained by the CBCT.

16. Negligent Implant Placement
Simplant/CBCT showing space previously occupied by removed implant

17. Fracture of the Mandible
Sometimes a tooth is fused or ankylosed to the surrounding bone and it will not budge when the dentist tries to elevate it out using routine technique

18. Surgical Extraction of the Lower Molars
Dental Malpractice and the Lingual Nerve

19. Dental Malpractice and the Lingual Nerve