1. Techniques of Mandibular Anesthesia
Faisal A. Quereshy, M.D., D.D.S., F.A.C.S.
Assistant Professor / Residency Director
Case Western Reserve University
School of Dental Medicine
Dept. Oral & Maxillofacial Surgery
Monday March 5, 2007

2. Mandibular Anesthesia
Lower success rate than Maxillary anesthesia - approx %
Related to bone density
Less access to nerve trunks  
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

3. Mandibular Nerve Blocks
Inferior alveolar
Mental - Incisive
Buccal
Lingual
Gow-Gates
Akinosi
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

4. Mandibular Anesthesia
Most commonly performed technique
Has highest failure rate (15-20%)
Success depends on depositing solution within 1 mm of nerve trunk
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

5. Inferior Alveolar Nerve Block
Not a complete mandibular nerve block.
Requires supplemental buccal nerve block
May require infiltration of incisors or mesial root of first molar
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

6. Inferior Alveolar Nerve Block
Nerves anesthetized
Inferior Alveolar
Mental
Incisive
Lingual
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

7. Inferior Alveolar Nerve Block
Areas Anesthetized
Mandibular teeth to midline
Body of mandible, inferior ramus
Buccal mucosa anterior to mental foramen
Anterior 2/3 tongue & floor of mouth
Lingual soft tissue and periosteum
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

8. Inferior Alveolar Nerve Block
Indications
Multiple mandibular teeth
Buccal anterior soft tissue
Lingual anesthesia
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

9. Inferior Alveolar Nerve Block
Contraindications
Infection/inflammation at injection site
Patients at risk for self injury (eg. children)
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

10. Inferior Alveolar Nerve Block
10%-15% positive aspiration
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

11. Inferior Alveolar Nerve Block
Alternatives
Mental nerve block
Incisive nerve block
Anterior infiltration
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

12. Inferior Alveolar Nerve Block
Alternatives (cont.)
Periodontal ligament injection (PDL)
Gow-Gates
Akinosi
Intraseptal
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

13. Inferior Alveolar Nerve Block
Technique
Apply topical
Area of insertion:
medial ramus, mid-coronoid notch,
level with occlusal plane (1 cm above),
3/4 posterior from coronoid notch to pterygomandibular raphe
advance to bone (20-25 mm)
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

14. Inferior Alveolar Nerve Block
Target Area
Inferior alveolar nerve, near mandibular foramen
Landmarks
Coronoid notch
Pterygomandibular raphe
Occlusal plane of mandibular posteriors
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

15. Inferior Alveolar Nerve Block
Precautions
Do not inject if bone not contacted
Avoid forceful bone contact
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

16. Inferior Alveolar Nerve Block
Failure of Anesthesia
Injection too low
Injection too anterior
Accessory innervation
-Mylohyoid nerve
-contralateral Incisive nerve innervation
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

17. Inferior Alveolar Nerve Block
Complications
Hematoma
Trismus
Facial paralysis
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

18. Faisal A. Quereshy, MD, DDS, FACS
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

19. Faisal A. Quereshy, MD, DDS, FACS
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

20. Faisal A. Quereshy, MD, DDS, FACS
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

21. Faisal A. Quereshy, MD, DDS, FACS
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

22. Faisal A. Quereshy, MD, DDS, FACS
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

23. Faisal A. Quereshy, MD, DDS, FACS
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

24. Long Buccal Nerve Block
Anterior branch of Mandibular nerve (V3)
Provides buccal soft tissue anesthesia adjacent to mandibular molars
Not required for most restorative procedures
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

25. Faisal A. Quereshy, MD, DDS, FACS
Buccal Nerve Block
Indications
Anesthesia required - mucoperiosteum buccal to mandibular molars
Contraindications
Infection/inflammation at injection site
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

26. Faisal A. Quereshy, MD, DDS, FACS
Buccal Nerve Block
Advantages
Technically easy
High success rate
Disadvantages
Discomfort
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

27. Faisal A. Quereshy, MD, DDS, FACS
Buccal Nerve Block
Alternatives
Buccal infiltration
Gow-Gates
PDL
Intraseptal
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

28. Faisal A. Quereshy, MD, DDS, FACS
Buccal Nerve Block
Technique
Apply topical
Insertion distil and buccal to last molar
Target - Long Buccal nerve as it passes anterior border of ramus
Insert approx. 2 mm, aspirate
Inject 0.3 ml of solution, slowly
gauge needle
Area of insertion:
- Mucosa adjacent to most distal
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

29. Faisal A. Quereshy, MD, DDS, FACS
Buccal Nerve Block
Landmarks
Mandibular molars
Mucobuccal fold
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

30. Faisal A. Quereshy, MD, DDS, FACS
Buccal Nerve Block
Complications
Hematoma (unusual)
Positive aspiration
0.7 %
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

31. Faisal A. Quereshy, MD, DDS, FACS
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

32. Faisal A. Quereshy, MD, DDS, FACS
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

33. Faisal A. Quereshy, MD, DDS, FACS
Mental Nerve Block
Terminal branch of IAN as it exits mental foramen
Provides sensory innervation to buccal soft tissue anterior to mental foramen, lip and chin
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

34. Faisal A. Quereshy, MD, DDS, FACS
Mental Nerve Block
Indication
Need for anesthesia in innervated area
Contraindication
Infection/inflammation at injection site
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

35. Faisal A. Quereshy, MD, DDS, FACS
Mental Nerve Block
Advantages
Easy, high success rate
Usually atraumatic
Disadvantage
Hematoma
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

36. Faisal A. Quereshy, MD, DDS, FACS
Mental Nerve Block
Alternatives
Local infiltration
PDL
Intraseptal
Inferior alveolar nerve block
Gow Gates
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

37. Faisal A. Quereshy, MD, DDS, FACS
Mental Nerve Block
Complications
Few
Hematoma
Positive aspiration
5.7 %
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

38. Faisal A. Quereshy, MD, DDS, FACS
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

39. Faisal A. Quereshy, MD, DDS, FACS
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

40. Faisal A. Quereshy, MD, DDS, FACS
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

41. Faisal A. Quereshy, MD, DDS, FACS
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

42. Faisal A. Quereshy, MD, DDS, FACS
Incisive Nerve Block
Terminal branch of IAN     
Originates in mental foramen and proceeds anteriorly
Good for bilateral anterior anesthesia           
Not effective for anterior lingual anesthesia  
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

43. Faisal A. Quereshy, MD, DDS, FACS
Incisive Nerve Block
Nerves anesthetized
Incisive
Mental
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

44. Faisal A. Quereshy, MD, DDS, FACS
Incisive Nerve Block
Areas Anesthetized
Mandibular labial mucous membranes
Lower lip / skin of chin
Incisor, cuspid and bicuspid teeth
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

45. Faisal A. Quereshy, MD, DDS, FACS
Incisive Nerve Block
Indication
Anesthesia of pulp or tissue required anterior to mental foramen
Contraindication
Infection/inflammation at injection site
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

46. Faisal A. Quereshy, MD, DDS, FACS
Incisive Nerve Block
Advantages
High success rate
Pulpal anesthesia w/o lingual anesthesia
Disadvantages
Lack of lingual or midline anesthesia
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS

47. Faisal A. Quereshy, MD, DDS, FACS
Incisive Nerve Block
Complications
Hematoma
Positive aspiration
5.7 %
March 5, 2007
Faisal A. Quereshy, MD, DDS, FACS