1. Techniques of Mandibular and Maxillary Anesthesia
Dr. Mumena C.H

2. Introduction Choice of anesthesia Mandibular technique
Maxillary technique

3. Choice of LA 3 Important factors; Specific nerve to be blocked,
Onset of action,
Duration action,

4. Duration of action
The duration of action of LA may vary from 30min to 180 minutes or longer,
Duration is related to dosage, increasing dosage increases duration,
Duration can be increased by adding Epinephrine (vasoconstrictor) to the local anaesthesia,
Duration of action differs for different agents
NB. Read the properties of each agent.

5. Nerve to be blocked
Small nerves are in general easier to be block than larger onces,
Nerve endings and cutaneous nerves are easily and quickly blocked by low concentration of drug given by infiltration,

6. Onset of action
Depending on the type of operation, e.g acute pain then rapid onset required,

7. Review Anat. Trigeminal nerve
5th cranial nerve.
Major sensory of the face, mouth and nasal cavity.
Motor and proprioceptive innervation to muscles of mastication.
Origin-
Sensory neurons-upper part of pons,
Motor neurons-inferior surface of pons
3 divisions
Ophthalmic,
maxillary, and
mandibular).
Successful practice of dentistry is based on blockade of the various branches of these nerves.

8. Mandibular nerve 3rd and largest branch of trigeminal nerve.
Composed of
motor and sensory roots.
Exits cranium
foramen ovale.
Motor innervation to the muscles of mastication.

9. Mandibular nerve
Sensory to mandibular teeth and gingiva, lower lip, cheek, anterior two thirds of the tongue, auricle and skin over temporal region.
Braches –
Inferior alveolar nerve,
Lingual nerve
Buccal nerve
Mental nerve
Incisive nerve

10. Inferior alveolar nerve block in Dental
Inferior alveolar nerve together with lingual nerve are anesthetized by the same or different injections.
Lingual nerve
mucous membrane of the floor of mouth, anterior 2/3 of tongue and lingual gingiva.
I.A.n
mandibular teeth and surrounding hard and soft tissue up to the midline, exception buccal soft tissues in the molar area.

11. Inferior alveolar nerve block in Dental
Anatomical landmarks
anterior border of ramus, external and internal oblique ridges, the coronoid notch, retromolar triangle and pterygomandibular ligament.
Target area for injection
mandibular foramen located in the mid-portion of ramus and 1 cm above the occlusal plane.
Sometimes found in the area between mid-portion of ramus and posterior 1/3 of ramus.

12. Inferior alveolar nerve block in Dental cont…
Several technique elaborated
difficulty of locating mandibular foramen hence LA failure.
There is two techniques:
Traditional technique,
Direct technique
Indirect technique
Alternative technique;
High ramus –neck of condyle approach (Gow-gates technique) and
Tuberosity approach (Akinos technique)-Tresmus.

13. Inferior alveolar Nerve Block Anesthesia
Lower success rate than Maxillary anesthesia - approx %
Related to bone density
Less access to nerve trunks 
Most commonly performed technique
Has highest failure rate (15-20%)
Success depends on depositing solution within 1 mm of nerve trunk

14. 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

15. Inferior Alveolar Nerve Block
Nerves anesthetized
Inferior Alveolar
Mental
Incisive
Lingual

16. 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

17. Inferior Alveolar Nerve Block
Indications
Multiple mandibular teeth
Buccal anterior soft tissue
Lingual anesthesia

18. Inferior Alveolar Nerve Block
Contraindications
Infection/inflammation at injection site
Patients at risk for self injury (eg. children)

19. Inferior Alveolar Nerve Block
10%-15% positive aspiration

20. Inferior Alveolar Nerve Block
Supplemental injection
Periodontal ligament injection (PDL)
Intraseptal

21. Inferior Alveolar Nerve Block
Target Area
Inferior alveolar nerve, near mandibular foramen
Landmarks
Coronoid notch
Pterygomandibular raphe
Occlusal plane of mandibular posterior teeth (molars).

22. Inferior Alveolar Nerve Block
Precautions
Do not inject if bone not contacted
Avoid forceful bone contact
Avoid use of cold agents

23. Inferior Alveolar Nerve Block
Failure of Anesthesia
Injection too low
Injection too anterior
Accessory innervation
-Mylohyoid nerve
-contralateral Incisive nerve innervation

24. Inferior Alveolar Nerve Block
Complications
Hematoma
Trismus
Facial paralysis (Inject into parotid gland).

25. Inferior Alveolar Nerve Block
General hints: 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)

26. Traditional technique of inferior alveolar nerve block-Direct technique
Palpate the oblique ridge in the oral vestibule with index finger.
Follow it posteriorly to where it ascends as sharp anterior border of the ramus of mandible.
Move the finger to the temporal crest (internal oblique line) of the mandible and is left in this position.
The finger is now in the retromolar fossa with the finger nail backwards.

27. Traditional technique of inferior alveolar nerve block-Direct technique
Draw an imaginary line from point between the occlusal surfaces of the two premolars in the opposite quadrant to the midpoint of the fingernail.
This imaginary line when extended posteriorly ends just above the mandibular foramen.
Therefore the syringe needle will be directed along this line.

28. Traditional technique of inferior alveolar nerve block-Indirect technique
After locating the injection site the syringe is held parallel to the mandibular occlusal plane on the same side as the tooth to be blocked.
The needle is directed approximately 1 cm (with the syringe) above the mandibular arch.
Aspirate the needle and inject 0.5 ml of LA for lingual nerve.
Then move the syringe to the other side of the arch over the opposite premolars teeth.

29. Alternative technique-
More reliable.
Gow gates technique;
Also known as high ramus- neck of condyle approach.
Penetration into the oral mucosa is along the medial border of the mandibular ramus lateral to the pterygomandibular depression, but medial to the temporalis muscle tendon.
The needle inserted along a line extending from the corner of the mouth opposite the site of injection
The needle should be 25G and usually 1in long.
The needle should advanced until bone is contacted and then withdrawn 1 mm.
Anesthetic solution deposited after negative aspiration

36. Alternative technique- cont…
Akinos technique;
Also known as Tuberosity approach.
This technique is useful where patient has intense trismus.
Mucosa is penetrated along the medial surface of the mandibular ramus.
The mouth is kept closed (teeth in occlusion) with the cheek and muscles of mastication relaxed.
The same needle side.
The depth of penetration is 1 ½ inches.

37. The Akinosi technique

38. The Akinosi
technique

39. Avoiding self-inflicted trauma
reduce area of soft tissue anaesthesia
intraligamentary anaesthesia
intra-osseous anaesthesia
palatal approaches to pulp

43. Intraligamentary anaesthesia
injection
dentine
gingiva
pulp
pdl
alveolus

44. Intraligamentary anaesthesia
injection
dentine
gingiva
pulp
alveolus

45. Intraligamentary anaesthesia
injection
dentine
gingiva
pulp
alveolus

46. Intraligamentary anaesthesia
injection
dentine
gingiva
pulp
alveolus

47. Intraligamentary and intra-osseous anaesthesia
injection
dentine
gingiva
pulp
intra-osseous
injection
alveolus

48. Intraligamentary and intra-osseous anaesthesia
injection
dentine
gingiva
pulp
intra-osseous
injection
alveolus

49. Success of intraligamentary anaesthesia depends on:
tooth
least successful with lower incisors
solution
dependent upon vasoconstrictor concentration

51. self-aspirating }
aspirating
non-aspirating

53. aspiration force
diaphragm deformation
basal diaphragm
recoils

54. Force
Time
initial aspiration force
subsequent
force

56. Buccal nerve block Anterior branch of Mandibular nerve (V3)
Provides buccal soft tissue anesthesia adjacent to mandibular molars
Not required for most restorative procedures
Buccal is blocked by the injection in the buccal mucosa right to the 3rd molar just above the occlusal plane.

57. Buccal Nerve Block Indications Contraindications
Anesthesia required - mucoperiosteum buccal to mandibular molars
Contraindications
Infection/inflammation at injection site

58. Buccal Nerve Block Advantages Technically easy High success rate
Disadvantages
Discomfort

59. Buccal Nerve Block
Alternatives
Buccal infiltration
PDL
Intraseptal

60. Buccal Nerve Block
Landmarks
Mandibular molars
Mucobuccal fold

61. Buccal Nerve Block Complications Hematoma (unusual)
Positive aspiration
0.7 %

62. Long Buccal Nerve Block
Technique;
Apply topical
Retract the cheek
Insert the needle distal to the tooth with the syringe horizontal into the buccal fold.
About 0.5 ml of LA solution is injected.
The barrel of the needle should be facing downwards.

65. Mental nerve block Mental nerve exits mandible through mental foramen.
The foramen is located between root apices of 1st and 2nd premolrs.
Technique;
Insert the needle at an angle to the bony canal towards the mental foramen.
Inject ml LA solution, another injection is required in the lingual gingiva and mucosa.

66. Mental Nerve Block
Provides sensory innervation to buccal soft tissue anterior to mental foramen, lip and chin

67. Mental Nerve Block Indication Need for anesthesia in innervated area
Contraindication
Infection/inflammation at injection site

68. Mental Nerve Block Advantages Easy, high success rate
Usually atraumatic
Disadvantage
Hematoma

69. Mental Nerve Block Alternatives Local infiltration PDL Intraseptal
Inferior alveolar nerve block
Gow Gates

70. Mental Nerve Block Complications Few Hematoma Positive aspiration
5.7 %

75. 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  

76. Incisive Nerve Block
Nerves anesthetized
Incisive
Mental

77. Incisive Nerve Block Areas Anesthetized
Mandibular labial mucous membranes
Lower lip / skin of chin
Incisor, cuspid and bicuspid teeth

78. Incisive Nerve Block Indication
Anesthesia of pulp or tissue required anterior to mental foramen
Contraindication
Infection/inflammation at injection site

79. Incisive Nerve Block Advantages High success rate
Pulpal anesthesia w/o lingual anesthesia
Disadvantages
Lack of lingual or midline anesthesia

80. Incisive Nerve Block
Complications
Hematoma
Positive aspiration
5.7 %

81. Maxillary nerve Foramen rotundum Courses
pterygopalatine fossa & infraorbital canal.
Exit the face through infraorbital foramen.
Supply
sensory innervation-maxillary teeth, gingiva, maxillary sinus, hard & soft palate, lower eyelid, side of the nose, upper lip, mucous membrane of nasopharynx, and skin over the anterior temporal region.
Necessary to block one or more of nerve or branches listed above.
3 branches: Posterior, middle & anterior superior alveolar nerves

82. Maxillary nerve cont…
Posterior superior alveolar nerve-all molars except mesiobuccal root of 1st molar.
Technique-
Dry area with gauze,
Apply topical anesthesia
Insert palpating finger into muccobuccal fold of maxilla till contacts the zygomatic arch at it juncture with maxillary bone.
Cheek retracted gentle laterally,
Mouth partially opened.
Long needle 1 5/8 inches inserted through maxillary mucosa at 450 angle to all 3 planes of orientation.
Advance needle slowly in this orientation.
This ensure deposition of LA soln in close proximity to the nerve as it enters its foramina.

83. Maxillary nerve cont…
Avoids contact with the ptrygoid plexus of veins.
Needle should be advanced to a depth of one half to two thirds of the dental needle.
Inject slowly two thirds of LA soln after negative aspiration.
Withdraw needle the remaining one third may be used to block mesiobuccal root of 1st molar.
Middle superior alveolar nerve-located within the maxilla.
Innervate mesiobuccal root of 1st molar, premolars, antral lining corresponding to these teeth and buccal alveolar bone and soft tissues in this area.
Technique;
Retract cheek mucosa after preparation as described previously.
1 to 1 5/8 inches needle should be used.
Orient needle so that it conforms to the maxilla curvature in this area.

84. Maxillary nerve cont…
Advance slowly to a depth where whereby its tip approximates the level of the apices of the premolar teeeth.
Inject slowly following negative aspiration.
LA diffuses through the maxilla blocking the MSAn.
Anterior superior alveolar nerve (ASAn)- supply canine, lateral and central incisors, buccal alveolar bone, and soft tissues in this region.
Technique;
1 to 1 5/8 inches needle.
Needle inserted and advanced slowly along the long canine eminence,
Until tip approximates the level of the apex of canine tooth.
Inject slowly after negative aspiration.

85. Maxillary nerve cont…
Greater palatine nerve (GPn)- exit into the hard palate though greater palatine foramen located at level of 1 cm above margin of palatal gingiva and between 2nd and 3rd molar.
Technique;
Insert the needle slightly anterior to the greater palatine (depression btn 2nd & 3rd Molars) foramen and perpendicular to the hard palate.
The needle advanced to contact the bone.
Withdraw 2mm and approximately one fourth of a dental cartilage (0.5 ml) injected.
Nasopalatine nerve (NPn)- enters oral cavity through incisive foramen, located in the midline of the anterior hard palate directly beneath incisive papilla.
Technique; insert a needle into the incisive papilla at an angle

86. Maxillary nerve cont…
To the midline and advanced until the rim of the foramen is contacted.
Needle withdrawn 1-2 mm and one fourth of a dental cartilage injected following negative aspiration.
Infra-orbital block; exits via infra orbital firamen,
Technique; foramen located in vertical line with the pt’s pupil as he looks straight ahead.
Palpate the foramen, retract the cheek to expose the buccal vestibule adjacent to the bicuspids.
Insert the needle between bicuspids and parallel to their long axes.
Penetrate far to enough to reach infra orbital foramen.
Following negative aspiration deposit LA.
It is possible to produce unilateral analgesia of I, C, P, and mesiobuccal root of 1st molar.

87. Palatal access

88. I hope L.A is the bridge to Effective surgical procedures.
BEST OF LUCKY