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Techniques of Mandibular Anesthesia including Inferior Alveoar Nerve Block

Mandibular Anesthesia
  • Lower success rate than Maxillary anesthesia (approx. 80-85 %)
  • Related to bone density
  • Less access to nerve trunks  
Mandibular Nerve Blocks
  1. Inferior alveolar
  2. Mental - Incisive             
  3. Buccal
  4. Lingual
  5. Gow-Gates
  6. Akinosi
Mandibular Anesthesia
  • Most commonly performed technique
  • Has highest failure rate (15-20%)
  • Success depends on depositing solution within 1 mm of nerve trunk
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

Nerves anesthetized
  • Inferior Alveolar
  • Mental
  • Incisive   
  • Lingual
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
Indications of inferior Alveolar nerve block
  • Multiple mandibular teeth
  • Buccal anterior soft tissue
  • Lingual anesthesia
Contraindications of inferior Alveolar nerve block
  • Infection/inflammation at injection site
  • Patients at risk for self injury (eg. children)
10%-15% positive aspiration
Alternatives for inferior Alveolar nerve block
  1. Mental nerve block
  2. Incisive nerve block
  3. Anterior infiltration
  4. Periodontal ligament injection (PDL)
  5. Gow-Gates
  6. Akinosi  
  7. Intraseptal
Technique for of inferior Alveolar nerve block
Apply topical anaesthesia
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)


Target Area
    Inferior alveolar nerve, near mandibular foramen
Landmarks
    Coronoid notch
    Pterygomandibular raphe
    Occlusal plane of mandibular posteriors
Inferior Alveolar Nerve Block
Precautions
    Do not inject if bone not contacted
    Avoid forceful bone contact
Failure of Anesthesia in inferior Alveolar nerve block
    Injection too low
    Injection too anterior
    Accessory innervation
        -Mylohyoid nerve
        -Contra lateral Incisive nerve innervation
Complications of inferior Alveolar nerve block
  1. Hematoma
  2. Trismus
  3. Facial paralysis
Mandibular nerve block 
Other Techniques of Manidilar nerve block
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
Buccal Nerve Block
Indications
    Anesthesia required - mucoperiosteum buccal to mandibular molars
Contraindications
    Infection/inflammation at injection site
Advantages
    Technically easy
    High success rate
Disadvantages
    Discomfort
Alternatives
    Buccal infiltration
    Gow-Gates
    PDL
    Intraseptal

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
  •    25-27 gauge needle
Area of insertion:- Mucosa adjacent to most distal
Landmarks
    Mandibular molars
    Mucobuccal fold
Complications
    Hematoma (unusual)
    Positive aspiration-0.7 %
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
Indication
    Need for anesthesia in innervated area
Contraindication
    Infection/inflammation  at injection site
Advantages
    Easy, high success rate
    Usually atraumatic
Disadvantage
    Hematoma
Alternatives
    Local infiltration
    PDL
    Intraseptal
    Inferior alveolar nerve block
    Gow Gates
Complications
    Few
    Hematoma
    Positive aspiration-5.7 %
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  
Nerves anesthetized
    Incisive
    Mental
Areas Anesthetized
    Mandibular labial mucous membranes
    Lower lip / skin of chin
    Incisor, cuspid and bicuspid teeth
Indication
    Anesthesia of pulp or tissue required anterior to mental foramen
Contraindication
    Infection/inflammation at injection site
Advantages
    High success rate
    Pulpal anesthesia w/o lingual anesthesia
Disadvantages
    Lack of lingual or midline anesthesia
Complications
    Hematoma
    Positive aspiration-5.7 %
Mandibular nerve block (other techniques)
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