Mandibular nerve block

intraoral and extraoral

technique

Group Report 3
.‫احمد حسن جاسم‬ -1
.‫عبد هللا عباس علي‬ -2
.‫سيف عايد هاشم‬ -3
.‫مقتدر احمد حبيب‬ -4
Oral and .‫حسين جاسب رسن‬ -5

maxillofacial Al-ameed University

surgery 3rd stage College of dentistry
*Introduction*
NERVE SUPPLY FOR MANDIBULAR TEETH
❖ INCISIVE NERVE :
The Pulp &
Investing structure Of the lower anterior teeth ( 1 , 2 , 3 )
❖ INFERIOR ALVEOLAR NERVE :
The Pulp &Investing structure of the lower premolars (4 ,5 )
& molar teeth (6 ,7 ,8 )
❖ LONG BUCCAL NERVE :
Buccal mucoperiosteum of the lower molars ( 6 ,7 , 8 ) .
❖ LINGUAL NERVE : Lingual mucoperiosteum of the all lower
teeth ( 1 , 2 , 3 , 4 , 5 , 6 , 7 ,8 )
 Oral surgery Al-ameed University
3th stage Part – 1 - College of dentistry
St.n: ‫احمد حسن جاسم‬
[mandibular nerve block intraoral and extraoral technique]

INTRAORAL NERVE BLOCK TECHNIQUES

➢ CLASSICAL INFERIOR ALVEOLAR NERVE BLOCK

Indication : Analgesia for surgical & operative

dentistry on mandibular teeth & supporting structures,
Diagnostic & Therapeutic purposes

Nerve anesthetized :Inferior alveolar nerve ,Mental.N

,Incisive.N, Lingua N. commonly

●Area anesthetized:
1. Mandibular teeth to the midline
2. Body of the mandible, inferior portion of the ramus.
3. Buccal mucoperiosteum, mucous membrane anterior
to the mental foramen (mental nerve).
4. Anterior two thirds of the tongue and floor of the oral
cavity (lingual nerve).
5. Lingual soft tissues and periosteum (lingual nerve).

Technique:
1. A 25 gauge long needle is preferred.
2. Area of insertion : Mucous membrane on the medial side of
the ramus of the mandible, at the intersection of two lines-
• One horizontal representing the height of needle insertion
• The other vertical ,representing the antero-posterior plane
of injection.
3. Target area : inferior alveolar nerve as it passes downwards
to the mandibular foramen but before it enters into the
foramen.
4. Landmarks:
• Coronoid notch (greatest concavity on the anterior border
of the ramus)
• Pterygomandibular raphe (vertical portion )
• Occlusal plane of the mandibular posterior teeth
Procedure
1-Assume the correct position
• For a right IANB , 8 o’clock position facing the pt.
• For a left IANB, 10 o’clock position facing in the
same direction as the patient.

2. Position the patient in a supine or a semisupine

position.
Open the mouth wide to allow greater visibility and access
3. Three parameters must be considered during the administrations of IANB:
• Height of injection
• Anteroposterior placement of the needle
• Depth of penetration

ADVANTAGES:
●Wide area of Anesthesia
DISADVANTAGES:
● Wide area of anesthesia
● Inadequate anesthesia
● +ve aspiration(10% to 15%)
● Intra oral landmarks
● Lingual & lower lip anesthesia
● Partial anesthesia-bifid mandible canals.

Penetration depth
1-Slowly advance the needle until you
can feel a bony resistance.
2. The average depth of penetration to
bony contact will be 20-25 mm,
approx. 2/3 or ¾ the length of the
long dental needle.
3. Needle tip should be located slightly
superior to the mandibular foramen
When the bone is contacted , withdraw approx. 1mm to prevent subperiosteal injection.
5. Aspirate in two planes. If negative , slowly deposit 1.5ml of anesthetic over a
minimum of 60 seconds.
6. Slowly withdraw the syringe , and when half of its length remains within the
tissues, reaspirate. If negative , deposit 0.2ml of the remaining solution to
anesthetize the lingual nerve.
• In most patients this is not necessary as the LA from the IANB anesthetizes the
lingual nerve.
7. Withdraw the needle and make the needle safe.
Oral surgery Al-ameed University
3th stage Part – 2 - College of dentistry
St.n: ‫عبد هللا عباس علي‬
[mandibular nerve block intraoral and extraoral technique]

INTRAORAL NERVE BLOCK TECHNIQUES

❖ Height injection of IANB

1. Place the index finger or the thumb of your
left hand in the coronoid notch.
2. An imaginary line extends posteriorly from the
fingertip in the coronoid notch to the deepest
portion on the Pterygomandibular raphe.
3-This imaginary line should be parallel to the occlusal
plane of the mandibular molar teeth and lies
6-10 mm above the occlusal plane in most patients.

❖ Anteroposterior site of injection

It is three fourths of the anteroposterior
distance from the coronoid notch back to the deepest part of the Pterygomandibular raphe.
Prepare tissue at the injection site and place the barrel of syringe in the corner of the mouth
on the contralateral side , usually corresponding the premolars.

❖ Failure of anesthesia
The most common causes of absent or incomplete IANB are :
1. Deposition of anesthetic too low , below the mandibular foramen.
2. Deposition of anesthetic too far anteriorly (laterally) on the ramus.
3. Accessory innervation to the mandibular teeth.
• Several nerves provide the mandibular teeth with accessory innervation but
mylohyoid nerve acts as the prime candidate.
4. Incomplete anesthesia of central and lateral incisor.
• This is due to overlapping fibers of the contralateral inferior alveolar nerve

❖Complications
1- HEMATOMA
• Swelling of tissues on the medial side of the
mandibular ramus after deposition of anesthetic
2. TRISMUS
• Muscle soreness or limited movement
• A slight degree of soreness when opening the
mandible is common
• More severe soreness is rare
3. TRANSIENT FACIAL NERVE PALSY
• Produced by deposition of local anesthesia into
the body of the parotid gland, blocking the VII
cranial nerve.
• Signs and symptoms include inability to close
the lower eyelid and drooping of upper lip on
the effected side
ANATOMIC VARIATIONS
Mandible
- Mandibular foramen in children 4 years old and less
is below the plane of occlusion.
- The foramen moves superiorly in the ramus with the
eruption of 6’s.
Oral surgery Al-ameed University
3th stage Part – 3 - College of dentistry
St.n:‫سيف عايد هاشم‬
[mandibular nerve block intraoral and extraoral technique]

INTRAORAL NERVE BLOCK TECHNIQUES

❖ BLOCK OF TERMINAL BRANCHES

A-LONG BUCCAL NERVE BLOCK

Nerve anesthetised:Buccal branch of anterior division of V3
●Area anesthetized: buccal mucous membrane& mucoperiosteum of mandibular
molars.
●Indication : surgery of mandibular buccal mucosa & adjunct to IANB
●Technique: Inserted into buccal mucosa distal to 3rd molar.
Insert approx. 2 mm, aspirate. 25-27 gauge needle

●alternative : into retromolar triangle

●Symptoms : instrumentation
■Infiltration in the buccal sulcus distal
to permanent molar tooth
●Amount deposited-0.2-0.5 ml.( slowly)
Complication
• Hematoma (unusual)
Positive aspiration
• 0.7 %

B-MENTAL NERVE BLOCK

Nerve anesthetized: Mental nerve
Area anesthetized :lower lip Mucolabial fold anterior to the mental foramen
Anatomical landmarks: mandibular bicuspids
Indication : procedures where manipulation of buccal
soft tissue anterior to the mental foramen is necessary.
Contraindications : acute inflammation and infection
over the injection site.
Technique:
•Mental foramen lies below the apex of the 2nd
premolar or between the two premolars.
•It faces posteriorly & thus when making an
injection the approach should be from behind
•Mental foramen palpated.
Symptoms : Tingling & Numbness of lower lip
Advantage : No loss of lingual sensation –
better for children.
Complication: Hematoma ,partial anesthesia of central & lateral incisors.
C-INCISIVE NERVE BLOCK
●Nerve anesthetized: Incisive & Mental nerve
●Area anesthetized :Lower lip, Mandible &Overlying structures
anterior to mental foramen ,Bicuspids , Cuspids &
Incisors.
Anatomical landmarks: Mandibular bicuspids
Indication : Structures anterior to mental foramen,
cases where IANB is contraindicated .
Contraindications : acute inflammation & infection
over the injection site.
Technique: same as mental nerve block. Anesthetic
solution to be penetrated into mental foramen
Symptoms : Sub: Numbness & tingling
Obj:Anesthesia of anterior teeth & structures on instrumentation
Complication :hematoma.
Positive aspiration 5.7
Oral surgery Al-ameed University
3th stage Part – 4 - College of dentistry
St.n: ‫مقتدر احمد حبيب‬
[mandibular nerve block intraoral and extraoral technique]

INTRAORAL NERVE BLOCK TECHNIQUES

❖ BLOCK OF TERMINAL BRANCHES

D-LINGUAL NERVE BLOCK
Nerve anesthetized :Lingual nerve
Area anesthetized: Anterior 2/3rd of tongue, floor of oral
cavity & mucoperiosteum on lingual side of mandible
Indication : surgery of anterior 2/3rd of tongue, floor of
oral cavity & mucoperiosteum on lingual side of mandible
Technique: same as IANB
Symptoms : sub:numbness & tingling
Obj:Anesthesia of anterior teeth & structures
on instrumentation
TECHNIQUES TO BLOCK LINGUAL NERVE
Blocking lingual nerve at the same time as an intraoral inferior dental injection by
depositing 0.5ml of solution after the needle has been inserted for approx. 1cm By
giving submcosal infiltration of 0.5 ml few millimeters below and behind the region of
the lower 3rdmolar on its lingual aspect. Infiltration immediately lingual to the gingiva or
mucosa to be treat.
❖ Mandibular nerve block
The entire mandibular branch of the trigeminal nerve is anesthetized. The mandibular
nerve could be blocked by:
• Intra-oral approach as in Gow-Gates mandibular nerve block and Akinosi (closed
mouth) mandibular nerve block.This technique is indicated when the conventional
inferior alveolar nerve block is unsuccessful.
GOW GATES TECHNIQUE
Nerve anesthetized: inferior
alveolar,mental,incisive,lingual,mylohyoid,auriculotemporal,buccal.
Area anesthetized: mand. teeth to midline, buccal & lingual mucoperiosteum &
mucous membrane, ant. 2/3rd of tongue, floor of oral cavity, skin over the zygoma,
posterior portion of cheek& temporal region.
Indication: multiple procedure on mandible,
buccal soft procedures from third molar to
midline, lingual soft tissue anesthesia, IANB
unsuccessful. Diagnosis of facial pain
Contraindication
Infection & acute inflammation& site, young
patients, trismus
LANDMARKS
Extraoral :External ear, Intertragic notch Corner of the mouth.
Intraoral: Tendon of temporal muscle ,Anterior border of the ramus,
Mesiolingual cusp of maxillary 2nd molar.
➢ The patient mouth should be wide open,supine position .Needle is inserted at a
point lateral to the pterygomandibular depression but medial to the temporal
tendon on a plane from the corner of the mouth to intertragic notch.
TECHNIQUES:
➢ Position the patient
➢ Locate extra oral landmarks
➢ Visualize intraoral landmarks
➢ Prepare tissues at site of penetration
➢ Direct the syringe
➢ Insert the needle
➢ Align the needle with the plane.
➢ Slowly advance the needle.
➢ Depth of penetration:25mm.
➢ Withdraw the needle 1mm.
➢ Aspirate: if –ve slowly deposit 1.8ml in 60-90 secs
➢ Withdraw the syringe.
➢ Request the pt. to keep mouth open for 1-2mins .
➢ Upright position.
➢ Wait for 3-5mins before starting dental procedure.
Oral surgery Al-ameed University
3th stage Part – 5 - College of dentistry
St.n: ‫حسين جاسب رسن‬
[mandibular nerve block intraoral and extraoral technique]
❖ Mandibular nerve block
VAZIRANI- AKINOSI TECHNIQUE CLOSED MOUTH
MANDIBULAR BLOCK
Indication: Patient unable to open mouth.
Contraindication: Where trismus is present due to
infection in the tissues through which a needle would
have to pass.
Landmarks
• Occlusal plane of occluding teeth.
• mucogingival Junction of the maxillary molar teeth.
• Anterior border of the ramus.

■The needle is placed parallel to the gingival margins of

the maxillary teeth or to the alveolar ridge in the
edentulous patient.
■The point of insertion is the mucosa, pterygomandibular
fold, buccinator and buccal aponeurosis on the inner
aspect of the ascending ramus to reach the
pterygomandibular space.

EXTRAORAL NERVE BLOCK TECHNIQUES

❖ Extraoral Mandibular Nerve Block
Nerves anesthetized
*Mandibularnerve and subdivisions *Inferior alveolar nerve *Buccinator nerve *Lingual
nerve*Mental nerve *Incisive nerve
Areas anesthetized
All those areas innervated by the mandibular nerve and its subdivisions
Temporal region , Auricle of the ear , External auditory meatus
Temporomandibular joint , Salivary glands,Anterior 2/3 of the tongue
, Floor of the mouth, Mandible , Lower teeth, gingiva, and
buccal mucosa. Lower portion of the face (except at the angle of the jaw)
Indications
A. When it is desirable to anesthetize the entire mandibular nerve
and its subdivisions with one needle insertion and a minimum of anesthetic solution.
B. When infection or trauma makes anesthesia of the nerve’s
subdivisions difficult or impossible.
C. Diagnostic or therapeutic purposes.
Technique
With a 25-gauge hypodermic needle, a skin wheal is raised just below this mark in the
depression, which the dentist identifies by having the patient open
and close the jaw. Using a 4-inch (8.8 cm), 22-gauge needle attached to a Luer-Lok
type of syringe, one measures 5 cm and marks with a rubber marker.
After the needle contacts the lateral pterygoid plate, when
reinserted, the needle is directed upward and slightly posteriorly so
that the needle will pass posterior to the lateral pterygoid plate.
The needle should not be introduced to a depth greater than the
measured 5 cm.
The structures through which the needle passes and the structures
adjacent to the needle when it is in contact with the lateral
pterygoid plate are given in the section on the maxillary nerve block.
Symptoms of Anesthesia
a. Subjective symptoms
Tingling and numbness of the lower lip and anterior 2/3 of the tongue
b. Objective symptoms
Opening of the mandible and tapping of the jaws shut will
demonstrate a decided difference in the feeling of the lower teeth
and the floor of the mouth. Instrumentation will also demonstrate
the presence of anesthesia.

Extraoral Mental and Incisive Nerve Block

Nerves Anesthetized : Mental Nerve Incisive Nerve
Areas Anesthetized
• Lower Lip.
• Mandible and overlying buccal and labial
structures anterior to the mental foramen .
• Mandibular teeth anterior to the mental foramen
Anatomical Considerations
Bicuspid teeth , Lower edge of body of mandible
Supra orbital notch, Infra orbital notch, Pupil of Eye
Indications
When anesthesia of the mandibular teeth and labia; and buccal
supporting structures anterior to the mental foramen or lower lip is
desired and a block of the inferior alveolar nerve is contraindicated.
Technique
Patient should close the mouth in a normal position and ;look
straight forward.The supraorbital notch and the infraorbital notch are palpated
and located. With the patient looking straight forward , an imaginary line
drawn . From the supraorbital notch or foramen through the pupil of the
eye and the infraorbital notch or foramen will , if continued pass
through the mental foramen.
After the skin wheal is raised at this point , a 2 inch , 22 gauge
needle is introduced in a slightly anterior and downward direction.
With gentle probing , the mental foramen should be located and
entered. One milliliter of anesthetic solution should be adequate
to produce satisfactory anesthesia.
When the mental block via the extraoral approach is being
executed , the needle passes through the following structures-
Skin ، Subcutaneous tissue، Triangular is muscle.

Thanks
 Subject parts name

Intraoral mandibular nerve block Part ‫احمد حسن جاسم‬ 1

1
CLASSICAL IANB
Height injection of IANB Part ‫عبد هللا عباس‬ 2
2
Failure of anesthesia IANB
Complications of IANB
BLOCK OF TERMINAL Part ‫سيف عايد هاشم‬ 3
3
BRANCHES ‫جوده‬
Long buccal nerve block
mental nerve block
Incisive nerve block
LINGUAL NERVE BLOCK Part ‫مقتدر احمد حبيب‬ 4
4
Mandibular nerve block (GOW
GATES TECHNIQUE )

VAZIRANI- AKINOSI Part ‫حسين جاسب‬ 5

5
TECHNIQUE ‫رسن‬

Extraoral mand.nerve block

techniques

Reference
• Stanley F . Mablamed . Handbook of local anesthesia ,6th
ed,capter 14, page No. 1-61•
• Bennett, CR: Techniques of regional anesthesia and analgesia.
In Bennett, CR (Ed.): Monheim's
• local anesthesia and pain control in dental practice. ed 7, 1984,
CV Mosby, St Louis.
• Google images