INFERIOR ALVEOLAR NERVE

BLOCK
Fig. 18.5: Pterygomandibular
nerve block. Direct technique.
NERVES ANESTHETIZED
1. Inferior alveolar nerve
2. Mental nerve
3. Incisive nerve
4. Lingual and buccinator nerves
AREAS ANESTHETIZED
1. Body of the mandible
and an inferior portion
of the ramus.
2. Mandibular teeth
3. Mucous membrane
and underlying tissues
anterior to the first
mandibular molar
ANATOMICAL LANDMARKS
1. Mucobuccal fold
2. Anterior border of ramus of the mandible
3. External oblique ridge
4. Retromolar triangle
5. Internal oblique ridge
6. Pterygomandibular ligament
7. Buccal sucking pad
8. Pterygomandibular space
INDICATIONS

1. Analgesia for operative dentistry on all the

mandibular teeth.
2. Surgical procedures on mandibular teeth and
supporting structures anterior to the first molar
when supplemented by anesthesia of the lingual
nerve.
3. Surgical procedures on mandibular teeth and
supporting structures posterior to the second
bicuspid (if supplemented by anesthesia of the
lingual nerve and buccinator nerves).
4. Diagnostic and therapeutic purpose.
NEEDLE PATHWAY DURING INSERTION
 The needle passes
through mucosa, a thin
plate of the buccinator
muscle, loose
connective tissue and a
variable amount of fat.

17, buccinator muscle

10, IA nerve
APPROXIMATING STRUCTURES WHEN
NEEDLE IS IN POSITION

A. Superior to the following:

1. Inferior alveolar vessels
2. Inferior alveolar nerve
3. Insertion of the medial pterygoid muscle
4. Mylohyoid vessels
5. Mylohyoid nerve
B. Anterior to the deeper lobe of the parotid gland
C. Medial to the medial surface of ramus of the
mandible
D. Lateral to the following:
1. Lingual nerve
2. Medial pterygoid muscle
3. Sphenomandibular ligament
Dissection of the right infratemporal
fossa on a horizontal section showing
the needle at the injection site for the
inferior alveolar block. 1, Coronoid notch
(superior to external
oblique ridge); 2, mylohyoid line; 3,
lingula; 4, mandibular foramen;
5, parotid salivary gland; 6, styloid
process; 7, maxillary artery; 8,
IA vein; 9, IA artery; 10, IA nerve; 11,
lingual nerve; 12,
sphenomandibular ligament; 13,
medial pterygoid muscle; 14, long
buccal nerve; 15, temporalis muscle; 16,
pterygomandibular raphe;
17, buccinator muscle; 18, masseter
muscle; 19, mandibular ramus;
20, buccal fat pad; 21, tongue
POSITION OF ADMINISTRATOR

(A) right and (B) left inferior alveolar nerve block.

TECHNIQUE FOR RIGHT INFERIOR
ALVEOLAR NERVE

a) If the patient is in a dental chair, the head

should be positioned so that when the mouth is
open, the body of the mandible is parallel to the
floor.
b) The operator stands to the right front side of the
patient and with the left index finger or thumb
palpates the mucobuccal fold.
c) The finger or thumb is then moved posteriorly
until contact is made with the external oblique
ridge on the anterior border of the ramus of the
mandible.
 TECHNIQUE FOR RIGHT INFERIOR
ALVEOLAR NERVE
d) When the finger or thumb contacts
the ramus of the mandible, it is moved
up and down until the greatest depth
of the anterior border of the ramus is
identified. This area of greatest depth
is called the coronoid notch and is in a
direct line with the mandibular
sulcus. This places the height of the
mandibular sulcus.
e) The palpating finger is moved
lingually across the retromolar
triangle and onto the internal oblique
ridge.
f) The finger or thumb, still in line with
the coronoid notch and in contact with
the internal oblique ridge, is moved to
the buccal side, taking with it the
buccal sucking pad. This gives better
exposure to the internal oblique ridge,
the pterygomandibular raphe, and the
pterygotemporal depression.
 TECHNIQUE FOR RIGHT INFERIOR
ALVEOLAR NERVE
g) When palpating the intraoral landmarks
with the thumb, the operator may place
the index finger extraorally behind the
ramus of the mandible, thus literally
holding the mandible between the thumb
and index finger. In this manner the
anteroposterior width of the ramus may be
assessed.

h) A syringe with a 1 5/8 inch, 25- gauge

needle is then inserted parallel to the
occlusal plane of the mandibular teeth
from the opposite side of the mouth, at a
level bisecting the finger or thumbnail,
penetrating the tissues of the
pterygotemporal depression and entering
the pterygomandibular space. One can
best determine the depth of the needle
penetration by estimating half the
distance between the palpating left thumb
and index finger.
 TECHNIQUE FOR RIGHT INFERIOR
ALVEOLAR NERVE
i) During insertion, the patient is asked to keep
the mouth wide open. The needle is
penetrated into the tissues until gently
contracting bone on the internal surface of
the ramus of the mandible. This could be in
the area of the mandibular sulcus, which
funnels into the mandibular foramen.

j) The needle is then withdrawn about 1mm,and

1 to 1.8ml of solution is deposited slowly(1 ½
to 2 minutes).

k) The needle is now withdrawn slowly, and

when about one half of its inserted depth has
been withdrawn, the remainder of the
solution is injected in this area to anesthetize
the lingual nerve. In many instances the
deliberate injection of the anesthetic solution
to anesthetize the lingual nerve is
unnecessary because diffusion of the initially
injected solution will also anesthetize the
lingual nerve.
TECHNIQUE FOR LEFT INFERIOR
ALVEOLAR NERVE

 Same patient position

 Operator stands at the
right side and slightly
toward the back of
patient
 The left arm of the
dentist is placed around
the patients’s head so
that the landmarks
may be palpated with
the left index finger or
thumb.