Mandibular Anesthesia Techniques – Flashcards
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Why is it challenging to achieve successful pulpal anesthesia in the mandible? (3)
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1. greater density of bone 2. limited accessibility to targeted nerve 3. wide variation of anatomy 80-85% success rate, compared to 95% in maxilla
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Six nerve blocks utilized for mandibular anesthesia
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1. Inferior alveolar nerve block 2. Incisive nerve block 3. Gow-Gates mandibular block 4. Varizani-Akinosi mandibular block 5. Mental nerve block 6. Buccal nerve block (1-4 pulpal anesthesia, 5-6 soft tissue only)
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Injection technique most frequently used?
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Inferior alveolar nerve block
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Highest percentage of clinical failures?
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Inferior alveolar nerve block
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Is mandibular block an accurate term for the IAN?
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No, it anesthetizes the IAN, incisive, mental and lingual nerves
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IAN: where does it provide anesthesia?
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- mandibular teeth to the midline - body of the mandible - inferior portion of the ramus - buccal mucoperiosteum - mucous membrane anterior to the mandibular first molar (mental nerve) - anterior 2/3s of tongue and floor of the oral cavity (lingual nerve) - lingual soft tissues and periosteum (lingual nerve)
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IAN: Indications (3)
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1. procedures involving multiple mandibular teeth in one quadrant 2. the involvement of the lingual soft tissue 3. the involvement of the buccal (anterior to the first molar) soft tissue
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IAN: Contraindications (1)
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- infection or acute inflammation in the area of injection
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IAN: Advantage (1)
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- very useful in one quadrant dentistry
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IAN: Disadvantages (6)
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1. not good for procedures involving a small area 2. relatively high rate of inadequate anesthesia 3. intraoral landmarks are not always consistent 4. highest incidence of positive aspiration 5. may be uncomfortable due to numbness of lip and tongue 6. may be bifid IAN, mandibular canal may result in partial anesthesia
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IAN: Landmarks (3)
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1. coronoid notch (primary landmark) 2. occlusal plane of the mandibular posterior teeth 3. pterygomandibular raphe
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IAN: Needle used
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25 gauge or 27 gauge long needles
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IAN: Area of Insertion
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Medial side of the ramus
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IAN: Target Area
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IAN before it enters the mandibular foramen
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IAN: Needle Penetrations Depth
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- needle must contact bone - 20-25mm (2/3 of long needle)
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IAN: What if need contacts bone too soon?
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- needle is too far anteriorly on the ramus (lingula will prevent anesthetic from reaching IAN) - adjust the direction of the needle more posterior
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IAN: What if bone isn't contacted and the entire needle is embedded?
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- needle to far posterior - adjust the direction of the needle more anterior
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IAN: How much anesthetic is deposited?
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- a whole carpule (1.8ml)
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IAN: How long to wait before starting procedure?
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- 3-5 min
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IAN: Signs and Symptoms of Success (3)
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1. tingling or numbness of the lower 2. tingling or numbness of the tongue 3. no pain felt during therapy
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IAN: Common causes of failed anesthia (4)
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1. anesthesia deposited too low in relation to the mandibular foramen 2. anesthesia deposited too far anteriorly 3. cross innervation (especially of the anterior teeth) 4. presence of bifid IAN
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IAN: What do you do if there is failure due to cross innervation?
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- supplemental infiltration in the area of the central incisors
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Buccal Nerve Block: What does it innervate?
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- long buccal nerve: soft tissues and periosteum buccal to the mandibular molars - does NOT anesthetize the lower lip (can be given after IAN and won't interfere with tingling lip that shows IAN was successful)
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Buccal Nerve Block: Indications
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- when dental procedure involves the buccal soft tissue in the mandibular molar region
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Buccal Nerve Block: Contraindications
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- infection or acute inflammation in the are of injection
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Buccal Nerve Block: Advantages (2)
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1. high success rate 2. technically easy
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Buccal Nerve Block: Disadvantage
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- potential pain if the needle contacts periosteum during injection
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Buccal Nerve Block: Landmarks (2)
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1. mandibular molars 2. mucobuccal fold
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Buccal Nerve Block: Needle used
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- 25 gauge or 27 gauge short needle
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Buccal Nerve Block: Area of Insertion
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- mucous membrane distal and buccal to the most distal molar tooth in the arch
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Buccal Nerve Block: Target Area
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- buccal nerve as it passes over the anterior border of the ramus
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Buccal Nerve Block: Depth of penetration
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- rarely more than 2-4 mm - will contact bone
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Buccal Nerve Block: How much anesthetic used
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- 1/8th of carpule (.3ml)
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Buccal Nerve Block: How long to wait until you start procedure
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- 1 minute
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Buccal Nerve Block: Signs and Symptoms of Success (2)
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1. patients rarely feel obvious subjective symptoms 2. instrumentation in the area without pain
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Buccal Nerve Block: Common cause of failed anesthesia
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- inadequate volume of anesthetic
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Mandibular Nerve Block: Gow-Gates Technique
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- true mandibular block bc it provides anesthesia to almost all of V3: IAN lingual mylohyoid mental incisive auricolotemporal buccal -larger area than IAN
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Gow-Gates: Indications (3)
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1. when an IAN block is unsuccessful 2. when more profound mandibular anesthesia is needed (ex. patients jaw is locked open) 3. as an alternative to the traditional IAN block
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Gow-Gates: Contraindications (2)
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1. presence of infection or inflammation in the area of injection 2. patients who are unable to open their mouth wide
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Gow-Gates: Advantages (5)
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1. only one injection for large area 2. high success rate 3. minimum aspiration rate 4. few post-injection complications 5. successful anesthesia where bifid IAN and mandibular canals are present
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Gow-Gates: Disadvantages (2)
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1. high learning curve due to injection difficulty 2. time of onset is longer
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Gow-Gates: Landmarks (3)
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Extraoral 1. lower border of the tragus 2. corner of the mouth Intraoral 3. mesiolingual cusp of the maxillary second molar or third molar if present
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Gow-Gates: Needle used
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- 25 gauge or 27 gauge long needles
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Gow-Gates: Area of insertion
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- mucous membrane on the mesial of the mandibular ramus on a line from the intertragic notch to the corner of the mouth, just distal to the maxillary second molar
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Gow-Gates: Target Area
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- lateral side of the condylar neck, just below the insertion of the lateral pterygoid muscle
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Gow-Gates: Signs and Symptoms (2)
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1. tingling and numbness of lower lip and tongue 2. no pain during dental procedure
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Gow-Gates: Common causes of failed anesthesia (2)
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1. too little anesthesia (volume) 2. anatomical variations resulting in injection away form intended target
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Akinosi Closed Mouth Mandibular Block
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- used primarily where there is limited mandibular opening
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Akinosi: What does it anesthetize? (5)
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IAN incisive mental lingual mylohyoid
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Akinosi: Indications (2)
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1. limited mandibular opening 2. inability to visualize landmarks for IAN block
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Akinosi: Advantages (5)
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1. relatively atraumatic 2. patient does not need to open mouth 3. lesser trismus occurrence 4. lower aspiration rate 5. provides successful anesthesia where bifid IAN or mandibular canals are present
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Akinosi: Disadvantages (3)
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1. difficult to visualize the path of needle and the depth of insertion 2. no bony contact (depth is arbitrary) 3. potential traumatic if the needle is too close to periosteum
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Akinosi: Landmarks (3)
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1. mucogingival junction of the maxillary third molar 2. maxillary tuberosity 3. coronoid notch of the mandibular ramus
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Akinosi: Needle used
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- 25 gauge or 27 gauge long needle
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Akinosi: Area of Insertion
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- soft tissue overlying the medial border of the mandibular ramus directly adjacent to the maxillary tuberosity at the height of the mucogingival junction adjacent to the maxillary third molar
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Akinosi: Signs and Symptoms (2)
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1. tingling and numbness of the lower lip, tongue 2. no pain felt during dental treatment
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Akinosi: Common causes of failed anesthesia (3)
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1. needle directed too medially 2. needle insertion point too low 3. underinsertion and over insertion is common due to the soft tissue penetration is arbitrary
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Lingual Nerve Block
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- located in the proximity of the IAN - anesthetized nearly 100% of the time when the IAN, Gow-Gates or Akinosi blocks are given
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Mental Nerve Block
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- used mainly for buccal soft tissue procedures involving mucosa anterior to the mental foramen to the midline, and the lower lip and chin as well - anesthetizes the mental nerve
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Mental Nerve Block: Indications (3)
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1. periodontal procedures limited to the area supplied by the mental nerve 2. soft tissue biopsies on the area supplied by the mental nerve 3. suturing of soft tissues
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Mental Nerve Block: Contraindication
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- infection or inflammation in area of injection
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Mental Nerve Block: Advantages (3)
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1. high success rate 2. technically easy 3. usual atraumatic
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Mental Nerve Block: Disadvantage
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- hematoma, lots of blood vessels
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Mental Nerve Block: Landmarks (2)
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1. mandibular premolars 2. mucobuccal fold
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Mental Nerve Block: Needle used
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-25, 27 or 30 gauge short needle
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Mental Nerve Block: Area of Insertion
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- mucobuccal fold at or just anterior to the mental foramen
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Mental Nerve Block: Target Area
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- mental nerve as it exits the mental foramen
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Mental Nerve Block: How deep is needle penetration?
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- 5-6mm - needle may be parallel to long axis of tooth or 45 degrees
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Mental Nerve Block: How much anesthesia is deposited?
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- .6ml
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Mental Nerve Block: How long to wait before starting procedure?
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- 2-3 minutes
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Mental Nerve Block: Signs and Symptoms (2)
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1. tingling and numbness of lower lip 2. no pain during dental procedure
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Incisive Nerve Block
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- anesthetizes mental and incisive nerve: buccal mucous membrane anterior to the mental foramen lower lip and skin of chin pulps of the premolars, canines and incisors - rarely used bc IAN does everything anyways
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Incisive Nerve Block: Indications (2)
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1. when IAN is not indicated due to not needing mandibular molars anesthetized 2. supplement to IAN block if anesthesia not profound in mand. ant. region
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Incisive Nerve Block: Contraindication
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- infection or inflammation in the area of injection
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Incisive Nerve Block: Advantage
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- provides pulpal and hard tissue anesthesia without lingual anesthesia
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Incisive Nerve Block: Disadvantages (2)
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1. if anesthesia for the lingual surface is needed, another injection has to be done 2. local infiltration of the buccal of the mandivular central incisors may also be necessary
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Incisive Nerve Block: Landmarks (2)
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1. mandibular premolars 2. mucobuccal fold
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Incisive Nerve Block: Needle used
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- 25, 27, 30 gauge short needle
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Incisive Nerve Block: Area of Insertion
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- mucobuccal fold at or just anterior to the mental foramen
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Incisive Nerve Block: Target Area
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- mental foramen
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Incisive Nerve Block: Depth of needle penetration
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- 5-6mm
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Incisive Nerve Block: How much solution is deposited?
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- .6ml of 20 seconds
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Incisive Nerve Block: How long to wait before starting procedure
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- maintain pressure on injection site for 2 min - wait another 3 min before starting procedure
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Incisive Nerve Block: Signs and Symptoms (2)
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1. tingling and numbness of the lower lip 2. no pain during the dental procedure
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Incisive Nerve Block: Common causes of failed anesthesia (3)
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1. inadequate volume of anesthetic solution 2. inadequate duration of pressure following injection 3. solution not deposited close enough to the foramen
