Mandibular Anesthetic Techniques

Hesham El-Hawary
Lecturer OMFS
Cairo University
www.elhawarydentalclinic.com

ELHAWARY
Types of mandibular injections
Anterior labial
infl anesth

Infiltration Anterior lingual

anesthesia inf anesth

Long buccal inf

anesth
Mandibular
anethesia
IA and L NB

Nerve block
Mental NB
anesthesia

Long Buccal
NB

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 The mandibular nerve
1. Main Trunk
2. Nervous Spimosum
3. Nerve to medial pterygoid
4. Anterior Division
1. N. to Temporalis msc.
2. N. to Massetter msc.
3. N. to Lateral Pterygoid
msc.
4. Long Buccal N.
5. Posterior Division
1. Auriculo-temporal N.
2. Lingual Nerve
3. Inferior Alveolar N.
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Nerve supply to mandibular teeth

Pulp , Investing structures

Anterior teeth
(1,2,3) Incisive nerve

Premolars (4,5) &

Molars (678) Inferior alveolar nerve

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Nerve supply to mandibular teeth
Cont.
Labial (buccal) mucoperiosteum
Mental nerve
Anterior teeth
(1,2,3) Cutaneous coli nerve
& ( branch of cervical plexus C2 & c3 )
gives additional sensory supply for
Premolars (45)
premolars ( 4 , 5 ) in about 20 % pt.
Molars (678) Long buccal nerve

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Nerve supply to mandibular teeth
Cont.

Lingual mucoperiosteum

Anterior teeth
(1,2,3) Premolars Lingual nerve
(4,5) & Molars (678)

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The accessory innervation of Mandibular teeth

The lower anterior teeth cross innervation

may take place i.e. branch from the
incisive nerve of the other side
The lower premolar may receive additional
nerve supply from the cutaneous coli
nerve (branch from the cervical plexus of
nerves)
The lower molars may receive additional
nerve supply from the nerve to mylohyoid
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Mandibular Anesthetic Techniques

Infiltration Anesthesia

Anteriors Labial Infiltration

anesthesia

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Anteriors Labial infiltration anesthesia
Nerve to be anesthetized
Incisive Nerve
Inferior dental plexus

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Anteriors Labial infiltration anesthesia
Patient position Dentist position
Head , neck and trunk on the From infront and to the
same straight line right
The back of the chair is tilted so
that it make a 45 degree angle
with the floor
So that when the patient open his
mouth the occlusal plane of the
mandibular teeth becomes
parallel to the floor
The occlusal plan of mandibular
teeth near to the operators
elbow

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Anteriors Labial infiltration anesthesia
Cont.

Needle:
25-27 gauge
Short needle
Syringe
Non-Aspirating syringe
The target area
The apical region of the tooth to be anesthetized

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Anteriors labial Infiltration Anesthesia
Cont.

The point of needle insertion

The point of intersection of 2
imaginary lines
1st line is a vertical line
parallel to the long axis of
the tooth
2nd line is a horizontal line
along the mucobuccal fold

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Anteriors Labial Infiltration Anesthesia
Cont.

Direction of needle insertion

45 with the buccal cortical
plate of bone

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 Steps for Labial infiltration
The lip/cheek is retracted using dental mirror or your
finger to make almost a right angle with the
labial/buccal aspect of the jaw
The point of insertion is determined as mentioned
The needle is inserted with its bevel toward the bone
and making an angle of 45 with the buccal aspect
The needle is pushed through the soft tissue until
the bone is reached (within 2mm)

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Steps for Labial infiltration Cont.
The needle is held firmly and 1.5cc of the solution is
slowly deposited for buccal/labial injection, and 0.3
cc for lingual anesthesia
The needle is then withdrawn gently and recap it

Wait 2-3 minutes before starting your dental

procedure

Check your anesthesia using the dental probe

(objective finding)
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 Confirming the Anesthesia
Subjective findings
Numbness of the lower lip
Objective findings
Probing does not lead to pain

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Mandibular Anesthetic Techniques

Infiltration Anesthesia

Anteriors lingual Infiltration Anesthesia

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 Lingual Infiltration Anesthesia
Nerve to be anesthetized
Terminal branches of the lingual nerve

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 Anteriors Lingual infiltration
anesthesia
Patient position Dentist position
Head , neck and trunk on the From infront and to the
same straight line right except when
The back of the chair is tilted so anesthetizing the lower left
that it make a 45 degree angle
with the floor
anterior teeeh the operator
So that when the patient open his
stands in the right rear
mouth the occlusal plane of the position
mandibular teeth becomes
parallel to the floor
The occlusal plan of mandibular
teeth near to the operators
elbow

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Anteriors Lingual infiltration anesthesia
Cont.

Needle:
25-27 gauge
Short needle
Syringe
Non-Aspirating syringe
The target area
Apical to the tooth to be anesthetized lingually

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Anteriors Lingual Infiltration Technique
Cont.

The point of needle insertion

Above the The point of intersection of 2 imaginary lines

1st line is a vertical line parallel to the long axis of the tooth
2nd line is a horizontal line above the floor of the mouth
(mucolingual fold)
By 2-3 mm
i.e. 3-5 mm cervical to the free gingival margin along the long axis of
the tooth

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Anteriors lingual Infiltration Technique
Cont.

Direction of needle insertion Direction of needle insertion

in left side in right side

DIRECT VISION TECHNIQUE: INDIRECT VISION TECHNIQUE:

The syringe is directed from The syringe is directed from the

the corner of the mouth of the corner of the mouth from the left
rt. Side side

The bevel towards the bone Bevel towards bone

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 Steps for Anteriors Lingual
infiltration
The tongue is retracted and the light is reflected using dental
mirror held in the left hand
The point of insertion is determined as mentioned
The needle is inserted with its bevel toward the bone
Direction: As mentioned before in Left/Right sides
The needle is pushed through the soft tissue until the bone is
reached (within 2mm)
Administer 0.2-0.3ml of anesthetic sol

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 Steps for Lingual infiltiration
Cont.
The needle is then withdrawn gently and recap it

Wait 2-3 minutes before starting your dental

procedure

Check your anesthesia using the dental probe

(objective finding)

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 Confirming the Anesthesia
Subjective findings
No Subjective findings
Objective findings
Probing does not lead to pain

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Mandibular Anesthetic Techniques

Infiltration Anesthesia

Long Buccal Infiltration anesthesia

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Long buccal infltration anesthesia
Nerve to be anesthetized
Terminal parts of the long buccal nerve

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 Long Buccal infiltration anesthesia
Patient position Dentist position
Head , neck and trunk on the From infront and to the
same straight line right
The back of the chair is tilted so
that it make a 45 degree angle
with the floor
So that when the patient open his
mouth the occlusal plane of the
mandibular teeth becomes
parallel to the floor
The occlusal plan of mandibular
teeth near to the operators
elbow

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Long Buccal infiltration anesthesia Cont.
Needle:
25-27 gauge
Long needle
Syringe
Non-Aspirating syringe
Except when injecting long buccal infiltration following Inferior
alveolar nerve block)

The target area

Distal to The apical region of the tooth to be
anesthetized
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Long Buccal Infiltration Anesthesia Cont.
The point of needle insertion
The point of intersection of 2 imaginary lines
1st line is a vertical line parallel to the long axis of
the DISTAL root of the molar
2nd line is a horizontal line along the mucobuccal
fold
Direction of needle insertion
45 with the buccal cortical plate of bone

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Steps for Long Buccal infiltration
The cheek is retracted using dental mirror or your
finger to make almost a right angle with the
labial/buccal aspect of the jaw
The point of insertion is determined as mentioned
The needle is inserted with its bevel toward the bone
and making an angle of 45 with the buccal aspect
The needle is pushed through the soft tissue until
the bone is reached (within 2mm)

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Steps for Long buccal infiltiration
Cont.
The needle is held firmly and 0.2-0.3 cc of the
solution is slowly deposited
The needle is then withdrawn gently and recap it

Wait 2-3 minutes before starting your dental

procedure

Check your anesthesia using the dental probe

(objective finding)

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 Confirming the Anesthesia
Subjective findings
No subjective findings
Objective findings
Probing does not lead to pain

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Mandibular Anesthetic Techniques

Nerve Block Anesthesia

Inferior Alveolar & Lingual Nerve Block

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IA & Lingual Nerve Block Anesthesia
Aim
To deposit the anesthetic solution in close
vicinity to the Inferior alveolar nerve just before
its entry to the mandibular foramen
To deposit the anesthetic solution in close
vicinity to the lingual nerve as it pass anterior
and medial to the IAN

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 Methods for anesthesia the inf.alv.nerve
Intra oral Extraoral techniques
Inf. Alv N. block Inf. Alv N. block
technique Mental N.block
Gow gates technique
Vazironi-akeinosi
technique

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IA & Lingual Nerve Block Anesthesia
Nerve to be anesthetized
Incisive Nerve
Mental nerve
Inferior alveolar nerve
Lingual nerve

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IA & Lingual Nerve Block Anesthesia
Areas to be anesthetized
All lower teeth in the side of anesthesia
Pulp
Investing structures
Buccal mucoperiosteum of the anterior teeth
and premolars
The lingual mucoperiosteum of the same side
Floor of the mouth of the same side
Half the tongue of the same side

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 Indications
Analgesia for all restorative procedures on the
mandibular teeth
Surgical procedures on mandibular teeth and
supporting structures
Diagnostic or therapeutic purposes, for
neuralgias of the mandibular nerve

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 Contraindications
Patients who might bite either the lip or
tongue (physically or mentally handicapped
patients, or very young children)
Infection or acute inflammation in the area of
injection

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 Advantages
one injection provides wide area of anesthesia

Disadvantages
Wide area of anesthesia

Rate of inadequate anesthesia is 15-20% which will need a

second injection
Anatomical variations

Lower lip anesthesia is discomforting to many patients while possibly dangerous

in children

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IA & Lingual Nerve Block Anesthesia
Patient position Dentist position
Head , neck and trunk on the Right side:
same straight line From infront and to the right
The back of the chair is tilted so Left side:
that it make a 45 degree angle
with the floor From infront and to the right
using
So that when the patient open his Cross hand technique
mouth the occlusal plane of the Using left hand
mandibular teeth becomes
From right rear position using
parallel to the floor
From behind technique
The occlusal plan of mandibular
teeth near to the operators
elbow

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IA & Lingual Nerve Block Anesthesia
Cont.

Needle:
25-27 gauge
Long needle
Syringe
Aspirating syringe
The target area
The point of entry of the IAN into the mandibular
canal

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 IA & Lingual Nerve Block Anesthesia
Cont.

Landmarks: Landmarks:
Soft tissue landmarks: Bony landmarks:
Muccobuccal fold External oblique ridge
Buccal pad of fat Internal oblique ridge
Retromolar area triangle Anterior border of the
Pterygomandibular raphe ramus
Cronid process
Cronoid notch

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Steps for right mandibular injection
Right handed operator
The operator is positioned on the right
front of the patient

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 The operator uses his left index finger to
determine the landmarks.

He first puts his index finger in the muco-

buccal fold opposite to the premolar area.
(nail upwards)

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 Gently slide the index finger posteriorly to
encounter the ext. oblique ridge, then
ascending ramus till the coronoid process
.(highest convexity)

Then slide the finger down the ascending

ramus untill it reaches the point of greatest
depth.
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 At this point rotate your finger medially so
the finger nail faces the tongue. (sagittal
plane)

There you will feel a bony depression

under your finger tip.

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 The point of needle insertion is 5mm along
an imaginary line bissecting the finger nail.

Ask the pt. to open wide, dry the area and

apply topical antiseptic and then topical
anesthetic.

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 With finger in place pull the underlying tissues
laterally, stretching the tissue over injection site
making the needle insertion less traumatic.

Using a 25 gauge long needle, we approach the

target area from the opposite side (premolar
area) on the level of the occlusal plane.

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 Advance the needle slowly untill it touches bone
. (about 2/3 of its length)

Aspirate, if negative administer 1.5ml slowly .

This amount is to anesthetize the inf. Alv. Nerve

and the lingual nerve (how).

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 After the subjective symptoms start then the long
buccal inj. is performed administering the
remaining 0.3ml distal to the tooth to be
extracted.

Now you can proceed with your extraction

procedure.

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 Confirming the Anesthesia
Subjective findings
Numbness of the lower lip
Objective findings
Probing does not lead to pain

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 Steps for left mandibular injection
Right handed operator
The operator is positioned on the right front of
the patient
From infront and to the right
Cross hand technique
Left hand technique
Right rear position
From behind technique

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 Errors during injection
Too high injection
Anesthesia of the auriclotemporal nerve : Numbness of the ear
Injection into lateral pterygoid muscle : Soreness and trismus
Too low injection:
Deposited in parotid gland
Temporary facial nerve paralysis
Parotitis
Deposited into medial pterygoid muscle,
Pain
Trismus
Deposited into the posterior facial vein :
Toxicity

Too medial injection

Deposited into the constrictor muscle of pharynx : disphagya
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 Gow-gates technique

This technique was introduced in 1973 by the

Australian operator Dr. George Gow-gates

It provides sensory anesthesia to all branches of

the Posterior Division and Buccal nerve

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 Vazirani -Akinosi Technique

This technique was reported in 1977 by

Dr. Joseph Akinosi

The main advantage is that it could be

administrated to patients with very limited
mouth opening

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Mandibular Anesthetic Techniques

Nerve Block Anesthesia

Mental Nerve Block

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 Mental Nerve Block
Aim Inject the anesthetic
solution in the vicinity
of the mental foramen

Nerves to be Mental nerve

anesthetized Incisive nerve
Part of the inferior
alveolar nerve

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 Mental Nerve Block
Needle 25-27 gauge
Short needle

Syringe Aspirating syringe

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 Mental Nerve Block anesthesia
Patient position Dentist position
Head , neck and trunk on the Right rear position
same straight line
The back of the chair is tilted so
that it make a 45 degree angle
with the floor
So that when the patient open his
mouth the occlusal plane of the
mandibular teeth becomes
parallel to the floor
The occlusal plan of mandibular
teeth near to the operators
elbow

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 Mental Nerve Block Anesthesia Cont.
The point of needle insertion
The point of intersection of 2
imaginary lines
1st line is a vertical line
parallel to the long axis of
both premolars and
between them
2nd line is a horizontal line
along the mucobuccal fold

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Anterior Labial Infiltration Anesthesia
Cont.

Direction of needle insertion

45 with the buccal cortical
plate of bone

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 Steps of injection
Palpate the mental foramen with your
index finger
It lies in between the apices of the first and
second premolars
The bone anterior and posterior to the
foramen is smooth
The bone immediately around it is rough
The mental foramen opening is directed
posteriorly

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 Steps of injection Cont.
Insert the needle in the mucobuccal fold between
the two bicuspids directing the syringe towards
the mental foramen
Advance the needle till the foramen is reached
The depth of penetration is usually 5-6 mm
Aspirate, if negative deposit the local anesthetic
solution (1.5 ml)
withdraw syringe and recap needle
Wait 3 minutes before commencing dental
procedure
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 Confirming the Anesthesia
Subjective findings
Numbness of the lower lip
Objective findings
Probing does not lead to pain

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Mandibular Anesthetic Techniques

Nerve Block Anesthesia

Long Buccal Nerve Block

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 Long buccal nerve block
Nerve to be anesthetized
Long buccal nerve
Needle
25-27 gauge
Long needle
Syringe
Aspirating Syringe
Leads to the anesthetization of the buccal
mucosa of the molar teeth
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 Long buccal nerve block
0.2 ml of anesthetic solution is deposited at the
apex of the retromolar triangle between the
external and internal oblique ridges
Point of insertion
apex of the retromolar triangle between the external
and internal oblique ridges
Direction of injection
Parallel to the occlusal plane from the same side

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 Long buccal nerve block
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
The syringe oriented over the teeth of the
same side to be injected and parallel to the
occlusal plane.

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 Confirming the Anesthesia
Subjective findings
Numbness of the mucosa of the cheek
opposite to the lower molars
Objective findings
Probing does not lead to pain

N.B. This long buccal infiltration or block should

be administered after the onset of subjective
symptoms of the inf. Alv.N.block
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Mandibular anesthetic techniques
Supplementary Anesthesia

Intraosseous anesthesia
Interseptal anesthesia
Intrapulpal anesthesia
Intraligamentry anesthesia
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Mandibular anesthetic techniques
Supplementary Anesthesia

Interseptal anesthesia

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 Interseptal anesthesia
(Inter dental)
Indications:
It anesthetizes the terminal nerve endings of
the soft and hard tissues at the site of
injection
Obtaining hemostasis at the surgical site

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 Interseptal anesthesia
(Inter dental)
Point of insertion:
At the center of the Base of the inter dental
papillae
Direction of injection:
45 degrees with the buccal plate of bone
Bevel directed to the bone
Amount of injection:
0.2-0.4ml

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 Interseptal anesthesia
(Inter dental)

Type of syringe
Non-aspirating syringe

Pressure syringe

Type of needle
Short needle

Gauge 25-27

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 Interseptal anesthesia
(Inter dental)

Advantages:

Very quick onset

Disadvantages:

Causes blanching of the gingiva

Resistance during administration

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Mandibular anesthetic techniques
Supplementary Anesthesia

Intrapulpal anesthesia

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 Intrapulpal injection
Administration of anesthesia directly into pulp
Indications
Acute pulpitis
Endodontic treatment
Needle
25-27 gauge
Long needle
Syringe
Pressure syringe
Non-Aspirating syringe

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 Intrapulpal injection
Technique:
The needle is inserted into the pulp chamber
Wedged firmly in the pulp chamber or the root canal
Deposit the anesthetic solution under pressure
N.B. Bend the needle if necessary to gain access to the pulp
chamber or canal
Amount administered:
About 0.2-0.3 ml

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 Intrapulpal injection
Advantages:
Profound
Fast
Allows painless pulp exterpation
Disadvantages:
Painful
Needs pressure
Variable duration

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Mandibular anesthetic techniques
Supplementary Anesthesia

Intraligamentary anesthesia

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 Intraligamentry Anesthesia
Delivering the anesthetic sol. through the
periodontal ligament to reach the periapical area
Needle
25-27 gauge
Short needle
Syringe
Non-Aspirating
Pressure syringe

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 Intraligamentry Anesthesia
Indications / advantages:
Pulpal and soft tissue anesthesia in a localized area
(one tooth)
Avoids extensive anesthesia of the soft tissues that is
achieved through block anesthesia
Contraindications / Disadvantages:
Infection or inflammation at the site of injection
Use in primary teeth
Enamel hypoplasia
Enamel hypomineralization

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 Intraligamentry Anesthesia
Technique:
The needle is inserted mesial or
distal to the tooth in the
inteproximal area at the depth of
the gingival sulcus
The bevel facing towards the root
of the tooth
Advance the needle apically until
resistance is encountered
Deposit 0.2 ml of the anesthetic
solution in about 20 seconds
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 Its main advantage is that it does not lead to
numbness of the whole segment, but just the
tooth involved

While its disadvantages are:-

Doesnt work for all patients.

Contraindicated in cases of infection.

Contraindicated in children with primary

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dentition.
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www.elhawarydentalclinic.com

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