TECHNIQUES OF LOCAL ANAESTHESIA
Dr. Mahmoud Khalifa Prof & Consultant of OMFS ILOs
You should be known and understand Types of LA techniques Indications of each one Maxillary techniques Mandibular techniques Basic steps for accurate tech Steps for infiltration tech Steps for NB tech Attention clinical, oral, and written
Why the trigeminal nerve course is important for LA
What is the difference between bone of mandible and maxilla
Ophthalmic Nerve Maxillary Nerve Mandibular Nerve
Definition
L A is a local and temporary state of insensibility in an area without loss of consciousness Loss of pain sensation ( local analgesia) can be achieved by : Mechanical means →→pressure on main N T Physical means → cold application Chemical means → Drugs METHODS OF PRODUCTION OF L A
Refrigerant effect
Application of pressure
Using of drugs Topical anaesthesia
infiltration
Nerve block
L A can be produced by action of LA agent on Free nerve endings Terminal nerve endings Main nerve trunk Accordingly 1. Topical 2. Infiltration 3. Nerve block Techniques of local Anesthesia ♦ Local Infiltration: Small terminal nerve endings are flooded with local anesthetic solution.
♦Field Block Local anesthetic is deposited near the larger terminal nerve branches so the anesthetized area will be circumscribed
♦ Nerve Block Local anesthetic is deposited close to a main nerve trunk Infiltration techniques
Bony infiltration Soft tissue infiltration intraseptal Supraperiosteal infiltration Intraosseus Sub periosteal infiltration Para periosteal infiltration Supplementary tech Intraligamintal (preiodontal) Intrapluplal
Maxilla Mandible Main technique Anterior region Multiple foramina + thin cortex and spongy bone Mandibular Nerve Maxillary nerve Blocks block Intra-oral techniques Intra-oral techniques Inferior alveolar Posterior superior N B Standard (Direct) Infraorbital nerve block: indirect Greater palatine nerve block Gow-Gates Nasopalatine nerve block: Akinosi Maxillary nerve block Mental – Incisive Buccal
Lingual
Extra-oral techniques Extra-oral techniques mandibular,Inferior alveolar , mental Maxillary, infraorbital
Factors affect the choice of LA technique
1. Area to be anaesthetized
2. Extent of surgery
3. Duration and profoundness required
4. Age of the patient
5. Need for haemostasis
6. Presence of infection
7. Skill of operator Infiltration techniques
It is more commonly used and is successful in suitable cases when used in the indicated regions Submucosal Paraperiosteal Paraperiosteal infilteration
Aim of tech: is deposit the LA solution in close proximity to the nerve fibers inside the bone
Success of this technique depends on : Diffusion of LA solution through periosteum and minute foramina in the cortex then through the cancellous bone to reach the target nerve Regions for infiltration
All maxillary region The anterior mandibular region NERVES TO BE ANESTHETIZED.
AREAS TO BE ANESTHETIZED.
ANATOMICAL LANDMARKS.
INDICATIONS.
CONTRAINDICATIONS.
ADVANTAGES.
DISADVANTAGES.
TECHNIQUE.
SYMPTOMS OF ANESTHESIA:
A) SUBJECTIVE SYMPTOMS.
B) OBJECTIVE SYMPTOMS. (infiltration anesthesia):
Basic steps for all techniques
♦ Step 1 : Use a sterilized sharp needle ♦ Step 2:Check the flow of local anesthetic solution ♦ Step 3: Armamentum and anesthetic should be room temperature ♦ Step 4: Position the patient ♦ Step 5: Dry the tissue ♦ Step 6: Apply topical antiseptic ♦ Step 7A: Apply topical anesthetic ♦ Step 7B :Communicate with the patient.
The patient should be in the semisupine position. The right handed operator should be in the eight o’clock position The left handed operator should be in the four o’clock position. Accessibility Visibility Comfortability Safety
♦ Step 8 :Establish a firm hand rest ♦ Step 9: Make the tissue taut ♦ Step 10:Keep the syringe out of the patient's line of sight. ♦ Step 11A:Insert the needle into the mucosa. ♦ Step 11B:Watch and communicate with the patient. ♦ Step 12 :Inject several drops of local anesthetic solution (optional). ♦ Step 13:Slowly advance the needle toward the target.
♦ Step 15: Aspirate. ♦ Step 16A: Slowly deposit the local anesthetic solution ♦ Step 16B: Communicate with the patient. ♦ Step 17: Slowly withdraw the syringe ♦ Step 18: Observe the patient
summary of the atraumatic injection technique
1. Use a sterilized sharp needle. 11a. Insert the needle into the mucosa. 2. Check the flow of local anesthetic 11b. Watch and communicate with the patient. solution. 12. Inject several drops of local anesthetic solution 3. Determine whether to warm the (optional). anesthetic cartridge and/or syringe. 13. Slowly advance the needle toward the target. 4. Position the patient. I4. Deposit several drops of local anesthetic before 5. Dry the tissue. touching the periosteum. 6. Apply topical antiseptic (optional). 15. Aspirate. 7a. Apply topical anesthetic. 16a. Slowly deposit the local anesthetic solution. 7b. Communicate with the patient. 16b. Communicate with the patient. 8. Establish a firm hand rest. 17. Slowly withdraw the syringe. Cap the needle and 9. Make the tissue taut. discard. I0. Keep the syringe out of the patient's line 18. Observe the patient after the injection. of sight. 19. Record the injection on the patient's chart.
Techniques of Maxillary Anesthesia Techniques of Maxillary Anesthesia
♦ Local Infiltration: Small terminal nerve endings are flooded with local anesthetic solution.
♦ Nerve Block Local anesthetic is deposited close to a main nerve trunk
1 Supraperiosteal (infiltration), recommended for limited treatment protocols 2 Periodontal ligament (PDL, intraligamentary) injection, 3 Intraseptal injection, 4 Intracrestal injection, 5 Intraosseous (IO) injection,
6 Posterior superior alveolar (PSA) nerve block 7 Infraorbital nerve block 8 Greater (anterior) palatine nerve block 9 Nasopalatine nerve block 10 Maxillary (V2, second division) nerve block ( intra oral +extra oral)
Paraperiosteal infilteration
Nerves Anesthetized Large terminal branches of the dental plexus. (buccal) Branches of greater palatine or nasopalatine n (palatally) Areas Anesthetized Pulp , periodontal legmints and supporting alveolar bone , buccal mucoperiosteum + lingual mucoperiosteum Indications 1 Pulpal anesthesia of the maxillary teeth when treatment is limited to one or two teeth 2 Soft tissue anesthesia when indicated for surgical procedures in a circumscribed area Contraindications 1. Infection or acute inflammation in the area of injection. 2. Dense bone covering the apices of teeth Advantages 1 High success rate (>95%) 2 Technically easy injection 3 Usually entirely atraumatic Disadvantages Not recommended for large areas because of the need for multiple needle insertions and the necessity to administer larger total volumes of local anesthetic. Positive Aspiration Negligible, but possible (<1%). Alternatives PDL, IO, regional nerve block. Technique
1. A 27-gauge short needle is recommended. 2. Area of insertion: height of the mucobuccal fold above the apex of the tooth being anesthetized 3. Target area: apical region of the tooth to be anesthetized 4. Landmarks: * Buccl ( 2 imaginary lines) a Mucobuccal fold b-long axis of tooth *Palatal midway between 2 line a- midpalatal suture line b- palatal free gingival line 5 Orientation of the bevel *: toward bone
6 procedure:
a Prepare tissue at the injection site. (1) Clean with sterile dry gauze. (2) Apply topical antiseptic (optional). (3) Apply topical anesthetic for minimum of 1 minute. b Orient needle so bevel faces bone. c Lift the lip, pulling the tissue taut. d Hold the syringe parallel with the long axis of the tooth e Insert the needle into the height of the mucobuccal fold over the target tooth. f Advance the needle until its bevel is at or above the apical region of the tooth g Aspirate . If negative deposit LA solution slowly over 60 seconds. (Do not allow the tissues to balloon.) h Slowly withdraw the syringe. i Make the needle safe. j Wait 3 to 5 minutes before commencing the dental procedure. Signs and Symptoms 1 Subjective: feeling of numbness in the area of administration 2 Objective: use of electrical pulp testing (EPT) with no response from tooth with maximal EPT output (80/80) 3 Absence of pain during treatment Safety Features 1 Minimal risk of intravascular administration 2 Slow injection of anesthetic; aspiration Mandibular infiltration tech
Infiltration tech Young age with primary dentition Anterior region Failures of anesthesia
1 Needle tip lies below the apex (along the root) of the tooth Depositing anesthetic solution below the apex of a maxillary tooth results in excellent soft tissue anesthesia but poor or absent pulpal anesthesia.
2 Needle tip lies too far from the bone (solution deposited in buccal soft tissues). To correct: Redirect the needle closer to the periosteum Nerve block techniques
Infraorbital Nerve Block
The anterior superior alveolar (ASA) nerve block or infraorbital nerve block is a useful technique for → the maxillary central and lateral incisors and canine as well as premolars and the surrounding soft tissue on the buccal aspect.
The infraorbital foramen lies just inferior to the notch usually in line with the second premolar
Nerves Anesthetized 1 Anterior superior alveolar 2 Middle superior alveolar 3 Infraorbital nerve a Inferior palpebral b Lateral nasal c Superior labial Areas Anesthetized 1 Pulps of the maxillary central incisor through the canine on the injected side 2 In about 72% of patients, pulps of the maxillary premolars and mesiobuccal root of the first molar 3 Buccal (labial) periodontium and bone of these same teeth 4 Lower eyelid, lateral aspect of the nose, upper lip
Indications 1 Dental procedures involving more than two maxillary teeth and their overlying buccal tissues 2 Inflammation or infection 3 When supraperiosteal injections have been ineffective because of dense cortical bone Contraindications 1 Discrete treatment areas (one or two teeth only; supraperiosteal preferred) 2 Hemostasis of localized areas. Technique
Area of insertion: height of the mucobuccal fold directly over the first premolar Target area: infraorbital foramen (below the infraorbital notch). Landmarks: a Mucobuccal fold b Infraorbital notch c Infraorbital foramen
Orientation of the bevel: toward bone Locate the infraorbital foramen. (1) Feel the infraorbital notch. (2) Move your finger downward from the notch, applying gentle pressure to the tissues. (3) The bone immediately inferior to the notch is convex (felt as an outward bulge). (4)As your finger continues inferiorly, a concavity is felt; this is the infraorbital foramen. (5) While applying pressure, feel the outlines of the infraorbital foramen at this site. The patient senses a mild soreness Maintain firm pressure with your finger over the injection site both during and for at least 1 minute after the injection (to increase the diffusion of local anesthetic solution into the infraorbital foramen). Signs and Symptoms 1 Subjective: Tingling and numbness of the lower eyelid, side of the nose, and upper lip
2 Objective: • No response from tooth with use of electrical pulp testing • Absence of pain during treatment
Anterior and middle superior alveolar nerve block (infraorbital). : a) Bicuspid approach.
Anterior and middle superior alveolar nerve block (infraorbital). b) Central incisor approach. It is recommended that pressure be kept over the site of injection to facilitate the diffusion of anesthetic solution into the foramen. Successful execution of this technique results in aesthesia of the lower eyelid, lateral aspect of the nose, and the upper lip. Pulpal anesthesia of the maxillary central and lateral incisors, canine, buccal soft tissue, and bone is also achieved. In a certain percentage of people, the premolar teeth and the mesiobuccal root of the 1st molar is also anesthetized.
Posterior Superior Alveolar Nerve Block
Other Common Names Tuberosity block, zygomatic block. Nerves Anesthetized Posterior superior alveolar and branches. Areas Anesthetized 1 Pulps of the maxillary third, second, and first molars (entire tooth = 72%; mesiobuccal root of the maxillary first molar not anesthetized = 28%) 2 Buccal periodontium and bone overlying these teeth
Indications 1 When treatment involves two or more maxillary molars 2 When supraperiosteal injection is contraindicated (e.g., with infection or acute inflammation) 3 When supraperiosteal injection has proved ineffective Contraindication When the risk of hemorrhage is too great (as with a hemophiliac), in which case a supraperiosteal or PDL injection is recommended.
Technique Area of insertion: height of the mucobuccal fold above the maxillary second molar Target area: PSA nerve—posterior, superior, and medial to the posterior border of the maxilla Insert the needle into the height of the mucobuccal fold over the second molar Advance the needle slowly in an upward, inward, and backward direction in one movement (not three). (1) Upward: superiorly at a 45-degree angle to the occlusal plane (2) Inward: medially toward the midline at a 45-degree angle to the occlusal plane (3) Backward: posteriorly at a 45-degree angle to the long axis of the second molar
Advance the needle to the desired depth (1) In an adult of normal size, penetration to a depth of 16 mm (2) For smaller adults and children Penetrating to a depth of 10 to 14 mm Aspirate in two planes then inject if negative . Posterior superior alveolar nerve block (zygomatic):
Anterior Middle Superior Alveolar Nerve Block (AMSA) The anterior middle superior alveolar nerve block (AMSA) injection represents a recently described maxillary nerve block injection. Anterior Middle Superior Alveolar Nerve Block This technique provides pulpal anesthesia to multiple maxillary teeth (incisors, canine, and premolars) from a single injection site on the hard palate about halfway along an imaginary line connecting the midpalatal suture to the free gingival margin. The line is located at the contact point between the first and second premolars
Other Common Name Palatal approach anterior middle superior alveolar (AMSA). Nerves Anesthetized 1 ASA nerve 2 MSA nerve, when present 3 Subneural dental nerve plexus of the anterior and middle superior alveolar nerves Areas Anesthetized 1 Pulpal anesthesia of the maxillary incisors, canines, and premolars 2 Buccal attached gingiva of these same teeth 3 Attached palatal tissues from midline to free gingival margin on associated teeth
Indications 1 Is more easily performed with a C-CLAD system 2 When dental procedures involving multiple maxillary anterior teeth or soft tissues are to be performed 3 When anesthesia to multiple maxillary anterior teeth is desired from a single-site injection 4 When scaling and root planing of the anterior teeth are to be performed 5 When anterior cosmetic procedures are to be performed and a smile-line assessment is important for a successful outcome 6 When a facial approach supraperiosteal injection has been ineffective because of dense cortical bone Nasopalatine nerve block (incisive canal injection):
Anterior (greater) palatine nerve block.
Maxillary nerve block: Nerve Anesthetized Maxillary division of the trigeminal nerve. Areas Anesthetized 1 Pulpal anesthesia of the maxillary teeth on the side of the block 2 Buccal periodontium and bone overlying these teeth 3 Soft tissues and bone of the hard palate and part of the soft palate, medial to midline 4 Skin of the lower eyelid, side of the nose, cheek, and upper lip Technique (High-Tuberosity Approach)
1 A 25-gauge long needle is recommended. A 27-gauge long is acceptable. 2 Area of insertion: height of the mucobuccal fold above the distal aspect of the maxillary second molar 3 Target area: a Maxillary nerve as it passes through the pterygopalatine fossa b Superior and medial to the target area of the PSA nerve block 4 Landmarks: a Mucobuccal fold at the distal aspect of the maxillary second molar b Maxillary tuberosity c Zygomatic process of the maxilla Place the needle into the height of the mucobuccal fold over the maxillary second molar.
Advance the needle slowly in an upward, inward, and backward direction as described for the PSA nerve block
Advance the needle to a depth of 30 mm.
(1) No resistance to needle penetration should be felt. If resistance is felt, the angle of the needle in toward the midline is too great.
(2) At this depth (30 mm), the needle tip should lie in the pterygopalatine fossa in proximity to the maxillary division of the trigeminal nerve.
Maxillary NB Technique
(greater palatine foramen Approach)
2- Extra oral techniques: a) Anterior and middle superior alveolar nerve block (infraorbital). b) Maxillary nerve block.
It is commonly stated that the significantly higher failure rate for mandibular infiltration anesthesia due to thickness of the cortical plate of bone in the adult mandible
Mandibular infiltration is successful in cases where the patient has a full primary dentition
Once a mixed dentition develops, → mandibular cortical plate of bone has thickened → infiltration might not be effective, →recommendation that “mandibular block” Nerve blocks
Six nerve blocks are described Two of these involving the mental and buccal nerves ( mainly soft tissues) The four remaining blocks inferior alveolar, incisive, Gow-Gates mandibular, and Vazirani-Akinosi (closed-mouth) mandibular ( teeth + supporting bone) Supplementary tech
periodontal ligament, intraosseous, and intraseptal
Inferior alveolar nerve block (IANB)
Nerves anesthetized. Areas anesthetized. Indications. Contraindications. Advantages Disadvantages Technique. Armamentarium. Anatomical landmarks. Symptoms of anesthesia: a) Subjective symptoms. b) Objective symptoms. Nerves anesthetized
Inferior Alveolar Mental Incisive Lingual
Areas Anesthetized
Mandibular teeth to midline and their investing structures IA Body of mandible, inferior ramus Buccal mucosa anterior to mental foramen
Anterior 2/3 tongue & floor of mouth Ling Lingual soft tissue and periosteum
Areas anaesthetized
I A N
Lingual n
Mental n
INDICATIONS CONTRAINDICATIONS
Infection or acute Procedures on multiple inflammation in area of mandibular teeth in one injection quadrant Patients who might bite When buccal soft tissue either the lip or tongue ( a anesthesia ( anterior to the first molar ) is very young child, physically required or mentally handicapped adult or child When lingual soft tissue anesthesia is required
Advantages Disadvantages
Wide area of anaesthesia not necessary for localized procedures One injection Rate of inadequate anesthesia (31%- provides a wide area 81%) of anaesthesia Intraoral landmarks not consistently reliable Positive aspiration( 10%to15%) Lip and tongue anesthesia discomfiting for many patients Partial anesthesia possible Alternatives
1 Mental nerve block,
2 Incisive nerve block, foramen (usually second premolar to central incisor)
3 Supraperiosteal injection
4 Gow-Gates mandibular nerve block
5 Vazirani-Akinosi mandibular nerve block
6 PDL injection
7 IO injection IANB Technique ( Standard Right side) Armamentariums position (Patient & Operator) Area of needle Insertion landmarks Procedures ( locate injection site , insert the needle, Aspiration, Injection) Onset Signs and symptoms of anaesthesia
Armamentariums
Aspirated dental syringe Long needle With the mouth open maximally, identify the coronoid notch and the pterygomandibular raphae. . landmarks for IANB
Coronoid notch
Pterygomandibular raphe
Occlusal plane of mandibular posteriors Pterygo-mandibular space Point of needle insertion
Three quarters of the anteroposterior distance between these two landmarks, and approximately six to ten millimeters above the occlusal plane is the injection site Direct inferior alveolar nerve block and Lingual NB
Inferior alveolar nerve block:
Standard (direct) technique. Direct Left IAN block
The same as right but the difference is the operator positions Cross Hand technique Behind technique Left hand technique
Precautions Do not inject if bone not contacted Avoid forceful bone contact
Failure of anathesia
Injection too low Injection too high Injection too anterior Injection to deep Accessory innervation Mylohyoid nerve contralateral Incisive nerve innervation
Mylohyoid nerve contralateral Incisive nerve innervation
Complications
1 Hematoma (rare) 2 Trismus 3 Transient facial paralysis (facial nerve anesthesia) Buccal Nerve Block
The buccal nerve block, otherwise known as the long buccal or buccinator block. The target for this technique is the buccal nerve as it passes over the anterior aspect of the ramus. Nerve Anesthetized
Buccal (a branch of the anterior division of the V3). Area Anesthetized Soft tissues and periosteum buccal to the mandibular molar teeth
Indication Contraindication When buccal soft tissue Infection or acute anesthesia is necessary for inflammation in the area of dental procedures in the injection. mandibular molar region. Advantages Disadvantages
1 High success rate Potential for pain if the 2 Technically easy needle contacts the periosteum during injection Alternatives
1 Buccal infiltration 2 Gow-Gates mandibular nerve block 3 Vazirani-Akinosi mandibular nerve block 4 PDL injection 5 Intraosseous injection 6 Intraseptal injection Technique 1 A 25- or 27-gauge long needle is recommended 2 Area of insertion: Mucous membrane distal and buccal to the most distal molar tooth in the arch 3 Target area: Buccal nerve as it passes over the anterior border of the ramus 4 Landmarks: Mandibular molars, mucobuccal fold 5 Orientation of the bevel: Toward bone during the injection Procedure
a Assume the correct position. 1) For a right buccal nerve block, a right-handed operator should sit at the 8 o'clock position directly facing the patient (2) For a left buccal nerve block, a right-handed operator should sit at 10 o'clock facing in the same direction as the patient b Position the patient supine (recommended) or semisupine. c Prepare the tissues for penetration distal and buccal to the most posterior molar d With your left index finger (if right-handed), pull the buccal soft tissues in the area of injection laterally e Direct the syringe toward the injection site with the bevel facing down toward bone and the syringe aligned parallel to the occlusal plane on the side of injection but buccal to the teeth f Penetrate mucous membrane at the injection site The depth of penetration is seldom more than 2 to 4 mm,
Withdraw the syringe slowly and immediately make the needle safe. Wait approximately 3 to 5 minutes before commencing the planned dental procedure Signs and Symptoms
Mandibular Nerve Block:
The Gow-Gates Technique Nerves Anesthetized
1 Inferior alveolar 2 Mental 3 Incisive 4 Lingual 5 Mylohyoid 6 Auriculotemporal 7 Buccal (in 75% of patients) Areas Anesthetized
1 Mandibular teeth to the midline 2 Buccal mucoperiosteum and mucous membranes on the side of injection 3 Anterior two thirds of the tongue and floor of the oral cavity 4 Lingual soft tissues and periosteum 5 Body of the mandible, inferior portion of the ramus 6 Skin over the zygoma, posterior portion of the cheek, and temporal regions
Advantages
1 Requires only one injection 2 High success rate (>95%), with experience 3 Minimum aspiration rate 4 Few postinjection complications (e.g., trismus) 5 Provides successful anesthesia where a bifid inferior alveolar nerve and bifid mandibular canals are present Disadvantages
1 Lingual and lower lip anesthesia is uncomfortable for many patients and is possibly dangerous for certain individuals. 2 The time to onset of anesthesia is somewhat longer (5 minutes) 3 Clinical experience is necessary Technique
1 25- or 27-gauge long needle recommended 2 Area of insertion: 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 3 Target area: Lateral side of the condylar neck, just below the insertion of the lateral pterygoid muscle
Procedure
a Assume the correct position c Locate the extraoral landmarks: (1) Intertragic notch (2) Corner of the mouth d Place your left index finger or thumb on the coronoid notch e Visualize the intraoral landmarks. (1) Mesiolingual (mesiopalatal) cusp of the maxillary second molar (2) Needle penetration site is just distal to the maxillary second molar at the height of the tip of its mesiolingual cusp f Align the needle with the plane extending from the corner of the mouth on the opposite side to the intertragic notch on the side of injection
Slowly advance the needle until bone is contacted. Signs and Symptoms
1 Subjective: Tingling or numbness of the lower lip Tingling or numbness of the tongue I 2 Objective: No response with electrical pulp No pain is felt during dental therapy Vazirani-Akinosi Closed-Mouth Mandibular Block Other Common Names
Akinosi technique, closed-mouth mandibular nerve block, tuberosity technique Nerves Anesthetized
1 Inferior alveolar 2 Incisive 3 Mental 4 Lingual 5 Mylohyoid Areas Anesthetized
1 Mandibular teeth to the midline 2 Body of the mandible and inferior portion of the ramus 3 Buccal mucoperiosteum and mucous membrane anterior to the mental foramen 4 Anterior two thirds of the tongue and floor of the oral cavity (lingual nerve) 5 Lingual soft tissues and periosteum (lingual nerve) Indications
1 Limited mandibular opening 2 Multiple procedures on mandibular teeth 3 Inability to visualize landmarks for IANB (e.g., because of large tongue) Contraindications
1 Infection or acute inflammation in the area of injection (rare) 2 Patients who might bite their lip or their tongue, such as young children and physically or mentally handicapped adults 3 Inability to visualize or gain access to the lingual aspect of the ramus
Advantages
1 Relatively atraumatic 2 Patient need not be able to open the mouth. 3 Fewer postoperative complications (e.g., trismus) 4 Lower aspiration rate (<10%) than with the inferior alveolar nerve block 5 Provides successful anesthesia where a bifid inferior alveolar nerve and bifid mandibular canals are present Disadvantages
1 Difficult to visualize the path of the needle and the depth of insertion 2 No bony contact; depth of penetration somewhat arbitrary 3 Potentially traumatic if the needle is too close to the periosteum Technique
1 A 25-gauge long needle is recommended (although a 27-gauge long may be preferred in patients whose ramus flares laterally more than usual). 2 Area of insertion: Soft tissue overlying the medial (lingual) border of the mandibular ramus directly adjacent to the maxillary tuberosity at the height of the mucogingival junction adjacent to the maxillary third molar
Target area
Soft tissue on the medial (lingual) border of the ramus in the region of the inferior alveolar, lingual, and mylohyoid nerves as they run inferiorly Landmarks:
a Mucogingival junction of the maxillary third (or second) molar b Maxillary tuberosity c Coronoid notch on the mandibular ramus Procedure: c Place your left index finger or thumb on the coronoid notch, d Visualize landmarks: (1) Mucogingival junction of the maxillary third or second molar (2) Maxillary tuberosity
Ask the patient to occlude gently Reflect the soft tissues on the medial border of the ramus laterally. The barrel of the syringe is held parallel to the maxillary occlusal plane Direct the needle posteriorly and slightly laterally
Advance the needle 25 mm into tissue Aspirate in two planes. If negative, deposit 1.5 to 1.8 mL of anesthetic solution in approximately 60 seconds. Withdraw the syringe slowly and immediately make the needle safe
Signs and Symptoms
1 Subjective: Tingling or numbness of the lower lip Tingling or numbness of the tongue I 2 Objective: No response with electrical pulp No pain is felt during dental therapy
Mental Nerve Block