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Mandibular Injections
1) 2) 3) 4) 5) 6) Mandible has dense cortical plate covering cancellous interior Density of buccal alveolar plate precludes the use of supraperiosteals Wide variation of anatomy exists with location of IAN 1 in 5 patients will require reinjection when given the IANB (80%) Mandibular molar anesthesia requires a successful IANB Height of the mandibular foramen is unpredictable from patient to patient 7) Mental and buccal injections anesthetize the soft tissues only 8) IANB, Gow-Gates, Vazirani-Akinosi and incisive blocks anesthetize pulps 9) PDL, Intraosseous and Intraseptal injections are used in maxillary and mandible
1) Mandibular teeth to the midline (beware of cross over fibers teeth #24, 25) 2) Body of the mandible 3) Inferior portion of the ramus 4) Buccal mucoperiosteum, mucous membrane anterior to the mandibular 1st molar 5) Anterior 2/3rds of the tongue and floor of the mouth (lingual nerve) 6) Lingual soft tissues and periosteum (lingual nerve)
not anesthetized
Alternatives To IANB
1) Mental Nerve Block; buccal soft tissue anterior to the 1st molar 2) Incisive Nerve Block; pulpal and soft tissue anesthesia to teeth anterior to the mental foramen 3) Supraperiosteal (although rather unsuccessful) 4) Gow-Gates 5) Vazirani-Akinosi 6) PDL injection for pulpal anesthesia of any mandibular tooth 7) Intraosseous: osseous and soft tissue anesthesia 8) Intraseptal: osseous and soft tissue anesthesia
IANB TECHNIQUE
3 IMPORTANT PARAMETERS TO CONSIDER: 1) Height of the injection 2) Anteroposterior placement of the needle tip 3) Depth of needle penetration
Technique of IANB
1) 25 gauge long needle 2) Insert needle into mucous membrane on the medial side of the mandibular ramus 3) Target is the inferior alveolar nerve before it enters the mandibular foramen 4) Use coronoid notch, pterygomandibular raphe and occlusal plane of the mandibular teeth as landmarks for proper injection 5) Ask the patient to open widely
The needle is inserted approximately 23 mm; rarely do you need to insert the needle to its hub
Common Problems
If Bone Contacted Too Soon
1) less than half of the dental needle penetrated until bone contact means the needle tip is located too far anteriorly on the ramus
SOLUTION -withdraw needle slightly; do not remove completely -bring the syringe barrel around to the front of the mouth over the canine or lateral incisor on the contralateral side -needle tip is now located more posteriorly
After bone is contacted (IANB) 6) Withdraw syringe 1 mm to avoid subperiosteal injection 7) Aspirate; slowly inject solution ~ 1.5 1.8 ml (1 cartridge) 8) Wait 20 seconds and return the patient to the upright position to allow gravity to move the solution inferiorly; begin treatment in 3-5 minutes 9) Lingual Nerve will be anesthetized with this injection on the ipsalateral side; patients will say that half of their tongue is numb; Lingual Nerve is in the posterior division of V3 and can be numb without having any other structures numb So, having a numb tongue does not necessarily mean the patient will have numb teeth!
Bells Palsy
Do not inject solution if bone is not contacted; more than likely the needle tip will be within the parotid gland; Injection will cause a transient Bells Palsy which is anesthesia of CN VII
Accessory Innervation
Failure of the IANB is related to accessory innervation of mandibular molar teeth by branches of the Mylohyoid Nerve
Gow-Gates injection will block the Mylohyoid Nerve but the IANB will not provide anesthesia of these accessory nerves
3) Bifid inferior alveolar nerve which would require IANB more inferior to the normal location 4) Poor injection technique
Complications of IANB
1) Hematoma (rare) 2) Trismus (common) 3) Transient Facial Paralysis (Bells Palsy)
Trismus occurs because the needle pierces the buccinator muscle when giving the IANB
2) Deep seated rubber dam clamp 3) Removal of subgingival caries 4) Placement of gingival retraction cord
4) Penetrate the mucosa distal and buccal to the last molar 5) Advance the needle slowly until bone is contacted gently 6) Depth of penetration is approximately 2-4 mm (1-2 mm)
Gow-Gates Injection
Gow-Gates Block
Discovered by George Gow-Gates in 1973 Gow-Gates Block is a true complete mandibular block Australian general dentistry practitioner Onset is longer than IANB; 5 minutes with GG; 2-5 minutes with IANB
*Remember, when doing extractions, the buccal nerve block is needed in addition to the IANB, however, with GG, only one injection is required
Gow-Gates Technique
1) 25 gauge long needle 2) Insertion point: mucous membrane of the mesial of the mandibular ramus, on a line from the intertragic notch to the corner of the mouth, just distal to the maxillary 2nd molar 3) Target area: lateral side of the condylar neck, just below the insertion of the lateral pterygoid muscle 4) Landmarks: corner of the mouth and lower border of the tragus 5) Height of injection: place needle tip just below the mesiolingual cusp of the maxillary 2nd molar
6) Ask patient to open wide to allow the condyle to assume a frontal position
7) Direct syringe from the corner of the mouth from the opposite side of mouth
8) Height of insertion is considerably greater than the IANB by 10-25 mm 9) Average depth of penetration is 25 mm (same as IANB)
13) Do not deposit solution unless bone is contacted 14) Withdraw the needle 1 mm, aspirate, deposit 1.8 ml of solution 15) Request that the patient keep their mouth open for 1-2 minutes to allow diffusion of the anesthetic solution
16) Return the patient to the upright position; wait 3-5 minutes to start
penetration
2) There is 5-10 mm between the solution deposition site and
Vazirani-Akinosi
VA Block
Nerves Anesthetized 1) Inferior Alveolar Nerve 2) Incisive Nerve 3) Mental Nerve 4) Lingual Nerve 5) Mylohyoid Nerve
Disadvantages of VA Block
1) Difficult to visualize the path of the needle and depth of insertion 2) No boney contact (similar to PSA); depth of penetration is arbitrary 3) Traumatic other technique other than extraorally is available if needle scrapes across periosteum 4) No if this block can not be done due to a patients inability to open their mouth
VA Block Technique
1) 25 gauge long needle 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 3rd molar 3) Target area: soft tissue on the medial (lingual) border of the ramus as the inferior alveolar, lingual and mylohyoid nerves run inferiorly from the foramen ovale toward the mandibular foramen *Height of injection of the VA is below that of the GG but above that of the IANB
Height of Injections
Gow-Gates Highest Vazirani-Akinosi Middle Inferior Alevolar Lowest
4) Landmarks are the mucogingival junction of the maxillary 3rd molar, maxillary tuberosity and the coronoid notch of the ramus 5) Bevel is directed away from the bone of the ramus (toward midline) 6) Reflect the tissue on the medial aspect of the ramus laterally with the Minnesota Retractor or mouth mirror 7) Ask the patient to occlude gently, if they are not already occluded, this will relax the cheek and muscles of mastication 8) Barrel of the syringe is held parallel to the maxillary occlusal plane with the needle at the level of the mucogingival junction of the maxillary 3rd molar
9) Direct the needle posterior and slightly laterally 10) Advance the needle 25 mm into tissue (same as GG and IANB) distance is measured from the maxillary tuberosity 11) Tip of the needle will lie in the midportion of the pterygomandibular space where the branches of V3 are located
If the there is tingling or numbness in the tongue, which is a branch of the posterior division of the mandibular nerve then you can feel confident that your injection has reached its target
Provides sensory innervation to the buccal soft tissues lying anterior to the foramen and the soft tissues of the lower lip and chin Mental nerve block is the least used of the mandibular blocks Anesthetizes buccal mucous membranes anterior to the mental foramen and skin of the lower lip and chin Used for suturing tissues, biopsies in this area
5) With gentle finger pressure it is possible to feel the mental nerve as it exits the foramen (patient will complain of discomfort) 6) Penetrate needle 5-6 mm and inject 1/3rd cartridge of anesthetic
7) No need to enter the foramen with the needle tip to gain anesthesia
Incisive nerve is the terminal branch of the inferior alveolar nerve Incisive nerve is a direct continuation of the inferior alveolar nerve continuing anteriorly in the incisive canal, providing sensory innervation to those teeth located anterior to the mental foramen No need to enter the mental foramen for this injection to be successful No lingual anesthesia is noted with this injection; supraperiosteal is necessary through the papilla which is atraumatic to the patient The incisive nerve is always blocked when an inferior alveolar nerve block is successful, therefore, you do not have to anesthetize this nerve in addition to the IANB
Reference
Malamed, Stanley: Handbook of Local Anesthesia. Mosby. 5th Edition. 2004