Inferior Alveolar Nerve Block

The inferior alveolar nerve block technique is the one with the highest
percentage of failure (15%-20%), so we have to train well to do it.

Causes of failure:
1. Anatomical variation in the height of the mandibular foramen
on the ramus.
2. Wrong anatomical determination.
3. Injection into area of infection.
4. Greater depth of soft tissue penetration required.
5. Intravascular injection.

Anesthetized area Nerve anesthetized

Body of the mandible & inferior portion of Inferior alveolar nerve & its
the ramus subdivisions (Lingual nerve &
- Mandibular teeth nerve to buccinator)
- Mucous membrane & underlying
tissues (anterior to the molars)

Symptoms of anesthesia: (How to test anesthesia??):

1. In the maxilla, we test the anesthesia only by instrument
(objective).We use the probe in certain point & pierce the mucosa
till it touches the bone. If anesthesia is given correctly, so no pain
will be felt except for pressure..
2. In the mandible, they are 2 ways (subjective & objective)
a) Subjective symptoms: tingling & numbness of the lower lip,
corner of the mouth & tip of the tongue due to lingual nerve
block. N.B: Numbness always ends @ the midline.
b) Objective symptoms: Instrumentation reveals absence of pain
sensation.

FOR YOU: Tell the patient not to close her/his eyes cause eyes is
the 1 part of the body that detect pain, also early signs of toxicity can be
detected through eyes. Therefore, opening eyes is very important for
communication with the patient without words & for detecting early
responses.
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Contraindication of inferior alveolar nerve block:

1. Infection or acute inflammation in area of injection.
2. Very young children, physically or mentally handicapped
patients.

Advantages:
One injection provides wide area of anesthesia

Disadvantages:
1.
2.
3.
4.
5.

Failure (15%-20%)
Wide area of anesthesia
Positive aspiration rate 10%- 15%
Intraoral landmarks not consistently reliable
Lingual & lower lip anesthesia discomforting to may patients &
possibly dangerous in certain individuals.

Technique:
Use long needle, aspiration is very important because inferior alveolar
artery is very close..
FOR YOU: Never ever redirect the needle inside the tissue, otherwise
fracture may happen.
1. The index finger @ the left hand (for right handed) is placed in the
mucobuccal fold opposite to the bicuspid teeth or area.
2. Move the finger posteriorly until reaching the external oblique ridge,
then the anterior border of the ramus & to the coronoid process. N.B:
tell the patient to open his mouth as wide as he can, so you can insert
the needle correctly to get the correct landmark..
3. Keep the finger in contact with the anterior border of the coronoid
process & move the finger down until the greater depth on the anterior
border of the ramus (coronoid notch) is reached.

4. The finger is kept in contact with coronoid notch, and then rotates the
finger so that the finger nail is turned towards the sagittal plane.
5. At this point, slide the finger tip lingually & felt the internal oblique
ridge, this area is called the retromolar triangle.
6. The point of the needle insertion lies @ about 0.5 cm in front of the
middle of the tip of the left index finger nail, the needle is distal to
ptrygopalatine raphe. The anesthetic syringe loaded with the carpule,
mounted with long needle (42mm) held by the operator right hand in a
pen grasp & parallel to the occlusal plane of the lower teeth & directed
from the premolar area of the opposite side the needle is inserted
to the previous point.
7. If the needle is in the correct position, it should touch bone @ about
20 -40mm (2/3 of the needle is inserted), inject about 1.5 cc of the
anesthetic solution.
8. Withdraw the needle about 0.5 mm & inject 0.5 cc of the anesthetic
solution to anesthetize the lingual nerve (1/3 needle is inserted). Long
buccal nerve will be anesthetized (block) if extraction of the 6th, 7th&

8th or large flab is done in this area ( 0.01 cc for long buccal nerve

infiltration)

Needle pathway during insertion:

- Mucosa, a thin plate of buccinator muscle, loose C.T & fat

- If the needle is inserted far more posteriorly Trismus may occur.

- If the needle is very deep inserted or inserted from the same site
parotid gland may be hurt & facial nerve injury may occur (facial
nerve palsy) but it's more severe when inserted from the same side.

Approximating structures when the needle is in position, the

position of the needle should be:
- Superior to the inferior alveolar vessels , inferior alveolar insertion
of the medial ptrygoid muscle, mylohyoid vessels & nerves
- Anterior to deep part of the parotid gland
- Medial to the inner surface of the ramus of the mandible
- Lateral to the lingual nerve & medial ptrygoid muscle &
sphenomandibular ligaments.

Errors in the needle insertion in case of inferior

alveolar nerve block:
1. If the needle puncture is too high & too far medially from the internal
oblique ridge the solution may be injected into the lateral ptrygoid
muscle & this result in trismus
2. The solution may be injected into superior constrictor muscle of the
pharynx causing profound numbness of the throat & patient will
complain of feeling something in the throat.
3. The needle may penetrate on the ptrygoid venous plexus which cover
the medial ptrygoid muscle , and this may result into hematoma in the
ptrygomandibular space (so for this reason we nerve give it to
hemophilic patient).
4. Puncture point along the internal oblique ridge but too high & the
needle is advance d to deeply
5. Numbness of the ear will result from anesthesia of the
articulotemporal nerve or the solution may be deposited in the
insertion of lateral ptrygoid muscle with subsequent soreness &
trismus & no effective anesthesia to the teeth.
6. The needle may be passed through the sigmoid notch , the solution is
deposited in the masseter resulting in muscle edema , trismus & no
effective anesthesia
7. The needle puncture may be high , but not advanced too deeply, the
solution may be deposited into temporalus muscle & the patient will
complain of trismus, soreness & failure of anesthesia

8. If the needle passed the insertion of temporalus muscle, the patient

may have weak anesthesia
9. If the needle puncture is along the internal oblique ridge but too low ,
this is the most common error , & it results in failure of anesthesia
a) The solution may deposited to the insertion of medial ptrygoid
& the patient will complain of pain & trismus
b) The solution may deposited into the parotid gland with the
resultant parotitis
c) The solution may be deposited into the parotid gland near the
facial nerve with resultant relaxation of all facial muscles
d) The solution may deposit into the parotid & facial vein with
resultant toxicity, pallor, weakness, nausea, convulsion, are
quickly manifested & patient skin become pall & his blood
pressure & pulse are lowered.