MANDIBULAR NERVE BLOCK TECHNIQUES
- 1. BY:- NIDHI , BDS FINAL YEAR
- 2. CONTENTS:- • INTRODUCTION • MANDIBULAR NERVE BLOCKS • INFERIOR ALVEOLAR NERVE BLOCK • BUCCAL NERVE BLOCK • GOW GATES MANDIBULAR NERVE BLOCK TECHNIQUE • VAZIRANI – AKINOSI CLOSED – MOUTH MANDIBULAR NERVE BLOCK • MENTAL NERVE BLOCK • INCISIVE NERVE BLOCK
- 3. INTRODUCTION • MANDIBULAR NERVE (V3) IS THE LARGEST BRANCH OF TRIGEMINAL NERVE. • IT IS A MIXED NERVE WITH TWO ROOTS: 1. LARGE SENSORY ROOT 2. SMALLER MOTOR ROOT • THE LARGE SENSORY ROOT ARISES FROM THE SEMILUNAR GANGLION. • THE MOTOR ROOT IS LOCATED IN MIDDLE CRANIAL FOSSA. • IT DIVIDES MAINLY IN 2 BRANCHES AFTER COMING OUT FROM CRANIUM THROUGH FORAMEN OVALE.
- 4. • UNDIVIDED NERVE:- 1. NERVUS SPINOSUS 2. NERVE TO MEDIAL PTERYGOID • DIVIDED NERVE:- 1. ANTERIOR DIVISION : A. BRANCH TO EXTERNAL PTERYGOID MUSCLE B. BRANCH TO MASSETER MUSCLE C. BRANCHES TO TEMPORAL MUSCLES - ANTERIOR DEEP TEMPORAL NERVE - POSTERIOR DEEP TEMPORAL NERVE D. BUCCAL (LONG BUCCAL) NERVE 2. POSTERIOR DIVISION : A. AURICULOTEMPORAL NERVE B. LINGUAL NERVE C. INFERIOR ALVEOLAR NERVE
- 5. MANDIBULAR NERVE BLOCKS • INFERIOR ALVEOLAR NERVE BLOCK • LINGUAL • LONG BUCCAL • MENTAL • INCISIVE • GOW GATES TECHNIQUE • VAZIRANI - AKINOSI TECHNIQUE
- 7. • NERVE ANESTHETIZED:- 1. INFERIOR ALVEOLAR, A BRANCH OF POSTERIOR DIVISION OF THE MANDIBULAR DIVISION OF THE TRIGEMINAL NERVE. 2. INCISIVE 3. MENTAL 4. LINGUAL (COMMONLY) • AREA ANESTHETIZED:- 1. MANDIBULAR TEETH TO MIDLINE 2. BODY OF THE MANDIBLE, INFERIOR PORTION OF THE RAMUS 3. BUCCAL MUCOPERIOSTEUM AND MUCOUS MEMBRANE ANTERIOR TO THE MENTAL FORAMEN (MENTAL NERVE) 4. ANTERIOR TWO THIRDS OF THE TONGUE AND FLOOR OF THE ORAL CAVITY (LINGUAL NERVE) 5. LINGUAL SOFT TISSUES AND PERIOSTEUM (LINGUAL NERVE).
- 8. • INDICATIONS:- 1. PROCEDURE ON MULTIPLE MANDIBULAR TEETH IN ONE QUADRANT. 2.WHEN BUCCAL SOFT TISSUE ANAESTHESIA (ANTERIOR TO THE MENTAL FORAMEN) IS NECESSARY. 3. WHEN LINGUAL SOFT TISSUE ANAESTHESIA IS NECESSARY. • CONTRAINDICATIONS:- 1. A VERY YOUNG CHILD OR A PHYSICALLY OR MENTALLY HANDICAPPED ADULT OR CHILD, WHO ARE MORE LIKELY TO BITE THEIR LIP OR TONGUE. 2. INFECTION OR ACUTE INFLAMMATION IN THE AREA OF INJECTION (RARE).
- 9. TECHNIQUE:- • A 25 GAUGE LONG NEEDLE IS PREFERRED. • AREA OF INSERTION - MUCOUS MEMBRANE ON THE MEDIAL SIDE OF MANDIBULAR RAMUS, AT THE INTERSECTION OF TWO LINES – ONE HORIZONTAL , REPRESENTING THE HEIGHT OF NEEDLE INSERTION, THE OTHER VERTICAL, REPRESENTING THE ANTEROPOSTERIOR PLANE OF INJECTION. • TARGET AREA – INFERIOR ALVEOLAR NERVE AS IT PASSES DOWNWARD TOWARDS THE MANDIBULAR FORAMEN BUT BEFORE IT ENTERS INTO THE FORAMEN. • LANDMARKS – A. CORONOID NOTCH (GREATEST CONCAVITY ON THE ANTERIOR BORDER OF THE RAMUS). B. PTERYGOMANDIBULAR RAPHE ( VERTICAL PORTION ). C. OCCLUSAL PLANE OF THE MANDIBULAR POSTERIOR TEETH.
- 10. PLACEMENT OF NEEDLE AND SYRINGE FOR AN INFERIOR ALVEOLAR NERVE BLOCK
- 11. BUCCAL NERVE BLOCK (Long buccal nerve block / buccinator nerve block)
- 12. • NERVE ANESTHETIZED:- BUCCAL BRANCH OF ANTERIOR DIVISION OF MANDIBULAR NERVE. • AREA ANESTHETIZED:- BUCCAL MUCOUS MEMBRANE& MUCOPERIOSTEUM OF MANDIBULAR MOLARS • INDICATION:- SURGERY OF MANDIBULAR BUCCAL MUCOSA & ADJUNCT TO IANB. • CONTRAINDICATION:- INFECTION OR ACUTE INFLAMMATION IN THE AREA OF INJECTION.
- 13. TECHNIQUE:- • A 25 0R 27 GAUGE NEEDLE IS RECOMMENDED. • AREA OF INSERTION:- MUCOUS MEMBRANE DISTAL AND BUCCAL TO THE MOST DISTAL MOLAR TOOTH IN THE ARCH. • TARGET AREA:- BUCCAL NERVE AS IT PASSES OVER THE ANTERIOR BORDER OF THE RAMUS. • LANDMARKS:- MANDIBULAR MOLARS, MUCOBUCCAL FOLD.
- 14. AREA ANESTHETIZED AREA OF INSERTION
- 15. THE GOW – GATES TECHNIQUE (MANDIBULAR NERVE BLOCK / THIRD DIVISION NERVE BLOCK)
- 16. • IN 1973, GEORGE ALBERT EDWARDS GOW – GATES DESCRIBED A NEW APPROACH TO MANDIBULAR ANESTHESIA. • NERVE ANESTHETIZED:- 1. INFERIOR ALVEOLAR 2. MENTAL 3. INCISIVE 4. LINGUAL 5. MYLOHYOID 6. AURICULOTEMPORAL 7. BUCCAL (IN 75% OF PATIENTS)
- 17. • AREA ANESTHETIZED:- 1. MANDIBULAR TEETH TO MIDLINE 2. BUCCAL & LINGUAL MUCOPERIOSTEUM & MUCOUS MEMBRANE. 3. ANTERIOR 2/3RD OF TONGUE AND FLOOR OF ORAL CAVITY. 4. SKIN OVER THE ZYGOMA, POSTERIOR PORTION OF CHEEK AND TEMPORAL REGION. • INDICATION:- 1. MULTIPLE PROCEDURE ON MANDIBULAR TEETH 2. BUCCAL SOFT TISSUE ANESTHESIA FROM THIRD MOLAR TO MIDLINE. 3. LINGUAL SOFT TISSUE ANESTHESIA. 4. IANB UNSUCCESSFUL .
- 18. • CONTRAINDICATIONS:- 1. INFECTION & ACUTE INFLAMMATION AT THE SITE OF INJECTION. 2. YOUNG PATIENTS, WHO MIGHT BITE THEIR LIP OR TONGUE. 3. TRISMUS • ADVANTAGES:- 1. ONLY 1 INJECTION NEEDED, 2. HIGH SUCCESS RATE (>95%) 3. DECREASED ASPIRATION RATE AND POST INJECTION COMPLICATION. • DISADVANTAGES:- LONGER TIME OF ONSET THAN IANB (I.E. 5 TO 7 MINUTES).
- 19. • 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. • TARGET AREA:- LATERAL SIDE OF THE CONDYLAR NECK, JUST BELOW THE INSERTION OF THE LATERAL PTERYGOID MUSCLE. • LANDMARKS:- 1. EXTRAORAL : - LOWER BORDER OF TRAGUS (INTERTRAGIC NOTCH). - CORNER OF THE MOUTH . 2. INTRAORAL: - BELOW THE MESIOLINGUAL CUSP OF MAXILLARY 2ND MOLAR. - NEEDLE PENETRATION SITE IS JUST DISTAL TO THE MAXILLARY 2ND MOLAR AT THE HEIGHT OF THE TIP OF ITS MESIOLINGUAL CUSP.
- 20. PROCEDURE:- • POSITION THE PATIENT • LOCATE EXTRA ORAL LANDMARKS • VISUALIZE INTRAORAL LANDMARKS • PREPARE TISSUES AT SITE OF PENETRATION • DIRECT THE SYRINGE TOWARDS THE SITE OF INJECTION • INSERT THE NEEDLE • ALIGN THE NEEDLE WITH THE PLANE • SLOWLY ADVANCE THE NEEDLE UNTIL BONE IS CONTACTED. POSITION OF THE PATIENT
- 21. • DEPTH OF PENETRATION:25MM • WITHDRAW THE NEEDLE 1MM • ASPIRATE: IF NEGETIVE SLOWLY DEPOSIT 1.8ML IN 60-90 SECS • WITHDRAW THE SYRINGE • REQUEST THE PATIENT TO KEEP MOUTH OPEN FOR 1-2MINS • RETURN THE PATIENT TO UPRIGHT OR SEMIUPRIGHT POSITION . • WAIT FOR 3-5MINS BEFORE STARTING DENTAL PROCEDURE
- 22. EXTRAORAL LANDMARKS FOR GOW GATES MANDIBULAR NERVE BLOCK INTRAORAL LANDMARKS
- 23. VAZIRANI – AKINOSI CLOSED – MOUTH MANDIBULAR BLOCK (TUBEROSITY TECHNIQUE)
- 24. • NERVE ANESTHETIZED:- 1. INFERIOR ALVEOLAR 2. INCISIVE 3. MENTAL 4. LINGUAL 5. MYLOHYOID • AREA ANESTHETIZED:- 1. MANDIBULAR TEETH TO MIDLINE 2. BUCCAL & LINGUAL MUCOPERIOSTEUM & MUCOUS MEMBRANE. 3. ANT 2/3RD OF TONGUE AND FLOOR OF ORAL CAVITY 4. BODY OF MANDIBLE AND INFERIOR PORTION OF THE RAMUS.
- 25. • INDICATION:- 1. PATIENT UNABLE TO OPEN MOUTH. 2. MULTIPLE PROCEDURE ON MANDIBULAR TEETH. 3. INABILITY TO VISUALIZE LANDMARKS FOR IANB DUE TO LARGE TONGUE. • CONTRAINDICATION:- WHERE TRISMUS IS PRESENT DUE TO INFECTION IN THE TISSUES THROUGH WHICH A NEEDLE WOULD HAVE TO PASS. • ADVANTAGES:- 1. RELATIVELY ATRAUMATIC. 2. PATIENT NEED NOT BE ABLE TO OPEN THE MOUTH. • DISADVANTAGES:- DIFFICULT TO VISUALIZE THE PATH OF THE NEEDLE AND THE DEPTH OF INSERTION.
- 26. TECHNIQUE:- • A 25 GAUGE LONG NEEDLE IS RECCOMENDED. • AREA OF INSERTION:- SOFT TISSUE OVERLYING THE MEDIAL (LINGUA) BORDER OF THE MANDIBULAR RAMUS DIRECTLY ADJACENT TO THE MAXILLARY TUBEROSITY AT THE HIGHEST OF THE MUCOGINGIVAL JUNCTION ADJACENT TO THE MAXILLARY THIRD MOLAR. • TARGET AREA:- SOFT TISSUE ON THE MEDIAL BORDER OF THE RAMUS IN THE REGION OF THE INFERIOR ALVEOLAR, LINGUAL, AND MYLOHYOID NERVES. • LANDMARKS:- 1. MUCOGINGIVAL JUNCTION OF THE MAXILLARY THIRD MOLAR. 2. MAXILLARY TUBEROSITY. 3. CORONOID NOTCH ON THE MANDIBULAR RAMUS.
- 27. PROCEDURE:- • THE NEEDLE IS PLACED PARALLELTO THE GINGIVAL MARGINS OF THE MAXILLARY TEETH OR TO THE ALVEOLAR RIDGE IN THE EDENTULOUS PATIENT. • THE POINT OF INSERTION IS THE MUCOSA, PTERYGOMANDIBULAR FOLD, BUCCINATOR AND BUCCAL APONEUROSIS ON THE INNER ASPECT OF THE ASCENDING RAMUS TO REACH THE PTERYGOMANDIBULAR SPACE.
- 30. • NERVE ANESTHETIZED :- MENTAL NERVE, A TERMINAL BRANCH OF THE INFERIOR ALVEOLAR. • AREA ANESTHETIZED :- SKIN OF THE LOWER LIP AND CHIN , BUCCAL MUCOUS MEMBRANE ANTERIOR TO THE MENTAL FORAMEN TO THE MIDLINE. • INDICATION :- PROCEDURES WHERE ANESTHESIA OF BUCCAL SOFT TISSUE ANTERIOR TO THE MENTAL FORAMEN IS NECESSARY. • CONTRAINDICATIONS :- ACUTE INFLAMMATION AND INFECTION OVER THE INJECTION SITE. • ADVANTAGES:- - NO LOSS OF LINGUAL SENSATION - BETTER FOR CHILDREN
- 31. • TECHNIQUE:- 1. A 25 OR 27 GAUGE NEEDLE IS RECOMMENDED. 2. AREA OF INSERTION – MUCOBUCCAL FOLD AT OR JUST ANTERIOR TO THE MENTAL FORAMEN. 3. TARGET AREA – MENTAL NERVE AS IT EXITS THE MENTAL FORAMEN. 4. LANDMARKS – MANDIBULAR PREMOLARS AND MUCOBUCCAL FOLD. • SYMPTOMS :- 1. SUBJECTIVE – TINGLING & NUMBNESS OF LOWER LIP . 2. OBJECTIVE – NO PAIN DURING TREATMENT. • COMPLICATION:- HEMATOMA AT THE INJECTION SITE.
- 32. AREA ANESTHETIZED NEEDLE PENETRATION SITE
- 34. • NERVE ANESTHETIZED :- INCISIVE & MENTAL NERVE • AREA ANESTHETIZED :- 1. BUCCAL MUCOUS MEMBRANE ANTERIOR TO THE MENTAL FORAMEN. 2. LOWER LIP AND SKIN OF THE CHIN. 3. PULPAL NERVE FIBRES TO THE PREMOLARS, CANINE, AND INCISORS. • INDICATION :- 1. MANDIBULAR TEETH ANTERIOR TO MENTAL FORAMEN, 2. CASES WHERE IANB IS NOT INDICATED. • CONTRAINDICATIONS:- ACUTE INFLAMMATION & INFECTION OVER THE INJECTION SITE.
- 35. • TECHNIQUE :- SAME AS MENTAL NERVE BLOCK. ANAESTHETIC SOLUTION TO BE PENETRATED INTO MENTAL FORAMEN • SYMPTOMS:- 1. SUBJECTIVE – TINGLING AND NUMBNESS OF LOWER LIP. 2. OBJECTIVE – NO PAIN FELT DURING THE TREATMENT. • COMPLICATION:- HEMATOMA.
- 36. AREA ANESTHETIZED AREA OF INSERTION
- 37. THANKYOU