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Which nerves are commonly anesthetized in an inferior alveolar nerve block?
What is NOT a contraindication for performing an inferior alveolar nerve block?
What is one advantage of performing an inferior alveolar nerve block?
Which of the following statements about the inferior alveolar nerve block is true?
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Which nerve blocks can serve as alternatives to the inferior alveolar nerve block?
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When is the inferior alveolar nerve block indicated?
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What is a significant disadvantage of the inferior alveolar nerve block?
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Which nerve is NOT part of the divided inferior alveolar nerve?
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What is the primary target area for the inferior alveolar nerve block injection?
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Which injection technique is specifically indicated for pulpal anesthesia of any mandibular tooth?
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Which gauge needle is recommended for the inferior alveolar nerve block in adults?
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Where should the needle be inserted for the inferior alveolar nerve block?
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What is the purpose of intraosseous injection in mandibular anesthesia?
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What anatomical landmark represents the greatest concavity on the mandible for anesthesia techniques?
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Which technique is best for osseous and soft-tissue anesthesia specifically for molars?
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What represents the intersection point for needle insertion in the inferior alveolar nerve block?
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What is the purpose of moving the palpating finger to the buccal side during the nerve block procedure?
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How deep should the needle typically penetrate to contact bone during the Inferior Alveolar Nerve Block?
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What should be done after contacting bone during the needle insertion for the Inferior Alveolar Nerve Block?
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Why is it recommended to aspirate in two planes during the procedure?
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What is the total volume of anesthetic that should be slowly deposited after confirming negative aspiration?
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What additional step is performed to anesthetize the lingual nerve in the procedure?
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What should the patient be instructed to do during the needle insertion process?
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What technique helps assess the anteroposterior width of the ramus?
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What is the recommended needle gauge for an adult patient receiving an inferior alveolar nerve block?
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Which anatomical landmark is identified as the greatest concavity on the anterior border of the ramus?
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What is the target area for the inferior alveolar nerve as it passes toward the mandibular foramen?
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In which position should the operator be seated when administering the right inferior alveolar nerve block?
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What is the significance of the coronoid notch in the administration of the inferior alveolar nerve block?
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What patient position is generally recommended for administering the inferior alveolar nerve block?
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Which structure is palpated first when preparing for an inferior alveolar nerve block?
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What happens after the palpation of the mucobuccal fold during the preparation for an inferior alveolar nerve block?
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Where should a right-handed administrator position themselves when performing a left inferior alveolar nerve block?
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What subjective symptom indicates anesthesia of the mental nerve during an inferior alveolar nerve block?
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Which objective test serves as a nearly guaranteed indication of successful pulpal anesthesia in nonpulpitic teeth?
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Which of the following is a precaution that should be taken during an inferior alveolar nerve block?
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What is a common cause of failure in achieving adequate anesthesia during an inferior alveolar nerve block?
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What complication may occur after depositing anesthetic during an inferior alveolar nerve block?
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What is an appropriate management technique for a hematoma that occurs after an inferior alveolar nerve block?
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Which branch of the inferior alveolar nerve is indicated by tingling or numbness of the tongue?
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Study Notes
Mandibular Nerve
- The Mandibular Nerve is a branch of the Trigeminal Nerve (cranial nerve V)
- It is divided into an Undivided portion and a Divided portion
- The Undivided portion contains the Nervus Spinosus and the nerve to the medial pterygoid muscle.
- The Divided portion has two branches: The Anterior Division, and the Posterior Division.
- The Anterior Division contains the nerve to the lateral pterygoid muscle, the nerve to the masseter muscle, the nerve to the temporal muscle, and the Buccal nerve
- The Posterior Division contains the Auriculotemporal nerve, the Lingual nerve, the Mylohyoid nerve, the Inferior Alveolar nerve, the Incisive branch, and the Mental nerve.
Inferior Alveolar Nerve Block
- Other name: Mandibular block
- Anesthetizes the Inferior Alveolar nerve, Incisive nerve, Mental nerve, and commonly the Lingual nerve.
Indications for Inferior Alveolar Nerve Block
- Procedures on multiple mandibular teeth in one quadrant.
- When buccal soft-tissue anesthesia (anterior to the first molar) is necessary.
- When lingual soft-tissue anesthesia is necessary.
Contraindications for Inferior Alveolar Nerve Block
- Infection or acute inflammation in the area of injection (rare).
- Potential for lip or tongue biting—consider for very young children or those with physical or mental disabilities.
Advantages of Inferior Alveolar Nerve Block
- One injection provides a wide area of anesthesia.
Disadvantages of Inferior Alveolar Nerve Block
- Wide area of anesthesia (not necessary for localized procedures).
- A rate of inadequate anesthesia (15% to 20%).
- Intraoral landmarks are not consistently reliable.
- Positive aspiration (10% to 15%, the highest of all intraoral injection techniques).
- Lingual and lower lip anesthesia, discomforting to many patients and possibly dangerous for certain individuals.
- Potential for partial anesthesia if a bifid inferior alveolar nerve and bifid mandibular canals are present.
- Positive Aspiration: 10% to 15%
Alternatives to Inferior Alveolar Nerve Block
- Mental nerve block, for buccal soft-tissue anesthesia anterior to the first molar.
- Incisive nerve block, for pulpal and buccal soft-tissue anesthesia of teeth anterior to the mental foramen.
- Supraperiosteal injection, for pulpal anesthesia of the central and lateral incisors, and sometimes the premolars (success rate extremely variable).
- Gow-Gates mandibular nerve block
- Vazirani-Akinosi mandibular nerve block
- PDL injection for pulpal anesthesia of any mandibular tooth.
- Intraosseous (IO) injection for osseous and soft-tissue anesthesia of any mandibular region, but especially molars.
- Intraseptal injection for osseous and soft-tissue anesthesia of any mandibular region.
Technique: Right Inferior Alveolar Nerve Block
- Operator position: Right-handed administrator should sit at the 8 o’clock position facing the patient.
- Patient positioning – Supine or semi-supine, with the head positioned so that the body of the mandible is parallel to the floor when the mouth is open.
- Palpation of Intraoral landmarks:
- Left index finger or thumb palpates the mucobuccal fold.
- The finger or thumb is then moved posteriorly until contact is made with the external oblique ridge on the anterior border of the ramus of the mandible.
- When the finger or thumb contacts the ramus of the mandible, it is moved up and down until the greatest depth of the anterior border of the ramus is identified. This area of depth is called the coronoid notch and is in a direct line with the mandibular sulcus.
- The palpating finger is moved lingually across the retromolar triangle and onto the internal oblique ridge.
- The finger or thumb, still in line with the coronoid notch and in contact with the internal oblique ridge, is moved to the buccal side, taking with it the buccal sucking pad.
- When palpating the intraoral landmarks with the thumb, the operator may place the index finger extraorally behind the ramus of the mandible, thus literally holding the mandible between the thumb and index finger. In this manner, the anteroposterior width of the ramus may be assessed.
Needle Insertion:
- A syringe with a 15/8 inch, 25 – gauge needle is inserted parallel to the occlusal plane of the mandibular teeth from the opposite side of the mouth, at a level bisecting the finger or thumbnail, penetrating the tissues of the pterygotemporal depression, and entering the pterygomandibular space.
- During insertion, the patient should be asked to keep their mouth wide open.
- Penetration continues until gentle bone contact is made on the internal surface of the ramus of the mandible.
- The average depth of penetration to bony contact, in the adult, is 20 to 25 mm.
Injection Technique
- Withdraw the needle by 1 mm after contacting bone, to prevent subperiosteal injection.
- Aspirate in two planes.
- If negative, slowly deposit 1.5 mL of anesthetic over a minimum of 60 seconds.
- Slowly withdraw the syringe, and when approximately half its length remains within tissues, reaspirate.
- If negative, deposit a portion of the remaining solution (0.2 mL) to anesthetize the lingual nerve (while not always necessary, this helps ensure full anesthesia of the lingual nerve).
Technique: Left Inferior Alveolar Nerve Block
- For a left IANB, a right-handed administrator should sit at the 10 o’clock position facing the patient.
- The left arm of the dentist is placed around the patient’s head so that the landmarks may be palpated with the left index finger or thumb.
Signs and Symptoms of Successful Inferior Alveolar Nerve Block
- Subjective: Tingling or numbness of the lower lip indicates anesthesia of the mental nerve, a terminal branch of the inferior alveolar nerve. This is a good indication that the IAN is anesthetized, although it is not a reliable indicator of the depth of anesthesia. Soft tissue anesthesia is never a guarantee of pulpal anesthesia.
- Subjective: Tingling or numbness of the tongue indicates anesthesia of the lingual nerve, a branch of the posterior division of V3. It usually accompanies IANB but may be present without anesthesia of the inferior alveolar nerve.
- Objective: Use of a freezing spray (e.g., Endo-Ice) or an electric pulp tester (EPT) with no response to maximal output (80/80) on two consecutive tests at least 2 minutes apart serves as a “guarantee” (∼99%) of successful pulpal anesthesia in nonpulpitic teeth.
- Objective: No pain is felt during dental therapy. Lack of pain when a blunt instrument is applied on the buccal gingiva anterior to the mental foramen.
- Safety Feature: The needle contacts bone preventing over insertion, with its attendant complications.
Precautions
- Do not deposit local anesthetic if bone is not contacted. The needle tip may be resting within the parotid gland near the facial nerve (cranial nerve VII), and a transient paralysis of the facial nerve is produced if solution is deposited.
- Avoid pain by not contacting bone too forcefully.
Failures of Anesthesia:
- The most common causes of absent or incomplete IANB:
- Deposition of anesthetic too low (below the mandibular foramen).
- Deposition of anesthetic too far anteriorly (laterally) on the ramus.
- Accessory innervation to the mandibular teeth.
Complications
- Hematoma (rare)
- Swelling of tissues on the medial side of the mandibular ramus after the deposition of anesthetic.
- Management: pressure and cold (e.g., ice) to the area for a minimum of 3 to 5 minutes.
- Trismus
- This is a rare complication but is usually reported after a failed IAN block, most often in combination with a hematoma.
Conclusion
The Inferior Alveolar Nerve Block is a valuable technique for providing anesthesia to the mandibular teeth and surrounding tissues, however it is important to understand the technique, understand the potential for complications, and have alternative options available if the technique fails.
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Description
Test your knowledge of the Mandibular Nerve and its components, including the Undivided and Divided portions. Understand the significance of the Inferior Alveolar Nerve Block and its indications for dental procedures. This quiz is essential for students studying dental anatomy and anesthesia.
