Mandibular Anesthesia Lecture Notes PDF

Mandibular Anesthesia b very important lecture Dr. Mohammed Amjed BDS, MSc, PhD L10 7.11.2023 1 References Dr. Mohammed Amjed, UoS, 2023-2024 2 Objectives: Gow gate is better according to aspiration and succes rate tehy Aminos I is close mouth technique pateint can’t open their mouth or lar...

Mandibular Anesthesia b very important lecture Dr. Mohammed Amjed BDS, MSc, PhD L10 7.11.2023 1 References Dr. Mohammed Amjed, UoS, 2023-2024 2 Objectives: Gow gate is better according to aspiration and succes rate tehy Aminos I is close mouth technique pateint can’t open their mouth or large tongue we can’t see landmarks Recognizing 1. Mandibular infiltration anesthesia 2. Inferior alveolar nerve block used more 3. Buccal nerve block 4. Gow-Gates mandibular nerve block betterawardingtoaspiration 5. Akinosi-Vazirani block usedfor indication closedmouthtechnique can'tsee you 6. Incisive and mental nerve block ex large tongue landmark YLY the inferijhere ftp.fik.tt Dr. Mohammed Amjed, UoS, 2023-2024 man infilter Regional 3 Q whatAre the man Infiltration for pulpal anesthesia may be considered as first-choice injections Depend on: • The age of the patient • The tooth of interest 8 1. Age of the patient anteriorteethof the mandible especially incisor have thin corticalbonessoinfiltration will work I - Mandibular infiltration is successful in cases where the patient has a full primary dentition. - Once a mixed dentition develops, the mandibular cortical plate of bone has thickened to the degree that infiltration might not be effective, leading to the recommendation that “mandibular block” techniques should be employed I II I F Dr. Mohammed Amjed, UoS, 2023-2024 4 Infiltration Methods 1. Age of the patient - The technique is similar to that described for maxillary buccal infiltrations as the approach is from the buccal side. - In the lower jaw the area of penetration is made taut by pulling the tissues laterally and inferiorly rather than superiorly. Man Inf whatsthe - The point of penetrationfor is in the depth of the buccal sulcus and the technique is identical to maxillary buccal infiltration. - A 30-gauge needle is used, and 1 mL of solution deposited over 30 seconds. gIfhwsmimYyitmuce Q.ge Initiate.in bothsides thiftftfttgeI.bgnnekaiitTye'Intnfrom Dr. Mohammed Amjed, UoS, 2023-2024 ofgiveinfiltrationthenE.geothieffYhhsbeeanetete adisadvantages 5 Infiltration Methods 2. Tooth of interest - In adults, infiltration anaesthesia is the first choice for pulpal anaesthesia of the lower incisor teeth. 1. Thin and porous buccal plate 2. Contralateral inferior alveolar nerve why - infiltrationformanincisors Man Pulpal anaesthesia is best achieved by depositing solution both buccally and lingually in the apical region of the tooth involved. - A volume of at least 0.5 mL at each site is recommended. - The buccal injection is in the depth of the buccal sulcus and the technique is again identical to maxillary buccal infiltration. The lingual infiltration is performed in the reflected mucosa in the apical region of the tooth of interest !!! The onset of anaesthesia may take longer than a maxillary buccal infiltration. It may be 8 to 10 minutes Dr. Mohammed UoS, 2023-2024 before pulpal anaesthesia is of sufficient depth to allow pain-free Amjed, operative procedures on the tooth. - 6 Regional block methods in the mandible - Most dental treatment on the adult dentition that requires anaesthesia is performed using regional block methods. - As is the case with the maxilla, there are extra oral approaches to the mandibular nerve. These are not recommended in dental practice. whatarethe Q - Regional block methods used in the mandible include: • Inferior alveolar and lingual nerve block • Gow-Gates block opensifiedmouth • Akinosi-Vazirani block • long buccal nerve block • Mylohyoid nerve block • Incisive and mental nerve block most likely anesthetizedtogether Dr. Mohammed Amjed, UoS, 2023-2024 7 The inferior alveolar and lingual nerve block Is the second most frequently usedtechnique (after infiltration) IAN is to deposit local anesthetic solution close to the mandibular The aim of the injection foramen on the medial aspect of the mandibular ramus thus blocking transmission in the inferior alveolar nerve at the point of entry into the bone - I 0 lock IAN Positive aspiration (10% to 15%, highest of all intraoral injection techniques) - bathf.name Mand which Nerves Anesthetized 1. Inferior alveolar, a branch of the posterior division of the mandibular division of the trigeminal nerve (V3) 2. Incisive 3. Mental 4. Lingual (commonly) m 7 iiiii.in which Areas Anesthetized 1. Mandibular teeth to the midline 2. Body of the mandible, inferior portion of the ramus 3. Buccal mucoperiosteum, 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) I 1 1 11 11 Dr. Mohammed Amjed, UoS, 2023-2024 8 Inferior Alveolar And Lingual Nerve Block EFE.n.tk nlEEfyfffkhf jd - Administration of bilateral IANBs is rarely indicated in dental treatments other than bilateral mandibular surgeries. - They produce considerable discomfort, primarily from the lingual soft tissue anesthesia. The patient feels unable to swallow and, because of the absence of all sensation, is more likely to self-injure the anesthetized soft tissues. + affect patient speak. ayg I I - Despite widespread apprehensions about bilateral inferior alveolar nerve block, the absence of scientific evidence concerning the complications of BIANB, supported by considerable clinical experience in the use of this loco-regional anesthesia, shows that BIANB is a safe method and one that improves the quality of life of patients. be usuallylingualanesthetized hit - If block technique is required in the anterior mandible, like in case of presence of abscess. Two excellent alternatives to bilateral IANBs are bilateral incisive nerve blocks (where lingual soft tissue anesthesia is not necessary) and unilateral inferior alveolar blocks on the side that has the greater number of teeth requiring restoration or that requires the greater degree of lingual intervention, combined with an incisive nerve block on the opposite side. sin ftp.ationscaktangjefonffifciin Dr. Mohammed Amjed, UoS, 2023-2024 f siaE iffi t.sn fI la a.intitiimiiifiIiiiffjififkgffffjff fi iiiii 9 Inferior Alveolar And Lingual Nerve Block - The success rate of the inferior alveolar nerve block is considerably lower than that of most other nerve blocks. - Difficulty with the traditional Halsted approach (IANB) is the absence of consistent intraoral landmarks. Failure rates for the IANB are commonly high, ranging from 31% and 41% in mandibular second and first molars to 42%, 38%, and 46% in second and first premolars and canines, respectively, and 81% in lateral incisors. Due to central core theory Dr. Mohammed Amjed, UoS, 2023-2024 Why? 10 When we give IAN block this nerve is bers located at the cneter “core” supplying anterior is taking a longer timefor LA to penetertate into the center. On the periphery of IA nerve they have mantle bers for posteriors so LA reach mantle faster that’s why lower 7 and 6’s get anesthetized faster anetshtisa than incisors Inferior Alveolar And Lingual Nerve Block requites them Periphery requires why lower 7 6 gets less anesthesia more anesthesia than 485 as you go anteriorly it getsreduced - The central core theory best explains this problem. Nerves on the outside of the nerve bundle supply the molar teeth, while nerves on the Ephy inside (core fibers) supply incisor teeth. Therefore, the local anesthetic solution deposited near the IAN may diffuse and block the outermost fibers but not those located more centrally, leading to incomplete mandibular anesthesia. Dr. Mohammed Amjed, UoS, 2023-2024 11 Inferior Alveolar And Lingual Nerve Block EXAM Q. When we give IAN block which muscle is teh only one that’s pierced? Buccinator ** in this technique you must touch teh bone, this is good and bad: good you have a feedback when you touch teh bone means you reached the area. Bad- you will hit teh peroisteum whihc is painful if you didnt hit the bone you will hit teh parotid gland—-> contain facial nerve ——> lead to facial palsy 1. The direct technique - This method is also known as the Halstead approach and relies on simple anatomical landmarks. -The aim is to deposit the local anesthetic in the pterygomandibular space. before IANentersthe man foramen -Target area: Inferior alveolar nerve as it passes downward toward the mandibular foramen but before it enters into the foramen Pterygomanspare - This anatomical space is bordered posteriorly by the parotid gland, mm laterally by the ramus of the mandible, medially and inferiorly by netflix.it the medial pterygoid muscle, superiorly by the lateral pterygoid muscle and anteriorly by the buccinators muscle. Q whenTegiveblock whichmusclefifth only onethatcouldbe pierced Dr. Mohammed Amjed, UoS, 2023-2024 i 12 b - lThe position of the foramen is variable. It should be noted that the mandibular foramen is usually apparent on dental panoramic radiographs and if one of these is available it should be consulted. Information regarding the height (in relation to the teeth) and anteroposterior position of the foramen will be obtained from the radiograph. Coronoid notch • Why do we insist on coronoid notch? Because when we inject we place our nger on coronoid notch and retract the tissue and teh height of injection is a teh deepest point of coordination notch = meaning indication that the mandibular foramen is at teh same level of deepest point of coronoid d notch • Dr. Mohammed Amjed, UoS, 2023-2024 13 Landmarks defame Hinging a depression a. Coronoid notch (greatest concavity on the anterior border of the ramus) mostimp structure b. Pterygomandibular raphe (vertical portion) c. Occlusal plane of the mandibular posterior teeth Orientation of the needle bevel: Less critical than with other nerve blocks, because the needle approaches the inferior alveolar nerve at roughly a right angle should identify it byopening widely Dr. Mohammed Amjed, UoS, 2023-2024 14 81 4 Three parameters must be considered during administration of IANB: titsaisiihdenotch it's t.ae depthpihw.dk (1) The height of the injection Y81hm b.it i (2) The anteroposterior placement of the needle (which helps to locate a precise hecoronoi needle entry point) 90484418 t.HR (3) The depth of penetration (which determines the location of the inferior alveolar nerve) zIYYussntidgosinttthyokthattheSheathe the.fi Dr. Mohammed Amjed, UoS, 2023-2024 15 fmrm ipfnfy Man9stMnkhdblfwkentfMfrmap'ne'refinement.tn M (1) Height of injection: - Place the index finger or the thumb of your left hand in the coronoid notch. - An imaginary line extends posteriorly from the fingertip in the coronoid notch to the deepest part of the pterygomandibular raphe (as it turns vertically upward toward the maxilla), determining the height of injection. - This imaginary line should be parallel to the occlusal plane of the mandibular molar teeth. In most patients, this line lies 6 to 10 mm above the occlusal plane). heightofinject Dr. Mohammed Amjed, UoS, 2023-2024 gotemporaltriangle Jen p 16 tfu SIT.ggm Needle penetration occurs at the intersection of two points (1& 2). 1 was mentioned in the previous slide (2) Anteroposterior site of injection: siteofinjection 2. Ant post site. Three-fourths of the anteroposterior distance from the coronoid notch back to the deepest part of the pterygomandibular raphe: The line should begin at the midpoint of the notch and terminate at the deepest (most posterior) portion of the pterygomandibular raphe Dr. Mohammed Amjed, UoS, 2023-2024 17 (3) Penetration depth: In the third parameter of the IANB, bone should be contacted. Slowly advance the needle until you can feel it meet bony resistance. (usually 20-25 mm) Dr. Mohammed Amjed, UoS, 2023-2024 18 The inferior alveolar and lingual nerve block -The finger on the coronoid notch is used to pull the tissues laterally, stretching them over the injection site - IUto.de aspiration Gauge: In adults A 25-gauge long needle is preferred, 27-gauge is acceptable - Length: Should be long. This is due to the depth of penetration that may be required - Patient mouth: The patient’s mouth is opened wide - - - - I Position of the Dentist’s non-dominant hand: The ramus is held between the operator’s thumb and index finger. The index or middle finger is placed extraorally on the posterior aspect of the ramus at the same height as the thumb. In the adult mandible the mandibular foramen is often approximately halfway between the operator’s thumb and index finger about halfway up the thumbnail. 1 415 I The syringe is introduced across the premolars of the opposite side aiming to enter mucosa at the level of halfway up the operator’s thumbnail. T the it is withdrawn urinposition When the needle has contacted bone in the correct slightly, aspiration performed, and 1.5 mL of solution deposited slowly (over a minimum of 60 seconds). Aspiration should done. means are aspiration yomji.LIdfwiafoEtnteinghkf I Dr. Mohammed Amjed, UoS, 2023-2024 19 yo 9 ThereMedialthanIAN The inferior alveolar and lingual nerve block This injection anaesthetizes the inferior alveolar nerve and may block transmission in the lingual nerve. When lingual nerve anaesthesia is definitely required a modification to the technique is added. Following injection at the original site the needle is withdrawn halfway through nerve mucosa, aspiration performed, and solution deposited at atlingual this point. The injection continues as the needle is completely withdrawn, stopping just as the needle exits mucosa to prevent local anesthetic spilling into the mouth. Dr. Mohammed Amjed, UoS, 2023-2024 20 (20-25 mm) Henot if y the bone reaching If bony contact is made too soon then the area contacted is probably the internal oblique ridge of the mandible. Deposition of solution here will not anaesthetize the inferior alveolar nerve. Solution= Pull Direct more medially Insert Touch the bone at 20-25 mm If bone is not palpated then it is possible that the needle is placed too far posteriorly. This can result in the needle entering the parotid gland. Injection into this gland can produce loss of transmission in the motor fibers of the facial nerve (this is a temporary but embarrassing problem). facialpalsy Solution= Pull Direct more laterally Insert Touch the bone at 20-25 mm I don'tbend nsidethe issues not recommended be offracture oftheneedle don'tcompletely withdraw • When you hit teh bine prematurely meniang you are going laterlly or theres a variation • Mandibule is ared 20 degrees naturally some people have more aring • When we re insert we make reinjury Māori posunlity of injection Indirect technique Insert needle parallel the same entry point but not teh same target . Insert 1cm then shift your hand to premolars and continue Dr. Mohammed Amjed, UoS, 2023-2024 22 2. The indirect technique - This modification of the inferior alveolar nerve block Q.isimatedwhy - It overcome the problem of contacting bone too soon with the direct method. - Same as direct technique, but the needle is introduced across the occlusal plane of the mandibular teeth on the same side as the injection. insertparallel - The needle penetrates the same point in the mucosa as in point but not direct technique. target sameentery the same ICS - After the needle has been inserted about a centimeter the syringe is swung across to the premolars of the opposite side and the injection then continues as described before for the direct method. avoids early contact of the bone - This method involves more movement of the syringe than the direct technique [disadvantages in comperes to direct technique] Dr. Mohammed Amjed, UoS, 2023-2024 23 what are the Q Problems with inferior alveolar nerve block anaesthesia The inferior alveolar nerve block is not successful in 100% of cases 1. Poor technique. thistechniqueFdependent on the position ofthemandibygamen 2. An ectopic mandibular foramen. This foramen is not in the same position in every patient (and therefore the standard anatomical landmarks will not apply in every case). The position varies with age. In young patients the foramen may be below the occlusal plane, in adults it is usually above this level. I 3. Bending of the needle during administration. Dental local anesthetic needles are not rigid structures and may be deflected during advancement through tissues. Thus, the needle may not reach the intended target area. 4. Accessory nerve supply. The inferior alveolar nerve block may not provide satisfactory anesthesia because nerves other than the inferior alveolar may provide innervation to the pulps of mandibular teeth. (1) lingual nerve cervical nerves (2) long buccal nerve (3) mylohyoid nerve Dr. Mohammed Amjed, UoS, 2023-2024 (4) auriculotemporal nerve (5) upper 24 Long buccal nerve anaesthesia En'ftp.ty Itiiiactio pf iusttoanesthetinthebiffneffy.tn gYfg'ti.EE dingsfpitemoY fatggf'fypffff.fm Long buccal nerve anesthesia is just to anesthetize teh buccal soft tissue DURING EXTRACTION of posteriors No need to anbetshtise the long buccal nerve for restoration/ endo Area of insertion: Mucous membrane distal and buccal to the most distal molar tooth in the arch distaltothemost Foski h.mg long nerve as it passes over the anterior border of the Target area: Buccal ramus li molars Area Anesthetized Soft tissues and periosteum buccal to the mandibular molar teeth Dr. Mohammed Amjed, UoS, 2023-2024 25 Long buccal nerve anaesthesia - extract onlylongbuccal fish oiytap.fm failedto The long buccal nerve may be anaesthetized at various points along its length. This may be performed in a zone from the depth of the mandibular b buccal sulcus to the occlusal plane level in the buccal mucosa. Need for 0- A true long buccal block can be performed by depositing solution at the Dial anterior aspect of the mandibular ramus. (distal and buccal to the lower third molar). The depth of penetration is seldom more than 2 to 4 mm, and usually only 1 or 2 mm When we extract lower 6,7,8 from 4 nd 5 its supplied by long buccal nerve C You just go distal last tooth - A buccal nerve block is carried out after an inferior alveolar nerve block for specific procedures, such as extraction of mandibular molar teeth - The coronoid notch is palpated, and the needle is inserted at this point until bony contact is made. The needle is withdrawn slightly, aspiration performed, and 0.3- 0.5 mL of solution injected slowly. Start of rec 2 Dr. Mohammed Amjed, UoS, 2023-2024 26 36 anesthetize IANblock extraction of anesthetize anesthetize IAN lingualnerve buccal long fillingof Lowercentralincisors infdthff.IN When you give anesthesia we have to exmiane 3 nerve E.g upon extraction, you must examine 3 nerves: 1. Examine the IAN: A. Subjective : mental nerve should be anesthetized by IAF, so you ask teh pateint do the both sides feel teh same ( your comparing to see if theres a difference) B. Objective : place probe of explorer and press on tissue ask teh pateint to sense any pain 2. Examine lingual A. Subjective : have on tongue must be numb 3. Long buccal nerve if it didn'twork flock ii ifeng.ee ntiIattii Teh rst step of extraction you need to separate tissue, if pateint fee pain tehn the lingual nerve isn’t anesthestized Case; Extraction of 36 whihc block do we use? IAN block whihc anestizes IAN + lingual nerve ALSO we need to anetshtise long buccal to anetshtise teh buccal tissue Case: Filling for lower central incisors In ltertaion only near tooth itself —-> if in lteration didn’t work go for block IAN ◦If we extracted we use lingual and buccal in lteration, QWhatare the Dr. Mohammed Amjed, UoS, 2023-2024 high methods27 0 of Gow-Gates mandibular nerve block anything - This method is one of the “high” methods of anesthetizing the inferior alveolar nerve. nerve - The advantage of this method is that it can block transmission in many accessory supplies to the dental pulps including that provided by the lingual, long buccal, mylohyoid and auriculotemporal nerves (if any present). Themes - The aim is to deposit solution at the mandibular condyle. a - There is evidence that this technique is more successful than the conventional inferior alveolar nerve block and that there is less likelihood of intravascular injection. Dr. Mohammed Amjed, UoS, 2023-2024 28 Nerves Anesthetized 1. Inferior alveolar 2. Mental 3. Incisive 4. Lingual 5. Mylohyoid 6. Auriculotemporal 7. Buccal (in 75% of patients) Direction of needle Draw a line from corner of the mouth to the in lteration line or sin upward direction in y axis In x axis from the opposite side of teh mouth the needle is going to be under the 1. Mandibular teeth to the midline ML cusp of lower 7 and by this line will go distally so area pf insertion is higher than IAN it will be on soft tissue distal to upper 7 2. Buccal mucoperiosteum and mucous membranes on the side of injection For x axis you need two points 3. Anterior two thirds of the tongue and floor of the oral cavity ◦Corner of mouth 4. Lingual soft tissues and periosteum ◦ML cusp of upper second molar • for y axis 5. Body of the mandible, inferior portion of the ramus ◦Upward from corner of the mouth till in letration notch 6. Skin over the zygoma, posterior portion of the cheek, and temporal• regions pateint should open their mouth Worley not closed why because the condyle Dr. Mohammed Amjed, UoS, 2023-2024 will go back changing teh alndmaks 29 Yong Areas Anesthetized Gow-Gates mandibular nerve block I 1 IE1 EthEIkhtfupper The technique - Patient’s mouth opened wide cornerofthemonth theopp - The syringe is introduced into the mouth parallel to a plane running from the angle of the mouth to the inter-tragal notch of the ear - across the opposite maxillary canine. The syringe is then directed across the palatal cusps (mesiolingual) of the maxillary second molar on the side receiving the injection and enters the mucosa at a point much higher than that penetrated during the standard Halstead approach. - The needle is advanced through mucosa until bony contact is made on the condyle, withdraw slightly and after aspiration the contents of the cartridge are deposited. The average depth of soft tissue penetration to bone is 25 mm - The patient maintains the mouth in the open position for a few minutes. slide52 IMP why When initially described it was recommended that 3 mL of solution was used and thus a second injection may be required. experience with the GGMNB shows that 1.8 mL is usually adequate to provide clinically acceptable anesthesia in virtually all cases. of OI Dr. Mohammed Amjed, UoS, 2023-2024 side 30 mesial part oftheramus i 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 Dr. Mohammed Amjed, UoS, 2023-2024 108m 1 waittill the insect diffusereally anesthesia takestime 5 10 31 a 84th Gow-Gates mandibular nerve block technique IMP Once the patient closes even slightly, two negatives occur: (1) The thickness of soft tissue increases besits notstretched why (2) The condyle moves in a distal direction Both of these make it more difficult to locate the condylar neck with the needle. KEY it Find Dr. Mohammed Amjed, UoS, 2023-2024 32 Gow-Gates mandibular nerve block a whyisggtecuniguenkteg.ME's - The Gow-Gates technique is a true mandibular nerve block because it provides sensory anesthesia to virtually the entire distribution of V3. The inferior alveolar, lingual, mylohyoid, mental, incisive, auriculotemporal, and buccal nerves all are blocked in the Gow-Gates injection. - Significant advantages of the Gow-Gates technique over IANB include its 1. higher success rate intravascularinjection 2. its lower incidence of positive aspiration (approximately 2% vs. 10% to 15% with the IANB), 3 Anesthe accessorynerves 3. and the absence of problems with accessory sensory innervation to the mandibular teeth. beyou'llanesthetizemorenerves Disadvantage - The time to onset of anesthesia is somewhat longer (5 minutes) than with an IANB (3 to 5 minutes), primarily because of the size of the nerve trunk being anesthetized and the distance of the nerve trunk from the deposition site (approximately 5 to 10 mm). Dr. Mohammed Amjed, UoS, 2023-2024 1 33 • Also called “closed mouth technique” • Mouth is closed during injection • Indicated when? Pateint can’t open their mouth, large tongue we can’t see landmarks • Entry?retrach to see where the loose and tight tissue is located. Enter between tuberosity and croronoid process go for the same approach maxillary block or tuborsoty approach which is teh last point you can see of teh mucogingival junction between loose and hard tissue the difference is not 45 we go parallel ◦Entry point is teh same but different target Ilosedduring Dr. Mohammed Amjed, UoS, 2023-2024 tiutdiffer ifeng.si say target retract inordertosee ftp.fwteshe 34 Akinosi-Vazirani block - closedmouthtechnique This is another “high” block. It is often referred to as the anene but w closedmouth “Akinosi” technique. As was the case with the Gow-Gates technique, it may anesthetize accessory supply to the dental pulps from the lingual, long buccal and mylohyoid nerves. It has no bony end-point. So the depth of soft tissue penetration is somewhat arbitrary. notspecific Akinosi recommended a penetration depth of 25 mm in the average-sized adult, measuring from the maxillary tuberosity. is administered with the patient’s mouth closed. It can achieve anaesthesia of the inferior alveolar nerve in cases where access to the normal approach is difficult due to trismus or because of a large or uncontrollable tongue. Giudicated Lower aspiration rate (<10%) than with the inferior alveolar nerve block Gow IANB For gate opehfh.tn Dr. Mohammed Amjed, UoS, 2023-2024 givenwhenpt can't 35 I 0111 ge argue whereofselemolars interferes tongue 0 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 (coronoid process laterally; tuberosity medially) 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 from the foramen ovale toward the mandibular foramen (the height of injection with the Vazirani-Akinosi being below that of the GGMNB but above that the IANB) Dr. Mohammed Amjed, UoS,of 2023-2024 36 4 bet g g The Technique is as follows laterally offammed - Place your left index finger or thumb on the coronoid notch, reflecting the tissues on the medial aspect of the ramus laterally. Reflecting the soft tissues aids in visualization of the injection site and decreases trauma during needle insertion. - Ask the patient to occlude gently with the cheeks and muscles of mastication relaxed. - 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, with the needle at the level of the mucogingival junction of the maxillary third (or second) molar - Advance the needle 25 mm into tissue (for an average-sized adult). This distance is measured from the maxillary tuberosity. The tip of the needle should lie in the midportion of the pterygomandibular space, close to the branches of V3 Dr. Mohammed Amjed, UoS, 2023-2024 37 - Orientation of the bevel : The bevel must be oriented away from the bone of the mandibular ramus. - Deposit 1.5 to 1.8 mL of anesthetic solution in approximately 60 seconds. - Motor nerve paralysis develops. The patient with trismus begins to notice increased ability to open the jaws shortly after the deposition of anesthetic. Dr. Mohammed Amjed, UoS, 2023-2024 38 Q Where is LA for incisive mental here deposited at mentalforamen seen inpano PA not always located Q How is it Q What areas are anesthetized Buced soft tissue from pan fanterior Dr. Mohammed Amjed, UoS, 2023-2024 Teeth PM A 39 Ian'tblockincisivenervewithoutblockingmental Incisive and mental nerve block - involves depositing local anesthetic solution at the mental foramen. The hope is that sufficient solution will enter the foramen to block transmission in the incisive nerve to anesthetize the premolar and anterior mandibular teeth. - As is the case with the mandibular foramen, the mental foramen is not in a constant position although it can be visualized in periapical radiographs. Unfortunately, it is not always apparent on panoramic radiographs. - This injection is useful in providing soft tissue anaesthesia, as the mental nerve is readily accessible in the soft tissues. - The amount entering the foramen to anaesthetize the incisive branch must vary. The patient has the mouth partly open and the needle is inserted through reflected mucosa aiming for bone in the region between the premolar apices Dr. Mohammed Amjed, UoS, 2023-2024 sucessfulratepremolarante a patient 40 Incisive and mental nerve block only nerveyou can massage 1 - Once bone is contacted the needle is withdrawn slightly, aspiration performed and 1.5 mL of solution deposited slowly. Massaging (or just pressure) the tissues following injection may encourage entry of solution into the mental foramen. I - Pulpal anaesthesia is not as reliable following incisive nerve blocks compared with inferior alveolar nerve blocks. Incisive nerve block anaesthesia is unreliable for lower incisors, but premolar pulpal anaesthesia of short duration can be obtained. Dr. Mohammed Amjed, UoS, 2023-2024 41 Incisive and mental nerve block b incisive Dr. Mohammed Amjed, UoS, 2023-2024 42 Incisive and mental nerve block - Positive Aspiration 5.7% Area of insertion: Mucobuccal fold at or just anterior to the mental foramen. Target area: Mental foramen, through which the mental nerve exits and inside of which the incisive nerve is located - The mental foramen usually is found around the apex of the second premolar. However, it may be found anterior or posterior to this site (manual palpation & radiograph are beneficial). - Advance the needle slowly until the foramen is reached. The depth of penetration is 5 to 6 mm. For the mental nerve block to be successful, there is no need to enter the mental foramen or to contact bone. - For Incisive n. Advance the needle slowly until the mental foramen is reached. The depth of penetration is 5 to 6 mm. There is no need to enter the mental foramen for the incisive nerve block to be successful. 43 Dr. Mohammed Amjed, UoS, 2023-2024 Dr. Mohammed Amjed, UoS, 2023-2024 44 Dr. Mohammed Amjed, UoS, 2023-2024 45