Mandibular Nerve Blocks Part 2 PDF

Buccal Nerve Block Other Common Names: Long buccal nerve block, buccinator nerve block Nerve Anesthetized: Buccal (a branch of the anterior division of the mandibular) Area Anesthetized: Soft tissues and periosteum buccal to the mandibular molar teeth Buccal Nerve Block Indication: When bucca...

Buccal Nerve Block Other Common Names: Long buccal nerve block, buccinator nerve block Nerve Anesthetized: Buccal (a branch of the anterior division of the mandibular) Area Anesthetized: Soft tissues and periosteum buccal to the mandibular molar teeth Buccal Nerve Block Indication: When buccal soft-tissue anesthesia is necessary for dental procedures in the mandibular molar region. Contraindication: Infection or acute inflammation in the area of injection. Advantages: 1. High success rate 2. Technically easy Disadvantages: Potential for pain if the needle contacts periosteum during injection. Positive Aspiration: 0.7% Buccal Nerve Block Alternatives: 1. Buccal infiltration 2. Gow-Gates mandibular nerve block 3. Vazirani-Akinosi mandibular nerve block 4. PDL injection 5. Intraosseous injection 6. Intraseptal injection Buccal Nerve Block Technique 1. A 25-gauge long needle is recommended. This is most often used because the buccal nerve block is usually administered immediately after an IANB. A 27-gauge long needle also may be used. The long needle is recommended because of the posterior deposition site, not the depth of tissue insertion (which is minimal). 2. Area of insertion: mucous membrane distal and buccal to the most distal molar tooth in the arch. 3. Target area: buccal nerve as it passes over the anterior border of the ramus. 4. Landmarks: mandibular molars, mucobuccal fold. 5. Orientation of the bevel: toward bone during the injection. Buccal Nerve Block 6. Procedure a. Assume the correct position. (1) For a right buccal nerve block, a right-handed administrator should sit at the 8 o’clock position directly facing the patient (Fig. A). (2) For a left buccal nerve block, a right-handed administrator should sit at 10 o’clock facing in the same direction as the patient (Fig. B). b. Position the patient supine (recommended) or semisupine.  Buccal Nerve Block c. Prepare the tissues for penetration distal and Buccal to the most posterior molar.∗ (1) Dry with sterile gauze. (2) Apply topical antiseptic (optional). (3) Apply topical anesthetic for 1 to 2 minutes. d. With your left index finger (if right-handed), pull the buccal soft tissues in the area of injection. Laterally so that visibility will be improved. Taut tissues permit an atraumatic needle penetration. e. Direct the syringe toward the injection site with. The bevel facing down toward bone and the syringe aligned parallel with the occlusal plane on the side of injection but buccal to the teeth (Fig. A). f. Penetrate mucous membrane at the injection site, distal and buccal to the last molar (Fig. B).  Buccal Nerve Block g. Advance the needle slowly until mucoperiosteum is gently contacted. (1) To prevent pain when the needle contacts mucoperiosteum, deposit a few drops of local anesthetic just before contact. (2) The depth of penetration is seldom more than 2 to 4 mm, and usually only 1 or 2 mm. h. Aspirate. i. If negative, slowly deposit 0.3 ml over 10 seconds. (1) If tissue at the injection site balloons (becomes swollen during injection), stop depositing solution. (2) If solution runs out the injection site (back into the patient’s mouth) during deposition (a) Stop the injection. (b) Advance the needle deeper into the tissue.∗ (c) Reaspirate. (d) Continue the injection. j. Withdraw the syringe slowly and immediately make the needle safe. k. Wait approximately 1 minute before commencing the planned dental procedure. Buccal Nerve Block Signs and Symptoms 1. Because of the location and small size of the anesthetized area, the patient rarely experiences any subjective symptoms. 2. Objective: Instrumentation in the anesthetized area without pain indicates satisfactory pain control. Safety Features 1. Needle contacting bone and preventing over insertion. 2. Minimum positive aspiration. Precautions 1. Pain on insertion from striking unanesthetized periosteum. This can be prevented by depositing a few drops of local anesthetic before contacting the periosteum. 2. Local anesthetic solution not being retained at the injection site. This generally means that needle penetration is not deep enough, the bevel of the needle is only partially in tissues, and solution is escaping during the injection. a. To correct: (1) Stop the injection. (2) Insert the needle to a greater depth. (3) Reaspirate. (4) Continue the injection. Buccal Nerve Block Failures of Anesthesia: Rare with the buccal nerve block 1. Inadequate volume of anesthetic retained in the tissues. Complications 1. Few of any consequence. 2. Hematoma (bluish discoloration and tissue swelling at the injection site). Blood may exit the needle puncture point into the buccal vestibule. To treat: Apply pressure with gauze directly to the area of bleeding for a minimum of 3 to 5 minutes. Mental Nerve Block Nerve Anesthetized: Mental, a terminal branch of the inferior alveolar nerve. Areas Anesthetized: Buccal mucous membranes anterior to the mental foramen (around the second premolar) to the midline and skin of the lower lip and chin. Indication: When buccal soft-tissue anesthesia is necessary for procedures in the mandible anterior to the mental foramen, such as the following: 1. Soft-tissue biopsies 2. Suturing of soft tissues Contraindication: Infection or acute inflammation in the area of injection Advantages: 1. High success rate 2. Technically easy 3. Usually entirely atraumatic Disadvantage: Hematoma Positive Aspiration: 5.7%  Mental Nerve Block Alternatives: 1. Local infiltration 2. Inferior alveolar nerve block 3. Gow-Gates mandibular nerve block 4. Vazirani-Akinosi nerve block Technique: 1. A 25- or 27-gauge short 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 (usually located between the apices of the first and second premolars) 4. Landmarks: mandibular premolars and mucobuccal fold Mental Nerve Block 5. Orientation of the bevel: toward bone during the injection a. Assume the correct position. (1) For a right or left mental nerve block. a right handed administrator should sit comfortably in front of the patient so that the syringe may be placed into the mouth below the patient’s line of sight. b. Position the patient. (1) Supine is recommended, but semisupine is acceptable. (2) Have the patient partially close. This permits greater access to the injection site. Mental Nerve Block c. Locate the mental foramen. (1) Place your index finger in the mucobuccal fold and press against the body of the mandible in the first molar area. (2) Move your finger slowly anteriorly until the bone beneath your finger feels irregular and somewhat concave. Mental Nerve Block (a) The bone posterior and anterior to the mental foramen is smooth; however, the bone immediately around the foramen is rougher to the touch. (b) The mental foramen usually is found around the apex of the second premolar. However, it may be found either anterior or posterior to this site. (c) The patient may comment that finger pressure in this area produces soreness as the mental nerve is compressed against bone. (3) If radiographs are available, the mental foramen may be located easily. d. Prepare tissue at the site of penetration. (1) Dry with sterile gauze. (2) Apply topical antiseptic (optional). (3) Apply topical anesthetic for minimum of 1 minute. Mental Nerve Block e. With your left index finger pull the lower lip and buccal soft tissues laterally. (1) Visibility is improved. (2) Taut tissues permit an atraumatic penetration. f. Orient the syringe with the bevel directed toward bone. g. Penetrate the mucous membrane at the injection site, at the canine or first premolar, directing the syringe toward the mental foramen. h. 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. i. Aspirate. j. If negative, slowly deposit 0.6 ml (approximately one third cartridge) over 20 seconds. If tissue at the injection site balloons (swells as the anesthetic is injected), stop the deposition and remove the syringe. k. Withdraw the syringe and immediately make the needle safe. (1) Wait 2 to 3 minutes before commencing the procedure. Mental Nerve Block Signs and Symptoms: 1. Subjective: Tingling or numbness of the lower lip 2. Objective: No pain during treatment Safety Feature: The region is anatomically “safe.” Precautions: Striking the periosteum produces discomfort. To prevent: Avoid contact with the periosteum or deposit a small amount of solution before contacting the periosteum. Failures of Anesthesia: Rare with the mental nerve block Complications: 1. Few of consequence 2. Hematoma (bluish discoloration and tissue swelling at the injection site). Blood may exit the needle puncture point into the buccal fold. To treat: Apply pressure with gauze directly to the area of bleeding for at least 2 minutes. Incisive Nerve Block Other Common Name: Mental nerve block (inappropriate) Nerves Anesthetized. Mental and incisive. Areas Anesthetized: 1. Buccal mucous membrane anterior to the mental foramen, usually from the second premolar to the midline. 2. Lower lip and skin of the chin. 3. Pulpal nerve fibers to the premolars, canine, and incisors. Indications: 1. Dental procedures requiring pulpal anesthesia on mandibular teeth anterior to the mental foramen. 2. When IANB is not indicated a. When six, eight, or ten anterior teeth (e.g., canine to canine or premolar to premolar) are treated, the incisive nerve block is recommended in place of bilateral IANBs. Contraindication: Infection or acute inflammation in the area of injection Incisive Nerve Block Disadvantages: 1. Does not provide lingual anesthesia. The lingual tissues must be injected directly if anesthesia is desired. 2. Partial anesthesia may develop at the midline because of nerve fiber overlap with the opposite side (extremely rare). Local infiltration on the buccal of the mandibular central incisors may be necessary for complete pulpal anesthesia to be obtained. Positive Aspiration: 5.7% Alternatives: 1. Local infiltration for buccal soft tissues and pulpal anesthesia of the central and lateral incisors. 2. Inferior alveolar nerve block 3. Gow-Gates mandibular nerve block 4. Vazirani-Akinosi mandibular nerve block 5. Periodontal ligament injection Incisive Nerve Block Technique: 1. A 25-gauge short needle is recommended (although a 27-gauge short is more commonly used and is perfectly acceptable). 2. Area of insertion: mucobuccal fold at or just anterior to the mental foramen. 3. Target area: mental foramen, through which the mental nerve exits and inside of which the incisive nerve is located. 4. Landmarks: mandibular premolars and mucobuccal fold. 5. Orientation of the bevel: toward bone during the injection. Incisive Nerve Block 6. Procedure a. Assume the correct position. (1) For a right or left incisive nerve block and a right-handed administrator, sit comfortably in front of the patient so that the syringe may be placed into the mouth below the patient’s line of Sight. b. Position the patient. (1) Supine is recommended, but semisupine is acceptable. (2) Request that the patient partially close; this will permit greater access to the injection site. c. Locate the mental foramen. Incisive Nerve Block (1) Place your thumb or index finger in the mucobuccal fold against the body of the mandible in the first molar area. (2) Move it slowly anteriorly until you feel the bone become irregular and somewhat concave. (a) The bone posterior and anterior to the mental foramen feels smooth; however, the bone immediately around the foramen feels rougher to the touch. (b) The mental foramen is usually found at the apex of the second premolar. However, it may be found either anterior or posterior to this site. (c) The patient may comment that finger pressure in this area produces soreness as the mental nerve is compressed against bone. (3) If radiographs are available, the mental foramen may be located easily.  Incisive Nerve Block d. Prepare tissues at the site of penetration. (1) Dry with sterile gauze. (2) Apply topical antiseptic (optional). (3) Apply topical anesthetic for minimum of 1 minute. e. With your left index finger pull the lower lip and buccal soft tissue laterally. (1) Visibility is improved. (2) Taut tissues permit atraumatic penetration. f. Orient the syringe with the bevel toward bone. g. Penetrate mucous membrane at the canine or first premolar, directing the needle toward the mental foramen. h. 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.  Incisive Nerve Block i. Aspirate. j. If negative, slowly deposit 0.6 ml (approximately one third of a cartridge) over 20 seconds. (1) During the injection, maintain gentle finger pressure directly over the injection site to increase the volume of solution entering into the mental foramen. This may be accomplished with either intraoral or extraoral pressure. (2) Tissues at the injection site should balloon, but very slightly. k. Withdraw the syringe and immediately make the needle safe. l. Continue to apply pressure at the injection site for 2 minutes. m. Wait 3 to 5 minutes before commencing the dental procedure. (1) Anesthesia of the mental nerve (lower lip, buccal soft tissues) is observed within seconds of the deposition. (2) Anesthesia of the incisive nerve requires additional time. Incisive Nerve Block Signs and Symptoms: 1. Subjective: Tingling or numbness of the lower lip 2. Objective: No pain during dental therapy Safety Feature: Anatomically “safe” region Precaution: Usually an atraumatic injection unless the needle contacts periosteum or solution is deposited too rapidly Failures of Anesthesia: 1. Inadequate volume of anesthetic solution in the mental foramen, with subsequent lack of pulpal anesthesia. 2. Inadequate duration of pressure after injection. It is necessary to apply firm pressure over the injection site for a minimum of 2 minutes to force the local anesthetic into the mental foramen and provide anesthesia of the second premolar, which may be distal to the foramen. Failure to achieve anesthesia of the second premolar is usually caused by inadequate application of pressure after the injection. Complications 1. Few of any consequence 2. Hematoma Infiltration Needle Selection: A 25- or 27-gauge long needle is common following an lA injection. If administered separately, a 27 gauge short needle may be used. Injection Procedure: To gain access to the site of penetration, reflect the lip to expose the mucobuccal fold opposite the buccal surfaces of the tooth or teeth to be anesthetized. Penetrate into the mucobuccal fold of the tooth (single root) or mesial and distal apical areas buccal to the tooth (multiple roots) without making bony contact. Following a negative aspiration , slowly deposit a minimum of between 0.6 ml (1/3 of a cartridge) and 0.9 ml (1/2 of a cartridge) of solution over each apex. The insertion depth varies and is anywhere from about 3 to 6 mm. If a lingual infiltration is also desired, a similar procedure can be followed except that the deposition sites are either lingual to each apex or a single deposition site has been described that is located just below the attached gingiva lingual to the tooth.