VIII - Local and Regional Anesthesia For Mandible

LOCAL
AND REGIONAL
ANESTHESIA IN THE
LOWER JAW
Comprises of:

1. Inferior alveolar nerve block (anesthesia at the
lingula);
2. Lingual nerve block;
3. Mental and incisive nerve block;
4. Buccal nerve block;
5. Masseter nerve block;
6. Simultaneous anesthesia
Anatomy
http://collegeofdiplomates.org/
© Baart et al. 2009

Inferior alveolar
nerve block -‐
intraoral
Inferior alveolar nerve
block

Nerves Anesthetized:

Ø Inferior alveolar
Ø Incisive
Ø Mental
Ø Lingual
=> Areas anesthetized!!
Inferior alveolar nerve block
Indications:
Procedures :
-‐ on the mandibular teeth to
the midline,
-‐ body of the mandible,
-‐ buccal mucoperiosteum
anterior to the M1 up to
the midline,
-‐ soft tissues of the lower lip
and mental area. © Malamed S.F. 2004
Contraindications:
Ø Presence of infections or tumors in the puncture area.
Alternative techniques:
1. Mental nerve block for buccal soft tissues anterior to M1;
2. Supraperiosteal infiltration for pulpal anesthesia of incisors;
3. Gow Gates procedure;
4. Vazirani-‐Akinosi mandibular nerve block
5. Periodontal ligament infiltration.

Disadvantages:
Advantages
§ Area of injection is vascularized; 10
-‐15% chance of positive aspiration

§ Practitioner § Unlikely to anaesthetize accessory
nerves trunks
acceptance § Unlikely to anaesthetize long buccal
nerve

§ Faster onset than § Difficult to see landmarks in some
patients (e.g., macroglossia)
higher blocks §

Wide area of anesthesia

§ Bony landmark

Anatomical landmarks:

Ø Internal side of the
ascending ramus;
Ø Sigmoid notch;
Ø Coronoid process;
Ø Temporal crest;
Ø Anterior border of the
ramus;
Ø Retromolar triangle; © Malamed S.F. 2004
Anatomical landmarks:

Ø Mandibular canal;
Ø Lingula;
Ø Inferior alveolar, lingual
and buccal nerve
Ø Mental foramen.
© Malamed S.F. 2004

block
Landmarks
1. Lingula
2. Distal border of the ramus
3. Coronoid process 9
4. Sigmoid notch
5. Neck of the condyle
6. Mandibular canal 8
7. Temporal crest

2. Angle
9. Inferior border of the ramus
11. Mandibular foramen
13. Mental foramen
19. Oblique line

Puncture landmarks:

1. Lower molars occlusal plane;
2. Temporal crest, medial and

posterior to the anterior
border of the ramus;
3. Pterygomandibular raphe.


Patient’s position: Dentist’s position:

Ø Head in slight extension; Ø Right IANB – 8 o’clock
position, facing the
patient
Ø Mouth fully opened!!! Ø Left IANB – 10 o’clock
position
block
Puncture: Needle direction:

Ø between temporal crest Ø Parallel to the sagittal plane
and pterygomandibular when the contact with the
raphe bone, at the temporal crest,
is established;
Ø 1 cm above the occlusal Ø Then, while the needle is
plane of the lower molars pushed backwards the
syringe body goes to the
opposite side.
© Baart et al. 2009 © Malamed S.F. 2004

Anesthetic deposit:
Ø Can start when the first bone contact is established
and goes on up to 1,5-‐2 cm depth;
Ø at 1 cm depth the lingual nerve is anesthetized;
Ø at 1,5 -‐ 2 cm the inferior alveolar nerve is
anesthetized;
Ø Can start only when lingula is reached and
continues till the needle is taken out from tissues
Ø Aspiration is done before each anesthetic deposit.
block

Dielaufe technique:
-‐ puncture -‐ 10 mm above the lower molars occlusal plane,
lateral to the pterygomandibular raphe
-‐ syringe -‐ in contact with the opposite oral commissure;
-‐ needle is inserted directly behind the lingula, at 2,5 – 3 cm
depth;
-‐ anesthetic is left in place after aspiration;
-‐ Retracting the needle, at 1 cm depth, the lingual nerve can
be reached;
-‐ Very simple technique

block
Dielaufe technique:
1. Palpate the anterior ramus border at the coronoid notch.

http://collegeofdiplomates.org
block
Dielaufe technique:
2. Slide the finger or thumb posteriorly and medially until a ridge of
bone is palpated. This is the internal oblique ridge, temporal crest.

block
Dielaufe technique:

3. Insert the needle into soft tissue in the
pterygotemporal depression, which is halfway
between the palpating finger or thumb and the
pterygomandibular raphe.

4. Approximate the height of the injection by the
middle of the palpating fingernail or thumbnail.

Dielaufe technique:
5. Ensure that the barrel of the
syringe is located over the
contralateral mandibular bicuspids.

6. Insert until bone is contacted, and
then withdraw ~1 mm. The depth
of insertion for the average-‐sized
adult is approximately 25 mm.
7. Aspirate
8. Leave the anesthetic substance
© Baart et al. 2009 © Malamed S.F. 2004

Maccary technique
-‐ puncture – 1,5 cm above the lower molars occlusal
surface;
-‐ 2-‐3 mm, medial to the temporal crest;
-‐ syringe -‐ barrel at the level of contralateral upper
LI.
Sargenti technique
-‐ puncture -‐ directly at the level of mandibular
foramen
-‐ medial to the temporal crest, 8-‐10 mm
above the lower molar occlusal surface;
-‐ syringe – barrel in contact with contralateral upper
C-‐PM
Difficulties

Ø Anatomical variations of the lingula (form, dimension);
Ø Variable inclination of the mandibular ramus to the sagittal
plane;
Ø Width variations of the ramus;
Ø Position variation of the mandibular foramen in the vertical
plane;
Ø Presence of some accessory nervous branches responsible
for the dental pulp;
block

The reasons for incomplete local anaesthesia are as follows:

1. local anaesthetic pka -‐ ph factors and tissue ph factors

2. needle-‐to-‐jaw size discrepancy

3. needle deflection

4. volume factors – time – Wait 3-‐4 min!!!!

5. skeletal and neuroanatomic variations

6. local anaesthetic or vasoconstrictor degradation

7. non-‐cooperative patients
Failures of Anesthesia:

Deposition of anesthetic
too far medially -‐ LA
is blocked by the
s p h e n o m a n d i b u l a r
ligament, dysphagia
block
Failures of Anesthesia:

Ø Deposition of anesthetic too low – below the
mandibular foramen
Ø Deposition of LA too laterally on the ramus –
lack of anesthesia
Ø Deposition of LA too posteriorly – facial nerve
anesthesia
Ø Deposition of LA too superiorly – anesthesia of
auriculotemporal nerve, masseter muscle
paralysis
Accidents:
Ø during needle penetration:
-‐ puncture of the inferior alveolar vessels in the
pterygomandibular space with the intravascular
anesthetic deposit generating:
-‐ paleness,
-‐ palpitations,
-‐ syncope.
-‐ lack of anesthesia
Accidents:
Ø needle
-‐ too medial to the pterygomandibular raphe,
the pharyngeal wall will be infiltrated resulting in
dysphagia
-‐ to deep (posterior):
-‐ transient paralysis of the facial nerve
-‐ too lateral: the needle will stop into the bone,
anesthesia not obtained
-‐ too high: masseter muscle paralysis.

block
Complications
1. Hematoma
a. Swelling of tissues on the medial side of the ramus
b. Management: pressure 3-‐5 min
2. Trismus
a. Muscle soreness or limited movement
b. Causes and management
3. Transient facial paralysis

-‐ Deposition of LA in the body of the parotid gland
Inferior alveolar
nerve block -‐
extraoral
Indications:
-‐ when the intraoral access is restricted by:
-‐ trismus,
-‐ inflammations
-‐ tumors.

Ø Ways to perform:
Ø Submandibular;
ØRetromandibular;
ØSigmoid notch.
block -‐ submandibular
Patient’s position:

Ø Head -‐ complete extension and rotation to
the opposite site in order to:
ØExpose the submandibular area;
ØEvidence the bone at the lower border
and angle.
Puncture: Needle
direction:
Øunder the lower Ø upward
border; Ø The lower insertion of
Ø at 1,5 cm anterior to the internal pterygoid
the distal border of muscle is traversed;
the ramus; Ø The needle parallel with
the distal border of the
ramus, 1,5 cm anterior

Anesthetic deposit
Ø at 4-‐4,5 cm depth, the needle must be 7-‐8 cm long

Inferior alveolar nerve block -‐
submandibular
submandibular
Difficulties
Ø bone prominences at the insertion of the

internal pterygoid muscle
block -‐ retromandibular
Ø Head completly rotated to the opposite side
Ø Landmarks:
ØDistal border of the ramus
ØMandibular angle
Ø Temporal process of the zygomatic
bone.
Ø Straight forward
Ø under the ear lobe,
Ø at half distance between
the mandible angle and
the root of the zygomatic
arch

Anesthetic deposit:

Ø at 2,5 cm depth;
Ø at 3-‐4 cm depth in patients with abundant soft

tissues of the face.
retromandibular
retromandibular

Accidents:
Ø When going through parotid gland needle can
puncture:
-‐ facial nerve;
-‐ external carotid artery;
-‐ jugular vein.
Inferior alveolar nerve block –
sigmoid notch
Indications:

Ø trismus,
Ø perimandibular inflammation;
Ø cystic tumors of the angle or ramus.
block – sigmoid notch
Ø Head rotated to the opposite side in order to
evidence:
Ø the inferior border of the zygomatic
arch, anterior to the temporal
eminence

Ø at the level of the sigmoid Ø horizontal towards the
notch, midline;
Ø over the sigmoid notch,
Ø below the inferior border anterior to the condile
of the zygomatic arch neck;
Ø Downward on the
internal side of the
ramus

Anesthetic deposit

Ø at 4 cm depth

Ø A curved needle is necessary.

Alternative techniques
VAZIRANI-‐AKINOSI
Indications:
§ Anesthesia of inferior alveolar and lingual nerve;
§ Limited mouth opening;
§ Inability to visualize landmarks for classical techniques.
§ Patients with a strong gag reflex, macroglossia
Contraindications:
§ Infections or tumors in the area of puncture;
§ Inability to gain access.
§ Difficult in patients with pronounced zygomatic buttress or
internal oblique ridge, widely flaring ramus
VAZIRANI-‐AKINOSI

VAZIRANI-‐AKINOSI
Advantages: Disadvantages:

§ Difficult to visualize the
§ Relatively atraumatic;
path of insertion;
§ Close mouth (trismus). § Depth of penetration
§ Fewer postoperative arbitrary. (no bony
complications contact)
§ Lower aspiration rate § Potentially traumatic –
needle close to
periosteum
VAZIRANI-‐AKINOSI
§ Head slightly rotated to the
opposite site;
§ Mouth closed with cheeks and
muscle relaxed.
Dentist’s position:
§ In front and right side of the
patient;
§ Index or thumb of the left
hand retracts the soft tissue
and fixates the coronoid
notch.
VAZIRANI-‐AKINOSI
Landmarks:
§ Mucogingival
junction of the
maxillary 3rd or 2nd
molar;
§ Maxillary tuberosity;
§ Coronoid notch.
VAZIRANI-‐AKINOSI
http://www.nature.com/bdj/journal/
VAZIRANI-‐AKINOSI
Puncture:
§ In the buccal mucosa covering the ascending ramus, at
the level of mucogingival junction of the maxillary 3rd or
2nd molar;
§ Laterally to the maxillary tuberosity;
§ Medially to the coronoid notch.

Needle direction:
§ Posteriorly and slightly laterally, parallel with the occlusal
plane of the upper molars;
§ Tangent to the maxillary tuberosity, as close as possible to
the coronoid process;
§ At a depth of 2,5 cm the anesthetic is released.
VAZIRANI-‐AKINOSI

VAZIRANI-‐AKINOSI
Technique:
1. Prepare the needle and syringe by bending the
needle approximately 15o to 20o. This bend
accommodates for the flare of the ramus. Do not
bend the needle more than once when
preparing.

2. Ask the patient to slightly open (a few
millimeters) his or her mouth and execute a
lateral excursion toward the side that is being
injected.
VAZIRANI-‐AKINOSI
§ Technique:
§ 3. Palpate the
coronoid notch
a n d s l i d e t h e
finger or thumb to
r e s t o n t h e
internal oblique
ridge
VAZIRANI-‐AKINOSI
Technique:

4. Move the finger
or thumb
superiorly
approximately 10
mm.

VAZIRANI-‐AKINOSI
Technique:

5. Insert the needle tip
between the finger and
maxilla at the height of the
maxillary buccal
mucogingival line. Orient
the bend of the needle such
that the needle looks as
though it is going laterally
in the direction of the ear
lobe on the injection side.
The needle remains parallel
to the occlusal plane. http://collegeofdiplomates.org/
VAZIRANI-‐AKINOSI
Technique:
6. After the needle has
been inserted 5 mm,
remove the palpating
finger or thumb and use
it to reflect the
maxillary lip and oral
commissure to enhance
vision.

7. Inject to the final
depth of approximately
28 mm for the average-‐
sized adult, therefore
visualizing the rest of http://collegeofdiplomates.org/
needle remaining
outside the tissue (if
using a long needle).

VAZIRANI-‐AKINOSI
Technique:
8. Aspirate.

9. Inject a full cartridge.
Onset and duration
Onset for hard tissue anaesthesia is 3 to 4 minutes

There is an increased possibility of obtaining long buccal
nerve anaesthesia as compared to the inferior alveolar
nerve block.
VAZIRANI-‐AKINOSI
Complications:
§ Hematoma (rare);
§ Trismus (rare);
§ Transient facial nerve paralysis.
Lingual nerve
block
Lingual nerve block
Indications:
Surgical procedures on:
ú attached gingiva of the lingual side of the mandible,
midline to 3rd molar;
ú floor of the mouth;
ú anterior 2/3 of the tongue.
Contraindications:
Presence of inflamations or tumors in the posterior 1/3 of
the mouth floor
Lingual nerve block
Alternative techniques:
Ø Simultaneous anesthesia:
Ø along with IAN block;
ØGow-‐Gates;
Ø Veisbrem;
ØGinestet.
Lingual nerve block
Landmarks:

Ø Internal angle of the mandible
Ø Last lower molar;
Ø Mandibulo-‐lingual sulcus.
Lingual nerve block
Ø Head flexed, rotated to the same side;
Ø Mouth largely open;
Ø The tongue is retracted medially with a
dental mirror or with a tongue retractor.

Lingual nerve block
Puncture:
Ø at the level of 3rd lower
molar;
Ø anterior and medial to the
internal angle;
Ø in the mandibulo-‐lingual
sulcus;
Ø half distance from the
gingival free margin and the
base of the tongue © Malamed S.F. 2004
Lingual nerve block
Needle direction:
Ø backward and slightly
outward, toward the
bone.
Anesthetic deposit:
Ø immediately under the
mucosa, over an area of 1
cm length;
Ø 1,5-‐2 ml of anesthetic.
Lingual nerve block
D. Theodorescu
Indications

§ Anesthesia of the:
ú Anterior 1/3rd of the mouth floor and tongue;
ú Gingiva on the lingual side of the frontal teeth (CI-‐
C).
Lingual nerve block
D. Theodorescu
Landmarks:
Ø Lower canine or first premolar;
Ø The angle between the lingual gingiva of the
mandible and the floor of the mouth

Lingual nerve block
D. Theodorescu

Ø at the level of the C or Ø Downward and slightly
PM1, in the angle outward, towards the
between the mandible bone
and the mouth floor;
Ø a thin needle is used;
Lingual nerve block
D. Theodorescu

Anesthetic deposit

Ø at 0,5 cm depth;
Ø about 1,5-‐2 ml of anesthetic solution.

Whole tongue anesthesia

Ø Can be done through a single injection;
Ø The puncture is done in the submental area, on the
midline, half distance between the hyoid bone and the
mandible;
Ø The needle progress through skin, subcutaneous
tissue, muscles of the mouth floor and then enters the
tongue at it’s base;
Ø The anesthetic solution is infiltrated progressively.
Mental and
incisive nerve
block
Mental and incisive nerve block
Indications
§ Procedures on:
ú Teeth, alveolar bone, vestibular mucosa from midline
to PM1-‐PM2;
ú Soft tissues of the labio-‐mental area – biopsies,
sutures
§ Completion: of the contralateral inferior alveolar
nerve block;
§ Treatment: of the trigeminal neuralgia having
the trigger zone on mental nerve.
Anesthesia of the:

Ø Lower lip;
Ø Mental area;
Ø Bone;
Ø Teeth, periodontium, buccal (vestibular)
mucosa from middle line to PM1-‐PM2.
Mental and incisive nerve
block
Alternatives:

1. Local infiltration
2. IAN block
3. Vazirani-‐Akinosi nerve block
4. Gow-‐Gates or other simultaneous nerve
block

Landmarks:
Ø Mental foramen – located on
the external side of the
mandibular body, ½ distance
between the alveolar process
and the lower border;
Ø Between the PM1 and PM2
Ø In edentulous patients: ½
distance between the symphysis
and the anterior border of the
masseter m.
§ In edentulous patients – the mental foramen

can reach the top of the alveolar process due to
the resorption of the bone
§ Rx!!!!!
Mental and incisive nerve
block
http://jiskjoseph.com
Intraoral
-‐ head flexed, mouth half
opened;
Puncture:
-‐ in the lower vestibule, in the
mobile mucosa, at the level of
the mesial root of the M1
Intraoral
Needle direction:
-‐ oblique, downward, inward and forward, in an
angle of 15-‐20° with the axis of the PM 2
Anesthetic deposit:
-‐ 0,5-‐1ml
-‐ for the incisive nerve the needle must penetrate
the incisive canal for another 4-‐5mm and another
0,5 ml solution must be injected.

Intraoral

Extraoral
Indications:
Procedures: on the labio-‐mental soft tissues
Anesthesia: same as previous;
Treatment: of trigeminal neuralgia.

Extraoral
-‐ head slightly rotated to the opposite side.
Puncture:
-‐ in the cheek, at the level of the oral
commissure, at about 2 cm posterior, above and
behind the mental foramen.
Extraoral
Needle direction:
-‐ downward, inward and forward, through the soft
tissues up to the bone. Find the mental foramen
and, if needed, enter the canal for 0,5 cm.

Anesthetic deposit:
-‐ at a distance of 1,5-‐2cm from the puncture;
-‐ same quantity as intraoral.

Extraoral
Buccal nerve block
Buccal nerve block
Anesthesia of the:

Ø Gingival and buccal mucosa corresponding to
the lower molars;
Ø Mucosa of the cheek
Ø The skin and muscles of the cheek and oral
commissure.
Buccal nerve block
Indications:

Procedures: on soft tissues of the cheek;

Anesthesia: as a completion for the buccal
mucosa corresponding to the lower molars.
Buccal nerve block
Intraoral
Landmarks:

Ø Anterior margin of the coronoid process;
Ø Upper molars occlusal plane;
Ø 1 cm posterior and inferior from Stenson’s duct papilla

Buccal nerve block
Intraoral

Ø Mouth fully open;
Ø Head rotated to the same side of the

anesthesia.
Buccal nerve block
Intraoral

Ø at the junction Ø horizontal, backward
between the anterior and outward till the bone
margin of the contact with the
coronoid process with coronoid process is
obtained;
Ø occlusal plane of the
Ø syringe barrel in contact
upper molars. with the contralateral
oral commisure.
Buccal nerve block
Extraoral

Landmarks:

Ø The base of the coronoid process which can be palpated through the cheek soft tissues

Buccal nerve block
Extraoral

Ø Head slightly rotated to the opposite side,
mastication muscles relaxed;

Dentist’s position

Ø In front and on the right side of the patient;
Ø Left hand index positioned in the upper vestibule.
Buccal nerve block
Extraoral
Puncture: Anesthetic deposit:

Ø in the cheek, at 2 cm Ø at the level of the
under the zygomatic anterior margin of the
arch. mandible (coronoid
process).
Masseter nerve
block
Masseter nerve block
Indications:

-‐ in trismus -‐ to facilitate the mouth opening
in order to perform:
-‐ anesthesia;
-‐ surgical maneuvers.
Landmarks:

Ø Sigmoid notch (Bereher technique)
Ø anterior to the tragus, under the inferior margin of

the zigomatic arch, in front of the mandibular
condile
Puncture: Anesthetic deposit:

ØPerpendicular to the Ø At 2,5 cm depth;
skin, having a Ø Injecting about 2-‐3ml
transverse direction anesthetic solution.
from outside to
inside.
Simultaneous
blocks
VEISBREM block
Indications:

-‐ simultaneous block of inferior alveolar,
lingual and buccal nerve
VEISBREM block
Landmarks:

Ø pterygomandibular raphe;
Ø anterior margin of the ascending ramus;
Ø occlusal plane of the upper molars.

VEISBREM block

ØHead straight, slightly rotated to
the same side;
ØMouth fully open.
VEISBREM block

Ø perpendicular to the mucosa;
Ø lateral to the pterygo-‐
Ø at 1,5 cm, the mandibular
mandibular raphe; tuberosity is touched (for the
Ø medial to the base of the lingual and inferior alveolar
coronoid process. nerve)
Ø at 0,5 cm under the Ø the needle is retracted about 3-‐4
oclussal plane of the mm leaving the rest of the
upper molars. solution for the bucal nerve.
VEISBREM block
Gow Gates block
Indications:
Ø When conventional
IAN block is
unsuccessful;
Ø For IA, lingual, buccal,
auriculotemporal nerve
block.
© Malamed S.F.
2004
Gow Gates block

Nerves anesthetized:
1. Inferior alveolar with
2. Mental
3. Incisive
4. Lingual with
5. Mylohyoid
6. Auriculotemporal
© Malamed
7. Buccal S.F. 2004
Gow Gates block
Advantages: Disadvantages:
§ Simultaneous § Risk of vascular
anesthesia; puncture (IMA);
§ High success rate; § Longer time to onset;
§ Successful for bifid IAN § Large area
and mandibular canal. anesthetized;
§ Learning curve.
Gow Gates block
§ Supine, semisupine;
§ Head slightly extended
and rotated to the
same side
§ Mouth largely opened.

Gow Gates block
Target area:
§ Lateral side of the condylar neck, just below the
insertion of the lateral pterygoid muscle
Gow Gates block
Landmarks:
§ Extraoral:
ú Intertragic notch;
ú Oral commissure.
§ Intraoral:
ú Mesiopalatal cusp of the 2nd or 3rd upper M;
ú Area distal to the maxillary 2nd or 3rd M.
Gow Gates block

Gow Gates block
Puncture:
§ Mucosa on the mesial side of the ramus, on a line
from intertragic notch to the corner of the mouth,
distal to the upper 2nd molar.
Needle direction:
§ Posterior, on the plane already described;
§ Insert up to the bone contact (condylar neck)(2.5
cm);
§ Then aspirate and deposit the anesthetic.
Gow Gates block

Gow Gates block

Technique
1. Ask the patient to open his
or her mouth wide.

2. Palpate the coronoid notch
and slide the finger or
thumb to rest on the internal
oblique ridge.

3. Move the finger or thumb
superiorly approximately 10 http://collegeofdiplomates.org/
mm.

Gow Gates block

4. Rotate the finger or thumb to parallel an imaginary line
from the ipsilateral corner of the mouth to the intertragic
notch.

Gow Gates block

5. Insert the needle at a point
between the palpating
fingernail and the
pterygomandibular raphe at
the middle aspect of the
fingernail.

6. Ensure that the barrel of the
syringe is located over the
contralateral bicuspids. http://collegeofdiplomates.org/
Gow Gates block

7. As the injection proceeds, ensure that the angle of the
needle and syringe is parallel to the imaginary line from
the corner of the mouth to the tragus of the ear.

Gow Gates block

§ 8. Insert until bone is
contacted (at the neck of
the condyle), which
should occur at a depth of
approximately 25 mm.
(Note: This is not a
deeper injection, because
the patient's mouth is
open wide and, as a
result, the condyle has
translocated anteriorly to
provide a target.) http://collegeofdiplomates.org/

§

Gow Gates block

9. Once bone is contacted, withdraw the needle

tip 1 mm to prevent injecting into the
periosteum, which would be painful.

10. Aspirate.

11. Inject a full cartridge.
Gow Gates block
Complications:
Ø Puncture of the IMA;
Ø Hematoma;
Ø Trismus (rare);
Ø Temporary paralysis of the cranial nerves III, IV
and VI.
Precautions:
Ø Aspirate;
Ø Do not deposit the anesthetic unless the bone is
contacted!!!
Ginestet block
Indications:

-‐ simultaneous block of inferior alveolar,
lingual, masseter and buccal nerve
Ginestet block

ØHead straight, slightly rotated to
the same side;
ØMouth fully open.
Ginestet block
Puncture:
Ø at 1 cm above the occlusal surface of the last

lower molar;(M3)
Ø on the anterior margin of the ascending ramus.
Ginestet block
Needle direction
-‐ At the level of anterior margin, 1 ml anesthetic solution is injected
for the buccal nerve;
-‐ On the external side of the ramus, at 1-‐1,5 cm depth -‐ 1 ml
anesthetic solution is injected for the masseter nerve;
-‐ On the internal side of the ramus, at 1 cm posterior to the
temporal crest, 1 ml anesthetic solution is injected for the lingual
nerve;
-‐ Another 0,5 -‐1 cm deeper, anesthetic solution is injected for the
inferior alveolar nerve.

VIII - Local and Regional Anesthesia For Mandible

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LOCAL

© Baart et al. 2009

© Baart et al. 2009

2. Supraperiosteal inﬁltration for pulpal anesthesia of incisors;

3. Gow Gates procedure;

4. Vazirani-­‐Akinosi mandibular nerve block

5. Periodontal ligament inﬁltration.

© Malamed S.F. 2004

© Malamed S.F. 2004

© Malamed S.F. 2004

© Baart et al. 2009

2. Temporal crest, medial and

© Malamed S.F. 2004

Puncture: Needle direction:

© Baart et al. 2009 © Malamed S.F. 2004

© Baart et al. 2009

© Baart et al. 2009 © Malamed S.F. 2004

Failures of Anesthesia:

3. Transient facial paralysis

Ø bone prominences at the insertion of the

© Malamed S.F. 2004

Ø at 3-­‐4 cm depth in patients with abundant soft

Puncture: Needle direction:

© Malamed S.F. 2004

© Malamed S.F. 2004

© Malamed S.F. 2004

Ø Internal angle of the mandible

Ø Last lower molar;

Ø Mouth largely open;

Ø The tongue is retracted medially with a

dental mirror or with a tongue retractor.

Ø The angle between the lingual gingiva of the

mandible and the ﬂoor of the mouth

Puncture: Needle direction:

Anesthesia of the:

© Malamed S.F. 2004

§ In edentulous patients – the mental foramen

© Malamed S.F. 2004

Anesthesia: same as previous;

Treatment: of trigeminal neuralgia.

Anesthesia of the:

Ø Anterior margin of the coronoid process;

Ø Upper molars occlusal plane;

Ø 1 cm posterior and inferior from Stenson’s duct papilla

Ø Head rotated to the same side of the

Puncture: Needle direction:

© Baart et al. 2009

© Malamed S.F. 2004

Puncture: Anesthetic deposit:

Ø Sigmoid notch (Bereher technique)

Ø anterior to the tragus, under the inferior margin of

Puncture: Anesthetic deposit:

Ø anterior margin of the ascending ramus;

Ø occlusal plane of the upper molars.

Puncture: Needle direction:

© Malamed S.F. 2004

© Malamed S.F. 2004

4. Vazirani-‐Akinosi mandibular nerve block

Ø at 3-‐4 cm depth in patients with abundant soft