Anesthesia of the lower alveolar nerve

based on the book

Local Anesthesia in Dentistry
by Stanley F. Malamed.
Lek. dent. Mateusz Frątczak.
• The rate of successful lower alveolar nerve blockage (LANB) is
lower than for most other nerve blockages. The anatomical
structure of the mandible (and especially the high cohesion of
the bone forming it) means that the operator must deposit an
anesthetic solution close to the target nerve with an accuracy
not exceeding one millimeter. A significantly lower
percentage of successes in the inferior alveolar nerve
blockage results from two factors - 1) anatomical differences
in the height of the mandibular opening on the lingual side of
the branch, and 2) the need for deeper penetration into soft
tissues, which usually reduces the accuracy of injection.
• Lower alveolar nerve block (LANB), commonly
called (but inaccurately) mandibular nerve
block, is the most commonly used dentistry
and seems to be the most important injection
technique. Unfortunately, it also brings the
most frustration, because it is burdened with
the highest percentage of failures (about 15-
20%), even when observing the right
performance.
 Anesthetized nerves:

• 1) Lower alveolar nerve, (branch of the back of

the mandibular nerve branch)
• 2) Language nerve (usually).
• 3) Chin nerve.
• 4) Incisal nerve.
 Anesthesia area

• 1. Teeth of the lower jaw to the midline.

• 2. Mandible shaft, lower part of its wing,
• 3. The buccal mucosa adjacent to the periosteum
mucosa anteriorly to the first mandibular molar
(nerve nerve),
• 4. Front two-thirds of the tongue and bottom of
the mouth (lingual nerve)
• 5. Linguistic soft tissues and the periosteum
(lingual nerve).
Area of ​anesthesia after inferior alveolar
nerve block (yellow area)
 Indications

• 1. Treatments on several jaw teeth in one

quadrant.
• 2. If there is a need for anesthesia of the soft
tissues of the cheek (forward from the first
molar).
• 3. If necessary, anesthesia the soft tissue of
the tongue.
 Contraindications

• 1. Infection or acute inflammation in the

injection area (rare).
• 2. Patients who may bite their lips or tongue,
such as very young children or adults, or
children with physical or mental disability.
 Anesthesia of the lower alveolar nerve

• 1. The use of a long 25G needle is

recommended for adult patients.
• 2. Needle injection area: mucosa on the medial
surface of the mandible branch, the
intersection of two lines: one horizontal
corresponding to the injection height and the
other vertical - corresponding to the
anteroposterior injection plane.
• 3. Target region: the inferior alveolar nerve at
the point of its descent towards the
mandibular hole, but before it enters the hole.
 4. Landmarks a-c:

• a. punctate indentation (larger indentation on

the anterior branch of the mandible - anterior
edge of bone) = red circle in the picture
 4. Landmarks a-c:
• b. pterygo-mandibular suture
 4. Landmarks a-c:
• c. occlusal plane of posterior mandibular
teeth.
• 5. Needle shear setting: It is less important
than other blockages because the needle
approaches the lower alveolar nerve at a
more or less sharp angle.
 6. Performing anesthesia of the lower
alveolar nerve:
• A. Take the right position:
• A1) for right lower alveolar nerve blockage,
the right-handed operator should sit at 8
o'clock, facing the patient (Fig. 14-4. A).
Operator position for right lower alveolar
nerve blockade
• A2) for blockage of the left lower alveolar
nerve, the right-handed operator should sit at
10 o'clock, facing the same direction as the
patient (Fig. 14-4, B).
Operator position for blockage of the left
lower alveolar nerve
• B. Place the patient on his back
(recommended) or in a half-sitting position.
The mouth should be wide open for best
visibility and access to the injection site.
• C. Locate the injection site (injection).
• D. Puncture needle. After contact with the
bone, retract it approximately 1 mm to
prevent periosteal injection.
• E. Perform a trial aspiration. If it fails, slowly
deposit 1.5 ml of the anesthetic solution over
at least 60 s. (Due to the more frequent
positive test result and the natural tendency
to inject the anesthetic more quickly, the
order of slow injection, retry aspiration, slow
injection, aspiration again, complete
injection).
• F. Slowly withdraw the syringe, and when
approximately half the length of needle
remains in the tissues, retry aspiration. If it
fails, deposit the remaining amount (0.1 ml) to
numb the lingual nerve.
-> In most patients, a special injection for
anesthesia of the lingual nerve is not necessary
because it is reached by the solution deposited
during anesthesia of the lower alveolar nerve.
• G. Slowly withdraw the syringe completely
and secure the needle.
• H. After about 20 s, restore the patient to a
sitting or semi-sitting position.
• I. Wait 3 to 5 minutes before starting the
procedure.
 Three parameters should be taken into
account when administering anesthesia:

1) injection site,
2) antero-posterior positioning of the needle
(which facilitates more accurate location of
the puncture site) and
3) penetration depth (which depends on the
location of the inferior alveolar nerve).
 1) PLACE OF INJECTION:
• Place the forefinger or thumb of your left
hand in the peck notch. = red circle in the
picture
• a) The injection site is defined by an imaginary
line extending from the fingertip in the
punctate indentation to the innermost portion
of the pterygo-mandibular suture (where it
turns vertically up towards the jaw). This
imaginary line should run parallel to the
occlusal plane of the mandibular molars. For
most patients, this line runs 6-10 mm above
the occlusal plane.
• b) Tissue pulled to the side with a hollow
finger, pulling the tissues to the side,
stretching them over the injection site, thanks
to which the needle insertion is less traumatic,
while improving visibility.
• c) The needle injection site is located at three-
quarters of the antero-posterior distance from
the punctate process to the rear towards the
deepest part of the pterygo-mandibular
suture. Note: This line should start in the
middle of the appendix and end at the
deepest (lying as far back as possible) part of
the pteromandibular suture, where the seam
bends vertically up towards the palate.
 The tip of the needle contacts the most distal end of the
pterygo-mandibular suture and the syringe is placed in the
corner of the mouth which corresponds to premolars
d) The posterior edge of the mandible branch can be approached from the
side of the mouth, using the pterygo-mandibular suture in the place of its
vertical rise towards the jaw.
 * Pterygo-mandibular suture
• runs backwards horizontally from the cystic cushion,
then turns vertically towards the palate; only the
posterior portion of the pterygo-mandibular suture
serves as an indication of the posterior margin of the
branch.
• e) An alternative method of approximate
branch length assessment is to place the
thumb on the beak process and the index
finger outside the mouth on the posterior
branch and to assess the distance between
these points. However, many practitioners
(including the author) have difficulty imagining
the width of branches on this basis.
 2) FRONT-REAR POSITION OF INJECTION
POINT:
• The needle is inserted at the intersection of two
points.
• a) Point 1 falls on a horizontal line running from the
punctate process to the innermost portion of the
pterygo-mandibular suture, in the place of its vertical
rise towards the palate, as described above.
• b) Point 2 lies on a vertical line drawn through point
1 approximately three-quarters of the distance from
the anterior branch of the jaw. This is the
anteroposterior site of injection.
 3) NEEDLE PENETRATION DEPTH:
• The third parameter of LANB is the need for
contact of the needle with the bone. The
needle is inserted slowly until it meets the
bone resistance.
3) NEEDLE PENETRATION DEPTH a-f
• a) Most patients do not need to inject an
anesthetic solution as the needle passes
through soft tissue.
• b) In particularly anxious or very sensitive
patients, it may be advised to deposit small
amounts as the needle moves.
• c) The average depth of penetration into bone contact is 20-
25 mm, which corresponds to two-thirds to three-quarters of
the length of the long dental needle.
• d) The tip of the needle should be slightly upwards from the
mandibular opening (where the lower alveolar nerve
penetrates). This hole cannot be seen or felt with a finger.
3) NEEDLE PENETRATION DEPTH a-f
• e) If the bone comes into contact too early (before
introducing less than half the length of the long dental
needle), it means that the end is on the branch too far
forward (lateral). To correct it:
• i) slightly withdraw the needle, but do not remove it from
the tissues;
• ii) rotate the syringe barrel to the front of the mouth,
above the canine or lateral incisor on the opposite side
• iii) change the direction of the needle until it reaches a
more appropriate depth of penetration. The tip of the
needle is now backwards from the mandibular furrow.
• A. Needle inserted too far forward
(laterally) in the branch.

• B. Correction method: slightly

withdraw it from the tissues (1) and
move the syringe barrel towards the
lateral incisor or canine (2); re-enter
I'm going to the right depth.
3) NEEDLE PENETRATION DEPTH a-f
• f) If no contact is made with the bone, the tip of
the needle is usually too far (medial). The
following must be corrected:
• i) slightly withdraw the needle without removing
it from the tissues (leaving about a quarter of its
length in them) and position the syringe barrel
more backwards (above the mandibular molars);
• ii) continue piercing until bone contact is at the
proper depth (20-25 mm).
• A. Too deep introduction of the
needle without contact with the
bone. The needle is usually
found on the back (medial) in
relation to the branches.

• B. Correction method: slightly

withdraw it from the tissues (1)
and reposition the syringe
barrel above premolars (2); re-
insert the needle.
 Symptoms of anesthesia of the lower
alveolar nerve
• 1. Subjective: tingling or numbness of the lower lip
indicates anesthesia of the nerve nerve, the terminal
branch of the inferior alveolar nerve. This is a good
indication that it has been anesthetized, but one
cannot infer from this the depth of anesthesia.
• 2. Subjective: tingling or numbness of the tongue
proves anesthesia of the lingual nerve, branches of
the posterior branch V3. It usually accompanies LANB,
but can also occur without effective anesthesia.
• 3. Objective: painless dental surgery.
 Safety rules.
• Contact of the needle with the bone prevents
it from entering too deeply, which is
associated with complications.
Thank you for your attention

• It's not over yet

 Important information
• anesthesia of the inferior alveolar nerve is
given to the pterygo-mandibular space.
• do not forget.