Classical Inferior alveolar nerve block

Armamentarium
o PPE (Gloves, Mask, Head cap, Eyewear)
o Basic Hand Instruments
o Topical Anesthesia
o Cotton Buds
o 2% Lidocaine HCl with 1:100000 epinephrine
o Aspirating Syringe
o Long Needle Gauge 25
Nerves anesthetized
o Inferior alveolar nerve and its subdivisions, mental nerve, incisive nerve, and
occasionally, the lingual and buccinators nerves, which are branches of the mandibular
nerve.
Areas anesthetized
o Body of the mandible and an inferior portion of the ramus
o Mandibular teeth
o Mucous membrance and underlying tissues anterior to the first mandibular molar
Anatomical Landmarks
o Mucobuccal fold
o Anterior border of the ramus of the mandible
o External oblique ridge
o Retromolar triangle
o Internal oblique ridge
o Pterygomandibular ligament
o Buccal sucking pad
o Pterygomandibular space
Procedure
o If the patient is in a dental chair, the head should be positioned so that when the mouth
is open, the body of the mandible is parallel to the floor.
o The operator stands to the right front side of the patient and with the left inde finger or
thumb palpates the mucobuccal fold.
o 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.
o 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
greatest depth is called the coronoid notch and is in a direct line with the mandibular
sulcus. This places the height of the mandibular sulcus.
o The palpating finger is moved lingually across the retromolar triangle and onto the
internal oblique ridge.
o 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. This
gives better exposure to the internal oblique ridge, the pterygomandibular raphe, and
the pterygotemporal depression.
 o 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.
o A syringe with a 15/8-inch, 25-guage needle is then 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. One can best determine the depth of the needle
penetration by estimating when the needle tip has been advanced half the distance
between the palpating left thumb and index finger.
o During insertion, the patient is asked to keep the mouth wide open. The needle is
penetrated into the tissues until gently contracting bone on the internal surface of the
ramus of the mandible. This should be in the area of the mandibular sulcus, which
funnels into the mandibular foramen.
o The needle is then withdrawn about 1mm, and 1 to 1.8ml of solution is deposited
slowly.
o The needle is now withdrawn slowly, and when about one half of its inserted depth has
been withdrawn, the remainder of the solution is injected in this area to anesthetize the
lingual nerve. In many instances the deliberate injection of the anesthetic solution to
anesthetize the lingual nerve is unnecessary because diffusion of the initially injected
solution will also anesthetize the lingual nerve.

Long Buccal Nerve Block

Armamentarium
o PPE (Gloves, Mask, Head cap, Eyewear)
o Basic Hand Instruments
o Topical Anesthesia
o Cotton Buds
o 2% Lidocaine HCl with 1:100000 epinephrine
o Aspirating Syringe
o Short Needle Gauge 25
Nerves Anesthetized
o Buccinator nerve
Areas Anesthetized
o Buccal mucous membrane and mucoperiosteum of the mandibular molar area
Anatomical Landmarks
o External oblique ridge
o Retromolar triangle
Procedure
o A 1-inch, 25-guage needle is inserted into the buccal mucosa just distal to the third
molar, and 0.25 to 0.5 ml of solution is deposited in this area. An alternative technique
is to insert the needle and deposit the solution directly into the retromolar triangle.

Mental Nerve Block

 Armamentarium
o PPE (Gloves, Mask, Head cap, Eyewear)
o Basic Hand Instruments
o Topical Anesthesia
o Cotton Buds
o 2% Lidocaine HCl with 1:100000 epinephrine
o Aspirating Syringe
o Short Needle Gauge 25
Nerves Anesthetized
o Mental nerve
Areas Anesthetized
o Lower Lip
o Mucous membrane in the mucolabial fold anterior to the mental foramen
Anatomical Landmarks
o Mandibular bicuspids, since the mental foramen usually lies at the apex and just
anterior to the second bicuspid root.
Procedure
o The apices of the bicuspid teeth should be estimated
o A 1-inch, 25-guage needle should be inserted into the mucolabial fold after the cheek
has been pulled to the buccal side. The tissue is penetrated until the periosteum of the
mandible is gently contacted slightly anterior to the apex of the second bicuspid.
o The solution, 0.5 to 1ml, is slowly deposited in this area.