Mandibular Nerve

Largest of 3 branches of Trigeminal nerve Sensory (afferent) and motor (efferent) Motor root passes below f. ovale to join mandibular division immediately below skull
Branches from the Undivided Nerve:

NS (Nervus Spinosus) NIPM (Nerve to Internal Pterygoid Muscle)

Branches from the Divided Nerve:

Anterior Division PN (Pterygoid Nerve) MN (Masseter Nerve) BN (Buccal Nerve) NTM (Nerves to Temporal Muscle) ADTN PDTN Posterior Division AN (Auriculotemporal Nerve) LN (Lingual Nerve) IAN (Inferior Alveolar Nerve) MN (Mental Nerve) IN (Incisive Nerve)
Intraoral Approach:

Classic Inferior-Alveolar Nerve Block Closed-mouth approach to mandibular nerve block (Akinosi Technique) Mandibular Gow-Gates Block Lingual nerve block Mental nerve block Incisive nerve block Block of terminal nerve branches Local inltration Mandibular nerve block Mental nerve block Incisive nerve block Local inltration

Extraoral Approach:

CLASISIC INFERIOR-ALVEOLAR NERVE BLOCK: Nerves Anesthetized:

IAN and its subdivisions

 Mental and Incisve nerves Lingual and buccal nerves (occasionally)

Area Anesthetized:

Body of mandibule and inferior portion of ramus Mandibular teeth Mucous membrane and underlying tissues anterior to 1st molar (Local inltration technique cannot be done on mandible because of dense compact bone)
Anatomical Landmarks:

Mucobuccal fold External oblique ridge Anterior border of the ramus Coronoid notch Retromolar triangle Internal oblique ridge Pterygomandibular raphe (connects superior pharyngeal constrictor to buccinator m.) Pterygomandibular fossa Pterygomandibular space Buccal sucking pad

Indications:

Analgesia for operative dentistry on all mandibular teeth Surgical procedures on mandibular teeth and supporting structures anterior to the 1st molar when supplemented by anesthesia of the lingual nerve This nerve is usually anesthetized at the same time that the IAN is anesthetized Surgical procedures on mandibular teeth and supporting structures posterior to the 2nd premolar if supplemented with lingual and buccal nerve blocks Diagnostic and therapeutic purposes Eg. Facial pain without toothache (Tic Doloreux / Trigeminal Neuralgia) do NB on side of pain and see if pain subsides
Symptoms of Analgesia:

Subjective Numbness of lower lip Tip of tongue (if lingual nerve affected) Objective Instrumentation necessary
Needle Pathway During Insertion:

The needle passes through mucosa, a thin plate of the buccinator muscle, loose connective tissue, and a variable amount of fat
In its nal position, it should be: Superior to:

Inferior alveolar vessels Inferior alveolar nerve

Anterior to: Medial to:

Insertion of the internal pterygoid muscle Mylohyoid vessels Mylohyoid nerve The deep part of the parotid gland Inner ramus of the mandible Lingual nerve Internal pterygoid muscle Sphenomandibular ligament

Lateral to:

Technique for Right Inferior Alveolar Nerve Block:

Patients head should be positioned so that mouth if fully open, body of mandible is parallel to oor Operator stands on right front side of patient and with left index nger of thumb palpates the mucobuccal fold (Landmark 1) The nger or thumb is moved posteriorly until contact is made with the external oblique ridge (landmark 2) on the anterior border of the ramus of the mandible When the fnger 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 (landmark 3) is identied This area is called the coronoid notch (landmark 4) and is in direct line with the mandibular sulcus; this places the height of the mandibular sulcus The palpating nger is moved lingually across the retromolar triangle (landmark 5) and onto the internal oblique ridge (landmark 6) The nger 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 pterygomandibular depression When palpating the intraoral landmarks with the thumb, the operator may place the index nger extraorally behind the ramus of the mandible, thus literally holding the mandible between the thumb and the index nger In this manner the anteroposterior width of the mandible may be assessed A syringe with a 1 5/8 inch, 25 gauge 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 nger or thumbnail, penetrating the tissues of the pterygotemporal despression* and entering the ptergomandibular space * Because this is where pterygomandibular space is PGM space contains lingual nerves PGM space also can expand; you can deposit whole capsule in 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 nger

 During insertion, the patient is asked to keep the mouth wide open; the needle is penetrated into the tissues until gently contacting 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 The needle is then withdrawn about 1mm and then half of the solution is depressed slowly (1.5 to 2 minutes) Prevent distention and pain The needle is now withdrawn slowly, and when about 1/2 of the inserted depth has been withdrawn, another half of the remaining 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 it
Technique for Left Inferior Alveolar Nerve Block:

The patient is placed in the chair in exactly the same position as for the right side The operator stands at the right and slightly toward the back of the patient The left arm of the dentist is placed around the patient's head so that the landmarks may be palpated with the left index nger or thumb The needle is inserted from the opposite side of mouth, at a level that bisects the nail of the nger, and the tissues are penetrated with the same technique as that used for the right side Alternative Technique: Stand to the right and slightly toward the front of the patient The landmarks are palpated with the right index nger or thumb and the needle insertion and injection are made with the left hand More feasible for left-handed operators
Two Points to Remember:

The objective is to anesthetize the IAN before it enters the mandible The depth of the needle is usually 2/3 of the needle (or 3/4 until you contact bone)
Reality:

Estimate correct position by depth of needle penetration to contact with bone (guesstimate) 20-25mm (2/3 to 3/4 of the long needle) feels "right" <16mm - not deep enough Needle too anterior Withdrawal slightly, aim more posteriorly, advance to bone No bone - too deep Needle too posterior Withdraw slightly, aim more anteriorly, advance to bone NO BONE = NO INJECTION

 Most common reason cited for missing the IANB is being TOO LOW HIGHER is BETTER (force of gravity will diffuse anesthetic solution downwards to nerve)
CLOSED MOUTH APPROACH TO MANDIBULAR NERVE BLOCK (Akinosi Technique):

Nerves Anesthetized

IAN and its subdivisions Mental & Incisive nerves Lingual and buccal nerves
Area Anesthetized

All mandibular hard and soft tissues to the midline Floor of the mouth Anterior 2/3 of the tongue
Landmarks

Occlusal plane of occluded teeth Mucogingival junction of maxillary molar teeth Anterior border of the ramus
Indications

Analgesia for operative / surgical procedures on mandibular hard or soft tissues Diagnostic and therapeutic purposes
Symptoms

Subjective Numbness of lip and tip of tongue on the injected side Objective Instrumentation necessary
Needle Pathway During Insertion

With the mouth closed, the needle is aligned parallel to the occlusal plane and positioned at the level of the mucogingival junction of the maxillary molars The needle penetrates mucosa just medial to the ramus and is inserted approximately 1 1/4 inches
When the needle is in its nal position, it should be: Superior to the following:

Inferior alveolar vessels Inferior alveolar nerves Insertion to the internal pterygoid muscle Lingual nerve Buccinator muscle Mylohyoid vessels Mylohyoid nerve
Anterior to the:

Deep part of the parotid gland

Medial to the: Lateral to the:

Inner surface of the ramus Inner pterygoid muscle Sphenomandibular ligament

Techniques for Closed-Mouth Approach Mandibular Nerve Block (Akinosi's Technique):

With the patient seated comfortably in the dental chair, the operator stands to the patient's right side and slightly to the front The patient is instructed to occlude the teeth The operator retracts the patient's lip exposing the maxillary and mandibular teeth n the right side The syringe with a 1 5/8 inch, 25-gauge needle, is aligned parallel to the occlusal and saggital planes but positioned at the level of the mucogingival junction of the maxillary molars The needle penetrates the mucosa just medial to the ramus and is inserted approximately 1 1/2 inches Following negative aspiration, the contents if the dental cartridge are slowly deposited Successful anesthesia will be determined by instrumentation of the inferior alveolar nerve and its subdivisions (mental and incisive nerves plus the buccinator and lingual nerves) Care must be taken to ensure that the needle is inserted as closely as possible ti the medial surface of the ramus Allowing the needle to be advanced too far medial,y is likely to result in the deposition of the solution in the medial side of the pterygomandibular space and sphenomandibular ligament resulting in inadequate anesthesia or an unsuccessful nerve block
CMAtMNB (AT) Used as an alternative to Classical Open-Mouth Approach Due to These Advantages:

Landmarks area easily identied and technique is simple to master The three major nerves innervating the mandible may be anesthetized with one needle insertion Patient feels less threatened Closed jaw due to mass or malignancy