Appendix 13-1. Summary of Mandibular Injections
| Inferior Alveolar Block | ||||
| Areas Anesthetized | Landmarks | Administration Sites | Technique | Adverse Effects |
Teeth Mandibular teeth to midline Other Structures Lingual periodontium and gingiva to midline; facial periodontium and gingiva of the mandibular anterior teeth and premolars to midline; lower lip, anterior two-thirds of tongue, and floor of the mouth to midline | Medial surface of mandibular ramus Mandibular foramen Lingula Coronoid notch Pterygomandibular fold (raphe) Pterygomandibular space Mandibular occlusal plane | Injection Site Two-thirds to three-fourths the distance from the coronoid notch to the pterygomandibular fold (raphe), demarcating the posterior border of the ramus and at the middle of the pterygomandibular space, as well as approximately 6 to 10 mm superior to the mandibular occlusal plane Deposit Location At mandibular foramen on the medial surface of the mandibular ramus that is overhung by lingula with inferior alveolar (IA) nerve; lingual nerve by diffusion | Insert the needle in the deepest part of the depression created by the pterygomandibular space and at the intersection of these two imaginary lines moving through soft tissue until bone is gently contacted; aspirate Depth of Insertion Long 25-gauge needle at approximately 20 to 25 mm or two-thirds to three-fourths of needle length until bone is gently contacted Anesthetic Agent Approximately 1.8 to 3.6 mL or one to two cartridges; 60 to 120 seconds to deposit | Transient facial paralysis from deposition in parotid salivary gland Hematoma; lingual shock when moving needle through tissue; inadequate anesthesia possibly caused by depositing agent inferior to mandibular foramen; incomplete anesthesia of first molar due to mylohyoid nerve; incomplete anesthesia from crossover-innervation of incisive nerve |
| Buccal Block | ||||
| Areas Anesthetized | Landmarks | Administration Sites | Technique | Adverse Effects |
Teeth None Other Structures Buccal periodontium and gingiva of mandibular molars | Most distal mandibular molar Anterior border of the mandibular ramus Retromolar pad (triangle) | Injection Site Buccal mucosa distal and buccal to most distal mandibular molar Deposit Location (Long) buccal nerve as it passes over the anterior border of the mandibular ramus in the area of the retromolar pad (triangle) | Direct the syringe barrel parallel to the occlusal plane but directly superior to the mandibular molars; aspirate Depth of Insertion Long 25-gauge if after IA or short 27-gauge if no IA at approximately 2 to 4 mm of needle length until bone is gently contacted Anesthetic Agent Approximately 0.3 mL one-eighth of cartridge; 10 seconds to deposit | Leakage of agent at injection site with bitter taste of anesthetic agent; ballooning of the tissue caused by rapid deposit of agent |
| Mental Block | ||||
| Areas Anesthetized | Landmarks | Administration Sites | Technique | Adverse Reactions |
Teeth None Other Structures Facial periodontium and gingiva of mandibular anterior teeth and premolars to midline; lower lip and skin of chin to midline | Mandibular premolars Mental foramen Mandibular mucobuccal fold | Injection Site Anterior to mental foramen at depth of the mandibular mucobuccal fold inferior to the apices of the mandibular premolars or location determined by radiographs and/or palpation Deposit Location At mental foramen and inferior to the apices of the mandibular premolars or location determined by radiographs and/or palpation | Horizontal approach: insert the needle to the depth of the mucobuccal fold, directing the needle anterior to the mental foramen; vertical approach: direct the syringe vertically with the patient’s cheek anterior to the mental foramen Aspirate Depth of Insertion Short 27-gauge needle at approximately 5 to 6 mm or one-fourth of needle length Anesthetic Agent Approximately 0.6 mL or one-third of cartridge; 20 seconds to deposit | Hematoma |
| Table Continued | ||||
| Incisive Block | ||||
| Areas Anesthetized | Landmarks | Administration Sites | Technique | Adverse Reactions |
Teeth Mandibular anterior teeth and premolars to the midline Other Structures Facial periodontium and gingiva of anesthetized mandibular teeth to midline; lower lip and skin of chin to midline | Mandibular premolars Mental foramen Mandibular mucobuccal fold | Injection Site Depth of mucobuccal fold anterior to mental foramen Deposit Location At mental foramen inferior to the apices of the mandibular premolars or location determined by radiographs and/or palpation | Horizontal approach: insert the needle to the depth of the mucobuccal fold, directing the needle anterior to the mental foramen; vertical approach: direct the syringe vertically with the patient’s cheek anterior to the mental foramen Aspirate; deposit agent then massage agent into foramen for 2 minutes Depth of Insertion Short 27-gauge needle at approximately 5 to 6 mm or one-fourth of needle length Anesthetic Agent Approximately 0.6 to 0.9 mL or one-third to one-half of cartridge; 20 seconds to deposit | Hematoma; inadequate anesthesia due to inadequate volume of anesthetic into mental foramen or inadequate duration of pressure and massage over the mental foramen after injection |
| Gow-Gates Mandibular Block | ||||
| Areas Anesthetized | Landmarks | Administration Sites | Technique | Adverse Effects |
Teeth Mandibular teeth to midline Other Structures Lingual periodontium and gingiva of anesthetized mandibular teeth as well as facial periodontium and gingiva of anesthetized mandibular anterior teeth and premolars to midline and possibly buccal periodontium and gingiva of the anesthetized mandibular molars; lower lip, anterior two-thirds of tongue and floor of the mouth to midline; skin over zygomatic bone and posterior part of buccal and temporal regions; additional innervation by way of mylohyoid nerve to muscles and also can serve as afferent nerve for mandibular first molar | Extraoral: Intertragic notch (lower border of the tragus) Corner of mouth Intraoral: Mesiolingual cusp of maxillary second molar Buccal mucosa just distal to maxillary second molar | Injection Site Buccal mucosa on the medial surface of the mandibular ramus, just distal to height of the mesiolingual cusp of the maxillary second molar Deposit Location Anteromedial border of neck of mandibular condyle | Insert needle parallel to the determined imaginary line until gentle bony contact is made with the neck of the condyle Depth of Insertion Long 25-gauge needle at approximately 25 mm or three-fourths of the needle length until bone is gently contacted Anesthetic Agent Approximately 1.8 mL or one cartridge; 60 to 90 seconds to deposit | Buccal periodontium and gingiva of the mandibular molars does not have an adequate level of anesthesia; hematoma |
| Table Continued | ||||
| Vazirani-Akinosi Mandibular Block | ||||
| Areas Anesthetized | Landmarks | Administration Sites | Technique | Adverse Effects |
Teeth Mandibular teeth to the midline Other Structures Lingual periodontium and gingiva of anesthetized mandibular teeth as well as facial periodontium and gingiva of anesthetized mandibular anterior teeth and premolars to midline and possibly buccal periodontium and gingiva of the anesthetized mandibular molars; lower lip, anterior two-thirds of tongue, and floor of the mouth to midline; additional innervation by way of mylohyoid nerve to muscles that can also serve as afferent nerve for mandibular first molar | Coronoid process Maxillary occlusal plane Medial surface of mandibular ramus Pterygomandibular space Maxillary tuberosity Mucogingival junction of maxillary third or second molar | Injection Site Medially past the coronoid process and then into the buccal mucosa on medial surface of mandibular ramus at the same height as the mucogingival junction of the maxillary third or second molar directly across the way and with the bevel oriented away from the bone of the mandibular ramus so it faces toward the midline Deposit Location Center of pterygomandibular space and at approximately halfway between the mandibular foramen and neck of the mandibular condyle as well as being adjacent to the maxillary tuberosity | Direct the syringe barrel parallel to the maxillary occlusal plane and medially past the coronoid process. Place needle at the same height as the mucogingival junction of the maxillary third or second molar to determine the height of the injection. Insert needle into the buccal mucosa Depth of Insertion Long 25-gauge needle at approximately 25 mm or two-thirds to three-fourths of the needle length without contacting bone, with the hub of the syringe ending up opposite the mesial aspect of the maxillary second molar Aspirate Anesthetic Agent Approximately 1.8 mL or one cartridge; 60 to 90 seconds to deposit | Transient facial paralysis when facial nerve is mistakenly anesthetized; hematoma |
| Periodontal Ligament Injection (for mandibular supraperiosteal and intraseptal injections, see Appendix 12-1) | ||||
| Areas Anesthetized | Landmarks | Administration Sites | Technique | Adverse Reactions |
Teeth Selected tooth Other Structures Associated periodontium and gingiva | Selected tooth Root(s) of selected tooth | Injection Site Long axis of tooth either mesial or distal with a single-rooted tooth; mesial or distal to each root for a multirooted tooth Deposit Location Alveolar bone proper of the alveolar process | Direct the syringe until the depth of the gingival sulcus is reached and resistance is felt.Applying pressure, push the needle slightly deeper at approximately 1 to 2 mm into the alveolar bone proper.Depth of Insertion Extra-short or short 27-gauge needle at approximately 1 to 2 mm into the alveolar bone proper after bony contact Anesthetic Agent 0.2 mL, one stopper of anesthetic; 20 seconds to deposit | Postoperative soreness; may cause tissue damage |
