Clinically acceptable mandibular anesthesia is more difficult to achieve than maxillary anesthesia because of the thickness of the cortical bone

Requires anesthetic deposition in the pterygomandibular space at the region of the mandibular foramen lateral to the sphenomandibular ligament

Requires proper needle penetration and correct needle angulation in the pterygomandibular space

Properly performed, it anesthetizes 2 nerves:

• Inferior alveolar nerve (and its branches—the incisive and mental nerves)

• Lingual nerve

Areas anesthetized:

• All mandibular teeth (inferior alveolar nerve)

• Epithelium of the anterior 2/3rds of the tongue (lingual nerve)

• All lingual gingiva and lingual mucosa (lingual nerve)

• All buccal gingiva and mucosa from the premolars to the midline (mental nerve)

• Skin of the lower lip (mental nerve)

Steps:

• Insert the needle into the mucosa between the deepest portion of the coronoid notch (which should represent the vertical height of the mandibular foramen) and just lateral to the pterygomandibular raphe

• Orient the needle from the contralateral premolars and advance it along the occlusal plane of the mandible

• The needle contacts the mandible after entering 20 to 25 mm (if bone is contacted immediately on penetration into the mucosa, then the temporal crest has been contacted; the needle should be reoriented to allow insertion to the proper depth)

• Withdraw the needle slightly and perform aspiration to determine whether the needle is in a blood vessel (inferior alveolar vessels)

• After a negative result on aspiration (no blood observed in the syringe), slowly inject the anesthetic into the pterygomandibular space

• If the result of aspiration is positive, readjust the needle position and perform aspiration again before injecting into the pterygomandibular space

In children, the mandibular foramen is located closer to the posterior border of the mandible until more bone is added with age

In edentulous patients, the alveolar bone is lost; thus, the deepest part of the coronoid notch is lower than normal, which could lead the clinician to aim the needle too low

In class II malocclusion, when the mandible is hypoplastic, the mandibular foramen is typically located more inferior than the clinician may think

In class III malocclusion, when the mandible is hyperplastic, the mandibular foramen is typically located more superior than the clinician may think

A transient, dental-induced Bell’s palsy can result if the needle is placed too far posteriorly in the parotid bed and anesthetic is introduced close to the facial nerve

A branch of the mandibular division of the trigeminal nerve, the long buccal nerve is not anesthetized in an inferior alveolar injection

This block anesthetizes all buccal gingiva opposite the mandibular molars, including the retromolar trigone

Steps:

• Insert the needle into the mucosa posterior to the last molar in the mandibular arch on the buccal side (the needle will be inserted a very short distance—about 2 mm)

• Perform aspiration; after a negative result, inject the anesthetic

A hematoma is rare with this block

This injection seldom fails

A branch of the inferior alveolar nerve within the mandibular canal

Areas anesthetized:

• All buccal gingiva and mucosa from the premolars to the midline (mental nerve)

• Skin of the lower lip (mental nerve)

Steps:

• Locate the mental foramen via palpation

• Insert the needle into the mucosa at the mucobuccal fold at the location of the mental foramen (normally around the 2nd mandibular premolar) (the needle will be inserted a short distance in the direction of the mental foramen)

• Perform aspiration; after a negative result, slowly inject the anesthetic

X-ray imaging can help the clinician locate the mental foramen if palpation does not do so

This block seldom fails

A variation of the inferior alveolar nerve block, it anesthetizes the following nerves:

• Inferior alveolar nerve (and its branches, the mental and incisive nerves)

• Mylohyoid nerve

• Lingual nerve

• Long buccal nerve (often)

• Auriculotemporal nerve (often)

Low positive aspiration rate relative to that for the standard inferior alveolar nerve block injection

When the injection is properly administered, the needle contacts the neck of the mandibular condyle

Areas anesthetized:

• All mandibular teeth (inferior alveolar nerve)

• Epithelium of the anterior 2/3rds of the tongue (lingual nerve)

• All lingual gingiva and lingual mucosa (lingual nerve)

• All buccal gingiva and mucosa (long buccal and mental nerves)

• Skin of the lower lip (mental nerve)

• Skin along the temple, anterior to the ear, and posterior part of the cheek (auriculotemporal and buccal nerves)

Steps:

• The mouth is opened as wide as possible

• Insert the needle high into the mucosa at the level of the 2nd maxillary molar just distal to the mesiolingual cusp

• Use the intertragic notch as an extraoral landmark to help reach the neck of the mandibular condyle

• Advance the needle in a plane from the corner of the mouth to the intertragic notch from the contralateral premolars (this position varies in accordance with individual flare of the mandible) until it contacts the condylar neck

• Withdraw the needle slightly and perform aspiration to observe whether the needle is in a blood vessel

• After a negative result on aspiration, slowly inject the anesthetic

• Have the patient keep the mouth open for a few minutes after injection, to allow the anesthetic to diffuse around the nerves

Useful for multiple procedures on mandibular teeth and buccal soft tissue

Few complications

Works well for a bifid inferior alveolar nerve

A closed-mouth approach for the mandibular nerve block, it anesthetizes the following nerves:

• Inferior alveolar nerve (and its branches, the mental and incisive nerves)

• Mylohyoid nerve

• Lingual nerve

Useful when mandibular depression (opening) is limited, such as with trismus

Considered a “blind” injection

Areas anesthetized:

• All mandibular teeth (inferior alveolar nerve)

• Epithelium of the anterior 2/3rds of the tongue (lingual nerve)

• All lingual gingiva and lingual mucosa (lingual nerve)

• All buccal gingiva and mucosa from the premolars to the midline (mental nerve)

• Skin of the lower lip (mental nerve)

Steps:

• Have the patient close the mouth

• Insert the needle into the mucosa between the medial border of the mandibular ramus and the maxillary tuberosity at the level of the cervical margin of the maxillary molars

• Advance the needle parallel to the maxillary occlusal plane

• Once the needle is advanced approximately 23 to 25 mm, it should be located in the middle of the pterygomandibular space near the inferior alveolar and lingual nerves (note: no bone will be contacted)

• After a negative result on aspiration, slowly inject the anesthetic

Often used in patients with a limited ability to open the mouth and when intraoral landmarks for a standard inferior alveolar nerve block are difficult to view

A transient, dental induced Bell’s palsy can result if the needle is placed too far posteriorly in the parotid bed and anesthetic is introduced close to the facial nerve

Good for patients with a strong gag reflex or macroglossia

A frequently used block

The injection is in the infratemporal fossa

Areas anesthetized:

• All maxillary molars, with the possible exception of the mesiobuccal root of the 1st maxillary molar

• Buccal gingiva opposite the teeth

Steps:

• With the mouth open, the patient is instructed to deviate the mandible toward the same side as the injection, to produce more work space for the clinician

• Insert the needle into the mucosa at the mucobuccal fold just superior to the maxillary 2nd molar, between the medial border of the ramus of the mandible and the maxillary tuberosity

• In a single motion, the needle needs to be advanced approximately 15 mm in the following x-y-z plane at the same time, to reach the posterior superior alveolar nerve along the posterior surface of the maxilla:

• Medially at a 45-degree angle to the maxillary occlusal plane

• Superiorly at a 45-degree angle to the maxillary occlusal plane

• Posteriorly at a 45-degree angle to the maxillary occlusal plane

• Perform aspiration due to the close proximity of the pterygoid plexus

• After a negative result on aspiration, slowly inject the anesthetic

Significant potential for formation of a hematoma involving the pterygoid plexus

Short needles are preferred, to reduce the risk of hematoma

Considered the most painful of dental injections

Because of the sensitivity of the area, pressure anesthesia (e.g., using a cotton swab applicator) is helpful at the site of injection

Areas anesthetized:

• The area’s palatal gingiva and mucosa from the maxillary canine on the right to the maxillary canine on the left side of the maxilla

• Both the right and left nasopalatine nerves, because they exit onto the hard palate in close proximity

Oral mucosa in this region is tightly adhered to the hard palate; thus deposition of anesthetic in the area has less space to diffuse

Steps:

• Use a cotton swab applicator to apply pressure to the injection site

• Insert the needle into the palatal mucosa lateral to the incisive papilla

• Deposit a small amount of anesthetic to help lessen the trauma; the vasoconstrictor norepinephrine then causes the area’s soft tissue to blanch

• Advance the needle until it contacts the hard palate

• Withdraw the needle slightly and perform aspiration

• After a negative result on aspiration, very slowly inject the anesthetic

Pressure anesthesia is beneficial to help lessen the pain

Because the tissue is so dense and is attached to the bone, this block requires a slow injection

Another commonly used block to anesthetize areas of the hard palate

Not as traumatic for the patient as the nasopalatine nerve block

Because of the sensitivity of the area, pressure anesthesia (e.g., using a cotton swab applicator) is helpful at the site of injection

Areas anesthetized:

• Palatal gingiva and mucosa in the area from the maxillary 1st premolar (anteriorly) to the posterior portion of the hard palate to the midline

Steps:

• Locate the greater palatine foramen by using a cotton swab applicator to press down on the tissue in the region of the 1st maxillary molar, moving posteriorly until the swab dips into the tissue (usually posterior to the 2nd maxillary molar)

• Use a cotton swab applicator to apply pressure to the injection site

• Insert the needle and inject a small amount of anesthetic to lessen patient discomfort; the tissue of the area will begin to blanch from the effects of the anesthetic agent

• Advance the needle until it contacts the hard palate

• Withdraw the needle slightly and perform aspiration

• After a negative result on aspiration, slowly inject the anesthetic

The clinician should be able to feel the needle contact bone; otherwise, the needle could be too posterior in the soft palate

The middle superior alveolar nerve is reported to be present in about 30% of all people

Areas anesthetized:

• All maxillary premolars and possibly the mesiobuccal root of the 1st maxillary molar

• Buccal gingiva opposite the teeth

Steps:

• Insert the needle into the mucosa at the mucobuccal fold just superior to the area of the maxillary 2nd premolar

• Advance the needle until the tip is superior to the apex of the maxillary 2nd premolar for maximum anesthesia

• After a negative result on aspiration, slowly inject the anesthetic

Local infiltrations are a common substitute for this block

This area is somewhat avascular, and hematoma formation is rare

Less frequently used because of the risk of the clinician injuring the patient’s eye

This block anesthetizes the following nerves:

• Anterior superior alveolar nerve

• Middle superior alveolar nerve

• Infraorbital nerve

Areas anesthetized:

• All maxillary teeth from the central incisor to the premolars, with the possible inclusion of the mesiobuccal root of the 1st maxillary molar

• Buccal gingiva opposite these teeth

• Lateral aspect of nose, lower eyelid, and upper lip

Steps:

• Locate the infraorbital foramen via palpation

• Insert the needle into the mucosa at the mucobuccal fold in the area superior to the 1st maxillary premolar

• Advance the needle parallel to the long axis of the tooth until it contacts the bone of the infraorbital foramen

• After a negative result on aspiration, slowly inject the anesthetic

No significant potential for a hematoma

Useful when pulpal anesthesia cannot be achieved in a local infiltration because of dense bone or when anesthesia is required on multiple teeth that would need more than one injection

An excellent technique to achieve hemimaxillary anesthesia

Anesthetizes all of the branches of the maxillary division of the trigeminal nerve

Useful in extensive quadrant procedures and surgery

With blocking of the entire division, the following nerves are anesthetized:

• Posterior superior alveolar nerve

• Middle superior alveolar nerve

• Anterior superior alveolar nerve

• Nasopalatine nerve

• Greater palatine nerve

• Infraorbital nerve

Areas anesthetized:

• All maxillary teeth

• All buccal gingiva

• All palatal gingiva and mucosa

• Lateral aspect of nose, lower eyelid, and upper lip

Goal: to deposit the anesthetic in the pterygopalatine fossa using its eventual connection with the greater palatine foramen

Steps:

• Locate the greater palatine foramen by using a cotton swab applicator to press in the region of the 1st maxillary molar, moving posteriorly until the swab dips into the tissue (usually posterior to the 2nd maxillary molar)

• Use a cotton swab applicator to apply pressure to the injection site

• Insert the needle into the mucosa and inject a small amount of anesthetic to lessen patient discomfort; the tissue will begin to blanch as a result of effects of the anesthetic agent

• Insert the needle further and locate the greater palatine foramen with the needle

• Once the foramen is located, insert the needle and advance it approximately 28 to 30 mm; at this location, the needle should be in the pterygopalatine fossa

• During the passage, if any bony resistance is met, the needle may be rotated to aid insertion (note: under NO circumstances should the needle be forced)

• After a negative result on aspiration, slowly inject the anesthetic

The needle should NEVER be forced into the greater palatine foramen, because occasionally the canal is not vertical, so that forced entry will fracture the bone

Because the orbit is located superior to the pterygopalatine fossa, if the needle is placed too far superiorly, the anesthetic can be deposited in this region, affecting the eye

Because the palatine vessels also are contents of the canal, care must be taken to prevent hematoma