1. Types and Techniques of
Mandibular nerve block
By
Dr. Said Ahmed Mohamed
B.D.S. , FDSRCS Edin.
Consultant Oral & Maxillofacial
Surgery
Saqr Hospital

2. Types of Mandibular Regional
Anesthesia
• Inferior Alveolar Nerve Block
Mandibular teeth on side of injection, buccal and lingual hard and soft tissue, lower lip
• Buccal Nerve Block
Buccal soft tissue of molar region
• Gow-Gates Mandibular Nerve Block
Mandibular teeth to midline, hard and soft tissue of buccal and lingual aspect,
anterior 2/3 of tongue, FOM, skin over zygoma, posterior aspect of cheek, and
temporal region on side of injection
• Vazirani-Akinosi Closed Mouth
Mandibular teeth to midline, hard and soft tissue of buccal aspect, anterior 2/3 of
tongue, FOM
• Mental Nerve Block
Buccal soft tissue anterior to mental foramen, lower lip, chin
• Incisive Nerve Block
Premolars, canine and incisors, lower lip, skin over the chin, buccal soft tissue anterior
to the mental foramen

3. Techniques of Mandibular Regional
Anesthesia
• Techniques used in clinical practice for the anesthesia of the hard
and soft tissues of the mandible include the supraperiosteal
technique, PDL injection, intrapulpal anesthesia, intraseptal
injection, inferior alveolar nerve block, long buccal nerve block,
Gow-Gates technique, Vazirani-Akinosi closed mouth mandibular
block, mental nerve block, and incisive nerve block.
• The supraperiosteal, PDL, intrapulpal, and intraseptal techniques
are executed in the same manner as described above for maxillary
anesthesia. When anesthetizing the mandible the patient should be
in the semisupine or reclined position. The right handed operator
should stand at the nine o’clock to ten o’clock position whereas the
left handed operator should stand at the three o’clock to four o’
clock position.

4. Inferior Alveolar Nerve Block
• The inferior alveolar nerve block is one of the most
commonly employed techniques in mandibular
regional anesthesia.
• It is extremely useful when multiple teeth in one
quadrant require treatment. While effective, this
technique carries a high failure rate even when strict
adherence to protocol is maintained.
• The target for this technique is the mandibular nerve
as it travels on the medial aspect of the ramus, prior to
its entry into the mandibular foramen. The lingual,
mental, and incisive nerves are also anesthetized.
• A 25 gauge long needle is preferred for this technique.

5. • Technique :
• The patient should be in the semisupine position. The right handed
operator should be in the eight o’clock position whereas the left
handed operator should be in the four o’clock position.
• With the mouth open maximally, identify the coronoid notch and
the pterygomandibular raphae.
• Three quarters of the anteroposterior distance between these two
landmarks, and approximately six to ten millimeters above the
occlusal plane is the injection site.
• Use a retraction instrument to retract the cheek and bring the
needle to the injection site from the contralateral premolar region.
• As the needle passes through the soft tissue, deposit one or two
drops of anesthetic solution.

6. • Advance the needle until bone is contacted. Once bone is
contacted, withdraw the needle one millimeter and redirect the
needle posteriorly by bringing the barrel of the syringe towards the
occlusal plane (Fig. 18, A and B).
• Advance the needle to three quarters of its depth, aspirate, and
inject three quarters of a cartridge of anesthetic solution slowly
over the course of one minute.
• As the needle is withdrawn, continue to deposit the remaining one
quarter of anesthetic solution so as to anesthetize the lingual nerve
(Fig. 18, C).
• Successful execution of this technique results in anesthesia of the
mandibular teeth on the ipsilateral side to the midline, associated
with buccal mucosa anterior to the mental foramen, lingual soft
tissue, lateral aspect of the tongue on the ipsilateral side, and lower
lip on the ipsilateral side.

9. Figure 18 A: Location of the inferior alveolar nerve. B: After contacting bone,
the needle is redirected posteriorly by bringing the barrel of the syringe
towards the occlusal plane. The needle is then advanced to three quarters of
its depth

10. Figure 18 C: Location of the lingual nerve which is anesthetized
during the administration of an inferior alveolar nerve block

12. Buccal Nerve Block
• The buccal nerve block, otherwise known as the long
buccal or buccinator block, is a useful adjunct to the
inferior alveolar nerve block when manipulation of the
buccal soft tissue in the mandibular molar region is
indicated.
• The target for this technique is the buccal nerve as it
passes over the anterior aspect of the ramus.
• Contraindications to the procedure include acute
inflammation and infection over the site of injection.
• A 25 gauge long needle is preferred for this technique.

13. • Technique-
• The patient should be in the semisupine position. The right
handed operator should be in the eight o’clock position
whereas the left handed operator should be in the four
o’clock position.
• Identify the most distal molar tooth on the side to be
treated. The tissue just distal and buccal to the last molar
tooth is the target area for injection (Fig. 19, A and B).
• Use a retraction instrument to retract the cheek.
• The bevel of the needle should be toward bone and the
syringe should be held parallel to the occlusal plane on the
side of the injection.
•

14. • The needle is inserted into the soft tissue and a
few drops of anesthetic solution are
administered.
• The needle is advanced approximately one or
two millimeters until bone is contacted. Once
bone is contacted and aspiration is negative,
0.2cc of local anesthetic solution is deposited.
• The needle is withdrawn and recapped.
Successful execution of this technique results in
anesthesia of the buccal soft tissue of the
mandibular molar region.

15. Figure 19 A:Location of the buccal nerve. B: The tissue just distal
and buccal to the last molar tooth is the target area for injection.

16. Gow-Gates Technique
• The Gow-Gates technique or third division nerve block is useful
alternative to the inferior alveolar nerve block
• it is often used when the latter fails to provide adequate
anesthesia.
• Advantages of this technique versus the inferior alveolar technique
are its low failure rate and low incidence of positive aspiration.
• The Gow-Gates technique anesthetizes the auriculotemporal,
inferior alveolar, buccal, mental, incisive, mylohyoid and lingual
nerves. Contraindications to this procedure include acute
inflammation and infection over the site of injection and trismatic
patients. A 25 gauge long needle is preferred for this technique.

17. • Technique-
• The patient should be in the semisupine position. The right
handed operator should be in the eight o’clock position
whereas the left handed operator should be in the four
o’clock position.
• The target area for this technique is the neck of the condyle
below the area of insertion of the lateral pterygoid muscle.
A retraction instrument is used to retract the cheek.
• The patient is asked to open maximally and the
mesiolingual cusp of the maxillary 2nd molar on the side of
desired anesthesia is identified.
• The insertion site of the needle will be just distal to the
maxillary 2nd molar at the level of the mesiolingual cusp.
• Bring the needle to the insertion site in a plane that is
parallel to an imaginary line drawn from the intertragic
notch to the corner of the mouth on the same side as the
injection (Fig. 20, A and B).

18. • The orientation of the bevel of the needle is not important in this
technique. Advance the needle through soft tissue approximately
25mm until bone is contacted. This is the neck of the condyle. Once
bone is contacted, withdraw the needle one millimeter and
aspirate. Redirect the needle superiorly and reaspirate. If aspiration
in two planes is negative, slowly inject one cartridge of local
anesthetic solution over the course of one minute. Successful
execution of this technique provides anesthesia to the ipsilateral
mandibular teeth up to the midline, and associated buccal and
lingual hard and soft tissue. The anterior two thirds of the tongue,
floor of the mouth, skin over the zygoma, posterior aspect of the
cheek and temporal region on the ipsilateral side of injection are
also anesthetized.1,8

19. Figure 20 A: The patient is asked to open mouth maximally. The mesiolingual
cusp of the maxillary 2nd molar is the reference point for the height of the
injection. B: The needle is then moved distally and is held parallel to an
imaginary line drawn from the intertragic notch to the corner of the mouth

21. Vazirani-Akinosi Closed Mouth
Mandibular Block
• The Vazirani-Akinosi closed mouth mandibular block is a useful
technique for patients with limited opening due trismus or
ankylosis of the temporomandibular joint.
• Limited mandibular opening precludes the administration of the
inferior alveolar nerve block or use of the Gow-Gates technique
both of which require the patient to be open maximally.
• Other advantages to this technique are the minimal risk of trauma
to the inferior alveolar nerve, artery, vein, and pterygoid muscle,
low complication rate and minimal discomfort upon injection.
• Contraindications to this technique are acute inflammation and
infection in the pterygomandibular space, deformity or tumor in the
maxillary tuberosity region or an inability to visualize the medial
aspect of the ramus.
• A 25 gauge long needle is preferred for this technique.

22. • Technique-
• The patient should be in the semisupine position. The right handed
operator should be in the eight o’clock position whereas the left
handed operator should be in the four o’clock position.
• The gingival margin above the maxillary 2nd and 3rd molars and
the pterygomandibular raphae serve as landmarks for this
technique.
• A retraction instrument is used to stretch the cheek laterally.
• The patient should occlude gently on the posterior teeth. The
needle is held parallel to the occlusal plane at the level of the
gingival margin of the maxillary 2nd and 3rd molars.
• The bevel is directed away from the bone facing the midline.
• The needle is advanced through the mucous membrane and
buccinator muscle to enter the pterygomandibular space.

23. • The needle is inserted to approximately one half to three quarters
of its length.
• At this point the needle will be in the midsection of the
ptyerygomandibular space.
• Aspirate and if negative, one cartridge of local anesthetic solution
is deposited over the course of one minute.
• Diffusion and gravitation of the local anesthetic solution will
anesthetize the lingual and long buccal nerves in addition to the
inferior alveolar nerve.
• Successful execution of this technique provides anesthesia of the
ipsilateral mandibular teeth up to the midline, and associated
buccal and lingual hard and soft tissue. The anterior two thirds of
the tongue and floor of the mouth are also anesthetized.9,10

26. Mental Nerve Block
• The mental nerve block is indicated for
procedures where manipulation of buccal soft
tissue anterior to the mental foramen is
necessary.
• Contraindications to this technique are acute
inflammation and infection over the injection
site.
• A 25 or 27 gauge short needle is preferred for this
technique.

27. • Technique-
• The patient should be in the semisupine position. The
right handed operator should be in the eight o’clock
position whereas the left handed operator should be in
the four o’clock position.
• The target area is the height of the mucobuccal fold
over the mental foramen (Fig. 21, A and B).
• The foramen can be manually palpated by applying
gentle finger pressure to the body of the mandible in
the area of the premolar apicies.
• The patient will feel slight discomfort upon palpation of
the foramen.
•

28. • Use a retraction instrument to retract the soft
tissue.
• The needle is directed toward the mental
foramen with the bevel facing the bone.
• Penetrate the soft tissue to a depth of five
millimeters, aspirate and inject approximately
0.6cc of anesthetic solution.
• Successful execution of this technique results in
anesthesia of the buccal soft tissue anterior to
the foramen, lower lip and chin on the side of the
injection.1

29. Figure 21, A: Location of the mental and incisive nerves.
Figure 21, B: Block of the mental and incisive nerves: The needle is inserted at
the height of the mucobuccal fold over the mental foramen for both the
mental nerve block and incisive nerve block.

30. Incisive Nerve Block
• The incisive nerve block is not as frequently employed
in clinical practice however it proves very useful when
treatment is limited to mandibular anterior teeth and
full quadrant anesthesia is not necessary.
• The technique is almost identical to the mental nerve
block with one additional step. Both the mental and
incisive nerves are anesthetized using this technique.
• Contraindications to this technique are acute
inflammation and infection at the site of injection.
• A 25 or 27 gauge short needle is preferred for this
technique.

31. • Technique-
• The patient should be in the semisupine position. The right handed
operator should be in the eight o’clock position whereas the left
handed operator should be in the four o’clock position.
• The target area is the height of the mucobuccal fold over the
mental foramen (See Fig. 21, B).
• Identify the mental foramen as previously described. Give the
patient a mental nerve block as described above and apply digital
pressure at the site of injection during administration of anesthetic
solution.
• Continue to apply digital pressure at the site of injection two to
three minutes after the injection is complete to aid the anesthetic
in diffusing into the foramen.
• Successful implementation of this technique provides anesthesia to
the premolars, canine, incisor teeth, lower lip, skin of the chin, and
buccal soft tissue anterior to the mental foramen.

32. Figure 21, B: Block of the mental and incisive nerves: The needle
is inserted at the height of the mucobuccal fold over the mental
foramen for both the mental nerve block and incisive nerve
block.