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

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