This block is important to master because clinically acceptable mandibular anesthesia is more difficult to achieve than maxillary anesthesia owing to 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 2/3 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)

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 20–25 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 obtaining 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 procedure–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 by an inferior alveolar injection; therefore a long buccal nerve block may be performed in conjunction with an inferior alveolar nerve block

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

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 obtaining 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)

• ▪

  Skin of the chin anterior to mental foramen

Locate the mental foramen by means of 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 obtaining 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 to achieve excellent dental anesthesia

Often not effective for surgical procedures

Risk of damaging the nerve if the needle drops into the mental foramen

A variation of the inferior alveolar nerve block that can be especially helpful when a patient has a history of inferior alveolar nerve block failure likely caused by anatomic variability or accessory innervation, it anesthetizes:

• ▪

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

• ▪

  Mylohyoid nerve

• ▪

  Lingual nerve

• ▪

  Long buccal nerve

• ▪

  Auriculotemporal nerve

Low positive aspiration rate (less than 2%) 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 2/3 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)

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 obtaining 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