Mandibular nerve branch block
To achieve profound anesthesia of specific mandibular zones, targeted blockade of peripheral branches is applied.
Mental nerve The nature of anesthesia depends on the depth of needle insertion. If the solution is left in the soft tissues, only the chin and lower lip will become numb. When the drug is administered directly into the mental foramen/canal, the zone expands: the incisors, canine, premolars, corresponding section of the alveolar process, and vestibular mucosa become anesthetized. The effect develops in approximately 5 minutes. Vascular trauma may lead to hematomas and skin ischemia, whereas damage to the nerve trunk can cause neuritis.
Buccal nerve (n. buccalis) This is the only sensory nerve of the anterior group. Its blockade is strictly mandatory during surgical manipulations in the region of the mandibular molars and premolars.
- Infiltration method: used when working with 1–2 teeth. The solution is injected along the mucobuccal fold near the target teeth.
- Conduction method: the needle is inserted into the buccal mucosa at the intersection of the occlusal plane of the upper molars and the projection of the anterior border of the coronoid process. The needle is inserted to a depth of 1.0–1.5 cm. The anesthetic volume is 1–2 ml.
Lingual nerve Usually blocked simultaneously with mandibular anesthesia. If an isolated block is required, the insertion is made into the deepest part of the retromolar/pterygomandibular triangle at the level of the middle of the lower wisdom tooth crown (up to 1 ml of solution is injected).
Periodontal local anesthesia techniques
If the intervention is limited to hard dental tissues, extensive soft tissue numbness is undesirable. In such cases, periodontal techniques (intraligamentary, intraseptal, and intraosseous) are used, which act via an infiltration mechanism.
The solution reaches the root apex through two pathways:
- Through bone marrow spaces: diffusion along the alveolus leads to the blockade of pulp and periodontal nerves.
- Through the vascular bed: spread occurs radially (in the mandible—toward the mandibular canal).
Due to the rich vascular network, drugs can be administered only with a vasoconstrictor; otherwise, the drug is washed out too rapidly into the systemic circulation. The injection is performed under high pressure, forcing the liquid even against the blood flow, causing acute ischemia (whitening) of the mucosa and hypoxic blockade of nerve fibers.
Intraligamentary and intraseptal techniques
Intraligamentary (periodontal ligament) anesthesia The solution is injected into the periodontal ligament space, from where it is forced under high pressure through the cribriform plate (lamina cribriformis) into the cancellous bone. Features:
- Requires a specialized syringe with a mechanical ratchet (e.g., CITOJECT) delivering strictly 0.06 ml per click.
- The needle is positioned at a 30° angle to the tooth axis. It is injected slowly (one dose over 7 seconds).
- A major advantage is the absence of soft tissue numbness. This is the ideal choice for children (eliminating the risk of the child biting their lip) and patients with high speech demands.
- Contraindicated in the presence of periodontal pockets and acute periodontitis.
Intraseptal anesthesia The drug is injected directly into the interdental bone septum. Features:
- The gingiva is punctured at a 90° angle, and then the needle is forcibly inserted into the bone to a depth of 1–2 mm.
- The practitioner must feel strong resistance of the plunger—this is the primary criterion for entering the bone tissue.
- Provides deep anesthesia and pronounced local hemostasis, which is extremely convenient for flap operations and curettage.
- The zone of action is limited to the teeth adjacent to the septum, and the effect develops in less than a minute.
Briefly: answers to topical questions
Which nerves must be blocked for complete pain control during the extraction of a mandibular molar?
For complete pain control during the extraction of a mandibular molar, the inferior alveolar, lingual, and buccal nerves must be blocked.
- Inferior alveolar nerve (n. alveolaris inferior) — innervates the teeth and bone tissue of the alveolar part of the mandible.
- Lingual nerve (n. lingualis) — blocked simultaneously with the inferior alveolar nerve to anesthetize the mucosa on the lingual side.
- Buccal nerve (n. buccalis) — its additional blockade is mandatory to anesthetize the gingiva of the alveolar process from the vestibular side in the molar region.
What intraoral methods of mandibular anesthesia exist?
There are several intraoral methods of mandibular anesthesia performed using various anatomical landmarks.
The main intraoral methods include:
- Palpatory method — performed by palpating the inner border of the mandibular ramus.
- Apodactyl (non-palpatory) method — performed without palpation, using the pterygomandibular raphe as a landmark.
- Gow-Gates technique — performed with the mouth wide open, creating an anesthetic depot in the pterygomandibular space.
- Vazirani-Akinosi technique (Malamed method) — used when the jaws are clenched (trismus).
- P.M. Egorov method — upper molars and the intermaxillary triangle serve as landmarks.
- Torusal anesthesia (Vaisbrem method) — injection of the solution into the mandibular torus region.
What branches arise from the mandibular nerve?
Motor and sensory branches arise from the mandibular nerve (n. mandibularis).
Motor branches:
- Masseteric nerve (n. massetericus).
- Deep temporal nerves (nn. temporales profundi).
- Medial and lateral pterygoid nerves (n. pterygoideus medialis, n. pterygoideus lateralis).
- Mylohyoid nerve (n. mylohyoideus).
- Nerves to the tensor tympani (n. tensor tympani) and tensor veli palatini (n. tensor veli palatini) muscles.
Sensory branches:
- Auriculotemporal nerve (n. auriculotemporalis).
- Inferior alveolar nerve (n. alveolaris inferior) and its continuations: the incisive branch (n. incisivus) and the mental nerve (n. mentalis).
- Lingual nerve (n. lingualis).
- Buccal nerve (n. buccalis).
What is the target landmark during torusal anesthesia according to Vaisbrem?
The target landmark during torusal anesthesia according to Vaisbrem is the mandibular torus (torus mandibularis or torus mandibulae).
Anatomically, this region represents the junction of bone ridges extending from the coronoid and condylar processes. This torus is located superiorly and anteriorly to the lingula of the mandible. Administering the local anesthetic solution into this zone simultaneously blocks the inferior alveolar, lingual, and buccal nerves, which run inferiorly and medially to the torus in loose connective tissue.
Class and exam questions
Why is mandibular anesthesia alone insufficient for lower molar extraction?
Mandibular anesthesia does not anesthetize the buccal nerve, which innervates the mucosa and gingiva on the vestibular side in the posterior tooth region. For a painless surgical intervention, blockade of the buccal nerve is strictly mandatory.
What is the main advantage of intraligamentary anesthesia in pediatric dentistry?
During intraligamentary administration, soft tissue numbness (of the lips, cheeks, tongue) is completely absent. This prevents severe self-inflicted trauma when a child involuntarily bites the insensate tissues in the postoperative period.
Why do periodontal injections need to be administered with pressure?
The solution is injected into dense tissues (periodontal ligament or cancellous bone). Noticeable resistance of the plunger is the primary clinical sign that the drug is entering the bone rather than leaking into the soft tissues or oral cavity.
What else to study on this topic
- Topography of horizontal levels of anesthetic spread in the vascular bed
- Errors in intraseptal anesthesia (solution leakage, incorrect angle)
- Dosage calculation in intraligamentary anesthesia depending on the number of roots
- Criteria for selecting drugs for premedication and sedation before local anesthesia
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Other topics in "Chapter 4. Anesthesia in Oral Surgery (S.A. Rabinovich, S.T. Sokhov)"
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