Jaw surgeries and complex dental procedures require high-quality anesthesia. Mandibular anesthesia techniques are used to block the alveolar, buccal and lingual nerves in the mandible. How is mandibular anesthesia performed, what tissues are temporarily deprived of sensitivity, what complications are possible, what medications do doctors use? Let's look at these questions in the article.
What is mandibular anesthesia
Dentistry today has a large selection of types of pain relief. This opens up wide opportunities for the dental surgeon, especially in terms of treating young patients. Mandibular anesthesia is a conduction-type local anesthesia. Provodnikova - temporary blocking of the transmission of nerve impulses through a large nerve trunk. It is used when there is a need for an absolute block of pain while keeping the patient fully conscious.
Mandibular anesthesia is required if surgical intervention on the lower jaw is planned. An unpleasant moment of injection is a short-term feeling of fullness, pain and burning in the injection area. This sensation lasts a few seconds and is comparable to a prick when blood is drawn from a vein.
Extraoral (tuberal) anesthesia
The method is practiced during long-term surgery or in case of jaw injuries, when the patient is unable to open the oral cavity.
Indications:
- extensive inflammatory process of oral tissues;
- long-term surgical intervention - 2 or more teeth;
- injury to the bones and muscles of the jaw.
The anesthetic anesthetizes a large area of the facial part of the skull, including 2/3 of the tongue, all teeth on the selected side, the alveolar process, gum tissue, and the skin of the lower lip.
Methods of administering anesthetic differ in the location of the needle insertion:
- submandibular;
- retromaxillary;
- anteriormaxillary.
This method of pain relief is especially indicated in the treatment of children, who may be difficult to force to open their mouths for therapy. Also, conduction anesthesia is indicated for severe infection of the oral mucosa, accompanied by copious secretion of saliva. In such conditions it is difficult to maintain sterility and it is easy to add a new type of infection to an existing one. Also, children do not always comply with the dentist’s request not to close their mouth, preventing the doctor from performing manipulations in compliance with sanitary standards.
Another problem when treating children: they do not understand the request not to touch the mucous membrane sanitized with antiseptics with their tongue and often change the position of their head, provoking contamination of the mucous membrane treated for medical manipulation. Therefore, the extraoral route of pain relief is the only possible method when dealing with young patients.
Postmaxillary route of mandibular anesthesia
This method was proposed by Peckert and Wustrow in 1937. The essence is to instill an anesthetic from a point at the posterior edge of the arch of the lower jaw to the pterygoid muscle. The advantage of the method is the accessibility of the inferior alveolar nerve, the path to which is not blocked by the uvula of the lower jaw. The nerve can be blocked from a great distance, so there are no obstacles to successful blocking.
However, the method is also characterized by disadvantages, among which there is a very significant one - puncture of the parotid gland. Also, for instillation, a needle of a special shape is required - with a curve. If the needle breaks, it will be difficult to remove the fragments. For patients, instillation at the specified point is felt as painful, and the proximity to the injection point of the carotid artery adds additional risk to the manipulation. Therefore, the retromaxillary method is practically not used in modern dentistry.
Submandibular path
This method is much safer than the mandibular method. During the puncture, the needle moves parallel to the jawbone. To find the correct place to insert the needle, you need to place your hand on your neck so that your index finger touches the lower edge of the auricle. Then the thumb will indicate the point through which instillation is carried out.
If it is necessary to block the nerves in the right facial part, the patient's left hand is used to determine the injection point. Accordingly, to determine the point of entry of the needle into the left part of the facial zone, use the right hand. This technique was proposed by German scientists Sicher and Klein in 1915.
The extraoral anesthesia technique should be mastered by every practicing dentist, as it is used in cases of inflammation in the mucous membranes of the gums and soft tissues. Thanks to it, it is possible to carry out surgical intervention, stopping pain impulses and gaining free access.
Bershe Dubov method
This is one of the types of extraoral anesthesia of the lower jaw, from the subzygomatic part of the skull. The needle is inserted under the zygomatic area of the face two centimeters from the tragus of the ear. Novocaine is used as an anesthetic, but other options are also possible. After instillation, the entire half of the jaw is frozen.
Dubov slightly modified Berche's technique, simply changing the depth of insertion of the needle into the tissue: it increased by 1 cm.
Uvarov also made his own adjustments to the technique of administering the anesthetic according to Berchet, proposing to insert the needle to a depth of 4.5 cm. Compared to the proposal of Berchet (2.5 cm) and Dubov (3.5 cm), this looks somehow bold. Berdyuk and Egorov proposed their own adjustments. Their innovations are associated with changing the angle of the needle.
Anteriormaxillary path
This anesthesia technique is not widely used due to the risk of puncture of the cheek and penetration of the needle into the oral cavity. Although, with a successful injection, three nerves can be immediately anesthetized - buccal, lingual and inferior alveolar.
Methods of mandibular anesthesia
There are two common methods of performing mandibular anesthesia. The first method is intraoral and is carried out according to the modification of Gou-Gates and Akinosi. The second method is extraoral, carried out in three ways - mandibular, retromaxillary or subzygomatic.
From a technical point of view, there are the apodactyl (without palpation) method, the finger method, as well as modifications of Go-Gates and Akinosi.
Mandibular anesthesia using the apodactyl technique is performed most often. In the area of the required tooth in the lower jaw, infiltration anesthesia is first performed to anesthetize the buccal space. Then, with the maximum opening of the mouth, the patient feels the line between the lower and middle third of the pterygomandibular fold in its lateral slope. This is the place where the needle is inserted. First, it is inserted all the way into the bone, then it is turned in the opposite direction and one milliliter is injected at the level of the incisors. A total of 2 to 2.5 ml of anesthetic is injected.
With the finger method, an injection of an anesthetic solution in an amount of 3-4 ml is carried out in the area of the retromolar space and temporal ridge. The anesthetic is administered, as with the apodactylic technique, in two stages with a change in the position of the needle.
The Go-Gates modification involves anesthesia of three branches of the mandibular nerve at once. For this purpose, an injection of an anesthetic solution is administered in the area of the condylar process of the mandible.
If the patient has limited ability to open his mouth, mandibular anesthesia is performed using the Akinosi method. The patient does not open his mouth and closes his teeth. The injection is placed at the border of the buccal mucosa and the retromolar region of the upper jaw.
To perform mandibular anesthesia, the doctor must be highly qualified and have deep anatomical knowledge of the structure of the lower jaw.
Medical Internet conferences
To motivate children for timely dental treatment, it is necessary that all interventions in the dental chair are minimally painful. This can only be achieved with high-quality anesthesia. In pediatric dental practice, of all types of anesthesia, infiltration, mandibular, torus and palatal anesthesia are most often used. In the lower jaw, mandibular anesthesia is often used, in which the inferior alveolar and lingual nerves are switched off. The area of anesthesia is: the mucous membrane and periosteum of the alveolar process on the lingual side on half of the jaw; anterior 2/3 halves of the tongue; half of the lower lip; all teeth on the corresponding half of the lower jaw: mucous membrane and periosteum on the vestibular side of the alveolar process, except for the area near the molars, which requires additional infiltration anesthesia, since this area is innervated by the buccal nerve. Fig.1.
Knowledge about the features of mandibular anesthesia is significant when planning measures to provide emergency care in emergency conditions and in the treatment of surgical pathology in children, therefore, during its implementation, you should know the following landmarks or features: the location of the bone tongue and the mandibular foramen on the medial surface of the lower branch jaws. There are anatomical differences in the size and proportions of the bones of the maxillofacial region in children, which must be taken into account when administering anesthesia.
In a 3-5 year old child, the mandibular tongue is located approximately at the level of the occlusal surface of the teeth; with age, the position of the tongue changes upward and posteriorly relative to the occlusal plane, and already in a 15-16 year old teenager it is located approximately 1 cm above it (as in an adult) , therefore, when carrying out anesthesia, the needle is injected not 1 cm above the chewing surface of the lower molars, as in adults, but at the level of the chewing surface of these teeth and the lower the younger the child.
The branch of the lower jaw in children 3-5 years old is twice as narrow as in an adult; the volume of the pterygomaxillary space in children is less than in adults, therefore the mandibular, lingual and buccal nerves are located closer to each other. The angle of the lower jaw in an infant is 140º-145º, due to which the mandibular foramen itself is located lower, being in the same plane with the chewing surface of the lower molars. With age, the angle of the lower jaw decreases due to the eruption of permanent teeth, including wisdom teeth. In preschool children, the needle penetrates soft tissue by 10-15 mm (in adults by 15-25 mm). Therefore, children are given pain relief with a short needle. For anesthesia of the inferior alveolar nerve, 0.5-1 ml is enough for children. anesthetic (adults 1.5-1.8 ml). In preschool age, using mandibular anesthesia, it is often possible to turn off the sensitivity of all three nerves (inferior alveolar, lingual, buccal) that innervate the teeth of the lower jaw, which makes it possible to use additional anesthesia of the buccal nerve less often.
In accordance with the growth of the jaws, the change in the location of the mandibular foramen has the following patterns: Fig. 2. In children 3-5 years old it is located 1-2 mm below the chewing surface of the teeth of the lower jaw, and in children over 6-8 years old - at the level of the chewing surface of these teeth, in children 9-11 years old - 3-5 mm higher level of the chewing surface of these teeth, 12 years and older - as in adults - 1 cm above the level of the chewing surface of these teeth.
Based on the above, it follows that mandibular anesthesia at different ages is carried out taking into account the anatomical features of the structure of the jaws, ignorance of which can lead to poor quality anesthesia and, consequently, to more painful necessary manipulations. As a result, the young patient is left with a negative memory of the dental appointment and a reluctance to be observed and treated in the future, which leads to the more frequent occurrence of advanced diseases.
Possible complications
Mandibular anesthesia in rare cases leads to the development of complications. One of them is numbness of the tissues of the pharynx with subsequent limitation of movements of the lower jaw. Physiotherapy, mechanical therapy and administration of medicinal solutions are prescribed as treatment. A hematoma can occur as a result of damage to a vessel. If it does not resolve on its own, a puncture may be required. When a nerve is damaged, neuritis sometimes develops, the treatment of which requires physiotherapeutic procedures using heating elements or electric current. A very rare complication is temporary muscle paralysis as a result of medical error. If the injection technique is violated, the needle rarely breaks off and gets stuck in soft or tendon tissue. In such cases, surgical removal is used after an X-ray examination. If the needle does not cause concern to the patient and has grown into the tissue, it does not need to be removed.
Recommendations after the event
Any type of anesthesia is stress for the body, which must be minimized. Immediately after applying anesthesia, you must rise from the dental chair carefully to avoid dizziness. After pain relief, you must avoid drinking hot and alcoholic drinks. Do not massage the injection area or eat hot food. It is necessary to rinse your mouth with soda-salt or any other solution as prescribed by your doctor several times a day. It is better to sleep on the side opposite to the injection.
Innervation and anatomical landmarks
Lower jaw: Main features and landmarks. The most powerful and largest bone of the facial skull. Consists of 2 thick plates of cortical bone: lingual and buccal.
The teeth are located in the horseshoe-shaped body of the lower jaw. The branch of the lower jaw extends upward from the angle. The coronoid notch is a notch (concavity) on the anterior surface of the ramus of the mandible, used to locate the mandibular foramen, which is usually located at the level of the occlusal plane.
Innervation:
• The inferior alveolar nerve penetrates the thickness of the mandible through the mandibular foramen
• The lingual nerve enters the oral cavity passing opposite the lingual tuberosity
• The buccal nerve lies on the buccal protuberance.
Contraindications for mandibular anesthesia
Mandibular anesthesia is not used for liver diseases, which is associated with a large load on it. Novocaine is the only anesthetic that is not subject to this contraindication. If a major operation is required, local anesthesia is not suitable due to the need to administer a large amount of it. Epilepsy and mental illness, as well as problems of the cardiovascular system are contraindications to mandibular anesthesia. During pregnancy, it is necessary to weigh the risk to the fetus when exposed to drugs. For blood diseases and bronchial asthma, mandibular anesthesia is not performed. Contraindications to anesthesia must be considered individually; sometimes their list can be shortened or, conversely, expanded at the discretion of the attending physician.
Material and methods
A topographic-anatomical study of the pterygo-maxillary space was carried out on cadaveric material from the Department of Topographic Anatomy and Operative Surgery of Tver State Medical University. The work was carried out on 12 preparations taken from fixed corpses of people of different sexes and ages using the methods of macro- and micropreparation, morphometry, photography and sketching. Data obtained during the study were entered into the protocol manually. A clinical study of the use of the universal apodactylic method of mandibular anesthesia was carried out on the basis of the dental clinic of the Tver State Medical University. The study involved 20 patients (10 men and 10 women) aged from 20 to 52 years, who gave informed consent to participate in the study.
