Professor: R.

Padmanabhan Adesh University

INFERIOR ALVEOLAR-LINGUAL-LONG BUCCAL NERVE INJECTION

By executing the inferior alveolar-lingual-long buccal nerve injection, anesthesia is secured for surgical and exodontic measures upon the teeth and the tissues immediately surrounding them. Actually, the lingual nerve is blocked in the course of the inferior alveolar nerve injection, while the long buccal nerve requires a separate puncture in a different region. At the present time, this form of block anesthesia is carried out by three different techniques: 1. The Fischer technique, known as the "1, 2, 3" method. 2. The single path technique, known as the "1" method. 3. The straight line modification of the single path technique

THE FISCHER OR '1, 2, 3" TECHNIQUE This method of blocking the inferior alveolar nerve by the intraoral route is older than the single path technique, and has many staunch-adherents who, after modifying it slightly in some instances, claim for it many major advantages which will be discussed somewhat further on in this chapter. Not its variations, but the original procedure, will be taken up at this point, first for the right inferior alveolar nerve and then for the left one. Fischer or "1, 2, 3" Technique for Right Side.Instruct the patient to keep the mouth wide open and so adjust the head rest as to maintain the mandibular occlusal plane parallel to the floor. Raise or lower the chair until the subject's head is on a level with your right shoulder. As a source of illumination for the recesses of the oral cavity, a surgical headlight is perhaps the most efficient. Examine the anesthesia tray to ascertain whether the serrated thumb forceps is w i t h i n t h e easy reach. Do not commence any conduction i n je c t i o n unless
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Professor: R. Padmanabhan Adesh University

t h i s instrument is at h a n d to pluck t h e needle fro m t h e tissues, should i t fracture. S l i d e t h e ball o f t h e l e f t finger u p wa r d a n d b a c k wa r d , starting wi t h the alveolar mucosa on the buccal aspect o f t h e molar teeth, until the sharp external oblique l i n e i s f e l t . To e l i mi n a t e t h e anterior border of the masseter muscle, request that t h e patient alternately open and close t h e mo u t h slowly. I f t h e r e i s n o a l t e r a t i on i n t h e hardness of t h e ridge, it is t h e bone a n d n o t t h e mu s c l e . P a l pa t e for t h e deepest p o i n t of t h e concavity on t h i s ridge. Keeping t h e ball of the finger stationary, rotate t h e finger u n t i l t h e radial o r t h u mb side just touches t h e bucco-occlusal line angle o f t h e mo l a r t e e t h , a n d t h e dorsal surface faces t h e median l i n e .

Note t h a t the fleshy t i p o f t h e finger is now lying in t h e r e t r o mo l a r fossa, t h a t t h e edge of t h e n a i l is superimposed upon the b l u n t i n t e r n a l o b l i q u e l i n e ; a n d t h a t t h e ball t h e finger i s upon t h e external oblique l i n e . Wi t h o u t changing its position, scrub the palpating finger-tip a n d t h e a d jo i n i n g mu c o u s membrane, first w i t h a dry cotton-wound wooden applicator to remove the mucous a n d t h e n wi t h t h e c o mb i n e d surface a n t i s e p t i c - a n e s t h e t i c . Allow atleast thirty seconds for the action of the drugs. The loaded syringe is now picked Up with the right hand, pen grasp, with the bevel toward the internal surface of the ramus. The needle recommended for this injection is 42 mm or 1 5/8 inches long and of gauge No. 22 and 23. Advancing from the two bicuspids of the left side, the point head of the needle is made to pierce the mucous membrane at the mid-point of the finger-nail, to a depth of about '6mm or inch, whereupon the bony obstruction of the internal oblique line should be encountered. Contact is sufficient; do not engage the needle-point in the periosteum. Gently swing the syringe back to the right side until it is parallel to the molar teeth, both in a vertical as well as in a horizontal
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Professor: R. Padmanabhan Adesh University

plane. Holding the syringe lightly, allow the needle-to penetrate a little deeper, approximately another 6mm or inch. The second movement is designed to permit the needle to pass the internal oblique line and to bring it into the vicinity of the lingual nerve. Slowly deposit 0,5cc of anesthetic at this level. If with the syringe on right side (second position) difficulty is experienced in rounding the internal oblique line, probe gently with the needle-point until the resistance disappears and continue for 6 mm. as before.

Having injected for the lingual nerve, the-syringe is carefully brought back to approximately the first position, i.e., somewhere between the left lateral incisor and the left first bicuspid, and kept parallel to the floor. Observe that this third position is not fixed as is the first. The third position varies according to the inclination of the internal surface o f the ramus. The needle is carefully inserted for an additional depth of 10-15mm or 1 to 1.5 cm. (2/5 to 3/5 inches). If bone is encountered within these l i mi t s , it may be confidently assumed that the opening of the needle has struck the ramus directly a t the posterior ledge of the mandibular sulcus, and 1.5 cc of solution is slowly released without pressure.

After making 'contact with the bone, it is preferable to withdraw the needle 1 or 2 mm. to prevent injury to the 'periosteum with the resulting after-pain. The total length of the needle which is buried in the tissues can readily be calculated as being between 22 -27mm. (7/8 to 1 1/8 inches). Under no circumstances, except in the case of a patient with an unusually wide ramus, should the total depth of insertion exceed 1 1/8 inches. For children the normal length is between 12 to 15 mm, (1/2 to 5/8 inches).

Professor: R. Padmanabhan Adesh University

The width of the ramus can be estimated by placing the thumb in

the

subject's cheek and pressing backward, while the index finger palpates the posterior border of the ramus just below the external ear.

The patient's mouth being half open. I n the event that an insertion of 1 1/8 inches fails to reach bone, the needle should be withdrawn until only the bevel is engaged in the tissues, the syringe swung further posteriorly, to a position between the two left bicuspids, and then reinserted the proper distance until contact is made.

By anesthetizing the inferior alveolar nerve, we have assured insensibility of the teeth of the same side, as well as the mucous membrane supplied by the terminal branches of he mental nerve, i. e. the gums i n the anterior and

bicuspid region. The lingual nerve injection adequately desensitizes the lingual mucosa. However a small patch of mucous membrane on the buccal aspect of the molar teeth frequently retains sensation for the very good reason that its nerve supply is from neither of the nerves mentioned but from the long buccal branch, which therefore requires a separate injection.

The long buccal nerve injection is simple and almost error-proof. Consequently, when any surgery or exodontia involving the area innervated by the long buccal nerve is anticipated, it should be blocked routinely as a timesaving measure. There are t wo methods of accomplishing this. Where no infection is present on the buccal surface of the mandibular molars, simple submucous infiltration of the tissue just buccal to the tooth to be removed or in the fold near the disto-buccal angle of the third molar with 0.5 cc. of solution is sufficient to intercept the fibers of the long buccal nerve.

Professor: R. Padmanabhan Adesh University

An alternate method is to insert the point of the needle beneath the mucosa about 6mm. or 1/4 inch buccally to the mesial root of the last molar, with the shaft of the needle held at an angle of about 30 degrees

upward and outward. The point of the needle is then slid along beneath the mucosa until the region of the distal root of the last molar is reached. The deposition of 0.5 cc. of anesthetic solution will block the terminal branches of the long buccal nerve. .

Where infection contraindicates this procedure, the nerve may be blocked by inserting the same needle used for the inferior alveolar injection into the mucous membrane about 0.5 inch or little more than 1 cm below a n d behind the opening of Stenson's duct. After t h e i n i t i a l puncture, t h e needle is slid along submucously (without entering t h e buccinator muscle, i f possible) for about 1.5cm posteriorly, and a total of 1 cc. of anesthetic deposited during-the progress of the needle. An excellent way to block the buccinator nerve is described by Dr. E. G. Sloman in his article "Anatomy a n d Anesthesia of the Buccinator (Long Buccal) Nerve .

The technique which he evolved for ordinary practice is to make the puncture at a point 1 cm above the occlusal surface of the lower molars and 4 millimeter medially to the external oblique ridge in the retromolar fossa. The needle is directed backward and slightly outward and is inserted until bone is felt. It is then withdrawn slightly (2 millimeters) and the solution deposited . In the second method, which supposes the necessity of injecting still farther distally from the body of the mandible, an imaginary line is drawn on the surface of the mucous membrane which follows the course of the buccinator nerve upward in the temporal muscle. As the author states, in order to select a point at which to inject, the operator need but to remember that from the point at which the nerve emerges from the temporalis (at the sharp anterior border of the ramus of t h e
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Professor: R. Padmanabhan Adesh University

ma n d i b l e on a level with the occlusal surfaces of the lower posterior teeth) it passes upward, medially and very slightly posteriorly, and that for every 8mm. of its ascent, it passes 3 millimeters medially and about 1 millimeter posteriorly. As it passes upward in the temporalis, it departs farther and farther from the surface of the bone, but remains (in the lower four-firths of its course through the muscle) about 3 millimeters from the surface of the overlying oral mucosa."

Edentulous Mandibles.- Since in these cases, the occlusal surfaces of the molar teeth are not available as landmarks, the technique just described must be modified slightly.

Place the hall of the left index finger on the buccal alveolar mucosa in the right molar region and carefully palpate upward and backward to determine the deepest point of the concavity on the external oblique line. Test as described, to eliminate the anterior border of the masseter muscle. With the ball of the finder resting in the base of the curve on the sharp outer ridge, turn the hand until the dorsal surface of the finger faces the median line and the thumb side is 1 cm. or 2/5 inch above the edentulous molar area. If this step is properly executed, the base of the finger will touch the incisal tips of the anterior teeth, or will be slightly less than 1 cm. above the anterior edentulous ridge.

Following the surface sterilization and anesthetization of the mucous membrane, the first and second positions are completed as outlined, with the exception that the lower border of the mandible is taken as a guide for the horizontal position of the syringe, instead of the occlusal surfaces of the molar teeth. I n the third thrust, the needle may*he given a slightly upward
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Professor: R. Padmanabhan Adesh University

direction to overcome the tendency to set the site of puncture at too low a level. Due to the fact that the angle formed by the body and the ramus of the mandible in the aged is greater than in the young adult, the mandibular foramen will appear t o be higher than usual as compared with the body of the mandible. Children's Mandible. : Examination of the mandible of a child will reveal the fact that the relationships of the several landmarks vary from those existing in the adult's jaw. To compensate for the smaller size of the bone and for the differing angles, the inferior alveolarlingual nerve injection technique is revised to some extent. Thus, although the "1, 2, 3" positions are continued, the following changes are instituted: (a) The level of the first puncture is reduced to 3/8 inch or 10 mm. above the occlusal surfaces of the molars. (b) To reach the lingual nerve from the second position, a depth of |inch or 6 mm. is adequate. (c) The total distance from the mucous membrane to the mandibular sulcus is 1/2 inch to 3/4 inch (12 mm. to 15 mm.) as compared to twice that length in the adult. (d) Finally the needle should take a slightly downward path in proceeding from the third position toward the mandibular foramen.

Imperfect Anesthesia of the Anterior Teeth Following Inferior Nerve Block. Theoretically, anesthesia of the inferior alveolar nerve of any one side guarantees anesthesia of all parts of that side as far as the median line. Practically, however, it is found that a certain degree of sensation remains in the anterior teeth due to the interlacing of the fibers from t h e incisive branch of the unanesthetized inferior alveolar nerve of t h e opposite side. To insure the complete desensitization of al l nerves ramifying to the anterior teeth, operations
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Professor: R. Padmanabhan Adesh University

on these organs should not ho attempted before giving the incisive fossa injection as described in the chapter on "Infiltration Anesthesia," or an incisive nerve block a t the mental foramen of the opposite side, or an inferior alveolar nerve block on the opposite side.

Fischer or "1, 2, 3" Technique for Left Side.- Regardless of which side of the mandible is to be anesthetized, the left index finger is employed for palpation, while the right hand manipulates the syringe. The only difference that exists is that, when injecting the nerve of the left side, either the hands are crossed or the operator's left hand surrounds the head of the patient. When the correct height of the puncture is decided upon, it will he found that the thumb side of the left index finger is now pointing upward (instead of downward as in the case of the injection for the right side) but that the dorsal surface still faces the median line. The first position of the syringe is from the right; the second, from the left; and the third from the right again. In all other respects t h e right and left side injections are identical.