Landmarks:

• Mucogingival junction of maxillary third or second molar

• Maxillary tuberosity

• Coronoid notch on the mandibular ramus

Target:

Superior portion of the pterygomandibular space, approximating the branches of the inferior alveolar nerve.

Procedure:

The mandible is in a state of near or complete closure. The needle tip is placed outside the maxillary teeth parallel to the buccal surfaces of the maxillary molars. The bevel of the needle is oriented medially such that soft tissue deflection will cause the needle tip to approach the medial border of the mandibular ramus. The insertion site is the soft tissue area at the height of the mocogingival junction of the maxillary third molar. The needle is inserted 25 to 30mm. This technique is inherently the most variable in that there is no definite bony contact at the extent of needle insertion.

Nerves anesthetized:

• Inferior alveolar

• Mental

• Incisive

• Lingual

• Mylohyoid

Areas anesthetized:

• Mandibular teeth to midline

• Buccal mucoperiosteum and mucous membranes in front of the mental foramen

• Anterior two thirds of tongue and floor of mouth

• Lingual soft tissues and periosteum

• Body of mandible

• Inferior ramus

Indications:

• Patients with limited mandibular opening

• Multiple procedures on mandibular teeth

Contraindications:

• Infection at the site of the injection

• Patients with the potential to bite their lip or tongue (handicapped patients, young children)

• When the administrator has the inability to visualize or gain access to the lingual aspect of ramus

Advantages:

• Relatively atraumatic technique

• Patient need not be able to open their mouth

• Fewer post-operative complications such as trismus

• Low aspiration rate of less than 10 per cent

Disadvantages:

• Difficult to visualize path of needle and depth of insertion

• No bony contact

• Risk of facial paralysis of facial nerve (CN VII) with overinsertion into parotid gland

• Potentially traumatic if too close to periosteum