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Figure16.16 Three perspectives of the needle insertion zone in the Laguardia–Akinosi mandibular block. Source: Redrawn from

Gustainis and Peterson (1981).

● Disadvantages ⚪ It fails more frequently than the conventional tech-

nique. Its Grade A anesthesia success rate is 80–85%, compared to 85% for the conventional technique (Table16.3).

⚪ Onset is longer than with the conventional tech-

nique, with a 30% incidence of failed blocks within 5 minutes of administration, as compared to a 10% incidence of failed blocks in the conventional technique (Annex 28).

⚪ Appropriate needle depth is difficult to determine

because no contact is made with bone.

⚪ This method is not reliable in pediatric patients due to

the difficulty experienced in estimating the depth to which the needle should penetrate in the growing child (Akinosi1977; Jendi and Thomas2019).

Use

The Laguardia–Akinosi closed- mouth technique is not designed for routine use, but as an alternative with patients:

1) Unable to open their mouth wholly or partially (trismus)

(Laguardia 1940; Vazirani1960; Akinosi1977).

2) In whom having the dentist’s fingers in their mouth

induces nausea (Small and Waters1983) or in patients whose tongue persistently obstructs the view of softtissue landmarks used in the conventional mandibular block (Haas2011).

Extraoral techniques may also be used in many of these cases (Roberts and Sowray 1987), although this intraoral technique is currently preferred over the extraoral approaches to mandibular blocks.

Distribution ofthe Anesthetic Solution

Diffusion- weighted imaging with contrast studies have shown that the anesthetic spreads well upward, backward, and outward in the pterygomandibular space. Anesthesia fails if the needle is too medial (inward), as this position hinders entry of the solution into the pterygomandibular space, where it spreads upward and inward or downward and outward (Gustainis and Peterson1981).

Zone Anesthetized

The zone anesthetized is as described in the general remarks, although the degree to which each element is numbed varies from one technique to another. All techniques must anesthetize the inferior alveolar nerve, a sure sign of which is soft tissue anesthesia of the lower lip on the side in question. In 85%

of cases, the lingual nerve is also anesthetized with this technique and the buccal nerve in 70% (Table16.3 and Annex 29).

Technique

● Use a long (35–42 mm) needle, given the depth of the

insertion. A 25G needle is ideal because it affords good aspiration and as it is thick and stiff, it deviates very little. If 25G is not available, 27G can be used, although less effectively (larger degree of deviation).

● Patient’s position: ⚪ Reclining or semireclining in dentist’s chair, with head

turned slightly toward the dentist.

⚪ Lips open but teeth occluded or at rest (separation of a

few millimeters between upper and lower arches) and chewing muscles relaxed to favor separation of the buccal mucosa and lips.

⚪ In edentulous patients, upper and lower arches sepa-

rated to the estimated height of their former teeth (Vazirani1960; Gustainis and Peterson1981).

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● Dentist’s position and position of their non- dominant

hand (i.e. the left in right-

handed clinicians), depending

on the side to be anesthetized.

⚪ Right side:

○ Dentist at 8:00 o’clock. ○ Left index finger in the patient’s mouth. ○ All other fingers stretching across the patient’s face

to block their vision and control the position of the mouth (Figure16.3)

⚪ Left side:

○ Dentist at 9:00.10:00 o’clock. ○ Non- dominant thumb in the patient’s mouth, requir-

ing the right-

handed dentist to pass their left arm

over the patient’s forehead (Figure16.4).

○ Dentist’s non- injection palm and wrist blocking

patient’s vision.

● Intraoral finger or thumb. The finger in the patient’s

mouth should rest on the anterior edge of the ramus of the mandible, in the concavity known as the coronoid notch

(Figure16.5) to:

⚪ Retract the upper lip and cheek upward and outward

to have a good view of the vestibule.

⚪ Tighten and stretch the soft tissue to make the needle

insertion less traumatic.

● Intraoral syringe position. The syringe should be placed

on the buccal side of the maxillary molars to (Figure16.17):

⚪ Hold it parallel to the occlusal plane of the maxil-

lary molars.

⚪ Hold it at either (Table16.8):

■ A lower height along the cervical or gingival margin

of the upper molars.

■ A greater height along the muco- gingival line that

separates the inserted or attached gingiva from the alveolar mucosa.

● The needle is inserted into the mucosa between the ramus

of the mandible and the maxillary tuberosity beside the second or third upper molar to reach a middle position inside the pterygomandibular space (Figure16.16).

● The recommended insertion depth is 25 mm, but may

range from 20 to 30

mm (Table16.8). Inserting the needle to the hub is a technical error for two reasons: (i) it is the weakest part of the needle (therefore it may break) and (ii) this depth is excessive.

● Pre- injection aspiration. There is a 5% incidence of posi-

tive aspiration (Annex 22).

● Injection of the anesthetic.

⚪ A 1.8- ml cartridge should be slowly injected in

40–60

seconds (Table16.8), although one author (Shaw

and Fierst1988) recommends 3.6

⚪ Many clinicians aspirate every 0.25–0.50 ml to further

ml or two cartridges.

guarantee the safety of the injection with a series of negative aspirations; this also helps retard the injection by curbing the natural tendency to inject rapidly.

● Subjective symptoms of anesthesia. ⚪ Soft tissue anesthesia appears in the lower lip on the

anesthetized side around 5 in about 80% of cases in less than 10

28), with a mean of 3

minutes after injection and

minutes (Annex

minutes (Table16.9). Soft tissue anesthesia may be described as tingling, numbing, itching, dullness, feeling “pins and needles,” and feeling a “fat lip” sensation (Table13.1, Chapter13).

⚪ In around 20% of cases the lower lip is not anesthe-

tized in the first 10

minutes (Annex 28). Such cases are regarded as failures and a second Laguardia–Akinosi mandibular block is recommended.

⚪ Soft tissue anesthesia is denoted by the following:

■ In the lower lip, from the corner of the mouth to the

midline on the ipsilateral side to the injection site it is

Figure16.17 Needle insertion site in the closed mouth technique: (a) at mucogingival margin and (b) crossing the buccinator

muscle. Source: Redrawn from Roberts and Sowray (1987).

Piercing buccinator

muscle

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Table16.8 Insertion depth, site, andvolume inLaguardia–Akinosi mandibular block.

Reference Insertion depth (mm) Insertion site Volume injected (ml)

Vazirani (1960) 15 Cervical margin — Akinosi (1977) 25–30 Cervical margin 1.5–2.0 Gustainis and Peterson

(1981) Jasmin etal. (1983) 20–23 Mucogingival junction — Small and Waters (1983) 25–30 Mucogingival junction 1.8 Dewitt (1984) 25 Mucogingival junction 1.8 Vailland (1985) 25 Mucogingival junction — Todorovic etal. (1986) 25 Cervical margin 2.0 Mean 25 mm 1.8 ml

38 Mucogingival junction 1.5–1.8

Table16.9 Onset (minutes) inlower lip withLaguardia–

Akinosi mandibular block.

Reference Sample size Latency (min)

Todorovic etal. (1986) 30 3 MartínezLenka etal. (2014) 40 2.8 Kiran etal. (2018) 70 3.2 Jendi and Thomas (2019) 70 1.5 Nakkeeran etal. (2019) 100 3.6

Mean 2.98 Rounded mean 3

González etal. (2003) 28 3.8

± 0.6 ± 1.0 ± 0.4 ± 1.6

a sign that the primary aim of the procedure (anesthesia of the inferior alveolar nerve) has been achieved.

■ In the tongue ipsilateral to the injection site it is an

indication of anesthesia of the lingual nerve; this is attained in 85% of cases (Table16.3 and Annex 29).

■ In the area around the ipsilateral periauricular and

temporal region it is a sign of anesthesia of the auriculotemporal nerve, although this is less common.

● Supplemental buccal infiltration. Although no clinical

studies have been published in this regard, this measure is recommended here just as it is for the conventional technique.

⚪ It is recommended to wait for both the onset of soft tis-

sue anesthesia in the lower lip (sign of effective mandibular block) and at least 10 minutes following the injection. One should wait to ensure that there is anesthesia of the inferior alveolar nerve and that the block has not been missed. A supplemental buccal infiltration is recommended to enhance anesthesia in posterior mandibular teeth requiring profound pulpal anesthesia.

⚪ The infiltration is performed after 10 minutes to avoid

the risk of masking or concealing mandibular block failure due to the overlapping of the effects of mandibular block and infiltration in the soft tissue.

⚪ In adults a potent solution such as a whole cartridge

ml) of 4% articaine with 1:100 000 epinephrine

(1.8

(A-

100) is inserted on the buccal aspect of the poste-

rior teeth to be treated. This procedure aims to increase the number of teeth with pulpal anesthesia.

⚪ It takes an additional 5–10 minutes (15–20 minutes

after starting mandibular block) for pulpal anesthesia to be fully effective.

● Duration of soft tissue anesthesia. This usually lasts

hours (200 minutes). The patient should be advised

3–4 about this in the process of obtaining informed consent prior to treatment.

Efficacy ofthis Technique

As noted previously, the Laguardia–Akinosi technique exhibits the same 80% success rates the conventional technique in terms of Grade A anesthesia (Table 16.3). Nonetheless, given the fair number of shortcomings and uncontrolled factors associated with this assessment method, its values must be regarded as indicative only (Annex 30). Unfortunately, no clinical studies on the evaluation of pulpal anesthesia with an electric pulp tester have been published to date for this technique.

Complications Specific tothis Technique

● Technical errors in the Laguardia–Akinosi technique.

Inappropriate maneuvering, the most common complication, leads to failed mandibular block and other complications, depending on the injection position (Figures3.13 and 3.14, Chapter3).

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⚪ A needle inserted too mesially/internally reaches the

pterygomandibular ligament or raphe, which is tantamount to insertion from outside to inside the pterygomandibular space (Gustainis and Peterson 1981; Shaw and Fierst1988). This is more common when right-

handed dentists anesthetize the left side

(Gustainis and Peterson1981).

⚪ The needle may be too high, injecting the solution

over the muco-

gingival line, when inserted too slowly

(Gustainis and Peterson1981).

● Non- applicability of the technique in the presence of a

large hyperplasia on the lateral maxillary edge that prevents correct needle positioning (Gustainis and Peterson1981).

● Most common complications:

1) The upper arch may be anesthetized if the anesthetic

solution or part of it is deposited outside the pterygomandibular space. According to some reports symptoms of soft tissue anesthesia of the upper lip appear in nearly 8% of cases and of the infraorbital zone in 2% (Donkor etal.1990).

2) The side of the face affected may also pale (blanch-

ing) (Donkor etal.1990).

Keys toSuccess

The following maneuvers can raise the success rate of double injection in the anterior mandibular teeth:

● Infiltrating not only buccally but also lingually with

ml (double infiltration) (Meechan and

0.5–0.9 Ledvinka2002; Jaber etal.2010; Nuzum etal.2010) may block the accessory innervation penetrating the many foramina located along the mylohyoid line from the premolars to the mental symphysis (Shiller and Wiswell1954; Sutton1974; Chapnick1980).

● Potent solutions such as 4% articaine with 1:100 000 epi-

nephrine (10 standard lidocaine (L-

μg/ml) (A- 100) can be used instead of the

100) solutions (Annex 31), given

cortical thickness.

● Greater volume of anesthetic could be infiltrated, prefer-

ably a full cartridge (1.8

ml) instead of 0.9–1.5 ml and distributed between the buccal and lingual zone, either half (0.9 ml) on each side or more buccally and less lingually

● The anesthetic should be allowed more time, from 5 to

minutes, to take effect in the dental pulp (Annex 31), given that the cortical bone is thicker and therefore penetrated more slowly.

Double Infiltration inAnterior Teeth

This technique is also known as double infiltration because the anesthetic is injected twice, first buccally and then lingually. Given that, as noted earlier, mandibular block yields very poor results in the lower anterior incisors and canines (Table 16.1), double injection is deployed to attain pulpal anesthesia (Adatia and Gehring1972). Infiltration is successful in these teeth for a number of reasons.

● The mandibular cortical bone in the anterior teeth, while

thicker than the maxilla, is thinner than at the back of the mandible (Arens et al. 1984; Denio et al. 1992; Gowgiel1992) (Table3.2, Chapter3).

● The mandibular zone has many foramina that favor the

spread of the anesthetic (Starkie and Stewart 1931; Sutton1974; Naitoh etal.2009).

● In this part of the mandible, the mandibular incisive

nerve or its plexus runs adjacent to the buccal aspect of the cortical bone (Annex 4).

Curiously, in the lower premolars the aforementioned is partly attributable to the presence of the mental foramen, with a 2–4 mm diameter, and in 5% of patients to the presence of accessory foramina (Annex 5), which favors the spread of the anesthesia.

Zone Anesthetized

● Tooth (periodontal pulp and ligament) injected, often

extending to the mesial and distal adjacent teeth.

● Buccal and lingual zone, including fibromucosa (alveo-

lar mucosa, gum and interdental papillae), bone, and periosteum.

● Lower lip and chin in the injection zone.

Technique

● A 25G or 27G short (20–25 mm) needle is used, except

where the technique is supplemental to mandibular block, in which case a long needle is acceptable.

● The solution of choice for adults is 4% articaine with

1:100 000 (10 μg/ml) epinephrine (A- 100) and in children the standard 2% lidocaine with 1:100 000 epinephrine (L- 100) (Annex 31).

● Patient’s position: ⚪ Supine or semisupine with head raised slightly and

chin tilted downward toward the sternum.

⚪ Mouth half open with muscles partially relaxed to

favor lower lip and buccal mucosa relaxation.

● Dentist’s position: ⚪ For anterior mandibular teeth on the left and even the

right side, behind the patient, at 11:00–12:00 o’clock.

⚪ For anterior mandibular teeth on the right side, if pre-

ferred, at 8:00 o’clock.

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● Buccal approach: ⚪ With the non- dominant index finger and thumb (i.e.

left hand in right-

handed dentists), the lower lip is retracted to view the floor of the vestibule and the mucogingival junction (line separating the darker attached gingiva from the lighter tone oral mucosa) to:

■ Improve visibility.

■ Stretch the oral mucosa to facilitate needle penetra-

tion and reduce pain on injection.

⚪ The needle is inserted (Figure16.18) into the tensed

oral mucosa about 2–3

mm under the mucogingival

junction (Figure 16.19) (Roberts and Sowray 1987),

because:

■ The roots of the mandibular teeth are very short.

■ The technique ensures deposit of the anesthetic in the

submucosal connective tissue rather than in the chin muscles, where spread to the bone (and thus pulpal anesthesia) would be less likely and the intravascular absorption of the local anesthetic would be more likely.

● Lingual approach (Figure16.20): ⚪ The patient is asked to raise their tongue and where

they are unable to do so a mirror is used for retraction of the tongue and visualization of the floor of the mouth.

⚪ If necessary, the needle stem/shaft of the needle is bent

slightly to facilitate insertion, but never at the hub, the weakest part of needles, where they tend to break.

⚪ The needle is inserted into the lingual vestibule,

approximating the apex of the tooth to be treated to a depth of just 2–3

mm to position the anesthetic close to the bone and not in the mylohyoid muscle on the floor of the mouth.

● Minimal intervention (minimum volume/minimum injec-

tion time). This procedure, which significantly reduces the pain of injection, is implemented in four steps:

⚪ One or two drops of anesthetic are injected first buc-

cally for 1–2 1–2

seconds and then needle is removed to anesthetize

seconds and then lingually, likewise for

the soft tissue around the injection zone.

⚪ After a 60- second pause to anesthetize the soft tissue,

another one or two drops are injected for 1–2

seconds first buccally and then lingually in the same vestibular and lingual sites (normally identifiable by tiny blood droplets caused by the first injection) and the needle is removed.

⚪ After a 30- second pause and after aspirating, a small

amount (1/8 of a cartridge or 0.25

ml) of solution is injected into the same buccal and lingual sites for 7–10 seconds to reinforce the first two steps and begin pulpal anesthesia, waiting a further 30

⚪ Thirty seconds later and again after aspirating, more

of the anesthetic remaining in the 1.8-

seconds.

ml cartridge is injected buccally and the rest lingually. Alternatively, the same amount may be injected on each side.

(a) (b)

Figure16.18 Approach for buccal injection in anterior mandibular teeth: (a) more parallel and (b) more perpendicular to tooth.

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Figure16.19 Needle insertion immediately below the

mucogingval junction, with millimetric penetration (1) due to shallowness of mandibular incisors and (2) to prevent injection in chin muscles. Source: Redrawn from Roberts and Sowray (1987).

Figure16.20 Lingual injection in anterior mandibular teeth.

● Pre- injection aspiration. Positive aspirations appear

(Annex 22):

⚪ In <1% of anterior mandibular teeth. ⚪ In 5% in the premolar buccal zone due to the proxim-

ity of the mental foramen neurovascular bundle.

● Submucosa lump or blister. This protrusion must not be

touched to enable the anesthetic to spread across the periosteum, cortical, and spongy bone to reach the apex and from there the nerve fibers in the teeth. Massaging the blister forces the anesthetic to spread along the pathway of least resistance, the lax soft tissues, carrying it away from the injection site and lowering the concentration at the target zone and hence the capacity to reach the dental apex.

● Subjective symptoms of anesthesia, for example soft tissue

anesthesia, appear in the lower lip after 2–3 minutes. Soft tissue anesthesia may be described as tingling, numbing, itching, dullness, feeling “pins and needles,” and feeling a “fat lip” sensation (Table 13.1, Chapter 13). The total waiting period prior to intervening is 5–10 minutes to ensure pulpal anesthesia since the cortical bone is fairly thick and its penetration slow (Annex 31).

● Duration of soft tissue anesthesia. This usually lasts 3–4 hours

(200 minutes). The patient should be advised about this prior to treatment as part of the informed consent process.

Efficacy ofthis Technique

Clinical studies conducted with an electric pulp tester and a potent anesthetic solution such as A- 100 found the efficacy of this technique to be on the order of 98% in adult

Table16.10 Electric pulp tester- measured degree (%)

ofpulpal anesthesia after double infiltration inincisors andsingle infiltration inmandibular premolars andfirst molars (see Annex 31).

1.8 ml of anesthetic

solution Incisors Premolars First molar

4% articaine + 1:100 000 epinephrine

100)

(A2% lidocaine + 1:100 000

epinephrine (L- 100)

98% 80% 65%

91% 80% 40%

mandibular incisors (Table16.10). The 80% efficacy in premolars can be raised to 93% if two cartridges (3.6 ml) are administered (Dressman etal.2013).

Complications Specific tothis Technique

Fortunately, this technique seldom poses complications. The most frequent is a subcutaneous hematoma, particularly where the minimum volume/minimum time technique is used, due to the repeated injections in the mucosa. Hematomas, which may arise around the insertion sites due to small vessel damage, are usually asymptomatic and often disappear spontaneously in a few days.

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