Mental Nerve Block

Mental Nerve Block

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Lacerations of the lower lip and of facial soft tissue in the lower chin require proper anesthesia to ensure adequate cosmetic closure. The mental nerve block is a simple technique to supply anesthesia to this area. The mental nerve is a branch of the inferior alveolar nerve that exits via the mental foramen and divides into 3 branches below the depressor anguli oris muscle. One branch supplies the skin of the chin and the other 2 innervate the skin and mucous membrane of the lower lip. Note that this nerve block does not provide anesthesia to the teeth or mandibular soft tissue. The pain associated with the mental nerve block is significantly less than with other intraoral nerve blocks. [1, 2, 3, 4]

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Lacerations of the lower lip

Lacerations to the soft tissue of the chin that extend from the lip anteriorly to the alveolar process (see side view below) and caudally to the mid body of the mandible (see front view below)

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Noncooperative patient

Overlying cellulitis

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Some local anesthetic agents are typically used for dental procedures.

Lidocaine 1% (Xylocaine); rapid onset with duration of action lasting 30-60 min (longer duration if epinephrine added)

Mepivacaine 3% (Carbocaine); moderate onset with duration of action lasting 45-90 min

Bupivacaine 0.5% (Marcaine, Sensorcaine); slow onset with duration of action 2-4 h [5, 6]

Topical anesthetic agents are often useful prior to local anesthetic administration but are not required.

Viscous lidocaine (Xylocaine)

Tetracaine (Pontocaine)

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Local anesthetic agent of choice

25-27 gauge needle

5 mL syringe

Topical anesthetic (optional)

Gauze pads

Adequate light source

Place the patient in a semi-recumbent position, or in a dental/ENT chair, if available.

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Apply topical anesthesia if desired.

Draw 2-5 mL of local anesthetic into the syringe. Agents may be combined (eg, lidocaine and bupivacaine) to achieve a longer duration of anesthesia

The intraoral approach to the mental nerve block with adjunctive topical anesthesia has been reported as subjectively and objectively less painful than the percutaneous approach. [7]

Locate the mental foramen.

Retract the cheek laterally.

The mental foramen is palpable between the 2 lower premolar teeth in adults and between the first and second primary molars in children.

The position of the mental foramen may differ among ethnic groups. [8]

Insert the needle along the lower gum line into the buccal fold between the premolar teeth (in adults) near the foramen (see image below). Do not place the needle directly into the foramen.

Aspirate.

Inject 2-3 mL of anesthetic.

Do not inject directly into the foramen.

Slow injection is significantly more comfortable than rapid injection (P < 0.001) [9]

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The mental nerve block provides anesthesia only to the lower lip and soft tissue of the chin.

If the foramen is not directly palpable, the anesthetic can be injected into the buccal mucosa between the 2 lower premolar teeth. Never inject into the foramen, as this can permanently damage the neurovascular bundle.

A dental aspirating syringe with a dental carpule can be used in place of a regular syringe. Slide the carpule into the syringe and place the needle on the end.

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Bleeding

Infection

Needle fracture

Intravascular injection

Neurapraxia (secondary to direct injection into the mental foramen)

Kaufman E, Epstein JB, Naveh E, Gorsky M, Gross A, Cohen G. A survey of pain, pressure, and discomfort induced by commonly used oral local anesthesia injections. Anesth Prog. Winter 2005. 52(4):122-7. [Medline].

Salam, G MD, DO. Regional Anesthesia for Office Procedures Part I Head and Neck Surgeries. American Family Physician. 2/2004. 69:585-590. [Full Text].

Park HG, Park PG, Kim WJ, Park YH, Kang H, Baek CW, et al. Ultrasound-assisted mental nerve block and pulsed radiofrequency treatment for intractable postherpetic neuralgia: three case studies. Korean J Pain. 2014 Jan. 27(1):81-5. [Medline]. [Full Text].

Jaber A, Whitworth JM, Corbett IP, Al-Baqshi B, Jauhar S, Meechan JG. Effect of massage on the efficacy of the mental and incisive nerve block. Anesth Prog. 2013 Spring. 60(1):15-20. [Medline]. [Full Text].

Thomson CJ, Lalonde DH. Randomized double-blind comparison of duration of anesthesia among three commonly used agents in digital nerve block. Plast Reconstr Surg. Aug 2006. 118(2):429-32. [Medline].

Mesgarzadeh AH, Afsari H, Pourkhamne S, Shahamfar M. Efficacy of bilateral mental nerve block with bupivacaine for postoperative pain control in mandibular parasymphysis fractures. J Dent Res Dent Clin Dent Prospects. 2014 Summer. 8(3):172-5. [Medline]. [Full Text].

Syverud SA, Jenkins JM, Schwab RA, Lynch MT, Knoop K, Trott A. A comparative study of the percutaneous versus intraoral technique for mental nerve block. Acad Emerg Med. Nov-Dec. 1(6):509-13. [Medline].

Yesilyurt H, Aydinlioglu A, Kavakli A, et al. Local differences in the position of the mental foramen. Folia Morphol (Warsz). 2008 Feb. 67(1):32-5. [Medline].

Whitworth JM, Kanaa MD, Corbett IP, Meechan JG. Influence of injection speed on the effectiveness of incisive/mental nerve block: a randomized, controlled, double-blind study in adult volunteers. J Endod. Oct 2007. 33(10):1149-54. [Medline].

Amsterdam JT. Mental nerve block. Rosen P, Chan T, Vilke G, Sternbach G. Atlas of Emergency Procedures. St. Louis, Mo: Mosby; 2001. 166-7.

Marc S Orlewicz, MD Clinical Assistant Professor of Anesthesiology, Director of Clinical Simulator and Residency Site-Director for WSU/DMC Anesthesiology Residency Program, Wayne State University and Detroit Medical Center (WSU/DMC); Clinical Assistant Professor of Osteopathic Anesthesiology Residency Program, Michigan State University; Co-Director of Anesthesia Critical Care Services, Department of Anesthesiology, Surgical Intensivist, Harper Hospital and Sinai-Grace Hospital through WSU/DMC

Marc S Orlewicz, MD is a member of the following medical societies: American Society of Anesthesiologists, Society of Cardiovascular Anesthesiologists, Society of Critical Care Medicine, Society of Critical Care Anesthesiologists

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Meda Raghavendra (Raghu), MD Associate Professor, Interventional Pain Management, Department of Anesthesiology, Chicago Stritch School of Medicine, Loyola University Medical Center

Meda Raghavendra (Raghu), MD is a member of the following medical societies: American Society of Anesthesiologists, American Society of Regional Anesthesia and Pain Medicine, American Association of Physicians of Indian Origin

Disclosure: Nothing to disclose.

Andrew K Chang, MD, MS Vincent P Verdile, MD, Endowed Chair in Emergency Medicine, Professor of Emergency Medicine, Vice Chair of Research and Academic Affairs, Albany Medical College; Associate Professor of Clinical Emergency Medicine, Albert Einstein College of Medicine; Attending Physician, Department of Emergency Medicine, Montefiore Medical Center

Andrew K Chang, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American Academy of Pain Medicine, American College of Emergency Physicians, American Geriatrics Society, American Pain Society, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Michael Lawrence Hochberg, MD Clinical Instructor, Emergency Medicine, Albert Einstein College of Medicine; Attending, Emergency Medicine, Montefiore Medical Center

Michael Lawrence Hochberg is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, and Society for Academic Emergency Medicine.

Disclosure: Nothing to disclose.

Vito J Rocco, MD, FACEP Associate Residency Director, Emergency Medicine, William Beaumont Hospital

Vito J Rocco, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Elizabeth Tillem, MD Assistant Attending, Department of Emergency Medicine, Bronx Lebanon Hospital Center

Disclosure: Nothing to disclose.

Mental Nerve Block

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