Procedural Blog EXTRA: Inferior Alveolar Nerve Block


A blog series on emergency medicine procedures

Video and idea proposed by the brilliant Dr. Michael Prucha

  • Dental pain control
Location of Numbing:
  • Ipsilateral teeth along the mandible, as well as the lower lip and chin (mental nerve is distal to inferior alveolar nerve)
  • 50/50 mixture: 1-2% lidocaine with epinephrine + 0.5% bupivacaine (lasts up to 6 hours)
  • Syringe with 25-27 g needle
  • Consider topical anesthesia on gauze or as viscous gel prior to injection
  • Patient seated upright, back of head against stretcher, mandible parallel to floor
  • Position yourself opposite side of target nerve
  • HAND #1: thumb in cheek (not in between the teeth…ouch!), palpate RETROMOLAR FOSSA and find CORONOID NOTCH (image A), visualize the PTERYGOMANDIBULAR TRIANGLE (image C)
  • HAND #2: syringe between first and second premolars on opposite side, enter space until mandibular bone is felt, pull back small amount (and check for aspiration of blood) (complication note: if no bone is felt, you increase your chances of injecting into the parotid gland, i.e.: facial nerve…a temporary facial nerve palsy may occur)
  • Inject (image B)
  • Patient may jump/jerk. BE PREPARED.
  • ~2ml or double amount if needed
  • Wait 3-5 minutes for anesthetic to work



Images from Roberts and Hedges’ Clinical Procedures in Emergency Medicine, 6th ed, 2013

Thank you to Dr. Fearon and the Samuels Sinclair Dental Center for allowing us to use this footage. 
Please offer your own tips on head and neck nerve blocks in the comments section!

Textbook References

Amsterdam JT, Kilgore KP. Regional Anesthesia of the Head and Neck. Chapter 30, 541-553.e1. In: Roberts J, et al. Roberts & Hedges’ Clinical Procedures in Emergency Medicine. 6th Saunders; 2013.

Jonathan Ameli MD

4 thoughts on “Procedural Blog EXTRA: Inferior Alveolar Nerve Block

  1. This is great!! One pearl I learned at ACEP this year is to shake/vibrate the patient’s lip (or have an assistant do it) as a distracting technique while the needle penetrates the mucosa. Apparently it cuts way down on pain perception. (I’ve experienced that at the dentist’s office, but could never ask why because hands were in my mouth!)

  2. This technique is absolutely Draconian as the full on wince of the patient face shows. The instruction of “the patient may jerk/jump”? WTF? I’m sure this technique is great for repeat business and does wonders for the dental phobic patient. Brutal.

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