Lingual Nerve Block

[Ostracized]

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Hey all.

I need to give a lingual nerve block on a patient without hitting the IAN. Can someone please explain the approach to me?

Thanks.

 

[dentstd]

Hey all.

I need to give a lingual nerve block on a patient without hitting the IAN. Can someone please explain the approach to me?

Thanks.

Palpate for the lingula, so you know exactly where the IA nerve is. Aim the needle anterior or posterior to it, so you hit bone and not the nerve. Pull out half way and adjust for angulation if needed. Aspirate, administer.

 

[Ostracized]

Palpate for the lingula, so you know exactly where the IA nerve is. Aim the needle anterior or posterior to it, so you hit bone and not the nerve. Pull out half way and adjust for angulation if needed. Aspirate, administer.

That sounds like a regular IAN block. What if I only want to get the lingual nerve and not the IAN?

 

[armorshell]

Palpate for the lingula, so you know exactly where the IA nerve is. Aim the needle anterior or posterior to it, so you hit bone and not the nerve. Pull out half way and adjust for angulation if needed. Aspirate, administer.

Seems like it would work fine, but in this situation I don't know why you would bother sounding bone with your needle tip, especially if you've already palpated the lingula.

 

[DrTacoElf]

You could just infiltrate in the floor of the mouth lingual to the 3rd molar

 

[dentstd]

Seems like it would work fine, but in this situation I don't know why you would bother sounding bone with your needle tip, especially if you've already palpated the lingula.

Because it's hard to determine the depth of the injection. Contacting bone largely gives me a reference for the lingual nerve location.

 

[dentstd]

That sounds like a regular IAN block. What if I only want to get the lingual nerve and not the IAN?

So you only administer anesthetic next to the lingual nerve, not the IA nerve. Come on, now.

 

[monreal]

Palpate for the lingula, so you know exactly where the IA nerve is. Aim the needle anterior or posterior to it, so you hit bone and not the nerve. Pull out half way and adjust for angulation if needed. Aspirate, administer.

Would anyone care to explain to me how the hell are you supposed to palpate the lingula?

 

[armorshell]

Would anyone care to explain to me how the hell are you supposed to palpate the lingula?

Good question.

 

[dentstd]

Would anyone care to explain to me how the hell are you supposed to palpate the lingula?

You can do it on some people but not everyone. Sometimes, you only feel the anterior portion. Other times, you can't feel it at all. In which case, you approximate the location,...find the width of the ramus, find the halfway point, and aim 4-5mm behind it.

I can't feel it at all on one side of my jaw, but I feel its beginning on the other side.

Or just feel for a depression with the needle tip.

 

[drhobie7]

You can do it on some people but not everyone. Sometimes, you only feel the anterior portion. Other times, you can't feel it at all. In which case, you approximate the location,...find the width of the ramus, find the halfway point, and aim 4-5mm behind it.

I can't feel it at all on one side of my jaw, but I feel its beginning on the other side.

Or just feel for a depression with the needle tip.

Really? I have never heard of palpating the lingula. Geez, it's not even that easy to find when you have a flap raised for a BSSO. If someone tried to palpate my lingula I think I would vomit...they would be jabbing a finger in my lateral pharynx. There's quite a bit of tissue between lateral pharyngeal mucosa and mandible.

 

[sokrman14]

Im quite curious to know why you only want the lingual and don't want the IAN. Care to elaborate?

 

[dentstd]

Really? I have never heard of palpating the lingula. Geez, it's not even that easy to find when you have a flap raised for a BSSO. If someone tried to palpate my lingula I think I would vomit...they would be jabbing a finger in my lateral pharynx. There's quite a bit of tissue between lateral pharyngeal mucosa and mandible.

I know I'm getting a lotta **** for it, but try it. It starts about 15mm behind the anterior border of the ramus. You only need to know where it starts. In older patients esp, there's little tissue remaining. I'm not making a theoretical argument. I've felt it on some of my patients. A nice, rounded bulb on the inside of the mandible.

And no, it doesn't stimulate the gag reflex.

 

[sw4gger]

curious did they give you guys videos or CDs to look over when taking anesthesiology?

 

[dentstd]

Im quite curious to know why you only want the lingual and don't want the IAN. Care to elaborate?

Perhaps he nicks the tongue on a PRR.

 

[drhobie7]

I know I'm getting a lotta **** for it, but try it. It starts about 15mm behind the anterior border of the ramus. You only need to know where it starts. In older patients esp, there's little tissue remaining. I'm not making a theoretical argument. I've felt it on some of my patients. A nice, rounded bulb on the inside of the mandible.

And no, it doesn't stimulate the gag reflex.

OK, we have an orthognathic case tomorrow. I'm gonna palpate the heck out of the mandible under general anesthesia. Of course, the attending is going to think I'm insane. 🙂

 

[monreal]

OK, we have an orthognathic case tomorrow. I'm gonna palpate the heck out of the mandible under general anesthesia. Of course, the attending is going to think I'm insane. 🙂

The mandible flares like crazy in that area, so unless the pharynx gets twice as wide as the oral cavity, there is no chance you can palpate any lingula. Heck that's why you guys use the nerve hook in BSSO! right?

Sorry dentstd. You must have been sticking your finger in a different hole.

 

[monreal]

Speaking of anesthesia. Once upon a time in a dental school 5k miles east of NYC, an instructor was demonstrating a ASA injection at the infraorbital foramen, he was jerking up and down after inserting 1/2 the length of the needle (and must have bent it somehow) and saying: "One of the possible complication of this technique... is this" when the needle poked out of the patient cheek, 5 mm in front of his eye pupil. The look at the patient face was priceless.😀

 

[Noble6]

You could just infiltrate in the floor of the mouth lingual to the 3rd molar

Why not just do this?

 

[DrJeff]

The majority of the time when I'm going for the IAB, and end up just getting the lingual nerve, I've given the injection too low and anterior to the "classical IAB" location. Best bet would be to say go just distal to the second molar with an injection site at/slightly below the level of the CEJ, instead of the usual occlussal plane height/medial surface of the ascending ramus.

 

[dentstd]

The mandible flares like crazy in that area, so unless the pharynx gets twice as wide as the oral cavity, there is no chance you can palpate any lingula. Heck that's why you guys use the nerve hook in BSSO! right?

Sorry dentstd. You must have been sticking your finger in a different hole.

Could be the wrong hole. However, on one patient, I felt a pronounced bump, stuck the needle DEAD ON, and she jumped because she felt an electric shock radiating to the lip. I repeated it too.

Try it before you say it's impossible. You guys aren't convincing me it's impossible when you've never tried to feel for it. It's beyond obvious you fellas have never tried it and are saying it's impossible, using various theories and guesses to support your ideas. I won't believe it's impossible, because I've done it before.

And FYI, I don't palpate it THRU the arch muscles. I do it LATERAL to it, where there's less resistance. Find the anterior border of the ramus, and trace it back. About 15mm back, you'll begin to feel a bump. This isn't theory. This is what I've done.

 

[OceanDMD]

You can do it on some people but not everyone. Sometimes, you only feel the anterior portion. Other times, you can't feel it at all. In which case, you approximate the location,...find the width of the ramus, find the halfway point, and aim 4-5mm behind it.

I can't feel it at all on one side of my jaw, but I feel its beginning on the other side.

Or just feel for a depression with the needle tip.

Ive got to call total BS on this one. When a patient is opening, there is a pretty thick band of muscle(medial pterygoid) that lies over the area of the mandible where the lingula should lie. I find it rare when Im walking a needle from anterior to posterior along the ramus that I can feel the lingula.
Dr. Jeff has the answer (unless its a pedo which if I remember correctly you aim lower to get the IA).

 

[bluemanchews]

Lingual Nerve
- Injection just distal to 2nd molar w/ 30G short (do NOT use a long and anesthetize the carotid body 🙂, use 1/3 carpule
- Innervates:
Lingual tissue extending from molar teeth anteriorly to anterior teeth
Anterior 2/3 of tongue
- May communicate w/ mylohyoid N anteriorly

 

[dentstd]

Ive got to call total BS on this one. When a patient is opening, there is a pretty thick band of muscle(medial pterygoid) that lies over the area of the mandible where the lingula should lie. I find it rare when Im walking a needle from anterior to posterior along the ramus that I can feel the lingula.
Dr. Jeff has the answer (unless its a pedo which if I remember correctly you aim lower to get the IA).

You're welcome to ball BS after you've tried it on a few patients.

 

[Ostracized]

Lingual Nerve
- Injection just distal to 2nd molar w/ 30G short (do NOT use a long and anesthetize the carotid body 🙂, use 1/3 carpule
- Innervates:
Lingual tissue extending from molar teeth anteriorly to anterior teeth
Anterior 2/3 of tongue
- May communicate w/ mylohyoid N anteriorly

Thanks. So distal to 2nd molar but not disto-lingual?

 

[OceanDMD]

You're welcome to ball BS after you've tried it on a few patients.

Look, go find your gross anatomy skull, and put your thumb, or index finger, whatever you apparently palpate the lingula with, and grab a minute steak and lay it over the ramus and try again. I remember a classmate like you telling me that when he gives his IAB he "bumps the lingula" before injecting. As far as "trying it on a few patients", I have a little experience. You cant frickin palpate the lingula. My partner has been placing implants and doing sinus lifts since the 80's and he has never "palpated the lingula". If you could palpate the lingula, every frickin dentist would try before giving an IAB injection. Why? Because as far as I am concerned, there is nothing more frustrating than a patient who will not get numb. And guess where it occurs most? #18 and # 31. So, tomorrow I have 13 patients on my schedule. Let me estimate 1/3 are mandibular cases. I will try to "palpate" the lingula, and in addition I will use a long 27 gauge needle(which I have probably only needed a dozen times in the last 5 years) to make sure I can bump the hell out of the ramus and let you know how well I can feel the lingula.

In real life dentistry, I block the inferior alveolar nerve with a short 30. I usually dont try to bump any bone(thats when it hurts), aim off the contralateral premolars and go well above the occlusal plane. Missing the block is infrequent. Like Dr. Jeff said, when you miss, you almost always get the tongue(too low and anterior).

 

[dentstd]

Look, go find your gross anatomy skull, and put your thumb, or index finger, whatever you apparently palpate the lingula with, and grab a minute steak and lay it over the ramus and try again. I remember a classmate like you telling me that when he gives his IAB he "bumps the lingula" before injecting. As far as "trying it on a few patients", I have a little experience. You cant frickin palpate the lingula. My partner has been placing implants and doing sinus lifts since the 80's and he has never "palpated the lingula". If you could palpate the lingula, every frickin dentist would try before giving an IAB injection. Why? Because as far as I am concerned, there is nothing more frustrating than a patient who will not get numb. And guess where it occurs most? #18 and # 31. So, tomorrow I have 13 patients on my schedule. Let me estimate 1/3 are mandibular cases. I will try to "palpate" the lingula, and in addition I will use a long 27 gauge needle(which I have probably only needed a dozen times in the last 5 years) to make sure I can bump the hell out of the ramus and let you know how well I can feel the lingula.

In real life dentistry, I block the inferior alveolar nerve with a short 30. I usually dont try to bump any bone(thats when it hurts), aim off the contralateral premolars and go well above the occlusal plane. Missing the block is infrequent. Like Dr. Jeff said, when you miss, you almost always get the tongue(too low and anterior).

Look, try it before you open your mouth again.

Ever been to a physical therapist? I was treated for tennis elbow, and they felt every single tuberosity on the joint THRU ARM MUSCLES. They also felt my shoulder joint to determine rotator cuff status. They felt the joint THRU the friggin' DELTOID muscle.

Don't tell me what you can't do when you've never tried it. You'd be surprised to find out what you THOUGHT you knew. You can do as many sinus lifts as you want, but the reason why your partner never felt the lingula is because he never placed a finger there. You can't feel what you don't touch.

 

[OceanDMD]

Look, try it before you open your mouth again.

Ever been to a physical therapist? I was treated for tennis elbow, and they felt every single tuberosity on the joint THRU ARM MUSCLES. They also felt my shoulder joint to determine rotator cuff status. They felt the joint THRU the friggin' DELTOID muscle.

Don't tell me what you can't do when you've never tried it. You'd be surprised to find out what you THOUGHT you knew. You can do as many sinus lifts as you want, but the reason why your partner never felt the lingula is because he never placed a finger there. You can't feel what you don't touch.

You are comparing your elbow to the lingula? Please. And I did try it on 5 patients yesterday. No lingula. My partner has been practicing dentistry for over 30 years. Im sitting here on my arse trying to jam my finger through my pterygoid muscle, I cant even feel my ramus through that muscle. Please. Would somebody hear go talk to their anatomy professor, or OMFS professor and ask if its possible to palpate the lingula. I want to learn something. Otherwise we will have to agree to disagree, but I dont see anyone else here saying the can palpate the lingula. I'll bet you never miss an IAB either right?

 

[browncrack]

Thanks. So distal to 2nd molar but not disto-lingual?

disto-lingual. not on the floor of the mouth. very tricky with big tongues. however, i use this as a second choice to iab.

 

[dentstd]

You are comparing your elbow to the lingula? Please. And I did try it on 5 patients yesterday. No lingula. My partner has been practicing dentistry for over 30 years. Im sitting here on my arse trying to jam my finger through my pterygoid muscle, I cant even feel my ramus through that muscle. Please. Would somebody hear go talk to their anatomy professor, or OMFS professor and ask if its possible to palpate the lingula. I want to learn something. Otherwise we will have to agree to disagree, but I dont see anyone else here saying the can palpate the lingula. I'll bet you never miss an IAB either right?

No one's comparing it to the elbow. Of course not. Not our mystical lingula. No other bone in the human body can compare to our beloved mandible. What other bone in our body has two - count them - TWO chambers in the joint? Point was (in the event you're learning to intuit written language) you can feel bony structures thru muscle. There's an entire field of healthcare where they do it on a regular basis.

Do it on more people. Different racial demographics. Different age groups. I can't find the lingula on myself either (which tells me to shoot the needle farther back, so that's the information I'd have), and I havn't found it on pediatric patients yet. But I've found it on a great many people.

Doesn't matter to me how many years someone's been practicing. If they havn't done something or even tried to do something, then it's 30 years of inexperience.

And I don't even know what tha hell you're doing if you can't feel the ramus. My guess is you're already too old and set in your ways to learn anything new.