American Society of Regional Anesthesia and Pain Medicine November 2017 - 41

Figure 7: Sublabial approach to the infraorbital nerve block.

of 0.5% bupivacaine is injected (Figure 7).6 If an intraoperative
computerized tomography image guidance for FESS is used, this
block should be performed after registration because the system
uses skin depth, and topography that can be altered by this block.
INFRA-ALVEOLAR (INFERIOR ALVEOLAR NERVE BLOCK, V3)
The mandibular (V3) nerve is the largest branch of the trigeminal
nerve. It exits the skull through the oval foramen and then divides
into the posterior trunk, which becomes the inferior alveolar nerve
that innervates the molar and premolar teeth. This branch travels
posterior and lateral to become the lingual nerve along with the
inferior alveolar artery and vein, and then exits the mental foramen
to become the mental nerve, which provides sensation to the lower
lip and chin. The lingual nerve provides sensory innervation to the
anterior two-thirds of the tongue, mucosa of the floor of the mouth,
and lingual gingiva. Both the inferior alveolar nerve and lingual
nerve are blocked concurrently with this block. We use this block
for procedures involving the mandible, all mandibular teeth, the
floor of the mouth, the anterior two-thirds of the tongue, and the
mucosa and skin of the lower lip and chin.
The target for the block is the mandibular nerve as it travels on the
medial aspect of the ramus of the mandible, prior to its entry into
the mandibular foramen.7 We use a 25-gauge needle 1.5 inches
in length for the single shot. The patient is supine, the mouth is
opened, and the cheek is retracted. The coronoid notch and the
pterygomandibular raphe are identified.8 The coronoid notch is the
most concave area on the anterior border of the ramus, shown in
Figure 8a as the innermost solid blue lines. If not obvious on exam,

Figure 8: The inferior alveolar and lingual nerve blocks. A: The coronoid notch represented as innermost solid blue lines. B: Needle
approach to the inferior alveolar nerve block.

American Society of Regional Anesthesia and Pain Medicine
2017

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