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Department of Emergency Medicine

Regional Anesthesia - Face

Facial Blocks

General:  Facial blocks provide anesthesia with little to no distortion of the anatomy, thus are ideal for repairing lacerations on the face; where precise alignment of tissue structures is desirable.  Facial blocks also provide excellent anesthesia for abrasions on the face/forehead.

Hints:

 Watch an  introduction video
identifying nerve locations on the face.

Remember that the supraorbital, infraorbital and mental nerves all line along an imaginary vertical line drawn through the pupil.
When injecting in the mouth, provide topical anesthetic, retract mucosa to enhance vision & minimize needle insertion trauma, dry the injection site, and penetrate mucosa using distracting pain to minimize the pain of injection.

Supraorbital and Supratrochlear Nerves • Infraorbital Nerve  • Mental Nerve  • Inferior Alveolar Nerve



Supraorbital and Supratrochlear Nerves

  Watch the Video


Anatomy:  

The supraorbital nerve exits the superior surface of the optical rim from the supraorbital foramen.  The Supratrochlear nerve exits out of the medial portion of the orbital rim just superior and medial to the lateral canthus. 

Distribution of anesthesia:

Blocking both of these nerves will provide anesthesia to the entire forehead up to the vertex of the scalp.

Technique

Prep and drape the area just superior to the eyebrow(s).  Inject topical anesthetic into the subcutaneous space in a plane just superior to the eyebrow from the midline to the lateral edge of the orbit.

Pitfalls:

  • Intraneural injection will cause significant pain, therefore withdraw the needle a few millimeters and continue injecting the anesthetic. 

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Infraorbital Nerve

  Watch the Video


Anatomy

The infraorbital nerve exits the infraorbital foramen just inferior to the anterior portion of the optic rim, and just cranial / superior to the first maxillary pre molar (just posterior to canines).   The maxillary premolars can be identified by remembering that the Central incisors are your front two teeth, Lateral incisors are just that, followed by the Canines, two Premolars, and finally three Molars.

Distribution of anesthesia

Infraorbital nerve provides sensation to the lower lid, medial cheek, the side of the nose, and the upper lip.

Technique

Use topical anesthesia to first anesthetize the mucosa.  This is best performed using two cotton swaps dipped in topical anesthesia and placed just superior to the first maxillary pre-molar.  With the non-injecting hand retract the mucosa by placing the index and middle fingers on the inferior optic rim and retracting the upper lip with the thumb.  Dry the mucosa to enhance vision and minimize needle insertion trauma.  Penetrate the mucosa just superior to the first maxillary pre-molar.  Insert the needle cranially between the cheek and gingival until half the distance to the optic cup.  Inject approximately 3 to 5 ml of anesthesia.

Pitfalls

  • Intraneural injection will cause significant pain, therefore withdraw the needle a few millimeters and continue injecting the anesthetic. 

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Mental Block Nerve

 Watch the Video



Anatomy:  

The inferior alveolar nerve gives rise to the mental nerve which exits the mental foramen. 

Distribution of anesthesia:

The mental nerve block provides anesthesia to the labial mucosa, gingiva and the lower lip adjacent to the incisors and canines.

Technique:
Identify the first and second pre-molars on the lower jaw.  Retract the lip, apply topical anesthetic, and dry.  Advance the needle inferiorly into the mucosal fold adjacent to the first and second pre-molar.  At approximately one centimeter, inject 3 to 5 ml of anesthesia. 

Pitfalls:

  • Intraneural injection will cause significant pain, therefore withdraw the needle a few millimeters and continue injecting the anesthetic. 

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Inferior Alveolar Nerve

 Watch the Video



Anatomy:  

The inferior alveolar nerve arises from the mandibular division of trigeminal (V3).     Identify the mandibular sulcu the cornoid notch and the pterygomandibular raphe.  The failure rate for injection is 15% to 20% in the most experienced hands, and the rate of positive blood aspiration is 10% to 15%.

Distribution of anesthesia

The inferior alveolar nerve provides anesthesia to all the lower teeth and gums from the retromolar region to the midline as well as the anterior labial and lingual areas.   The lingual nerve is usually affected by the inferior alveolar block; therefore patients may experience difficulty speaking after this procedure. 

Technique:   

Retract the lip, apply topical anesthetic and dry the mucosa.  With the non-injecting hand, place the thumb inside the mouth in the coronoid notch of the ramus.  The needle should be directed from the contralateral lower incisor to the medial aspect of the ramus.  Insert the needle 1 to 2 centimeters posterior  and medial to the thumb in the raphe.  Advance the needle until you gently tap bone and withdraw approximately two to three millimeters.  Inject approximately 2 to 3 ml of anesthesia slowly. 

Pitfalls

  • Intraneural injection will cause significant pain, therefore withdraw the needle a few millimeters and continue injecting the anesthetic.

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Health Information

 

 

 

 

 
 
 

 

 

 

 

 

 

 

 
     = Supraorbital Nerve 
   = Supratrochlear Nerve
   = Infraorbital Nerve
 = Mental Nerve
   
 
 Click on photo of face to enlarge.

Click on photo to enlarge.

 

 

 

 

 

 

     = Supraorbital Nerve 
   = Supratrochlear Nerve
   = Infraorbital Nerve
 = Mental Nerve
   

 

 

Click on photo to enlarge.

 

 

 

 

 

 

 

 

 
     = Supraorbital Nerve 
   = Supratrochlear Nerve
   = Infraorbital Nerve
 = Mental Nerve
   
 Click on photo of face to enlarge.
Click on photo to enlarge.
 

 

 

 

 

 

 

 

 

 

 
     = Supraorbital Nerve 
   = Supratrochlear Nerve
   = Infraorbital Nerve
 = Mental Nerve
   
 Click on photo of face to enlarge.
Click on photo to enlarge.