Caudal maxillary (maxillary) regional block
The caudal maxillary block allows infiltration of the local-anesthetic combination adjacent to the infraorbital nerve and
the pterygopalatine nerve caudal to the second maxillary molar (Photos 4 and 5). These nerves are branches of the maxillary
nerve that supply sensory innervation to the maxilla. In addition to the structures affected by the infraorbital block, it
will anesthetize the caudal cheek teeth and associated bone and soft tissue. The soft palatal mucosa, hard palatal mucosa
and bone will be affected by this block. To perform this block, the mouth is opened wide and the lips retracted caudally at
the lateral commissure. The needle is directed in a dorsal direction immediately behind the central portion of the maxillary
second molar tooth. Advancement of the needle need not be more than 2-4 mm, depending on patient size.
Photo 6: Rostral mandibular (mental) block. The mandibular labial frenulum is retracted in a ventral direction. The needle
is passed into the rostral aspect of the frenulum adjacent to the bone and into the foramen.
Rostral mandibular (mental) regional block
The rostral mandibular block infiltrates the rostral extent of the inferior alveolar nerve just before it exits the middle
mental foramen (Figures 6 and 7). The structures anesthetized include the incisors, the canine and the first three premolars.
The adjacent bone and soft tissue also are affected. The middle mental foramen is located about one-third of the distance
from the ventral border to the dorsal border of the mandible at the level of the mesial root of the second premolar. The landmark
for infiltration is the mandibular labial frenulum. The frenulum is retracted ventrally. The needle is inserted at the rostral
aspect of the frenulum and advanced along the mandibular bone to just enter the canal. If bone is encountered, the needle
should be backed out and redirected until the needle passes freely into the foramen. Placement can be confirmed by moving
the syringe laterally to encounter the lateral aspect of the canal. The patient's jaw, rather than the alveolar mucosa, will
move slightly if the needle is within the canal.
Photo 7: Proper needle placement for the rostral mandibular block on a skull.
Caudal mandibular (inferior alveolar) regional block
The caudal mandibular block is performed by infiltrating the inferior alveolar nerve prior to its entry into the mandibular
foramen on the lingual aspect of the caudal mandibular body (Photos 8 and 9). The lateral canthus of the eye is the landmark
for this block. An imaginary plumb line is drawn from the lateral canthus of the eye directly to the ventral mandible. The
needle is inserted into the skin at the lingual aspect of the ventral mandible at this point. The needle is advanced along
the bone following the imaginary plumb line to a point one-third of the distance from the ventral to the dorsal mandible.
The needle will now be in the vicinity of the mandibular foramen where the inferior alveolar nerve enters the mandibular canal.
It is not critical to be exactly at the foramen. Radiographic dye studies indicate that the agent diffuses to encompass a
large area around the point of infusion (Photo 10). This technique blocks all of the teeth of the mandible on the side of
infiltration as well as the adjacent bone and soft tissue.
Photo 8: Caudal mandibular (inferior alveolar) block. A plumb line is drawn from the lateral canthus to the ventral border
of the mandible. The needle is placed through the skin adjacent to the lingual aspect of the mandibular bone. It is advanced
to a point one-third of the distance from the ventral to dorsal border of the mandible.
Although very uncommon, patients receiving a caudal mandibular nerve block can traumatize their tongues by mastication in
the postoperative period. Observation and proper recovery assistance during this period will eliminate this complication.
Staff members monitoring the recovering patient should ensure visually that the tongue is not trapped between the carnassial
teeth if the patient is recovered in lateral recumbency. Maintaining the patient in sternal recumbency precludes the tongue
deviation expected when a patient is laterally recumbent.
Photo 9A: Proper needle placement for the caudal mandibular block on a skull.