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Transcript of Trigminal Nerve V3 Condensed Grayscale Slides
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Alex ForrestAssoci ate Profess or of For ensic Od ontol ogyForensic Science Research & Innovation Centre, Griffith UniversityConsultant Forensic Odontologist,Queensland Health Forensic and Scientific Services,
39 Kessels Rd, Coopers Plains, Queensland, Australia 4108
Oral Biology
Trigeminal Nerve: V3Trigeminal Nerve: V3
COMMONWEALTH OF AUSTRALIA
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Do not remove this notice.
Mandibular Division V3Mandibular Division V3
Recall the area
supplied with
sensory innervationby the mandibular
division of thetrigeminal nerve
(V3).
Grays Anatomy, Longmans, London,
38th Ed 1989 p. 1106
The mandibular
division of thetrigeminal nerve,
often known simplyas the mandibular
nerve, contains both
sensory fibres andmotor fibres.
Modified from: Evers, H & Haegerstam, G.
Introduction to Local Anaesthesia, Mediglobe SA,
Fribourg, 2nd Edition 1990. P. 60
Mandibular Division V3Mandibular Division V3
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The sensory portion of
the mandibular nerve
passes into the
trigeminal ganglion andfrom there to the
brainstem along withthe sensory fibres from
V2 and V1.
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989
p. 1107
Mandibular Division V3Mandibular Division V3
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989
p. 1107
The somatic motor
nerve fibres leave the
pons in a separate
motor root, which joinsthe main trunk of themandibular nerve just
after it exits thecranium through
foramen ovale in thegreater wing of the
sphenoid bone.
Mandibular Division V3Mandibular Division V3
Here it forms a common
trunk for a very shortdistance, before giving
off its first branch.
Modified from: Evers, H & Haegerstam, G.
Introduction to Local Anaesthesia,
Mediglobe SA, Fribourg, 2nd Edition, 1990.
P. 60
Mandibular Division V3
This is a small twigcontaining sensory fibres,
and it dives back into the
cranium with the middlemeningeal artery through
foramen spinosum of thesphenoid bone to supply
most of the dura mater
with sensation. It is knownas the recurrent
meningeal nerve, ornervus spinosus.
Modified from Grays Anatomy, Longmans, London, 38th Ed
1989 p. 1105
Mandibular Division V3
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The common nerve
trunk now gives offsmall muscular
branches containing
motor fibres to thetensor palati and
tensor tympanimuscles, and the
medial pterygoid
muscle.
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989
p. 1105
Mandibular Division V3
It also acquires smallcommunicating
branches from the
otic ganglion, a
parasympatheticmotor ganglion which
lies deep to it in theinfratemporal fossa.
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989
p. 1105
Mandibular Division V3
The nerve now divides into a larger posterior division and a
smaller anterior division. A general (and inaccurate) rule:
The posterior division is entirely composed of sensory
branches except for one motor one.
The anterior division comprises entirely motor branchesexcept for one sensory one.
Mandibular Division V3
Posterior DivisionPosterior Division
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Posterior DivisionPosterior Division
The branches of the posterior division of the
mandibular nerve are:
Auri cul otemporal nerve (sensor y)
Inferior dental nerve (sensory)
Lingual nerve (sensory)
Nerve to mylohyoid and anterior belly of digastric (motor)
Auriculotemporal NerveAuriculotemporal Nerve
Auricu lo temporal NerveAuricu lo temporal Nerve
The auriculotemporal
nerve or nerves are
important because it is
the sensory nerve tothe TMJ and carriessecretomotor fibres
from the otic ganglion
to the parotid gland.
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989
p. 1105
It leaves the main trunk ofthe mandibular nerve
shortly after the motor root
attaches to it, and passes
posteriorly towards themiddle meningeal artery.
It splits into two, the twobranches pass around the
middle meningeal artery
and circle it, and then theyjoin up again to form a
single branch.Modified from Grays Anatomy, Longmans, London, 38th Ed 1989
p. 1105
Auricu lotemporal NerveAuricu lotemporal Nerve
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Modified from Grays Anatomy, Longmans, London, 38th Ed 1989
p. 1105
Auricu lo temporal NerveAuricu lo temporal Nerve
It continues to runposteriorly, lying on the
tensor palati muscle,
and reaches the deep
aspect of the neck of themandible past which it
runs, between the boneand the
sphenomandibular
ligament.
Modified from Grays Anatomy, Longmans, London, 38th Ed 1989
p. 1105
Auricu lotemporal NerveAuricu lotemporal Nerve
It then curves around
behind the
temporomandibular jointwhich it supplies with
sensory fibres and runs
into the parotid salivarygland.
It gives off sensory and parasympathetic secretomotor fibres
acquired from the otic ganglion to the gland, and then curvesto run superiorly in the gland, and terminates in the superior
temporal branches, which supply common sensation to theskin and underlying structures in the posterior temple area and
the side of the scalp.
Auricu lo temporal NerveAuricu lo temporal Nerve
Inferior Dental NerveInferior Dental Nerve
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Modified from: Evers, H & Haegerstam, G. Introduction to
Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition,
1990. P. 60
Inferior Dental NerveInferior Dental Nerve
The inferior dental nerve, also
known as the inferior alveolar
nerve, is of great importance
because it provides thesensory nerve supply to the
pulps of the lower teeth.
To do so, it must enter thebody of the mandible.
It does this by passing through the
mandibular foramen on the internal
surface of the mandibular ramus,and running in the inferior dental
canal.
Modified from: Evers, H & Haegerstam, G. Introduction to
Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition,
1990. P. 60
Inferior Dental NerveInferior Dental Nerve
Initially, the nerve lies in the mandibular canal as a single trunk,
but soon divides into numerous smaller branches which form aplexus within the body of the mandible.
Inferior Dental NerveInferior Dental Nerve
From Shigeru Tajiri, An Atlas of Anatomy of the Head and Neck, Aproman 1998
J.M. Sanchis, Miguel Penarrocha, and F. Soler, BifidMandibul ar Canal. J Oral Maxillofac Surg 61:422-424, 2003
Purpose: To determine the incidence and characteristics of bifidmandibular canals.
Methods:A retrospective study was performed using panoramicradiographs of 2012 patients subjected to dental treatment in the Dental
Clinic of the Valencia University Dental School (Valencia, Spain) between
1996 and 1999. The goal was to investigate the presence of doublemandibular canals.
Results: The extraoral panoramic radiographs revealed a total of 7 imagessuggestive of bifid canals. Mandibular computed tomography revealed the
existence of this anatomic variant in 2 of 3 patients. An analysis wasperformed on the incidence of this type of image in extraoral panoramic
radiography, its
possible interpretations, and the clinical implications of bifid mandibularcanals.
Conclusions: In this study, 0.35% of canals were bifid. All cases were inwomen.
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The nerve supplies
the pulps of the lower
teeth and theirperiodontal
ligaments, themandibular bone, and
the labial gingivaeand buccal gingivaeback about as far as
the second premolar.
Inferior Dental NerveInferior Dental Nerve
Evers, H & Haegerstam, G. Introduction to Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition, 1990. P. 85
While in the body of the
mandible, the nerve
splits into two branches.
Grays Anatomy, Longmans, London, 38 th Ed 1989 p. 1101
Inferior Dental NerveInferior Dental Nerve
One of these continues
forwards in the body ofthe mandible to supply
labial gingivae and
pulps of the lower
anterior teeth, and it isknown as the incisive
nerve, or more
correctly, the incisiveplexus, because it hasceased to be a single
nerve trunk by thisstage.
Grays Anatomy, Longmans, London, 38 th Ed 1989 p. 1101
Inferior Dental NerveInferior Dental Nerve
The other exits themandible through a
small backwards-
directed foramen in the
external surface of thebody of the mandible
called the mental
foramen, usually found
between the roots of the
lower first and secondpermanent premolar
teeth.
Inferior Dental NerveInferior Dental Nerve
Grays Anatomy, Longmans, London, 38 th Ed 1989 p. 1101
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This branch is called themental nerve, and it
supplies common
sensation to the lower
lip and the front of thechin.
Inferior Dental NerveInferior Dental Nerve
Grays Anatomy, Longmans, London, 38 th Ed 1989 p. 1101
Nerve to the MylohyoidNerve to the Mylohyoid
Nerve to the MylohyoidNerve to the Mylohyoid
The nerve to the mylohyoid
muscle and anterior belly of the
digastric branches off from theinferior dental nerve just before
it passes into the mandibular
foramen.
It is the only motor branch of
the posterior division, which is
why it supplies muscles insteadof other tissues.
Modified from: Evers, H & Haegerstam, G. Introduction to
Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition,
1990. P. 60
Frommer and colleagues,
however, showed that
histologically, the mylohyoid
nerve contains both sensoryand motor nerve fibres.
Modified from: Evers, H & Haegerstam, G. Introduction to
Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition,
1990. P. 60
Frommer, J, Mele, FA, & Monroe, CW. 1972.The possible role of the mylohyoid nerve in
mandibular posterior tooth sensation. J.
American Dental Assoc. 85, 113-117.
Nerve to the MylohyoidNerve to the Mylohyoid
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Other studies have shown that
it may pass through small
lingual foramina in the mandible
with varying frequency in theanterior and premolar regions.
Modified from: Evers, H & Haegerstam, G. Introduction to
Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition,
1990. P. 60
(Madeira, MC, Percinoto, C, & Silva, M. 1978.Clinical significance of supplementary
innervation of the lower incisor teeth: a
dissection study of the mylohyoid nerve. Oral
Surg. 46: 608-614.
Wilson, S, Johns, P, & Fuller, PM. 1984. The
inferior and mylohyoid nerves: an anatomic
study and relationship to local anaesthesia of
the lower anterior teeth. J American Dental
Assoc. 108: 350-352).
Nerve to the MylohyoidNerve to the Mylohyoid
If the nerve branches from themain trunk of V3 high enough in
the infratemporal fossa to avoid
being bathed in anaesthetic
solution, then such patientsmay show signs of successful
anaesthesia and still show
sensitivity when dentalprocedures are undertaken.
Modified from: Evers, H & Haegerstam, G. Introduction to
Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition,
1990. P. 60
Nerve to the MylohyoidNerve to the Mylohyoid
Bennett and Townsend haveshown that the mean height of
the nerve branch in their series
of 6 dissections was 13.4 mmwith a maximum height of 20.7
mm, high enough in somecases to avoid anaesthesia with
a conventional block.
Modified from: Evers, H & Haegerstam, G. Introduction to
Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition,
1990. P. 60
(Bennett S and Townsend G. Distribution of the
mylohyoid nerve: anatomical variability and
clinical implications. [online].Aust Endod J,
2001 Dec; 27 (3): 109-11).
Nerve to the MylohyoidNerve to the Mylohyoid
This would seem to suggest a
possible accessory nerve
supply for anterior and premolar
mandibular teeth.
Additional anaesthesia of the
mylohyoid nerve can beobtained with a lingual
infiltration injection in the
premolar region.
Modified from: Evers, H & Haegerstam, G. Introduction to
Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition,
1990. P. 60
(Bennett S and Townsend G. Distribution of the
mylohyoid nerve: anatomical variability and
clinical implications. [online].Aust Endod J,
2001 Dec; 27 (3): 109-11).
Nerve to the MylohyoidNerve to the Mylohyoid
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Indeed, Sillanpaa and
colleagues anaesthetized the
mylohyoid nerves of volunteer
dental students and in 21%reported obtaining partial
anaesthesia of the lower teeth,
including the first mandibular
molar.
Modified from: Evers, H & Haegerstam, G. Introduction to
Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition,
1990. P. 60
(Sillanpaa M, Vuori V & Lehtinen R. The
mylohyoid nerve and mandibular anaesthesia.
Int J Oral Maxillofac Surg. 1988 Jun; 17(3): 206-
207).
Nerve to the MylohyoidNerve to the Mylohyoid
A specific cutaneous sensory
branch of this nerve supplying
an area of the chin has recentlybeen recognized.
Modified from: Evers, H & Haegerstam, G. Introduction to
Local Anaesthesia, Mediglobe SA, Fribourg, 2nd Edition,
1990. P. 60
(Hwang K, Han JY, Chung IH & Hwang SH.Cutaneous sensory branch of the mylohyoid
nerve. J Craniofac Surg. 2005 May; 16(3): 343-
345 (Discussion 346)).
Nerve to the MylohyoidNerve to the Mylohyoid
Lingual NerveLingual Nerve
Lingual NerveLingual Nerve
The lingual nerve leaves the
anterior aspect of the maintrunk of the posterior division
well above the mandibular
canal, and runs parallel to theinferior dental nerve for a
considerable distance.
It often goes numb when theinferior dental nerve is
anaesthetized.
Modified from: Evers, H & Haegerstam, G.
Introduction to Local Anaesthesia, Mediglobe
SA, Fribourg, 2nd Edition, 1990. P. 60
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Lingual NerveLingual Nerve
Modified from: Evers, H & Haegerstam, G.
Introduction to Local Anaesthesia, Mediglobe
SA, Fribourg, 2nd Edition, 1990. P. 60
It comes to lie a little deeper
than the inferior dental nervethough, and does not run
into the mandible.
Lingual NerveLingual Nerve
Instead, it curves gently above the mylohyoid muscle, passing
between the body of the mandible and the duct of the
submandibular gland to pass beneath the duct, rising again
medially to terminate in the substance of the anterior part of thetongue.
Netter, F.
1989,
Atlas of
Human
Anatomy,
Summit,
New
Jersey,
Ciba-
Geigy
Medical,
Plate 53.
The lingual nerve is the
major sensory nerve of
the anterior two-thirds ofthe tongue, and therefore
also carries the specialsensation of taste, as well
as common sensation.
Lingual NerveLingual Nerve
Modified from: Evers, H & Haegerstam, G.
Introduction to Local Anaesthesia, Mediglobe
SA, Fribourg, 2nd Edition, 1990. P. 60
It also supplies common
sensation to the tissues ofthe floor of the mouth, and
to the lingual gingival
tissues.
It must therefore be
anaesthetized if extractionof a lower tooth is required.
Lingual NerveLingual Nerve
Modified from: Evers, H & Haegerstam, G.
Introduction to Local Anaesthesia, Mediglobe
SA, Fribourg, 2nd Edition, 1990. P. 60
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It is commonly
anaesthetized along
with the inferior dental
nerve during theinferior dental nerve
block.
Modified from: Haglund, J. & Evers, H Local
Anaesthesia in Dentistry, Astra Lkemedel
Sdertlje, 2nd Edition, 1975. p. 52.
Lingual NerveLingual Nerve
Grays Anatomy, Longmans, London, 38 th Ed 1989 p. 1101
Lingual NerveLingual Nerve
During its path as it
descends towards the
mylohyoid, it picks up a
small branch called thechorda tympani, whichcarries secretomotor
parasympathetic fibres
which it distributes to the
submandibular andsublingual salivary glands,as well as to minor salivary
glands in the floor of themouth.
These are preganglionicfibres initially, and they
synapse in the
submandibular ganglionwhich is located just inferior
to the lingual nerve close tothe submandibular gland.
The postganglionic fibres
pass to the submandibular
gland and some hook a ridewith the continuing lingual
nerve to reach thesublingual gland.
Lingual NerveLingual Nerve
Grays Anatomy, Longmans, London, 38 th Ed 1989 p. 1101
The lingual nerve can often provide accessory innervation to
anterior teeth, as can small branches from the ascendingbranch of the transverse cutaneous nerve of the neck.
Depositing a small amount of anaesthetic lingually (with
aspiration to avoid intravascular injection) will often solve theproblem.
Accessory Nerve Suppl iesAccessory Nerve Suppl ies
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McGeachie JK. Anatomy of the lingual nerve in relation to
possibl e damage during clinical procedures. Ann RAust ralas Col l Dent Surg. 2002 Oct;16:109-10.
Oral Health Centre of Western Australia. [email protected]
Damage to the lingual nerve, resulting in transient or permanentparaesthesia or anaesthesia, is a common undesirable complication of
surgical interventions to the lower third molar region. The anatomy of thenerve, as it travels from its origin high in the infra-temporal fossa, to thefloor of the mouth is quite variable. The most critical part of its course iswhere it enters the sublingual region just alongside the lingual alveolar
plate of the lower third molar.
A s igni ficant number of lingual n erves are lo cated above the alveo larbone in the gingival tis sues, or very close to the bone. Retraction of
the lingual mucosa can lead to lingual nerve trauma. There is no doubt thatthe lingual nerve is extremely vulnerable in this region and clinicians must
assume that it is closely adjacent to the lingual region of the lower thirdmolar, in all cases, in order to minimize possible damage.
Anterior Division of V3Anterior Division of V3
Anter ior Division of V3Anter ior Division of V3
The branches of the anterior division of themandibular nerve are:
Nerves to masseter (motor)
Nerves to temporalis (motor)
Nerve to lateral pterygoid (motor)
Nerve to medial pterygoid (motor)
Buccal nerve (Sensory)
Buccal NerveBuccal Nerve
The buccal nerve,
sometimes known as the
long buccal nerve (especially
in oral surgery), is thesource of common sensationto most of the cheek and the
buccal gingival tissues of the
lower posterior teeth.
Modified from: Haglund, J. & Evers, H Local
Anaesthesia in Dentistry, Astra Lkemedel
Sdertlje, 2nd Edition, 1975. p. 53.
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Buccal NerveBuccal Nerve
It must thereforealso be
anaesthetized if a
lower posteriortooth is to be
extracted.
Modified from: Haglund, J. &
Evers, H Local Anaesthesia in
Dentistry, Astra Lkemedel
Sdertlje, 2nd Edition, 1975. p. 53.
Nerve Supply to Lower TeethNerve Supply to Lower Teeth
Pain sensation to the dental pulps of the lower teeth and
common sensation to buccal and labial gingival tissues is
supplied by the inferior dental nerve.
Therefore, any procedure that requires anaesthesia of thepulps of any lower tooth can be performed successfully if the
inferior dental nerve is blocked.
We try to anaesthetize
it just before it enters
the mandibularforamen, and this
ensures that toothpulps along the whole
of the anaesthetizedside remain numb.
Nerve Supply to Lower TeethNerve Supply to Lower Teeth
Modified from: Haglund, J. & Evers, H Local
Anaesthesia in Dentistry, Astra Lkemedel
Sdertlje, 2nd Edition, 1975. p. 52.
Because there is some
crossing over of nervesupplies from the right
and left inferior dental
nerves near themidline, sometimes
infiltration anaesthesiais also required in this
area.
Nerve Supply to Lower TeethNerve Supply to Lower Teeth
Modified from: Evers, H & Haegerstam,
G. Introduction to Local Anaesthesia,
Mediglobe SA, Fribourg, 2nd Edition,
1990. P. 87
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Nerve Supply to Lower TeethNerve Supply to Lower Teeth
If anaesthesia is required for extraction, however, then the
nerve supply of the gingival tissues must also be
considered. The lingual nerve can be blocked to ensure
anaesthesia of the lingual gingivae.
Posteriorly, the buccal gingivae are supplied by the buccalnerve, and this must therefore also be anaesthetised for
extractions in this region.
For premolar and anterior teeth, the buccal and labial gingivae
are supplied by the inferior dental nerve, and they willtherefore have been successfully anaesthetised already by an
inferior dental nerve block.
Nerve Supply to Lower TeethNerve Supply to Lower Teeth
Accessory Nerve SuppliesAccessory Nerve Supplies
Difficulty in anaesthetizing palatal teeth is most commonly due
to accessory innervation of those teeth by branches of thegreater palatine nerve or from the terminal branches of the long
sphenopalatine nerve.
Injection of a small amount of anaesthetic palatally will normallysecure anaesthesia. Other techniques such as intra-ligamental
or intraosseous injections may also be useful, as may newer
methods of anaesthetic delivery such as the wand.
Accessory Nerve Suppl iesAccessory Nerve Suppl ies
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Difficulty in anaesthetizing mandibular teeth is most commonly
encountered in the molar area.
It it recognized that the long buccal nerve, lingual nerve,
mylohyoid nerve, and branches of the inferior dental nerve mayall contribute to such problems. In addition, sensory fibres from
the muscles of mastication may also provide an accessoryinnervation to these teeth.
Accessory Nerve Suppl iesAccessory Nerve Suppl ies
Problems due to the long buccal nerve can be overcome by
administering a buccal block injection.
Accessory Nerve Suppl iesAccessory Nerve Suppl ies
Those from the mylohyoid nerve or from accessory innervation
from muscles of mastication can usually be solved by injectinginto the floor of the mouth between the submandibular fold and
the mandible, taking care not to inject intravascularly, especially
into the facial artery. Inject through the mylohyoid muscle.
Accessory Nerve Suppl iesAccessory Nerve Suppl ies
The cortical bone here is sometimes porous and thin enough to
allow diffusion of anaesthetic into the bone to anaesthetize
accessory nerve bundles from the muscles of mastication.
Accessory Nerve Suppl iesAccessory Nerve Suppl ies
Copyright
A. Forrest2004
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The lingual nerve can often also provide accessory innervation
to anterior teeth, as can small branches from the ascendingbranch of the transverse cutaneous nerve of the neck.
Depositing a small amount of anaesthetic lingually (with
aspiration to avoid intravascular injection) will often solve theproblem.
Accessory Nerve Suppl iesAccessory Nerve Suppl ies
Why is dental pulpal pain difficult to localize?
The pulp contains only pain fibres (A-delta and C fibres),therefore touch, temperature and pressure are only perceived
as pain. Any potentially damaging stimulus will cause
changes to the fluid in the dentinal tubules.
This pain is difficult to localize unless the inflammationextends to the periodontal ligament where additional sensory
receptors (pressure, proprioception) give further information.
In addition, the numerous pain fibres of the pulp converge onto
fewer fibres in the brainstem and information about the specific
tooth is lost.
Dental pain can be referred from one arch to the other arch,
but it never crosses the midline. It may also be referred to the
ear, neck etc.
Dental pain may sometimes be a pain referred to the teeth
from a non-odontogenic source e.g. sinuses, heart.
The only way to ensure accurate diagnosis of dental pain is bythorough history taking, examination and testing.
The following resources might be useful to you:
A good page on LA techniques is found at:
http://www.septodont.ca/Septodont/english/other/cea_di01.html
For a discussion on accessory foramina and innervation in themandible, see:
http://dmfr.birjournals.org/cgi/reprint/29/3/170.pdf
For a recent American discussion of LA in Dentistry, see:
http://www.cda.org/member/pubs/journal/jour0503/budenz.htm
Accessory Nerve Suppl iesAccessory Nerve Suppl ies
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The End