maxillofacial injuries have the potential to cause airway compromise and are associated with pain and swelling causing difficulty in mouth opening , chewing and deglutition .
it helps in intraoperative pain relief and also helps in early post operative rehabilitation of maxilla facial trauma patients
mandibular nerve block is often performed for diagnostic , therapeutic and anesthetic purposes for surgery involving mandibular region .
we report a case where intraoperative and post - operative pain in a case of unilateral fracture mandible was effectively managed through intermittent mandibular nerve block via a catheter .
a 30-year - old male with right sided parasymphyseal fracture mandible was scheduled for open reduction and internal fixation .
the patient had difficulty in opening the mouth due to pain ( 3 cm ) .
informed written consent for the nerve block was obtained and visual analogue scale ( vas ) of 0 - 10 , was explained to patient . in the operation theater ,
neuromuscular blockade was achieved with vecuronium and anesthesia was maintained with o2 and n2o using controlled ventilation .
the right side of the face was prepared for mandibular nerve block with lateral extraoral approach [ figure 1 ] .
arrow showing skin site of epidural needle insertion for mandibular nerve block an 18-gauge i.v .
cannula was inserted at midpoint of lower border of the zygomatic arch and was advanced perpendicular to face until it contacted the lateral pterygoid plate .
the length of the cannula outside the skin was marked and cannula was redirected slightly posterior to reach behind the posterior border and was advanced further by 0.5 cm .
catheter was tunnelled subcutaneously and the filter was attached to its other end [ figure 2 ] . for surgical analgesia , a bolus dose of 4 ml of 0.25% bupivicaine was given through the catheter .
fentanyl 1mg/ kg i.v . was given only when there was more than 20% increase in heart rate or blood pressure above base line .
the surgery lasted for 2 h. at the end of surgery , neuromuscular blockade was reversed and the trachea extubated .
following extubation , the patient was conscious and pain free and then shifted to ward .
post operatively , he received 4 ml of 0.25% bupivacaine through the epidural catheter every 12 h for two days .
vas score was measured immediately after surgery and thereafter at 1 , 2 , 4 , 6 , 12 , 24 , and 48 h respectively .
patient was observed for numbness at the surgical site , need for rescue analgesia , complications ( nausea , vomiting ) .
numbness in area of lower jaw line was present throughout the period but subsided after discontinuation of local anesthetic through epidural catheter .
he was discharged on fourth post operative day with advice for follow up in o.p.d .
mandibular nerve block can be used to manage intra as well as post operative pain in cases of fracture mandible .
we performed lateral extra oral approach because of restricted mouth opening and the need to retain the catheter for post operative analgesia .
18 g cannula instead of epidural needle was used to minimize the bleeding from pterygoid plexus of veins .
the cannula was advanced further after contacting lateral pterygiod plate so that the catheter comes in vicinity of mandibular nerve and there is no displacement during jaw movements .
the catheter was further tunnelled subcutaneously to prevent dislodgement and filter was used to prevent infection .
there was excellent post operative analgesia achieved with this technique as shown in decreased pain scores , both static as well as dynamic .
 mandibular nerve block is often performed for diagnostic , therapeutic and anesthetic purposes for surgery involving mandibular region . 
 advantages of a nerve block include excellent pain relief and avoidance of the side effects associated with the use of opiods or non - steroidal anti - inflammatory drug ( nsaids ) . 
 a patient with maxillo facial trauma was scheduled for open reduction and internal fixation of right parasymphyseal mandibular fracture . 
 the mandibular nerve was approached using the lateral extraoral approach with an 18-gauge i.v . 
 cannula under general anesthesia . 
 he received 4 ml boluses of 0.25% plain bupivacaine for intraoperative analgesia and 12 hourly for 48 h post operatively . 
 vas scores remained less than 4 through out observation period . 
 the only side effect was numbness of ipsilateral lower jaw line , which subsided after local anesthetic administration was discontinued . 
 patient was discharged after four days . 