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In Children
▪ A suitable premedication
▪ to obtain safe anesthetic effect it is necessary to
have specific knowledge about some anatomical
characteristic.
Basic Injection
Technique
◆ Step 1: Use
a Sterilized
Sharp Needle
Fig 1. a fishhook-type
barb may appear on the
tip
◆ Step 2: Check the Flow of Local
AnestheticSolution
After the cartridge has been properly loaded into
the syringe, and with the aspirator tip (harpoon)
embedded in the sili- cone rubber stopper
(unless a self-aspirating syringe is being used), a
few drops of local anesthetic should be expelled
from the cartridge.
◆ Step 3: Determine Whether to Warm
the AnestheticCartridge or Syringe
If the cartridge is stored at room temperature
(approxi- mately 22°C, 72°F), there is no reason for
a local anesthetic cartridge to be warmed before
injection of the anesthetic into soft tissues
◆ Step 4: Position the Patient
it is recommended that during local anesthetic
administration, the patient should be placed in a
supine position (head and heart parallel to the
floor) with the feet elevated slightly
Fig. 2 .Physiologic position of patient for receipt of local
anesthetic injection.
◆ Step 5:
Dry the
Tissue
Fig. 3. A 2- × 2-inch gauze
should be used to dry the
tissue in and around the site
of needle penetration and to
remove any gross debris
To do so requires a steady hand so that tissue penetra-
tion may be accomplished readily, accurately, and without
inadvertent nicking of tissues. A firm hand rest is
Fig. 7 (A) Tissue at needle penetration site is pulled taut, aiding both visibility and
atraumatic needle insertion. (B) Taut tissue provides excellent visibility of the
penetration site for a posterior superior alveolar nerve block.
◆ Step 9 : Keep the Syringe Out of
the Patient’s Line of Sight
Aspiration mustalwaysbeperformed beforea volume of local anestheticisdepositedat any site. Aspiration dramatically minimizes
thepossibilityofintravascularinjection.Thegoalofaspirationistodeterminewheretheneedletipissituated(withinabloodvesselor
without)
Fig. 10 (A) Needle tip within blood vessel but bevel abuts the wall of the vein. (B) On
aspiration the vein wall is sucked into the needle tip, producing a false negative aspiration
test result. (C) Rotating the syringe 45 degrees and reaspirating will provide a true “positive”
aspiration in this scenario.
◆ Step 15:
Slowly Deposit Slow injection is defined ideally as the deposition
Solution
◆ Step 16: Slowly
Withdraw the
Syringe Fig. 11. “Scoop” technique for recapping needle after
use.
◆ Step 17: (and its blood level increases). Most true adverse
drug reactions, especially those related to
Observe the intraorally administered local anesthet- ics,
develop either during the injection or within 5 to
Patient 10 minutes of its completion
Nerves Anesthetized
1.Inferior alveolar nerve, a branch of the posterior
division of the mandibular division of the trigeminal
nerve (V3)
2.Incisive nerve
1.A long dental needle is recommended for the adult patient or any pediatric patient where the soft tissue depth at the
injection site is approximately 20 mm. A 25-gauge long needle is preferred; a 27-gauge long is acceptable.
2.Area of insertion: mucous membrane on the medial (lingual) side of the mandibular ramus, at the intersection of two
lines—one horizontal, representing the height of needle insertion, the other vertical, representing the anteroposterior
plane of injection.
3.Target area: inferior alveolar nerve as it passes downward toward the mandibular foramen but before it enters into
the foramen.
4.Landmarks (Figs. 14.2 and 14.3):
a. Coronoid notch (greatest concavity on the anterior
5.border of the ramus).
b. Pterygomandibular raphe (vertical portion).
c. Occlusal plane of the mandibular posterior teeth.
6.Orientation of the needle bevel: less critical than with other nerve blocks, because the needle approaches the IAN at
roughly a right angle.
1.Procedure:
a. Assume the correct position:
i. For a right IANB, a right-handed administra- tor should sit at the 8 o’clock position facing the patient (Fig. 14.4A).
ii. For a left IANB, a right-handed administrator should sit at the 10 o’clock position facing in the same direction as the
patient (see Fig. 14.4B).
b.Position the patient supine (recommended) or semisupine (if necessary). The mouth should be opened wide to
allow greater visibility of, and access to, the injection site.
c. Prepare tissue at the injection site:
1. Dry it with sterile gauze.
2. Apply topical antiseptic (optional).
3. Apply topical anesthetic for 1 to 2 minutes.
4. Place the barrel of the syringe in the corner of the mouth on the contralateral side
5.Locate the needle penetration (injection) site.
1. Height of injection: Place the index finger or the thumb of your left hand in the coronoid notch.
An imaginary line extends posteriorly from the fingertip in the coronoid notch to the deepest part of
thepterygomandibular raphe (as it turns vertically upward toward the maxilla), determining the height of injection.
This imaginary line should be parallel to the occlusal plane of the mandibular molar teeth. In most patients, this line
lies 6 to 10 mm above the occlusal plane.
2. The finger on the coronoid notch is used to pull the tissues laterally, stretching them over the injection site, making
them taut, and enabling needle insertion to be less traumatic, while providing better visibility. If possible, use a mouth
mirror to minimize the risk of accidental needlestick injury to the administrator.
3. The needle insertion point lies three-fourths of the anteroposterior distance from the coronoid notch back to the
deepest part of the pterygomandibular raphe: The line should begin at the midpoint of the notch and terminate at the
deepest (most posterior) portion of the pterygomandibular raphe as the raphe bends vertically upward toward the
palate.
4. The posterior border of the mandibular ramus can be approximated intraorally by use of the pterygoman- dibular
raphe as it bends vertically upward toward the maxilla (see Fig. 14.3).a
5. An alternative method of approximating the length of the ramus is to place your thumb on the coronoid notch and
your index finger extraorally on the pos- terior border of the ramus and estimate the distance between these points.
However, many practitioners (including this author) have difficulty envisioning the width of the ramus in this manner.
2. Anteroposterior site of injection: Needle penetration occurs at the intersection of two points. (Fig. 14.7):
a. Point 1 falls along the horizontal line from the coronoid notch to the deepest part of the pterygoman- dibular raphe as it
ascends vertically toward the palate as just described.
b. Point 2 is on a vertical line through point 1 about three-fourths of the distance from the anterior border of the ramus. This
determines the anteroposterior site of the injection.
3. Penetration depth: In the third parameter of the IANB, bone should be contacted. Slowly advance the needle until you can feel
it contact bone. For most patients, it is not necessary to inject any Local anesthetic solution as soft tissue is penetrated.
2.For anxious or sensitive patients, it may be advisable to deposit small volumes as the needle is advanced. Buffered local
anesthetic solutions are recommended as they decrease the patient’s sensitivity during needle advancement.
3.The average depth of penetration to bony contact, in the adult, is 20 to 25 mm, approximately two-thirds to three-fourths the
length of a long dental needle (Fig. 14.8).
4.The needle tip should now be located slightly superior to the mandibular foramen (where the IAN enters [disappears into]
bone). The foramen can neither be seen nor be palpated clinically. If bone is contacted too soon (less than half the length of a
long dental needle in an adult), the needle tip is usually located too far anteriorly (laterally) on the ramus. To correct this (Fig.
14.9):
i. Withdraw the needle slightly but do not remove it from the tissue.
ii. Bring the syringe barrel more toward the front of the mouth, over the canine or lateral incisor on the contralateral side.
iii. Redirect the needle until a more appropriate depth of insertion is obtained. The needle tip is now located more posterio rly in
the mandibular sulcus.
If bone is not contacted, the needle tip is usually located too far posterior (medial) (Fig. 14.10). To correct this: i. Withdraw
it slightly in tissue (leaving approximately one-fourth of its length in tissue) and reposition the syringe barrel more
posteriorly (over the mandibular molars).
Continue needle insertion until contact with bone is made at an appropriate depth (20 to 25 mm).
7. Insert the needle. When bone is contacted, withdraw approximately the needle by 1 mm to prevent sub- periosteal
injection.
8. Aspirate in two planes. If negative, slowly deposit 1.5 mL of anesthetic over a minimum of 60 seconds. (Because of the
high incidence of positive aspiration and the natural tendency to deposit solution too rap- idly, the sequence of slow
injection, reaspiration, slow injection, and reaspiration is strongly recommended.)
9. Slowly withdraw the syringe, and when approximately half its length remains within tissues, reaspirate. If nega- tive,
deposit a portion of the remaining solution (0.2 mL) to anesthetize the lingual nerve.
in most patients, this deliberate injection for lingual nerve anesthesia is not necessary because local anes- thetic from the
IANB anesthetizes the lingual nerve.
10. Withdraw the syringe slowly and make the needle safe.
11. After approximately 20 seconds, return the patient to comfortably upright or semiupright position.
12. Wait 3 to 5 minutes before testing for pulpal anesthesia.
13. Following completion of the IANB, the author strongly recommends the infiltration of approxi- mately 0.6 to 0.9 mL of
articaine hydrochloride (preferably buffered) in the buccal fold at the apex of each mandibular tooth to be treated. This
has been demonstrated to increase the success rate of IANBs (as well as other “mandibular” nerve blocks). 29 (See Chapter
20 for a more detailed dis- cussion of buffered local anesthetic solutions.)
Pterygomandibular raphe
IANB
IANB
Other Common Names
Long buccal nerve block, buccinator nerve block. Nerve
Anesthetized
Buccal nerve (a branch of the anterior division of V3). Area
Anesthetized
Soft tissues and periosteum buccal to the mandibular molar
teeth (Fig. 14.13).
Buccal Nerve
Block
▪ Other Common Names
▪ Areas Anesthetized
▪ Buccal mucous membranes anterior to the mental foramen (around the second
premolar) to the midline and skin of the lower lip (Fig. 14.28) and chin.
Thank you
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