Inferior alveolar and lingual nerve blocks
The administration of the inferior alveolar and lingual nerve block is easier to perform
successfully in children compared to adults. A common fault in adults is placing the
needle too low on the ramus of the mandible with deposition of solution inferior to the
mandibular foramen. In children, the mandibular foramen is low in relation to the
occlusal plane (170HFig. 5.3), and it is difficult to place the needle inferior to the
mandibular foramen if it is introduced parallel to the occlusal plane. Thus in children
it is easier to ensure that the solution is deposited around the nerve before it enters the
mandibular canal. The technique of administration is identical to that used in adults
and is best performed with the child's mouth fully open. The direct
approach⎯introducing the needle from the primary molars of the opposite side⎯is
recommended as less needle movement is required after tissue penetration with this
method compared to the indirect technique. The operator's non-dominant hand
supports the mandible with the thumb intraorally in the retromolar region of the
mandible. The index or middle finger is placed extraorally at the posterior border of
the ramus at the same height as the thumb. The needle is advanced from the primary
molar region of the opposite side with the syringe held parallel to the mandibular
occlusal plane. The needle is inserted through mucosa in the mandibular retromolar
region lateral to the ptery-gomandibular raphe midway between the raphe and the
anterior border of the ascending ramus of the mandible, aiming for a point halfway
between the operator's thumb and index finger. The height of insertion is about 5 mm
above the mandibular occlusal plane, although in young children entry at the height of
the occlusal plane should also be successful. The needle should be advanced until the
medial border of the mandible is reached. In young children bone will be reached
after about 15 mm and thus a 25-mm needle can be used; however, in older children a
long (35 mm) needle should be employed as penetration up to 25 mm may be
required. Once bone has been touched the needle is withdrawn slightly until it is
supraperiosteal, aspiration is performed, and 1.5 ml of solution deposited. The lingual
nerve is blocked by withdrawing the needle halfway, aspirating again, and depositing
most of the remaining solution at this point. The final contents of the cartridge are
expelled as the needle is withdrawn through the tissues. A common fault is to contact
bone only a few millimetres following insertion. In most children this will lead to
unsuccessful anaesthesia. This usually occurs due to entry at too obtuse an angle. If
this occurs the needle should not be completely withdrawn but pulled back a couple of
millimetres, and then advanced parallel to the ramus for about 1 cm with the barrel of
the syringe over the mandibular teeth of the same side. The body of the syringe is then
repositioned across the primary molars or premolars of the opposite side and
advanced towards the medial border of the ramus.
Long buccal, mental, and incisive nerve blocks
The long buccal injection usually equates to a buccal infiltration in children. The
mental and incisive nerve block is readily administered in children as the orientation
of the mental foramen is such that it faces forward rather than posteriorly as in adults
(171HFig. 5.4). Thus it is easier for solution to diffuse through the foramen when
approached from an anterior direction. The needle is advanced in the buccal sulcus
and directed towards the region between the first and second primary molar apices.
Blockade of transmission in the mental nerve provides excellent soft tissue
anaesthesia; however, anaesthesia of the incisive nerve (which supplies the dental