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Becoming a Clinical Master: Perfecting Your IA Injections

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    Everyone who's experienced their first “stab lab” knows that injections can be nerve-racking the first few times around. There is a lot going on and, when you have a real patient in the chair, the complexity of the situation increases even more. In order to successfully practice “pain-free dentistry,” it is essential that you learn to be systematic and consistent in your local anesthetic administration. 


    The inferior alveolar (IA) nerve block is arguably the most critical injection to master, as it is more technique-sensitive than simple periosteal “infiltrations.” It must be used anytime invasive dentistry is being performed anywhere on the mandible. Even for experienced dentists, achieving profound anesthesia with an IA can be less than straightforward—with failure rates ranging from 5% to 30% depending on the design of the study1 


    It is imperative that you are well-acquainted with intraoral anatomy if you are to be successful in administering an effective IA block. However, this will only get you so far, as every patient varies anatomically. For example, if you are attempting to administer a block on a patient with drastically flared mandibular rami, there will be a certain amount of impromptu adjustment required before you will be able to locate the mandibular foramen and deliver the anesthetic.


Here are some tips to help you perform a successful and comfortable IA block:


     1. Palpation is key. Do not put a needle in the patient's mouth until you have palpated and identified the key anatomical landmarks.

          A.Palpate the mid-coronoid notch. This landmark determines the level on the axial plane at which you will insert the needle.

          B. Palpate the pterygomaxillary raphe. Insert the needle just lateral to this border, at the level of the notch.

   2. Ensure that the window of the syringe is facing towards you. If not, you will be unable to visualize aspirate. 

     3. Ensure that the bevel of the needle is towards bone. If you are not depositing your anesthetic towards the mandibular canal, you will have a lesser chance of delivering enough anesthetic to properly block the nerve.

     4. Be aware of your angulation. Start out with the barrel of your syringe just over the contralateral mandibular premolars, just above the occlusal plane. In many cases you will have to adjust the angulation, but this is the most reliable starting point.

     5. Don’t forget to aspirate prior to injecting! Never inject without first achieving a negative aspiration. You DO NOT want to inject the local anesthetic intravascularly!

     6. Patient comfort is the main goal. You can perform a perfect injection, but if the patient is in pain the entire time they will not appreciate it. Stable and gentle needle control and tugging on the cheek during administration will help keep the patient comfortable.


    It’s my hope that you’ll keep this advice in mind and be a bit more confident the next time you deliver an IA block. Also, always keep in mind that a calm and collected demeanor goes a long way in assuring your patient that there is nothing to worry about. Happy anesthetizing!


1. Milles M. The missed inferior alveolar block: a new look at an old problem. Anesth Prog. 1984 Mar-Apr; 31(2):87–90.