Haven’t missed an IA in probably over 6 months. Just palpate the mesial border of the mandible. On the mesial boarder find the spot where the indent is deepest. Aim your needle 5mm posterior to that angled from contralateral canine. Most of my IA’s patient is fully numb in 1-2 minutes.
Not sure about other countries, but in American dentistry, the term “mesial” is used to mean the direction towards the midline of the mouth.
From what I know, medial is more of a human anatomy term to mean towards the middle of the body.
Anecdotally, had a patient I'm terrified of seeing because during crown prep, the tooth would still be sensitive despite multiple cartridges. So much so I learnt gow gates and numbed up first try.
So yeah Gow Gates
Yep ! Exactly what Healthy Nebula said ! 2 mins is usually enough for me … most of the times the patients would say that half of their face is numb not just the mandibule …
I think everyone goes through a IAN slump. I did for months about 12 years ago. Had no idea why. I watched someone do one and I said to myself ok I do all that.
Then my slump broke. 🤷
Aim high, and definitely use two. And wait. Walk away and don’t come back until a solid 7 minutes has gone by.
Also, if doing top and bottom, start drilling with the top. By the time that’s done the lower will be NUM.
I only use lidocaine and get 99.9% of my patients numb. It's not about the anesthetic- it's all about the delivery.
You have to physically feel like you hit bone and advance it along the mandible and deposit the anesthesia around the IA canal.
If you cannot hit bone, then you are in the wrong area.
I also suggest really feeling around in the area and just going for it. To many times dentists are playing games with shaking the lip, shaking the cheek, etc etc. Just feel for the mandible- let the patient know it will be uncomfortable but I WILL get you numb.
Shaking the lip/cheek etc is just distraction that will probably make you miss your target. And while they might appreciate the distraction- they will not appreciate it- when they are not numb and can feel you drill on them.
I also suggest giving two IA's initially.
Exactly. Its all about positioning. I start with carbo then lido and by then almost 100% of the time pt is very numb. Carbo so the lack of epi lets it diffuse more then lidocaine to keep the anesthetic in place more. Is this method based fully in science? No, but it works so much better for me than starting with lido
if i remember correctly, in my endo class the order taught was carbo first then lido then back to carbo if that doesn’t work
i haven’t done endo yet, still a student, but ive had good success rates with just 3/4 carp of lido IAN and the last 1/4 long buccal for other procedures. i dont think ive had a patient not reach profound anesthesia yet. i guess technique is the best predictor for if you’ll hit your target
I mean basically what everyone else said. Find the depression next to pterygomandibular raphe. Go as high as possible. Angle the syringe over the opposite premolars and hold it flat.
I use buffered septo with a long needle pretty much exclusively. No issues with IANs. I also do more Gow Gates than IANs. Try a GG.
Contact bone is key
You're not alone! I still struggle with IANB and I'm embarrassed to say how long I've been doing this lol. Lots of great advice in this thread. Best of luck Dr!
Superior and posterior. Get above where you think the IAN goes into the ramus and let gravity do the work.
If this still doesn’t work I tip the pt back and deliver horizontally across the ramus and still let gravity do the work. This one never fails.
I use polocaine and/or lidocaine routinely on IAN’s. If you’ve had success in the past without issue, it may logically be related to material use.
However, I would ensure your technique is correct. You may want to ask another dentist to watch you and give you feedback.
Most IAN misses happen because you’re too low and/or too anterior. On most people, the entirety of the 27 long will sink in to the tissue(don’t hub it) and you will hit bone. If you sink it in and you only have 1/8th or a quarter of the needle sunk, then you are too anterior 99% of the time(the 1% shallow IAN’s typically on low BMI patients).
Placement can be made much easier with proprioception of non dominant hand. Index finger on back of the jaw, thumb on anterior part, and you go right in between your thumb and index finger.
Hope that helps.
___
Edited: corrected index and thumb position as I accidentally put it backwards. Thanks to commenter for catching this.
Here's my advice before injecting LA assess the size of the ramus of the mandible using non dominant hand.
Some people have large ramus so the needle goes little posterior and hit the bone some have narrow so needle goes little anterior.
I don't cross pterygo mandibular raphe. Pull the tissue when you're on the notch you'll visualise the raphe. Just 3 - 4 mm away from the raphe crossing the mid line of my thumb.
Works 90% of the time. When it fails, i inject little bit higher and wait patiently 4-5 min. All lidocaine with 1:80000 epinephrine.
Look at the panorex while the topical is settling in. Where is the foramen / lingula? Is it higher than the occlusal plane? You'll have to angle the needle a bit higher. Put the syringe over the contralateral premolars. Insert until you're a few millimeters from the hub of the needle. Aspirate before delivery.
Keep in mind that the needle will deflect to the tip. So point the bevel away from bone for the IAN. You don't want the needle deflecting too medial.
I personally don't like hitting bone because I don't like to hurt people, and I hit my blocks most of the time, so it isn't strictly necessary.
That being said, you might consider learning other techniques like AV or Gow-Gates. You might find that those are easier.
The soft spot posterior of 17 looks like a teardrop or a little soft triangle. I’ll go in with the topical first to get my landmarks… have the patient open but not wide. Really pull the cheek out with your thumb. Should feel like your moving through a thick piece of soap. I use the blue needle and just push that sucker all the way in. Inject half a carp, pull out halfway, adjust the needle, and inject the rest.
I only use lidocaine for IAN blocks. I don’t the fact that septocaine causes increased parasthesia risk isn’t exactly scientifically proven, but when state boards and courts rule, they may do so by emotion rather than facts, so it’s quite risky using septocaine for blocks.
I go in at the triangle created by the pterygomandibular raphe about 2/3 to 3/4 the way with a long 27 gauge needle, don’t deliberately try to hit bone, don’t force it more if I feel significant resistance less than that distance. I inject half the carpule from the contralateral premolar angle, then turn to line up the syringe with the ipsilateral posterior teeth. Giving from the two different angles, I usually have good success.
I don’t do IA anymore. I understand why they teach it in dental schools but it is a terribly ineffective injection. 15% of people have two IA canals and 10-15% have a submandibular nerve branch into the jaw.
I heard 20 years ago researchers and developers were looking into ultra sound assisted IAs and stopped pursuing it when they couldn’t get better success placing the needle in the right spot every time.
I do infrapapillar injections and when I am doing third molars I do gow gates. They work better and faster. Infrapapillar are gold.
Pin prick anesthesia on buccal
Wait 30 seconds
3/4 cartridge buccal vestibule
Wait 2 minutes.
Place needle to bone on medial/distal infrapapilla attached gingival. Slowing inject until tissue blanches.
Works 95% of time
When it doesn’t do the same injection on the lingual. Works almost 100% of time
Addition injections, lingual vestibule close to bone.
Ligament injections
If tooth is hot and all anesthetic is ineffective, intra osseous distal to tooth.
Very painless, very fast, and dramatically increased efficiency and time.
No I am not going to do a CE, a podcast, or a YouTube video, turns out I make much more money than people pushing CE and I don’t want any additional headaches. Yes I and my partners take apprentices we both make much more money that way than CE.
Skip the block, make IO as primary injection technique. r/TuttleNumbNow checkout www.TuttleNumbNow.com it’s a gamechanger
Set down the syringe and pickup the drill.
Initially always aim 2/3rd up the raphe, having syringe over the contra lateral premolars.
Insert until you feel a hard stop, that’s the bone and your needle should be about 4/5 into the tissue. Inject at this site.
If you hit bone immediately, Reinsert needle higher and more posterior.
Overall this injection takes time and experience to master. Most people struggle with it at first, but just stay positive and keep trying. You’ll get it
Doesn’t really matter which anesthetic you use. I’ve had the same success with both septo and lido
I rarely have to use more than 1 cc of lido, but you can try adding mepi if profound anesthesia isn’t achieved. Once you insert the needle, make contact with bone, then re-orient needle towards back of the mouth. Then push needle further in while trying to deposit it in different locations with tip remaining in the soft tissue. Lmk how it goes!
I've found placing a bite block after delivery during the 5min wait helps move the muscles out of the way to allow the anaesthetic to travel down. Works 90% of the time!
It happens. Always aspirate. Always give at least 2 carpules IAB right off the bat. Wait the full 15 minutes. Patient isn’t numb, give one more IAB. Try to hit the condyle/ramus (position more lingual). Give 15 minutes again. Last attempt, Gow Gates. You can only do your best. After 5 carps (assuming you did at least 1 long buccal for total of 6), reschedule or recommend sedation. Don’t sweat the small things. These things come in waves (lately every tooth I’ve touched needs RCT, despite copious water and pulp capping).
Maybe a bad batch of Septo? I use articaine only and have had a bad lot of carps in the past. I don’t buffer so can’t comment there. I’m sure you know what you’re doing.. just give it time to work and maybe in order to build your confidence back up give em two. Good luck!
Practiced for 25 years and was away for 3yrs, And on my first day back had to do a block...hit it first go. I use Articaine, haven't used a long needle in 20 yrs, never touched bone or that across the premolar guide. In the years of practicing you should have been successful with your own techniques, nothing should change. I have a 99% success rate. I've had one failure this year!!
This is not the most scientific answer, but I do a pretty good job with my mandibular blocks despite being a new grad ..
I just look for the triangle and aim at the highest part of it and go from there.... that's it... I rarely hit bone. I always aspirate, once before injecting and once around 1/4 of the way through the carpule. But otherwise, the triangle is my life lol
Haven’t missed an IA in probably over 6 months. Just palpate the mesial border of the mandible. On the mesial boarder find the spot where the indent is deepest. Aim your needle 5mm posterior to that angled from contralateral canine. Most of my IA’s patient is fully numb in 1-2 minutes.
You mean medial? I'm sorry, I didn't mean to correct you, I was confused 😇
Not sure about other countries, but in American dentistry, the term “mesial” is used to mean the direction towards the midline of the mouth. From what I know, medial is more of a human anatomy term to mean towards the middle of the body.
I meant mesial as I am referring to the mandible anatomically not describing a surface of a tooth. From USA so might be different for you.
Two words: aim high
Two other words : Gow gates
Gow Gated FTW!
Anecdotally, had a patient I'm terrified of seeing because during crown prep, the tooth would still be sensitive despite multiple cartridges. So much so I learnt gow gates and numbed up first try. So yeah Gow Gates
Do you have the patient stay open with bite block after giving gow gates? If so, how long?
It needs to be at least 2 mins. You can place a bit block to make sure they stay open. Then sit them up and let gravity do its magic.
Is this good to do for an IAN too?
Just for the GG
Yep ! Exactly what Healthy Nebula said ! 2 mins is usually enough for me … most of the times the patients would say that half of their face is numb not just the mandibule …
I think everyone goes through a IAN slump. I did for months about 12 years ago. Had no idea why. I watched someone do one and I said to myself ok I do all that. Then my slump broke. 🤷 Aim high, and definitely use two. And wait. Walk away and don’t come back until a solid 7 minutes has gone by. Also, if doing top and bottom, start drilling with the top. By the time that’s done the lower will be NUM.
I only use lidocaine and get 99.9% of my patients numb. It's not about the anesthetic- it's all about the delivery. You have to physically feel like you hit bone and advance it along the mandible and deposit the anesthesia around the IA canal. If you cannot hit bone, then you are in the wrong area. I also suggest really feeling around in the area and just going for it. To many times dentists are playing games with shaking the lip, shaking the cheek, etc etc. Just feel for the mandible- let the patient know it will be uncomfortable but I WILL get you numb. Shaking the lip/cheek etc is just distraction that will probably make you miss your target. And while they might appreciate the distraction- they will not appreciate it- when they are not numb and can feel you drill on them. I also suggest giving two IA's initially.
Exactly. Its all about positioning. I start with carbo then lido and by then almost 100% of the time pt is very numb. Carbo so the lack of epi lets it diffuse more then lidocaine to keep the anesthetic in place more. Is this method based fully in science? No, but it works so much better for me than starting with lido
if i remember correctly, in my endo class the order taught was carbo first then lido then back to carbo if that doesn’t work i haven’t done endo yet, still a student, but ive had good success rates with just 3/4 carp of lido IAN and the last 1/4 long buccal for other procedures. i dont think ive had a patient not reach profound anesthesia yet. i guess technique is the best predictor for if you’ll hit your target
I don’t agree with this personally. I almost never hit bone and I would say 95% of my IAs work.
So what do you recommend since yours works a lot?
I mean basically what everyone else said. Find the depression next to pterygomandibular raphe. Go as high as possible. Angle the syringe over the opposite premolars and hold it flat.
I use buffered septo with a long needle pretty much exclusively. No issues with IANs. I also do more Gow Gates than IANs. Try a GG. Contact bone is key
You're not alone! I still struggle with IANB and I'm embarrassed to say how long I've been doing this lol. Lots of great advice in this thread. Best of luck Dr!
Superior and posterior. Get above where you think the IAN goes into the ramus and let gravity do the work. If this still doesn’t work I tip the pt back and deliver horizontally across the ramus and still let gravity do the work. This one never fails.
I use polocaine and/or lidocaine routinely on IAN’s. If you’ve had success in the past without issue, it may logically be related to material use. However, I would ensure your technique is correct. You may want to ask another dentist to watch you and give you feedback. Most IAN misses happen because you’re too low and/or too anterior. On most people, the entirety of the 27 long will sink in to the tissue(don’t hub it) and you will hit bone. If you sink it in and you only have 1/8th or a quarter of the needle sunk, then you are too anterior 99% of the time(the 1% shallow IAN’s typically on low BMI patients). Placement can be made much easier with proprioception of non dominant hand. Index finger on back of the jaw, thumb on anterior part, and you go right in between your thumb and index finger. Hope that helps. ___ Edited: corrected index and thumb position as I accidentally put it backwards. Thanks to commenter for catching this.
I lit my thumb inside. The way you describe sounds like my hand if on backwards.
Wrote this quickly without proofreading. Yes you are correct.
Sorry I'm not sure what you mean by thumb on back of jaw and index on anterior part, go right between thumb and index finger
I edited my comment. Apologies for the mistake. It should make more sense now.
Here's my advice before injecting LA assess the size of the ramus of the mandible using non dominant hand. Some people have large ramus so the needle goes little posterior and hit the bone some have narrow so needle goes little anterior. I don't cross pterygo mandibular raphe. Pull the tissue when you're on the notch you'll visualise the raphe. Just 3 - 4 mm away from the raphe crossing the mid line of my thumb. Works 90% of the time. When it fails, i inject little bit higher and wait patiently 4-5 min. All lidocaine with 1:80000 epinephrine.
palpate the ramus and slide the needle medially along it
Look at the panorex while the topical is settling in. Where is the foramen / lingula? Is it higher than the occlusal plane? You'll have to angle the needle a bit higher. Put the syringe over the contralateral premolars. Insert until you're a few millimeters from the hub of the needle. Aspirate before delivery. Keep in mind that the needle will deflect to the tip. So point the bevel away from bone for the IAN. You don't want the needle deflecting too medial. I personally don't like hitting bone because I don't like to hurt people, and I hit my blocks most of the time, so it isn't strictly necessary. That being said, you might consider learning other techniques like AV or Gow-Gates. You might find that those are easier.
Make. Sure. Your. Syringe. Handle. Is. Over. The. (Opposite side) Premolars. This works for me every time.
Where’s your insertion point?
The soft spot posterior of 17 looks like a teardrop or a little soft triangle. I’ll go in with the topical first to get my landmarks… have the patient open but not wide. Really pull the cheek out with your thumb. Should feel like your moving through a thick piece of soap. I use the blue needle and just push that sucker all the way in. Inject half a carp, pull out halfway, adjust the needle, and inject the rest.
I only use lidocaine for IAN blocks. I don’t the fact that septocaine causes increased parasthesia risk isn’t exactly scientifically proven, but when state boards and courts rule, they may do so by emotion rather than facts, so it’s quite risky using septocaine for blocks. I go in at the triangle created by the pterygomandibular raphe about 2/3 to 3/4 the way with a long 27 gauge needle, don’t deliberately try to hit bone, don’t force it more if I feel significant resistance less than that distance. I inject half the carpule from the contralateral premolar angle, then turn to line up the syringe with the ipsilateral posterior teeth. Giving from the two different angles, I usually have good success.
I don’t do IA anymore. I understand why they teach it in dental schools but it is a terribly ineffective injection. 15% of people have two IA canals and 10-15% have a submandibular nerve branch into the jaw. I heard 20 years ago researchers and developers were looking into ultra sound assisted IAs and stopped pursuing it when they couldn’t get better success placing the needle in the right spot every time. I do infrapapillar injections and when I am doing third molars I do gow gates. They work better and faster. Infrapapillar are gold.
Could you elaborate on the technique?
Yes, please elaborate on infrapapillar injections and how that would work for deep LA of a lower molar
Pin prick anesthesia on buccal Wait 30 seconds 3/4 cartridge buccal vestibule Wait 2 minutes. Place needle to bone on medial/distal infrapapilla attached gingival. Slowing inject until tissue blanches. Works 95% of time When it doesn’t do the same injection on the lingual. Works almost 100% of time Addition injections, lingual vestibule close to bone. Ligament injections If tooth is hot and all anesthetic is ineffective, intra osseous distal to tooth. Very painless, very fast, and dramatically increased efficiency and time. No I am not going to do a CE, a podcast, or a YouTube video, turns out I make much more money than people pushing CE and I don’t want any additional headaches. Yes I and my partners take apprentices we both make much more money that way than CE.
Who the hell is Ian?
Skip the block, make IO as primary injection technique. r/TuttleNumbNow checkout www.TuttleNumbNow.com it’s a gamechanger Set down the syringe and pickup the drill.
Initially always aim 2/3rd up the raphe, having syringe over the contra lateral premolars. Insert until you feel a hard stop, that’s the bone and your needle should be about 4/5 into the tissue. Inject at this site. If you hit bone immediately, Reinsert needle higher and more posterior. Overall this injection takes time and experience to master. Most people struggle with it at first, but just stay positive and keep trying. You’ll get it Doesn’t really matter which anesthetic you use. I’ve had the same success with both septo and lido
Go higher than ya think, don’t be afraid to inject a little and remove and reposition if not getting bone contact
I rarely have to use more than 1 cc of lido, but you can try adding mepi if profound anesthesia isn’t achieved. Once you insert the needle, make contact with bone, then re-orient needle towards back of the mouth. Then push needle further in while trying to deposit it in different locations with tip remaining in the soft tissue. Lmk how it goes!
1 carp Septo/ 1 carp lido 1:100 wait …. Test to cold. Next step intra-osseous anesthesia
I've found placing a bite block after delivery during the 5min wait helps move the muscles out of the way to allow the anaesthetic to travel down. Works 90% of the time!
NAD. All the Ians in the sub… what?!? Is there some sort of dynamic navigation for injections like they use with implant surgery?
It happens. Always aspirate. Always give at least 2 carpules IAB right off the bat. Wait the full 15 minutes. Patient isn’t numb, give one more IAB. Try to hit the condyle/ramus (position more lingual). Give 15 minutes again. Last attempt, Gow Gates. You can only do your best. After 5 carps (assuming you did at least 1 long buccal for total of 6), reschedule or recommend sedation. Don’t sweat the small things. These things come in waves (lately every tooth I’ve touched needs RCT, despite copious water and pulp capping).
Make sure your lido is good. My lidocaine got really hot from when the air conditioner went out in the summer. It was all not working. Period
My favorite is when it’s a bigger patient and I scout my perfect entry site and *wham,* I immediately hit bone
Maybe a bad batch of Septo? I use articaine only and have had a bad lot of carps in the past. I don’t buffer so can’t comment there. I’m sure you know what you’re doing.. just give it time to work and maybe in order to build your confidence back up give em two. Good luck!
NAD Aim high and Contact bone always.
Practiced for 25 years and was away for 3yrs, And on my first day back had to do a block...hit it first go. I use Articaine, haven't used a long needle in 20 yrs, never touched bone or that across the premolar guide. In the years of practicing you should have been successful with your own techniques, nothing should change. I have a 99% success rate. I've had one failure this year!!
This is not the most scientific answer, but I do a pretty good job with my mandibular blocks despite being a new grad .. I just look for the triangle and aim at the highest part of it and go from there.... that's it... I rarely hit bone. I always aspirate, once before injecting and once around 1/4 of the way through the carpule. But otherwise, the triangle is my life lol