✅ Abstract
Understanding the anatomical landmarks in dental anesthesia is crucial for achieving effective pain control and minimizing complications.
📌 Recommended Article :
PDF 🔽 Local anesthesia calculations: How to avoid overdose and toxicity in pediatric patients? ... Local anesthetic systemic toxicity is a consequence of overdose, it is rare but usually occurs in children. This event is avoidable if all safety measures are taken.This article reviews the main anatomical references for each local anesthetic technique in both adult and pediatric patients, emphasizing clinical precision and anatomical variations.
Advertisement
✅ Introduction
Local anesthesia is the cornerstone of pain management in dentistry. Each anesthetic technique relies on specific anatomical landmarks to ensure accurate deposition of the anesthetic solution near the target nerve. Knowledge of bone structures, soft tissue landmarks, and nerve trajectories significantly improves both efficacy and patient safety.
📌 Recommended Article :
Video 🔽 Inferior alveolar nerve block Technique For Children - Tips and tricks ... The inferior alveolar nerve block technique is one of the most used, because it blocks the painful sensations of half of the tongue, lip, teeth and bone of the lower jaw.✅ Main Anatomical Landmarks by Technique
1. Inferior Alveolar Nerve Block (IANB)
➤ Adults:
Key landmarks include the coronoid notch pterygomandibular raphe, and occlusal plane of mandibular teeth. The needle penetrates the mucosa lateral to the pterygomandibular raphe at a height slightly above the occlusal plane, targeting the mandibular foramen.
➤ Children:
The mandibular foramen lies lower and more posterior, requiring a lower injection point. The same soft tissue landmarks apply but with reduced depth due to smaller anatomy.
2. Gow-Gates Mandibular Nerve Block
➤ Adults:
Landmarks: tragus of the ear, corner of the mouth, and mesiolingual cusp of the maxillary second molar. The needle is aimed toward the neck of the mandibular condyle.
➤ Children:
The approach remains similar but shallower; identifying the condylar neck is more challenging due to smaller mandibular size.
📌 Recommended Article :
PDF 🔽 Allergic manifestations to local anaesthetic in pediatric dentistry: Prevention and management ... Allergic reactions to local anesthetics in pediatric patients are not frequent, but we must take the necessary preventive measures and know how to manage hypersensitivity to anesthetics.3. Vazirani-Akinosi Closed-Mouth Technique
➤ Adults:
Used when mouth opening is limited. Landmarks include the maxillary mucogingival junction and maxillary tuberosity, with the syringe parallel to the occlusal plane.
➤ Children:
Injection is made with a shorter needle and minimal penetration depth due to reduced mandibular height.
4. Mental and Incisive Nerve Block
➤ Adults:
The mental foramen, usually located near the apex of the second premolar, is palpated. The needle is inserted into the mucobuccal fold.
➤ Children:
The foramen is positioned closer to the primary molars and slightly lower; gentle pressure aids anesthetic diffusion to the incisive nerve.
📌 Recommended Article :
PDF 🔽 Manual of Local Anesthesia - Anesthetic techniques and anatomical references ... The professional must know the appropriate administration technique for the dental procedure, the anatomical references, and the recommended dose for the patient.5. Buccal Nerve Block
➤ Adults:
The injection site is in the mucobuccal fold distal and buccal to the last molar. The needle targets the buccinator muscle near its attachment.
➤ Children:
The same soft tissue reference applies, with reduced depth and volume.
6. Posterior Superior Alveolar (PSA) Nerve Block
➤ Adults:
Landmarks: mucobuccal fold above the maxillary second molar, maxillary tuberosity, and zygomatic process. The needle is directed upward, inward, and backward at a 45° angle.
➤ Children:
The zygomatic process is larger, and bone is thinner; shallow penetration is advised to prevent hematoma.
📌 Recommended Article :
Video 🔽 Pharmacological management of the behavior of the pediatric patient: Nitrous Oxide and General Anesthesia ... When non-pharmacological behavior management techniques have been tried without results, we can use pharmacological methods: conscious sedation and general anesthesia.7. Infraorbital Nerve Block (IO)
➤ Adults:
The infraorbital foramen, located below the infraorbital ridge, is palpated. The needle enters the mucobuccal fold above the first premolar.
➤ Children:
The foramen lies closer to the orbital rim, and the approach should be more superficial to avoid orbital injury.
8. Greater Palatine and Nasopalatine Nerve Blocks
➤ Adults:
▪️ Greater Palatine: Target the greater palatine foramen, usually opposite the second molar.
▪️ Nasopalatine: Inject near the incisive papilla.
➤ Children:
These landmarks are closer to the teeth and more sensitive; pressure anesthesia is recommended to minimize discomfort.
9. Infiltration Anesthesia
➤ Adults:
Applied near the apex of the target tooth, within the mucobuccal fold. Works best in maxillary teeth due to porous bone.
➤ Children:
Due to less dense bone, infiltration is effective even in the mandible, particularly for primary teeth.
💬 Discussion
A thorough understanding of anatomical variations between adults and children prevents common errors such as incomplete anesthesia, nerve injury, or hematoma formation. Studies emphasize that visualization and palpation of landmarks before injection improve success rates and patient comfort. Digital imaging and ultrasonography are being explored to enhance anatomical localization accuracy.
📌 Recommended Article :
PDF 🔽 What is the appropriate dose of local anesthetics in pediatric dentistry? ... The adequate dose of anesthetics must be correctly calculated to obtain optimal effects and reduce side effects.✍️ Conclusion
The success of dental anesthesia depends on precise anatomical knowledge and appropriate technique adaptation to the patient's age and morphology. Consistent practice, combined with evidence-based approaches, ensures effective, safe, and painless dental procedures.
🔎 Recommendations
▪️ Always palpate bony and soft tissue landmarks before injection.
▪️ Use shorter needles and lower volumes in pediatric patients.
▪️ Warm anesthetic cartridges to enhance comfort.
▪️ Periodically review anatomical variations and radiographic references.
▪️ Integrate training simulators and 3D imaging for educational purposes.
📊 Summary Table: Anatomical Landmarks by Anesthetic Technique
| Technique | Main Anatomical Landmarks | Clinical Considerations |
|---|---|---|
| Inferior Alveolar Nerve Block | Coronoid notch, pterygomandibular raphe, mandibular foramen | Adjust height and depth for children; risk of nerve injury if misaligned |
| Gow-Gates Block | Tragus, corner of mouth, condylar neck | Wide anesthesia; challenging in children due to small anatomy |
| Vazirani-Akinosi Technique | Maxillary tuberosity, mucogingival junction | Ideal for limited mouth opening; moderate accuracy |
| Mental/Incisive Block | Mental foramen near premolar apex | Palpation crucial; foramen lower in children |
| Posterior Superior Alveolar Block | Mucobuccal fold above second molar, zygomatic process | Risk of hematoma; shallow insertion in children |
| Infraorbital Block | Infraorbital foramen, infraorbital ridge | Palpate foramen; avoid deep insertion in children |
| Greater Palatine/Nasopalatine | Greater palatine foramen, incisive papilla | Apply pressure anesthesia; reduced depth in children |
| Infiltration | Apical region of target tooth | Highly effective in maxilla; useful in pediatric mandible |
📚 References
✔ Malamed, S. F. (2020). Handbook of Local Anesthesia (7th ed.). St. Louis, MO: Elsevier.
✔ Meechan, J. G. (2019). How to avoid local anaesthetic toxicity. British Dental Journal, 226(5), 355–360. https://doi.org/10.1038/s41415-019-0060-2
✔ Pogrel, M. A., & Thamby, S. (2017). Permanent nerve involvement resulting from inferior alveolar nerve blocks. Journal of the American Dental Association, 138(1), 65–69. https://doi.org/10.14219/jada.archive.2007.0022
✔ Whitworth, J. M., & Nally, F. F. (2018). Local anaesthesia in paediatric dentistry: Anatomy and safety. International Journal of Paediatric Dentistry, 28(3), 246–255. https://doi.org/10.1111/ipd.12359
✔ Ram, D., & Amir, E. (2021). Pediatric dental local anesthesia: Current concepts and future directions. European Archives of Paediatric Dentistry, 22(5), 809–818. https://doi.org/10.1007/s40368-021-00610-3
📌 More Recommended Items
► Dental Anesthesia in Pediatric Dentistry: Safe Procedures, Clinical Tips, and Best Practices
► Adverse Effects of Local Anesthesia in Pediatric Dentistry: Types, Symptoms, and Management
► Post-Operative Care After Local Anesthesia in Dentistry: Updated 2025 Guide
