Dear Author,

Here are the proofs of your article.

• You can submit your corrections online, via e-mail or by fax.

• For online submission please insert your corrections in the online correction form. Alwaysindicate the line number to which the correction refers.

• You can also insert your corrections in the proof PDF and email the annotated PDF.

• For fax submission, please ensure that your corrections are clearly legible. Use a fine blackpen and write the correction in the margin, not too close to the edge of the page.

• Remember to note the journal title, article number, and your name when sending yourresponse via e-mail or fax.

• Check the metadata sheet to make sure that the header information, especially author namesand the corresponding affiliations are correctly shown.

• Check the questions that may have arisen during copy editing and insert your answers/corrections.

• Check that the text is complete and that all figures, tables and their legends are included. Alsocheck the accuracy of special characters, equations, and electronic supplementary material ifapplicable. If necessary refer to the Edited manuscript.

• The publication of inaccurate data such as dosages and units can have serious consequences.Please take particular care that all such details are correct.

• Please do not make changes that involve only matters of style. We have generally introducedforms that follow the journal’s style.Substantial changes in content, e.g., new results, corrected values, title and authorship are notallowed without the approval of the responsible editor. In such a case, please contact theEditorial Office and return his/her consent together with the proof.

• If we do not receive your corrections within 48 hours, we will send you a reminder.

• Your article will be published Online First approximately one week after receipt of yourcorrected proofs. This is the official first publication citable with the DOI. Further changesare, therefore, not possible.

• The printed version will follow in a forthcoming issue.

Please note

After online publication, subscribers (personal/institutional) to this journal will have access to thecomplete article via the DOI using the URL: http://dx.doi.org/[DOI].If you would like to know when your article has been published online, take advantage of our freealert service. For registration and further information go to: http://www.springerlink.com.

Due to the electronic nature of the procedure, the manuscript and the original figures will only bereturned to you on special request. When you return your corrections, please inform us if you wouldlike to have these documents returned.

Metadata of the article that will be visualized in OnlineFirst

ArticleTitle Mandibular block success rate in relation to needle insertion and position: a self-report survey

Article Sub-Title

Article CopyRight European Academy of Paediatric Dentistry(This will be the copyright line in the final PDF)

Journal Name European Archives of Paediatric Dentistry

Corresponding Author Family Name AshkenaziParticle

Given Name MalkaSuffix

Division

Organization Pediatric Dentistry Dental Clinic

Address 7A Haim Gilad St, Petach-Tikva, 49377, Israel

Email Malka.ashkenazi@gmail.com

Author Family Name SherParticle

Given Name ItzhakSuffix

Division

Organization The Hebrew University, Hadassah School of Dental Medicine

Address Jerusalem, Israel

Email

Author Family Name RackozParticle

Given Name MeirSuffix

Division Division of Pediatric and Hospital Dentistry

Organization The Chaim Sheba Medical Center

Address Tel Hashomer, Israel

Email

Author Family Name Schwartz-AradParticle

Given Name DevorahSuffix

Division The Day-Care Surgical Center, Oral and Maxillofacial Surgery

Organization Advanced Implantology, Periodontology and Endodontology

Address Ramat Hasharon, Israel

Email

Schedule

Received 19 June 2013

Revised

Accepted 17 July 2013

Abstract Aim:

To evaluate possible associations between successful mandibular block injection and location of penetratingthe oral mucosa, location of injection on the ramus and the needle insertion length.Study design:The study consisted of 101 dentists, of whom, 33 were oral surgeons, 33 certified paediatric dentists and 35general dental practitioners. The dentists were asked to estimate their rate of success in mandibular blockinjections, defined as the proportion of their patients for whom only a single carpule is necessary, and toindicate the needle insertion length and the location of the injection on a photograph of a ramus and on aphotograph of oral mucosa.Results:Injecting a single carpule for achieving full anaesthesia in 90 % or more of their patients was reported by 79.3and 57.8 % of the dentists treating children and adults, respectively. Of practitioners treating children,experienced dentists (>5 years in occupation) reported higher success rates than did inexperienced ones(p = 0.05). A positive correlation was found between failure rate reported in children, shorter length of theinserted needle (R = 0.356, p = 0.001) and injecting at the central (superior inferior dimension) most anteriorquarters of the ramus (p = 0.006; odd ratio = 3.9375). Routine waiting period of more than 5 min after theinjection and before operative treatment was associated with higher rates of failure (p = 0.042, χ2 = 6.335).No correlation was found between the success rates of mandibular block injection and the location ofpenetrating the oral mucosa in children (p = 0.94), adults (p = 0.57), or between success rates and the targetlocation on the ramus in adults (p = 0.42).Statistic:χ2 test was used to determine the significance of differences among proportions and t test for continuousvariables. Pearson’s correlation analysis was used to analyse the correlation between the length of the needleinserted in children and adults by the same dentist.Conclusion:Shorter needle insertion lengths and targeting the injecting to the most anterior quarters of the ramus werepositively correlated with failure of anaesthesia in children, according to dentists’ reports. A routine waitingperiod of over 5 min did not increase the success rates of mandibular block injection.

Keywords (separated by '-') Inferior alveolar nerve - Injection - Local anaesthesia

Footnote Information

UNCORRECTEDPROOF

ORIGINAL ARTICLE1

2 Mandibular block success rate in relation to needle insertion

3 and position: a self-report survey

4 Malka Ashkenazi • Itzhak Sher • Meir Rackoz •

5 Devorah Schwartz-Arad

6 Received: 19 June 2013 / Accepted: 17 July 20137 � European Academy of Paediatric Dentistry 2013

8 Abstract

9 Aim To evaluate possible associations between successful

10 mandibular block injection and location of penetrating the

11 oral mucosa, location of injection on the ramus and the

12 needle insertion length.

13 Study design The study consisted of 101 dentists, of

14 whom, 33 were oral surgeons, 33 certified paediatric den-

15 tists and 35 general dental practitioners. The dentists were

16 asked to estimate their rate of success in mandibular block

17 injections, defined as the proportion of their patients for

18 whom only a single carpule is necessary, and to indicate

19 the needle insertion length and the location of the injection

20 on a photograph of a ramus and on a photograph of oral

21 mucosa.

22 Results Injecting a single carpule for achieving full

23 anaesthesia in 90 % or more of their patients was reported

24 by 79.3 and 57.8 % of the dentists treating children and

25 adults, respectively. Of practitioners treating children,

26 experienced dentists ([5 years in occupation) reported

27higher success rates than did inexperienced ones

28(p = 0.05). A positive correlation was found between

29failure rate reported in children, shorter length of the

30inserted needle (R = 0.356, p = 0.001) and injecting at the

31central (superior inferior dimension) most anterior quarters

32of the ramus (p = 0.006; odd ratio = 3.9375). Routine

33waiting period of more than 5 min after the injection and

34before operative treatment was associated with higher rates

35of failure (p = 0.042, v2 = 6.335).

36No correlation was found between the success rates of

37mandibular block injection and the location of penetrating

38the oral mucosa in children (p = 0.94), adults (p = 0.57),

39or between success rates and the target location on the

40ramus in adults (p = 0.42).

41Statistic v2 test was used to determine the significance of

42differences among proportions and t test for continuous

43variables. Pearson’s correlation analysis was used to ana-

44lyse the correlation between the length of the needle

45inserted in children and adults by the same dentist.

46Conclusion Shorter needle insertion lengths and targeting

47the injecting to the most anterior quarters of the ramus were

48positively correlated with failure of anaesthesia in children,

49according to dentists’ reports. A routine waiting period of

50over 5 min did not increase the success rates of mandibular

51block injection.

52

53Keywords Inferior alveolar nerve � Injection �

54Local anaesthesia

55Introduction

56The inferior alveolar nerve block, also known as mandib-

57ular block injection (MBI) is the procedure most routinely

58used for anesthetizing mandibular posterior teeth, yet the

A1 M. Ashkenazi (&)

A2 Pediatric Dentistry Dental Clinic, 7A Haim Gilad St,

A3 Petach-Tikva 49377, Israel

A4 e-mail: Malka.ashkenazi@gmail.com

A5 I. Sher

A6 The Hebrew University, Hadassah School

A7 of Dental Medicine, Jerusalem, Israel

A8 M. Rackoz

A9 Division of Pediatric and Hospital Dentistry, The Chaim Sheba

A10 Medical Center, Tel Hashomer, Israel

A11 D. Schwartz-Arad

A12 The Day-Care Surgical Center, Oral and Maxillofacial Surgery,

A13 Advanced Implantology, Periodontology and Endodontology,

A14 Ramat Hasharon, Israel

123Journal : Large 40368 Dispatch : 23-7-2013 Pages : 6

Article No. : 73h LE h TYPESET

MS Code : EAPD-D-13-00084 h CP h DISK4 4

Eur Arch Paediatr Dent

DOI 10.1007/s40368-013-0073-0

Au

tho

r P

ro

of

UNCORRECTEDPROOF

59 documented success rate is only 63–87 % (Kaufman et al.

60 1984; Childers et al. 1996). To achieve complete anaes-

61 thesia, the local anesthetic solution should be delivered as

62 close as possible to the mandibular foramen (MF). How-

63 ever, researchers disagree on the exact location of the MF

64 in the anteroposterior dimension. Although approximately

65 half of the studies on adults show that the MF is located

66 posterior to the mid-line of the ramus (Hayward et al. 1977;

67 Hetson et al. 1988; da Fontoura et al. 2002; Fujimura et al.

68 2006; Ashkenazi et al. 2011), the other half positions it at

69 the mid-line of the ramus (Sweet 1943; Monheim 1969;

70 Weiss 1972; Ricketts 1975; Nicholson 1985). Moreover,

71 there is disagreement regarding the existence and degree of

72 positional changes of the MF in the anteroposterior

73 dimension during child development. Changes during

74 childhood in the MF location of the anteroposterior

75 dimension have been evaluated in only four studies. In a

76 study conducted in the United States, analysing cephalo-

77 metric radiographs, the percent of depth of the MF between

78 the anterior and posterior areas of the ramus did not change

79 significantly with age (Benham 1976). In contrast, Tsai

80 (2002, 2004) reported, in a Taiwanese population, that the

81 MF moves anteriorly with age. Harrison (1948) concluded

82 from measurements of 51 developing mandibles [15 with

83 primary dentition (age up to 6 years), 29 with mixed

84 dentition (6–13 years), and 7 with permanent dentition],

85 that the length of the posterior ramus increased with age

86 from an average of 9 mm in primary dentition to 16 mm in

87 permanent dentition. Nevertheless, she stated that tech-

88 niques for inferior alveolar injection should not rely on

89 fixed measurements for obtaining either the correct inser-

90 tion point or the depth of insertion of the needle necessary

91 to reach the sulcus. In a recent analysis of 121 dry man-

92 dibles with primary, mixed and permanent dentitions,

93 Ashkenazi et al. (2011) found that the MF distance from

94 the posterior border of the ramus increased significantly

95 with age by 66 % from the primary (mean of 7.75 mm) to

96 permanent dentition stage (mean of 12.9 mm) (p\ 0.001).

97 Based on the available data, Malamed (2004) and

98 McDonald et al. (2004) recommended injecting the man-

99 dibular block more posteriorly in children than in adults.

100 Although Pinkham et al. (2005) mentioned that the MF is

101 located at the mid-line of the ramus and changes with age,

102 they did not detail the change.

103 The length of the needle that should be inserted in the

104 tissue during mandibular block injection is recognised as

105 important for precise location of the MF; however, there is

106 also disagreement in the literature in this regard. Malamed

107 (2004) recommended inserting a 20–25 mm long needle to

108 a depth of about 2/3 to 3/4 its total length. McDonald

109 (2004) recommended inserting 15 mm of the needle’s

110 length, and Jorgensen and Hayden (1980) did not mention

111 the needle’s length at all. No study has been performed to

112evaluate the relationship of needle insertion length and

113successful anaesthesia.

114The aims of the present study were to examine possible

115associations between the success rate of mandibular block

116injection and needle insertion length, the site target of

117penetration in the oral mucosa and the site of injection on

118the ramus, according to a self-report survey.

119Materials and methods

120A total of 101 dentists participated in the present study. Of

121whom, 33 were certified oral surgeons, 33 certified paedi-

122atric dentists and 35 general dental practitioners. A struc-

123tured anonymous questionnaire was designed to assess

124demographic details including age, gender, number of

125years from graduation, post-graduation specialty, number

126of years from completing specialty or from graduation, age

127of patient population (children or/and adults). An experi-

128enced practitioner was defined as one who has been prac-

129ticing for at least 5 years.

130The dentists were asked to mark on photographs the

131length of the needle they usually inserted into the oral

132mucosa during mandibular block injection and the location

133of the injection on the oral mucosa (Fig. 1) and on the

134ramus (Fig. 2). The illustrations of the needles (short and

135long) were in 1:1 dimension. To estimate the location of

136injection on the oral mucosa and the ramus, the dentist

137received a picture of the oral mucosa and a ramus (without

138the MF, which was erased by Photoshop); the sites of

139injection in the oral mucosa and the ramus were marked

140with grid lines. The ramus was divided into four quarters in

141anterior posterior dimension and in vertical dimension

Fig. 1 Illustration of oral mucosa for indicating the site of injection

during mandibular block anaesthesia

Eur Arch Paediatr Dent

123Journal : Large 40368 Dispatch : 23-7-2013 Pages : 6

Article No. : 73h LE h TYPESET

MS Code : EAPD-D-13-00084 h CP h DISK4 4

Au

tho

r P

ro

of

UNCORRECTEDPROOF

142 (total 16 squares). Dentists who treat both children and

143 adults were asked to mark the length of the inserted needle

144 and the location of injection on the oral mucosa and on the

145 ramus on two different illustrations (Figs. 1, 2).

146 Dentists were asked to report separately for children and

147 for adults, the duration of time they waited from comple-

148 tion of the injection until initiation of treatment, to estimate

149 the percent of their patients for whom the injection of only

150 one carpule suffices for achieving full anaesthesia with

151 MBI, and to estimate the frequency that they interpreted a

152 complaint of pain as pressure sensation.

153 The present study was approved by the ethics committee

154 of the Chaim Sheba Medical Center, Tel Hashomer, Israel.

155 Statistical analysis

156 We performed univariant analysis using the v2 test to

157 determine the significance of differences among propor-

158 tions (location of injection, gender) and Student’s t test for

159 continuous variables (success in anesthesia, years of work,

160 length of needle). Pearson’s correlation analysis was used

161 to analyse the correlation between the length of the needle

162 inserted in children and adults by the same dentist.

163 The data were analysed by SPSS 10.0 (SPSS, Inc.,

164 Chicago, IL, USA).

165 Results

166 Study population

167 The study included 101 dentists, of whom 59 (58.4 %)

168 were males and 42 (41.6 %) females. The mean ± SD age

169 of the dentists was 42.9 ± 10.4 (range 26–72 years).

170 Duration of practice was 15.5 ± 10.5 (range 1–46 years).

171 Of them, 30 (29.7 %) reported that they treat only children,

172 20 (19.8 %) only adults and 51 (50.5 %) both children and

173adults. Thirty-five were general practitioners, 33 paediatric

174dentists and 33 oral surgeons.

175Success rate for achieving full anaesthesia

176The distribution of dentists who reported injecting more

177than one carpule to achieve full anaesthesia in mandibular

178block injection is presented in Fig. 3.

179Of the 81 dentists, who treat children, 64 (79 %)

180reported successful rates of anaesthesia (1 carpule sufficed

181for achieving full anaesthesia in at least 90 % of their

182patients), compared with 41 of 71 (57.8 %) of the dentists

183who treat adults. Considering only paediatric dentists and

184general practitioners, and not the oral surgeons, the success

185rate increased to 82.1 % (46/56) for dentists, who treat

186children and 64.0 % (32/50) for those who treat adults.

187Of the dentists participating in the study, 36 (35.6 %)

188reported that they interpreted a complaint of pain as a

189sensation of pressure in more than 10 % of their cases.

190Correlation between the location of the penetration

191of the oral mucosa and successful anaesthesia in MBI

192The distribution of dentists penetrating different locations

193in the oral mucosa during mandibular block delivery is

194presented in Fig. 4. More dentists reported penetrating the

195oral mucosa in the anterior half of the chart (62 vs. 30 %)

196and in the lower half of the chart (67 vs. 39 %) when

197treating children than adults (Fig. 4). No correlation was

198found between the reported location of penetration in the

199oral mucosa and reported successful rates of anaesthesia

200(injection of only 1 carpule for achieving full anaesthesia in

201at least 90 % of their patients following MBI) for children

202(N = 81, p = 0.94) and for adults (N = 71, p = 0.57).

Fig. 2 Illustration of mandibular ramus for indicating the site of

injection during mandibular block anaesthesia

Fig. 3 Distribution of dentists (%) injecting more than one carpule

for achieving full anaesthesia in mandibular block injection in

children and adults

Eur Arch Paediatr Dent

123Journal : Large 40368 Dispatch : 23-7-2013 Pages : 6

Article No. : 73h LE h TYPESET

MS Code : EAPD-D-13-00084 h CP h DISK4 4

Au

tho

r P

ro

of

UNCORRECTEDPROOF

203 Correlation between the target location of the injection

204 on the ramus and successful anaesthesia in MBI

205 The distribution of dentists injecting the local anesthetic

206 solution in different locations on the mandibular ramus is

207 presented in Fig. 5. Although most of the dentists who treat

208 children and adults (57 and 78 %, respectively) target their

209 injection to the area covered by the four central squares of

210 the chart, about 25 % of the dentists who treat children

211 target their injection more anteriorly. In adults, no corre-

212 lation was found between the target location of injection on

213 the ramus and reported successful anaesthesia (N = 71,

214 p = 0.42). When treating children, a statistically signifi-

215 cant lower success rate in achieving anaesthesia (only 1

216 carpule for achieving full anaesthesia in at least 90 % of

217 their patients following MBI) was reported by dentists,

218 who targeted their injection to the area covered by the two

219central (in superior inferior dimension) most anterior

220quarters in the chart (square numbers 8, 12; Fig. 5) versus

221dentists who target their injection to the area covered by

222the four central quarters (in superior inferior and anterior–

223posterior dimensions; square numbers 5, 6, 7, 9, 10, 11;

224Fig. 5), p = 0.006. The risk estimation for adding more

225carpules when injecting at the mid most anterior squares (8

226and 12 square locations) is higher by 3.94 times than when

227injecting at 5, 6, 7, 9, 10, 11 (95 % confidence interval—

228ODD ratio = 1.248877–12.4142791).

229Association between the length of needle insertion

230and reported success rate of MBI

231All dentists, who treated children (80.2 % of the partici-

232pants) reported inserting a short needle (26 mm) to a mean

233depth of 15.43 mm ± 4.5. A positive statistically signifi-

234cant correlation was found between the length of the

235inserted needle and self-reported achievement of full

236anaesthesia with MBI in 90 % or more patients (p = 0.001,

237R = 0.356). Hence, practitioners who used shorter needles

238more often needed to inject more than one carpule.

239In treating adults, all the dentists reported inserting long

240needles (35 mm) to a mean depth of 28.9 mm ± 2.9 mm.

241No correlation was found in adults between the needle

242insertion length and self-reported achievement of full

243anaesthesia with MBI in 90 % or more patients.

244The duration of routine waiting period from MBI

245administration to the start of operative treatment

246When treating both children and adults, most dentists

247reported routine waiting period of 2–5 min before treat-

248ment (63.6 and 58.1 %, respectively). Dentists, who

249reported longer routine waiting periods in children tended

250to report using more carpules to achieve complete

Fig. 4 Distribution of dentists (%) according to their reports of the

location of the oral mucosa they penetrate in children and adults

Fig. 5 Distribution of dentists

(%) according to their reports of

injecting to different locations

of the mandibular ramus in

children and adults

Eur Arch Paediatr Dent

123Journal : Large 40368 Dispatch : 23-7-2013 Pages : 6

Article No. : 73h LE h TYPESET

MS Code : EAPD-D-13-00084 h CP h DISK4 4

Au

tho

r P

ro

of

UNCORRECTEDPROOF

251 anaesthesia (p = 0.042, v2 = 6.335). This trend was not

252 reported for treatment of adults.

253 Certified paediatric dentists reported routine shorter

254 waiting period from injection until the start of treatment

255 than did general practitioners who treated children; how-

256 ever, this tendency did not reach statistical significance

257 (p = 0.085).

258 Discussion

259 In this study, 20.5 and 42.1 % of dentists reported injecting

260 more than one carpule in at least 11 % of their paediatric

261 and adult patients, respectively, to achieve full anaesthesia

262 in mandibular block injection. This compares with Mala-

263 med’s (2004) recommendation to inject 0.89 % of a carp-

264 ule for mandibular block anaesthesia (1.5 ml for

265 mandibular block and 0.1 ml for lingual nerve

266 anaesthesia).

267 The reported rates of successful anaesthesia in the

268 present study are consistent with previous reports of a

269 63–87 % success rate (Kaufman et al. 1984; Childers et al.

270 1996). This reinforces the validity of the results reported

271 herein.

272 The higher success rate reported in children may result

273 from the decreased density of the mandibular bone, which

274 permits more rapid and complete diffusion of the anesthetic

275 solution (Malamed 2004). Moreover, the more inferior

276 location of the mandibular foramen in children facilitates

277 transporting the anesthetic solution into the mandibular

278 foramen, by gravitation, even when the injection is per-

279 formed more superiorly (Malamed 2004).

280 We found that in children, but not in adults, lower

281 needle insertion lengths and targeting the injecting to the

282 most anterior quarters of the ramus were positively corre-

283 lated with failure of anaesthesia. The discrepancy in these

284 findings between children and adults may relate to a greater

285 variation of muscle and fat mass in adults than in children.

286 This may result in greater difficulty in locating the target

287 on the ramus, especially in overweight adults. Moreover,

288 the standard deviation of the reported inserted needle

289 length in children was higher than in adults (4.5 vs.

290 2.9 mm). This difference may in fact be greater, since the

291 anteroposterior dimension of the ramus in children was

292 shown to be shorter than that in adults by 9.53 mm: 22.48

293 vs. 32.01, respectively (Ashkenazi et al. 2011). Another

294 factor that may contribute to these differences is that only

295 11 % of dentists treating adults targeted their injection to

296 the area of the two central most anterior quarters, as

297 compared to 25 % of the dentists treating children.

298 To compensate for an unsuccessful attempt at anaes-

299 thesia (defined as the use of more than one carpule), some

300 clinicians increase the routine waiting period from

301completion of injection to the start of the operative treat-

302ment. According to the findings of the present study,

303extending the routine waiting period over 5 min did not

304increase the chance of achieving successful anaesthesia.

305Such trend was found mainly in treating children. A pos-

306sible explanation may lie in the fact that the bone of

307children is more spongeous; consequently, most of the

308diffusion of the local anesthetic solution to the mandibular

309bone occurs during the first 5 min.

310The self-reporting design is a limitation of the present

311study. Further clinical studies should be conducted to

312affirm the relation between the length of the inserted needle

313and successful mandibular block anaesthesia in children

314and adults.

315In conclusion, shorter lengths of needle insertion and

316targeting the injection to the central most anterior quarters

317of the ramus were positively correlated with unsuccessful

318anaesthesia in children. In adults, the needle insertion

319length was not correlated with successful anaesthesia.

320Routine waiting period of over 5 min was not associated

321with a greater rate of successful achievement of MBI in

322children.

323Appendix

324Questionnaire

325Demographic questions: gender; age; years in practice;

326specialty (yes/no); type of specialty (paediatric dentistry,

327oral surgery), number of years in specialty.

328Which population do you usually treat? (Children,

329adults, children and adults).

330Please mark on the attached figure of the oral mucosa

331the location you usually penetrate to inject routine inferior

332alveolar block (mandibular block) in children.

333Please mark on the attached figure of the oral mucosa

334the location you usually penetrate to inject mandibular

335block in adults.

336Please mark on the attached figure of the mandibular

337ramus the location you usually direct your injection to,

338when you deliver routine inferior alveolar block (mandib-

339ular block) in children.

340Please mark on the attached figure of the mandibular

341ramus the location you usually direct your injection when

342you deliver routine inferior alveolar block (mandibular

343block) in adults.

344What is the needle length that you usually leave out of

345the oral mucosa during delivery of routine inferior alveolar

346block (mandibular block) injection in children? Please

347mark the needle length on the attached figure according to

348the length of needle you usually used (short or long).

Eur Arch Paediatr Dent

123Journal : Large 40368 Dispatch : 23-7-2013 Pages : 6

Article No. : 73h LE h TYPESET

MS Code : EAPD-D-13-00084 h CP h DISK4 4

Au

tho

r P

ro

of

UNCORRECTEDPROOF

349 What is the needle length that you usually leave out of

350 the oral mucosa during delivery of routine inferior alveolar

351 block (mandibular block) injection in adults? Please mark

352 the needle length on the attached figure according to the

353 length of needle you usually used (short or long).

354 How long (minutes) do you usually wait after comple-

355 tion of routine inferior alveolar block (mandibular block)

356 injection and before starting the operative treatment in

357 children? (A. 0–1 min, B. 2–5 min, C. 5–10 min, D. Over

358 10 min).

359 How long (minutes) do you usually wait after comple-

360 tion of routine inferior alveolar block (mandibular block)

361 injection and before starting the operative treatment in

362 children? (A. 0–1 min, B. 2–5 min, C. 5–10 min, D. Over

363 10 min).

364 How long (minutes) do you usually wait after comple-

365 tion of routine inferior alveolar block (mandibular block)

366 injection and before starting the operative treatment in

367 adults? (A. 0–1 min, B. 2–5 min, C. 5–10 min, D. Over

368 10 min).

369 In what percentage of your children patients do you need

370 to inject another carpule of local anesthetic in order to

371 achieve full anesthesia (no complain of pain)? A. 0–5 %,

372 B. 6–10 %, C. 11–15 %, D. 16–20 %, E. 21–25 %, F.

373 26–40 %, G. Over 40 %.

374 In what percentage of your adult-patients do you need to

375 inject another carpule of local anesthetic to achieve full

376 anesthesia (no complain of pain)? A. 0–5 %, B. 6–10 %, C.

377 11–15 %, D. 16–20 %, E. 21–25 %, F. 26–40 %, G. Over

378 40 %.

379 When your patients complain of pain, in what frequency

380 do you attribute it to pressure?

381 A. 0–10 % of the cases, B. 10–25 % of the cases, C.

382 Over 25 %.

383

384 References

385 Ashkenazi M, Taubman L, Gavish A. Age-associated changes of the386 mandibular foramen position in anteroposterior dimension and of387 the mandibular angle in dry human mandibles. Anat Rec.388 2011;294:1319–25.

389Benham NR. The cephalometric position of the mandibular foramen390with age. ASDC J Dent Child. 1976;43:233–7.391Childers M, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic392efficacy of the periodontal ligament injection after an inferior393alveolar nerve block. J Endod. 1996;22:317–20.394da Fontoura RA, Vasconcellos HA, Campos AE. Morphologic basis395for the intraoral vertical ramus osteotomy: anatomic and396radiographic localization of the mandibular foramen. J Oral397Maxillofac Surg 2002;60: 660–5 (discussion 665–6).398Fujimura K, Segami N, Kobayashi S. Anatomical study of the399complications of intraoral vertico-sagittal ramus osteotomy.400J Oral Maxillofac Surg. 2006;64:384–9.401Hayward J, Richardson ER, Malhotra SK. The mandibular foramen:402its anteroposterior position. Oral Surg Oral Med Oral Pathol.4031977;44:837–43.404Harrison SM. Regional anesthesia for children. Dent Rec.4051948;68:146–55.406Hetson G, Share J, Frommer J, Kronman JH. Statistical evaluation of407the position of the mandibular foramen. Oral Surg Oral Med Oral408Pathol. 1988;65:32–4.409Jorgensen NB, Hayden JJ. Sedation, local and general anesthesia in410dentistry, 3rd ed. Philadelphia: Lea & Febiger; 1980. p. 98.411Kaufman E, Weinstein P, Milgrom P. Difficulties in achieving local412anesthesia. J Am Dent Assoc. 1984;108:205–8.413Malamed SF. Handbook of local anesthesia, 5th ed. California:414Elsevier Mosby; 2004. p. 231, 274–5.415McDonald RE, Avery DR, Dean JA. Local anesthesia and pain416control for the child and adolescent. In: McDonald RE, Avery417DR, Dean JA, editors. Dentistry for the child and adolescent. 8th418ed. St. Louis: Mosby; 2004. p. 273.419Monheim LM. Local anesthesia and pain control in dental practice.4204th ed. St. Louis: The C.V. Mosby Company; 1969. p. 47.421Nicholson ML. A study of the position of the mandibular foramen in422the adult human mandible. Anat Rec. 1985;212:110–2.423Pinkham JR, Casamassimo PS, McTigue DJ, Fields HW, Nowak AJ,424editors. Paediatric dentistry: infancy through adolescence. 4th425ed. St. Louis, MO: Elsevier Saunders; 2005. p. 452–3.426Ricketts RM. Mechanisms of mandibular growth: a series of inquiries427on the growth of the mandible, determinants of mandibular form428and growth. Ann Arbor: Center for Human Growth and429Development, The University of Michigan. 1975. p. 77–100.430Sweet APS. Canals and foramina of maxilla and mandible. Dent431Radiogr Photogr. 1943;16:13–6.432Tsai HH. Panoramic radiographic findings of the mandibular growth433from deciduous dentition to early permanent dentition. J Clin434Pediatr Dent. 2002;26:279–84.435Tsai HH. Panoramic radiographic findings of the mandibular foramen436from deciduous to early permanent dentition. J Clin Pediatr437Dent. 2004;28:215–9.438Weiss KM. On the systematic bias in skeletal sexing. Am J Phys439Anthropol. 1972;37:239–49.

440

Eur Arch Paediatr Dent

123Journal : Large 40368 Dispatch : 23-7-2013 Pages : 6

Article No. : 73h LE h TYPESET

MS Code : EAPD-D-13-00084 h CP h DISK4 4

Au

tho

r P

ro

of