Primary tooth be restored. The waiting period before beginning the restorative procedure is about 3 to 5 minutes.

The problem with this technique is that profound mandibular anesthesia cannot be reliably achieved. Our experience indicates that the technique works best for young children (up to 5 years of age) who require restoration of mandibular first primary molars, cuspids, and incisors. For older children, or in the region of the second primary molars, bone is denser. Thus the supraperiosteal injection does not always produce profound anesthesia. To increase the chance of adequate anesthesia with the supraperiosteal technique, the rule of 20, which works in the following manner, can be applied. According to world health organization nomenclature, the first primary molar is tooth no. 4 (the second is no.5). the number of the tooth is multiplied by chronological age. Consider, for example, a 4 year-old who requires restoration of the first primary molar. The formula-age (4) times tooth umber (4)- produces 16. The lower the product number, the greater the chance of successful anesthesia. If the product in the formula exceeds 20, the chance of good anesthesia with this technique is lessened (the older the child or the more distal the tooth, the denser the mandibular bone). Thus the procedure is limited to shallow or moderate restorations in the young childs mandibular molar teeth. Intraligamental anesthesia is an alteranative method for anesthetizing the mandibular molars. Two devices for this technique are the ligmaject and the peripress Syringe. These provide intraligamental anesthesia, using the periodontal ligament (PDL) as a route for the anesthetic to reach the root apex, resulting in anesthesia of individual teeth. The reliability of the PDL technique in the mandible of 100 adult patients was tested and found to be successful in 65 of 71 restorative cases. When asked their preference, an overwhelming majority preferred the PDL injection rather than the mandibular block (Melamed, 1982). The apparatus for intraligamental anesthesia resembles a gun. It works by expelling small amounts of local anesthetic under pressure into the tissues: one squeeze of the trigger releases approximately 0.2ml. Injections can be made mesially and distally to the tooth to be treated. To anesthetize the mandibular teeth for other procedures, the inferior alveolar nerve injection (mandibular nerve block injection) is most often used. A detailed description of this technique is omitted; however, some noteworthy points are reviewed. Physical position can be an important factor when the dentist in injecting children. To accomplish the mandibular injection for the right side of the mandible, the right-handed dentist approaches the face from the front. The left thumb is placed with the middle of the thumbnail at the coronoid notch and lightly over the deep tendon of the temporalis muscle. The pterygomandibular raphe is medial to the thumb. The needle penetrates the tissue at the middle of the thumbnail and is thus carried between the deep tendon of the temporalis laterally and the pterygomandibular raphe medially, entering the mandibular sulcus at the level of the lingular notch. Unfortunately, this injection provides the dentist with little control over a childs head movement.

On the apposite side, or the left side of the arch, the right-handed operators arm may be placed over the head of the patient and the left thumb on the anterior border of the ramus, with the forefinger just anterior to the mandibular angle and the middle finger just above the mandibular angle. Again, the mandibular sulcus will be at the center of the triangle formed by the tips of these two fingers and the thumb. When the rigt-handed operator administers a left mandibular block and places the left forearm over a childs forehead, this technique controls head movements and helps to keep the syringe out of the childs view. For these reasons, when given a choice between right and left sides, many dentists prefer beginning with the left mandibular block. Another point has to do with anesthesia of the buccal mucosa, which may be required for extraction or placement of a rubber dam clamp. This is done by depositing solution in the buccal mucosa adjacent to the teeth to be extracted or where sof tissue anesthesia is desired. The long buccal nerve passes high into the buccinators muscle and courses along its lateral surface as fibers descend through the mucobuccal fold to the mucosa on the buccal of the teeth. Therefore it is difficult to block the long buccal nerve and, consequently, preferable to infiltrate the area in which anesthesia is desired. A separate injection for buccal anesthesia is not always necessary. After mandibular block anesthetic for extractin the mandibular primary first molar, the buccal tissue usually becomes anesthetized- probably a result of anesthetized nerve fibers that emanate from the mental foramen and enervate the buccal mucosa. Similarly, routine injections for buccal anesthesia following a mandibular block are unnecessary for placement of rubber damclamps. Many children tolerate clamp placement on the mandibular primary second molar or permaenent first molar without a buccal injection. Expelling the anesthetic solution on penetration and withdrawal probably affects some of the buccal enervating nerve fibers.