Journal of Medicine and Biomedical Sciences, ISSN: 2078-0273, May, 2010

INCIDENCE OF COMPLICATIONS OF INFERIOR ALVEOLAR NERVE BLOCK INJECTION

BDS, OMFS, DSC. Nasser Nooh 2 BDS, MSC, PhD, Walid A. Abdullah
Associate Professor; Head Division and Consultant of oral and maxillofacial surgery, Faculty of dentistry, King Saud University (KINGDOM OF SAUDI ARABIA) 2 Assistant Professor; Consultant of Oral and Maxillofacial Surgery, Faculty of dentistry, King Saud University (Kingdom of Saudi Arabia), and lecturer of Oral and Maxillofacial Surgery, Faculty of dentistry, Mansoura University (EGYPT) *Corresponding author: nnooh6@gmail.com
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ABSTRACT Objective: The aim of this study was to assess the immediate complications after injection of inferior alveolar nerve block (IANB) using a modified indirect technique. Patients and Methods: A total of 5000 IANB injections was performed by an oral and maxillofacial surgeon for a total of 3454 adults. Patients with hyperthyroidism were excluded from the study. The following data were collected: name, age, sex, and side of the IANB. Furthermore, the presence of any complication was noted as well as its type, persistence, and severity. All data were analyzed using SPSS (SPSS Inc., Chicago, IL), and descriptive statistics were generated. Results: Failures of IANB and the need for second injections were seen in 48 patients (1%). Positive aspirations were noted in 84 patients (1.7%). Blanching of the cheek was found in four patients (0.08%), which persisted for about 5 minutes. Two patients (0.04%) had electrical pain radiating to the tongue. In addition, facial paralysis was seen in one patient (0.02%), persisting about 4 hours, and there were two cases of blurred vision (0.04%) Conclusion: Based on the results and within the limitations of the study, the following can be concluded: This technique shows lower failure rate, lower positive aspiration rate, and lower incidence of facial paralysis than the standard technique described by Malamed. In addition, aspiration is important before the deposition of the anesthetic solution in IANB. Key words: immediate complications, inferior alveolar nerve block, oral and maxillofacial surgery

INTRODUCTION Probably one of the most common procedures in dentistry is the administration of local anesthetic. The inferior alveolar nerve block (IANB) is the most frequently used mandibular injection technique for achieving local anesthesia 2 for restorative and surgical procedures. In 1884, Halsted and Hall described the first inferior alveolar regional nerve block by injecting an anesthetic 3 solution ( cocaine) into the area of the mandibular foramen. Then, Fischer , described the classic technique which, 4 was modified later by many authors. Nowadays, most of the dentists all-around the world are using a technique 3,5 although, similar to the one described by Jorgensen and Hayden in 1967, which targeting the mandibular nerve. there are some complications associated with this standard IANB technique, it is still considered by many authors as 3,5 the technique with the least complications, safest administration, and least discomfort to the patients. An anesthetic complication can be defined as any deviation from the normally expected pattern during or after 6 the injection of local anesthesia. Complications of local anesthesia can be classified as local or systemic. These complications may include local and/or systemic immediate post-injection, as failure, needle breakage, penetration of a blood vessel, hematoma, nerve damage, facial nerve paresis, blanching, and reactions (eg, overdose, allergy, 15 idiosyncrasy). Different techniques are used in IANB. Therefore, the aim of this study was to assess the incidence, types, and severity of the complication(s) of IANB injection given using a modified, indirect injection technique. This study is 1 similar to research by Joseph et al ; this current study focused only on the inferior alveolar nerve injection with a larger number of injections for more reliable and accurate results. PATIENTS AND METHODS Patients This study period was from March 2001 to November 2008 with 3,454 adults Saudi patients who received a total of 5000 IANB injections. Only patients with hyperthyroidism were excluded. The study involved 1841 females and 1613 males between 17 to 56 years old with a mean age of 36. The reasons for IANB injections were extractions of wisdom teeth (74.7%) and extractions of other mandibular posterior teeth (25.3%) (Table 1). Only patients who are treated at Oral and Maxillofacial surgery clinic are included in this study. All patients are Saudi referred for extraction of the lower Molar teeth.
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 Journal of Medicine and Biomedical Sciences, ISSN: 2078-0273, May, 2010

IANB Technique All the IANB injections were done by one experienced oral and maxillofacial surgeon using the same syringe design and long 27-gauge needles (Fig.1). The needle was inserted from the opposite premolar to touch the anteromedial aspect of the ramus 1.5 cm above the occlusion level (Fig.2), then the needle was redirected by moving the syringe to the same side of injection above the occlusion level (Fig. 3). Then the needle was advanced in contact with the bone 75% of the needle length should be inserted( about 30 to 34 mm ) (Figs. 4,5).

Fig. 1. Syringe design and long 27-gauge needle used in the study

Fig. 2. The needle was inserted from the opposite premolar to touch the antero-medial aspect of the ramus 1.5 cm above the occlusion level

Fig. 3. The needle was redirected by moving the syringe to the same side of injection above the occlusion level Fig. 4. The needle was advanced in contact with the bone 75% of the needle length (about 30 to 34 mm)

Fig. 5. Showing the length of the needle that should be inserted before deposition of the anesthetic solution.

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 Journal of Medicine and Biomedical Sciences, ISSN: 2078-0273, May, 2010

Table 1. Demographic characteristics of participating subjects number Age Bilateral IANB Unilateral IANB Cause (wisdom teeth extractions) 1718 Cause (other lower posterior teeth extractions) 477

Male

1613

18:56 y Mean (37y) 17:52y Mean (35y) Mean (36y)

Female

1841

total

3454

582 1031 (1164 injections) 964 877 (1928 injections) 1546 1908 (3092 injections) 5000 IANB injections

2017

788

3735

1265

74.7 %

25.3%

If there is no bone contact, the needle is withdrawn and redirected until having bone contact, we never inject unless we have a bone contact. Aspiration was performed, and then 1.8 cc of local anesthesia solution (2% lidocaine with 1:100,000 epinephrine 1.8 cc cartridge) was deposited for the anesthesia of inferior alveolar and lingual nerves. Then 0.3 cc of 2% lidocaine with 1:100,000 epinephrine solutions was injected in the buccal sulcus opposing to the affected tooth as an infiltration to the long buccal nerve. We used only one 1.8 cc cartridge of (2% lidocaine with 1:100,000 epinephrine) in all patients as IANB at the start of the procedure, then if patients showed improper anesthetic effect for extraction we injected with a second cartridge and considered as a failure in the first injection trail. Data Collection and Statistical Analysis In all patients, the following data were collected: name, age, sex, and side of the IANB. The presence of any complications was noted, including type, persistence, and severity. All data were analyzed using SPSS, and descriptive statistics were generated. RESULTS A total of 5000 IANB injections were administered during the study period. Failures and the need for a second injection occurred in 48 patients (1%). Positive aspirations were noted in 84 patients (1.7%). Blanching of the cheek was seen in four patients (0.08%), which persisted about 5 minutes. Two cases of blurred vision (0.04%) were recorded in two female patients, both on the right side (IANB), and both patients showed complete improvement after about 7 minutes. Two patients (0.04%) had electrical pain radiating to the tongue. One person had facial paralysis (0.02%), which persisted about 4 hours. Needle breakage, overdose, allergy or idiosyncrasy, and persistent nerve damage were not found in any patient. Table 2 summarizes the incidence of complications and their duration in all patients. Table 2. Number (%) of complications encountered following IANB Complication Failure Positive aspiration Blanching Blurred vision Facial paralysis Electrical pain DISCUSSION According to failure rate, this study showed IANB failure was present in 1% of IANB injections. These results 2,3,7 7 were significantly different from previous studies. Wong and Jacobsen reported a failure rate of 5% to 15%. In 5 addition, Malamed identified the inferior alveolar nerve block as the injection with the highest clinical failure rate (15% to 20%) when properly administered. Furthermore, Malamed attributed failure to a high degree of variation in the morphology of the mandibular ramus and the location of the mandibular foramen; however, improper technique is the 3,5,8 Because of the specialty in which IANB is given, the authors results showed lower most common reason for failure. 9 10 failure rate (1%) when compared with the results of Cohen et al and Nusstein et al who reported that the failure rate of IANB to be between 38% and 75% of the time in their endodontic clinical trails. Incidence number 48 84 4 2 1 2 percentage 1% 1.7 % 0.08 % 0.04 % 0.02% 0.04 % duration

4 minutes 7 minutes 4 hours

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 Journal of Medicine and Biomedical Sciences, ISSN: 2078-0273, May, 2010

Most of the time, success rates are reportedly higher when a single individuals first demonstration of anesthesia success is published. A random prospective trial would be required using a standard technique for comparison. The authors of this current study saw a reasonably low positive aspiration rate (1.7%) compared with the results 11,12 11 12 Taghavi Zenouz et al reported an incidence of 15.3%, while Blanton and Roda stated that of previous studies. they had a positive aspiration rate of 10% to 15%. This relatively high percentage was decreased in the Gow-Gates 13 technique to 1.6% to 1.9%. 13 14 Garcia et al and Brodsky and Dower indicated the IANB method is superior to the Gow-Gates technique in percentages of intravascular puncture; this is related to the large quantity of vascular elements present in the pterygomandibular space. For this reason, it has been stated that the IANB technique is risky for patients who have 15 some kind of blood dyscrasias. From this point, the authors consider their technique to be more superior to the standard regular IANB injection method, as it has a significantly different positive aspiration rate and a comparable result with Gow-Gates. Although there is a significant difference between the authors study results regarding positive aspiration (1.7%) 16 and those of Frangiskos et al (20%), the authors of this paper agree with them that intravascular injection of local anaesthetic during inferior alveolar nerve block is more or less a common complication. So aspiration is mandatory 17 before the solution deposition during IANB. However, the authors disagree with Martis et al, who stated that aspiration is not necessary because complications from intravascular injection of local anesthesia are uncommon. Because even if the incidence is very low, yet the complication ( if happened) is serious , so we have to do our precautions to avoid this low incidence complication by making aspiration prior to each IANB injection. Visual problems include blurring of vision or blindness, which can be temporary or permanent. Motor problems include mydriasis, palpebral ptosis, and diplopia. Horner-like manifestations involving ptosis, enophthalmos and miosis 18-20 21 of the eye also have been reported. Fortunately, most complications in the eye are transient. Rood reported a case in which 1.5 mL of lidocaine with epinephrine (1:80,000) in IANB, immediate loss of vision developed in the ipsilateral eye, along with upper-eyelid ptosis. Yet, within 5 minutes to 45 minutes, all symptoms had disappeared. 20,22 In this study, the incidence of blurred Unfortunately, cases of permanent complications also have been reported. vision was (0.04%), which was improved completely within 7 minutes. This result is in agreement with what was 18 reported by Ngeow et al. 23 The authors agree with Uckan et al that blanching and ischemia are reported as rare local complications of local anesthesia Blanching incidence in the current study was (0.08%) Few articles document patients and clinical photographs. 1 Needle breakage was not seen during the study, and the authors agree with Lustig and Zusman who reported needles now are made of one piece of metal tube with a soft plastic hub. Occurrences of needle breakage are reported anecdotally; better manufacturing techniques and single use may account for this. 24 The incidence of temporary facial palsy in this study (0.02%) was less than Keetley and Moles results, which found a 0.3% rate. The facial nerve is embedded in the substance of the parotid gland, which has a deep lobe extending around the posterior ramus of the mandible and projecting forward on the medial surface of the ramus. If the injection is made too far posteriorly, the anesthetic solution may be injected into the substance of the parotid gland and could involve the facial nerve. If this happens, the patient will complain immediately of an inability to blink the eye, 25 followed by a sense of paralysis on the same side of the face. CONCLUSION The authors technique shows lower failure rate, lower positive aspiration rate, and lower incidence of facial 5 paralysis compared with the standard technique described by Malamed. Aspiration is important before the deposition of the anesthetic solution in IANB. REFERENCES

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