Why Does Inferior Alveolar Nerve Block Fail - A Review

10/13/2020 Why does Inferior Alveolar Nerve Block Fail?
A Review
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10/13/2020 Why does Inferior Alveolar Nerve Block Fail? A Review
Why does Inferior Alveolar Nerve Block Fail? A Review
*
Isabel Peixoto Tortamano 
Departmento De Estomatalogia, University Of Sao Paulo Medical School,, Brazil
*Corresponding Author:
Isabel Peixoto Tortamano
Departmento De Estomatalogia, University Of Sao Paulo Medical School,, Brazil
Email:iptortam@usp.br
Published on: 2017-08-25
Abstract
Keywords
Inferior Alveolar Nerve Block; Irreversible Pulpitis; Anesthesia Failure.
Introduction
Inferior alveolar nerve block (IANB) is the technique that is most frequently employed to achieve
local anesthesia of the posterior inferior teeth, especially in the case of endodontic procedures[1-5]
as well as restorative and surgical procedures in the mandibular molar teeth.[6] However, clinical
studies have demonstrated signi cant failure rates for this technique[7-10], indicating that IANB
does not always result in successful pulp anesthesia [8-11] even when it is performed by the most
experienced clinician[12].
Concerning pulpal anesthesia, success rates with absolute IANB range from 42% to 73% for non-
in amed pulp[13,14] whereas lower values are observed for irreversible pulpitis[1,2,8,13-21]
Numerous studies have emphasized that, although all patients report lip numbness following
IANB, this factor is negligible regarding the measure of the success of mandibular anesthesia
[1,6,21-24].
In the case of IANB, dentists normally begin treatment on their patients within 10 to 15 minutes
after injection of the anesthetics[1,3,7,8,15,21,25-27] Therefore, if the symptoms of anesthesia are
not identi ed within this period, anesthetic failure can be assumed to have taken place[28].
Another alternative is the use of supplementary techniques such as intraligamentary [29] or

intraosseous injections [26, 30-34] and intra-pulpal anesthesia [35] The reasons for IANB failure
are not yet fully understood. They may be due to an anxiety factor, which directly lowers the pain
threshold, as well as to psychological factors such as personality and expectations, which in uence
the perception of pain. Also, the theory of accessory innervations of mandibular molars should not
be overlooked, even though the IANB failure rate exceeds the incidence of this innervation.
Chat nowfrom in amed
Additionally, the resting potential and threshold of excitability of the neurons
tissues might change, which could culminate in chemical changes that can a ect anesthesia.
However, there seems to be no signi cant correlation between failure rates and the type,
concentration, and volume of anesthetic agents [19].

Fortunately, when local anesthesia fails, this can be managed e ectively in most cases. This may
involve modi cation of conventional techniques to overcome anatomical problems such as
variations in the location of the mandibular foramen [36] for example, the use of “high” blocks
such as the GowGates [32] or Vazirani-Akinosi [37] techniques [38]
Choice Of Anesthetic Agent

Anesthetics have di erent features in terms of latency period, potency, and action time of
anesthesia. The choice of anesthetic drug depends on the type of procedure that is to be performed
and on the overall health condition of the patient [39, 40].
However, some studies have shown that the appropriate selection of local anesthetics is not
enough to prevent transmission of nerve impulse. This is because the thresholds of excitability
might be reduced [41].
Sodium channels resistant to tetrodotoxin might also be involved in IANB failure, since these
channels have also been demonstrated to be resistant to the action of local anesthetics [42].
Inappropriate Technique:
As for the use of inappropriate techniques, it is important to emphasize the mandibular region. If
the injection is too low, lingual anesthesia will result in de cient anesthesia of the tooth and bone
structures. An injection that is applied too deep might mean that the solution will be deposited in
the parotid space. This culminates in temporary facial nerve anesthesia and paralysis, which will
last until complete absorption of the anesthetic is achieved, and no anesthesia of the mandibular
nerve takes place. If injection is too mesial, the solution will be deposited in the pterygoid muscle,
with super cial anesthesia and trismus. In the case of an excessively super cial injection, the
anesthetic solution will be super cially deposited in the pterygomandibular space (distant from
the mandibular foramen), and inadequate anesthesia may occur [28].
An injection applied too high may result in no anesthesia, since the solution is deposited in the
sigmoid condylar notch or neck. Finally, intravascular injection does not induce adequate
anesthesia and may cause systemic complications [43] It is also important to bear in mind that
anatomy varies with age and development of the facial structures. If a line tangential to the
occlusal surface of the last molar is drawn, the Spixs spine (lingula or elevation near the entrance
of the mandibular foramen) is localized one centimeter above this line in adults and at the level of
the line in children. In edentate patients, it is important to keep the horizontal plane in mind, in
order to avoid deposition of the anesthetic solution below the mandibular foramen [28].
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The error that is most likely to occur during the performance of anesthesia is wrong needle
placement. Absence of aspiration before injection can lead to intravascular deposition of the
solution, which can also cause failure of anesthesia. Successful anesthesia may be related to the

speed at which the solution is deposited. It is easy to imagine the anesthetic being directed away
from a nerve trunk during a forceful injection. Indeed, there is evidence that the solution should be
deposited slowly [44].
Practitioners who frequently fail to carry out this type of AINB should reassess their technique. The
best way to achieve success is to use a direct technique, where the dentist places the thumb intra-
orally at the deepest concavity of the anterior ascending ramus and the index nger at the same
height extra-orally on the posterior aspect of the ramus. The point between the mid-point of the
thumb nail and the pterygomandibular raphe is where the needle should be inserted. The needle
should then be advanced through this point parallel to the occlusal plane from the premolar teeth
of the opposite side. The nal point of the bone is achieved at a depth between 15 and 25 mm. A
common error is injecting the solution below the mandibular foramen, which can be corrected by
means of a higher injection.
In most cases, the practitioner who has frequently failed to carry out anesthesia attempts to
overcome the problem by repeating the injection. In this context, a panoramic radiograph shall
help localize the position of the mandibular foramen.
The patient-dependent failures may occur because of anatomic variation, bi d alveolar nerve,
bone density, retromolar foramen, accessory innervation, accessory mental foramen, and nerve
anastomoses [28].
Anatomical variations:
With respect to anatomical variations, in this review we highlight the myloyoid nerve accessory
supply. Accessory innervations of cutaneous cervical nerves, C1, C2, and auriculotemporal nerve;
variations in nerve pathways; di erences in the position of the foramen; bi d mandibular canal or
bi d alveolar nerve; accessory mental foramen; bone density; and nerve anastomoses12 will also
be discussed. The important mandibular foramen regarding regional anesthesia in anesthetic block
does not have consistent location among patients. Available radiographs may be helpful in
anticipating this situation [35] The inferior alveolar nerve is known to be located in apical and
lingual position with respect to the third and second molars [45] A greater distance from the
vestibular zone to the mandibular canal has been reported to occur between the rst and second
molar, with vestibular displacement of the nerve taking place at the second molar level, toward the
mental foramen [46]. A higher or lower position of the mandibular canal has been radiographically
observed [47]. Finally , the mandibular canal varies with patients age, being localized in a higher
position after 60 years of age [48].
Mandibular foramen:
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Knowledge of the precise location of the mandibular foramen (MF) is essential in dentistry for
e ective mandibularblock anesthesia injection and for certain other procedures in oral and
maxillofacial surgery [49-52], however, it is not universally successful[53]. A number of authors
describe the position of the foramen as halfway between the anterior and posterior borders of
the
ramus [52- 56] Nicholson [57] found in the population of 80 East Indian adult dry skulls the
position of the foramen was found to be variable, thus con rming the results of previous works
[58,59]. As far 36 on their study revealed that the MF can be localized in panoramic radiographs
but that its relation to clinically palpable and radiographically visible bony landmarks is highly
individualistic. In another study, were found statistically signi cant correlations between the
mandibular angle position and the narrowest anteroposterior diameter of the ramus and between
the distance from the deepest point of the ramus to the MF and the narrowest anteroposterior
diameter of the ramus in radiographs done with the Orthoralix SD Ceph [60]. The success of this
technique is dependent on placing the needle tip in close proximity to the MF36 and it is essential
to deposit the uid as close as possible to the nerve [61].
Accessory mental foramen:
This foramen is localized apically or near the mental foramen, and it also contains mental nerve
bers [45] However, data relative to its existence are controversial. While a study has reported a
prevalence of 6.62% of the accessory mental foramen in 138 mandibles [62] another investigation
has described a much smaller percentage (2.5%) [63] In another work, a series of 5000 panoramic
radiographs failed to detect this foramen [64] In a further study involving four population groups,
the authors found a lower percentage of this anatomical variation in whites and American Indians
from Asia (1.4% and 1.5%, respectively) [65].
Bi d inferior alveolar nerve:
The bi d alveolar nerve is a possible cause of IANB failure [45, 64] In 0.4% of the cases, the nerve
has two or three ways via an accessory foramen, which contains small sensory nerve bers. In a
series of 6000 panoramic radiographs, it was observed that 57 (0.95%) contained a bi d channel
[66] while another study found 7 images suggestive of bi d canal in a series of 2012 panoramic
radiographs [67] Additionally, 33 bi d channels were identi ed in another group of 3612 patients
(0.9%), 20 of which were bilateral and 13 were unilateral.48 These ndings indicate that the
channels are not commonly bi d. Indeed, the prevalence of bi d channels is around 1%
[64,66,68].
Bone density:
The most obvious barrier to di usion of anesthesia is the plate thickness of the mandibular
cortical alveolus, which blocks the in ltration of anesthesia in adults. The opposite is applied to
children, in which the in ltrative approaches are most commonly used due to the existing low
bone density [28].
Chat now
In the maxilla, the region of the rst molar in adults may also present a similar problem. This is
because it is a thicker zygomatic region that is sturdy enough to prevent the passage of anesthetics
to the dental apices [35]

Retromolar foramen:
The presence of a retromolar foramen with or without the existence of a bi d mandibular nerve
has been investigated. The presence of such nerve bers was detected in the mentioned foramen
[69] Likewise, a prevalence of 7.8% of the foramen has been reported for a series of 249 African-
American and 226 caucasians, without signi cant di erences in terms of race or sex [70].
In a study of 234 adult mandibles, a prevalence of 7.7% of the retromolar foramen has been
described, with no di erences between men and women [65].This anatomical variation provides
accessory innervation, which may cause failure during mandibular block.
Accessory innervations:
Teeth may receive innervation from more than one nerve trunk. The accessory nerve supply can
lead to failure of anesthesia, including IANB. The buccal nerve may occasionally provide pulpar
innervation to the inferior molars and, in this case, a buccal in ltration anesthesia might be
necessary. The lingual nerve may also contribute to pulpal anesthesia of the lower teeth, but this
will normally be counterbalanced by this nerve blockade in association with AINB. Other sources of
accessory nerves innervate the inferior teeth. This supply may be derived from mylohyoid,
auriculotemporal, and upper cervical nerves [35].
Several authors have emphasized that accessory innervations of lower teeth are a possible
explanation for the incidence of inadequate anesthesia [9,69,71-78]. The mylohyoid nerve is the
best documented accessory nerve of the mandibular teeth [17,19,32,35,69,79-81].
The mylohyoid nerve is a mandibular branch of the trigeminal nerve that provides motor
innervation to the mylohyoid and digastric muscles. However, it may also present a sensory
component, providing accessory innervations and causing IANB failure [81].The mylohyoid branch
leaves the main trunk of the inferior alveolar nerve one centimeter up the mandibular foramen
[82]. Therefore, it cannot be a ected by a conventional approach.
The auriculotemporal nerve has been reported to occasionally send branches to the pulps of the
inferior teeth via the upper branch [83]. This supply, such as the branch of the mylohyoid nerve,
can be counteracted with a “higher” blockade, including the Gow-Gates and Akinosi techniques.
The innervation that corresponds to the rst cervical branches can also be present, with bers
exhibiting gingival, bone and tooth action in the mandibular posterior region [28].
Anastomoses nerve:
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The contralateral innervation of the anterior teeth can cause failure of anesthesia in both the
maxilla and the mandible [28]. In a study analyzing a series of 38 patients and evaluating the
percentage of nerve anastomosis on the unilateral and bilateral anesthesia of the inferior alveolar
nerve, the authors found that cross innervations may cause a signi cant number of anesthetic
failures in the lateral and central incisor [84]. This fact was attributed to the cross passage of the
inferior alveolar nerve and to the accessory innervations of the oral and facial nerves and the
brachial plexus [85]. IANB failures may also be due to pathological, pharmacological and
psychological causes and to problems related to the anesthetic solution itself.
Psychological causes:
Fear of seeing and/ or feeling the needle and the sound of the dental handpiece are routinely cited
as causative agents in the creation of anxiety in dental patient [86]. Several methods have been
advocated for managing anxious patient pain [87, 88]. In any case, the clinician should establish a
positive and con dent relationship and avoid exposing the patient to obvious fear-producing
stimuli [17].
Many clinicians report that a sense of humor often helps to relax apprehensive patients [17]. Early
identi cation of the problem, a meticulous technique, and sedation can help in these situations
[43]. For apprehensive patients who report the absence of local analgesia, the use of sedative
techniques may be helpful for the success of anesthesia, since the patient will feel more relaxed
[9].
Ine ective anesthetic solution:
Even if the technique is correctly performed, the desired e ect will not be achieved if the solution
is altered. Certain batches of a particular drug can be past the expiration date and therefore should
not be used, or failure will result [45].
The storage of anesthetics at temperatures above 37 º C can also lead to failure of anesthesia,
especially in the case of those available in plastic cartridges [89].
The injection pressure, especially in the case of intraligamentar in ltration, can culminate in
cracking of the tube and thus anesthesia failure [90].
Central core theory of nerve block failure

The central core theory states that the nerve bers toward the center of the nerve travel the
furthest and are the last to be anesthetized [91, 92]. In some cases the anesthetic solution may not
completely di use into the nerve to produce an adequate nerve block in all teeth [92].
This theory may be the best explanation for the failure of inferior alveolar nerve block [91, 92]. It
states nerves on theoutside of the nerve bundle supply molar teeth, and nerves on the inside supply
incisor teeth. The anesthetic solution may not di use into the nerve trunk to reach all nerves and
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produce an adequate nerve block. The theory may explain the higher failure rates in incisor teeth
with the inferior alveolar nerve block [11, 93-97].
Conclusion 
E ective local anesthesia is an important aspect of dental practice. Hopefully the reader has found
this review to be informative and practical. Our objectives were to review the probable causes to
inferior alveolar nerve block failure in order to help the clinician to achieve a higher success rate of
inferior alveolar nerve block.
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Jacobs Journal of Surgery

Why does Inferior Alveolar Nerve Block Fail? A Review

Published on: 2017-08-25

Another alternative is the use of supplementary techniques such as intraligamentary [29] or

Choice Of Anesthetic Agent

Accessory mental foramen:

Bi d inferior alveolar nerve:

Ine ective anesthetic solution:

Central core theory of nerve block failure

7. Matthews R, Drum M, Reader A, Nusstein J, Beck M et al. Articaine forsupplemental buccal

9. Kaufman E, Weinstein P, Milgrom P. Di culties in achievinglocal anesthesia. J Am Dent Assoc.

22. Aggarwal V,Singla M, Kabi D. Comparative evaluation of anesthetic e cacy of Gow-Gates

42. Roy ML, Narahashi T. Di erential properties of tetrodotoxin-sensitive and tetrodotoxin-

60. Ka e I, Ardekian L, Gelerenter I, Taicher S. Location of the mandibular foramen in panoramic

94. McLean C, Reader A, Beck M, Meyers W. An evaluation of 4% prilocaine and 3% mepivacaine

97. Fernandez C, Reader A, Beck M, Nusstein J. A prospective, randomized, double-blind

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