Buccal Nerve Dissection Via an

Intraoral Approach: Correcting an

Error Regarding Buccal Nerve
Blockade
Joe Iwanaga, DDS, PhD,* and R. Shane Tubbs, PhDy
Purpose: The buccal nerve (BN) supplies sensation to the skin over the anterior part of the buccinator,
buccal mucosa, and buccal gingivae corresponding to the second and third molar teeth. Some dental
anatomy books depict the main trunk of the BN coursing over the buccal shelf of the mandible, which
leads to a serious misunderstanding of this anatomy. Therefore, this study aimed to show the course of
the BN on the retromolar area and establish new evidence-based anatomy for appropriate BN blockade.
Materials and Methods: Twenty sides from 10 fresh-frozen Caucasian cadaveric heads were used in
this study. The closest distance from the BN to the injection site of the BN blockade (Dis A) was measured.
Results: The mean Dis A was 12.69  2.95 mm. On 16 of 20 sides (80%), Dis A was longer than 10 mm. In
most specimens, the injection site of the BN blockade was too far from the course of the main trunk of the
BN and the injection site should be changed to 10 mm superolateral to the injection site based on the
present results and those of other previous studies.
Conclusions: Although the distribution of the BN is variable, in most specimens, the current injection
site for BN blockade was too far from the course of the BN.
Ó 2019 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 77:1154.e1-1154.e4, 2019

The buccal nerve (BN) is one of the branches of the
anterior division of the mandibular nerve (cranial
nerve V3). It travels between the superior and inferior
heads of the lateral pterygoid muscle, descends antero-
laterally, and perforates the tendon of the temporalis as
it inserts onto the anterior border of the ramus.1 The
BN supplies sensation to the skin over the anterior
part of the buccinator, buccal mucosa, and buccal
gingivae corresponding to the second and third
molars.2 Most anatomy textbooks and atlases depict
the course of the BN with a lateral view,2,3 which
also displays the course of the main trunk of the BN
as running along the middle of the buccinator
between the maxilla and mandible. Anatomically, the
buccal gingivae of the lower molar teeth are
supplied by one of the terminal branches of the BN,
not its main trunk. Some dental texts show the main
trunk of the BN running on the buccal shelf of the
mandible and this creates confusion of this
anatomy,4 which is due primarily to the lack of
anatomic study of the BN by intraoral dissection.
A nerve blockade procedure is defined as a local
anesthetic solution placed near a main nerve trunk.5
In dentistry, there are several different nerve blockade
techniques, such as inferior alveolar nerve, greater
palatine nerve, and posterior superior alveolar nerve

*Anatomical Researcher and Educator, Seattle Science
Foundation, Seattle, WA; Dental and Oral Medical Center, Kurume
University School of Medicine, Fukuoka, Japan.
yProfessor and Vice President, Seattle Science Foundation,
Seattle, WA; Department of Anatomical Sciences, St George’s
University, St. George’s, Grenada, West Indies.
Conflict of Interest Disclosures: Neither author has any relevant
financial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Iwanaga:
Seattle Science Foundation, 550 17th Avenue, Suite 600, Seattle,
WA 98122; e-mail: joei@seattlesciencefoundation.org
Received December 9 2018
Accepted January 22 2019
Ó 2019 American Association of Oral and Maxillofacial Surgeons
0278-2391/19/30113-2
https://doi.org/10.1016/j.joms.2019.01.038

1154.e1
IWANAGA AND TUBBS
FIGURE 1. Measurement of closest distance from the BN to point A
(Dis A). BN, buccal nerve; Dis A, closest distance from buccal nerve
to injection site of buccal nerve blockade; MM, masseter muscle;
point A, anterior border of mandibular ramus and 1 mm lateral to
third molar area.
Iwanaga and Tubbs. Correcting an Error of Buccal Nerve
Blockade. J Oral Maxillofac Surg 2019.
blockade.6,7 BN blockade, also referred to as long BN
blockade,8 is often applied to patients who undergo
third molar extraction as supplemental anesthesia
owing to the lack of the distribution of the inferior
alveolar nerve on the lower buccal gingiva.3,4,7,9 BN
blocks are performed in the retromolar area by
FIGURE 2. Closest distance from injection site to buccal nerve.
Iwanaga and Tubbs. Correcting an Error of Buccal Nerve Blockade. J Oral Maxillofac Surg 2019.
1154.e2
injection into the mucous membrane of the anterior
border of the ramus, just lateral to the third molar
area and in line with the occlusive plane.7,10
Based on the anatomic findings described earlier,
BN blockade techniques might not anesthetize the
main trunk of the BN but rather its small terminal
branches to the buccal gingivae of the molar area. To
the authors’ knowledge, to date, there have been no
anatomic studies of the BN by intraoral dissection to
show the BN in the same view as the dentists see in
their daily practice. This anatomic study aimed to bet-
ter describe the course of the BN in the retromolar
area for improved BN blockade.
Materials and Methods
Twenty sides from 10 fresh-frozen Caucasian cadav-
eric heads (7 female and 3 male) were used in this
study. The mean age at death was 71.5  13.4 years
(range, 57 to 93 yr).
First, the BN blockade injection site was marked on
the anterior border of the ramus of the mandible and
1 mm lateral to the third molar area (point A). The initial
incision was made from point A to 3 to 4 cm superiorly
along the anterior border of the ramus. The mucosa and
buccinator muscle were incised and the buccal fat pad
was exposed. Second, blunt dissection was performed
to identify the BN. Once the BN was identified, it was
traced to find the closest point to point A. The closest
distance from the BN to point A (Dis A) was measured
(Fig 1) and the relation of the BN to the tendon of the
temporalis muscle was recorded. All BNs were traced
proximally to confirm their identity.
One oral and maxillofacial surgeon (J.I.) and 1 clin-
ical anatomist (R.S.T.) performed all dissections and
measurements. All measurements were performed
1154.e3
FIGURE 3. Example of BN crossing anterior to the TT. BN, buccal
nerve; TT, tendon of temporalis muscle.
Iwanaga and Tubbs. Correcting an Error of Buccal Nerve
Blockade. J Oral Maxillofac Surg 2019.
with micro-calipers (Mitsutoyo, Kanagawa, Japan). No
scar or pathology was observed in the areas dissected.
The present study protocol did not require approval
FIGURE 4. Correct and incorrect illustrations of the course of the buccal nerve.
Iwanaga and Tubbs. Correcting an Error of Buccal Nerve Blockade. J Oral Maxillofac Surg 2019.
CORRECTING AN ERROR OF BUCCAL NERVE BLOCKADE
by the authors’ institutional ethics committees and
was performed in accordance with the requirements
of the Declaration of Helsinki (64th World Medical As-
sociation General Assembly, Fortaleza, Brazil,
October 2013).
Results
Dis A ranged from 8.54 to 19.51 mm (mean,
12.69  2.95 mm; right side, 8.54 to 16.00 mm
[mean, 13.05  2.49 mm]; left side, 7.31 to
19.51 mm [mean, 12.34  3.45 mm]). On 16 of 20
sides (80%), Dis A was longer than 10 mm (8 sides
on the right and 8 sides on the left). There was no sig-
nificant difference between genders or sides (P > .05).
In addition, on 11 sides (55%), Dis A was longer than
13 mm (7 sides on the right and 4 sides on the left;
Fig 2). On all sides (20 of 20), the BN ran anterior to
the tendon of the temporalis muscle (Fig 3).
Discussion
BN blockade is a well-known procedure for
dentistry and many dentists perform this technique
to anesthetize the buccal gingivae of the lower molar
area. Previous anatomic studies on the BN are the basis
for this procedure. Hendy et al11 investigated the dis-
tance from the site where the main trunk of the BN
crosses the external oblique ridge to the deepest con-
cavity of the external oblique ridge, which is a familiar
landmark to dentists for performing inferior alveolar
nerve blockade. In this study, the main trunk of the
BN crossed within 3 mm from the deepest concavity
in 70% (14 of 20) and 7 to 12 mm below the deepest
concavity in 30% (6 of 20).
IWANAGA AND TUBBS
Distribution of the BN in the retromolar area has
been well documented. Hendy and Robinson12 map-
ped the distribution of the BN by performing BN
blockade in patients. This study showed that the
most anterior limit of the anesthesia on the lower
buccal gingivae was between the first molar and the
second premolar teeth. Takezawa et al1 presented
detailed anatomic dissection of Japanese embalmed
cadavers to show the distribution of the BN to the
buccal gingiva, cheek, and lip.
The BN is often described as it penetrates the tempo-
ralis tendon. Merida-Velasco et al13 studied the relation
between the temporalis tendon and BN during the pre-
natal period. The origin and course of the BN were var-
iable; 49.4% (89 of 180) of BNs were located medial to
the temporalis tendon and 40.1% (73 of 180) penetrated
the temporalis tendon. In the present study, the BN
crossed anterior to the temporalis tendon on all sides.
The mean distance from point A to the BN on the
external oblique ridge was 13.05  2.49 mm on the
right side and 12.34  3.45 mm on the left side, with
a wide range. To anesthetize the main trunk of the
BN, the aforementioned traditional BN blockade pro-
cedure seems to be too low. This method can block
small branches to the gingivae of the lower molar
but cannot block the main trunk of the BN. Takezawa
et al1 also was concerned that the block of the distal
part of the BN (not the main trunk) might not anesthe-
tize the lower buccal mucosa of the molar area based
on their anatomic findings. As the present study and
the findings of Hendy et al11 showed, most BNs course
much higher than the point that is currently used for
the injection site of BN blockade. Therefore, based
on the present findings, for ideal BN blockade, the in-
jection site should be 10 mm superolateral to point A.
However, the current BN blockade site is still benefi-
cial for vasoconstriction around the surgical field,
especially for lower third molar removal. This site of
injection could be referred to as an ‘‘infiltration’’ tech-
nique of the BN branch rather than a ‘‘blockade.’’
Merida-Velasco et al13 found that 1.7% (3 of 180) of
BNs arose from the inferior alveolar nerve. Such an
aberrant nerve could emerge from the retromolar fora-
men located in the retromolar fossa of the mandible. In
adults, 8 to 40.4% of mandibles have a retromolar fora-
men that might contain a retromolar nerve.14-16 The
retromolar nerve might innervate the lower buccal
gingivae of the molar area. In a clinical setting,
Kikuta et al14 reported on a case of postoperative sen-
sory paralysis of the lower buccal gingiva of the molar
area after the retromolar nerve was cut in a patient un-
dergoing third molar extraction. Thus, the innervation
pattern of the BN is variable. In 1874, Panas17 reported
on a case of buccal neuralgia treated with neurotomy
(or neurectomy) with relief of symptoms. In this short
1154.e4
report, Panas mentioned that the BN was found by
making a 2- to 2.5-cm mucous incision on the external
oblique ridge and dividing the buccinators.
To the authors’ knowledge, this is the first study us-
ing intraoral dissection of the BN in fresh cadavers.
Although the distribution of the BN is variable, in
most specimens, the injection site for BN blockade
was too far from the course of the BN. Therefore,
based on these findings, the authors recommend an in-
jection site 10 mm superolateral to point A as a real
‘‘BN blockade.’’ Moreover, illustrations in many books
depicting the BN incorrectly should be amended (Fig
4). Clinical studies are required to support the present
cadaveric findings.
Acknowledgments
The authors thank all those who donate their bodies and tissues
for the advancement of education and research.
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