Failure of inferior alveolar nerve block:

Exploring the alternatives

GAUTAM A. MADAN, SONAL G. MADAN
and ARJUN D. MADAN
J Am Dent Assoc 2002;133;843-846

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Failure of inferior
alveolar nerve block
Exploring the alternatives

he inferior alveolar nerve block is the most

commonly used block in dentistry,1 having
widespread applications in all fields of dentistry, such as oral surgery, endodontics, periodontics and prosthodontics. Unfortunately,
this block has a comparatively high failure rate (15 to 20
percent).1 In this article, we discuss the reasons for
failure and the alternatives to the conventional inferior
alveolar nerve block.

Several
alternatives to
the inferior
alveolar nerve
block are
available.

FAILURE OF CONVENTIONAL
INFERIOR ALVEOLAR NERVE
BLOCK

There are a number of reasons for the

comparatively high failure rate of this
block, as listed below2:
danatomical: accessory nerve supply
(mylohyoid nerve, cervical cutaneous
nerve C1, C2, auriculotemporal nerve), variable course
of nerve, variation in foramen position, bifid alveolar
nerve or bifid mandibular canal;
dpathological: trismus, infection, inflammation, previous surgery;
dpharmacological: chronic alcohol abuse, chronic narcotic drug abuse;
dpsychological: fear, anxiety, apprehension;
dpoor technique: this is the most common reason for
failure of the conventional inferior alveolar nerve block.
We emphasize the three most commonly occurring problems with this technique.
Inadequate mouth opening. The target area for

Background. Achieving proper anesthesia

is imperative to performing most dental procedures. The conventional inferior alveolar
nerve block is the most commonly used
nerve block technique. In certain cases, however, this nerve block fails, even when performed by the most experienced clinician.
Overall. The authors explore the reasons
why the conventional inferior alveolar
nerve block fails and describe several alternate techniques. They also present the protocol used in their office to achieve
mandibular anesthesia.
Conclusions. Several alternatives to the
inferior alveolar nerve block are available.
Clinicians should investigate them, rather
than repeat the inferior alveolar nerve
block after it has failed.
Practice Implications. Mastering
anesthetic techniques maximizes success in
the dental office. It enables clinicians to
provide better and more comfortable treatment to patients.

this block is the mandibular sulcus, which

is at the level of the coronoid notch and
above the mandibular foramen.3 When
the mouth opening is not adequate, the
inferior alveolar nerve, which descends
from above, is relaxed and away from the
medial wall of the ramus. Consequently,
it is at a distance from the target area,
which leads to inadequate anesthesia.
When the mouth opening is adequate, the
nerve is flush against the medial wall of
the ramus and at the target area.3 Hence,
the patient reports experiencing almost
immediate onset of anesthesia. This is
why the block does not work in cases of
trismus and the closed-mouth block needs
to be administered.
Improper needle placement. A
common mistake is to insert the needle
too far forward or backward of the target
area.2 Clinicians need to insert the needle
just medial to the pterygomandibular
raphe such that it approaches from the
opposite side of the premolar region and
bisects the thumbnail (or fingernail)
placed at the deepest portion of the coronoid notch.1 The needle is inserted to a
depth of 20 to 25 millimeters.1

JADA, Vol. 133, July 2002

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843

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GAUTAM A. MADAN, M.D.S.; SONAL G. MADAN,

M.D.S.; ARJUN D. MADAN, M.D.S.

ABSTRACT

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Figure 1. Closed-mouth block (Vazirani/Akinosi technique).

Haste. Malamed1 recommends waiting three to

five minutes after the injection before starting the
procedure. We believe these minutes can be used
to build rapport with the patient and make him
or her feel at ease. While waiting for a
mandibular block to take effect, the practitioner
should ask the patient to sit up. This postural
change often facilitates the onset of anesthesia.1
WHAT TO DO IF THE CONVENTIONAL
BLOCK FAILS?

Repeat the block. If the conventional block

fails, most general dental practitioners tend to
repeat the block. Although this is effective in a
few cases, repeated injections in the same area
can lead to postinjection pain and even trismus.1
Alternatives to the conventional block may be
useful in this situation and are discussed below.
Closed-mouth block (Vazirani/Akinosi
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Figure 2. Gow-Gates block.

block). This technique is most useful when the

patient cannot open the mouth completely, as is
the case with trismus (Figure 1).4,5 It is a simple
technique that is comfortable for the patient.1
After the patient closes his or her mouth, the clinician advances a syringe fitted with a 35-mm
needle parallel to the maxillary occlusal plane at
the level of the cervical margin of the maxillary
molars. The needle is inserted medial to the anterior border of the ramus and buccal to the maxillary alveolus. The clinician then advances the
needle until the hub is level with the distal surface of the maxillary second molar. After performing aspiration, he or she then deposits a 1.8milliliter cartridge of local anesthetic solution.
This technique does not block the buccal nerve in
some cases, so a separate buccal nerve block may
be required to achieve anesthesia of the tissues
buccal to the mandibular molars.1
No bony landmark is available when performing this technique. Hence, a small chance
exists of overinserting the needle and injuring the
vessels in the pterygoid plexus. However, the
closed-mouth block is a reasonably safe technique
that many practitioners perform routinely to
achieve mandibular anesthesia.2
Gow-Gates block. The Gow-Gates block was
developed by a general dentist (Figure 2).6 It is
technically more difficult than the conventional
and closed-mouth blocks, but has a higher success rate.1 The point of mucosal penetration is
higher than it is with the conventional inferior
alveolar nerve block. This truly is a mandibular
block, because it blocks almost all the branches
of the mandibular branch of the trigeminal
nerve.1
The Gow-Gates block relies on deposition of
local anesthetic adjacent to the head of the
mandibular condyle. With the patients mouth
wide open, the dentist imagines a line drawn
from the ipsilateral angle of the mouth to the
intertragic notch. This is the plane of approach.
The dentist introduces the needle across the
contralateral mandibular canine and directs it
across the mesiopalatal cusp of the ipsilateral
upper second molar; the needle is advanced until
bony contact is made. This point of bony contact
is the condylar head, just below the attachment of
the lateral pterygoid muscle. The dentist withdraws the needle slightly and, after aspirating,
deposits a full cartridge of anesthetic. The patient
should keep the mouth open for a few minutes
until he or she reports experiencing signs of infe-

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rior alveolar anesthesia.

Intraligamentary injection. The intraligamentary injection can be used as a primary or secondary technique (Figure 3).7 It has limitations,
such as short duration, but can be used to overcome a failed alveolar nerve block.2 Although special syringes and needles are available, the
intraligamentary injection technique is equally
effective when a standard 27-gauge needle is used.
With this technique, the clinician inserts the
needle at the mesiobuccal aspect of the root and
advances it until maximum penetration is achieved.
The needle does not penetrate deeply into the periodontal ligament, but is wedged at the crest of the
alveolar ridge. Keeping the bevel toward the root
Figure 3. Intraligamentary injection.
helps to achieve better penetration.8
Approximately 0.2 mL of anesthetic solution is
should bathe the exposed pulp in a small amount
injected per root under pressure.8 This technique
of local anesthetic for about one minute before
is advantageous for patients with bleeding disorintroducing the needle as far apically as possible
ders, since injection into potential spaces, such as
into the pulp and injecting under pressure. This
the pterygomandibular space, is avoided.8 Howtechnique is a vital adjunct when the convenever, it requires multiple insertions for multitional block fails.
rooted teeth. The solution must be injected
Intraosseous injection. As with the
slowly, since rapid injection can cause pain and
intraligamentary injection, the intraosseous injeceven extrusion of teeth.8
tion method can be performed using conventional
Intrapulpal injection. This technique can be
or specialized equipment.10 The site of injection is
most useful in endodontics.9 Unlike other techthe interradicular bone,2 and radiographs are
niques, the intrapulpal injection achieves anesuseful in locating it. The clinician infiltrates the
thesia as a result of pressure, not as a result of
gingiva in the area of penetration with a small
the local anesthetic solution. Saline has been
volume of anesthetic. The region to perforate is
reported to be as
effective as an anesMouth Opening
thetic solution
when injected intrapulpally.9
Adequate
Inadequate
After locating a
Bleeding Diatheses
No Bleeding Diatheses
small access cavity
Closed-Mouth Block
into the pulp, the clinIntraligamentary Injection
Conventional Inferior Alveolar Nerve Block
ician selects a needle
(failure)
that will fit snugly
Closed-Mouth Block/Gow-Gates Block
into it. A small
(failure)
amount (0.1 mL) of
anesthetic is injected
Endodontics
Pediatric Dentistry
Oral Surgery/Periodontal Surgery
under pressure. The
Conservative Dentistry
Fixed Prosthodontics
patient will experiIntraligamentary/
Intraosseous/Intraseptal
Injection
ence some transient
Intraligamentary Injection
Intraligamentary Injection
Intrapulpal Injection
(not in primary teeth)
discomfort during the
(failure)
(failure)
injection. Onset of
Intraosseous Injection
Intraosseous Injection
anesthesia is rapid.
When the operative
(failure)
site is too large to
Conscious Sedation/General Anesthesia
allow a snug needle
fit, the clinician
Figure 4. Anesthesia protocol used in the authors clinic.

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only. Every practitioner must develop his or her

own protocol based on knowledge and mastery of
techniques.
CONCLUSION
Dr. Gautam Madan is in
private practice as a
consultant oral and
maxillofacial surgeon,
B-10, Nobles, Opp
Nehru Bridge, Ashram
Road, Ahmedabad,
India 380009, e-mail
gautammadan@yahoo.
com. Address reprint
requests to Dr. Gautam
Madan.

Dr. Sonal Madan is in

private practice as a
consultant oral and
maxillofacial surgeon,
Ahmedabad, India.

Dr. Arjun Madan is in

private practice as a
consultant orthodontist,
Ahmedabad, India.

846

1. Malamed SF. Techniques of mandibular anesthesia. In: Handbook

of local anesthesia. 4th ed. Noida, India: Harcourt Brace; 1997:193-219.
2. Meechan JG. How to overcome failed anesthesia. Br Dent J
1999;186(1):15-20.
3. DuBrul EL. Anatomy of mandibular anesthesia. In: DuBrul EL,
Sicher H, eds. Sicher and Dubruls oral anatomy. 8th ed. St. Louis:
Ishiyaku EuroAmerica; 1996:273-80.
4. Vazirani SJ. Closed mouth mandibular nerve block: a new technique. Dent Dig 1960;66:10-3.
5. Akinosi JO. A new approach to the mandibular nerve block. Br J
Oral Surg 1977;15(1):83-7.
6. Gow-Gates GA. Mandibular conduction anesthesia: a new technique using extraoral landmarks. Oral Surg Oral Med Oral Pathol
1973;36:321-8.
7. Walton RE, Abbott BJ. Periodontal ligament injection: a clinical
evaluation. JADA 1981;103:571-5.
8. Malamed SF. Supplemental injection techniques. In: Handbook of
local anesthesia. 4th ed. Noida, India: Harcourt Brace; 1997:220-31.
9. VanGheluwe J, Walton R. Intrapulpal injection: factors related to
effectiveness. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1997;83(1):38-40.
10. Replogle K, Reader A, Nist R, Beck M, Weaver J, Meyers WJ.
Anesthetic efficiency of the intraosseous injection of 2% lidocaine
(1:100,000 epinephrine) and 3% mepivacaine in mandibular first
molars. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1997;83(1):30-7.
11. Dunbar D, Reader A, Nist R, Beck M, Meyers WJ. Anesthetic efficiency of intraosseous injection after inferior alveolar nerve block. J
Endod 1996;22:481-6.
12. The peoples cyber nation. Available at: www.cyber-nation.com/
victory/quotations/authors/quotes_disraeli_benjamin.html. Accessed
May 30, 2002.

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within the attached gingiva,

about 2 mm below the gingival
margin of adjacent teeth in the
vertical plane bisecting the interdental papilla.
The perforation can be made with a sterile bur
on a slow-speed handpiece, which is advanced
until the obvious penetrating feeling into the cancellous space occurs. The dentist removes the perforator, advances a 6-mm 30-gauge needle
through the defect into the cancellous bone and
administers 0.2 to 0.5 mL of solution slowly. Plain
2 percent lidocaine solution is preferred because
lidocaine with epinephrine can cause palpitations.8 Although aspects of intraosseous anesthesia (such as increased risk of postoperative
pain, discomfort and infection) preclude its use as
a primary technique, it may be a useful adjunct to
an inferior alveolar nerve block.11
Other anesthetic techniques are available, such
as intraseptal injection and extraoral techniques,
but these are of limited clinical value and are not
discussed here.
Figure 4 illustrates the protocol followed in our
clinic for achieving local anesthesia in the
mandible. However, this is meant to be a guide

It is in the practitioners interest to understand

and master alternative techniques for achieving
local anesthesia so that a wide variety of options
is available. This should minimize failure and
maximize success. In addition, making use of
these techniques will enable practitioners to provide better and more comfortable treatment for
patients. After all, as Benjamin Disraeli said, As
a general rule, the most successful man in life is
the man who has the best information.12