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Researches

Original Article
Inferior alveolar nerve block: Alternative technique
K. Thangavelu, R. Kannan, N. Senthil Kumar

Department of Oral and Maxillofacial Surgery, Vinayaka Mission’s Sankarachariyar Dental College, Ariyanoor, Salem, Tamil Nadu, India
Corresponding author: Prof. K. Thangavelu, Vairam Hospital, EB Colony, Namakkal, Tamilnadu, India. E-mail: vairamhealthcare@yahoo.co.in

Abstract
Background: Inferior alveolar nerve block (IANB) is a technique of dental anesthesia, used to produce
anesthesia of the mandibular teeth, gingivae of the mandible and lower lip. The conventional IANB is
the most commonly used the nerve block technique for achieving local anesthesia for mandibular
surgical procedures. In certain cases, however, this nerve block fails, even when performed by the most
experienced clinician. Therefore, it would be advantageous to find an alternative simple technique.
Aim and Objective: The objective of this study is to find an alternative inferior alveolar nerve
block that has a higher success rate than other routine techniques. To this purpose, a simple
painless inferior alveolar nerve block was designed to anesthetize the inferior alveolar nerve.
Materials and Methods: This study was conducted in Oral surgery department of Vinayaka
Mission’s dental college Salem from May 2009 to May 2011. Five hundred patients between the
age of 20 years and 65 years who required extraction of teeth in mandible were included in the
study. Out of 500 patients 270 were males and 230 were females. The effectiveness of the IANB
was evaluated by using a sharp dental explorer in the regions innervated by the inferior alveolar,
lingual, and buccal nerves after 3, 5, and 7 min, respectively.
Conclusion: This study concludes that inferior alveolar nerve block is an appropriate alternative
nerve block to anesthetize inferior alveolar nerve due to its several advantages

Key words: Aanesthesia, inferior alveolar nerve block, mandible

INTRODUCTION is a routine block injection administered regularly in

Inferior alveolar nerve block (IANB) is a technique used
to produce anesthesia of the mandibular teeth, gingiva
of the mandible, and the lower lip. These procedures
anaesthetize the inferior alveolar nerve (IAN) prior
to entering the mandibular foramen. Although IANB
Access this article online
Website DOI
www.aeronline.org 10.4103/0259-1162.103375
Quick Response Code
dental practice, failure to achieve satisfactory levels
of analgesia is noticed in few cases.[1,2] Predictable
anesthesia is an essential requirement for both the
patient and the dentist in Dentistry. The patient’s
opinion about his dental treatment is closely related to
the local anesthesia experiences he has had. The proper
use of local anesthesia techniques and pain management
are indispensable for successful dental treatment.[3]
IANB is the most commonly used nerve block technique
in extraction of lower teeth and other minor surgeries
done in mandible. Various techniques are in current
use to anesthetize the IAN. Each technique has its
advantages and disadvantages. So the aim of this study
is to find an alternative IANB that has the minimal
failure rate and with less technical difficulty.

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Anesthesia: Essays and Researches; 6(1); Jan-Jun 2012 Thangavelu, et al.: IAN block-Alternative technique

AIM AND OBJECTIVE

The aim of this study is to present an alternative to the

current techniques available to anesthetize the IAN. To
this purpose, a simple painless IANB was designed to
anesthetize the IAN. The objective of this study is to find
an IANB that has higher success rate than other routine
techniques.

MATERIALS AND METHODS

This study was conducted in Vinayaka Mission’s Dental

Figure 1: Palpation of the anterior border of the ramus
College who came for extraction of Lower molars,
premolars and anterior teeth over a period of 2 years
from May 2009 to May 2011 based on the experience
gained from 500 patients. Out of 500 patients, 270 male
and 230 female, age 20 to 60 years, scheduled for lower
third molars, premolars, canines, and incisors extractions
and who have given their informed consent to participate.
The patients those who were normally healthy patients,
ASA I, who were not taking any medication and have
never had allergic or toxic reactions to any local
anesthetic agent and they were randomly selected. All
the injections were given by authors of this article.
Disposable 3 mL syringe with 32 mm length and 25 gauge
needles were used for this technique. Lignocaine hydro Figure 2: Midpoint and initial site of needle insertion
chloride with adrenalin 1 in 80 000 was the anesthetic
solution used in all 500 nerve blocks. For each technique
2.5 mL anesthetic solution was taken. The time required
to develop anesthesia was 3 to 7 min.

Technique
1. Patient is advised to sit in semi supine position and few
inches below the operator’s elbow level in the dental
chair.
2. The patient is advised to open the mouth fully so that
the occlusal table of mandible is parallel to the floor.
3. The operator’s thumb finger is placed over the anterior
border of ramus that helps in retraction of tissues mildly
as shown in Figure 1.
4. Imaginary midpoint between the upper occlusal plane
and lower occlusal plane, in anterior border of ramus
is selected [Figure 2] or coronoid notch in the anterior
border of mandible is identified.
5. 6 to 8 mm above this midpoint or coronoid notch and
8 to 10 mm posterior to the anterior border of ramus is
the first site of insertion of needle as shown in Figure 2.
6. The barrel of the syringe is placed between canine
and premolars of contra lateral side of extraction and
the needle is inserted at the selected site of insertion
[Figure 3].
7. Now the needle is advanced till it hits the bone that
is the medial side of ramus behind anterior border of
ramus. Few drops of the Local anesthetic solution are
deposited at this place. This may anesthetize the long
buccal nerve.
Figure 3: Site of needle insertion
8. The thumb finger over anterior border of ramus is
withdrawn and allows the free movement of tissues over
anterior and medial side of ramus. The barrel of syringe
is adjusted towards midline of mandible to insert the
needle freely further along the medial side of ramus.
9. ‘During the course of injection few drops of Lignocaine
solution is being deposited to anesthetize the path of
insertion and lingual nerve. Here closeness of needle
to the medial side surface of ramus is important than
position of barrel of syringe. The closeness of needle
to ramus is confirmed by frequent touch of tip of the
needle on the bone of ramus during the course of
injection.
10. The needle is advanced further into the tissues
supra periosteally towards the target area above the

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Anesthesia: Essays and Researches; 6(1); Jan-Jun 2012 Thangavelu, et al.: IAN block-Alternative technique
mandibular foramen by following the medial side of
ramus as guide.
11. When 21 to 24 mm length of the needle is inserted from
anterior border of ramus, needle distance with anterior
border of ramus was verified as shown in Figure 4.
According to Malamed study the distance between
mandibular foramen and anterior border of ramus is 20
to 24 mm.[14]
12. Now the tip of needle would be superior to IAN entry
into its mandibular foramen.
13. To bring the tip of needle closer to bone and IAN the
barrel of the syringe is taken back to the contra lateral
side. The closeness of tip of needle to bone is confirmed
by resistance of bone for further entry of needle as
shown in Figure 5.
14. One to 1.5 mL of local anesthetic solution should be
deposited at this place (pterygomandibular space) to
anesthetize inferior alveolar nerve.
15. To prevent failure of anesthesia spread the deposition
of solution equally from 21 mm distance to 24 mm
distance of needle. This helps in deposition of solution
over wide area.
16. To achieve buccal nerve anesthesia, few drops of local
anesthetic solution should be injected into the tissues
adjacent to the tooth to be extracted.
The effectiveness of the technique was evaluated by
subjective and objective symptoms in the patients.
To test the symptoms of anesthesia the following test was
done.
1. A sharp dental explorer applied in gingival tissues in
front of lower premolar on the extraction side. This was
to assess the IAN anesthesia.
2. One half of the tongue on the side of extraction was
tested with probe to assess lingual nerve anesthesia.
3. The tissues adjacent to the tooth to be extracted
were tested to check buccal nerve anesthesia. The
patient’s response was recorded for each test. When
patient shows no sign of pain on probing denotes that
corresponding nerve is anesthetized. Probe test started
after 3 min and repeated after each 2 min. When
there were no symptoms of anesthesia of a particular
Figure 4: Verification of length of needle entry from the anterior border
of the ramus
nerve after 7 min denotes failure of the technique that
requires repeat of the technique.
Another test used to determine anesthesia was based on
the answer from the patient to the following question.
Does this area feel numb compared to the other area?
This both test are still the most available practical clinical
test to ensure an objective anesthesia sign before any
dental extraction.[3] Immediately after achieving a positive
response for anesthesia in all three terminal nerve test
areas, the extraction began. Out of 500 patients, 476
patients experienced no pain. In the remaining 24 patients
second nerve block was given to obtain no pain status.
RESULTS
The technique proved to be effective in 95% of the
cases. The symptoms of IAN anesthesia developed after
first nerve block in 476 patients’ (95% success rate). The
symptoms of IANB developed after the second nerve
block of same technique in 24 numbers of patients.
Therefore, more than 95% was the success rate of this
technique. Complications such as positive aspirations,
trismus, needle breakage, hematoma and nerve injuries
were not encountered.
DISCUSSION
In 1884, William S. Halsted and Richard J. Hall first
achieved neuroregional anes­ thesia in the mandible
by injecting a solution of cocaine in the vicinity of the
mandibular foramen.[4] Since then many techniques
have been introduced. As a result of the difficulties and
failures observed in achieving IANB, various methods
of anesthesia have been suggested.[5] The following
anesthetic techniques are available to anesthetize
mandibular or IAN, lingual and buccal nerves. Namely
1. Conventional IANB;
2. Gow-Gates mandibular nerve block; 
3. Closed mouth block (Vazirani/Akinosi block);
4. Fischer 1.2.3 IANB;
5. IANB described by Malamed SF.
Figure 5: Barrel of syringe brought to contralateral side and the needle
closeness to the bone is verified and solution deposited
55
Anesthesia: Essays and Researches; 6(1); Jan-Jun 2012 Thangavelu, et al.: IAN block-Alternative technique
The conventional IANB is the most commonly used
nerve block technique for achieving local anesthesia
for mandibular surgical procedures. In certain cases,
however, this nerve block fails, even when performed
by the most experienced clinician. Unfortunately, this
block has a comparatively high failure rate[2] (15% to 20%).
Some authors have estimated the failure rate of this
conventional IANB to be approximately 20% to 25%.[2]
In this technique, the vertical line description two-thirds
to three-fourths the distance between the coronoid
notch and the posterior border is not very specific and
allows for a considerable margin of error.[6] The selection
of site of initial needle entry and anatomical landmarks
described by Malamed were difficult to identify and apply
by beginners clinically that can lead to failure.
A recognized disadvantage of the Gow-Gates technique
is slower onset of anesthesia. Malamed[7] stated that the
Gow-Gates technique has 5 to 7 min latency. Levy[8] stated
that the latency for a central incisor was achieved in 10 to
12 min. Agren and Danielson[9] stated that the latency
can be from 10 to 20, even to 30 min, and in rare cases
to 45 min. Joffre and Munzenmayer[10] achieved a range
of 8 to 25 min of induction time in his results. Tiol[11]
stated that 10 to 15 min post injection is a prudent time
to wait if anesthesia symptoms have not appeared yet.
Malamed further reported when the Gow-Gates technique
is administered by inexperienced dental surgeons, it can
produce more number of failures and complications than
conventional techniques.[8] It is technically more difficult
than the conventional and closed mouth technique.[2]
The success rate depends upon experience of a dental
surgeon.
Closed-mouth block (Vazirani/Akinosi block) technique is
most useful when the patient cannot open the mouth
completely; as is the case with trismus no bony landmark
is available when performing this technique. Hence, a
small chance exists of over inserting the needle and
injuring the vessels in the pterygoid plexus.[2] Failures
were observed in the conventional inferior nerve block
and in the Akinosi block technique.[12] According to the
Malamed Closed-mouth block technique has a more failure
rate than conventional IANB.[13] This technique cannot be
used due to its higher rate of failures. Thus, most dental
professionals do not utilize the Gow-Gates and Akinosi
techniques.[4] Despite the reported ad­ vantages of the
Gow-Gates and Akinosi techniques, the find­ings from this
study indicated that only a small percentage of clinicians
trained in these injec­tion techniques choose to use them
as their primary means of establishing mandibular anes­
thesia and a large percentage completely abandoned
these techniques.[4]
Fischer 1, 2, 3, technique relies on the presence and
identification of anatomi­cal landmarks such as the
external oblique ridge, coronoid notch, apex of buccal
56
pad of fat, pterygomandibular raphe, and the retro molar
pad. Failure to identify those landmarks may result in
improper technique and failure of anesthesia. During the
course of injection in the first stage 3–6 mm distance,
second stage 12 mm distance, and in the third stage
24 mm distance of needle insertion to be made from
42 mm length needle. Since there are no markings in the
needle it is difficult to apply by operators. The possibility
of over penetration may result in this technique that may
result in facial palsy.
The technical difficulties and failure of anesthesia in all
the available IANBs were written in literature and reviews.
It is essential to find an alternative technique that has
a minimal failure rate. The technique described in this
study would be an ideal alternative option for the current
techniques due to its non reliability of several anatomical
landmarks and its higher success rate. The anatomical
landmarks described in this IANB technique were
(a) Anterior border of ramus and (b) Mandibular occlusal
plane.
Since the highest distance of mandibular foramen from
the level of the occlusal plane is 11 mm,[7] the selection
of site of initial needle puncture is 12 to 16 mm above
the occlusal plane and also it is essential to insert the
needle to a distance of 20 to 25 mm from anterior border
to reach the space above mandibular foramen,[14] then the
needle tip would be nearer and above the nerve entry.
This favors the placement of the tip of needle superior
to mandibular foramen, on complete insertion of 22
to 24 mm needle distance from the anterior border.
The deposition solution above foramen and nearer to
nerve baths the IAN results in effective anesthesia. The
maintenance of needle nearer to bone helps to avoid
deposition of solution into the muscle that prevents post
injection trismus.
In our study only 24 patients (5%) of the sample required
second injection to produce the satisfactory level of
anaesthesia. This may be due to anatomical variation of
the mandibular foramen in the patients itself but exact
cause is not known.
Thus, with abovementioned all advantages our study
concludes IANB is an ideal option in anesthesia of IAN,
lingual, and buccal nerve.
CONCLUSION
This study concludes that IANB is an appropriate
alternative nerve block to anesthetize IAN due to its
several advantages.
REFERENCES
1. Madan GA, Madan SG, Madan AD. Failure of inferior alveolar nerve block:
Exploring the alternatives. J Am Dent Assoc 2002;133:843-6.
Anesthesia: Essays and Researches; 6(1); Jan-Jun 2012 Thangavelu, et al.: IAN block-Alternative technique

2. Dover WS. The mandibular block injections it sometimes fails. J Dent Assoc
South Afr 1971; 26:373-7.
3. Bernhard Rolf Kohler, DDS, Loreto Castello´n, DDS, MSc and Germa´n Laissle,
DDS. Gow-gates technique: A pilot study for extraction procedures with clinical
evaluation and review. Chile SCIENTIFIC REPORT- Anesth Prog 55:28 2008.
4. Johnson TM, Badovinac R, Shaefer J. Teaching alternatives to the standard
inferior alveolar nerve block in dental education: outcomes in clinical practice.
J Dent Educ 2007;71:1145-52.
5. Todorović L, Stajcić Z, Petrović V. Mandibular versus inferior dental
anesthesia; clinical assessment of 3 diff techniques. Int J Oral Maxillofac Surg
1986;15;733-8.
6. Quinn JH. Inferior alveolar nerve block using the internal oblique ridge. J Am
Dent Assoc 1998;129:1147-8.
7. Malamed SF. The gow-gates mandibular block. Evaluation after 4,275 cases.
Oral Surg Oral Med Oral Pathol 1981;5:463-7.
8. Levy TP. An assessment of the gow-gates mandibular block for third molar
surgery. J Am Dent Assoc 1981;103:37-41.
9. Agren E, Danielsson K. Conduction block analgesia in the mandible.
A  comparative investigation of the techniques of fischer and gow-gates.
Swed Dent J 1981;5:81-9.
10. Jofre J, Munzenmayer C. Design and preliminary evaluation of an extra
oral gow-gates guiding device. Oral Surg oral Med Oral Pathol Oral Radiol
Endod 1998;85:661.
11. Tiol A. Tecnica innovadora para el bloqueo mandibular, con el uso de una
guia metalica. Rev Pract Odontol 2001;6:7-14.
12. Boronat López A, Peñarrocha Diago M. Failure of loco regional anesthesia
in dental practice. Review of literature. Med. Oral Patol. Oral Cir. Bucal
(online) 2006;11:510-13.
13. Bremer G. Measurement of special significance in connection with anesthesia
of inferior alveolar nerve. Oral Surg Oral Med Pathol 1952;5:966-88.
14. Malamed SF. Handbook of local anesthesia. 4th ed. St. Louis: Mosby; 1997.
How to cite this article: Thangavelu K, Kannan R, Kumar  NS.
Inferior alveolar nerve block: Alternative technique. Anesth
Essays Res 2012;6:53-7.
Source of Support: Nil, Conflict of Interest: None declared.

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