GBR Patient Reporting Pain when Preparing Osteotomy Sites?

yes, there may be alternative sensation to this area through the mylo-hyoid nerve, while this is a nerve that controls muscular movement, it is shown to have sensory fibers as well. this is quite rare, and i don't think it's your issue. A lingual infiltarion into the floor of the mouth will get this branch. First question: do you know that you successfully blocked V3 in this area?? you may have missed and really gotten only buccal and lingual infiltration anesthesia. I have noticed in certain cases that I think I have a real block and I don't, a new block in a higher position and 15-20 minutes of time gets me there. The bifid- or muti-fid inferior alveolar nerve concept doesn't work here if you had pain only 4-6mm into the bone. If in this case, you truly had V3 anesthesia, the only thing that I can think of is granulomatous remnants of periapical or periodontal infection from the teeth that were previously there. These areas can be incredibly hard to anesthetize as there is highly inflamed bone adjacent to them. Sometimes lidocaine soaked gauze packed into the sites for 10-15 minutes will be the answer.

Thanks for your input sb oms. I was pretty sure I had a good block. I performed a Gow Gates. But I guess you can't be 100% sure.

Pain on the lower during the drilling may mean the clinician has gone too far toward toward the lingual.

Am I glad to hear that there was someone else in the big wide world, who also had to abort an implant placement procedure as a result of the local anesthetic not seeming to do its job... (apologies Dr AB for sounding so celebratory almost!!) ! We had a case that we had to abort as a result of the severe pain in the region of the intended implant placement as the patient was unable to take the pilot drill beyond a certain initial depth. With over 16 years of OMFS practice, my ego refused to let me believe it was a failure of anesthesia that could be attributable to either a flaw in the technique or my assessment of the anatomy... I was sure that I had accounted for any possible accessory innervation, closer looks at the Panoramic radiograph, RVG images et al gave me what I was sure was foolproof assessment of the neuroanatomy! I therefore looked at other possible causes for the issue. Interestingly, I was to stumble upon the answer as a result of the enthusiastic resourcefulness of one of our Post grad students, who upon the repitition of the same situation with a case we were doing together,went back and did her research really well to figure out what seemed like a plausible theory for the occurrence. when one opens up a large area in the proximity of a terminal nerve branch, there is a likelihood of injuries to smaller 'twigs' of this branch, which when it heals leads to the formation of traumatic Neuromas in the region after healing. Upon re-entry in the same vicinity the next time, these neuromas fail to get anesthetized because of an incomplete development of their lipo-protein (neuronal)sheaths. As Esters & Amides are particularly dependant on their dissociation constants (PKa), the altered surface pH of the areas where there are Neuromas, makes the anesthetic agent seem to work sub-optimally or not work at all at times! Although the objective and subjective signs of the block are elicited by the clinician, the specific areas are still "resistant" to the anesthetic! Seems like a theory!! Cheers

great explanantion by Sir (Dr. Jeevan Aiyappa, I have met you at Manipal in January 2010). Just wanted to know does the theory has any histological evidences??? (being an oral pathologist cum oral implantologist cant stop asking about histological evidences, no offense...

It may be a small posibility but distortion of the OPG may be the reason.I think ıt ıs best to use CT for ımplantology and not to trust OPG too much.

Dear Manish, I will seek the resourcefulness of our former PG Dr Bhatnagar to dig out the answer for me (I know I am passing the buck), but will hope to have the article with me sometime soon and be able to share it with you. Just didn't seem like this was a plausible hypothesis at the time, but more interaction with colleagues and other practitioners, leads me to believe ther could be something in it! Cheers Jeevan

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