Inferior alveolar nerve block ineffective: solution?

Quick question for everyone here. Have you ever faced a situation where you gave an inferior alveolar nerve block and it seemed to be effective with expected signs and symptoms with lip numb, etc.  But when you start reflecting  a flap in the premolar region, the patient experienced pain? I just faced this, and I assumed that the inferior alveolar nerve bifurcated higher than the level of my original block, so I gave a second at a higher level.  But this did not solve the problem.  How do I overcome this with a different injection protocol to get the premolar region numb?

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34 thoughts on “Inferior alveolar nerve block ineffective: solution?

  1. I typically after giving the IAN block will place a carpule in the mental foramen area and use Articaine for both shots. Rarely am I seeing issues in the premolar area with this. When your working on the 1st molar and are still getting some sensitivity a 1/4 carpule in the lingual floor adjacent to the molar will get the branch of the mylohyoid that some pts have

      1. It certainly CAN extend to the bicuspids. We did a CBCT study that was published in the journal Oral Implantology clearly showing extensions at the bicuspid positions and of substantial diameter. We also demonstrated differences within individuals from side to contralateral side. You should read it.

  2. The “closed mouth technique” is a great answer. Have the patient close in centric but not squeeze, then aligh your syringe at the level of the maxillary junction of the the attached and unattached gingiva with a 27 ga long needle. Go in and when you hit the ramus of the mandible, “shift” your needle so that you ca go straight back..maybe with buccal direction of the needle. Then bury the needle and inject. You will inject right at the Condyle level and get the long buccal, the lingual, and the inferior alveolar nerves. It works!

    1. I removed impacted mandibular third molars for eight years for a large practice owned by a general dentist. I encountered this situation a number of times over the years. One solution that has saved me over and over was this………………….. I took a full carpule of Marcaine or 1:50,000 Lidocaine HCL and injected it deeply down laterally to the buccal most of the way to the inferior angle of the mandible, and I repeat I buried the needle deeply. along with the lingual injection mentioned above this may help you if all else fails.

  3. When I do implants in the mandible I just use infiltrative anesthesia (always with articaine) in both sides (buccal and lingual) and that is enough…when I do extraction always do go gates and reinforce with infiltrative technic in the buccal side.

  4. If you are operating on the patient’s posterior buccal mandible, it appears your patient
    did not have profound enough anesthesia to the nerve(s) supplying the cheek and mucosa of the posterior mandible. I suggest you do a literature search of the long buccal nerve- also called the buccal nerve. In most patients, you’ll find the block injection anesthetizes the buccal nerve. But, ocassionally an injection at the depth of the vestibule inferior to the lower first molar is indicated- the dose of anesthesic solution varies.

  5. I start with a V3 block. If that doesn’t work, I dissect to the IA and resect the branch proximal to the bifurcation. Profound numbness every time.

  6. When using lidocaine for IAN block and then you find that the anesthesia is not good enough, if you try again with lidocaine the second injection will be less than half as effective as the first. Lidocaine injected is in both ionized and unionized states. About 25% in the area is unionized and fat soluble and effective for local anesthesia. Once injected the Ph of the tissue is lowered and the second injection, must less is unionized and fat soluble due to the lower Ph of the tissue. A second injection would be better with 3% carbocaine which will have more fat solubility (needed to permeate into the myelin sheath) and it will benefit from the epinephrine already injected with the lidocaine.

    Since Articaine is 4% and much more fat soluble it will infiltrate better even as a block and is probably a better first choice. Studies show that lasting paranesthesia from 1 or 2 carpules of Articaine is extremely rare and more likely due to needle stick.

    Nonetheless, if IAN blocks fail, buccal and lingual infiltration with Articaine will almost always remedy the lingering ability to feel pain.

    One last thought is that if your local anesthetic is stored above or below the recommended storage temperature, it will be ruined and should be replaced.

  7. Dr. Torchia’s answer is the correct one. Further attempts at another IFA nerve block will not work. Do a Long Buccal Branch block, as outlined by Dr. Torchia, and you will be good.

  8. Well thanks for so many useful comments.As i want to discuss little more,I have few genuine arguments.I already knew actually about the mylohyoid.so if it’s that then a higher block which I gave the 2nd time should have blocked that as the nerve is just outside the canal running with IANB. (Same with a gow gates or vazirani) as suggested by few of you.question regarding infiltration,I wonder how an infiltration should work better than a block as the mandible bone is very thick and a large amount of anesthetic is required for infiltration for it to seep through the bone and reach the nerve.About the long buccal,I had given it already.sorry didn’t mention (and that I don’t think should help in premolars anyway correct me if some new studies have come.)happy with so many great thinking dentists and answers.kind regards

  9. pain experienced in soft tissue when performing flap incision, and you didn’t mention that you gave the patient buccal infiltration which is a must to prevent soft tissue pain.

  10. All solutions are great. I think the original poster was looking for a clinical solution.
    Infiltrate
    Long buccal
    Closed mouth/ Akinosi- this technique is the bomb. Just saying.
    Between these three the area should be sufficiently numb 99.9% of the time.
    I would like to see that article though for my scientific edification.

  11. I am a little surprised with the comments about extra innervation to the premolars from the nerve to mylohyoid or long buccal. Actually the extra innervation comes from the cutaneous coli branches of the cervical plexus. (C2, C3). Infiltration anathesia at the premolar region is all that u need when this happens. Extra nerve block at a higher level will not work. Long buccal only innervates the buccal mucoperiosteum opposite the last 3 molar teeth, so again this won’t work.

    1. Dear Dr. Shalesh,
      I am currently in the process of rewriting the chapter I wrote, “Micro-Surgical Endodontics”, in Dr. Arnaldo Castellucci’s textbook, “Endodontics”, published in 2009. As an endodontic surgeon, profound anesthesia was a top concern. You mentioned the ascending branch of the mylohyoid nerve. The following is a paragraph from my new chapter in progress. References are no listed, but are in the chapter.

      Clinical studies have shown that even when a proper technique is employed, inferior alveolar nerve blocks (IANB) fail in approximately 30% to 45% of cases. [29] This may sometimes account for the pain during the operation following an apparently successful mandibular injection. Located to the lingual of the mandibular 2nd molar apex, an ascending branch of the mylohyoid nerve may exist, and innervate the mandibular teeth. [30] There is the possibility of a small branch of the mylohyoid nerve that enters the mandible through the foramen coli, which can cause considerable amount of discomfort if present and not anesthetized. [31,32] Traditionally, the nerve to the mylohyoid has been considered a motor nerve. However, dissection and clinical studies have challenged this dogma implicating the nerve to the mylohyoid as a nerve of accessory innervation to mandibular teeth. [33] This may possibly account for some IANB failures [Fig. 29.]. Not every patient will require this kind of anesthesia, but the dentist must be aware of its existence. In an attempt to minimize the IANB failure rate, the author routinely injects a small amount of 2.0% Lidocaine lingual to the apex of the mandibular second molar, immediately followed by approximately ½ carpule of 0.5% Bupivacaine, to the same area, for more predictable and profound anesthesia.

      The injection at the site of the foramen coli has been essential for all mandibular procedure on my patients over the past 50 years, with great results! I hope this helps!

      1. Thanks for your input. When we published several years ago about accessory innervation from the mylohyoid branch, people called us heretics. Great validation from another source. RJM

  12. You guys are much smarter than I, here’s my technique. Inferior alveolar with 2%lidocaine 1:100,000 epi. Then Long buccal. Wait a good 5 min. Then I stick the needle in between the canine and lateral incisor to bone, to test for completeness.(Trick I learned in residency) Extra infiltation in the mental area is also great it will give you hemostasis. Sometimes the patient will jump due to proprioception not pain when a flap is raised. I use Askinosi tech when there is trismus. The Gow gates has some significant sequela so I don’t recommend using it. I’m not familar with Articaine may give it a try. Also picked up an intraosseous technique with special needle. Most folks don’t wait long enough for the block to work. Most of my patients are sedated so I have some wiggle room but they DO move under anesthesia or they will tear up. It’s bad for business so I make sure they are comfortable. Practical advice since there variation in anatomy.

  13. Hi
    I have recently purchased the intraosseous injection Anesto manufactured by W&H.
    I do not use it for every case, but for those who do not respond well to a mandibular block – I find it a life saver.
    Good luck!

  14. Never do block in the mandibular area when doing implants of course this means flaps. In these cases I only use infiltration from both sides. Block only in extraction.

  15. Thank you all for the Anatomy 1 refreshing course, but why do you want to flap if you are implanting in the premolar area? in matter of fact, in ANY area. Unless you do not know how to read x Rays or tomographies flapping is ancient history. Once you determine the place of insertion, you cut a cross on the gum over the site and proceed to perforation. To do this, you only require infiltration on the soft tissue . Use the brand of your choice.

    1. I guess not all of us have machine and God-like precision as you do. I like to see what I am doing. I am not a machine and I do know how to interpret CTs. Flapping is indicated and a valuable tool.

  16. Why flap to implant in premolar region? Flapping is ancient history.
    Infiltrate the soft tissue surrounding the selected site, make a cross on the tissue and perforate. Use the brand name you are used to.

  17. When I hear someone never does flaps for implant surgery I shudder. There are many reasons a flap will provide you greater predictability and in many cases is an absolute requirement. I think those that have done decades of surgery understand what I mean. Great comments though on how to improve your ability to get profound anaesthesia.

  18. I like to see the bone and use the landmarks, there is very little morbidity in raising a flap by an experienced surgeon. Flapless has less accuracy and more margin for error. It is not ancient history but the treatment of choice.

    1. Thank you Rand and CRS. I think this forum is valuable especially when you can get feedback from experienced surgeons. For those of us that have built careers on dental implants it is always in our best interests to maximize our success and predictability and minimize complications. Too often I see implants that have been as I say “set up for failure” from the beginning. I could talk on this point for hours. Yes there are times I do not raise a flap but going flapless for all of your cases will not serve you or your patient’s in the long run. Some people choose not to flap either because they lack the training, confidence or simple want to do the procedure quickly for a greater profit based on productivity, none of which are appropriate reasons to not do the best for your patients. The more ways you learn to treat cases the better surgeon you will become. Remember it is called surgery for a reason. All the best.

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