Journal of Medicine and Biomdical Sciences, ISSN: 2078-0273, May, 2010

INCIDENCE OF COMPLICATIONS OF INFERIOR

ALVEOLAR NERVE BLOCK INJECTION
BDS, OMFS, DSC. Nasser Nooh^"
BDS, MSC, PhD, Walid A. Abdullah^
^Associate Professor; Head Division and Consultant of oral and maxillofacial surgery,
Faculty of dentistry, King Saud University (KINGDOM OF SAUDI ARABIA)
^Assistant Professor; Consultant of Oral and Maxillofacial Surgery, Faculty of dentistry,
King Saud University (Kingdom of Saudi Arabia), and lecturer of Oral and Maxillofacial Surgery,
Faculty of dentistry, Mansoura University (EGYPT)
Corresponding author; nnooh6(Q)qmail.com

ABSTRACT
Objective: The aim of this study was to assess the immediate complications after injection of inferior alveolar
nerve block (lANB) using a modified indirect technique. Patients and Methods: A total of 5000 lANB injections was
performed by an oral and maxillofacial surgeon for a total of 3454 adults. Patients with hyperthyroidism were excluded
from the study. The following data were collected; name, age, sex, and side of the lANB. Furthermore, the presence of
any complication was noted as well as its type, persistence, and severity. All data were analyzed using SPSS (SPSS
Inc., Chicago, IL), and descriptive statistics were generated. Results: Failures of lANB and the need for second
injections were seen in 48 patients (1%). Positive aspirations were noted in 84 patients (1.7%). Blanching of the cheek
was found in four patients (0.08%), which persisted for about 5 minutes. Two patients (0.04%) had electrical pain
radiating to the tongue. In addition, facial paralysis was seen in one patient (0.02%), persisting about 4 hours, and
there were two cases of blurred vision (0.04%) Conclusion: Based on the results and within the limitations of the
study, the following can be concluded; This technique shows lower failure rate, lower positive aspiration rate, and lower
incidence of facial paralysis than the standard technique described by Malamed. In addition, aspiration is important
before the deposition of the anesthetic solution in lANB,
Key words: immediate complications, inferior alveolar nerve block, oral and maxillofacial surgery

INTRODUCTION
Probably one of the most common procedures in dentistry is the administration of local anesthetic,^ The inferior
alveolar nerve block (lANB) is the most frequently used mandibular injection technique for achieving looal anesthesia
for restorative and surgical procedures,'^
In 1884, Halsted and Hall described the first inferior alveolar regional nerve block by injecting an anesthetic
solution ( cocaine) into the area of the mandibular foramen ^ Then, Fischer , described the classic technique which,
was modified later by many authors." Nowadays, most of the dentists all-around the world are using a technique
similar to the one described by Jorgensen and Hayden in 1967, which targeting the mandibular nerve. '^ although,
there are some complications associated with this standard lANB technique, it is still considered by many authors as
the technique with the least complications, safest administration, and least discomfort to the patients.
An anesthetic complication can be defined as any deviation from the normally expected pattern during or after
the injection of local anesthesia.^ Complications of local anesthesia can be classified as local or systemic. These
complications may include local and/or systemic immediate post-injection, as failure, needle breakage, penetration of a
blood vessel, hematoma, nerve damage, facia! nerve paresis, blanching, and reactions (eg, overdose, allergy,
idiosyncrasy).^^
Different techniques are used in lANB. Therefore, the aim of this study was to assess the incidence, types, and
severity of the complication(s) of lANB injection given using a modified, indirect injection technique. This study is
simitar to research by Joseph et a l \ this current study focused only on the inferior alveolar nerve injection with a larger
number of injections for more reliable and accurate results.
PATIENTS AND METHODS
Patients
This study period was from March 2001 to November 2008 with 3,454 adults Saudi patients who received a
total of 5000 lANB injections. Only patients with hyperthyroidism were excluded. The study involved 1841 females and
1613 males between 17 to 56 years old with a mean age of 36. The reasons for lANB injections were extractions of
wisdom teeth (74.7%) and extractions of other mandibular posterior teeth (25.3%) (Table 1). Only patients who are
treated at Oral and Maxillofacia! surgery clinic are included in this study. All patients are Saudi referred for extraction of
the lower Molar teeth.

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Journal of Medicine and Biomdical Sciences, ISSN: 2078-0273, May, 2010

lANB Technique
All the lANB injections were done by one experienced oral and maxillofacial surgeon using the same syringe
design and Icng 27-gauge needles (Fig.1). The needle was inserted from the opposite premolar to touch the anteromedial aspect of the ramus 1.5 cm above the occlusion level (Fig.2), then the needle was redirected by moving the
syringe to the same side of injection above the occlusion level (Fig. 3). Then the needle was advanced in contact with
the bone 75% of the needle length should be inserted( about 30 to 34 mm ) (Figs- 4,5).

Fig. 1. Syringe design and long 27'gauge

needle used in the study

Fig. 2. The needle was inserted from the opposite

premolar to touch the antero-medial aspect of the
ramus 1.5 cm above the occlusion level

Fig. 3. The needle was redirected by moving the

syringe to the same side of injection above the
occlusion level
Fig. 4. The needle was advanced in contact
with the bone 75% of the needle length
(about 30 to 34 mm)

Fig. 5. Showing the length of the needle that

should be inserted before deposition of the
anesthetic solution.

J_gj r__3

 Journal of Medicine and Biomdical Sciences, ISSN: 2078-0273, May, 2010

Table 1. Demographic characteristics of participating subjects

number

Age

Bilateral
lANB

Male

1613

18;56y
Mean (37y)

Female

1841

17;52y
Mean (35y)

total

3454

Mean (36y)

582
1031
(1164
injections)
964
877
(1928
injections)
1546
1908
(3092
injections)
5000 lANB injections

Unilateral
lANB

Cause
(wisdom
teeth
extractions)
1718

Cause
(other lower posterior
teeth extractions)

2017

788

3735

1265

477

74.7 %

25 3%

If there is no bone contact, the needle is withdrawn and redirected until having bone contact, we never inject
unless we have a bone contact. Aspiration was performed, and then 1.8 cc of local anesthesia solution (2% lidocaine
with 1;100,000 epinephrine 1.8 cc cartridge) was deposited for the anesthesia of inferior alveolar and lingual nerves.
Then 0.3 cc of 2% lidocaine with 1;100,000 epinephrine solutions was injected in the buccal sulcus opposing to the
affected tooth as an infiltration to the long buccal nerve.
We used only one 1 8 cc cartridge of (2% lidocaine with 1;100,000 epinephrine) in all patients as lANB at the
start of the procedure, then if patients showed improper anesthetic effect for extraction we injected with a second
cartridge and considered as a failure in the first injection trail.

Data Collection and Statistical Analysis

In all patients, the following data were collected: name, age, sex, and side of the lANB The presence of any
complications was noted, including type, persistence, and severity. All data were analyzed using SPSS, and
descriptive statistics were generated. .

RESULTS
A total of 5000 lANB injections were administered during the study period. Failures and the need for a second
injection occurred in 48 patients (1%). Positive aspirations were noted in 84 patients (1.7%). Blanching of the cheek
was seen in four patients (0.08%), which persisted about 5 minutes. Two cases of blurred vision (0.04%) were
recorded in two female patients, both on the right side (lANB), and both patients showed complete improvement after
about 7 minutes. Two patients (0.04%) had electrical pain radiating to the tongue. One person had facial paralysis
(0.02%), which persisted about 4 hours.
Needle breakage, overdose, allergy or idiosyncrasy, and persistent nerve damage were not found in any
patient. Table 2 summarizes the incidence of compiications and their duration in all patients.
Table 2. Number (%) of complications encountered following lANB
Complication

Incidence number

percentage

duration

Failure
Positive aspiration
Blanching

48
84
4

=4 minutes

Blurred vision
Facial paralysis
Electrical pain

2
1

=1 %
17%
0.08 %
0.04 %

0.02%
0.04 %

= 7 minutes
4 hours

DISCUSSION
According to failure rate, this study showed lANB failure was present in = 1 % of lANB injections. These results
were significantly different from previous studies.^^'' Wong and Jacobsen ^ reported a failure rate of 5% to 15%. In
addition, Malamed^ identified the inferior alveolar nerve block as the injection with the highest clinical failure rate (15%
to 20%) when properly administered. Furthermore, Malamed attributed failure to a high degree of variation in the
morphology of the mandibular ramus and the location of the mandibular foramen; however, improper technique is the
most common reason for failure.^'^ ^ Because of the specialty in which lANB is given, the authors' results showed lower
failure rate (1%) when compared with the results of Cohen et al^ and Nusstein et al^'^ who reported that the failure rate
of lANB to be between 38% and 75% of the time in their endodontic clinical trails-

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 Journal of Medicine and Biomdical Sciences, ISSN: 2078-0273, May, 2010

Most of the time, success rates are reportedly higher when a single individual's first demonstration of
anesthesia success is published. A random prospective trial would be required using a standard technique for
connparison.
The authors of this current study saw a reasonably tow positive aspiration rate (1.7%) compared with the results
of previous studies.^^''^TaghaviZenouz et a l " reported an incidence of 15.3%, while Blanton and Roda ^^ stated that
they had a positive aspiration rate of 10% to 15%. This relatively high percentage was decreased in the Gow-Gates
technique to 1.6% to 1,9%''^
Garcia et al^^ and Brodsky and Dower^** indicated the lANB method is superior to the Gow-Gates technique in
percentages of mtravascular puncture, this is related to the large quantity of vascular elements present in the
pterygomandibular space. For this reason, it has been stated that the lANB technique is risky for patients who have
some kind of blood dyscrasias.''^ From this point, the authors consider their technique to be more superior to the
standard regular lANB injection method, as it has a significantly different positive aspiration rate and a comparable
result with Gow-Gates.
Although there is a significant difference between the authors' study results regarding positive aspiration (1.7%)
and those of Frangiskos et al^ (20%), the authors of this paper agree with them that intravascular injection of local
anaesthetic during inferior alveolar nerve block is more or less a common complication. So aspiration is mandatory
before the solution deposition during lANB. However, the authors disagree with Mariis et al,^*" who stated that
aspiration is not necessary because complications from intravascular injection of local anesthesia are uncommon.
Because even if the incidence is very low, yet the complication ( if happened) is serious , so we have to do our
precautions to avoid this low incidence complication by making aspiration prior to each lANB injection.
Visual problems include blurnng of vision or blindness, which can be temporary or permanent. Motor problems
include mydriasis, palpebra! ptosis, and diplopia. Horner-like manifestations involving ptosis, enophthalmos and miosis
of the eye also have been reported.''^"^ Fortunately, most complications in the eye are transient. Rood ^^ reported a
case in which 1.5 mL of lidocaine with epinephrine (1:80,000) in lANB, immediate loss of vision developed in the
ipsilateral eye. along with upper-eyelid ptosis. Yet, within 5 minutes to 45 minutes, all symptoms had disappeared.
Unfortunately, cases of permanent complications also have been reported.^'^^ In this study, the incidence of blurred
vision was (0.04%), which was improved completely within 7 minutes. This result is in agreement with what was
reported by Ngeow et al.^^
The authors agree with Uckan et a P that blanching and ischemia are reported as rare local complications of
local anesthesia Blanching incidence in the current study was (0.08%) Few articles document patients and clinical
photographs.
Needle breakage was not seen during the study, and the authors agree with Lustig and Zusman^ who reported
needles now are made of one piece of metal tube with a soft piastic hub. Occurrences of needle breakage are reported
anecdotally; better manufacturing techniques and single use may account for this.
The incidence of temporary facial palsy in this study (0.02%) was less than Keetley and Moles' results,^" which
found a 0.3% rate. The facial nerve is embedded in the substance of the parotid gland, which has a deep lobe
extending around the posterior ramus o the mandible and projecting forward on the medial surface of the ramus. If the
injection is made too far posteriorly, the anesthetic solution may be injected into the substance of the parotid gland and
could involve the facial nerve. If this happens, the patient will complain immediately of an inability to blink the eye.
followed by a sense of paralysis on the same side of the face.^^
CONCLUSION
The authors' technique shows lower failure rate, lower positive aspiration rate, and lower incidence of facial
paralysis compared with the standard technique described by Malamed.^ Aspiration is important before the deposition
of the anesthetic solution in lANB.

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