Inferior alveolar nerve block ineffective: solution?

For bicuspids I am ONLY infiltrating with articaine these days. Intraligament injection if a buccal infiltration isn't enough. I try to stay away from mandibular block whenever I can.

The mylohyoid branch does not extend to the premolars and he was having issues on the buccal which wouldnt be infiltrated by the mylohyoid nerve

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.

Where is the article available to read? Is a pdf available?

Akinosi Block

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.

Yea. That works and a very mature answer.

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!

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

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.

Amen.

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.