Single-insertion technique for anesthetizing the inferior alveolar nerve, lingual nerve, and long buccal nerve for extraction of mandibular first and second molars: a prospective study

Abstract

Objectives:
Appropriate and accurate local anesthetic (LA) techniques are indispensable in the field of oral and maxillofacial surgery to obtain a satisfactory outcome for both the operating surgeon and the patient. When used alone, the inferior alveolar nerve block (IANB) technique requires supplemental injections like long buccal nerve block for extraction of mandibular molars leading to multiple traumatic experiences for the patient. The aim of this study was to anesthetize the inferior alveolar, lingual, and long buccal nerves with single-needle penetration requiring a minimal skillset such as administering a conventional IANB through introduction of the Benny Joseph technique for extraction of mandibular molars.

Materials and methods:
This was a prospective study conducted in the Department of Oral and Maxillofacial Surgery, Kunhitharuvai Memorial Charitable Trust (KMCT) Dental College, Calicut, India. The duration of the study was 6 months, from June to November 2017, with a maximum sample size of 616 cases. The LA solution was 2% lignocaine with 1:100,000 adrenaline. The patients were selected from a population in the range of 20 to 40 years of age who reported to the outpatient department for routine dental extraction of normally positioned mandibular right or left first or second molars.

Results:
Of the 616 patients, 42 patients (6.8%) required re-anesthetization, a success rate of 93.2%. There were no complications such as hematoma formation, trismus, positive aspiration, and nerve injuries. None of the cases required re-anesthetization in the perioperative period.

Conclusion:
The Benny Joseph technique can be employed and is effective compared with conventional IANB techniques by reducing trauma to the patient and also requires less technique sensitivity.

Full text

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ORIGINAL ARTICLE
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CC
Single-insertion technique for anesthetizing the inferior alveolar nerve,
lingual nerve, and long buccal nerve for extraction of
mandibular first and second molars: a prospective study
Benny Joseph1, Nithin Kumar2, Suresh Vyloppilli3, Shermil Sayd4, KP Manojkumar1, Depesh Vijaykumar1
1Department of Oral and Maxillofacial Surgery, Kunhitharuvai Memorial Charitable Trust (KMCT) Dental College, Calicut, India,
2Department of Oral Surgery, Dental Faculty, Tishk International University, Erbil, Iraq,
3Department of Oral and Maxillofacial Surgery, Malankara Orthodox Syrian Church Hospital and Medical College, Ernakulum,
4Department of Oral and Maxillofacial Surgery, Kannur Dental College, Kannur, India
Abstract (J Korean Assoc Oral Maxillofac Surg 2020;46:403-408)
Objectives:
Appropriate and accurate local anesthetic (LA) techniques are indispensable in the field of oral and maxillofacial surgery to obtain a satis-
factory outcome for both the operating surgeon and the patient. When used alone, the inferior alveolar nerve block (IANB) technique requires supple-
mental injections like long buccal nerve block for extraction of mandibular molars leading to multiple traumatic experiences for the patient. The aim
of this study was to anesthetize the inferior alveolar, lingual, and long buccal nerves with single-needle penetration requiring a minimal skillset such as
administering a conventional IANB through introduction of the Benny Joseph technique for extraction of mandibular molars.
Materials and Methods:
This was a prospective study conducted in the Department of Oral and Maxillofacial Surgery, Kunhitharuvai Memorial
Charitable Trust (KMCT) Dental College, Calicut, India. The duration of the study was 6 months, from June to November 2017, with a maximum
sample size of 616 cases. The LA solution was 2% lignocaine with 1:100,000 adrenaline. The patients were selected from a population in the range of
20 to 40 years of age who reported to the outpatient department for routine dental extraction of normally positioned mandibular right or left first or sec-
ond molars.
Results:
Of the 616 patients, 42 patients (6.8%) required re-anesthetization, a success rate of 93.2%. There were no complications such as hematoma
formation, trismus, positive aspiration, and nerve injuries. None of the cases required re-anesthetization in the perioperative period.
Conclusion:
The Benny Joseph technique can be employed and is effective compared with conventional IANB techniques by reducing trauma to the
patient and also requires less technique sensitivity.
Key words:
Benny Joseph technique, Lingual nerve block, Inferior alveolar nerve block, Long buccal nerve block
[paper submitted 2019. 10. 6 / revised 2019. 12. 13 / accepted 2019. 12. 17]
Copyright
©
2020 The Korean Association of Oral and Maxillofacial Surgeons. All
rights reserved.
https://doi.org/10.5125/jkaoms.2020.46 .6.403
pISSN 2234-7550 · eISSN 2234-5930
I. Introduction
Appropriate and accurate local anesthetic (LA) techniques
are indispensable in oral and maxillofacial surgery to obtain
a satisfactory outcome for both the operating surgeon and the
patient. For these purposes, various surgical techniques have
been utilized for the maxilla and mandible. To obtain anes-
thesia in the mandible, various techniques like the inferior
alveolar nerve block (IANB), Spix, Vazirani-Akinosi, and
Gow-Gates techniques are available1. The Spix IANB is the
most commonly used technique, but there have been reports
of its failure to achieve adequate anesthesia2,3. When used
alone, the IANB technique requires supplemental injections
like long buccal nerve block for extraction of mandibular mo-
lars, leading to multiple traumatic experiences for the patient.
Conventional mandibular nerve block techniques like Vazi-
rani-Akinosi and Gow-Gates require a larger volume of LA
solution and a well-experienced surgeon. The technical acuity
required and the lack of bony stops for these techniques dis-
courage their use by normal dental practitioners even though
they are single-penetration techniques4,5.
Shermil Sayd
Department of Oral and Maxillofacial Surgery, Kannur Dental College,
Anjarakandy, Kannur 670612, India
TEL: +91-484-2760251 FAX: +91-484-2760409
E-mail: shermil12@gmail.com
ORCID: https://orcid.org/0000-0002-1765-8955

J Korean Assoc Oral Maxillofac Surg 2020;46:403-408
404
Various techniques are currently employed for mandibular
tooth extraction or procedures, and all have their own advan-
tages such as increased spread of anesthesia and increased
patient comfort and disadvantages such as requiring increased
skills, technical sensitivity, number of failures, and multiple
penetrations. Therefore, the aim of this study was to anesthe-
tize the inferior alveolar nerve along with the lingual and long
buccal nerves with a single needle penetration requiring a
minimal skillset such as administering a conventional IANB
(Spix technique, Fischer 1-2-3 technique, etc.), aiding in
reduction of the number of penetrations to the patient and be-
ing comparatively less technique sensitive. A new technique
called the Benny Joseph single insertion IANB technique will
be introduced in this study.
II. Materials and Methods
This was a prospective study conducted in the Department
of Oral and Maxillofacial Surgery, Kunhitharuvai Memorial
Charitable Trust (KMCT) Dental College, Calicut, India. For-
mulation of the outline of the study was based on STROBE
(Strengthening the Reporting of Observational Studies in
Epidemiology) guidelines and Institutional Ethics Commit-
tee/Institutional Review Board of KMCT Dental College
approval (IEC/IRB No. KMCTDC/IEC/2017/05). The pa-
tients were selected from a population between 20-40 years
of age who reported to the outpatient department for routine
dental extraction of normally positioned mandibular right or
left first or second molars. The procedure and complications
were discussed with the patient, and informed consent was
obtained. Patients who reported no systemic disease and had
no historical incidence of allergy to the LA solution were in-
cluded in the study. Patients with grade II or grade III mobil-
ity or with chronic generalized periodontitis were excluded.
A single operator performed all the LA administration after
test dosing and following aseptic procedures with the help of
a 2.5 mL syringe with a 24-gauge needle 25 mm in length.
The duration of the study was 6 months, from June to No-
vember 2017. The LA solution used was 2% lignocaine with
1:100,000 adrenaline.
Technique:
① The patient was positioned in a semi-supine position so
that the mandibular occlusal plane was parallel to the floor
during opening of the oral cavity.
② The operator’s thumb was placed over the maximum
concavity of the anterior border of the ramus of the mandible,
the coronoid notch.(Fig. 1) Following this, the pterygoman-
dibular raphe was identified extending from the pterygoid
hamulus superiorly to the retromolar area inferiorly.
③ The site of insertion of the needle was 6-8 mm above
the occlusal plane and 4-6 mm anterior to the deepest point of
the pterygotemporal depression (PTD).(Fig. 2)
④ The technique commenced with the syringe barrel on
the ipsilateral side (Fig. 3) to the point of insertion.
PTD
CN
Fig. 1. Identification of the landmarks and points of needle inser-
tion. (PTD: pterygotemporal depression, CN: coronoid notch)
Benny Joseph et al: Single-insertion technique for anesthetizing the inferior alveolar
nerve, lingual nerve, and long buccal nerve for extraction of mandibular first and second
molars: a prospective study. J Korean Assoc Oral Maxillofac Surg 2020
Fig. 2. Needle insertion at the deepest point of the pterygotempo-
ral depression.
Benny Joseph et al: Single-insertion technique for anesthetizing the inferior alveolar
nerve, lingual nerve, and long buccal nerve for extraction of mandibular first and second
molars: a prospective study. J Korean Assoc Oral Maxillofac Surg 2020

Single insertion inferior alveolar nerve block for first and second molar extraction
405
⑤ After initial penetration, the needle was advanced poste-
riorly over the medial surface of the ramus of the mandible,
circumventing the dyke created by the internal oblique ridge.
Next, the syringe barrel was repositioned to the midline (be-
tween the central incisors) and advanced posteriorly until
the entire length of the needle was inside the tissue. It was
imperative during this entire procedure to ascertain that the
needle was close to the medial surface of the ramus (Change
in direction of the needle was performed only when it was
halfway inserted and crossed the dyke created by the inter-
nal oblique ridge, after which the needle was inserted to full
length, reducing the risk of needle breakage.).
⑥ The depth of penetration was limited to 25 mm based
on evidence provided by Malamed5 on the mandibular fora-
men limit to a distance between 20-25 mm from the anterior
border of the ramus. This also ensured that, when the needle
was completely inserted, it would be approximately superior
to the inferior alveolar nerve (IAN) entry into the mandibular
foramen, where 1.5 mL of LA was deposited to anesthetize
the inferior alveolar nerve.
⑦ Considering the probability of anatomical variation, it is
recommended that LA solution be deposited using a needle
of either 21 mm or 24 mm in length to reduce failure and to
ensure that the solution is deposited as close to the IAN as
possible.
⑧ After successful deposition of the solution, the syringe
was withdrawn 10-15 mm and moved to the ipsilateral side
for deposition of 0.5 mL of LA to anesthetize the lingual
nerve.
⑨ This was followed by removal of the thumb from the
coronoid notch for use in lateral retraction of the buccal mu-
cosa.
⑩ Once retraction was complete, the syringe barrel was
moved to the contralateral (to the first molar) side with simul-
taneous withdrawal to a distance of 5-6 mm or until it crossed
the internal oblique ridge prominence, allowing the needle tip
to rest on the medial surface of the ramus of the mandible an-
terior to the internal oblique ridge. Once in position, 0.5 mL
of LA solution was deposited to anesthetize the long buccal
nerve.(Fig. 4)
Effectiveness of the aforementioned technique was as-
sessed both subjectively and objectively. The following meth-
ods were utilized for assessment of anesthesia.
1) Objective assessment:
• A sharp dental explorer was applied to the gingival tissues
in front of the lower premolars on the side of the extraction to
assess IAN anesthesia.
• The half of the tongue on the side of extraction was tested
with a probe to assess lingual nerve anesthesia.
• A sharp dental explorer was applied to the gingival tissues
adjacent to the molar to be extracted to assess long buccal
nerve anesthesia.
• Use of an electric pulp tester to determine absence of re-
sponse to the maximal output of the tooth to be extracted.
Fig. 3. Retraction of buccal soft tissues and ipsilateral placement
of the needle during the initial steps of injection.
Benny Joseph et al: Single-insertion technique for anesthetizing the inferior alveolar
nerve, lingual nerve, and long buccal nerve for extraction of mandibular first and second
molars: a prospective study. J Korean Assoc Oral Maxillofac Surg 2020
Fig. 4. Contralateral placement of the syringe for administration
of inferior alveolar nerve block after crossing the internal oblique
ridge.
Benny Joseph et al: Single-insertion technique for anesthetizing the inferior alveolar
nerve, lingual nerve, and long buccal nerve for extraction of mandibular first and second
molars: a prospective study. J Korean Assoc Oral Maxillofac Surg 2020

J Korean Assoc Oral Maxillofac Surg 2020;46:403-408
406
2) Subjective assessment by questioning:
• Does your lip on the surgical side feel numb compared to
the non-surgical side?
• Does the front side of your tongue on the surgical side
feel numb compared to the non-surgical side?
The patient’s response to every test was recorded using a
chart in commercially available software. Negative responses
implied that the corresponding nerve was anesthetized. Probe
testing commenced 3 minutes after injection and repeated ev-
ery two minutes after the first test for a total of 4 tests. Failure
to elicit a negative response was considered a failure of this
technique. According to the literature, the above-mentioned
tests are the most common practical clinical tests to ensure
objective anesthesia before exodontia1,5.
III. Results
A total of 616 patients was willing to take part in the study
and provided informed consent. Totals of 270 male patients
and 346 female patients comprised the study group, and the
mean age was 29.9±5.9 years. Since our institution caters to
people with lower socioeconomic status, the most common
reason for tooth removal was caries (48.9%), followed by
fractured restoration for which the patient refused to undergo
root canal therapy (15.4%). The remainder of the etiologies
and their percentage constitution were 1) root canal treatment
failure (10.7%), 2) fractured crown (8.1%), 3) extraction of
molars following referral from the Department of Orthodon-
tics who were otherwise asymptomatic and were not willing
to under routine extraction (4.1%), 4) trauma (5.2%), and 5)
periodontitis (7.6%). From the sample size of 616 patients, 42
patients (6.8%) required re-anesthetization, a success rate of
93.2%. There was a 0% incidence of complications such as
hematoma formation, trismus, positive aspiration, and nerve
injuries. None of the cases required re-anesthesia during the
perioperative period.
IV. Discussion
In history, the first recorded case of neuro-regional anesthe-
sia was achieved by William S. Halsted and Richard J. Hall
in 18846, through administration of a solution of cocaine in
the vicinity of the mandibular foramen. Since then, a plethora
of advancements has been used for effective anesthetization
of the IAN and associated nerves for extraction of mandibu-
lar posterior teeth.
The Spix technique is the first choice for anesthetization of
the IAN if any invasive procedure is indicated in mandibular
posterior teeth7. This technique utilizes the mandibular lin-
gula by reversibly blocking IAN conduction before it enters
the mandibular foramen in the pterygomandibular space8,9,
with success rates varying from 71%-87%10. This technique
necessitates separate administration for anesthetization of
the long buccal nerve. In addition, there is a plethora of other
techniques claiming to be more effective with decreased inci-
dence of intravascular injection and damage to the IAN11.
The Gow-Gates and Vazirani-Akinosi techniques also are
single-injection techniques for anesthesia in the posterior
mandibular region. Various studies have shown a high inci-
dence of failure to achieve anesthesia with the Gow-Gates
technique, especially with an inexperienced surgeon3,12,13.
Another recognized disadvantage of the Gow-Gates tech-
nique is the slower onset of anesthesia. According to Agren
and Danielsson14, the onset of action can range from 10 to
30 minutes and rarely persists to 45 minutes. In addition, the
recommended amount of LA required to produce desirable
results for the Gow-Gates technique is 3 mL15. The Vazirani-
Akinosi technique is employed primarily when the patient
suffers from trismus and is technique-sensitive because of
the absence of bony landmarks for injection guidance, expo-
nentially increasing the chances for injury to the pterygoid
plexus3. According to Malamed5, closed mouth nerve block
techniques have greater failure rates than conventional IANB.
Despite the advantages of these techniques6, most dental pro-
fessionals do not prefer either of the above-mentioned tech-
niques because of the increased skill set required.
The Fischer 1-2-3 technique relies on identification of
anatomical landmarks for administration. Failure to identify
these will lead to failure of anesthesia. In addition, penetra-
tion and deposition of LA solution depend on length of nee-
dle penetration, which is arbitrary as there are no markings
on needles. This can cause difficulty for novice surgeons.
Overpenetration and deposition will lead to unwanted effects
such as facial palsy16.
When discussing our technique, the Benny Joseph tech-
nique described by Thangavelu et al.16 in 2012, the needle is
inserted 6 to 8 mm above the mandibular occlusal plane and
4 to 6 mm anterior to the PTD, with simultaneous ipsilateral
placement of the syringe barrel. With our approach, we were
able to avoid multiple bony contacts during administration
of LA solution, which decreased trauma to and increased
comfort of the patient. In contrast to the methods described
by Malamed5, the Benny Joseph technique is non-specific
and does not depend upon vertical or horizontal lines, allow-

Single insertion inferior alveolar nerve block for first and second molar extraction
407
ing the operator a considerable margin of error and increased
chance of success17.
Most of the techniques depend upon identification of soft
tissue landmarks for anesthetic administration. However, our
technique, the Benny Joseph technique, depends on identi-
fication of the bony landmark of the internal oblique ridge.
This increases the percentage of successful administrations
and is easier for novices.
Unlike other techniques, the Benny Joseph technique is
aided by early identification of the internal oblique ridge dur-
ing the first few millimeters of needle insertion. This provides
the surgeon easy identification of the landmarks and simpli-
fies further advancements of the needle, reducing the chances
of failure of anesthesia. Although not related to this study,
other surgeons in the Department of Oral and Maxillofacial
Surgery have started using this technique in their day-to-day
surgical practice and have noted reduced percentage of fail-
ure.
In this study, we compared the effectiveness of the tech-
nique in an objective assessment; no consideration was given
to the subjective aspect. This constitutes a drawback of this
study. To establish a good doctor-patient relationship, it is
imperative that the operator employ a less traumatic and less
painful anesthetic technique. This study did not demonstrate
increased patient comfort with the technique. We assume that
this it is more comfortable based on postsurgical comments
from patients with previous experience of mandibular extrac-
tion. Additional studies must be conducted to assess the sub-
jective outcomes of this technique.
V. Conclusion
The Benny Joseph technique can be employed and is effec-
tive compared with conventional IANB techniques by reduc-
ing trauma to the patient and requiring less technique preci-
sion because of the landmarks employed. Additional studies
are necessary for subjective assessment of this technique to
obtain data regarding patient compliance and pain during the
procedure.
ORCID
Benny Joseph,
https://orcid.org/0000-0002-5659-3218
Nithin Kumar,
https://orcid.org/0000-0001-6137-2391
Suresh Vyloppilli,
https://orcid.org/0000-0002-9423-3774
Shermil Sayd,
https://orcid.org/0000-0002-1765-8955
KP Manojkumar,
https://orcid.org/0000-0001-8865-3812
Depesh Vijaykumar,
https://orcid.org/0000-0002-3886-8994
Authors’ Contributions
B.J. invented, performed and taught the technique along
with overall review of the entire study. N.K., S.V., and S.S.
were involved in further implementation of the technique
on a research level including study design ethics committee
approval, patient consent, data collection, recording and cre-
ation of the manuscript. K.P.M. was involved with the overall
conduction of the study and D.V. associated with the patient
education, motivation, informed consent, data entry and also
with manuscript preparation and evaluation.
Ethics Approval and Consent to Participate
The study was approved by the Institutional Ethics Com-
mittee/Institutional Review Board of KMCT Dental College
approval (IEC/IRB No. KMCTDC/IEC/2017/05), and in-
formed consent was obtained.
Conflict of Interest
No potential conflict of interest relevant to this article was
reported.
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How to cite this article: Joseph B, Kumar N, Vyloppilli S, Sayd
S, Manojkumar KP, Vijaykumar D. Single-insertion technique
for anesthetizing the inferior alveolar nerve, lingual nerve, and
long buccal nerve for extraction of mandibular first and second
molars: a prospective study. J Korean Assoc Oral Maxillofac Surg
2020;46:403-408. https://doi.org/10.5125/jkaoms.2020.46.6.403