ISSN 1229-5418

Implantology 2014; 18(1): 30~36

Block Anesthesia versus Infiltration Anesthesia of Inferior Alveolar Nerve

When Placing Dental Implants in the Posterior Mandibular Region
Seong-June Park, Nam-Seok Chee, Min-Ho Son, Eoy-Jung Lee, Soo-Woon Lee

Department of Oral and Maxillofacial Surgery, Inje University Haeundae Paik Hospital, Busan, Korea

Abstract
Inferior alveolar nerve (IAN) block or infiltration anesthesia can be used during the dental implant placement in the posterior
mandibular region. The IAN block eliminates all somatosensory perceptions of the mandible and assures patient comfort during the
placement of implants, while complications or nerve damages by implants can occur when patients cannot feel pain. Infiltrations may
allow the patients to warn the surgeons when the IAN is in danger of being damaged, while it may also cause discomforts or pains during
the implantation. In this study, we present a case of IAN block and infiltration in a female patient who had three teeth missing in each
posterior mandibular region. Block anesthesia was used in the right side, while infiltration anesthesia used in the left side. After the
surgery, the patient was instructed to record her discomfort or pain during the anesthesia or operation on the visual analogue scale. The
patient preferred infiltration to IAN block as only anesthesia is being evaluated, because she considered that the acute pain by infiltration
was more endurable than the dull pain by block. Nevertheless, she preferred block anesthesia when including implant placement during
the evaluation because she had felt pain during preparation of the placement site under infiltration anesthesia.

Key Words: block anesthesia, cone-beam computed tomography, dental implant, inferior alveolar nerve, infiltration anesthesia

Reprint requests: Soo-Woon Lee

Department of Oral and Maxillofacial Surgery, Inje University Haeundae Paik
Hospital, 875, Haeun-daero, Haeundae-gu, Busan 612-896, Korea
Tel: 82-51-797-2151, Fax: 82-51-797-2154
E-mail: lsu0122@paik.ac.kr
Received for publication: February 17, 2014
Accepted for publication: February 22, 2014

Copyright © 2014. The Korean Academy of Oral & Maxillofacial Implantology

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits
unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

30 Implantology Vol. 18 No. 1, 2014


I Introduction
I
nferior alveolar nerve (IAN) is commonly
anesthetized in dentoalveolar and implant
surgery. IAN block anesthesia causes patients to
lose sensation in mandible on one side, mandibular
teeth on one side, ipsilateral tongue, and all but the
buccal gingivae1. Total IAN block anesthesia assures
patient comfort during surgical placement of
mandibular implants, giving the dentist the
opportunity to perform necessary surgical procedures
in a pain-free environment. However, three major
postoperative complications may occur with the use of
block anesthesia of the IAN when placing mandibular
implants: (1) prolonged mandibular anesthesia, during
which time the patient may injure his or her tongue or
lip in a variety of ways; (2) systemic toxicity from
iatrogenic, intraarterial injection of local anesthetic
solution; and, most importantly when placing
mandibular implants, (3) injury to the inferior or
mental nerves, unbeknown to the patient or doctor
until after the effects of the block anesthesia have
subsided1. As an alternative to the IAN block
anesthesia for the placement of mandibular dental
implants, mandibular infiltration anesthesia was
discussed1,2. Etoz et al.2 concluded that supra­
periosteal infiltration anesthesia is a safe and
effective method for posterior mandibular implant
surgery. Heller and Shankland1 considered that
supraperiosteal infiltration might be useful for the
patient’
s being able to sense when the IAN is in
danger of being damaged. In this paper, we present a
case of both mandibular block and infiltration in one
patient and the patient’
s evaluation of both methods.
II Case Report
A 55-year-old woman underwent dental implant
surgery in both sides of mandible. The patient missed
the canine, the second premolar, the first molar and
the second molar in the left side, and the first premo-
lar, the first molar and the second molar in the right
side. The patient showed good general health and had
been treated for existing periodontal disease. Before
the surgery, cone-beam computed tomography (CBCT)
images were taken for measurement of the accurate
height and width of the implant placement site.
Implant placement for the canine, the second premolar
and the first molar in the left side was first planned,
and infiltration anesthesia was used. Four carpules of
2% lidocaine (1.8 ml) with 1 : 100,000 epinephrine were
deposited in the buccal and lingual mucosa, and the
buccal and lingual periosteum. Anesthesia was per-
formed according to the method described by Heller
and Shankland1. After flap elevation, the implant
placement site was prepared in the order of the second
premolar, the first molar, and the canine. The patient
experienced pain during the preparation and received
additional injection into the gingiva. The length of the
placed implants was all 11.5 mm which allowed more
than 2 mm of space as safety margin between the
implants and the IAN. After the surgery, the patient
대한구강악안면임프란트학회지 18권 1호, 2014 31
 Case Reports

was instructed to note her discomfort and/or pain molar implants was shorter than that of the implants
during the anesthesia and the implant placement on used in the left side because the distance between the
the visual analogue scale (VAS) of 0 to 10 cm, which alveolar crest and the IAN was shorter than that of the
was designed as 0 being no pain and 10 being the left side. The panoramic view after implant placement
worst pain ever experienced. in both posterior regions is shown in the Fig. 1. The
To prevent the possible effect of the order of the
anesthesia on the patient’
s evaluation of the anesthe-
sia method, block anesthesia and implant placement in
the right side were performed after over 3 weeks of the
surgery in the left side. One carpule of the same kind
of lidocaine used in the right side was injected for IAN
block. Another carpule was used for anesthesia of
buccal nerve. After flap elevation, the implant place-
ment site was prepared in the order of the first molar,
Fig. 1. Panoramic radiography of the patient who
the second molar, and the first premolar. The length underwent dental implant placement in both sides of the
mandible. Infiltration anesthesia was used in the left side,
of the placed implants was 11.5 mm for the first pre- while block anesthesia was used in the right side.
molar, and 10 mm for the first molar and the second Seong-June Park et al. : Block Anesthesia versus Infiltration Anesthesia of Inferior
Alveolar Nerve When Placing Dental Implants in the Posterior Mandibular Region.
molar. The length of the first molar and the second Implantology 2014

Fig. 2. Safety margin of the mandibular left second premolar.

Seong-June Park et al. : Block Anesthesia versus Infiltration Anesthesia of Inferior Alveolar Nerve When Placing Dental Implants in the Posterior Mandibular Region. Implantology 2014

32 Implantology Vol. 18 No. 1, 2014

height of safety zone was all over 2 mm (Figs. 2~5). implants.
The implant in the first molar region of the right side The patient was requested to evaluate the pain dur-
was placed shorter than the intended depth and its ing the anesthesia and the implant surgery on the VAS
safety margin became larger than those of other molar (Table 1). She felt no pain in the right side during

Fig. 3. Safety margin of the mandibular left first molar.

Seong-June Park et al. : Block Anesthesia versus Infiltration Anesthesia of Inferior Alveolar Nerve When Placing Dental Implants in the Posterior Mandibular Region. Implantology 2014

Fig. 4. Safety margin of the mandibular right first molar.

Seong-June Park et al. : Block Anesthesia versus Infiltration Anesthesia of Inferior Alveolar Nerve When Placing Dental Implants in the Posterior Mandibular Region. Implantology 2014

대한구강악안면임프란트학회지 18권 1호, 2014 33

 Case Reports

Fig. 5. Safety margin of the mandibular right second molar.

Seong-June Park et al. : Block Anesthesia versus Infiltration Anesthesia of Inferior Alveolar Nerve When Placing Dental Implants in the Posterior Mandibular Region. Implantology 2014

Table 1. Visual analogue scale (cm) of discomfort Table 2. Preference for either anesthesia
and/or pain during anesthesia and implant placement
Anesthesia method
Anesthesia method Procedure
Procedure Infiltration Block
Infiltration Block Anesthesia only O
Anesthesia 3 3 Anesthesia+implant placement O
Implant placement Seong-June Park et al. : Block Anesthesia versus Infiltration Anesthesia of Inferior
Left Alveolar Nerve When Placing Dental Implants in the Posterior Mandibular Region.
Implantology 2014
Canine 4 -
Second premolar 3 -
First molar 3 - the VAS values were the same. However, when includ-
Right ing the procedure of implant placement, she preferred
First premolar - 0 block anesthesia because there was no pain after
First molar - 0
anesthesia (Table 2).
Second molar - 0
Seong-June Park et al. : Block Anesthesia versus Infiltration Anesthesia of Inferior
Alveolar Nerve When Placing Dental Implants in the Posterior Mandibular Region.
Implantology 2014
III Discussion
implant surgery after block anesthesia. Excluding the
procedure of implant placement, she preferred infil-
tration to block because she had felt more discomfort Mandibular block anesthesia is normally a safe and
with the dull pain during block anesthesia although rewarding method of pain control for interventions in

34 Implantology Vol. 18 No. 1, 2014

dental and oral and maxillofacial surgery practice.
Nerve injury caused by injection of local analgesics is
considered as rare3. Yet, a minor fraction of patients
do experience the undesired side effects of a temporary
or permanent impairment of neurosensory function
after mandibular block anesthesia with currently used
local analgesics. According to Hillerup and Jensen3,
mandibular block analgesia causes lingual nerve injury
more frequently than IAN injury. All grades of loss of
neurosensory and gustatory functions were found, and
a range of persisting neurogenic malfunctions was
reported. Subjective complaints and neurosensory
function tests indicate that lingual nerve lesions are
more incapacitating than IAN lesions. Besides the
injury by the block anesthesia itself, there are other
iatrogenic injuries of IAN4,5. Especially during dental
implant surgery, IAN is prone to be damaged when the
implant impinges the safety zone because the patient
loses all sensory perception of the mandible under
block anesthesia. Heller and Shankland1 and Etoz et
al.2 support infiltration anesthesia partially because of
this risk of block anesthesia. However, block anesthe-
sia may be better than infiltration for patients’comfort
only if there is little possibility of damaging the IAN by
implant. Furthermore, it can be avoided that the
patients get injured by sudden movements due to the
pain during preparation of the implant placement site.
The patient in this report felt pain after infiltration
anesthesia in the left side during preparation of the
implant placement site and needed more injections.
Actually, in the pre-operative planning using CBCT,
the length of the implants to be placed in the left side
was determined to allow enough safety margins and
the risk of damaging the IAN was not found in the
CBCT images. A surgical stent was also made based on
the CBCT images. The pain during the surgery could
be considered as a false positive maybe due to insuffi-
cient infiltration anesthesia or other reasons.
Therefore the pain which the patient had to undergo in
this case was unnecessary. As a result, the patient
preferred block anesthesia to infiltration in the evalu-
ation of the total procedure from anesthesia to implant
placement.
With the rapid development of technology, CBCT has
become available for the preoperative planning of oral
implant placement6,7. CBCT scans help in the planning
of oral implants; they enable measurement of the dis-
tance between the alveolar crest and mandibular canal
to avoid impingement of IAN, avoid perforation of the
mandibular posterior lingual undercut, and assess the
density and quality of bone, and help in planning of
the oral implant in the maxilla with special attention
to the nasopalatine canal and maxillary sinus6.
Accordingly, infiltration is not necessarily better for
avoiding damage to the IAN if safety is ensured in the
CBCT images. However this does not mean that the
safety margin in the CBCT images is the only deter-
mining factor of the kind of anesthesia. The choice
between block and infiltration can be also dependent
on the surgeons’preference and patients’preference.
For the surgeons who do not have a CBCT system or
feel uneasy about block anesthesia, it may be better to
have patients endure a little discomfort during the
procedure than to have them get nerve injury acciden-
tally. Meanwhile some patients may be willing to
undergo a little discomfort.
대한구강악안면임프란트학회지 18권 1호, 2014 35
Case Reports
IV Conclusion
Anesthesia method when placing dental implants in
the posterior mandibular region may be determined on
a case-by-case basis depending on the anatomical
evaluation of radiograph, surgeons’preference, and
patients’preference. However, block anesthesia can be
better than infiltration for patients’comfort if the
safety of IAN is guaranteed.
36 Implantology Vol. 18 No. 1, 2014
References
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block anesthesia when placing mandibular dental implants posterior to
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3. Hillerup S, Jensen R. Nerve injury caused by mandibular block
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