ANNALS OF ANATOMY
Complications of local dental anesthesia and
anatomical causes
Fritz-Ulrich Meyer
Department of Oral and Maxillofacial Surgery/Plastic Operations, Ernst Moritz Arndt
University, SauerbruchstraBe, D-17487 Greifswald, Germany
Summary. Anatomical descriptions usually include only
the average topographical relationships, but the anatomi-
cal structures particularly in the head region display great
variability. This is one of the essential causes underlying
side effects and complications of local dental anesthesia.
In examinations of intravascular needle placement in
over 6000 local anesthetic injections in the jaws, positive
blood aspiration occurred most frequently (5.8%) at the
mandibular foramen. The close proximitiy to the cerebral
vessels explains the frequency of severe side effects. Ana-
tomical studies on the course of the maxillary artery and
its branches as well as the course of the nerve demon-
strate that unexpected anatomical constellations can lead
to both anesthetic failure and dramatic side effects.
Key words: Local anesthesia - Side effects - Complica-
tions - Anatomy - Maxillary artery - Inferior alveolar
nerve
Despite the fact that in Germany alone, an estimated
30 million local dental anesthetizations are conducted
annually, there are no reliable figures on the frequency of
side effects and complications. This is understandable
insofar as the transition from "still normal" to side effect
to complication is a continuum.
In a questionnaire survey conducted by Kleeman et al.
(1982), 2% of dentists admitted to having given a local
anesthetic resulting in a fatal complication. Taken from
numerous mutually impingent factors, the following can
be named as fundamentally influential for side effects
and complications:
- the patient's general health and emotional stress level;
- the local anesthetic and interactions with other drugs;
- the anatomical situation and application technique.
Because of the intimate anatomical relationships be-
tween the target site for injection and the brain, the ef-
fects on the central nervous system are of crucial
I Ann Anat (1999)181:105-106
© Urban & Fischer Verlag
importance. The danger of a relative overdose of local an-
esthetic via inadvertent intravascular injection is espe-
cially great. To avoid this, it is necessary to take an
aspiration sample while rotating the syringe prior to
every injection. With a simple aspiration, the lumen of
the needle can be blocked by suctioning into the vascular
wall, i.e., the aspiration remains negative. Upon subse-
quent injection, the vascular wall is pushed away.
At this juncture, 3 facts must be mentioned:
1. the internal blood volume of the brain is, at 30 ml, ex-
tremely low (Penn et al. 1972);
2. the toxic threshold dose for lidocaine is ca. 5 to 6 gg
per ml blood (Benowitz and Meister 1978);
3. a 2-ml injection of 2% lidocaine corresponds to
40,000 gg of lidocaine.
Within the internal cerebrovascular system, less than
200 gg of lidocaine are necessary to exceed the toxic
threshold dose. If a 2-ml injection of lidocaine were to en-
ter only the internal cerebrovascular circulation, this
would be more than 200 times the toxic dose; i.e., 1/5
drop of a 2% lidocaine solution would already cross the
toxicity threshold. Due to the proximity of the jaw area
to the brain, intravascular needle placement can, under
certain circumstances, flood the vascular system of vitally
important regions with a bolus of anesthetic. Only about
6% of the lidocaine found in the body is still in the blood-
stream when the steady state has been reached (Benowitz
and Meister 1978). Experiments on dogs by Aldrete et al.
(1977) impressively illustrate this possibility. 15 seconds
after an injection into the facial artery, values far in ex-
cess of the 6 gg threshold dose were measured in the ex-
ternal and internal jugular veins. If the injection is
administered slowly, conditions are more favorable for
distribution throughout the organism, meaning that the
danger of an extreme peak concentration in a portion of
the vascular system is lessened.
0940-9602/99/181/1-105512.00/0
 With an intravascular injection of a vasoconstrictor
plus local anesthetic, the circulatory pathway is closed
from within, impairing distribution to all tissues and slow-
ing metabolism.
In many publications, the deposition of the injection so-
lution is recommended during insertion of the needle.
The underlying idea here is that the injection solution
will mechanically displace the vessels. However, particu-
larly in the head region, the vessels are generally firmly
embedded in connective tissue.
Investigations of over 6000 injections showed that at
5.8%, an intravascular needle position occurred most fre-
quently when applying an inferior alveolar nerve block
(Meyer 1992).
It was conspicuous that nearly half of all positive blood
aspirations were seen after rotation of the syringe. One
reason may be the movement of the oblique tip of the
needle through the vascular wall during aspiration. The
blood aspiration is positive only after the syringe has
been rotated 180 ° .
The question arises as to why most of the positive
blood aspirations and also side effects occur during block
anesthesia at the mandibular foramen. The target site of
this injection technique is the region above the mandibu-
lar foramen. For adults, the injection plane lies ca. I cm
above the mandibular occlusal plane. In the direct techni-
que, the needle approaches from the first premolar region
of the opposite side, and is directed between the anterior
border of the mandibular ramus and the pterygomandibu-
lar raphe; insertion continues toward the mandibular
foramen. In inserting the needle, the danger exists not
only of penetrating the inferior alveolar artery, but also
of inadvertently inserting the needle tip and thus deposit-
ing the local anesthetic into the maxillary artery, due to
its proximity. If high injection pressure is applied, it is
possible to inject against the blood stream. When apply-
ing great pressure to the syringe, this author measured a
horizontal range of over 2 meters.
The intimate relationship between the maxillary artery
and the lingual nerve or inferior alveolar nerve is given
briefly here.
The maxillary artery travels lateral to the lingual nerve
and the inferior alveolar nerve, or medial to both; the
maxillary artery is located lateral to the lingual nerve and
medial to the inferior alveolar nerve, or medial to the lin-
gual nerve and lateral to the inferior alveolar nerve.
The maxillary artery can have a straight or looping
course. The splitting of the medial meningeal artery is of
interest. It can lie both peripheral and central to the in-
106
ferior alveolar artery or directly opposite it. Once the lo-
cal anesthetic has entered the maxillary artery, the
bloodstream can carry it farther into sensitive cerebral re-
gions. With a frequency of less than 1% of cases, the
ophthalmic artery arises from the frontal branch of the
medial meningeal artery over the anastomotic ramus. The
central retinal ramus branches off from the ophthalmic
artery and, within the optic nerve, leads to the retina
(Tillmann 1997). If the local anesthetic reaches the retina
by this route, as a very rare complication, temporary or
permanent blindness can result.
The distance between the maxillary artery and the
mandibular foramen varies greatly. If the course of the
maxillary artery is looping, the distance is 9.3 m m and in
extreme cases, only 4 mm; in contrast, if the course is
straight, the distance is 17 mm. Compared to the 0.5-mm
lumen of the needle, the vascular diameters are consider-
able. For instance, the diameter of the maxillary artery at
the superficial temporal artery branch is 4.3 mm, and at
the maxillary tuberosity 2.8 mm; the diameter of the in-
ferior alveolar artery at the mandibular foramen is
1.8 m m (Blanton and Roda 1995).
Considering that the local anesthetics are highly toxic
substances for which there is no antidote, the importance
of the vascular system and its anatomical variants be-
comes obvious. It is thus of the utmost importance to pre-
clude the possibility of an intravascular placement of the
needle.
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