Clinical Anatomy 28:608–613 (2015)

ORIGINAL COMMUNICATION

Description and Evaluation of an Intraoral

Cervical Plexus Anesthetic Technique
DANIEL P. BITNER,1 DANIEL UZBELGER FELDMAN,1* KEVIN AXX,1 AND
JASIM M. ALBANDAR2
1
Department of Endodontology, Temple University Kornberg School of Dentistry, Philadelphia, Pennsylvania
2
Department of Periodontology and Oral Implantology, Director, Periodontal Diagnostics Research
Laboratory, Temple University Kornberg School of Dentistry, Philadelphia, Pennsylvania

Unsuccessful anesthesia of the inferior alveolar nerve (IAN) may be due to

supplementary innervations of mandibular molars from other branches, namely
the cervical plexus (CP). The purpose of this prospective, randomized, double-
blind, controlled trial was to determine the effectiveness of an intraoral cervical
plexus anesthetic technique (ICPAT) in mandibular molars with symptomatic
irreversible pulpitis (SIR) when the IAN and lingual nerve (LN) blocks failed,
and to provide a description of the technique. Forty patients diagnosed with
SIR received IAN and LN block anesthesia prior to treatment. After clinical
signs of anesthesia, patients were subjected to an electrical pulp test (EPT) at
2-min cycles for 10 min post-injection. The anesthesia was considered unsuc-
cessful if there was a positive EPT response ten minutes following profound lip
numbness. The experimental group (n 5 20) were administered 2% Lidocaine
with 1:100,000 epinephrine using the ICPAT. The control group (n 5 20) were
administered 0.9% sterile saline using the ICPAT. Success was defined as no
response on two consecutive readings from an EPT. In the experimental group,
60% of subjects showed successful anesthesia, whereas none of the subjects
in the control group had successful anesthesia. A multiple logistic regression
analysis showed that the anesthesia success rate using the ICPAT method was
significantly higher (P < 0.05) than in the control group, irrespective of molar
tooth type. The ICPAT method may be useful as a supplementary anesthetic
technique for mandibular molars with SIR in subjects whom the IAN and LN
blocks do not provide adequate anesthesia. Clin. Anat. 28:608–613,
2015. VC 2015 Wiley Periodicals, Inc.

Key words: cervical plexus; transverse cervical nerve; greater auricular nerve;
inferior alveolar nerve; lingual nerve; local anesthesia; anesthetic
failure; accessory innervation; anesthetic technique; randomized
controlled trial

INTRODUCTION
Local anesthesia is an essential part of modern
dental practice, with patients demanding better and
more painless dental procedures. To provide effective
teeth and adjacent tissues anesthesia in the adult
mandible, it is necessary to administer the local anes-
thetic drug at a site before the nerve enters the man-
dibular foramen and/or into the mandibular canal.
Because of the thickness of the buccal cortical plate,
*Correspondence to: Daniel Uzbelger Feldman, DDS, DMD,
Adjunct Assistant Professor. Department of Endodontology,
Temple University Kornberg School of Dentistry, 3223 North
Broad Street, Philadelphia, PA 19140, USA. E-mail: duzbelger@
gmail.com
Received 23 February 2015; Revised 8 March 2015; Accepted
10 March 2015
Published online 10 April 2015 in Wiley Online Library
(wileyonlinelibrary.com). DOI: 10.1002/ca.22543

C
V 2015 Wiley Periodicals, Inc.

Ingle and Bakland (2002) revealed that the use of
supraperiosteal anesthesia is ineffective in the mandi-
ble, obviating the use of local infiltration techniques in
adult patients. As reported by Sharaf (1997), only in
children it is possible to attain local anesthesia by
using mandibular buccal infiltration. Studies from
Lubit (1948), Coleman and Smith (1982), Bigby et al.
(2007) and Gaffen and Haas (2009) assisted to calcu-
late that from an estimated 300 million anesthetic
cartridges used each year in the US alone, local anes-
thetic failed in 13% (n 5 39 million) of injections over-
all, with 88% (n 5 34.32 million) occurring with the
inferior alveolar nerve (IAN) and lingual nerve (LN)
blocks, especially in lower molars with symptomatic
irreversible pulpitis (SIR). Additional publications from
Martinez Gonzalez et al. (2003) and Altug et al.
(2012) established anesthetic failure rates of 10.7%
for IAN and 17.8% for Akinosi technique in permanent
dentition during lower molar extractions as well lack
of success at a rate of 14.2% with the IAN during
implant drilling and suturing on the edentulous poste-
rior mandibular ridge.
To address this problem (Journal of Endodontics
Editorial Board, 2008), additional techniques have
been described such as Gow Gates, intrapulpal, intrali-
gamentary, intraseptal, intraosseous, mylohyoid,
Vazirani-Akinosi and buccal nerve (long buccal) as
well as buccal mandibular infiltration. Sharaf (1997)
found that a buccal mandibular infiltration approach
was as effective as IAN block anesthesia in pediatric
dentistry in 80 patients 3–9 years old. Following previ-
ous reports (Kanaa et al., 2006; Robertson et al.,
2007; Jung et al., 2008; Matthews et al., 2009;
Aggarwal et al., 2009; Meechan, 2011; Poorni et al.,
2011; Kanaa et al., 2012; Ashraf et al., 2013), in
adult patients, buccal infiltrations of lower molars
were shown to be successful 29% to 91.7% using dif-
ferent anesthetic solutions. Another trial (Foster et al.,
2007) concluded that adding a buccal or lingual infil-
tration to an IAN block did not increase anesthetic
success in mandibular molars. However, in all these
studies, a description of the nerve(s)/anatomical
structures affected was not presented other than the
IAN. In addition, several authors (Magnus, 1968; Jas-
tak and Yagiela, 1983; Gunsky and Moore, 1984;
Parente et al., 1998; Malamed et al., 2000; Reader
and Nusstein, 2002; Nusstein et al., 2002, 2003,
2005; Villette et al., 2008) have proposed new ideas
for devices, needles, and different anesthetic solution
types, volumes and concentrations in order to over-
come this problem of lack of profound anesthesia.
Previous research from Nusstein et al. (2010) and
Malamed (2011) provided several explanations for
this mandibular anesthetic failure, including lowered
pH of inflamed tissues and presence of accessory
nerves from the mental foramen and nerve to mylo-
hyoid. However, several studies (Stewart, 1932;
Adams, 1938; Novitzky, 1938; Jeffries, 1944; Sicher,
1946; Nevin, 1948; Cook, 1951; Ries Centeno, 1968;
De Arruda et al., 1974; Cruz Rizzolo et al., 1988;
Uzbelger Feldman et al., 2007) have suggested that
incidents of unsuccessful block anesthesia of the IAN
may be due to supplementary innervations of mandib-
ular teeth from nerves other than the nerves men-
Intraoral Cervical Plexus Anesthetic Technique 609
tioned above, namely the cervical plexus (CP). Thanks
to advances in imaging technologies, neurovascular
canals have been identified entering the mandible
through CT scan (mean diameter, 0.7 mm 6 0.3 [SD])
in papers published by Gahleitner et al. (2001) and
Naitoh et al. (2010). In addition, due to the small size
and thickness of the mandibular accessory foramina
and the CP branches, no proof of the TNC mandible
innervation was found since Lin et al. (2013) showed
evidence of the TNC entering into the mandible.
Another recent study from Ella et al. (2015) in 250
human cadavers (150 men and 100 women) con-
firmed the CP reached the mandible in 97% of cases
regardless of gender through the TCN and the great
auricular nerve (GAN). As a result, we hypothesized
that the administration of anesthesia at a point that
will infiltrate the TCN and GAN branches of the CP
may result in a more profound anesthesia of the pos-
terior mandibular molars.
Intraoral Cervical Plexus Anesthetic
Technique and Nerve Description
As compared to the cranial nerves innervating the
oral cavity, the CP arises from the spinal cord by two
roots, a dorsal root which supplies sensory fibers, and
a ventral root which supplies motor fibers. These roots
unite within the intervertebral space and exit the spi-
nal column as a single nerve through the interverte-
bral foramina. The anterior divisions of the 2nd, 3rd,
and 4th cervical nerves travel toward the lateral sur-
face of the sternocleidomastoid muscle where they
intermingle to form the CP which has muscular and
cutaneous branches. The CP cutaneous branches are
comprised of the supraclavicular (C3–C4), the lesser
occipital (C2), the GAN (C2–C3) and the TCN (C2–C3)
which innervates the anterior region of the neck and
mandible (Lin et al., 2013 and Ella et al., 2015).
For administering the intraoral cervical plexus anes-
thetic technique (ICPAT) for the TCN and GAN, the
patient should maintain the mouth closed or slightly
opened to allow the dentist to relax the soft tissues,
cheek and the masseter muscle permitting the syringe
to reach the area to be anesthetized. A syringe with a
30 gauge short needle is placed through the vestibular
area of the buccal mucosa below the roots of the
mandibular molar using an inclination of 45 degrees in
an anterior-posterior direction (Fig. 1). As suggested
by Cruz Rizzolo et al. (1988), the buccal approach
should be used rather than a lingual approach to elim-
inate the risks associated with injections in the floor of
the mouth. The tip of the needle is inserted below the
roots of the tooth to be anesthetized and should be in
direct contact with the bone (Fig. 2). An aspiration
must be performed before the placement of the anes-
thetic solution which should be administered slowly
while feeling no resistance along the external oblique
line of the body of the mandible (Fig. 3). Prior to the
administration of the injection it is recommended to
palpate along the border of the mandible for the
transverse facial artery. In addition, the finger should
be maintained externally to follow the path of the
610 Bitner et al
Fig. 1. ICPAT technique illustration of a lower left
second molar: needle positioning. [Color figure can be
viewed in the online issue, which is available at
wileyonlinelibrary.com.]
needle to ensure that it has reached the desired posi-
tion (Uzbelger et al., 2005).
The purpose of this investigation was to (1) provide
a description of a buccal intraoral cervical plexus anes-
thetic technique (ICPAT) and (2) to determine the
ICPAT efficacy when used in combination with the con-
ventional IAN and LN blocks for lower molars with SIR.
MATERIALS AND METHODS
Forty adult patients, 17 males and 23 females, with
ages ranging from 18 to 63 years recruited among
patients attending the Temple University Kornberg
School of Dentistry clinics participated in this study.
The inclusion criteria were patients experiencing den-
tal pain due to SIR in a lower molar, and responding
positively to electric pulp test (EPT), following a stand-
Fig. 2. ICPAT illustration of a lower left second molar:
needle insertion. [Color figure can be viewed in the online
issue, which is available at wileyonlinelibrary.com.]
Fig. 3. ICPAT illustration and X-ray view of a lower
left second molar using a conventional dental syringe and
a 1.8 ml anesthetic cartridge: anesthesia placement.
[Color figure can be viewed in the online issue, which is
available at wileyonlinelibrary.com.]
ard IAN and LN blocks. All patients were in good
health as determined by a health history. The Institu-
tional Board Review committee approved the study,
and a written informed consent was obtained from
each patient. The informed consent described the
nature of the procedures and fully explained the pos-
sible risks from the study.
Symptomatic irreversible pulpitis was diagnosed if
the tooth had a prolonged response (>10 sec) to cold
testing with 1,1,1,2 Tetrafluoroethane (TTF) (Endo-
Ice, Hygienic, Akron OH) applied to a cotton applicator
and placed on the tooth, and a positive EPT (Sybron
Endo, Elements Diagnostic Unit, 1717 West Collins
Orange, CA 92867) response. A same side maxillary
canine was used as the unanesthetized control to
ensure that the electric pulp tester was operating
properly and that the subject was responding appro-
priately during the experiment. Patients with no
response to cold testing and no response to the EPT or
had periradicular pathosis during the X-rays examina-
tion were excluded from the study.
Subjects who responded positively to EPT, following
the standard IAN and LN blocks, were assigned ran-
domly to either the experimental (n 5 20) or control
(n 5 20) groups comprising a total of 40 subjects sam-
ple size (Dreven et al., 1987). Age, gender and medi-
cal history were not taken into account for this
investigation. We used a prospective, randomized,
double-blind, controlled design. Patients diagnosed
with SIR in a lower molar tooth were anesthetized by
the same operator (DPB) with the conventional IAN
and LN blocks within the same technique using two
cartridges of 2% Lidocaine HCl (LE) with 1:100,000
epinephrine (Henry Schein, Melville, NY). The operator
was trained in the ICPAT before this study was initi-
ated. All patients indicated profound soft tissue numb-
ness (side of the tongue and lip of the anesthetized
side). After clinical signs of anesthesia with the IAN
and LN blocks the patients were subjected to an EPT
at 2-min cycles for 10 min post-injection so that pul-
pal anesthesia could be assessed. After the clinical

signs of anesthesia described as lip and half of the
tongue “numb” were confirmed, the blocks were con-
sidered successful when 2 consecutive negative EPT
readings were obtained. If a successful block was
obtained, the subject was then excluded from receiv-
ing the ICPAT. The patient then received the appropri-
ate treatment for their tooth as planned. The
injections were prepared by an independent investiga-
tor (KA) not associated with the administration of the
injections. Samples were prepared for the experimen-
tal and control groups to be visually identical so that
the investigator remained unaware of the type of drug
administered during the injection. The samples used
in the experimental group were prepared with LE by
withdrawing 2 ml of the anesthetic solution from mul-
tidose 50 ml vials (Hospira, Lake Forest, IL) using a
disposable 3 ml single use sterile syringe (Becton
Dickinson, Franklin Lakes, NJ). The samples used for
the control group were prepared in a similar manner
using single dose bags of 0.9% sterile saline (B. Braun
Medical, Irvine, CA) by withdrawing 2 ml of the sterile
saline using the same 3 ml disposable single use ster-
ile syringe. The experimental group was given the
ICPAT using the 2 ml of anesthetic solution of LE. The
control group was administered 2 ml of sterile saline
solution utilizing the same ICPAT.
After the ICPAT was performed the tooth was tested
again with the EPT after waiting 4 min and at 2-min
cycles for 10 min post-injection so that pulpal anes-
thesia could be assessed. No response from the sub-
ject to the maximum output (80 reading) of the EPT
was used as the criterion for pulpal anesthesia. Anes-
thesia was considered successful when two consecu-
tive 80 readings were obtained (Dreven et al., 1987).
Then, patients received their corresponding root canal
therapy according to a previously approved treatment
plan. However, pain was not measured during endo-
dontic access openings.
We used the multiple logistic regression analysis
(MLRA) using maximum likelihood method (JMP V8.0,
SAS Institute, Cary, NC) to model the success of the
anesthetic technique in the test and control groups,
and to study the effect of tooth type in this model
(Breslow and Powers, 1978). The level alpha level
was set to 5%. The majority of teeth were first or sec-
ond mandibular molars. Two of the study subjects had
a third molar each, and these were grouped with the
second molar teeth when evaluating the effect of
tooth type.
RESULTS
Table 1 shows the frequency of subjects in the test
and control groups, by tooth type. The table also
shows the anesthesia success rate in the two groups.
In the ICPAT group, 12 subjects (or 60%) showed
successful anesthesia, whereas none of the subjects
in the control group had successful anesthesia. The
success rate was comparable in 1st and 2nd molar
groups. The MLRA showed that the anesthesia method
(ICPAT vs. control) had significant effect on the anes-
thesia success rate (P 5 0.0001), whereas tooth type
did not show a significant effect (P 5 0.85). This
Intraoral Cervical Plexus Anesthetic Technique 611
TABLE 1. ICPAT Success Rate per Group and Tooth
Type
ICPAT Control
1st 2nd/3rd 1st 2nd/3rd
molar molar molar molar
Anesthesia
Outcome No. % No. % No. % No. %
Successful 7 58.3 5 62.5 0 0 0 0
Unsuccessful 5 41.7 3 37.5 10 100 10 100
Total 12 100 8 100 10 100 10 100
analytical model explained 45% of the variance in the
outcome variable.
DISCUSSION
Low pH due to inflammation has been cited by Nus-
stein et al. (2010) and Malamed (2011) as the most
frequent cause of anesthetic failure. However, Ueno
et al. (2008) demonstrated that tissue acidosis is not
the primary reason for the lack of anesthesia associ-
ated with inflammation. Prior studies (Nist et al., 1982
and Malamed, 2011) reported that the incisive nerve
block at the mental nerve helped to improve anes-
thetic success in first molars and premolars but the
success rate was not as favorable as other supple-
mental anesthetic techniques. Preceding research
from Parente et al. (1998) and Clark et al. (1999)
found no significant improvement in mandibular anes-
thesia when the nerve to mylohyoid injection or buc-
cal nerve (long buccal) techniques were used in
combination with the IANB. Few papers (Kanaa et al.,
2006; Robertson et al., 2007; Jung et al., 2008; Mat-
thews et al., 2009; Aggarwal et al., 2009; Meechan,
2011; Poorni et al., 2011; Kanaa et al., 2012; Ashraf
et al., 2013) suggested that buccal mandibular infil-
tration of anesthesia is effective in adult patients
(29% to 91.7% success rate) based on the local anes-
thetic agent used. However, in these reports a
description of the nerve(s) affected was not provided
other than the IAN or the mental nerve. As a result,
accessory innervation from other source namely the
CP may be the most important factor to take into
account in order to explain such clinical phenomena.
This is due to the thickness of the buccal cortical plate
obviates the use of local infiltration techniques in adult
patients (Ingle and Bakland, 2002). If the adult man-
dibular buccal cortical plate could infiltrate, there
would be no rationale to administer the local anes-
thetic drug at a site before the IAN enters the mandib-
ular foramen and/or exits the mandibular canal. In a
clinical study, amongst 100 patients with pulpal pain,
Mardani et al. (2008) found that 65% of the patients
experienced pain referral to the head, face and neck
region. In addition, evidence of the CP contribution to
angina pectoris pain in the lower jaw via afferent sym-
pathetic fibers has been described (White, 1957;
Bourke and Thomas, 1998; Foreman, 1999). In early
clinical research from Novitzky (1938) and Adams
(1938), the TCN was described as supplying sensory
innervations to the mandible. Also, anatomical
612 Bitner et al
evidence of supplemental innervations by the TCN
was supported clinically (Jeffries, 1944; Sicher, 1946;
Nevin, 1948) by a cervical plexus anesthetic technique
for the second premolar involving an injection in the
floor of the mouth lingual to the premolars. However,
local anesthesia of these branches through a lingual
approach may not be safe due to lingual vascularity
as reported by Adams (1938), Lopez et al. (2007) and
Goswami et al. (2008). Moreover, an extraoral anes-
thetic technique for the superficial cervical plexus
before surgery of mandibular cysts has been
described (Ries Centeno, 1968). It has also been
shown that a cervical plexus intraoral technique at the
“sulco gingivo geniano” in combination with IAN and
long buccal blocks resulted in adequate anesthesia of
molar teeth in 100% of the patients (De Arruda et al.,
1974). In addition, the clinical significance of the GAN
was apparent in some patients undergoing lower third
molar surgery under local anesthesia, as a result, a
separate infiltration may be needed to achieve total
analgesia of the region (Tong, 2000). Additionally,
Chiego et al. (1980) and Bolding and Hutchins (1993)
demonstrated that the CP entered the mandible and
provided direct innervations to teeth and dental pulps
in animal models using primates and cats, respec-
tively. In humans, the TNC path from the CP was
three dimensionally mapped for the first time by Lin
et al. (2013) showing that its branches entered into
the posterior mandible. A recent publication from Ella
et al. (2015) showed the superficial CP reached the
mandible in 97% of cases regardless gender through
the TCN and GAN: a study in 250 human cadavers.
During all these years, there has been a lack of
description of a reproducible and effective method to
reach the CP branches for obtaining satisfactory anes-
thesia when the IAN and LN blocks fail to anesthetize
lower molars with SIR. In this trial we described an
ICPAT method that uses a buccal approach below the
roots of the tooth to be anesthetized at the external
oblique line of the body of the posterior mandible in
order to infiltrate TCN and GAN branches that origi-
nate from the CP. The results of this study suggest
that in 60% of the cases in human patients there is
incomplete anesthesia of lower molars due to failure
to anesthetize the CP (Uzbelger Feldman et al., 2007).
A supplementary technique to anaesthetize the CP
seems to provide adequate pulpal anesthesia of
inflamed lower molar as tested with the EPT. In molars
with SIR, Nusstein et al. (1998) suggested that 42%
of the patients who tested negative to pulp tests
reported pain during treatment and required supple-
mental anesthesia. Nevertheless, a previous study
from Certosimo and Archer (1996) showed that
patients who do not feel a sensation at the maximum
voltage (80/80 reading) do not experience pain during
subsequent dental surgery.
In conclusion, the present study suggests that in
subjects in whom the IAN and LN blocks do not pro-
vide adequate pulpal anesthesia of mandibular molar
teeth with SIR, the ICPAT method may provide
adequate anesthesia in 60% of the cases. This tech-
nique of administering intraoral local anesthesia was
significantly more effective in the experimental than
the control group (P 5 0.0001). This anesthetic
method, which doesn’t require additional armamen-
tarium, may be useful not only for root canal therapies
but also in periodontal surgery, dental implant proce-
dures, dental extractions and oral and maxillofacial
surgeries as well as in operative dentistry in the pos-
terior adult mandible.
Consequently, these data propose that the TCN and
GAN supplementary innervations from the CP may be
responsible of a great percentage of IAN and LN
blocks failures. As a result, more research is needed
in order to study potential implications of additional
accessory innervation in the mandible other than the
CP in order to address persistent pain during the
treatment of lower molars diagnosed with SIR while
improving patient comfort and permit completion of
planned dental treatment.
ACKNOWLEDGMENT
We would like to acknowledge Drs. John Esposito,
Larry Koren, Roy Stevens and Amit Chattopadhyay for
all their support during the development of this study.
The authors report no conflict of interest.
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