REVIEW OF MANDIBULAR ANESTHESIA TECHNIQUES IN THE EXTRACTION OF IMPACTED THIRD MOLARS

BRAZILIAN JOURNAL OF ORAL AND SYSTEMIC HEALTH DOI doi.org/10.5281/zenodo.17717994 http://bjoshealth.com.br ISSN 3085-8097 REVIEW OF MANDIBULAR ANESTHESIA TECHNIQUES IN THE EXTRACTION OF IMPACTED THIRD MOLARS Revisão de técnicas anestésicas mandibulares na extração de terceiros molares retidos Volume 1 Issue!2 Jul-Dec 2025 LITERATURE REVIEW Fabian Andrés Pinargote Mendoza1 ; William Kluyvert Huilca Monga2 ; Zuly Belen Zapata Orellana2 ; Mishel Estefanía Añazco Tenicela2 ; Guillermo Alberto Lanas Teran2 ABSTRACT Objective: The objective of this review was to analyze and compare the effectiveness, advantages, limitations, and clinical applicability of mandibular anesthetic techniques commonly used during the extraction of impacted third molars. Special emphasis was placed on assessing success rates, onset time, duration, patient comfort, and potential complications associated with conventional and alternative approaches. Methods: A narrative review of the literature was conducted using electronic databases including PubMed, Scopus, Web of Science and SciELO. Articles published between 2010 and 2024 were screened using keywords related to mandibular anesthesia, inferior alveolar nerve block, GowGates technique, Vazirani-Akinosi technique, accessory innervation, and third molar surgery. Studies evaluating anesthetic success, failure rates, need for supplemental injections, and intraoperative complications were included. Experimental studies, clinical trials, observational studies, and systematic reviews were considered. Results: The literature shows that the conventional inferior alveolar nerve block (IANB) remains the most widely used technique, but it presents failure rates ranging from 15% to 30%, mainly due to anatomical variations and accessory innervation. The Gow-Gates technique demonstrates higher success rates, broader anesthetic coverage, and lower need for supplemental injections, though it requires greater operator skill and has a longer onset time. The VaziraniAkinosi closed-mouth block is particularly useful in patients with limited mouth opening and shows predictable anesthesia when performed correctly. Supplemental techniques—such as intraligamentary, intraosseous, and buccal nerve infiltration— are effective in managing incomplete anesthesia. Emerging technologies, including computer-controlled anesthetic delivery systems and ultrasound-guided injections, show promising improvements in precision and patient comfort. Conclusion: Mandibular anesthesia for impacted third molar extraction requires the selection of the most appropriate technique based on patient anatomy, clinical conditions, and operator expertise. While the conventional IANB remains standard practice, alternative techniques such as Gow-Gates and Vazirani-Akinosi provide effective solutions in cases of failed anesthesia or anatomical complexity. The integration of supplemental methods and modern guidance technologies can further enhance success rates and optimize patient outcomes. 1 – Universidad San Gregorio de Portoviejo, Facultad de Odontología, Portoviejo. Ecuador 2 - Universidad Central del Ecuador, Facultad de Odontología, Quito. Ecuador Corresponding Author: William Kluyvert Huilca Monga email: [email protected] Keywords: Third Molar, Tooth Extraction, Mandibular Nerve, Inferior Alveolar Nerve, Oral Surgery Brazilian Journal of Oral and Systemic Health, vol.1 n2, Publication date Dec 6, 2025 ISSN 3085-8097 Review of mandibular anesthesia techniques in the extraction of impacted third molars Mendoza FAP, Monga WKH, Orellana ZBZ, Tenicela MEA, Teran GAL 571 RESUMO Objetivo: O objetivo desta revisão foi analisar e comparar a eficácia, as vantagens, as limitações e a aplicabilidade clínica das técnicas anestésicas mandibulares comumente utilizadas durante a extração de terceiros molares impactados. Foi dado especial destaque à avaliação das taxas de sucesso, tempo de latência, duração, conforto do paciente e potenciais complicações associadas a abordagens convencionais e alternativas. Métodos: Foi realizada uma revisão narrativa da literatura utilizando bases de dados eletrônicas, incluindo PubMed, Scopus, Web of Science e SciELO. Artigos publicados entre 2010 e 2024 foram selecionados utilizando palavras-chave relacionadas à anestesia mandibular, bloqueio do nervo alveolar inferior, técnica de Gow-Gates, técnica de Vazirani-Akinosi, inervação acessória e cirurgia de terceiros molares. Foram incluídos estudos que avaliaram o sucesso anestésico, taxas de falha, necessidade de injeções suplementares e complicações intraoperatórias. Estudos experimentais, ensaios clínicos, estudos observacionais e revisões sistemáticas foram considerados. Resultados: A literatura demonstra que o bloqueio convencional do nervo alveolar inferior continua sendo a técnica mais amplamente utilizada, porém apresenta taxas de falha variando de 15% a 30%, principalmente devido a variações anatômicas e inervação acessória. A técnica de Gow-Gates apresenta maiores taxas de sucesso, cobertura anestésica mais ampla e menor necessidade de injeções suplementares, embora exija maior habilidade do operador e apresente tempo de latência mais prolongado. O bloqueio de boca fechada de Vazirani-Akinosi é particularmente útil em pacientes com abertura bucal limitada e demonstra anestesia previsível quando executado corretamente. Técnicas suplementares — como anestesia intraligamentar, intraóssea e infiltração do nervo bucal — são eficazes no manejo de anestesia incompleta. Tecnologias emergentes, incluindo sistemas computadorizados de administração de anestésicos e injeções guiadas por ultrassom, mostram avanços promissores em termos de precisão e conforto do paciente. Conclusão: A anestesia mandibular para extração de terceiros molares impactados requer a seleção da técnica mais apropriada com base na anatomia do paciente, nas condições clínicas e na experiência do operador. Embora o bloqueio convencional do nervo alveolar inferior permaneça como prática padrão, técnicas alternativas como Gow-Gates e Vazirani-Akinosi oferecem soluções eficazes em casos de falha anestésica ou complexidade anatômica. A integração de métodos suplementares e tecnologias modernas de orientação pode aumentar ainda mais as taxas de sucesso e otimizar os desfechos clínicos. . Keywords: Terceiros molares, extração dental, nervo mandibular, nervo alveolar inferior, cirurgia oral INTRODUÇÃO The extraction of impacted third molars is one of the most common surgical procedures in dental practice, particularly within oral and maxillofacial surgery. These teeth, commonly known as wisdom teeth, often exhibit incomplete or abnormal eruption due to insufficient space in the dental arch or improper angulation. Their impaction may lead to pain, infections, cyst formation, or damage to adjacent teeth. The surgical procedure not only requires clinical skill but also careful anesthetic planning. Therefore, it is essential to evaluate and compare the different mandibular anesthesia techniques prior to surgery, distinguishing their efficacy, safety, advantages, disadvantages, technique, and clinical applicability. This Brazilian Journal of Oral and Systemic Health, vol.1 n2, Publication date Dec 6, 2025 ISSN 3085-8097 Review of mandibular anesthesia techniques in the extraction of impacted third molars Mendoza FAP, Monga WKH, Orellana ZBZ, Tenicela MEA, Teran GAL 572 approach aims to ensure successful anesthetic blockade, minimize pain during the surgical intervention, and reduce potential postoperative complications. Proper administration of local anesthesia is a fundamental aspect for ensuring the success of the surgical procedure, as it provides effective pain control, facilitates the clinician’s work, and improves the patient’s overall experience. In the case of mandibular third molars whose anatomical position is closely related to the inferior alveolar nerve and other neurovascular structures the selection of the most appropriate anesthetic technique becomes particularly critical. Traditionally, lidocaine has been the local anesthetic of choice in dentistry. However, several clinical studies have evaluated alternative agents that, while maintaining comparable safety profiles, have demonstrated superior anesthetic efficacy. These alternatives are especially notable in infiltration techniques, showing greater diffusion capacity even in dense bone areas, such as the posterior mandible. This advancement offers an opportunity to optimize anesthetic management in complex surgical procedures, such as impacted third molar extractions, and highlights the need for a critical review of the most suitable anesthetic according to clinical case characteristics. Huang et al. reported a lack of comparative studies in the literature assessing the differences in safety and efficacy between articaine infiltration anesthesia and lidocaine nerve block anesthesia for this type of surgery. Therefore, the objective of the present study was to analyze and compare the various anesthetic techniques used in the mandibular region for the extraction of impacted third molars, evaluating their clinical effectiveness, safety, and applicability based on patient anatomy and the complexity of the surgical procedure (Huang, 2025). Mandibular Nerve Anesthesia Techniques: A Comparative Review Mandibular nerve anesthesia is essential for various dental procedures, and several techniques are available to achieve an effective nerve block. The Vazirani–Akinosi technique is one of the most frequently used approaches when the patient presents with limited mouth opening or trismus. This method, also known as the closed-mouth mandibular block technique, is characterized by the injection of the anesthetic solution into the pterygomandibular space, where several branches of the mandibular nerve are located. Among the nerves blocked with this technique are the inferior alveolar nerve, lingual nerve, mental nerve, and mylohyoid nerve, which are responsible for the sensory innervation of the mandibular teeth, the tongue, the skin of the chin, and certain muscles in the region. The main advantage of this technique is that it provides complete mandibular anesthesia without requiring wide mouth opening, making it particularly useful in cases of limited mandibular mobility (Haas, 2011; Martinus, 2024). Brazilian Journal of Oral and Systemic Health, vol.1 n2, Publication date Dec 6, 2025 ISSN 3085-8097 Review of mandibular anesthesia techniques in the extraction of impacted third molars Mendoza FAP, Monga WKH, Orellana ZBZ, Tenicela MEA, Teran GAL 573 The Gow-Gates technique, in contrast, requires the patient to open their mouth widely. In this procedure, the anesthetic is deposited in the region of the neck of the mandibular condyle, near the bifurcation of the mandibular nerve. This technique primarily affects branches of the mandibular nerve, including the inferior alveolar nerve and the lingual nerve, as well as other branches such as the auriculotemporal nerve. One of the main advantages of the Gow-Gates technique is that it provides a broader anesthetic effect, covering the entire mandibular nerve branch, which can be particularly useful for more complex surgical procedures in the mandible (Rudolph, 2022). Another widely used method is the Halstead technique, also known as the inferior alveolar nerve block, which is performed by inserting the needle toward the mandibular foramen. Its primary purpose is to anesthetize the inferior alveolar nerve, making it ideal for dental procedures involving mandibular teeth. Despite its effectiveness, the Halstead technique may present risks such as bone contact during needle insertion, and in some cases, anatomical variability among patients may complicate its execution (Brizuela et al., 2019). Therefore, a thorough understanding of the anatomy of the area and the nerves involved is essential before selecting the most appropriate technique. The Kurt-Thoma technique, less commonly used in clinical practice, is indicated in cases where previous techniques are unsuccessful due to the patient’s complex anatomy. The injection is administered in the region of the mandibular nerve, anesthetizing both the inferior alveolar nerve and the lingual nerve. This technique has proven effective in achieving mandibular anesthesia when more traditional methods fail, although its use remains limited due to the scarcity of extensive documentation comparing its success rates with other techniques (Vazirani & Akinosi, 2022). Finally, the Fisher 1-2-3 technique proposes a sequential approach for blocking the mandibular nerves. It begins with the blockade of the long buccal nerve, achieved by identifying anatomical landmarks in the distal region of the mandibular third molar. The needle is then directed toward the occlusal surface of the contralateral premolars and inserted into the external oblique ridge until it contacts the mandibular ramus, allowing localization of the mandibular foramen. Lastly, the needle is adjusted toward the ipsilateral side to complete the blockade of the lingual nerve and the inferior alveolar nerve. This sequential strategy ensures a more gradual and precise anesthetic effect, providing full coverage of the involved nerves and improving patient comfort during procedures such as the extraction of mandibular third molars (Krishna S, 2024). Anatomical Foundations of Each Technique Anatomy of the Mandibular Lingula Brazilian Journal of Oral and Systemic Health, vol.1 n2, Publication date Dec 6, 2025 ISSN 3085-8097 Review of mandibular anesthesia techniques in the extraction of impacted third molars Mendoza FAP, Monga WKH, Orellana ZBZ, Tenicela MEA, Teran GAL 574 D.-Y. Choi et al. reported that the mandibular lingula is clinically used as a reference point to locate the mandibular foramen. This structure has a prominent tongue-like shape and is situated on the medial surface of the mandibular ramus, near the mandibular foramen. The latter corresponds to the opening of the mandibular canal through which the inferior alveolar nerve passes, positioned inferior and posterior to the lingula. For this reason, both the lingula and the mandibular foramen are considered key anatomical landmarks not only for performing the inferior alveolar nerve block but also for surgical procedures such as orthognathic surgery (Choi, 2021). The inferior alveolar nerve block is a widely used anesthetic technique in the mandible. The most commonly employed approach is the direct technique, in which the needle is inserted into the pterygomandibular space by passing through the buccinator muscle. Once in this space, the goal is to deposit the local anesthetic near the inferior alveolar nerve before it enters the mandibular foramen. However, the considerable variability in the position of the lingula makes it difficult to determine an exact insertion point and precise depth during the block. The position of the lingula has been described in relation to: • The anterior and posterior borders of the mandibular ramus, • The coronoid notch, • The inferior border of the mandible, • The occlusal plane. Factors such as sex, age, and ethnicity influence its location. Nevertheless, it is generally situated in a more posterior and superior position relative to the center of the mandibular ramus. Prognathic mandibles have the lingula positioned even more posteriorly and superiorly than non-prognathic ones. In most cases, the lingula is located above the occlusal plane (80% according to Thai studies). Pediatric studies (ages 6–18) report that the number of lingulae found at or below the occlusal plane decreases with age, being more common in younger children than in adolescents. The triangular shape of the lingula is typically located slightly higher and more posteriorly than other shapes, which is clinically relevant in mandibular surgery. Studies have measured the distance from the anterior border of the mandibular ramus to the lingula or mandibular foramen, proposing mean values as a reference to locate the injection site more safely. Regarding vertical height, the occlusal plane is used as a reference. Some authors suggest an average of 3–5 mm above Brazilian Journal of Oral and Systemic Health, vol.1 n2, Publication date Dec 6, 2025 ISSN 3085-8097 Review of mandibular anesthesia techniques in the extraction of impacted third molars Mendoza FAP, Monga WKH, Orellana ZBZ, Tenicela MEA, Teran GAL 575 the plane, while others recommend aiming for the maximum reported value (14 mm above the occlusal plane) to reduce the risk of injecting too low and causing block failure. A detailed assessment of its anatomical characteristics allows for improved clinical efficacy and a reduction in failure rates. Knowledge of its morphological and positional variations is essential in both anesthetic and surgical procedures involving the mandible. Comparison of Mandibular Anesthesia Techniques Since mandibular nerve block is fundamental for performing complex procedures in the lower oral cavity, the choice of the appropriate technique directly influences patient comfort and procedural success. Several techniques have been developed for blocking this nerve, each with particular characteristics regarding success rate, duration of anesthesia, risks, and complications. This article aims to compare some of the most commonly used techniques: Halstead, Vazirani-Akinosi, Gow-Gates, Kurt-Thoma, and Fischer 1-2-3, with a detailed analysis of their advantages and disadvantages based on recent studies. 1. Halstead Technique (Inferior Alveolar Nerve Block) The Halstead technique is one of the most traditional and widely used methods in dental practice. In this technique, the anesthetic is injected near the inferior alveolar nerve at the mandibular ramus, providing complete anesthesia of the lower jaw. However, its success rate is not as high as that of newer techniques. Despite being used for over a century, it remains effective in a reasonable percentage of patients (Chandran & Thomas, 2021). • Success rate: The average success rate of the Halstead technique is approximately 73.3%, which, although acceptable, is lower than more recent techniques such as Vazirani-Akinosi (Naguib et al., 2023). • Duration: Anesthesia lasts between 60 and 90 minutes, generally sufficient for standard dental procedures but not for long or complex surgeries. • Advantages: Its main advantage is simplicity and ease of administration, making it a reliable technique, especially in patients without complex oral pathologies. • Disadvantages: Pain during injection is a common complaint, and the moderate success rate may limit its use in procedures with high anesthesia demands. 2. Vazirani-Akinosi Technique (Closed-Mouth Mandibular Block) Brazilian Journal of Oral and Systemic Health, vol.1 n2, Publication date Dec 6, 2025 ISSN 3085-8097 Review of mandibular anesthesia techniques in the extraction of impacted third molars Mendoza FAP, Monga WKH, Orellana ZBZ, Tenicela MEA, Teran GAL 576 The Vazirani-Akinosi technique is particularly useful for patients with limited mouth opening due to anatomical conditions or clinical situations such as post-surgical trismus. This method provides excellent inferior alveolar nerve block without requiring full mouth opening, making it ideal for patients with restricted oral access or severe pain (Naguib et al., 2023). • Success rate: The Vazirani-Akinosi technique shows a success rate of 96.7%, significantly higher than Halstead, making it a preferred option for many dentists (Chandran & Thomas, 2021). • Duration: This technique offers longer-lasting anesthesia, up to 2 hours, suitable for lengthier procedures. • Advantages: High success rate and reduced pain during injection, especially useful in patients with limited mouth opening. More effective than Halstead in terms of anesthetic duration. • Disadvantages: Requires greater technical skill and dexterity, posing a challenge for less experienced clinicians. 3. Gow-Gates Technique (High Mandibular Block) Introduced by Gow-Gates in 1973, this technique relies on anatomical landmarks outside the oral cavity, although access to the target site, the mandibular condylar neck, is intraoral. Vazirani and Akinosi later developed the closed-mouth technique now known as Vazirani-Akinosi. The Gow-Gates method primarily blocks the entire mandibular nerve and its branches, producing profound anesthesia, which is especially useful for irreversible pulpitis and complex surgical procedures. It is considered one of the most effective techniques, achieving deep anesthesia with high success (Chandran & Thomas, 2021). • Success rate: 80–90%, among the most effective for deep mandibular anesthesia (Chandran & Thomas, 2021). • Duration: 5–6 hours, making it ideal for lengthy and complex surgeries. • Advantages: High efficacy and prolonged duration, preferred for procedures requiring deep, longlasting anesthesia. • Disadvantages: More invasive, technically demanding, and potentially challenging for less experienced dentists (Mundodi, 2021). 4. Kurt-Thoma Technique (Extraoral Mandibular Block) The Kurt-Thoma technique is a deeper mandibular block performed via extraoral injection rather than intraoral. It is effective when other blocks fail but carries additional risks. Brazilian Journal of Oral and Systemic Health, vol.1 n2, Publication date Dec 6, 2025 ISSN 3085-8097 Review of mandibular anesthesia techniques in the extraction of impacted third molars Mendoza FAP, Monga WKH, Orellana ZBZ, Tenicela MEA, Teran GAL 577 • Success rate: 85%, a favorable outcome compared to other popular techniques (Smith et al., 2025). • Duration: Approximately 90 minutes. • Advantages: Rapid onset of anesthesia compared to other methods. • Disadvantages: Can cause significant injection pain and higher risk of trismus, affecting postoperative mouth opening (Smith et al., 2025). 5. Fischer 1-2-3 Technique (Sequential Mandibular Block) The Fischer technique, though less commonly known, is effective when precise control over anesthetic distribution is required. This sequential technique achieves deeper anesthesia, useful in complex procedures. • Success rate: 75%, slightly lower than the previously mentioned techniques. • Duration: 2–3 hours, sufficient for many standard dental procedures. • Advantages: Allows greater control over anesthetic distribution, useful when other techniques may be less effective. • Disadvantages: More time-consuming, less widely known, and a lower success rate can be a limiting factor (Johnson et al., 2015). The choice of mandibular anesthesia technique largely depends on the patient’s clinical situation, the dentist’s experience, and anatomical characteristics. While Vazirani-Akinosi and Gow-Gates offer higher success rates and longer duration, traditional techniques such as Halstead remain useful for simpler procedures. More complex techniques like Kurt-Thoma and Fischer 1-2-3, although effective in specific scenarios, require higher skill levels and may involve additional complications such as trismus. Table 1. Comparison of Success Rate and Duration Technique Success Rate Duration Advantages Disadvantages Halstead 73.3% 60-90 minutes Easy to perform Pain during injection VaziraniAkinosi 96.7% 2 hours High success rate, less pain Requires skill and technique Brazilian Journal of Oral and Systemic Health, vol.1 n2, Publication date Dec 6, 2025 ISSN 3085-8097 Review of mandibular anesthesia techniques in the extraction of impacted third molars Mendoza FAP, Monga WKH, Orellana ZBZ, Tenicela MEA, Teran GAL 578 Gow-Gates 80-90% 5-6 hours High efficacy and prolonged duration Technical complexity KurtThoma 85% 90 minutes Rapid onset of action Significant pain, trismus Fischer 1-23 75% 2-3 hours Sequential control Time-consuming Limitations and Complications of Mandibular Anesthesia Techniques A prospective comparative study evaluated the efficacy, complications, and limitations of five different techniques for inferior alveolar nerve block (IANB) in mandibular anesthesia. The main findings were as follows: Kurt-Thoma Technique (Extraoral) Although this technique showed the fastest onset of action (2.25 minutes), it was associated with the most significant complications: • Higher incidence of trismus: Difficulty opening the mouth was reported in 25% of patients, the highest rate among all evaluated techniques. • Higher pain perception: Patients rated pain during anesthesia administration at an average of 6.5 on the visual analog scale (VAS), making it the most painful technique in the study. • Increased patient anxiety and slower onset in practice, although it can be useful in specific clinical situations. • General dental anesthesia complications: May include dizziness, tachycardia, nausea, pallor, syncope, postoperative pain, and mild cardiovascular effects, with a total incidence ranging from 4.5% to 26.2% according to broad reviews. • Risk of infection if the skin is not properly disinfected. • Requires high technical skill due to reliance on external landmarks and injection depth. • Facial nerve involvement: If the needle is inserted too posteriorly and reaches the parotid gland, temporary facial nerve anesthesia can occur, causing difficulty closing the eye or asymmetrical smile. • Rare complications: Anesthetic migration toward vessels connecting to the orbit may cause diplopia.