Achieving anesthesia of the mandibular teeth can be a challenge. Traditionally, schools have taught the inferior alveolar nerve block as the primary technique for anesthetizing mandibular teeth.

Yet while the IANB technique has been considered the standard method for delivering anesthesia for mandibular teeth, it isn’t always successful. This is especially true in treating teeth with symptomatic irreversible pulpitis. It can be particularly frustrating when a patient's lip and tongue are anesthetized but their mandibular teeth are still sensitive.

Fortunately, there are a few additional anesthetic techniques that we can use to help ensure our patients are comfortable.

Supplementary anesthesia techniques

If our patient has soft tissue anesthesia, but is still experiencing discomfort, there are a few supplementary techniques that can help ensure profound pulpal anesthesia. One of the more common and simple techniques is a mandibular infiltration.

In this technique, an additional amount of anesthetic solution is delivered adjacent to the symptomatic tooth. For mandibular anterior teeth, infiltration of anesthetic to both the buccal and lingual cortical bone has shown to be more effective than administering to the buccal aspect alone.

However, for mandibular posterior teeth there is no difference when delivering solely to the buccal aspect vs. both buccal and lingual aspects. For mandibular infiltrations, 4% articaine solutions have been shown to be more effective at increasing the likelihood of pulpal anesthesia than 2% lidocaine solutions.1

The intraligamentary injection (also known as the periodontal ligament injection, or PDL) can be a useful supplementary technique. The PDL injection can be performed using a traditional aspirating syringe, or a PDL-injection system (such as a Ligmaject).

In this technique, anesthetic solution is delivered in to the PDL of the tooth and spreads to the cancellous bone surrounding the tooth. When positioning the needle, it’s important to have the bevel face the tooth (rather than the gingiva), and to ensure that significant back pressure is felt when delivering the anesthesia. Only a minimal amount of solution (approximately 0.2 mL, about the size of the carpule plunger) is delivered for the root of the tooth being anesthetized.2

In a similar fashion to the PDL injection, the intraosseous injection technique delivers anesthetic solution to the cancellous bone surrounding the tooth. In the intraosseous injection, a hole is created through the buccal cortical bone, exposing the cancellous bone adjacent to the tooth.

A small amount of anesthetic solution is delivered into the cancellous bone, which anesthetizes the adjacent tooth. Care must be taken to avoid contacting the tooth roots when perforating the buccal cortical bone. To avoid perforating a tooth, this technique is not advised for patients who are in their primary or mixed dentition due to the risk of damaging the unerupted teeth. Special delivery systems, such as the X-Tip and the Stabident, are necessary to perform intraosseous injections predictably.2

Additional techniques to achieve mandibular anesthesia

While the IANB has been taught as the standard technique for a mandibular block, other techniques are present that can predictably produce a mandibular nerve block. One of these techniques is the Akinosi-Vazirani technique.

In the Akinosi-Varzirani technique, the needle is inserted between the coronoid process and the maxillary tuberosity, at the height of the mucogingival junction. With this technique, the patient will close down to facilitate access to the injection site. This technique can be particularly useful in patients with trismus or an overactive tongue that may inhibit the ability to perform a traditional IANB.3

A second alternative to the traditional IANB is the Gow-Gates technique. With this technique, a mandibular block is achieved by delivering anesthetic solution adjacent to the condyle.

To perform the Gow-Gates technique, locate three landmarks: The intertragic notch (just below the tragus of the ear), the coronoid process, and the corner of the mouth.

patient's open mouth with the doctor using a wooden stick on the upper side
Locating the landmarks for the Gow-Gates technique.

Once these are identified, the barrel of the syringe will be adjacent to the contralateral canine, and the needle will be adjacent to the mesiopalatal cusp of the second molar.

Have the patient open as wide as possible during the injection and remain open for approximately 20 seconds after delivering the anesthetic solution. This helps maintain the position of the nerve as close to the anesthetic solution as possible, maximizing the chances of successfully achieving mandibular pulpal and soft tissue anesthesia.3

patient's open mouth with the doctor injecting into the side
Positioning the syringe for delivering anesthetic solution using the Gow-Gates technique.

Buffered anesthetics

Recently buffered anesthetics have been gaining popularity as a reliable way to predictably achieve pulpal anesthesia. Various systems are available that mix sodium bicarbonate with local anesthetics to increase the pH of the anesthetic solution.

Altering the pH of an anesthetic can be particularly useful for symptomatic teeth, where the inflammatory response leads to a more acidic, lower pH environment. Recent studies on buffered anesthetics have shown that a buffered anesthetic solution can be up to twice as effective to achieve adequate anesthesia in symptomatic teeth than non-buffered local anesthetics.4

Spear Online's “Mandibular Nerve Blocks” coursework, taught by Dr. Stanley Malamed, reviews these supplementary and alternate techniques for achieving mandibular anesthesia. The nine-lesson, two-part course has been especially helpful for me in cases where achieving mandibular anesthesia has been a challenge.

Hopefully these additional techniques can help you predictably, reliably and confidently keep your patients comfortable and happy.

Andy Janiga, D.M.D., is a contributor to Spear Digest.


1Meechan, J.G. “The use of the mandibular infiltration anesthetic technique in adults.” JADA 2011; 142 (9 suppl): 19S-24S.

2Moore, P.A. et al. “Periodontal ligament and intraosseous anesthetic injection techniques: Alternatives to mandibular nerve blocks.” JADA 2011; 142 (9 suppl): 13S-18S.

3Haas, D.A. “Alternative mandibular nerve block techniques: A review of the Gow-Gates and Akinosi-Vazirani closed-mouth mandibular nerve block techniques.” JADA 2011; 142 (9 suppl): 8S-12S.

4Kattan, S. et al. “Do buffered local anesthetics provide more successful anesthesia than nonbuffered solutions in patient with pulpally involved teeth requiring dental therapy? A systematic review.” JADA 2019; 150 (3): 165-177


Commenter's Profile Image Kevin H.
September 6th, 2019
This is a great article and is helpful information. One otger thing to consider is trouble shooting an inadequate IA block is the potential for referred pain from the masseters to the posterior teeth. While I can't share the image here, please search "Travell masseter image" in a browser; tgere are several of Janet Travell's diagrams showing pain referral patterns from the masseter. The risk of myofascial pain complicating anesthesia can often be assessed pror to injecting by palpating the masseters. A possible eesolve is to anesthetize the masseter with 3% mepivacaine without vasoconstrictor should an IA block be inadequate, and pain can be stimulated by gentle palpstion of the masseter. This injection can be from an intraoral approach or from an extraoral approach. The patient should be informed that Bell's palsy-like symptoms will iccur for the duration of the anesthetic because it is likely that the facial neeve will also be anesthetized because of the proximity of the parotid gland.