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Figure19.4 Branches of the mylohyoid nerve that supply the
molars (1), premolars (2), incisors and canines (3), and even
contralateral anterior teeth (4).
the mylohyoid groove and are found in 60–70% of mandibles (Shiller and Wiswell1954; Chapnick1980).
● Branches for the ipsilateral mandibular incisors
(Novitzky 1938; Sicher 1946; Carter and Keen 1971;
Sutton1974; Madeira etal.1978; Wilson etal.1984) and
contralateral incisors (Madeira etal. 1978). These penetrate via the foramina of the mandibular symphysis and
appear in 90% of mandibles (Shiller and Wiswell 1954;
Sutton 1974; Madeira et al. 1978). They have been
observed in 30% of dissections (Table19.3).
351
Buccal Nerve The buccal nerve is involved in the
innervation of the mandibular molars because it gives off a
series of variants:
● Foramen at the level of the retromolar fossa. The buccal
nerve or any of its branches penetrates via this foramen
and reaches the apices of the molars via an accessory
canal (Figure 19.5). This variant was suggested by
Stewart in 1932 (Stewart1932) and supported by clinical
experience (Jeffries1944). The dissection-
based explanation of the anatomy was put forward by Sutton in 1974
(Sutton1974). The variant may occasionally escape mandibular block.
● Retromolar canal. The buccal nerve or any of its branches
can emerge at a very low level and become separated
from the inferior alveolar nerve in the mandibular canal
itself and emerge in the retromolar fossa (Figure19.6)
via a foramen measuring 0.2–1.7
mm in diameter
(Turner1864; Schejtman etal.1967; Singh1981). Before
emerging behind the molars, it may give off a branch
that reaches the apices of the inferior molars via an
accessory canal (Schejtman etal.1967). The frequency of
this variant in the general population is unknown,
although it is found in 63% of Amazonian Indians
(Schejtman etal.1967) and in 12% of Nordic Europeans
(Löfgren1957). It is usually anesthetized with mandibular block.
Finally, the mylohyoid nerve is one of the best documented accessory innervations and is widely accepted by
most authors (Barker and Davies 1972b; Rood 1976;
Chapnick1980; Coleman and Smith1982).
Table19.3 Percentage ofcases ofmylohyoid nerve
inmandibular symphysis.
Reference Percentage
Sicher (1946) 10%
Carter and Keen (1971) 12.5%
Madeira et al. (1978) 50%
Wilson et al. (1984) 43%
Figure19.5 Branches of the buccal nerve penetrating via a
foramen of the retromolar fossa and an accessory channel can
30%
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reach the apex of the molars. Redrawn from
Ossenberg (1986).
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352
Figure19.6 Branches of the buccal nerve emerge at a low
level, within the mandibular channel itself, and emerge in the
retromolar fossa by giving off a branch to the apices of the
molars. Redrawn from Ossenberg (1986).
mandibular molars. The frequency of this variant in the
general population is 1.7% (Ossenberg1986). The variant
is not usually affected by mandibular block.
Accessory Branch for the Wisdom Teeth In 40% of cases,
the inferior alveolar nerve gives off a specific branch
forthe third molar immediately before or after it enters
the mandibular foramen (Sicher 1946; Barker and
Davies1972b). There is a possibility that this branch will
emerge at a high level, penetrating via its own foramen into
the area of the condyle (Figure19.8), where most foramina
are concentrated (Carter and Keen 1971; Barker 1972a;
Haveman and Tebo1976), and thus remaining unaffected
by mandibular block.
Auriculotemporal Nerve The auriculotemporal nerve emerges
from the common trunk of the third branch of the trigeminal
(mandibular nerve, V
) and crosses behind and outside in the
3
highest part of the pterygomandibular space. This sensory
nerve supplies the skin in the temporal region (which can
reach the limits of the parietal, masseter, frontal, and
supraorbital region), pinna with the tragus, external auditory
canal, and posterior part of the temporomandibular joint
capsule. Branches of this nerve have occasionally been found
to penetrate via the foramina in the region of the condylar
neck and the retromolar fossa and reach the apices of the
mandibular molars (Carter and Keen1971; Sutton1974). It is
worth remembering the high number of foramina present in
the retromolar region (Carter and Keen1971; Haveman and
Tebo1976) and the fact that nerve fibers have been found in
40% of these (Carter and Keen1971).
Figure19.7 The buccal nerve can course through a high
foramen in the temporal crest, with some branches diverting
through an accessory channel that reaches the apex of the
Redrawn from Ossenberg (1986).
molars.
● Temporal crest canal. The buccal nerve or any of its
branches can penetrate via a high foramen of the ascending branch behind the temporal crest (formerly the internal oblique line) and continue along a canal measuring
0.5–3 mm in diameter that opens just as it passes the
temporal crest at the anterior border of the mandibular
ascending ramus (Figure19.7). In many cases, an accessory canal emerges and reaches the apices of the
Figure19.8 Branch for the wisdom tooth that emerges at a
very high level and penetrates via its own foramen.
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Figure19.9 Labial plexus with branches that cross the midline
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and may enter via the buccal foramina to supply the anterior
teeth. Redrawn from Rood (1977).
Crossed Innervation in the Region of the Incisors (Labial
For embryological reasons (mandibular
Plexus)
symphyseal cartilage) and anatomical reasons, the
incisive nerve does not pass the midline of the mandible,
therefore there is no contralateral crossed innervation
(Olivier1927; Sicher1946) (Note: In only one case, in 535
patients, was the mandibular incisive canal found to pass
the symphysis area in one series; Zhang et al. 2019.).
However, the mental nerve gives off branches that form
the labial plexus in the area of the mucosa and the
anterior soft tissues, and these branches do cross the
midline (Figure 19.9). Some of these branches can
penetrate via the buccal mandibular foramina and
innervate the contralateral canines and incisors (Starkie
and Stewart1931; Rood1977; Pogrel etal.1997).
Other Uncertain Innervations Other nerve branches have
been involved in the accessory innervation, although these
have not been verified.
353
Meticulous dissection studies have shown that branches
of the transverse nerve of the neck approach the inferior
border of the mandible. However, these have never demonstrated contact with the periosteum or penetration via
foramina in which only feeder vessels have been found
(Novitzky 1938; Sicher 1946, 1950; Cook 1951; Rizzolo
etal.1988). Furthermore, embryologic data demonstrates
that the third branchial arch is the territory of the trigeminal nerve and that the passage of the transverse cervical
nerve to the area of the trigeminal nerve contradicts the
basic principles of embryology (Barker and Davies1972b;
Rizzolo etal. 1988), therefore this accessory innervation
is thought to be unlikely (Chapnick1980; Coleman and
Smith1982) and is probably confused with other nerve
trunks, particularly with the accessory innervation of the
mylohyoid nerve or the labial plexus.
Note: The transverse cervical nerve innervated the posterior inferior border of the mandible in one of two cadavers
in one study (Lin etal.2013).
● The lingual nerve may occasionally innervate the infe-
rior incisors (Stewart and Wilson 1928; Jeffries 1944;
Rood1976; Chapnick1980), although there is little ana-
tomical evidence to support this hypothesis (Coleman
and Smith1982). In 1932, Stewart reported how Wilfred
Ellison, in his anatomical dissections, found that
branches of the lingual nerve penetrated via the alveolar
vessels of the neck of the molars and premolars, suppos-
edly with the aim of Innervating them (Stewart1932).
This data has not been confirmed.
Finally, Table19.4 provides a summary of the accessory
innervations of each tooth, with emphasis on crossinnervation in the area of the incisors and, to a lesser
extent, of the canines, possibly owing to the course of the
mylohyoid nerve (Madeira etal.1978) and the labial plexus
(Starkie and Stewart1931; Rood1977; Pogrel etal.1997).
● The transverse nerve of the neck, or transverse cervical
nerve (previously known as the cutaneous colli nerve), is
a branch of the cervical plexus that innervates the skin
between the sternocleidomastoid and the mandible. At
the beginning of the twentieth century, Marshall proposed that it was a source of accessory innervation
(Stewart1932), and the theory became very popular with
various authors (Phillips1943; Jeffries1944; Cook1951;
Bremer1952; Sutton1974; Rood1976) who claimed that
branches of this nerve penetrated via the inferior border
of the mandible and thus innervated the teeth. Evidence
for this accessory innervation is only clinical, since complementary buccal and lingual infiltration often complete the pulpal anesthesia of mandibular block in the
anterior teeth.
Table19.4 Summary ofaccessory innervation inmandibular
teeth.
Teeth Possibleaccessoryinnervation
Molars Mylohyoid nerve
Premolars Mylohyoid nerve
Incisors and
canines
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Variant branches of the inferior alveolar nerve
Accessory branches for wisdom teeth
Buccal nerve
Auriculotemporal nerve
Mylohyoid nerve
Even contralateral
Labial plexus
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354
This anatomical finding has been clinically verified by
increasing pulpal anesthesia of these teeth with bilateral
mandibular block (Yonchak etal.2001).
Approach
Unfortunately, since the cause of failure is unknown in
most cases, the course of action in the posterior mandibular teeth will be as follows:
1) Absence of anesthesia of the lower lip. If injection of
mandibular block is not followed by anesthesia of half
of the lower lip within 5
minutes, the technique is considered to have failed (Cohen et al. 1993; Hersh
etal.1995; Nusstein et al.1998) and should therefore
not be repeated.
2) Complementary buccal anesthesia. If soft tissue anes-
thesia of the lower lip can be verified after 5 minutes
(sign that the mandibular block is taking effect), complementary buccal infiltration should be applied in
posterior mandibular teeth that require full pulpal anesthesia. This maneuver considerably improves pulpal
anesthesia. The recommended approach is infiltration
with a potent solution such as articaine 4% with epi-
nephrine 1:100 000 (A- 100). A whole cartridge should be
used for the buccal area in the posterior teeth to be
treated (1.8 ml) (Haase et al.2008; Kanaa etal. 2009;
Gazal2015).
After this infiltration, wait a further 5–10
10–15
minutes from initiation of mandibular block) to
minutes (total
ensure that pulpal anesthesia has taken full effect.
3) Complement this approach with a second injection in the
pterygomandibular space. If pain continues to be present
after mandibular block with the standard solution (L-
100)
and the lower lip is fully anesthetized (indicating that the
inferior alveolar nerve has been anesthetized), and after
administering complementary buccal anesthesia with
A- 100 and waiting 10–15 minutes, then a second injection
of L-
100 into the pterygomandibular space is recommended (now 3.6
additional 5
ml instead of 1.8 ml) and then wait an
minutes. This measure increases the efficacy
of pulpal anesthesia by 5% (Annex 25).
If the second injection, after a conventional approach,
is Gow-
Gates technique (Haas 2011; Saatchi et al.
2018) or Laguardia–Akinosi (Haas2011), the outcome
improves as this different approach can overcome
some anatomical variability and/or accessory innervations (Haas2011).
4) Supplementary techniques. If the above approach is not
sufficient and anesthesia fails after waiting a further
5 minutes, use supplementary techniques, namely, the
PDL and the intraosseous technique (IO). If complementary buccal anesthesia has been administered with a potent
solution such as A-
100, then the same solution should be
used in the periodontal ligament or IO technique so as not
to mix two different anesthetics at the same site.
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