Clinical Oral Investigations

, Volume 22, Issue 3, pp 1523–1530 | Cite as

Extraction of mandibular premolars and molars: comparison between local infiltration via pressure syringe and inferior alveolar nerve block anesthesia

  • Daniel G. E. Thiem
  • Florian Schnaith
  • Caroline M. E. Van Aken
  • Anne Köntges
  • Vinay V. Kumar
  • Bilal Al-Nawas
  • Peer W. Kämmerer
Original Article



The purpose of this study was to evaluate the anesthetic efficiency of local infiltration anesthesia administered with a pressure syringe (P-INF) via a special technique versus direct block anesthesia of the inferior alveolar nerve (IANB) for tooth extraction in the posterior mandible.

Materials and methods

In a prospective randomized study, 101 teeth in 101 patients were extracted in the posterior mandible under local anesthesia whereby two different administration techniques were used (P-INF n = 48; IANB n = 53). Primary objectives were comparisons of anesthetic success rate (yes/no) and efficacy (full/sufficient vs. insufficient). Secondary objectives were patients’ pain perception during treatment, pain of injection (numerical rating scale), need for second injections (always IANB), time until onset of anesthetic action (min), and duration of local numbness (min).


IANB was successful in all cases, whereas initial P-INF achieved 35% of success only. Furthermore, IANB reached significant higher values of anesthetic efficacy compared to P-INF (P < 0.001). Concerning pain of injection, patients rated IANB to be more painful (P = 0.039). Second injections were significantly more often necessary for P-INF (P = 0.006) whereas duration until onset of action as well as the duration of local numbness were found to be equal.


For anesthetic efficacy as well as anesthetic success, block anesthesia of the inferior alveolar nerve (IANB) turned out to be more proficient to local infiltration via special delivering system with a special technique.

Clinical relevance

Infiltration, even when performed with 4% articaine and a pressure syringe system, is not a suitable method of anesthesia in the posterior mandible.


Anesthetic success IANB Mandibular molar tooth extraction Molar region of the mandible Local anesthesia Pressure syringe system 


Author Contributions

All the authors of this manuscript had substantial contribution to the conception and design or acquisition, analysis, and interpretation of data; all revised it critically for important intellectual content and did the final approval of the version to be published. All authors read and approved the final manuscript. D.G.E. Thiem ( takes responsibility for the integrity of the work as a whole, from inception to finished article.


For this study, no funding was received.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Supplementary material

784_2017_2251_MOESM1_ESM.docx (28 kb)
ESM 1 (DOCX 27 kb)


  1. 1.
    Thomson WM, Dixon GS, Kruger E (1999) The West Coast Study. II: Dental anxiety and satisfaction with dental services. N Z Dent J 95(420):44–48PubMedGoogle Scholar
  2. 2.
    Kaufman E, Epstein JB, Naveh E, Gorsky M, Gross A, Cohen G (2005) A survey of pain, pressure, and discomfort induced by commonly used oral local anesthesia injections. Anesth Prog 52(4):122–127.[122:ASP]2.0.CO;2 CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Malamed SF (1997) Handbook of local anesthesia, vol 4. Mosby, St. LouisGoogle Scholar
  4. 4.
    Kämmerer PW, Schiegnitz E, von Haussen T, Shabazfar N, Kammerer P, Willershausen B, Al-Nawas B, Daublander M (2015) Clinical efficacy of a computerised device (STA) and a pressure syringe (VarioJect INTRA) for intraligamentary anaesthesia. Eur J Dent Educ 19(1):16–22. CrossRefPubMedGoogle Scholar
  5. 5.
    Kaakko T, Milgrom P, Coldwell SE, Getz T, Weinstein P, Ramsay DS (1998) Dental fear among university students: implications for pharmacological research. Anesth Prog 45(2):62–67PubMedPubMedCentralGoogle Scholar
  6. 6.
    Foster W, Drum M, Reader A, Beck M (2007) Anesthetic efficacy of buccal and lingual infiltrations of lidocaine following an inferior alveolar nerve block in mandibular posterior teeth. Anesth Prog 54(4):163–169.[163:AEOBAL]2.0.CO;2 CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Shabazfar N, Daublander M, Al-Nawas B, Kämmerer PW (2014) Periodontal intraligament injection as alternative to inferior alveolar nerve block—meta-analysis of the literature from 1979 to 2012. Clin Oral Investig 18(2):351–358. CrossRefPubMedGoogle Scholar
  8. 8.
    Davis MJ, Vogel LD (1996) Local anesthetic safety in pediatric patients. N Y State Dent J 62(2):32–35PubMedGoogle Scholar
  9. 9.
    Kämmerer PW, Palarie V, Daublander M, Bicer C, Shabazfar N, Brullmann D, Al-Nawas B (2012) Comparison of 4% articaine with epinephrine (1:100,000) and without epinephrine in inferior alveolar block for tooth extraction: double-blind randomized clinical trial of anesthetic efficacy. Oral Surg Oral Med Oral Pathol Oral Radiol 113(4):495–499. CrossRefPubMedGoogle Scholar
  10. 10.
    Hinkley SA, Reader A, Beck M, Meyers WJ (1991) An evaluation of 4% prilocaine with 1:200,000 epinephrine and 2% mepivacaine with 1:20,000 levonordefrin compared with 2% lidocaine with:100,000 epinephrine for inferior alveolar nerve block. Anesth Prog 38(3):84–89PubMedPubMedCentralGoogle Scholar
  11. 11.
    Vreeland DL, Reader A, Beck M, Meyers W, Weaver J (1989) An evaluation of volumes and concentrations of lidocaine in human inferior alveolar nerve block. J Endod 15(1):6–12. CrossRefPubMedGoogle Scholar
  12. 12.
    Nist RA, Reader A, Beck M, Meyers WJ (1992) An evaluation of the incisive nerve block and combination inferior alveolar and incisive nerve blocks in mandibular anesthesia. J Endod 18(9):455–459. CrossRefPubMedGoogle Scholar
  13. 13.
    Nusstein J, Reader A, Beck FM (2002) Anesthetic efficacy of different volumes of lidocaine with epinephrine for inferior alveolar nerve blocks. Gen Dent 50(4):372–375 quiz 376-377PubMedGoogle Scholar
  14. 14.
    Yonchak T, Reader A, Beck M, Meyers WJ (2001) Anesthetic efficacy of unilateral and bilateral inferior alveolar nerve blocks to determine cross innervation in anterior teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 92(2):132–135. CrossRefPubMedGoogle Scholar
  15. 15.
    Steinkruger G, Nusstein J, Reader A, Beck M, Weaver J (2006) The significance of needle bevel orientation in achieving a successful inferior alveolar nerve block. J Am Dent Assoc 137(12):1685–1691CrossRefPubMedGoogle Scholar
  16. 16.
    SF. M (2004) Handbook of local anesthesia, vol 4, 4th edn. Esevier Mosby, St LouisGoogle Scholar
  17. 17.
    Jung IY, Kim JH, Kim ES, Lee CY, Lee SJ (2008) An evaluation of buccal infiltrations and inferior alveolar nerve blocks in pulpal anesthesia for mandibular first molars. J Endod 34(1):11–13. CrossRefPubMedGoogle Scholar
  18. 18.
    Choi EH, Seo JY, Jung BY, Park W (2009) Diplopia after inferior alveolar nerve block anesthesia: report of 2 cases and literature review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 107(6):e21–e24. CrossRefPubMedGoogle Scholar
  19. 19.
    Hussein R, Muhammad D, Omar O (2015) Comparison between infiltration and inferior alveolar nerve block anesthesia in extraction of non-vital mandibular posterior teeth (prospective clinical study). Zanco Journal of Medical Sciences 18(3):822–825.  10.15218/zjms.2014.00340 CrossRefGoogle Scholar
  20. 20.
    Shabazfar N, Daublander M, Al-Nawas B, Kämmerer PW (2014) Periodontal intraligament injection as alternative to inferior alveolar nerve block-meta-analysis of the literature from 1979 to 2012. Clin Oral Invest 18(2):351–358. CrossRefGoogle Scholar
  21. 21.
    Berlin J, Nusstein J, Reader A, Beck M, Weaver J (2005) Efficacy of articaine and lidocaine in a primary intraligamentary injection administered with a computer-controlled local anesthetic delivery system. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 99(3):361–366. CrossRefPubMedGoogle Scholar
  22. 22.
    Kämmerer PW (2012) Clinical and histological comparison of pulp anaesthesia and local diffusion after periodontal ligament injection and intrapapillary infiltration anaesthesia. Journal of Pain & Relief 01(05).
  23. 23.
    Meechan JG (1992) Intraligamentary anaesthesia. J Dent 20(6):325–332CrossRefPubMedGoogle Scholar
  24. 24.
    Hochman MN (2007) Single-tooth anesthesia: pressure-sensing technology provides innovative advancement in the field of dental local anesthesia. Compend Contin Educ Dent 28 (4):186–188, 190, 192–183Google Scholar
  25. 25.
    Stoll P, Buhrmann K (1983) Intraligamental anesthesia for tooth extraction in patients with hemorrhagic diathesis. ZWR 92(11):545PubMedGoogle Scholar
  26. 26.
    Roahen JO, Marshall FJ (1990) The effects of periodontal ligament injection on pulpal and periodontal tissues. J Endod 16(1):28–33CrossRefPubMedGoogle Scholar
  27. 27.
    Roberts GJ, Simmons NB, Longhurst P, Hewitt PB (1998) Bacteraemia following local anaesthetic injections in children. Br Dent J 185(6):295–298CrossRefPubMedGoogle Scholar
  28. 28.
    Oulis CJ, Vadiakas GP, Vasilopoulou A (1996) The effectiveness of mandibular infiltration compared to mandibular block anesthesia in treating primary molars in children. Pediatr Dent 18(4):301–305PubMedGoogle Scholar
  29. 29.
    Corbett IP, Kanaa MD, Whitworth JM, Meechan JG (2008) Articaine infiltration for anesthesia of mandibular first molars. J Endod 34(5):514–518. CrossRefPubMedGoogle Scholar
  30. 30.
    Flanagan DF (2016) The effectiveness of articaine in mandibular facial infiltrations. Local Reg Anesth 9:1–6. PubMedGoogle Scholar
  31. 31.
    El-Kholey KE (2013) Infiltration anesthesia for extraction of the mandibular molars. J Oral Maxillofac Surg 71 (10):1658 e1651–1655. doi:
  32. 32.
    Fagade OO, Oginni FO (2005) Intra-operative pain perception in tooth extraction—possible causes. Int Dent J 55(4):242–246CrossRefPubMedGoogle Scholar
  33. 33.
    Mehlisch DR (2002) The efficacy of combination analgesic therapy in relieving dental pain. J Am Dent Assoc 133(7):861–871CrossRefPubMedGoogle Scholar
  34. 34.
    Vassend O (1993) Anxiety, pain and discomfort associated with dental treatment. Behav Res Ther 31(7):659–666CrossRefPubMedGoogle Scholar
  35. 35.
    Reed KL, Malamed SF, Fonner AM (2012) Local anesthesia part 2: technical considerations. Anesth Prog 59(3):127–136; quiz 137. CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Takasugi Y, Furuya H, Moriya K, Okamoto Y (2000) Clinical evaluation of inferior alveolar nerve block by injection into the pterygomandibular space anterior to the mandibular foramen. Anesth Prog 47(4):125–129PubMedPubMedCentralGoogle Scholar
  37. 37.
    Bataineh AB, Alwarafi MA (2016) Patient’s pain perception during mandibular molar extraction with articaine: a comparison study between infiltration and inferior alveolar nerve block. Clin Oral Investig.
  38. 38.
    Briggs M, Closs JS (1999) A descriptive study of the use of visual analogue scales and verbal rating scales for the assessment of postoperative pain in orthopedic patients. J Pain Symptom Manag 18(6):438–446. CrossRefGoogle Scholar
  39. 39.
    Wright GZ, Weinberger SJ, Marti R, Plotzke O (1991) The effectiveness of infiltration anesthesia in the mandibular primary molar region. Pediatr Dent 13(5):278–283PubMedGoogle Scholar
  40. 40.
    Sharaf AA (1997) Evaluation of mandibular infiltration versus block anesthesia in pediatric dentistry. ASDC J Dent Child 64(4):276–281PubMedGoogle Scholar
  41. 41.
    Lima-Junior JL, Dias-Ribeiro E, de Araujo TN, Ferreira-Rocha J, Honfi-Junior ES, Sarmento CF, Seabra FR, de Sousa Mdo S (2009) Evaluation of the buccal vestibule-palatal diffusion of 4% articaine hydrochloride in impacted maxillary third molar extractions. Med Oral Patol Oral Cir Bucal 14(3):E129–E132PubMedGoogle Scholar
  42. 42.
    Kämmerer PW, Seeling J, Alshihri A, Daublander M (2014) Comparative clinical evaluation of different epinephrine concentrations in 4% articaine for dental local infiltration anesthesia. Clin Oral Investig 18(2):415–421. CrossRefPubMedGoogle Scholar
  43. 43.
    Santos CF, Modena KC, Giglio FP, Sakai VT, Calvo AM, Colombini BL, Sipert CR, Dionisio TJ, Faria FA, Trindade AS Jr, Lauris JR (2007) Epinephrine concentration (1:100,000 or 1:200,000) does not affect the clinical efficacy of 4% articaine for lower third molar removal: a double-blind, randomized, crossover study. J Oral Maxillofac Surg 65(12):2445–2452. CrossRefPubMedGoogle Scholar
  44. 44.
    Isen D (2000) Articaine: pharmacology and clinical use of a recently approved local anesthetic. Dentistry today 19:72–77PubMedGoogle Scholar
  45. 45.
    Etoz OA, Er N, Demirbas AE (2011) Is supraperiosteal infiltration anesthesia safe enough to prevent inferior alveolar nerve during posterior mandibular implant surgery? Med Oral Patol Oral Cir Bucal 16(3):e386–e389CrossRefPubMedGoogle Scholar
  46. 46.
    Madeira MC, Percinoto C, das Gracas MSM (1978) Clinical significance of supplementary innervation of the lower incisor teeth: a dissection study of the mylohyoid nerve. Oral Surg Oral Med Oral Pathol 46(5):608–614CrossRefPubMedGoogle Scholar
  47. 47.
    Stein P, Brueckner J, Milliner M (2007) Sensory innervation of mandibular teeth by the nerve to the mylohyoid: implications in local anesthesia. Clin Anat 20(6):591–595. CrossRefPubMedGoogle Scholar
  48. 48.
    Yadav S (2015) Anesthetic success of supplemental infiltration in mandibular molars with irreversible pulpitis: a systematic review. J Conserv Dent 18(3):182–186. CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Rogers BS, Botero TM, McDonald NJ, Gardner RJ, Peters MC (2014) Efficacy of articaine versus lidocaine as a supplemental buccal infiltration in mandibular molars with irreversible pulpitis: a prospective, randomized, double-blind study. J Endod 40(6):753–758. CrossRefPubMedGoogle Scholar
  50. 50.
    Yang J, Liu W, Gao Q (2013) The anesthetic effects of Gow-Gates technique of inferior alveolar nerve block in impacted mandibular third molar extraction. Hua Xi Kou Qiang Yi Xue Za Zhi 31(4):381–384PubMedGoogle Scholar
  51. 51.
    Claffey E, Reader A, Nusstein J, Beck M, Weaver J (2004) Anesthetic efficacy of articaine for inferior alveolar nerve blocks in patients with irreversible pulpitis. J Endod 30(8):568–571CrossRefPubMedGoogle Scholar
  52. 52.
    Nusstein J, Reader A, Nist R, Beck M, Meyers WJ (1998) Anesthetic efficacy of the supplemental intraosseous injection of 2% lidocaine with 1:100,000 epinephrine in irreversible pulpitis. J Endod 24(7):487–491. CrossRefPubMedGoogle Scholar
  53. 53.
    Cohen HP, Cha BY, Spangberg LS (1993) Endodontic anesthesia in mandibular molars: a clinical study. J Endod 19(7):370–373. CrossRefPubMedGoogle Scholar
  54. 54.
    Devine M, Gerrard G, Renton T (2016) Current practice in mandibular third molar surgery. A national survey of British Association of Oral Surgeons membership. Oral Surgery:n/a-n/a.
  55. 55.
    Kanaa MD, Whitworth JM, Meechan JG (2012) A prospective randomized trial of different supplementary local anesthetic techniques after failure of inferior alveolar nerve block in patients with irreversible pulpitis in mandibular teeth. J Endod 38(4):421–425. CrossRefPubMedGoogle Scholar
  56. 56.
    Abdullah WA (2014) Articaine (4%) buccal infiltration versus lidocaine (2%) inferior alveolar nerve block for mandibular teeth extraction in patients on warfarin treatment. Journal of Anesthesia & Clinical Research 05(08).
  57. 57.
    Zain M, Khattak SuR, Shah SA, Sikandar H, Khattak Y (2015) Comparison of effectiveness of 4% articaine buccal infiltration versus inferior alveolar nerve block in symptomatic mandibular 1st molar tooth 29(2015)Google Scholar
  58. 58.
    Bataineh AB, Alwarafi MA (2016) Patient’s pain perception during mandibular molar extraction with articaine: a comparison study between infiltration and inferior alveolar nerve block. Clin Oral Investig 20(8):2241–2250. CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany 2017

Authors and Affiliations

  • Daniel G. E. Thiem
    • 1
  • Florian Schnaith
    • 2
  • Caroline M. E. Van Aken
    • 3
  • Anne Köntges
    • 1
    • 4
  • Vinay V. Kumar
    • 5
  • Bilal Al-Nawas
    • 2
  • Peer W. Kämmerer
    • 1
  1. 1.Department of Oral and Maxillofacial Surgery, Facial Plastic SurgeryUniversity Medical Centre RostockRostockGermany
  2. 2.Department of Oral and Maxillofacial Surgery, Facial Plastic SurgeryUniversity Medical Centre MainzMainzGermany
  3. 3.Department of GynecologyUniversity Medical Centre Hamburg-EppendorfHamburgGermany
  4. 4.Department of Operative Dentistry and PeriodontologyUniversity Medical Centre RostockRostockGermany
  5. 5.Head and Neck Institute, Mazumdar Shaw Cancer CenterNarayana HealthBangaloreIndia

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