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British Journal of Oral and Maxillofacial Surgery 52 (2014) 1617

Review

Should we be giving bilateral inferior alveolar and lingual

nerve blocks for third molar surgery?
J. Jabbar , V. Shekar, D.A. Mitchell, P.A. Brennan
Queen Alexandra Hospital, Southwick Hill Road, Cosham, Portsmouth PO6 3LY, United Kingdom
Accepted 5 September 2013
Available online 2 October 2013

Abstract
Extraction of mandibular third molars is one of the most common procedures in oral and maxillofacial surgery, and it is normal practice to
extract both teeth at one visit under general anaesthesia. However, when both teeth are extracted under local anaesthesia, bilateral inferior
alveolar and lingual nerve blocks are required, which is a subject of debate among clinicians. Much of the controversy surrounds the safety
and efficacy of bilateral anaesthesia even though many surgeons use local anaesthetic solutions for perioperative and postoperative pain relief
after day case general anaesthesia with no reports of unwanted effects. The evidence presented in this review explores published research for
and against the use of unilateral and bilateral inferior alveolar and lingual nerve blocks.
2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Keywords: Review; Inferior alveolar; Lingual; Nerve block; Third molar; Bilateral

The removal of third molars is probably one of the commonest

oral operations, and patients are treated as day cases or as
outpatients. Those who require removal of both lower third
molars are usually offered general anaesthesia which requires
2 inferior alveolar nerve blocks (IANBs), or treatment is done
under local anaesthesia over one or 2 visits. There seems to
be controversy about the safety of giving bilateral IANBs in
one visit and whether it is generally acceptable to patients as
a sole option, or whether they should be given a choice that
includes day case general anaesthesia.
We know of only one previous study that has investigated
the removal of wisdom teeth under local anaesthetic with
intravenous sedation over a one-stage or 2-stage visit.1 It
highlighted the advantage to patients of not having to take
as much time off work and minimal disruption to their daily
life, lower healthcare costs, and a reduction in the anxiety
associated with a second procedure. Costs of materials such
as intravenous drugs, suction apparatus, and sutures, and the
sterilisation of instruments, frequency of sterilisation, and
staff time, are considerably less for one-stage procedures.1,2

Corresponding author. Tel.: +44 2392 286099; fax: +44 2392 286089.
E-mail address: jjabbar@hotmail.co.uk (J. Jabbar).

Some clinicians do not recommend the use of bilateral IANBs.3 While we could not find any reported
contraindications,4 the most common complications thought
to be associated with its use are injury to the tongue during
anaesthesia; the unpleasant effects of bilateral anaesthesia;
loss of control of the tongue, which leads to respiratory
embarrassment; and bilateral anaesthesia of the tongue,
which leads to collection of fluid in the oral cavity and
aspiration.5
Few studies have reported the effects of bilateral anaesthesia on lingual movement. Early research in the 1930s
investigated position sense of the tongue in 8 volunteers using
2 or 3 applications of 5% cocaine to anaesthetise the lips,
labiodental groove, floor and roof of the mouth, tongue, and
pyriform fossa. Four patients lost sense of the tongues position completely, 3 had partial loss, and one did not lose any
sense of position.6 A later study concluded that there was no
ataxia of the tongue but speech and articulation were more
difficult for patients who had had bilateral infiltration of the
inferior alveolar and lingual nerves with 2% novocaine and
1:10 000 adrenaline.7
Adatia and Gehring explored proprioception of the
tongue.8 Twelve subjects were given bilateral IANBs using

0266-4356/$ see front matter 2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

http://dx.doi.org/10.1016/j.bjoms.2013.09.003

J. Jabbar et al. / British Journal of Oral and Maxillofacial Surgery 52 (2014) 1617

2% lignocaine and 1: 80 000 adrenaline. They found that proprioception was fully retained even after the sensations of
pain, taste, and touch had been lost.8 The most recent study
reported that sensory input from the tongue provides peripheral feedback to modulate some aspects of the control of
swallowing by the central nervous system, which affects the
neurophysiological control of lingual movement. This suggests that bilateral anaesthesia of the lingual nerve results
in the delay of lingual movement, which is responsible for
causing weak bolus propulsion during swallowing.9
There is a perception that patients will need longer
appointments for bilateral lower third molar surgery and
that they might have an increased potential for postoperative
complications.1 The patients preference for, and the clinicians experience of unilateral or bilateral IANBs are poorly
reported, but one study has found that patients do not object to
bilateral mandibular anaesthesia.10 Reports of the incidence
of its use for postoperative analgesia and of unwanted effects
would provide anecdotal evidence although little in the way
of a formalised study has been published.
No guidelines on the use of bilateral IANBs are currently
available. Some colleagues routinely use it while others do
not. Clearly, further research is required in this area.

17

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