DentaltownUK May 2018 - 43

The cervical plexus nerve and
anesthetic technique
The description below pertains to the cervical
plexus nerve and anesthetic technique as part of the
AIAP. The cervical plexus arises from the spinal cord
by two roots-a dorsal root that supplies sensory
fibers, and a ventral root that supplies motor fibers.
These roots unite within the intervertebral space and
exit the spinal column as a single nerve through the
intervertebral foramina. The anterior divisions of the
second, third and fourth cervical nerves travel toward
the lateral surface of the sternocleidomastoid muscle,
where they intermingle to form the CP, which has
muscular and cutaneous branches.
The CP cutaneous branches comprise the
supraclavicular (C3-C4), the lesser occipital (C2),
the great auricular nerve (C2-C3) and the transverse
cervical nerve, or TCN (C2-C3), which innervates
the anterior region of the neck and mandible. For
administration of the intraoral cervical plexus
anesthetic technique for the GAN and TCN, the
patient should keep the mouth closed, or only slightly
open, to allow the dentist to relax the soft tissues, cheek
and the masseter muscle, which permits the syringe
to reach the area to be anesthetized. A syringe with a
30-gauge short needle is placed through the vestibular
area of the buccal mucosa below the roots of the
mandibular molar, using an inclination of 45 degrees
in an anterior-posterior direction (Fig. 1). The tip of
the needle is inserted below the roots of the tooth to be
anesthetized, and should be in direct contact with the
bone (Fig. 2).
An aspiration must be performed before
placement of the anesthetic solution, which should be
administered slowly to minimize pain while feeling no
resistance along the external oblique line of the body
of the mandible. Before administering the injection,
it's recommended to palpate along the border of the
mandible for the transverse facial artery. In addition,
the finger should be maintained externally to follow
the path of the needle to ensure that it has reached the
desired position.5
Posterior mandible anesthetic failure is a major
public health issue, and the AIAP will help alleviate
the patient's fear to the dental chair while improving
our profession's reputation. After getting profound
pulpal anesthesia on the posterior mandible with the
AIAP, confidently you would be able to say more often,
"Hello, dental pulp!" ■

Fig. 1: Cervical plexus intraoral technique needle
insertion and angulation (second molar).

Fig. 2: Intraoral cervical plexus anesthetic technique,
lateral view (fi rst molar).

References
1.
Endodontics: Colleagues for Excellence. Important Clinical Factors
Related to Local Anesthesia. American Association of Endodontists.
Bonus Material A. Winter, 2009.
2.
Malamed S. Handbook of Local Anesthesia. 6th ed. St Louis, MO:
Mosby;
2013. p.387.
Uzbelger Feldman, D. The Cervical Plexus: An Evolution Shift in the
3.
Accessory Innervation Theory. Eur Endod J 2017; 2(1): 17-17.
4.
Resnik, CM. Pressure or Pain in the Dental Chair? Journal of
Anesthesia History 2 (2016) 69-70.
5.
Bitner D, Uzbelger Feldman D, Axx K, Albandar AM. Description
and evaluation of an intraoral cervical plexus anesthetic technique.
Clin Anat 2015; 28(5):608-13.
6.
Nusstein JM, Reader A, Drum M. 2010. Local anesthesia strategies for
the patient with a " hot" tooth. Dent Clin North Am 54:237-247.
7.
Malamed SF. 2011. Is the mandibular nerve block passe?. JADA
142:3S-7S.
8.
Gow-Gates GA, Watson JE. The Gow-Gates mandibular block:
further understanding. Anesth Prog. 1977 Nov-Dec;24(6):183-189.
9.
Uzbelger-Feldman D, Bitner D, Axx KT, Chattopadhyay A. 2007.
Effectiveness of supplemental cervical plexus anesthetic technique for
achieving anesthesia in mandibular molars with irreversible pulpitis.
J Endod 33:345.
10. Lin K, Uzbelger Feldman D, Barbe MF. Transverse cervical nerve:
implications for dental anesthesia. Clin Anat 2013; 26(6):688-92.
11. Ella B, Langbour N, Caix P, Midy D, Deliac P, Burbaud P.
Transverse cervical and great auricular nerve distribution in the
mandibular area: A study in human cadavers. Clin Anat 2014;
28(1):109-117.
12. Kim S, Uzbelger Feldman D, Yang J. A Systematic Review of
the Cervical Plexus Accessory Innervation and Its Role in Dental
Anesthesia. Journal of Anesthesia History 2016; 2(3):79-84.

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