The extraction of the lower third molar  is one of the most common procedures and, at the same time, one of those most subject to variability in   oral surgery.

Kim’s group has provided an updated compendium on this issue in relation to the anesthesiologic aspect. The article was published in the Journal of Dental Anesthesia and Pain Medicine. This paper aims to observe some aspects not treated (or only treated to a limited extent) by other articles that have appeared on these same pages.

First, we will address the anatomical bases. Since the mandibular foramen is not directly palpable, several anatomical findings have been proposed. Compared to the anteroposterior diameter of the mandibular branch, the foramen is usually located slightly (2.75 mm) spaced away from the midline and almost 2 cm below the coronoid notch. The ratios to the occlusal plane are reversed with growth; in adults, the foramen is about 4 mm above the occlusal plane .

Among the lower alveolar nerve block procedures, the conventional one remains the most widely used, with the Gow-Gates technique as the main alternative. To these is added the indirect technique, also known as Fischer’s 1-2-3 technique.

The article also indicates three different techniques recently introduced, mainly aimed at overcoming the different limitations associated with the conventional method.

In 2013, Boonsiriseth proposed an update of the conventional technique; the insertion point of the needle remains the same. At 20 mm from the tip (of a 30 mm needle), a rubber stop is placed whose function is to prevent contact with the periosteum. This reduces pain and the risk of nervous or vascular damage (positive aspiration).

A year earlier, Thangavelu had presented a simplification, based on the identification of a single point of reference, represented by the internal oblique crest, indicated by the tip of the thumb placed in the retromolar area. The reported success rate is 95%.

Again in 2013, Chakranarayan described the arched needle technique, tested on 100 patients with a success rate of 98%. It involves changing the angle of access to the pterygomandibular space by acting on the needle, which is then arched manually. Compared to the branch, the needle does not approach accidentally, but in practice perpendicularly.

The article concludes by considering, as a technological update, the use of computer-controlled local anesthetic delivery (CCLAD). These systems have the advantage of automatic control of the speed of administration, which is reduced and continuous, with a positive effect in terms of comfort and painful stimulus. The authors prefer those systems that integrate the cartridge within the main unit, allowing to minimize the weight of the hand-piece, with advantage in terms of stability of the grip and, consequently, ease and safety of use.

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