CASE REPORT

Accidental Intravascular Local Anesthetic Injection of the

Facial Artery
Matias Garcia-Blanco, DDS, PhD,* and Stephanie Scanlan, DDS†
*Department of Oral and Maxillofacial Surgery I, School of Dentistry, University of Buenos Aires, Buenos Aires, Argentina, and †Department of
Endodontics, School of Dentistry, University of Buenos Aires, Buenos Aires, Argentina

Local anesthesia techniques are widely used in dentistry because of their numerous advantages, including safety.
Several articles have been published on local and systemic complications stemming from the use of local anesthesia,
one of which is accidental intravascular injection, usually reported during inferior alveolar nerve blocks. A 58-year-old
man presented to the dental office for extraction of the lower left first molar. During delivery of a supplemental
injection in the buccal vestibular mucosa to anesthetize the buccal nerve, an accidental intra-arterial injection to the
facial artery occurred, causing sudden sharp pain and immediate pallor along the course of the facial artery. The pallor
resolved in approximately 20 minutes. Buccal infiltration was repeated successfully, and the tooth was extracted
uneventfully. This case appears to be the first report in the literature to describe the accidental intravascular injection
of local anesthetic involving the facial artery and discuss its clinical implications.

Key Words: Facial artery; Anesthesia; Pallor; Ischemia; Case report, Intravascular injection.

ocal anesthetics enable dental treatment to be increased sympathetic tone (ie, transient elevations in
L performed painlessly by reversibly blocking the
conduction of the sensory nerves.1 Intraoral local
heart rate and/or blood pressure) secondary to the
sympathomimetic effects of the vasoconstrictor and loss
anesthetic injections are safe procedures most dentists of consciousness.1,6–10 Most of the complications report-
use daily that commonly involve drug administration ed are associated with the inferior alveolar nerve (IAN)
near a terminal nerve branch (ie, supraperiosteal infiltra- block because this technique is deeper and has a relatively
tion or field block) or a nerve trunk (ie, a nerve block).2 blind approach, plus the IAN is closely associated with
The most popular anesthetic in many countries around the inferior alveolar blood vessels.4,5,11,12
the world, including the United States, is lidocaine, Aspiration is recommended before the injection of
although in some countries, articaine is used more often.3 local anesthetic to prevent accidental intravascular
These local anesthetic agents are normally administered deposition and potentially generate undesirable local
in combination with epinephrine, which produces vaso- and/or systemic effects or complications.1 However,
constriction via its agonistic activity on a1 adrenergic aspiration may not always be possible or accurate, as
receptors, slowing the systemic uptake of the local noted with some syringes that have an insufficiently
anesthetic and extending the duration of anesthesia.3–5 sharp harpoon unable to effectively engage the plunger
Complications from local anesthetic injections, which or when a false-negative aspiration occurs.11,13 If local
may be local or systemic, are rare. Local complications anesthetic with a vasoconstrictor is mistakenly admin-
include hematomas, intraglandular injection, intramus- istered intravascularly, expected consequences can
cular injection, trismus, nerve injuries, needle breakage, include inadequate anesthesia, shooting pain, skin pallor
and ophthalmologic symptoms, such as diplopia, partic- or ischemia, and/or heart palpitations.11–14 There are
ularly for select maxillary injections. Systemic complica- several existing reports in the literature of intravascular
tions include overdose/toxicity, allergic reactions, local anesthetic injection involving the inferior alveolar
artery,4,5,11,12 a few involving the posterior superior
alveolar artery,13,14 one report involving the superior
Received February 12, 2020; accepted for publication May 5, 2020.
Address correspondence to Dr Matias Garcia-Blanco, Av Incas palatine artery,15 and one involving the buccal artery,16
3295 (CP 1426), Buenos Aires, Argentina; matiasgarciablanco@ but none exist regarding direct injection into the facial
yahoo.com.ar. artery. The aim of this clinical report is to present an
Anesth Prog 68:29–32 2021 j DOI 10.2344/anpr-67-03-03 accidental local anesthetic injection into the facial artery
Ó 2021 by the American Dental Society of Anesthesiology and to discuss its consequences.

29
30 Facial Artery Intravascular Injection Anesth Prog 68:29–32 2021

Figure 1. Facial pallor after the initial attempt to anesthetize Figure 2. Resolution of the facial pallor 23 minutes after intra-
the buccal nerve along the body of the mandible. arterial injection involving the facial artery.

CASE REPORT aspiration, the patient reported experiencing a sharp,

intense, electrical, acute painful sensation. Immediate
A 58-year-old man (height 176 cm, weight 89 kg, body facial pallor was observed involving the cheek, the angle
mass index 28.7 kg/m2) presented to the office for of the mouth, minor aspects of the lower lip, the upper
extraction of the mandibular first left molar. His lip, the side of the nose crossing the midline, the medial
physical status was deemed American Society of commissure of the eye, and the infraorbital area, all
Anesthesiology class II due to controlled hypertension corresponding to the pathway of the facial artery
with no other systemic disease or any smoking habits. (Figure 1). Anesthesia of the buccal nerve was notedly
His medical history was otherwise unremarkable, and he absent. Intense ischemia persisted for approximately 10
reported no prior surgeries, although he had undergone
minutes, without any other complications. After partial
previous dental extractions. He reported taking only
resolution of the ischemia, local anesthesia of the buccal
enalapril to treat hypertension and had no known drug
nerve was successfully repeated by administering half an
allergies or history of social drug use. His panoramic
additional cartridge (0.9 mL; 36 mg of articaine and 9 lg
radiograph was evaluated, and 4% articaine with
1:100,000 epinephrine (Totalcaina Forte, Laboratorio of epinephrine) without further pain or facial ischemia.
Bernabo, Argentina) was selected for local anesthesia. The dental extraction was performed 10 minutes later
Using the conventional Halstead approach with a long with no additional complications. The initial facial
27-G needle, a left IAN block was performed unevent- ischemia resolved completely by the end of the dental
fully with 1.8 mL of the local anesthetic solution (72 mg procedure (Figure 2).
of articaine and 18 lg of epinephrine) administered after
confirming a negative aspiration. After the onset of the
IAN block, a supplemental buccal infiltration injection DISCUSSION
was administered to anesthetize the buccal nerve. While
injecting a quarter of a cartridge of local anesthetic (0.45 In this case, it is thought that an unexpected accidental
mL; 18 mg of articaine and 4.5 lg of epinephrine) into intraarterial injection of the facial artery occurred
the buccal vestibular mucosa after another negative despite a negative aspiration. We concluded that the
Anesth Prog 68:29–32 2021 Garcia-Blanco and Scanlan 31

negative aspiration was likely attributed to a false up beneath the digastric and stylohyoid muscles, over
negative. which it arches to enter a groove on the posterior surface
The administration of local anesthetics, especially of the submaxillary gland. It then curves upward over
those with epinephrine, is a dynamic procedure that can the lateral aspect of the body of the mandible at the
produce unintended side effects as a result of minor anteroinferior angle of the masseter, passing forward
movement of the needle or patient, resulting in and upward across the cheek to the angle of the mouth,
unintended deposition of the anesthetic solution beyond ascending along the side of the nose, and ending at the
the targeted areas. Facial pallor rarely occurs after medial commissure of the eye, under the name of the
delivering local anesthesia, and therefore, it is difficult to angular artery.19 In this case, the intra-arterial injection
state its exact etiology. As in this report, it is usually occurred at the level of the mandibular body, so all
attributed to intraarterial injection, but sometimes the facial branches were affected, including the infraorbital
pallor fails to correspond with the normal direct of area. An anastomosis with the infraorbital branch of the
blood flow. Alternative proposed explanations for this internal maxillary could be the reason for this final area
phenomenon include high-pressure intra-arterial injec- of pallor. The collateral blood supply of the infraorbital
tion, intravenous injection, or injury to the blood vessel artery could also be seen. When injecting local
vasomotor fibers with the tip of the needle.8,14 This anesthetic in the vestibular mucosa of the mandibular
conceptually involves injury to the sympathetic nerve molars or premolars, accidental intravascular injection
plexus on the arterial wall, triggering an axon-like reflex
of the facial artery is possible. It is important to aspirate
or vasospasm that is inverse to the arterial blood-
to avoid such a complication. However, if it does occur,
stream.1,8,14 It is important to consider this possibility,
the patient should be notified immediately and directed
even though that is not thought to have occurred with
to remain calm. Management of this complication is
this patient. In this case report, the local anesthetic
best addressed by immediately stopping the injection,
injection was delivered in the body of the mandible, and
formally assessing the patient, and reassuring them of
facial ischemia was noted in accordance to the arterial
the temporary and reversible nature of the anesthetic
bloodstream.
Positive aspiration before delivering an IAN block and/or vasoconstrictive effects.
has been reported to occur in 3.20% to 20% of
cases.17,18 Blood inside the dental cartridge indicates
an extravasation of blood from a vessel, which could be CONCLUSION
from the inferior alveolar artery or other minor blood
vessels in the area when performing an IAN block. If a To date, there is no report of an intravascular local
positive aspiration occurs, the injection attempt should anesthetic injection of the facial artery as described in
be aborted and the needle repositioned. This recom- this case. Reasons for the lack of reporting could include
mendation should be applied to all local anesthetic a relatively low rate of local anesthetic administration
injections. If this preventive step is not employed, or if a near the course of the facial artery, the smaller vessel
false-negative occurs, accidental intravascular deposi- diameter of the facial artery in comparison with inferior
tion of the local anesthetic might occur. It has been alveolar artery, or this complication being generally
widely reported that patient will suffer a sudden, sharp, underreported. Reassurance that this complication is
intense, electrical, brief painful insult, and a facial self-limiting, reversible, and carries no long-term effects
ischemia will develop immediately assuming concurrent is important for calming the patient and the dental
administration of a vasoconstrictor.13,16 The resulting health care provider.
ischemia has an expected duration of 20 to 30
minutes.4,12–16 Most reports in the literature include
this as a complication of an IAN block if the local ACKNOWLEDGMENT
anesthetic is injected intra-arterially under pressure into
the inferior alveolar artery causing retrograde flow into The authors thank the Journal Section of the School of
the maxillary artery.4,5,11,12 Intravascular injections Dentistry of University of Buenos Aires and Gonzalo
involving the posterior superior alveolar artery, superior Heredia for assistance with this article.
palatine artery, and buccal artery have also been
reported.13–16 However, there is no previous report of
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