**1. Introduction**

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Predictable anesthesia is an essential requirement for both the patient and the dentist. The patient's opinion about the dental treatment is closely related to the local anesthesia (LA) experience and the proper use of LA techniques and pain management which are indispen‐ sable for successful dental treatment. In modern dentistry, creating favorable local anesthesia is an important factor in patient satisfaction and relaxation, the general view of the most successful dentist is one who can do without pain and anxiety for patients. Local anesthesia is a technique that is indispensable for dental professionals. Preventing pain during dental treatment is the ultimate goal of all dentists who are working in their profession. Sometimes problems can prevent them from achieving this goal. These problems include: lack of anes‐ thesia in patients with possible aberrations, inner fears, infections etc. There are many causes for the occurrence of these problems, including: biological diversity in response to medications, anatomical differences between patients and considerable fear and anxiety associated with the injection of local anesthesia. Although this problem may arise in any part of the oral cavity, it most often occurs in the mandibular second molars. In the absence of complete anesthesia, performing dental treatment cannot be done and a significant number of cases of medical emergencies have arisen during dental treatment without LA. Although pain control is accomplished successfully in most cases, some anesthesia techniques like mandibular block are accompanied by drawbacks including difficulty in achieving anesthesia because of anatomic variations, deep and invasive needle penetration, paresthesia, trismus, paralysis, transportation of oral microbial flora to anatomic spaces, delayed onset of anesthesia, hema‐ toma formation, high incidence of positive aspiration, undesired soft and/or hard tissue anesthesia with possible patient-induced injury, and difficulty in hemostasis in those with bleeding disorders. [1]

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The inferior alveolar nerve block (IANB) is the most commonly used injection technique for achieving local anesthesia for mandibular restorative and surgical procedures. However, the IANB does not always result in successful pulpal anesthesia. Failure rates of 7 to 75% have been reported in experimental studies.

Supplementary anesthetic injection methods have evolved to circumvent the above disadvan‐ tages. These include intrapulpal, intraosseous, intraseptal and intraligamentary injections. Giffin introduced crestal anesthesia (CA) as a new variation of intraosseous anesthesia, which he claimed was tested for different dental procedures ranging from simple restorations to extractions. The technique relies on alveolar crestal perforations formed by canals of Zuckerkandl and Hirschfeld, which provide gingiva with innervation and circulation. Since then some have commented on the technique and approved it. However, to the best of our knowl‐ edge, no systematically designed case-controlled study has been done to evaluate its benefits and disadvantages. This chapter assesses our experience with this technique in the mandible.

**Mandible anatomy** the mandible, the largest and strongest bone of the face, encases the lower teeth. It consists of a curved, horizontal portion, the body, and two perpendicular portions, the rami, which unite with the ends of the body nearly at right angles.
