VAZIRANI AKINOSI NERVE BLOCK, GOW-GATES NERVE BLOCK.

1. MANDIBULAR NERVE BLOCKS…
A) THE GOW- GATES TECHNIQUE.
B) VAZIRANI- AKINOSI CLOSED MOUTH
MANIBULAR BLOCK.
-ANJU THOMAS
3RD BDS

2. THE GOW- GATES TECHNIQUE…
INTRODUCTION.
a) The Gow- Gates technique was introduced by
GEORGE ALBERT EDWARDS GOW-GATES in 1973.
b) It provides sensory anesthesia to all branches of
the Posterior Division and Buccal nerve.
c) Other common names- GOW-GATES TECHNIQUE,
THIRD DIVISION NERVE BLOCK.

3. AREAS ANESTHESISED….
a) Mandibular teeth to midline.
b) Buccal mucoperiosteum.
c) Anterior two-third of the tongue and floor of the oral cavity.
d) Lingual soft tissues and periosteum.
e) Body of the mandible, inferior portion of the ramus.
f) Skin over the zygoma, posterior portion of the cheek and
temporal regions.

4. ADVANTAGES DISADVANTAGES
a) Requires only one injection. a)Lingual and lower lip anaesthesia
which is uncomfortable for many
patients
b)High success rate(95%) b) The time of onset of anaesthesia is
longer (5-10min)than with an IANB(3-5
min)
c) Minimum aspiration rate(2%) c) Clinical experience required to learn
this technique properly.
d) Fewer post injection
complications(eg.trismus)

5. LANDMARKS..
A)EXTRAORAL:
1) Lower border of the tragus.
2) Corner of the mouth.
B)INTRAORAL:
1) Height of injection is established by placement of needle tip
below the mesiopalatal cusp of maxillary second molar.
2)Penetration of soft tissues just distal to maxillary second molar.

7. TARGET AREA…
*Lateral side of the condylar neck, just below the
insertion of the lateral pterygoid muscle.
AREA OF INSERTION:
*Mucous membrane on the
mesial side of ramus.

8. TECHNIQUE..
a) A 25 or 27 gauge needle is recommended.
b) The patient should be in supine position. For a right GGMNB, a right
handed administrator should sit in 8 o’clock position, and for a left
GGMNB a right handed administrator should sit in the 10 o’clock
position .
c) The patient is asked to open the mouth and then the mesiopalatal
cusp of the maxillary 2nd molar on the desired site is identified.
d) The insertion site of the needle will be just distal to the maxillary 2nd
molar at the level of the mesiopalatal cusp.
e) Bring the needle to the insertion site in a plane that is parallel to an
imaginary line drawn from the intertragic notch to the corner of the
mouth on the same side where injection is to be given.
f) Here the orientation of the bevel is not important.
g) Advance the needle through the soft tissues approximately 25mm
until the bone is contacted. This is the neck of the condyle.
h) Once the bone is contacted, withdraw the needle 1mm and aspirate.

9. i) Redirect the needle superiorly and reaspirate.If the aspiration in
two planes is negative then slowly inject one cartridge of local
anaesthetic solution over the course of 1minute.
j) Withdraw the needle. Make the needle safe.
k) Wait for 5-10 minutes before commencing the dental procedure.

10. SIGNS AND SYMPTOMS..
a) SUBJECTIVE:
1) tingling or numbness of the lower lip and tongue.
b)OBJECTIVE:
1)No pain is felt during dental therapy.

11. FAILURE OF ANESTHESIA OCCURS WHEN:
a) too little volume is administered.
b) Anatomic difficulties.
COMPLICATIONS:
a) Hematoma.
b) Trismus.

12. VAZIRANI- AKINOSI NERVE BLOCK
CLOSED MOUTH MANDIBULAR BLOCK..
INTRODUCTION.
a) This technique was introduced by Dr. JOSEPH AKINOSI in 1977
b) Useful for patients with limited mouth opening due to trismus
or ankylosis of the TMJ.
c) Limited mouth opening inhibits the administration of IANB and
GGMNB both of which require the patient to open mouth
widely.
d) Other common names: Akinosi technique, tuberosity
technique, closed mouth mandibular nerve block.
e) Nerves anesthetised: Inferior alveolar, mental, incisive, lingual,
mylohyoid.

13. AREAS ANESTHESISED….
a) Mandibular teeth to midline.
b) Anterior two-third of the tongue and floor of the oral cavity.
c) Lingual soft tissues and periosteum.
d) Body of the mandible, inferior portion of the ramus.
e) Buccal mucoperiosteum and mucous membrane anterior to the
mental foramen.

14. ADVANTAGES DISADVANTAGES
a)Relatively atraumatic. a) Difficult to visualise the path of the
needle and the depth of insertion.
b)Patient need not be able to open the
mouth.
b) No bony contact, depth of penetration
is somewhat arbitrary.
c)Fewer postoperative complications. c) Potentially traumatic if the needle is
too close to the periosteum.
d)Lower aspiration rate(less than 10%)
than with IANB.
e) provides successful anaesthesia.

15. AREA OF INSERTION…
a)Soft tissue overlying the medial border of the mandibular ramus,
adjacent to the maxillary tuberosity at the height of the
mucogingival junction adjacent to maxillary 3rd molar.
TARGET AREA…
a)Soft tissue on the medial border of the ramus in the region of
inferior alveolar, lingual and mylohyoid nerves.

17. *AREA OF INSERTION…..

18. TECHNIQUE..
a) A 25 gauge long needle is preferred for this technique
b) The patient should be in supine or semi supine position.
c) For left or right VAZIRANI- AKINOSI, a right handed
administrator should sit at an 8 o’clock position facing the
patient.
d)LANDMARKS;
1)Mucogingival junction of the maxillary second or third molar.
2)Maxillary tuberosity.
e) Ask the patient to occlude gently on the posterior teeth. The
barrel of the syringe is held parallel to the maxillary occlusal plane,
with the needle at the level of mucogingival junction of the
maxillary 2nd or 3rd molar.
f) The bevel is directed away from the bone.
g) The needle is advanced 25mm into the tissues. The tip of the
needle should lie in the midportion of the ptergomandibular space.

19. h) Aspirate in two planes. If negative deposit 1.5 to 1.8 ml of LA in
60 seconds.
i) Withdraw the needle, make the needle safe.
j) Anesthesia of the lip and tongue are noted in 1 min.
k) Then begin with the dental procedure after 5 minutes.

20. SIGNS AND SYMPTOMS…
1) SUBJECTIVE :a) tingling or numbness of the lower lip.
b) tingling or numbness of the tongue.
2)OBJECTIVE: a) no pain during dental therapy.

21. FAILURES OF ANESTHESIA..
a) Lateral flare of the mandible.
b) Needle insertion point too low.
c) Under insertion or over insertion of the needle.

22. COMPLICATIONS…
a) Hematoma.(less than 10%)
b) Facial nerve paralysis.
c) Trismus(rare)