Gow Gates Mandibular Nerve Block

IntroductionThe Gow-Gates mandibular nerve block is a true mandibular block, since it anesthetizes almost the entire mandibular division of the trigeminal nerveThus, the nerves anesthetized with a Gow-Gates mandibular nerve block are the inferior alveolar, mental, incisive, lingual, mylohyoid, auriculotemporal, and buccal (long) nerves in about 75% of patients

Target AreaNeck of condyle, below insertion of lateral pterygoid muscle

SiteThe injection site intraorally is on the mucosa on the mesial of the mandibular ramus, just distal to the height of the mesiolingual cusp of the maxillary second molar, following a line extraorally from the intertragic notch of the ear to the labial commissure of the same side

Gow-Gates Mandibular BlockTechnique Coordinate intraoral & extraoral landmarks

Align barrel of syringe over premolars and with extraoral landmarks

Gow-Gates Mandibular BlockTechnique (cont.) Penetrate mucosa distal to 2nd molar

Advance needle to bone (avg. 25 mm)

Aspirate, deposit 1.8 ml of solution slowly

Gow-Gates Mandibular BlockTechnique (cont.) Patients mouth must be fully open during injection and for 1-2 minutes afterward

May require reinforcement with second injection

With the mouth open, the condyle can assume a more frontal position, bringing the injection site closer to the mandibular nerve trunk. With the mouth less open, the condyle will move out of the injection site and the soft tissue become thicker.

DisadvantagesThe amount of time before the anesthetic takes effect; a Gow-Gates injection takes longer to work because the nerve trunk being anesthetized is larger, and farther from the site of depositionAnesthetization of the lower lip, as well as the temporal area.

ComplicationsHematoma

Trismus

Vazirani Akinosi Mandibular Nerve Block

Akinosi Closed Mouth Mandibular BlockAlternative for mandibular block when limited opening is present ( e.g.. Trismus, closed lock, etc..)

Akinosi Closed Mouth Mandibular BlockTarget Area Soft tissue medial to ramus Above foramen, below condyle

Landmarks Mucogingival junction of maxillary 2nd or 3rd molar Maxillary tuberosity

Akinosi Closed Mouth Mandibular BlockArea of insertion Soft tissue overlying medial ramus, adjacent to tuberosity

At height of mucogingival junction of maxillary 2nd or 3rd molar

Akinosi Closed Mouth Mandibular BlockTechnique Retract soft tissues, have patient occlude

Apply topical

Penetrate to 25 mm, parallel to maxillary occlusal plane, in a posterior and lateral direction

Akinosi Closed Mouth Mandibular Block Technique (cont.) Aspirate, deposit 1.8 ml slowly

Motor paralysis will develop first, allowing patient to open more widely

Akinosi Closed Mouth Mandibular BlockAdvantages Not necessary to open widely High success rate Relatively atraumatic Few complications, few positive aspirations

Akinosi Closed Mouth Mandibular BlockDisadvantages Visualization of path and depth of insertion is difficult

No bony contact

Traumatic if needle hits periosteum

Akinosi Closed Mouth Mandibular BlockComplications Hematoma (

Akinosi Closed Mouth Mandibular BlockFailures of anesthesia Lateral flaring of mandible

Insertion too low

Penetration too deep or shallow (adjust for patient size)