Akinosi &amp gow gates nerve blocks / prosthodontic courses

AKINOSI & GOW-GATES
NERVE BLOCKS
INDIAN DENTAL ACADEMY
Leader in continuing Dental
Education
www.indiandentalacademy.com

VAZIRANI-AKINOSI CLOSED-
MOUTH MANDIBULAR BLOCK
 In 1977 Dr. Joseph Akinosi reported on a
closed mouth approach to mandibular
anesthesia.
 This technique is preferred over Inferior
nerve blocks in cases of trismus.
 This nerve block is useful, when there is
spasm of the muscles of mastication on one
side of the mandible.

 Extra-oral mandibular blocks can be
administered either through the sigmoid
notch or inferiorly from the chin.
 The mandibular division of the trigeminal
nerve provides motor innervations to the
muscles of mastication which can be
anesthetized by extra-oral nerve blocks.
 Most of the practioners are hesitant to give
the extra-oral nerve blocks, in these cases
Akinosi nerve block is the definite option.www.indiandentalacademy.com

Indian Dental academy
• www.indiandentalacademy.com
• Leader continuing dental education
• Offer both online and offline dental
courses

 Akinosi closed mouth mandibular nerve
block is an intra oral technique to provide
both anesthesia & motor blockade in cases
of severe unilateral trismus.
 In 1960 this same technique was initially
described by Vazirani.
 Henceforth this intra oral mandibular nerve
block is known as VAZIRANI-AKINOSI
CLOSED-MOUTH MANDIBULAR BLOCK.

 Other common names:
1. Akinosi technique.
2. Closed mouth mandibular nerve block.
3. Tuberosity technique.
 Nerves anesthetized:
1. Inferior alveolar.
2. Incisive nerve.
3. Mental nerve.
4. Lingual nerve.
5. Mylohyoid nerve.www.indiandentalacademy.com

 Areas anesthetized:
1. Mandibular teeth to the midline.
2. Body of the mandible and inferior portion
of the ramus.
3. Buccal mucoperiosteum and mucous
membrane in front of the mental foramen.
4. Anterior two-thirds of the tongue and floor
of the oral cavity.
5. Lingual soft tissues and periosteum.

AREAS ANESTHETIZED

 Indications:
1. Limited mandibular opening.
2. Multiple procedures on mandibular teeth.
3. Inability to visualize landmarks for Inferior
alveolar nerve block (because of large
tongue or buccal pad of fat)
4. Analgesia for operative and / or surgical
procedures on mandibular hard or soft
tissues.
5. Diagnostic and therapeutic purposes.www.indiandentalacademy.com

 Contraindications:
1. Infection or acute inflammation in the
area of injection.
2. Patients who might bite their lip or their
tongue, such as young children and
mentally challenged adults.
3. Inability to visualize or gain access to the
lingual aspect of the ramus.

 Advantages:
1. Relatively atraumatic.
2. Patient need not be able to open the mouth.
3. Fewer post-operative complications (e.g.,
trismus)
4. Lower aspiration rate than with the inferior
alveolar nerve block.
5. Provides successful anesthesia where a bifid
inferior nerve and bifid mandibular canals are
present.

 Disadvantages:
1. Difficult to visualize the path of the needle
and the depth of insertion.
2. No bony contact; depth of penetration
somewhat arbitrary.
3. Potentially traumatic if the needle is too
close to periosteum.

 Needle pathway during insertion:
1. With the mouth closed, the needle is
aligned parallel to the occlusal plane and
positioned at the level of the mucogingival
junction of the maxillary molars.
2. The needle penetrates mucosa just medial
to the ramus and is inserted approximately
one and quarter inches.

TARGET AREAS

 Technique for closed mouth approach:
1. With the patient seated comfortably in the
dental chair, the operator stands to the
patients right side and slightly to the front.
2. The patient is instructed to occlude the
teeth.
3. The operator retracts the patient’s lips
exposing the maxillary teeth on the right
side.

RETRACTION OF PATIENT’S LIP

IDENTIFICATION OF THE ANTERIOR
BORDER OF RAMUS

INJECTION DONE AT MEDIAL
ASPECT OF RAMUS

WOLFE’S MODIFICATION
 This is a
modification of
bending the
needle at 45
degrees angle
to enable to
remain in
proximity to
medial aspect
to ramus.

4.The syringe ( with a 15/8
inch, 25 gauge
needle attached) is aligned parallel to the
occlusal and saggital planes but positioned
at the level of the mucogingival junction of
the maxillary molars.
5.The needle penetrates the mucosa just
medial to the ramus and is inserted
approximately 1½ inches.
6.Following negative aspiration, the contents
of the dental cartridge are slowly
deposited. www.indiandentalacademy.com

INJECTION DONE MEDIAL TO
RAMUS

7.Successful anesthesia will be determined by
instrumentation of the inferior alveolar nerve and
its subdivisions.
8.Care must be taken to ensure that the needle is
inserted as closely as possible to the medial
surface to the ramus.
9.Allowing the needle to be advanced too far
medially is likely to result in the deposition of LA
on the medial aspect of pterygomandibular space
and sphenomandibular ligament resulting in
unsuccessful nerve block.

 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 is felt during dental treatment.

 Failures of anesthesia:
1. If the needle is inserted medially there will be deposition
of solution into the medial aspect of pterygomandibular
space and sphenomandibular ligament and to prevent this
a 27 gauge needle should directed parallel with the lateral
flare of the ramus.
2. The point of insertion of needle could be low and to
correct this while insertion the needle should be slightly
above the mucogingival junction of the maxillary molars
and while the needle insertion into soft tissues, it must be
parallel to the occlusal plane.
3. The depth of needle insertion could be under or overdone,
since there is no bony landmarks in this technique so the
depth should be 25 mm in an adult.

 Complications:
1. Hematoma.
2. Trismus.
3. Transient facial nerve paralysis due to
a. Over insertion and injection of LA into the body
of parotid gland.
b. This can be prevented by modifying the depth of
needle penetration based on the length of the
mandibular ramus. The 25 mm depth of
penetration is the average for a normal sized
adult.

GOW-GATES NERVE BLOCK

 In 1973 Albert Edwards Gow-Gates
described a true mandibular nerve which
was administered by means of the intraoral
approach using intraoral and extraoral
landmarks to deposit the anesthetic
solution at the neck of the condyle.
 A single anesthetic injection provides hard
and soft tissue anesthesia of the mandible
to the midline.

 This is a true mandibular nerve block
because it provides sensory anesthesia to
virtually the entire distribution of
mandibular nerve.
 Other common names:
1. Gow-Gates technique.
2. Third division nerve block.

 NERVES ANESTHETIZED:
1. Inferior alveolar nerve.
2. Mental nerve.
3. Incisive nerve.
4. Lingual nerve.
5. Mylohyoid nerve.
6. Auriculotemporal nerve.
7. Buccal nerve.

 Areas anesthetized:
1. Mandibular teeth to the midline.
2. Buccal mucoperiosteum and mucous
membrane on the side of injection.
3. Anterior two-thirds of the tongue and floor
of the oral cavity.
4. Lingual soft tissues and periosteum.
5. Body of the mandible and inferior portion of
the ramus.

 Skin over the zygoma, posterior portion of
the cheek and temporal region.

 Indications:
1. Multiple procedures on mandibular teeth.
2. When buccal soft tissues anesthesia, from
the third molar to the midline, is necessary.
3. When lingual soft tissues anesthesia is
necessary.
4. When a conventional inferior alveolar nerve
block is unsuccessful.

 Contraindications:
1. Infection or acute inflammation in the area
of injection.
2. Patients who might bite their lip or tongue,
such as young children and mentally
challenged adults.
3. Patients who are unable to open their
mouth wide.

 Advantages:
1. Requires only one injection; a buccal nerve
block is usually unnecessary.
2. High success rate(more than 95%)
3. Minimum aspiration rate.
4. Few post-operative complications.
5. Provides successful anesthesia where a
bifid inferior alveolar nerve and bifid
mandibular canals are present.

 Disadvantages:
1. Lingual and lower lip anesthesia is
uncomfortable for many patients and
possibly dangerous for certain individuals.
2. The time to onset of anesthesia is
somewhat longer ( 5 mins) when compared
to inferior alveolar nerve.
3. There is a learning cure with the Gow-Gates
technique. Clinical experience is necessary
to learn the technique.www.indiandentalacademy.com

 Anatomical landmarks:
1. Anterior border of the ramus.
2. Tendon of temporal muscle.
3. Corner of the mouth.
4. Intertragic notch of the ear.
5. External ear.

TARGET AREA

 Needle pathway during insertion:
1. The patient’s mouth is wide open, and the
needle is inserted at a point lateral to the
pterygomandibular depression but medial
to the temporal tendon on a plane from the
corner of the mouth to the intertragic
notch.

EXTRAORAL LANDMARKS

 Technique:
1. Patient is placed in the supine position
(although semirecumbent position may also
be used)
2. Operator is positioned to the right and
slightly in front of the patient.
3. Patient keeps mouth open widely and
remains in that position until the injection is
completed. This position moves the condyle
anteriorly, thus facilitating the injection.www.indiandentalacademy.com

4. An imaginary line is drawn from the corner
of the mouth to the intertragic notch of the
ear.
5.The anterior border of the ramus is
palpated, and the tendon of the temporal
muscle is identified.

IDENTIFICATION OF ANTERIOR
BORDER OF RAMUS

INJECTION DIRECTED TOWARDS
THE TARGET AREA

6.Operator visually aligns the intraoral and
extraoral landmarks, and the needle is
introduced through the mucosa just medial
to the temporal tendon and directed toward
the target area on a line extending from the
corner of the mouth to the intertragic
notch.
7.The degree of divergence of the external
ear to the head is used as a guide to the
lateral flare of the ramus. Needle insertion
should parallel the degree of flare of the

NEEDLE INSERTION SHOULD BE
PARALLEL TO THE DEGREE OF FLARE
OF THE EAR

8.The needle should be advanced until the
fovea region of the condylar neck is
contacted. Depth of insertion should not
exceed 25 to 27mm.
9. If the bone contact is not established, the
needle should be withdrawn slightly and
redirected after checking landmarks.
10.The entre contents of the dental cartridge
should be injected only after establishing
proper needle placement.www.indiandentalacademy.com

11.After the operator withdraws the needle,
the patient is to keep the mouth open for
20 to 30 seconds to allow adequate bathing
of the nerve trunk that has been
straightened by opening the mouth.
12.Because of the larger diameter of nerve
trunk and distance from injection site
(about 1 cm), onset of anesthesia will occur
in 5 to 7 minutes.

13.A wavelike pattern of anesthesia starts in
the ramus and progresses steadily forward
to include the molars, premolars, and
anterior teeth in sequence.
14.Adequacy of anesthesia may be
demonstrated by a tingling and numbness
in the areas innervated by the mandibular
nerve and its subdivisions as well as by the
absence of pain on instrumentation.

 Signs and symptoms:
1. Subjective:
a. Tingling or numbness of the lower lip
indicates anesthesia of the mental nerve, a
terminal branch of the inferior alveolar
nerve.
b. Tingling or numbness of the tongue
indicates anesthesia of the lingual nerve, a
branch of the posterior division of the
mandibular nerve.www.indiandentalacademy.com

2.Objective:
1. No pain is felt during dental surgery.
 Safety features:
1. Needle contacting bone and preventing
overinsertion.
2. Very low positive aspiration rate; minimizes
the risk of intravascular injection( the
internal maxillary artery lies inferior to the
injection site.

 Precautions:
Do not deposit local anesthetic if bone is not
contacted; the needle tip usually is distal
and mesial to the desired site.
1. Withdraw slightly.
2. Redirect the needle laterally.
3. Reinsert the needle. Make gentle contact
with bone.
4. Withdraw 1mm and aspirate.
5. Inject if aspiration is negative.www.indiandentalacademy.com

 Failures of anesthesia:
1. Too little volume. The greater diameter of
the mandibular nerve may require a larger
volume of anesthetic solution. Deposit 1.2
ml of solution in the second injection if the
depth of anesthesia is inadequate after the
initial 1.8 ml.
2. Anatomical difficulties. Do not deposit the
solution unless the bone is contacted.

 Complications:
1. Hematoma.
2. Trismus.
3. Temporary paralysis of cranial nerves
Oculomotor, Trochlear and Abducens
nerves. Accidental rapid intravenous
administration of local anesthesia could
result in diplopia, right-sided blepharoptosis
and complete paralysis of the ipsilateral eye
for 20 minutes.www.indiandentalacademy.com

 To prevent these consequences, place the
needle on the lateral side of the anterior
surface of the condyle and then aspirate
carefully before depositing the solution
slowly.

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