Gow gates & vazirani akinosi technique of nerve

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1. Gow - Gates & Vazirani Akinosi Technique Of Nerve Blocks Presented by : Dr. POOJA KUMARI BDS

2. GOW-GATES TECHNIQUE

3. Gow – Gates Technique: Mandibular Nerve Block In 1973, George Albert Edwards Gow -gates (1910- 2001), a general practitioner of dentistry in Australia, described a new approach to mandibular anesthesia. He described a true mandibular nerve or trigeminal division III block administered by means of the intraoral approach using intraoral & extraoral landmarks to deposit the anesthetic solution at the neck of the condyle . A single anesthetic injection provides hard & soft tissue anesthesia of the mandible to the midline.

4. Other common names Gow -gates technique Third division nerve block V3 nerve block

5. Nerves anesthetized Inferior alveolar Mental Incisive Lingual Mylohyoid Auriculotemporal Buccal

6. Areas anesthetized Mandibular teeth to the midline. Buccal mucoperiosteum & mucous membranes on the side of injection. Anterior ⅔ of the tongue & floor of the oral cavity. Lingual soft tissues & periosteum . Body of the mandible, inferior portion of the ramus . Skin over the zygoma , posterior portion of the cheek, & temporal regions.

7. Anatomical landmarks Anterior border of the ramus Tendon of temporal muscle Corner of the mouth Intertragic notch of the ear External ear

8. Indications Multiple procedures on mandibular teeth . When buccal soft tissue anesthesia, from the third molar to the midline, is necessary. When lingual soft tissue anesthesia is necessary. When a conventional inferior alveolar nerve block is unsuccessful.

9. Contraindications Infection or acute inflammation in the area of injection ( rare) Patients who might bite their lip or tongue, such as young children & physically or mentally handicapped adults. Patients who are unable to open their mouth wide (e.g., trismus ).

10. Advantages Requires only 1 injection; a buccal nerve block is usually unnecessary. High success rate ( >95%), with experience. Minimum aspiration rate. Few postinjection complications (e.g., trismus ) Provides successful anesthesia where a bifid inferior alveolar nerve & bifid mandibular canals are present.

11. Disadvantages Lingual & lower lip anesthesia is uncomfortable for many patients & is possibly dangerous for certain individuals. The time to onset of anesthesia is somewhat longer (5 minutes) than with an IANB (3 -5 minutes), primarily because of the size of the nerve trunk being anesthetized & the distance of the nerve trunk from the deposition site ( approx. 5-10 mm).

12. Technique Patient is placed in the supine position. Operator is positioned to the right & slightly in front of patient. Patient keeps mouth open widely & remains in that position until the injection is completed. An imaginary line is drawn from the corner of the mouth to the intertragic notch of the ear. The anterior border of the ramus is palpated, & the tendon of the temporal muscle is identified. Operator visually aligns the intaoral & extraoral landmarks, & the needle is introduced through the mucosa just medial to the temporal tendon & directed toward the target area on a line extending from the corner of the mouth to the intertragic notch.

13. Continued ….. The needle should be advanced until the fovea region of the condylar neck is contacted. Depth of insertion should not exceed 25 to 27 mm. After the operator withdraws the needle, the patient has to keep the mouth open for 20 to 30 sec to allow adequate bathing of the nerve trunk that has been straightened by opening the mouth.

14. Signs & symptoms Subjective : Tingling or numbness:- Lower lip - anesthesia of the mental nerve, a terminal branch of the inferior alveolar nerve. Tongue - anesthesia of the lingual nerve, a branch of the posterior division of the mandibular nerve. 2. Objective : Using an Electrical Pulp Tester(EPT) & eliciting no response to maximal output (80/80). No pain is felt during dental therapy.

15. Precautions Do not deposit local anesthetic if bone is not contacted Withdraw slightly Redirect the needle laterally Reinsert the needle. Make gentle contact with bone. Withdraw 1 mm & aspirate in two planes. Inject if aspiration is negative.

16. Failures of anesthesia Rare Complications Hematoma Trismus (extremely rare) Temporary paralysis of cranial nerves III, IV, & VI.

17. Vazirani - Akinosi Technique

18. In 1977, Dr. Joseph Akinosi reported on a closed- mouth approach to mandibular anesthesia. Can be used whenever mandibular anesthesia is desired. Vazirani – Akinosi Closed Mouth Mandibular Block Other common names:- Akinosi technique Closed mouth mandibular nerve block Tuberosity technique

19. Nerves anesthetized Inferior alveolar Incisive Mental Lingual Mylohyoid

20. Areas anesthetized Mandibular teeth to the midline Body of the mandible & inferior portion of the ramus Buccal mucoperiosteum & mucous membrane anterior to the mental foramen Anterior two thirds of the tongue & floor of the oral cavity (lingual nerve) Lingual soft tissues & periosteum

21. Anatomical landmarks Occlusal plane of occluding teeth Mucogingival junction of the maxillary molar teeth Anterior border of the ramus

22. Indications Limited mandibular opening Multiple procedures on mandibular teeth Inability to visualize landmarks for IANB ( e.g , because of large tongue )

23. Contraindications Infection or acute inflammation in the area of injection ( rare ) Patients who might bite their lip or their tongue, such as young children & physically or mentally handicapped adults Inability to visualize or gain access to the lingual aspect of the ramus

24. Advantages Relatively atraumatic Patient need not be able to open the mouth Fewer postoperative complications (e.g., trismus ) Lower aspiration rate ( < 10% ) than with the IANB Provides successful anesthesia where a bifid inferior alveolar nerve & bifid mandibular canals are present

25. Disadvantages Difficult to visualize the path of the needle & the depth of insertion No bony contact Potentially traumatic if the needle is too close to the periosteum

26. Technique With the patient seated comfortably in the dental chair, the operator stands to the patient’s right side & slightly to the front. Patient is instructed to occlude the teeth. The operator retracts the patient’s lips exposing the maxillary & mandibular teeth on the right side. The syringe ( 25 gauge long needle attached ) is aligned parallel to the occlusal & sagital planes but positioned at the level of the mucogingival junction of the maxillary molars. The needle penetrates the mucosa just medial to the ramus & is inserted approx. 1 ½ inches. Following negative aspiration, the contents of the dental cartridge are slowly deposited.

27. Signs & symptoms Subjective - Tingling or numbness :- Lower lip- anesthesia of the mental nerve, a terminal branch of the inferior alveolar nerve. Tongue - anesthesia of the lingual nerve, a branch of the posterior division of the mandibular nerve. 2. Objective - Using an electrical pulp tester No pain is felt during dental therapy

28. Precaution Do not overinsert the needle. Decrease the depth of penetration in smaller patients Failures of anesthesia Almost always because of failure to appreciate the flaring nature of the ramus .

29. Complications Hematoma (<10%) Trismus (rare) Transient facial nerve paralysis

30. Reference Handbook Of Local Anesthesia - Stanley F. Malamed Mohneims local anesthesia & pain control in dental practice (C. RICHARD BENNETT)