Alternative mandibular nerve block techniques : A review of the Gow-Gates and Akinosi-Vazirani closed-mouth mandibular nerve block techniques

Daniel A. Haas JADA 2011;142;8S-12S The following resources related to this article are available online at jada.ada.org ( this information is current as of February 23, 2012):
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Alternative mandibular nerve block techniques

A review of the Gow-Gates and Akinosi-Vazirani closed-mouth mandibular nerve block techniques
Daniel A. Haas, DDS, PhD

chieving excellence in pain control is an intrinsic, yet challenging, goal of dentistry. Dentists are aware of the relative ease of successfully performing pain-free intraoperative procedures in maxillary teeth. The maxillas relatively porous alveolar bone allows for the use of straightforward local anesthetic techniques of paraperiosteal field blocks or infiltrations. The mandible is different. The outer layer of cortical bone is thick and nonporous and thus normally requires the use of a nerve block at a site away from the teeth being treated. Traditionally, the inferior alveolar nerve block (IANB), also known as the standard mandibular nerve block or the Halsted block, has been used to provide anesthesia in mandibular teeth. This technique, however, has a success rate of only 80 to 85 percent,1(p227) with reports of even lower rates.2-5 Investigators have described other techniques as alternatives to the traditional approach, of which the Gow-Gates mandibular nerve block6 and Akinosi-Vazirani closed-mouth mandibular nerve block7,8 techniques have proven to be reliable. Dentists who know how to perform all three techniques increase their probability of providing successful mandibular anesthesia in any patient. There are many reasons why the success rate of the IANB is low. One is that the dentist might make technique errors such as improperly locating a landmark or angling the syringe. These problems are resolved easily by reviewing the landmarks and steps for performing the technique involved. A second reason is the presence of inflamed or infected tissue. Infection sites are acidic, which may impair appropriate onset of action. When infection occurs, administer an injection at a deeper site away from the infection to avoid this problem. By itself, inflamed pulp can be more difficult to anesthetize profoundly. A third reason is that a patients apprehension often can cause local anesthetic failure.9 Nerve conduction may be blocked successfully from a neurophysiological perspective, but as soon as the patient anticipates or hears the sound of the drill, he or she perceives pain. This problem can be resolved by discussing with the patient his or her fear of injections and, if necessary, considering the use of minimal sedation such as that provided by nitrous oxide. Intravascular injection may be another reason for failure because the local anesthetic can be carried away from the site of action. This problem can be prevented by careful aspiration before any injection. Anatomical variability and accessory innervation also can be problems, often the biggest, in successfully providing mandibular anesthesia. The deeper nerve blocks rely more heavily on the use of landmarks to make certain assump-

AB STRACT
Background and Overview. The limited success rate of the standard inferior alveolar nerve block (IANB) has led to the development of alternative approaches for providing mandibular anesthesia. Two techniques, the GowGates mandibular nerve block and the Akinosi-Vazirani closed-mouth mandibular nerve block, are reliable alternatives to the traditional IANB. The Gow-Gates technique requires the patients mouth to be open wide, and the dentist aims to administer local anesthetic just anterior to the neck of the condyle in proximity to the mandibular branch of the trigeminal nerve after its exit from the foramen ovale. The Akinosi-Vazirani technique requires the patients mouth to be closed, and the dentist aims to fill the pterygomandibular space with local anesthetic. Conclusion. Both techniques are indicated for any type of dentistry performed in the mandibular arch, but they are particularly advantageous when the patient has a history of standard IANB failure owing to anatomical variability or accessory innervation. Clinical Implications. Having the skill to perform these alternative anesthetic techniques increases dentists ability to provide successful local anesthesia consistently for all procedures in mandibular teeth. Key Words. Local anesthesia; mandibular nerve block; inferior alveolar nerve; Gow-Gates; Akinosi-Vazirani. JADA 2011;142(9 suppl):8S-12S.
Dr. Haas is the Chapman Chair, associate dean of clinical sciences, and a professor and the head of dental anaesthesia, Faculty of Dentistry, a professor, Department of Pharmacology, Faculty of Medicine, and active staff, Sunnybrook Health Sciences Centre, University of Toronto. Address reprint requests to Dr. Haas at Faculty of Dentistry, University of Toronto, 124 Edward St., Toronto, Ontario, M5G 1G6, Canada, e-mail daniel.haas@dentistry. utoronto.ca.

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BOX 1

BOX 2

Indications for the three mandibular nerve block techniques.

STANDARD IANB*

Similarities among the three mandibular nerve block techniques.

dMay be used to provide anesthesia for procedures in
either one or multiple mandibular teeth in a quadrant

dProcedures in either one or multiple mandibular teeth

in one quadrant dProcedures in the buccal periodontium anterior to the mental foramen dProcedures in the lingual periodontium (the lingual nerve usually also is anesthetized by means of this technique) GOW-GATES MANDIBULAR NERVE BLOCK

dA 25-gauge long needle is used dFull cartridge of local anesthetic should be administered;
possible exception for the inferior alveolar nerve block is to administer three-quarters of a cartridge if a buccal nerve block is administered immediately afterward dAnterior border of the ramus of the mandible is palpated before needle insertion dInsertion depth is 25 millimeters (1 inch), although occasionally it needs to be deeper for the Gow-Gates technique dInferior alveolar and lingual nerves are anesthetized

dSame as for standard IANB dParticularly indicated if there is a history of IANB

failure, evidence of anatomical variability or evidence of accessory innervation

AKINOSI-VAZIRANI CLOSED-MOUTH MANDIBULAR NERVE BLOCK dSame as for standard IANB dParticularly indicated if there is a history of IANB failure, evidence of anatomical variability, evidence of accessory innervation, presence of trismus or difficulty in seeing intraoral landmarks for IANB * IANB: Inferior alveolar nerve block.

tions regarding the neuroanatomy of the trigeminal nerve. Once the needle has penetrated the mucosa, the dentist essentially is proceeding in a blind manner and is assuming that the patient has the same anatomy that the dentist learned in dental school; all patients anatomy, however, is not the same. Key landmarks such as the mandibular foramen can vary.10 Such anatomical variability may lead to failure of the IANB because needle placement will not be adjacent to essential structures. Accessory innervation occurs when the main trunk of the inferior alveolar nerve is not the only source of innervation to the pulp. Accessory innervation may arise from several sources, such as a distinct branch separating from the inferior alveolar nerve superiorly in the pterygomandibular space.11 If this distinct branch connects to the main trunk far enough superiorly to the mandibular foramen, then repeated deposition of local anesthetic near this site, as is done in the traditional IANB, still will not provide successful anesthesia. In addition to there being distinct branches, accessory nerves also may travel with the mylohyoid nerve, as well as the buccal, lingual or auriculotemporal nerves. Accessory innervation can be diagnosed when the patient has subjective signs of a successful mandibular nerve block, such as a numb lip, but the tooth still is sensitive when stimulated with a drill. This is common in mandibular molars, although it can occur in any tooth. The value of the alternative mandibular nerve block techniques is their ability to address these last two reasons for IANB failure. Dentists who are skilled at using the Gow-Gates and Akinosi-

Vazirani techniques will have a higher likelihood of successfully providing anesthesia in patients who have anatomy that differs from what is expected. Similarly, these two techniques have a higher likelihood of bathing an accessory branch of the inferior alveolar nerve with local anesthetic, because they result in the drugs being administered at a site deeper than that accomplished through the traditional IANB. Although some investigators report that the success rates for these alternative blocks are higher than those reported for the IANB,12-14 others have reported comparable rates2,15 or a better rate for the IANB.16 However, investigators in the latter study reported that the better rate for the IANB likely was due to the experience of the dentists administering the anesthetic blocks. The primary goal of each of the three mandibular nerve blocks is anesthesia of the inferior alveolar nerve, which innervates the pulps of the mandibular teeth on the same side of the mouth, as well as the buccal periodontium anterior to the mental foramen. For each of the three techniques, this goal is accomplished by depositing anesthetic within the pterygomandibular space. This anatomical space contains the inferior alveolar nerve, as well as the lingual nerve, which usually also is anesthetized by means of these techniques. The pterygomandibular space also contains the inferior alveolar artery and vein and the sphenomandibular ligament. This space is bordered laterally by the ramus of the mandible, medially and inferiorly by the medial pterygoid muscle, superiorly by the lateral pterygoid muscle, posteriorly by the parotid gland and anteriorly by the thin buccinator muscle. Box 1 summarizes the indications for using the three techniques. Any of these techniques may be used, and they can be the first choice when performing dental work in the mandibular arch. The Gow-Gates and Akinosi-Vazirani methods are
ABBREVATION KEY. IANB: Inferior alveolar nerve block.
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Figure 1. Final needle placement for the Gow-Gates technique. The needle tip is positioned at the neck of the condyle. Reprinted with permission of the Faculty of Dentistry, University of Toronto.

Figure 2. Extraoral landmarks for the GowGates technique. An imaginary line is drawn from the intertragic notch to the corner of the mouth, and the syringe is aligned parallel to this plane during insertion. Reprinted with permission of the Faculty of Dentistry, University of Toronto.

Figure 3. Needle insertion point for the Gow-Gates technique. Reprinted with permission of the Faculty of Dentistry, University of Toronto.

indicated particularly when there is anatomical variation or accessory innervation. The AkinosiVazirani method also is indicated when the patient has trouble opening his or her mouth or whose tongue persistently obstructs the view of the soft-tissue landmarks used in the IANB. These three techniques have similarities (Box 2), and each has advantages and disadvantages. The specific steps to performing the Gow-Gates and the Akinosi-Vazirani techniques follow.
GOW-GATES MANDIBULAR NERVE BLOCK

Gow-Gates6 initially described what became known as the Gow-Gates mandibular nerve block in 1973. The objective of the technique is to place the needle tip and administer the local anesthetic at the neck of the condyle (Figure 1). This position is in proximity to the mandibular branch of the trigeminal nerve after it exits the foramen ovale. As with the other two mandibular techniques, use a 25-gauge long needle. Before looking inside the patients mouth, determine the extraoral landmarks. Figure 2 shows where an imaginary line is drawn from the intertragic notch (the point immediately inferior to the tragus of the ear) to the corner of the mouth. Align the syringe parallel to this plane during insertion. Intraorally, find the bony landmark by palpating the external oblique ridge of the anterior surface of the ramus in the coronoid notch. Follow this maneuver by moving your thumb or finger superiorly to palpate the coronoid process. The temporalis muscle attaches onto the coronoid process, and it is important to miss this muscle when inserting the needle. After palpating the landmarks, hold the syringe at the correct angle, as determined previously, with the needle tip aiming for the neck of the condyle. The barrel of the syringe usually is over the contralateral mandibular canine or premolars. The intraoral insertion point is lateral and superior compared with that of the IANB. This
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point is on the lateral margin of the pterygotemporal depression and just medial to the attachment of the temporalis muscle (Figure 3). The superior boundary of the insertion point is the maxillary occlusal plane. Usually, the needle lies just below the mesiopalatal cusp of the maxillary second molar, which can be a reliable landmark, provided that this tooth has not drifted or rotated. Just before needle insertion, ask the patient to open his or her mouth as widely as possible. A wide opening is essential to the success of this technique, which should not be considered for patients who cannot open their mouths to a great enough extent. Once the needle is inserted, advance it slowly until it contacts bone (the neck of the condyle). This contact should occur at a depth of 25 millimeters, although a greater depth may be required for larger patients or those with a markedly flaring ramus. If bone is not contacted, do not administer the injection but instead redirect the needle until you feel the neck of the condyle. Once contact is made, withdraw the needle 1 mm and administer a full cartridge of local anesthetic after a negative aspiration. Do not administer less than a full cartridge. When he developed his approach, Gow-Gates, who was an Australian dentist, used cartridges containing 2.2 milliliters, which was the standard in Australia. This slightly greater volume, compared with the 1.8-mL cartridges used in the United States, may have contributed to this methods high success rate. The final position of the needle tip is just anterior to the neck of the condyle, inferior to the lateral pterygoid muscle, lateral to the medial pterygoid muscle and medial to the ramus. The nerves anesthetized by the Gow-Gates technique include the inferior alveolar and its branches (incisive and mental), lingual, mylohyoid, auriculotemporal and buccal (approximately 75 percent of the time). This group of nerves is different from the group anesthetized by the IANB, which includes only the inferior alveolar nerve and its branches (incisive

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Figure 4. Final needle placement for the Akinosi-Vazirani closed-mouth technique. The circle denotes the needle tips position within the pterygomandibular space. Reprinted with permission of the Faculty of Dentistry, University of Toronto.

Figure 5. Bony landmarks for the AkinosiVazirani closed-mouth technique insertion. Reprinted with permission of the Faculty of Dentistry, University of Toronto.

Figure 6. Needle insertion point for the Akinosi-Vazirani closed-mouth technique. Reprinted with permission of the Faculty of Dentistry, University of Toronto.

and mental) and the lingual nerve. Anesthesia of the buccal nerve precludes the need for performing a separate buccal nerve block. Anesthesia of the mylohyoid and auriculotemporal nerves could resolve the concern about accessory innervation, as would the more superior position of the administration of the local anesthetic. The GowGates technique has resulted in an approximately 2 percent rate of positive aspiration compared with 10 to 15 percent for the IANB.1(p237) This rate may be lower because the inferior alveolar vein and artery are further away from the target site than they are with the IANB, which also may be the reason that the investigators reported that exogenous epinephrine absorption is lower with the Gow-Gates technique than with the IANB. After the injection is administered, ask patients to keep their mouths open for at least 20 seconds, if possible, to keep the inferior alveolar nerve closer to the site of injection and improve onset of anesthesia.6 The onset of anesthesia usually is five to 10 minutes, which is longer than that for the IANB (usually three to five minutes).
AKINOSI-VAZIRANI CLOSED-MOUTH MANDIBULAR NERVE BLOCK

Two dentists independently described the closedmouth mandibular nerve block as an alternative to the IANB. In 1977, Akinosi7 brought this method to the attention of educators, but they soon realized that this technique had been published by Vazirani in 1960.8 This technique has the same indications as do the IANB or GowGates methods (Box 2), but it is indicated particularly if the patient has trismus or the dentist has difficulty seeing the intraoral landmarks used for the IANB. What makes this technique unique is that the patients mouth is closed. The objective is to place the needle tip between the ramus and the medial pterygoid muscle (Figure 4). Since the mouth is closed, seeing the intraoral landmarks can be difficult. Position yourself so that you can see the

needle clearly during the entire insertion process. A controversial decision to make is whether to bend the needle. A bend at an approximately 15 to 30 angle toward the ramus may help minimize the likelihood of the needles being inserted into the medial pterygoid muscle. The controversy is about the risk of breaking the needle, as the bend can cause a weakening at the hub. Thus, the needle should be bent only one time to minimize this possibility. As always, never bury the needle to its hub. Also, when bending the needle, use the cap to maintain the needles sterility. A final decision regarding the use of a straight or bent needle should take into account all of its inherent risks and benefits. Intraorally, the bony landmark is essentially the same as it is for the IANB and Gow-Gates methods. Palpate the external oblique ridge of the anterior surface of the ramus and then move the thumb or finger superiorly to palpate the coronoid process. The temporalis muscle attaches here, and the needle must not penetrate this sensitive structure. Thus, in a lateromedial plane, the point of insertion is medial to the coronoid process and lateral to the maxillary tuberosity (Figure 5). In a superoinferior plane, this point of insertion is at the height of the mucogingival junction of the maxillary teeth. With the tissue retracted laterally, the dentist should insert the needle in a posterior direction (Figure 6). Once the needle has been inserted a few millimeters, assess the position of the syringe. At this point, ask the patient to bring his or her teeth into occlusion, with the mastication muscles remaining relaxed. If the teeth are clenched, the mastication muscles will obliterate the pterygomandibular space and prevent the anesthetic from reaching the nerves necessary to provide anesthesia. Having the patient perform a lateral excursion to the injection side will help reveal the insertion point. The syringe should be at the level of the mucogingival junction of the maxillary molars,
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parallel to the maxillary occlusal plane and as close to the maxillary mucosa as possible without touching it. Advance the syringe so that the needle tip moves posteriorly and slightly laterally, all the while being parallel to the occlusal plane. If there is a bend in the needle, advance the syringe in an arclike fashion. The amount of arcing is correlated directly to the degree of bend. Once the needle is inserted 25 mm (for the average adult patient), stop advancing the syringe and administer one full cartridge after a negative aspiration. The goal of using the Akinosi-Vazirani technique is to fill the pterygomandibular space with local anesthetic, thereby bathing the inferior alveolar, lingual and mylohyoid nerves with anesthetic. Using the Akinosi-Vazirani technique should result in no bony landmarks being hit. Although no hard tissue should be contacted, if bone obstructs needle placement, it often occurs early and is due to contact with the coronoid process. This problem may occur if the insertion point is too far laterally and may be corrected by withdrawing the needle slightly and redirecting it around the obstruction. The nerves anesthetized by the AkinosiVazirani technique include the inferior alveolar and its branches (incisive and mental), lingual, mylohyoid and buccal (approximately 75 percent of the time). As with the Gow-Gates technique, a separate buccal nerve block may not be needed because successful anesthesia of the buccal nerve is common when this technique is used.2 Anesthesia of the mylohyoid nerve could resolve concerns about accessory innervation. The onset of anesthesia is intermediate (five to seven minutes) compared with that of the IANB and the Gow-Gates technique.
CONCLUSIONS

of the three techniques is equally easy to perform. The value in knowing how to perform all three techniques is that, for a specific patient, one of these alternative techniques most likely will provide satisfactory anesthesia in situations in which the IANB will not. Knowing how to perform only one method to block the inferior alveolar nerve limits the dentists ability to provide successful anesthesia consistently and makes reaching the goal of pain-free dentistry for all patients more difficult. Conversely, knowing how to perform all three techniques increases the likelihood that patients can be pain-free when undergoing dental procedures in the mandible.
Disclosure. Dr. Haas did not report any disclosures. The author thanks Andrea Cormier, Christine Nicolau, Bruno Rakiewicz and James Fiege of the Media Services Department of the Faculty of Dentistry, University of Toronto, for their skill in preparing the material used for Figures 1 through 6. 1. Malamed SF. Techniques of mandibular anesthesia. In: Handbook of Local Anesthesia. 5th ed. St. Louis: Mosby; 2004:227, 237. 2. Goldberg S, Reader A, Drum M, Nusstein J, Beck M. Comparison of the anesthetic efficacy of the conventional inferior alveolar, Gow-Gates and Vazirani-Akinosi techniques. J Endod 2008; 34(11):1306-1311. 3. Robertson WD. Clinical evaluation of mandibular conduction anesthesia. Gen Dent 1979;27(5):49-51. 4. Levy TP. An assessment of the Gow-Gates mandibular block for third molar surgery. JADA 1981;103(1):37-41. 5. DeSantis JL, Liebow C. Four common mandibular nerve anomalies that lead to local anesthesia failures. JADA 1996;127(7):1081-1086. 6. Gow-Gates GA. Mandibular conduction anesthesia: a new technique using extraoral landmarks. Oral Surg Oral Med Oral Pathol 1973;36(3):321-328. 7. Akinosi JO. A new approach to the mandibular nerve block. Br J Oral Surg 1977;15(1):83-87. 8. Vazirani SJ. Closed mouth mandibular nerve block: a new technique. Dent Dig 1960;66:10-13. 9. Kaufman E, Weinstein P, Milgrom P. Difficulties in achieving local anesthesia. JADA 1984;108(2):205-208. 10. Afsar A, Haas DA, Rossouw PE, Wood RE. Radiographic localization of mandibular anesthesia landmarks. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86(2):234-241. 11. Blanton PL, Jeske AH; ADA Council on Scientific Affairs; ADA Division of Science. The key to profound local anesthesia: neuroanatomy. JADA 2003;134(6):753-760. 12. Malamed SF. The Gow-Gates mandibular block: evaluation after 4,275 cases. Oral Surg Oral Med Oral Pathol 1981;51(5):463-467. 13. Sisk AL. Evaluation of the Gow-Gates mandibular block for oral surgery. Anesth Prog 1985;32(4):143-146. 14. Aggarwal V, Singla M, Kabi D. Comparative evaluation of anesthetic efficacy of Gow-Gates mandibular conduction anesthesia, Vazirani-Akinosi technique, buccal-plus-lingual infiltrations, and conventional inferior alveolar nerve anesthesia in patients with irreversible pulpitis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109(2):303-308. 15. Montagnese TA, Reader A, Melfi R. A comparative study of the Gow-Gates technique and a standard technique for mandibular anesthesia. J Endod 1984;10(4):158-163. 16. Todorovi L, Stajci Z, Petrovi V. Mandibular versus inferior c c c dental anaesthesia: clinical assessment of 3 different techniques. Int J Oral Maxillofac Surg 1986;15(3):733-738. 17. Viana AM, Campos AC, Morlin MT, Chin VK. Plasma catecholamine concentrations and hemodynamic responses to vasoconstrictor during conventional or Gow-Gates mandibular anesthesia. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100(4):415-419. 18. Johnson TM, Badovinac R, Shaefer J. Teaching alternatives to the standard inferior alveolar nerve block in dental education: outcomes in clinical practice. J Dent Educ 2007;71(9):1145-1152. 19. Jacobs S, Haas DA, Meechan JG, May S. Injection pain: comparison of three mandibular block techniques and modulation by nitrous oxide:oxygen. JADA 2003;134(7):869-876.

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Ideally, all three techniques for mandibular anesthesia should be taught to dental students. Nevertheless, use of all three techniques in practice does not necessarily follow, possibly because faculty who supervise predoctoral clinical dentistry are not familiar with the alternative techniques.18 For dentists who already are in practice, although it is difficult to learn new techniques, it is worth the challenge because the benefits are substantial. Dentists who are not comfortable using these alternative mandibular nerve blocks should be encouraged to take continuing education courses regarding local anesthetic techniques. There is no substantial difference in the pain experienced by patients who receive any of these three mandibular nerve blocks.19 There is no evidence that one technique will have a higher success rate than the other two. With training, each
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