SPECIAL TECHNIQUESSPECIAL TECHNIQUES

Indication For Special TechniqueIndication For Special Technique

InfectionInfection

PathologyPathology

TrismusTrismus

TraumaTrauma

Nerve Block TechniquesNerve Block Techniques

Extraoral Maxillary Nerve BlockExtraoral Maxillary Nerve Block

Extraoral Infraorbital Nerve BlockExtraoral Infraorbital Nerve Block

Extraoral Mandibular Nerve BlockExtraoral Mandibular Nerve Block

Nerve Block TechniquesNerve Block Techniques

Gow-Gates Mandibular Nerve BlockGow-Gates Mandibular Nerve Block

Akinosi Closed Mouth Mandibular Nerve Akinosi Closed Mouth Mandibular Nerve BlockBlock

Infiltration TechniquesInfiltration Techniques

Periodontal LigamentPeriodontal Ligament

IntraosseousIntraosseous

Mylohyoid NerveMylohyoid Nerve

Gow-Gates Mandibular BlockGow-Gates Mandibular Block

Developed to improve success rateDeveloped to improve success rate

True mandibular nerve blockTrue mandibular nerve block

Has a lower rate of positive aspiration Has a lower rate of positive aspiration

(2% vs. 10%-15% for IAN)(2% vs. 10%-15% for IAN)

Technique dependentTechnique dependent

Indication For Special TechniqueIndication For Special Technique

Anatomic variationAnatomic variation

Complete nerve trunk Complete nerve trunk

Selective pulpal / soft tissue anesthesiaSelective pulpal / soft tissue anesthesia

Gow-Gates Mandibular BlockGow-Gates Mandibular Block

Target AreaTarget Area

Neck of condyle, below insertion of lateral Neck of condyle, below insertion of lateral pterygoid musclepterygoid muscle

Gow-Gates Mandibular BlockGow-Gates Mandibular Block

LandmarksLandmarks

Mesiolingual cusp of maxillary 2nd molarMesiolingual cusp of maxillary 2nd molar

Intertragic notchIntertragic notch

Corner of the mouthCorner of the mouth

Gow-Gates Mandibular BlockGow-Gates Mandibular Block

TechniqueTechnique

Coordinate intraoral & extraoral landmarksCoordinate intraoral & extraoral landmarks

Align barrel of syringe over premolars and Align barrel of syringe over premolars and with extraoral landmarkswith extraoral landmarks

Gow-Gates Mandibular BlockGow-Gates Mandibular Block

Technique (cont.)Technique (cont.)

Penetrate mucosa distil to 2nd molarPenetrate mucosa distil to 2nd molar

Advance needle to bone (avg. 25 mm)Advance needle to bone (avg. 25 mm)

Aspirate, deposit 1.8 ml of solution slowlyAspirate, deposit 1.8 ml of solution slowly

Gow-Gates Mandibular BlockGow-Gates Mandibular Block

Technique (cont.)Technique (cont.)

Patient’s mouth must be Patient’s mouth must be fullyfully open during open during injection and for 1-2 mins afterwardinjection and for 1-2 mins afterward

May require reinforcement with second May require reinforcement with second injectioninjection

Gow-Gates Mandibular BlockGow-Gates Mandibular Block

ComplicationsComplications

Hematoma (< 2%)Hematoma (< 2%)

TrismusTrismus

Akinosi Closed Mouth Akinosi Closed Mouth Mandibular BlockMandibular Block

Alternative for mandibular block when Alternative for mandibular block when limited opening is presentlimited opening is present

( eg. trismus, closed lock, etc..) ( eg. trismus, closed lock, etc..)

Akinosi Closed Mouth Akinosi Closed Mouth Mandibular BlockMandibular Block

AdvantagesAdvantages

Not necessary to open widelyNot necessary to open widely

High success rateHigh success rate

Relatively atraumaticRelatively atraumatic

Few complications, few positive aspirationsFew complications, few positive aspirations

Akinosi Closed Mouth Akinosi Closed Mouth Mandibular BlockMandibular Block

DisadvantagesDisadvantages

Visualization of path and depth of insertion Visualization of path and depth of insertion is difficultis difficult

No bony contactNo bony contact

Traumatic if needle hits periosteumTraumatic if needle hits periosteum

Akinosi Closed Mouth Akinosi Closed Mouth Mandibular BlockMandibular Block

Target AreaTarget Area

Soft tissue medial to ramusSoft tissue medial to ramus

Above foramen, below condyleAbove foramen, below condyle

LandmarksLandmarks

Mucogingival junction of maxillary 2nd or 3rd molarMucogingival junction of maxillary 2nd or 3rd molar

Maxillary tuberosity Maxillary tuberosity

Akinosi Closed Mouth Akinosi Closed Mouth Mandibular BlockMandibular Block

Area of insertionArea of insertion

Soft tissue overlying medial ramus, Soft tissue overlying medial ramus, adjacent to tuberosityadjacent to tuberosity

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

Akinosi Closed Mouth Akinosi Closed Mouth Mandibular BlockMandibular Block

TechniqueTechnique

Retract soft tissues, have patient occludeRetract soft tissues, have patient occlude

Apply topicalApply topical

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

Akinosi Closed Mouth Akinosi Closed Mouth Mandibular Block Mandibular Block

Technique (cont.)Technique (cont.)

Aspirate, deposit 1.8 ml slowlyAspirate, deposit 1.8 ml slowly

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

Akinosi Closed Mouth Akinosi Closed Mouth Mandibular BlockMandibular Block

ComplicationsComplications

Hematoma (<10%)Hematoma (<10%)

Facial nerve paralysis (Bell’s Palsy)Facial nerve paralysis (Bell’s Palsy)

Trismus (rare)Trismus (rare)

Akinosi Closed Mouth Akinosi Closed Mouth Mandibular BlockMandibular Block

Failures of anesthesiaFailures of anesthesia

Lateral flaring of mandibleLateral flaring of mandible

Insertion too lowInsertion too low

Penetration too deep or shallow (adjust for Penetration too deep or shallow (adjust for patient size)patient size)