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1. 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
1. Inferior alveolar
2. Mental
3. Incisive
4. Lingual
5. Mylohyoid
6. Auriculotemporal
7. Buccal

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

8. Anatomical landmarks
a) Anterior border of the ramus
b) Tendon of temporal muscle
c) Corner of the mouth
d) Intertragic notch of the ear
e) External ear

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

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

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

12. Disadvantages
1. Lingual & lower lip anesthesia is uncomfortable for many
patients & is possibly dangerous for certain individuals.
2. 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).

13. Technique
1. Patient is placed in the supine position.
2. Operator is positioned to the right & slightly in front of patient.
3. Patient keeps mouth open widely & remains in that position until the
injection is completed.
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, & the tendon of the
temporal muscle is identified.
6. 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.

14. Continued…..
7. 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.
8. 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.

16. Signs & symptoms
1. 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.

17. 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.

18. Failures of anesthesia
• Rare
Complications
1. Hematoma
2. Trismus (extremely rare)
3. Temporary paralysis of cranial nerves III, IV, & VI.

19. Vazirani- Akinosi Technique

20. • 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

22. Nerves anesthetized
1. Inferior alveolar
2. Incisive
3. Mental
4. Lingual
5. Mylohyoid

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

25. Anatomical landmarks
a) Occlusal plane of occluding teeth
b) Mucogingival junction of the maxillary molar teeth
c) Anterior border of the ramus

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

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

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

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

30. Technique
1. With the patient seated comfortably in the dental chair, the operator stands
to the patient’s right side & slightly to the front.
2. Patient is instructed to occlude the teeth.
3. The operator retracts the patient’s lips exposing the maxillary & mandibular
teeth on the right side.
4. 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.
5. The needle penetrates the mucosa just medial to the ramus & is inserted
approx. 1 ½ inches.
6. Following negative aspiration, the contents of the dental cartridge are slowly
deposited.

32. Signs & symptoms
1. Subjective-
Tingling or numbness :-
• Lowerlip-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

33. 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.

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

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