1. SPECIAL TECHNIQUES

2. Indication For Special Technique InfectionPathologyTrismusTrauma

3. Nerve Block Techniques Extraoral Maxillary Nerve Block Extraoral Infraorbital Nerve Block Extraoral Mandibular Nerve Block

4. Nerve Block Techniques Gow-Gates Mandibular Nerve Block Akinosi Closed Mouth Mandibular Nerve Block

5. Infiltration Techniques Periodontal Ligament Intraosseous Mylohyoid Nerve

6. Gow-Gates Mandibular Block Developed to improve success rate True mandibular nerve block Has a lower rate of positive aspiration (2% vs. 10%-15% for IAN) (2% vs. 10%-15% for IAN) Technique dependent

7. Indication For Special Technique Anatomic variation Complete nerve trunk Selective pulpal / soft tissue anesthesia

8. Gow-Gates Mandibular Block Target Area Neck of condyle, below insertion of lateral pterygoid muscle Neck of condyle, below insertion of lateral pterygoid muscle

9. Gow-Gates Mandibular Block Landmarks Mesiolingual cusp of maxillary 2nd molar Mesiolingual cusp of maxillary 2nd molar Intertragic notch Intertragic notch Corner of the mouth Corner of the mouth

10. Gow-Gates Mandibular Block Technique Coordinate intraoral & extraoral landmarks Coordinate intraoral & extraoral landmarks Align barrel of syringe over premolars and with extraoral landmarks Align barrel of syringe over premolars and with extraoral landmarks

11. Gow-Gates Mandibular Block Technique (cont.) Penetrate mucosa distil to 2nd molar Penetrate 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 slowly Aspirate, deposit 1.8 ml of solution slowly

12. Gow-Gates Mandibular Block Technique (cont.) Patient’s mouth must be fully open during injection and for 1-2 mins afterward Patient’s mouth must be fully open during injection and for 1-2 mins afterward May require reinforcement with second injection May require reinforcement with second injection

13. Gow-Gates Mandibular Block Complications Hematoma (< 2%) Hematoma (< 2%) Trismus Trismus

20. Akinosi Closed Mouth Mandibular Block Alternative for mandibular block when limited opening is present ( eg. trismus, closed lock, etc..) ( eg. trismus, closed lock, etc..)

21. Akinosi Closed Mouth Mandibular Block Advantages Not necessary to open widely Not necessary to open widely High success rate High success rate Relatively atraumatic Relatively atraumatic Few complications, few positive aspirations Few complications, few positive aspirations

22. Akinosi Closed Mouth Mandibular Block Disadvantages Visualization of path and depth of insertion is difficult Visualization of path and depth of insertion is difficult No bony contact No bony contact Traumatic if needle hits periosteum Traumatic if needle hits periosteum

23. Akinosi Closed Mouth Mandibular Block Target Area Soft tissue medial to ramus Soft tissue medial to ramus Above foramen, below condyle Above foramen, below condyleLandmarks Mucogingival junction of maxillary 2nd or 3rd molar Mucogingival junction of maxillary 2nd or 3rd molar Maxillary tuberosity Maxillary tuberosity

24. Akinosi Closed Mouth Mandibular Block Area of insertion Soft tissue overlying medial ramus, adjacent to tuberosity Soft tissue overlying medial ramus, adjacent to tuberosity At height of mucogingival junction of maxillary 2nd or 3rd molar At height of mucogingival junction of maxillary 2nd or 3rd molar

25. Akinosi Closed Mouth Mandibular Block Technique Retract soft tissues, have patient occlude Retract soft tissues, have patient occlude Apply topical Apply topical Penetrate to 25 mm, parallel to maxillary occlusal plane, in a posterior and lateral direction Penetrate to 25 mm, parallel to maxillary occlusal plane, in a posterior and lateral direction

26. Akinosi Closed Mouth Mandibular Block Technique (cont.) Aspirate, deposit 1.8 ml slowly Aspirate, deposit 1.8 ml slowly Motor paralysis will develop first, allowing patient to open more widely Motor paralysis will develop first, allowing patient to open more widely

27. Akinosi Closed Mouth Mandibular Block Complications Hematoma (<10%) Hematoma (<10%) Facial nerve paralysis (Bell’s Palsy) Facial nerve paralysis (Bell’s Palsy) Trismus (rare) Trismus (rare)

28. Akinosi Closed Mouth Mandibular Block Failures of anesthesia Lateral flaring of mandible Lateral flaring of mandible Insertion too low Insertion too low Penetration too deep or shallow (adjust for patient size) Penetration too deep or shallow (adjust for patient size)