Recommended anesthesia techniques
In daily clinical practice, priority is given to techniques that ensure maximum patient safety and convenience for the clinician. Intraoral methods, as well as anesthetic administration via the anterior border of the mandibular ramus, are recognized as the most reliable.
Among intraoral mandibular nerve blocks, the following techniques demonstrate the highest efficacy:
- Gow-Gates anesthesia (Gow-Gates) — used exclusively on the condition that the patient can open their mouth freely.
- Egorov's anesthesia — also requires free mouth opening for correct execution.
- Vazirani-Akinosi anesthesia (Vazirani-Akinosi) — is the method of choice in clinical situations where the patient's mouth opening is limited.
Why are intraoral methods (Gow-Gates) preferred over the submandibular approach?
To understand the value of the Gow-Gates technique, one must consider the disadvantages of alternative extraoral routes. The submandibular route was historically recommended for restricted mouth opening. Technically, it involves advancing the needle in constant contact with the inner surface of the mandibular ramus until reaching the inferior alveolar nerve. However, this approach is associated with several serious problems.
First, the clinician often encounters technical difficulties. Establishing reliable needle-to-bone contact is extremely inconvenient and difficult in children and obese patients with short necks due to the loss of anatomical landmarks. Second, in patients with pronounced tuberocities on the inner surface of the mandibular ramus (in the muscle attachment area), uncontrolled deflection or deviation of the needle occurs.
The most significant and inevitable complication of the submandibular route is trauma to the medial pterygoid muscle. Damage to this structure is the main cause of trismus—complete jaw clenching or severe limitation of mobility. As a result, a paradoxical situation arises: a method used for restricted mouth opening creates additional causes that sustain this limitation.
Dangers of the posterior border of the ramus approach
Another historical option—the approach from the posterior border of the mandibular ramus—also clearly demonstrates the advantages of safe intraoral techniques. When using this posterior route, the needle trajectory inevitably passes through the soft tissues of the parotid gland.
This anatomical region conceals critically important structures:
- External carotid artery.
- Branches of the facial nerve.
The risk of injuring these elements during the posterior approach is extremely high. If the needle damages facial nerve branches, the patient rapidly develops a severe complication—facial muscle contracture. It is precisely because of such high risks and the severity of potential consequences that this anesthesia method has not gained widespread use in modern clinical practice, yielding to reliable intraoral blocks such as the Gow-Gates technique.
Briefly: answers to topical questions
What are the intraoral and extraoral anatomical landmarks for needle insertion in Gow-Gates anesthesia?
The intraoral and extraoral anatomical landmarks for needle insertion are the neck of the mandibular condyle, the tragus, and the pterygomandibular depression.
- Extraoral landmarks — the index finger is placed in front of the tragus or in the external acoustic meatus to palpate the movement of the condylar process.
- Intraoral landmarks — insertion is performed into the pterygomandibular depression (pterygomandibular space), medial to the tendon of the temporalis muscle. The main anatomical landmark is the neck of the condylar process.
Which branches of the mandibular nerve are blocked during Gow-Gates anesthesia?
During Gow-Gates anesthesia, a single injection blocks:
- inferior alveolar nerve;
- lingual nerve;
- mylohyoid nerve;
- auriculotemporal nerve;
- buccal nerve — in 65–75% of cases.
What is the needle insertion technique in Vazirani-Akinosi anesthesia?
Vazirani-Akinosi anesthesia utilizes an intraoral approach with closed jaws. The needle is inserted from the anterior border of the mandibular ramus. The method is used to block the inferior alveolar nerve and other sensory branches of the mandibular nerve in the presence of trismus.
What specific complications can occur directly during Gow-Gates anesthesia?
When performing Gow-Gates anesthesia, local post-injection complications occur extremely rarely. Possible complications include:
- hematoma;
- difficulty opening the mouth (trismus).
To memorize indications: Gow-Gates and Egorov like "open doors" (free mouth opening), while Vazirani-Akinosi works in "tight spaces" (limited mouth opening).
Class and exam questions
In what cases is Gow-Gates anesthesia indicated?
It is used as one of the most effective intraoral methods for blocking the inferior alveolar nerve, provided the patient can open their mouth freely.
What to do if the patient cannot open their mouth?
In such a situation, the Gow-Gates and Egorov techniques are not suitable. It is recommended to use the intraoral Vazirani-Akinosi block.
Why is the submandibular anesthesia approach rarely used nowadays?
It inevitably traumatizes the medial pterygoid muscle, leading to trismus, and is technically difficult in children and patients with short necks.
What are the risks of the posterior border of the mandibular ramus approach?
Passing the needle through the parotid gland creates a high risk of injury to the external carotid artery and facial nerve branches, leading to facial muscle contracture.
What else to study on this topic
- Topographic anatomy of the mandibular ramus and anterior border
- Egorov's anesthesia technique
- Vazirani-Akinosi anesthesia technique for trismus
- Mechanism of facial muscle contracture development in facial nerve branch trauma
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