**5. Modified Jorgensen & Hayden technique**

nerves anesthetized by Gow-Gates technique include the inferior alveolar and its branches (incisors and mental), lingual, mylohyoid, auriculotemporal and buccal (about 75 percent of the time). Anesthesia of the mylohyoid and auriculotemporal nerves resolve the concern with accessory innervation, as would be the uppermost position of the anesthetic administration. The gow-gates technique resulted in a rate of about 2% positive suction compared with 10 to 15% SIANB. [1] This rate may be lower because the inferior alveolar vein and artery are further

After the injection is administered, we should 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. The onset of anesthesia is usually five to 10 minutes, which

Two dentists independently described the closed mouth mandibular nerve block as an alternative to the IANB. In 1977, Akinosi [14] brought this method to the attention of educators, but they soon realized that this technique had been published by Vazirani in 1960. [15] This is indicated particularly if the patient has trismus or the dentist has difficulty seeing the intraoral

What makes this technique unique is that the patient's mouth is closed. The aim is to place the needle tip between the ramus and the medial pterygoid muscle. Since the mouth is closed, seeing the intraoral landmarks can be difficult. A curve at approximately 15° to 30° angle toward the ramus can help minimize the chance of the needle being inserted into the medial

Inside the mouth, the bone reference is essentially the same as it is for the SIANB and Gow-Gates methods. We palpate the external oblique ridge of the anterior surface of the ramus and then move the thumb superiorly to palpate the coronoid. The temporal muscle attaches here, and the needle should not enter this sensitive structure. Thus, in a lateral plane, the insertion point is medial to the coronoid process and lateral to the maxillary tuberosity. In superoinferior plane, this insertion point is at the height of the mucogingival junction of the upper teeth, with the tissue retracted laterally, the dentist should insert the needle in a posterior direction [14, 15]. The syringe should be at the level of the mucogingival junction of the upper molars, parallel to maxillary occlusal plane and as close to the maxillary mucosa as possible without touching it. We move the syringe such that the needle moves laterally and posteriorly. Once the needle is inserted 25 mm (for an average adult patient) to stop the advancement of the syringe and

The purpose of using the Akinosi-Vazirani technique is to fill the pterygomandibular space with local anesthetic, bathing the inferior alveolar, lingual and mylohyoid nerves with anesthetic solution. Using Akinosi-Vazirani technique should result in no bony references being hit. The nerves anesthetized by the Akinosi- Vazirani technique include the inferior

away than the target site are to SIANB [9, 10,12,13].

46 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

landmarks used for the SIANB.

pterygoid muscle [15].

is longer than that for the SIANB (usually three to five minutes) [13].

administer one full cartridge after a negative aspiration [10,15].

**4. Akinosi-Vazirani closed-mouth mandibular nerve block**

To achieve mandibular anesthesia, many dentists use an injection technique targeting the mandibular sulcus, similarly described by Jorgensen and Hayden in 1967. [16] This injection remains a proven method for the delivery of local anesthetic safely with minimal discomfort to the patient. However, there are disadvantages associated with standard inferior alveolar nerve block, usually associated with the identification of anatomical landmarks [14,16]. Therefore, we propose a modified Jorgensen - Hayden technique to achieve mandibular anesthesia.
