|Year : 2021 | Volume
| Issue : 1 | Page : 20-23
Efficacy of a conventional inferior alveolar nerve block compared to the Vazirani–Akinosi and Gow-Gates techniques for mandibular anesthesia
Rishabh Shah1, Pallavi Kalia2, BS Dayanithi3, Sunil Kumar Gulia4, Rishabh Bhanot5, Sasikanth Challari6
1 Department of Oral and Maxillofacial Surgery, K. M. Shah Dental College and Hospital, Vadodara, Gujarat, India
2 Department of Oral and Maxillofacial Surgery; Department of Dentistry, Jawaharlal Nehru Medical College, Ajmer, Rajasthan, India
3 Department of Oral and Maxillofacial Surgery, Meenakshi Medical College and Research Institute, Kanchipuram, Tamil Nadu, India
4 Department of Oral and Maxillofacial Surgery, SGT University, Gurugram, Haryana, India
5 Consultant Oral and Maxillofacial Surgeon, Jyoti Kendra General Hospital, Ludhiana, Punjab, India
6 Consultant Oral and Maxillofacial Surgeon, Eluru, India
|Date of Submission||31-Aug-2020|
|Date of Decision||24-Sep-2020|
|Date of Acceptance||07-Jan-2021|
|Date of Web Publication||16-Feb-2021|
Department of Oral and Maxillofacial Surgery, K. M. Shah Dental College and Hospital, Sumandeep Vidyapeeth, Pipariya, Waghodia, Vadodara, Gujarat
Source of Support: None, Conflict of Interest: None
Background: The conventional inferior alveolar nerve block (IANB) cannot be employed in clinical scenarios with trismus. In addition, it is a blind procedure, so failure to follow the ideal anatomical landmarks and improper positioning of the needle may result in anesthesia failure. This study evaluated whether the Vazirani–Akinosi (VA) and Gow-Gates (GG) techniques for mandibular anesthesia have superior outcomes in the form of fewer positive aspirations and rapid onset of action, as well as better anesthetic attainment. Objective: The objective of this study was to evaluate the anesthetic efficacy and associated complications of a conventional IANB compared to the VA and GG techniques. Method: The study involved 300 patients divided randomly into three groups of 100 patients each. Group I received mandibular anesthesia through the GG technique, Group II received mandibular anesthesia through the VA technique, and Group III received mandibular anesthesia through a conventional IANB. The onset of action, incidence of positive aspiration, and success of the anesthetic technique were assessed in all patients. Result: The Group II patients showed superior anesthetic success (97%) that was significantly different from the results of Groups I and III (P = 0.0241). The mean value of the onset of anesthesia was longer in Group I than in the other two groups. A significant difference was seen between the GG and VA techniques (P = 0.0001*) and between the GG and conventional IANB techniques (P = 0.0001*). Conclusion: The VA technique is considerably superior to either the GG or the conventional IANB techniques in terms of the onset of action and anesthesia success. Positive aspirations are encountered relatively more frequently with the conventional IANB technique.
Keywords: Gow- Gates, inferior alveolar nerve block, Vazirani–Akinosi
|How to cite this article:|
Shah R, Kalia P, Dayanithi B S, Gulia SK, Bhanot R, Challari S. Efficacy of a conventional inferior alveolar nerve block compared to the Vazirani–Akinosi and Gow-Gates techniques for mandibular anesthesia. Sci Dent J 2021;5:20-3
|How to cite this URL:|
Shah R, Kalia P, Dayanithi B S, Gulia SK, Bhanot R, Challari S. Efficacy of a conventional inferior alveolar nerve block compared to the Vazirani–Akinosi and Gow-Gates techniques for mandibular anesthesia. Sci Dent J [serial online] 2021 [cited 2021 Jun 21];5:20-3. Available from: https://www.scidentj.com/text.asp?2021/5/1/20/309546
| Background|| |
The successful accomplishment of any minor oral surgical intervention depends predominantly on the effectiveness of the administered nerve block. The conventional inferior alveolar nerve block (IANB) technique is traditionally used to achieve anesthesia in the mandible for surgical interventions, but mandibular anesthesia can also be achieved successfully via the Vazirani–Akinosi (VA) and Gow-Gates (GG) techniques., Previous studies have revealed that successful anesthesia can be accomplished about 80%–85% of the time with conventional IANB. However, it is a blind procedure; therefore, failure to follow the ideal anatomical landmarks and improper positioning of the needle can result in anesthesia failure. In addition, in clinical scenarios where the patients have restricted mouth opening, the conventional IANB is difficult to employ.
Previous studies have shown that the VA technique is generally employed in these patients, while the GG has even better success in accomplishing mandibular anesthesia than either of these other two techniques., Despite their specific advantages and disadvantages, all these methods have demonstrated contradictory outcomes. Therefore, the aim of the present study was to evaluate the anesthetic efficacy and its associated complications of a conventional IANB compared to the VA and GG techniques.
| Materials and Methods|| |
A comparative double-blinded study was designed involving 300 patients who underwent tooth extractions in the mandibular region between March 2018 and January 2020. Patients who gave written informed consent and agreed to participate in the study were included. Ethical clearance was obtained from the institution prior to commencement of the study. This study included systemically healthy patients aged 20–30 years. Patients who were allergic to the local anesthetic agent and pregnant patients were excluded.
All the patients who participated in this study were randomly assigned to three groups randomly using a computer-generated register generated by a statistician. This study was carried out by a single investigator who documented and analyzed the results in all the patients without knowing the type of anesthetic technique administered to any individual patient. Similarly, the patients were also not informed regarding the type of anesthetic technique administered to ensure double blinding.
Group I received mandibular anesthesia through the GG technique, Group II received mandibular anesthesia through the VA technique, and Group III received mandibular anesthesia through a conventional IANB. All three techniques of mandibular anesthesia were administered by a single experienced oral and maxillofacial surgeon in all patients.
Anesthesia was achieved with 2% lignocaine with adrenaline (1 in 200,000 concentration) in all the patients. The amount of local anesthesia (LA) used was 2.8 ml in all the patients. The onset of action, the incidence of positive aspiration, and the success of the anesthetic technique were assessed in all patients, in addition to any associated complications.
Success of the anesthetic technique
Following the administration of the mandibular nerve block, if the patient did not complain of pain during the course of extraction and if no supplementary nerve block was required to achieve anesthesia, then the anesthetic technique was considered successful.
Time of anesthetic onset
The time anesthetic onset was determined by running a straight probe at the gingival sulcus of the first premolar and lateral incisor region to check for objective signs following the administration of the LA.
Evaluation of aspiration
The needle was inserted at the ideal anatomical area for the delivery of anesthesia and an aspiration was done. Blood entering the barrel of the syringe at the time of aspiration was considered positive.
Need for supplementary nerve blocks
Any failure to attain appropriate anesthesia following the administration of the nerve block necessitated a supplementary nerve block.
Data were analyzed using the Statistical Package for the Social Sciences version 18 (Chicago, Illinois), and the Chi-square test was employed for the assessment of differences between the groups for the aspiration rate, anesthetic success, and onset of anesthesia.
| Results|| |
Positive aspiration was encountered in two patients who underwent the GG technique, in three patients who underwent the VA technique, and in nine patients who underwent a conventional IANB (P = 0.0948) [Figure 1]. The VA technique had superior anesthesia success (97%) when compared to either the GG technique (86%) or conventional IANB (95%) (P = 0.0241) [Figure 2].
|Figure 1: The incidence of positive aspiration in patients undergoing mandibular anesthesia via the Gow-Gates or the Vazirani–Akinosi technique versus a conventional inferior alveolar nerve block|
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|Figure 2: The anesthetic success in patients undergoing mandibular anesthesia via the Gow-Gates or the Vazirani–Akinosi technique versus a conventional inferior alveolar nerve block|
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The mean value for the time of onset of anesthesia was longest for the GG technique (5.5 min) than for either the VA technique (3.4 min) or the conventional IANB (3.1 min) (P = 0.0001*) [Figure 3]. A supplementary nerve block was required in 13 of the 100 patients in Group III, but no patients in either Group I or Group II required a supplementary nerve block [Table 1]. None of the patients involved in this study encountered any anesthetic failure or any complications associated with the administration of LA for blocking the inferior alveolar nerve.
|Figure 3: The anesthetic onset in patients undergoing mandibular anesthesia via the Gow-Gates or the Vazirani–Akinosi technique versus a conventional inferior alveolar nerve block|
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|Table 1: The demographic data of the patients included in this study and the comparison between the three groups|
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| Discussion|| |
The mandible is a cortical bone and requires an efficient nerve block for conducting surgical interventions, unlike the maxilla where local infiltrations can still be effective. The failure of a conventional IANB can arise for several reasons, including failure to adhere to the ideal anatomical landmarks during the administration of the LA, anatomical variations in the mandibular foramen, and improper orientation or position of the needle. In addition, the failure rates increase when the procedure is conducted by an inexperienced operator. Therefore, the techniques of GG and VA can be viewed as reliable alternatives to the conventional IANB for delivery of successful anesthesia, since the anesthetic solution is delivered at an anatomical region that is much deeper than that used for the IANB.
The GG technique involves deposition of the anesthetic solution close to the pterygoid fovea, which is present near the condylar head and therefore much higher than that used in the conventional IANB. This anesthetic solution then spreads downward due to gravity and enters the pterygomandibular space. A significant size of the nerve is also exposed to the anesthetic solution when compared to the conventional IANB. An added advantage of the GG technique is that it uses the upper second molar mesiopalatal cusp as a very reliable landmark during the delivery of anesthesia. However, the close proximity of the maxillary artery and pterygoid plexus of veins at the site of LA deposition requires due care to avoid iatrogenic injury that can lead to pain and hematoma.
The results of this study revealed that a positive aspiration rate was encountered in two patients with the GG technique, which was much lower than with the conventional IANB (seven patients). This can be attributed to the fact that the inferior alveolar vessels lie at a farther distance from the target area with the GG technique than with the conventional IANB. The major limitation with the GG technique is the time of onset of anesthesia, which is generally much longer than with the conventional IANB. The results of this study are in accordance with previous studies.,
The VA technique, similar to the GG technique, uses an anatomically higher position for anesthetic administration than the conventional IANB, thereby increasing the length of the nerve exposed to the anesthetic solution. The main benefit of the VA technique is that it can be employed in clinical scenarios with reduced mouth opening. The lack of an osseous contact end point during the administration of the LA is the limitation of this technique.
Despite their specific advantages and disadvantages, all these methods demonstrated contradictory outcomes. The published literature shows that the conventional IANB has a superior success rate over other techniques.,,,, However, a previous study reported that the success of the VA technique was comparable to that of the conventional IANB. In the current study, VA technique was considerably superior to either the GG technique or the conventional IANB with regard to the onset of action and the anesthetic success. Positive aspirations were encountered relatively more frequently with the conventional IANB technique.
A recent study advocated that the VA technique delivers the anticipated surgical anesthesia with a superior success rate and with a reduced occurrence of positive aspiration, and its use is therefore beneficial to oral and maxillofacial surgeons. Another study compared the efficacy and comfort of the IANB and the VA nerve block when administered by dental trainees and concluded that the VA is easier to perform, even by an inexperienced operator, and was more comfortable for patients compared to the conventional IANB. Therefore, based on the results of this study and the evidence available in the literature, the VA can be considered to represent an ideal replacement for the conventional IANB in clinical scenarios where the latter fails to achieve the desired pain control.
The conventional IANB technique is traditionally used to achieve anesthesia in the mandible for surgical interventions, rather than the VA and GG techniques, because the IANB is not technique sensitive like the VA nor does it require a longer time of onset of anesthesia like the GG technique. The anesthetic solution is also delivered at an anatomical region that is much more superficial than that accomplished by the VA and GG techniques. The present study had some limitations, including its small sample size, along with the failure to use the genuine clinical scenarios of trismus and the selection of only healthy individuals for conducting the study.
| Conclusion|| |
The results of this study suggest that the VA technique provided superior outcomes in the form of fewer positive aspirations and a rapid onset of action, in addition to attainment of better anesthesia. However, a notable finding was the lack of any statistically significant difference between the VA technique and conventional IANB. None of the techniques were associated with any key impediments. The GG was technique sensitive, with a notable variance concerning the time of onset of anesthesia and the anesthetic success of the VA versus GG technique.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]