THE GOW-GATES BLOCK

The mandibular block is perhaps the most commonl deli!ered ma"or ner!e
block in"ection in all o# dentistr$ E!er dentist is an e%pert in administration
o# mandibular blocks since &e ha!e all deli!ered thousands o# them$ On the
other hand' &e ha!e all run into patients #or &hom &e could not produce the
desired anesthesia usin( the standard techni)ue$ *t happens rarel' but
&hen it does' it is !er' !er #rustratin($
+ortunatel' an Australian dentist named ,r$ Geor(e A$E$ Go&-Gates
in!ented an alternati!e to the standard mandibular block in the mid -./01s$
This block is appropriatel named the Go&-Gates and is deli!ered at the neck
o# the condle "ust under the insertion o# the lateral pter(oid muscle$ The
Go&-Gates has a number o# ad!anta(es o!er it1s more traditional alternati!e$
2nlike the mandibular block' the path the needle tra!erses durin( a
Go& Gates block contains much less muscle tissue than is tra!ersed b
the needle in a standard mandibular block' and thus there is little
release o# bradkinins &hich are the chemicals &hich cause the achin(
that patients #eel &hen recei!in( a mandibular block$ +urthermore' the
tissue throu(h &hich the needle passes contains no ner!e receptors'
and thus there is little direct pain durin( the in"ection$ *t is not
uncommon #or patients to remark that the #elt nothin( durin( the
in"ection$
The area &here the Go&-Gates is deli!ered is less !asculari3ed than
the area ad"acent to the location o# in"ection in a standard mandibular
block$ Studies indicate that there is an 4.-.05 lo&er likelihood o#
(i!in( an intra-!ascular in"ection usin( this techni)ue$ *n addition'
because o# the lo&er !asculari3ation in the area' the anesthesia is less
rapidl absorbed into ad"acent blood !essels prolon(in( the presence
o# the anesthesia in the area' &hich means that mepi!icaine &ithout
!asoconstrictor ma be used to (reater and lon(er lastin( e6ect usin(
the Go&-Gates$ Some users o# this techni)ue recommend that no
!asoconstrictor be used at all$
+inall' the Go&-Gates anestheti3es the ner!e trunk be#ore it splits into
its three main branches7 the lin(ual branch' the buccal branch and the
al!eolar branch$ Thus the Go& Gates deli!ers three shots in one$ A
sin(le shot does the &ork o# three separate in"ections$
The Tar(et
The ima(e abo!e sho&s the medial aspect o# the ri(ht condle and the
relati!e position o# the ner!e trunk$ The shaded o!al indicates the area o#
the condle &here the tip o# the needle should be placed$ 8ote the pro%imit
o# the ner!e trunk &ith respect to the (eneral tar(et$
The E%ternal Landmarks

*n the ima(e o# the ear abo!e' the little prominence in the #ront is called the
tra(us$ The tra(us is a use#ul landmark since it lies "ust distal to the
temporomandibular "oint$ The little notch "ust belo& it is called the
intertra(al notch$ Both o# these landmarks are easil identi9ed' and' more
importantl #elt &ith the 9n(er$ The intertra(al notch is the landmark that is
used as the :aimin( point: o# the needle &hen (i!in( the Go&-Gates
in"ection$
This intra-oral ima(e sho&s the entr point o# the needle$ The patient1s
mouth must be W*,E open so that the condle is #ull translated o!er the
articular eminence$ The entr point o# the needle is hi(h and about a )uarter
inch distal to the distal palatal cusp o# the second molar$
The techni)ue
With the patient lin( #ull reclined in the chair' ha!e the patient open
his;her mouth as &ide as possible$ This techni)ue is not possible i# the
patient is not able to open &ide enou(h to allo& the condles to
translate #ull o!er the articular eminences$
<lace our thumb in the patient1s mouth retractin( the cheek$ The
thumb should be relati!el close to the site o# the entr point o# the
needle noted in the image abo!e$
<lace the middle 9n(er o# the same hand o!er the intertra(al notch$
This landmark is easil #elt &ith the 9n(er$ Thus the hand is held in a
:C: &ith the thumb inside the mouth retractin( the cheek and the
middle 9n(er outside the mouth placed 9rml o!er the intertra(al
notch$
2sin( a lon( =/ (au(e needle' and holdin( the handle o# the srin(e
at about the le!el o# the lo&er premolars' allo& the needle to enter the
buccal mucosa "ust distal and apical to the tuberosit$ >See the arro&
in the intra-oral image abo!e$?
Now aim the tip of the needle toward the the intertragal
notch. This is fairly easy because you can feel the notch under
your middle fnger, so in efect, you are simply aiming for your
fnger! Keepin( the middle 9n(er in this position' and usin( it as the
aimin( point makes (i!in( the Go&-Gates block eas and predictable$
<roceed until the needle hits bone$ The needle &ill enter about t&o-
thirds to three-)uarters o# its len(th be#ore hittin( bone$ *# the needle
does not hit bone' then ou ha!e missed the tar(et and should
&ithdra& and tr a(ain' aimin( sli(htl laterall' or mediall$ *t should
be noted that this techni)ue seems to produce !er #e& misses$ *n an
case' multiple tries do not lead to post operati!e pain since the needle
has penetrated little or no muscle$ Once ou become #amilliar &ith
the techni)ue' missin( the tar(et becomes a rare e!ent$
Once the needle hits bone' aspirate and then in"ect the entire carpule
slo&l$
A#ter &ithdra&in( the needle' ask the patient to remain open &ide #or
about one minute a#ter the shot$