The Vazirani-Akinosi closed mouth mandibular block is a useful technique for patients with limited opening due trismus or ankylosis of the temporomandibular joint. A 25 gauge long needle is recommended for this technique. The right handed operator should be in the eight o'clock position whereas the left handed operator should be in the four o'clock position. The gingival margin above the maxillary 2nd and 3rd molars and the pterygomandibular raphae serve as landmarks for this technique. The patient should close gently on the posterior teeth. The needle is held parallel to the occlusal plane at the level of the gingival margin of the maxillary 2nd and 3rd molars. The bevel is directed away from the bone facing the midline. The needle is advanced through the mucous membrane and buccinator muscle to enter the pterygomandibular space. The needle is inserted to approximately one half to three quarters of its length. At this point the needle will be in the midsection of the ptyerygomandibular space. . Nerves anesthetized are the lingual and long buccal nerves in addition to the inferior alveolar nerve.
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