Technique for Almost Painless Palatal Anesthesia

As stated previously, some clinicians (Sebastian Baumgaertel) claim that a palatal miniscrew can be inserted with a strong topical anesthetic only.  While I think that is probably true, the one time I tried it I could tell that the patient felt something.  Obviously, I don't want that to happen on a regular basis so I combine a strong topical with local anesthetic using an ultra small needle.

In the next blog post, I will talk about the verbal skills needed to compliment this technique.

Depending on your state law, the initial part of this technique can be delegated.  Either in my treatment plan or my "Next Time Notes," I will make an entry like "Two palatal TADs, 3rd rugae."  This let's my orthodontic technician know where to place the topical.  We also review all TAD insertions at morning huddle.

So after the technician seats the patient and obtains a blood pressure and pulse reading, they then evaluate the situation and confirm that the "Next Time" notes are correct and we will be placing a TAD or two today.  The technician explains the procedure to the patient and tries to assess the patient's anxiety level.

The technician dries the palatal mucosa with gauze and uses a Q-tip to place the Profound* gel over the area of the 3rd rugae.  It is covered with several layers of gauze which the patient is instructed to hold in place for 5 minutes.  It is then rinsed off and the technician will signal me that we are good to go to do the local anesthesia.  Typically, the time between initial application of the Profound gel and the actual insertion of local is 8 minutes so usually the tissue is pretty numb at that point.

I'll then explain again to the patient what to expect (more next time) and mark the tissue area with an intra-oral marker.

I will then insert the needle into that area.  I usually bend the needle 45 degrees if I the insertion site is left of the midline and 90 degrees if right of the midline.  The tissue is thin in this area so go slow to avoid impinging on the periosteum and causing pain.

I keep injecting very slowly until I've accomplished three clicks of the syringe.  That is a total amount of anesthesia of 0.18 ml or 10% of a 1.8 ml carpule.  You will notice a blanching of the tissues.  I'll then immediately check the level of anesthesia with a perio probe by making a hole in the tissue in each area.  I'll explain to the patient that what they just felt was me making two holes (one of each side) in their gums.  They are always amazed that they felt nothing.  You always can start inserting the screw immediately after finishing injecting.

I use a Rocky Mountain Orthonia electric torque driver to insert the TAD.  It is set at 30 RPM and 30 NCm of torque.  To the best of my knowledge, it will accept the contra angle driver from all TAD manufacturers.

I'll place it in the proper area and make sure the angle of the driver is correct and then place my finger on top of the head of the driver to create some downward pressure to help the screw penetrate the bone initially.  Then I'll remove my finger after the screw is about 50% in.  Repeat on the other side if appropriate.





Most TAD systems have impression caps that are placed over the TADs at this point prior to taking an impression (see below).










To capture the most precise impression possible, I combine alginate with impression compound (brown).  The impression compound gives a very rigid impression to help stabilize the impression caps without any float.

 You soften the end of a stick of brown impression compound until it slumps and then immerse in water.  Mold it with your gloved fingers into a thick wafer, reflame it to soften the tissue surface and blow some water on it to cool it.  Then place it in the mouth adapting it to the screws.  Spray it with air to harden it.  Take a routine alginate impression.  When you remove the impression tray, the compound and the impression caps will usually come out with the alginate.

Take it to the lab and insert analogs into the caps.  Pour in yellow stone.

If there is any doubt about the stability of the compound or the impression caps, I will stabilize them with cyanoacrylate.

Addendum:  Three days after I posted this, I did two palatal screws on a dental assistant from my dentist's office.  She was pretty anxious about the idea of palatal anesthesia.  After I was done, she stated that it was really nothing to it at all.  Certainly, no more uncomfortable than buccal infiltration.  She was really amazed.


*
http://www.woodlandhillspharmacy.com/profound_gel.html

Palatal Anesthesia Is Not The Big Bad Wolf of TAD Placement!!!

I bet you that many orthodontic residents decided to pursue the specialty of orthodontics because they had hoped to avoid all those nasty dental things like local anesthesia.  Unfortunately for them, since the advent of TADs, local anesthesia is a necessary skill in the orthodontic armamentarium.  And now, to make matters worse, we have all the miniscrew gurus saying that the best location in which to place a TAD is to insert it into the anterior palate where the bone density is ideal for TAD retention.  Oh no!  Not only is this local anesthesia but it is in an area where most dentists fear to tread.  Kind of like a double whammy.

I was lucky when I went through the orthodontic program at Tufts.  I had the chance of working as a general dentist Tuesday and Thursday evenings and all day Saturdays.  This was in a private fee for service practice where virtually every patient was an adult already treatment planned for restorative and they all were treated with local anesthesia.  I became very comfortable with the concept so it was easy to transfer those skills to the use of miniscrews.

I think the first key to doing palatal anesthesia in a patient friendly manner is to use the smallest needle available which is not a 30 gauge as most think but a 33 gauge ultra short.  A 33 gauge needle is approximately 30% smaller in diameter than a 30 gauge.  That is a big difference.

The second key is to use a strong topical anesthetic.  Some people claim that a strong topical is enough to allow you to insert a miniscrew without even local anesthetic.  I am unwilling to be that brave, nonetheless, I figure, if that is true, I can use that kind of strong topical to prior to local anesthetic.




The third key is to realize that because of the extremely small diameter of the 33 gauge needle, there will be a fair amount of back pressure so instead of using a standard syringe, you will need to use a intraligamentary syringe.  These typically have a lever arm and not a plunger.  Also,  the syringe looks more like a pen and I think that helps relax the patient.
I like the one from Septodont called a Paroject syringe.  It has a lever arm to dispense the solution.  It takes 30 activations of the lever arm to empty a 1.8 ml syringe and only 2 or 3 activations for adequate anesthesia to insert a palatal miniscrew.

Next time: Technique