LOCAL ANAESTHESIA & EXODONTIA OSCE PREP
Introduce yourself & Gain consent – “Hi good afternoon My name is Victoria Medford and I
am a 3rd year dental student. Are you Mr Charlie? Nice to meet you, today you are here to
remove your _____ tooth – is that correct? Good, do you agree to receiving anaesthetic?
Okay great I am going to now prepare you to receive the anaesthetic and once the area is
numb I will proceed to remove the tooth.”
LA Equipment
Syringe, cartridge, needle, topical anaesthetic, applicator stick, gauze.
Needle – larger gauge = smaller internal diameter; usual gauges in dentistry: 25, 27, 30
Length;
Long (~32-40mm) for NERVE BLOCKS
Short (~20-25mm) for infiltrations
Extra Short (~15mm) for LA w/in the PDL
Larger gauge needles tend not to deflect or break
Speed of injection - ~1ml/s & for blocks 2ml/s (SLOW DEPOSITION)
1. introduce yourself & gain consent
2. organize equipment
3. Adjust the patient position - 45 on the chair- SEMI HORIZONTAL – HORIZONTAL
POSITION ON THE CHAIR
DENTIST AT 9 – 10 O’CLOCK POSITION
4. Adjust light and bring bracket table closer
5. Dry the soft tissue at the site of injection prior to topical anaes. application; as saliva
would dilute the ta & its effects
6. Retract tissues using mirror / tissue retractor
7. Apply topical anaesthetic to the site of needle penetration for 2-4 mintues (2-3mm tissue
depth) [benzocaine/ lidocaine]
“I’m using this topical anaesthetic to make it more comfortable for you”
8. Make tissues taut – stretch the tissues
9. Insert needle, aspirate
10. deliver anaesthetic
11. recap needle using one hand technique
12. remove anaesthetic cartridge - remove needle & dispose of both in a sharps container
13. Observe patient & test for anaesthesia
14. Once successfully anaesthetized proceed with tx
INFILTRATION TECH.
Mainly used in the maxilla but can be used in the mandible for deciduous dentition – needle
is inserted into the depth of the buccal sulcus
Submucosal infil. long buccal nerve
Supra-periosteal maxillary infil. Conventional tech.
o 1st & 2nd premolars – 1st molar (dense buccal bone infl. x2 in less porous sites)
o pull tissues taut - Needle is positioned parallel to long axis of the tooth with
the bevel toward the apex & inserted at the depth of the buccal sulcus until
bone is contacted, at which point the needle is be withdrawn slightly –
aspirate – deposit anaes
o 1ml
o 45 min duration
Sub periosteal palatal infil.
o Is painful – warn patient
o Insert needle at 90 to palate – avoid injecting into palatine foramen
o A few drops
Intraligamentary 30 bevel to long axis of tooth – needle wedge btwn tooth & Supplement
crestal bone single tooth procedures - discomfort (numbness of tongue, lips- ary Tech.
self trauma) – localized aids diagnosis bitter taste (leakage of anaes.- good
suction is essential) – risk of shattering cartridge due to forces applied – post inject.
Pain lasts for a few days – tooth extrusion – avoid if there is gingival infection, plaque
calculus (debridement necessary) – long rooted teeth (canine etc)
o Children, endo, perio
o 27 gauge short needle –
o needle is inserted along the long axis of tooth in the gingival sulcus bevel of
needle is toward the root – advance needle apically until resistance is met
o 1/8th of cartridge/0.2ml per root
o onset 30s – duration 45-55mins
REGIONAL BLOCKS – punctures, drug used, duration, safety (less risk of developing
toxicity
Anaesthesia of deciduous teeth – 1 ml of solution – infiltration & intraligamentary techs –
do not misjudge root lengths; shorter!
MAXILLA –
Posterior Superior Alveolar - maxillary molar teeth, associated bone and buccal gingivae
o Max molars
o Distal to the malar process - 45 to md plane & bl plane - depositing solution high
in the buccal sulcus in the plane of the distal surface of the maxillary second
molar tooth - Distal to the malar process - 45° to md plane & bl plane The needle
is advanced to a depth of 15-16mm
o 2.0ml is deposited
In those individuals with a middle superior alveolar nerve the first molar
will not be satisfactorily anesthetized with this method as the mesio-
buccal root of this tooth is supplied by that nerve Maxillary molar
nerve block - patient mouth half closed - operator’s finger palpates the
zygomatic process of the maxilla intraorally and advances the finger
posteriorly towards the maxillary tuberosity. The needle penetrates
mucosa high in the buccal sulcus between the finger and the distal
surface of the zygomatic process and advanced about 10mm into the
space above the buccinator attachment – 2ml dep- maintain finger
pressure – close mouth after injection & massage swelling above
buccinator in a sup med + dist dirctn twd post sup alveolar foramen
Nasopalatine – soft tissues on palatal aspect k9-k9 & premaxilla
o Crown preps & surgical tx
o 25 gauge short (20 mm) needle
o mouth open- position needle point adjacent to the incisive papilla
o 0.2–0.5mL of solution – 1cm-1/4 of the cartridge
Greater Palatine -anaesthetizes ½ the maxilla – bend needle & carefully insert the entire
length of the needle into pterygopalatine fossa via the greater palatine foramen wh lies
1 cm sup to 2nd + 3rd molar & 0.5 cm ant to pterygoid hamulus mouth open wide and
the greater palatine foramen is identified as a depression medial to the distal surface of
the second maxillary molar tooth. The needle is inserted into the greater palatine
foramen and advanced at an angle of 45° superiorly and posteriorly to a depth of 30mm.
o 2.0mL of solution is deposited. – 1 to ½ cartridge
o onset 2-3mins
if patient has small maxilla anaesthetic fluid may reach the parasym
sphenopalatine ganglion = diplopia
Infraorbital – true ant sup alveolar nerve (ASA) block – numerous extractions in incisor &
canine region – to avoid infiltration anaes around sites of infection – skin of cheek, upper
lip, lat aspect of nose and ipsilateral max front teeth – Tx & surgery
o 25 gauge long (25-35mm) needle
o Lift lip w thumb & index finger + palpate the infraorbital foramen
o Intraoral tech -
Method 1: insert needle into the buccal sulcus ~1cm from the alveolar
process of the max canine – directed toward the pupil of the eye
Method 2: Insert needle 1.5-2cm deep parallel to 2nd premolar; keeping it
close to the periosteum in the dirxn of the longitudinal axis of the tooth
o 1/2 cartridge - 1–1.5mL of solution is deposited following aspiration
o Extraoral tech – prep skin, palpate, inject at foramen not into the canal.
MANDIBLE
Pterygomandibular space – contains Inf. Alveolar + lingual nerve- boundaries; ant -ptgm
raphe, buccinator + sup constrictor fibres – post – parotid gland w facial nerve passing
through it – laterally – inner surf of asc ramus – floor medial pterygoid m.
Inferior Alveolar; anaesthetize; Long Buccal & Lingual
o 25 /27 gauge long (35mm) needle
o Pat head parallel to floor w mouth open
o Dent; right anaes – infront pat; left anaes – behind pat
o mouth open wide, visually identify ptgm raphe and the operator places the
thumb of the non-syringe hand in the mouth to palpate external oblique
ridge, rolling it slowly into the retromolar fossa - the coronoid notch of the
mandible; the index finger is extraoral at the same height on the posterior
border of the ramus. The syringe is advanced to the point of needle
penetration with the barrel of the syringe parallel to the occlusal plane of the
lower 2nd premolar teeth of the opposite side. The point of penetration of the
needle is between the internal oblique ridge of the mandible (which was
palpated by the operator’s thumb before resting on the coronoid notch) and
the pterygomandibular raphe (which is visible). The height of needle
penetration is halfway up the operator’s thumb nail wh corresponds to the
deepest part of the coronoid notch. At 0.5 cm within tissues aspirate inject a
few drops of anaes to anaesth the lingual nerve. Advance needle until bone is
contacted ~ 25mm or 1.5 – 2cm. Aspirate.
o 1.5-2.0ml - 1 carpule
o Onset – 3-4mins --- 45min duration (up to 8 hrs w long acting solutions
In the elderly point of insertion is usually higher due to resorption
Remember divergence & flare of asc ramus
Usually no more than 2cm – never insert the needle all the way up
to the hub!
Other Inf Alvrolar tech –
Gow Gates - The syringe is advanced in a plane parallel to a line visualized between the
corner of the mouth and the intertragal notch. The syringe, fitted with a long needle, is
introduced into the mouth across the maxillary canine tooth of the opposite side to that being
injected and advanced across the palatal cusps of the maxillary second molar on the side to be
injected
Akinosi-Vazirani – pat mouth closed (helpful in pats w trismus & uncooperative kids) - no
bony end point – 27 gauge long needle The syringe is introduced intraorally in the buccal
sulcus along a plane level with the mucogingival junction of the maxillary mucosa. It is
advanced at this level towards the posterior aspect of the maxilla until the hub of the needle is
adjacent to the distal surface of the maxillary second molar. – 2ml dep
Long Buccal - mucobuccal fold – direct infiltration
o 0.3-0.5 ml – ¼ carpule
Mental nerve – estimated location; supra/infra orbital line – usually between the
apices of the mand premolars
premolars – anteriors up to midline
o 25 guage short needle
o 0.6ml – ½ carpule
o 2-3min onset
Infiltration Of Lower Anteriors - infiltration in the labial and lingual sulcus
o 0.6-0.9 – ½ carpule
ANAESTHESIA FOR EXTRACTION OF;
MAXILLARY INCISORS & CANINES
o Regional Block anaesthesia – INFRAORBITAL NERVE BLOCK & NASOPALATINE
NERVE BLOCK
o Buccal & interdental/Palatine supra periosteal infiltration
MAXILLARY PREMOLARS
o GREATER PALATINE NERVE BLOCK & NASOPALATINE NERVE BLOCK [generally
discouraged as it reqs 2 injections gp foramen & incisive papilla]
o Buccal 1ml & Palatal 0.25ml infiltration – much higher than the apices
MAXILLARY MOLARS
o POSTERIOR SUPERIOR ALVEOLAR NERVE BLOCK & GREATER PALATINE NERVE
BLOCK
o Buccal supra periosteal infiltration anaesthesia (1-1.5 ml)
MANDIBULAR INCISORS & CANINES
o Buccal & Lingual infiltration – needle inserted more caudally to the apex
o Take into account sensory anastomoses – anaesthetize contralateral side as well
MANDIBULAR PREMOLARS
o MANDIBULAR BLOCK ANAESTHESA OF INFERIOR ALVEOLAR NERVE & LINGUAL
NERVE
o Supplemented in infiltration of the long buccal nerve
o Mental nerve may also be anaesthetized – superficially to avoid damage to the
nerve
MANDIBULAR MOLARS
o MANDIBULAR BLOCK ANAESTHESIA OF INFERIOR ALVEOLAR NERVE & LINGUAL
NERVE
o Supplemented by block or infiltration anaesthesia of the long buccal nerve
Testing for LA
Ask patient if they experience any in sensation (depends on area anaesthetized).
“Could you show me where it is tingling or were it feels numb? Does it have the
same feeling as this (unanaesthetised) side? If I touch here does it feel the same as
here?”
Patient response to tooth percussion
Use a sharp instrument to test response of gingival surrounding tooth – test at diff
pts. Both buccally and palatally/lingually.
EXODONTIA
“You will not feel pain, but you will feel the pressure that I’m going to apply to remove the
tooth okay”
1. Identify tooth/ teeth to be removed. Gain consent.
2. Set up equip – periosteal elevator & coupland’s elevator – forcep of choice – root tip pick
– bone file – curette – suction
3. Test anaesthesia
4. separate periosteum from bone + detach gingival tissues – PERIOSTEAL ELEVATORS
5. Dilate the socket + luxate the tooth with the coupland’s elevators 123
6. engage tooth with FORCEPS
7. Slow Bucco-lingual/palatal movement followed by rotational movement (for single rooted
teeth) OR figure of 8 movement (for multirooted teeth)
8. Displace tooth buccally
9. Examine roots
10. remove debris from socket using suction or curette
11. Compress socket by applying pressure buccopalatally/buccolingually
12. Apply cotton gauze over extraction site and ask patient to bite down for 30 mins apply
pressure achieve homeostasis and control haemorrhage
13. Give post op instructions
14. replace cotton w a new one and send patient home.
ARMAMENTARIUM
Surgical suction, mouth prop (stabilize the jaw) – mouth prop is placed on the
opposite side – flat surface twd teeth
Periosteal elevators – detach the periosteum from bone following an incision or to
detach the gingival tissues from around the neck of the tooth– No 9 Molt’s elevator
Periosteal retractors, curettes, rongeurs (pliers) – removing + scraping out bone
Surgical curette – remove debris
Bone file – smoothing the bone – remove sharp bits of bone after removal of tooth
Drill for removing bone (not included in osce)
Dental elevator – surrounding alveolar bone = fulcrum for the action of the elevator
[ do not use adjacent tooth as fulcrum] –
o Cryer’s Elevators [left & right] – remove roots of multirooted mandibular
teeth via counter-clockwise rotation
o Coupland Elevators [1-2-3] –palm grip+finger support- mesial aspect of the
tooth btwn alveolar bone & root – rotate in a clockwise-counter-clockwise
direction dilate socket & luxate tooth
o Warwick-James Elevators [ left, right, straight]
Root tip picks – removed fractured root tips
Dental forceps – inline forceps; handle is in line w dental arch – Cowhorn forceps
-ash forceps; handle comes out at 90 to the arch (mandibular teeth)
MANDIBULAR EXODONTIA
PATIENT POSITION
Chair = waist height – pat head near elbows
Occlusal plane near parallel to floor
Position Light & Bracket table
FORCEPS
#73 FORCEPS – lower molars – engage the furcation of a 2 rooted molar
#74 FORCEPS – lower molar roots – close beak
COW HORN FORCEPS – lower molars – engage furcation
#151 FORCEP – UNIVERSAL – typically for lower premolars
MOVEMENT
Single rooted tooth – apical pressure, buccal/lingual movement & rotational movement
Multi-rooted tooth – Position the lingual side of the forcep 1st – and then close on the the
buccal side – finger pressure = apical pressure followed by buccal – lingual movement and
then figure of 8 movement – dilates the socket deliver tooth buccally
Soft tissue retraction left hand thumb (lingual) + forefinger (buccal) retract soft tissues -
remaining fingers support the jaw
MAXILLARY EXODONTIA
PATEINT POSITION
Chair - 30 position
Upper jaw inline w elbow
OPERATOR – standing infront of patient
MAXILLARY FORCEPS
#1 FORCEP [MD1]– anterior max teeth
18L & 18R – upper molar forceps [3 roots; 2 on the buccal aspect, 1 on the palatal
aspect]
#150 – upper premolars (can be used on the rt or lt side of the upper jaw)
Bayonette [650– upper root forcep, incisors & fragments
MOVEMENT
Apply apical pressure with slow bucco-palatal movements followed by figure of 8 movement
-deliver tooth buccally
Soft tissue retraction – left hand thumb retract buccal tissues – cheek – forefinger on palatal
aspect – remaining fingers extra orally stabilize the jaw
Thumb also acts as a finger stop
RADIOLOGY OSCE PREP
