all right Kathy well the time is finally here you're going to walk me through my first gal
gates and let me say before we get started that dr. Morrison who graduated from dental school
this year and had tuition costs I'm just going to guess of over $250,000 a quarter of a million
dollars and didn't learn the gal gates and as a dentist you know here you are at Pierce College
teaching the hygiene students how to do it and you and I as dental students didn't get to learn
how to do it so I'm going to make a demand of the ATA that they step in and do it anyway neither of
us I thought maybe just because I'm old let in right but she graduated this year still didn't
learn it so that's fine so she want to experience one and this will be good for both of us so how
do we get started what should we do first well first off is just you know switch our thinking
from the parallel to lose all table that we think of for the ia to finding what's going to be your
upward inclination so the area we're looking at is from the corner for mouth mm-hmm to her inner
trig notch okay and you know just hold the mirror up there and then just kind of imprint that angle
there and this is different on everybody are there are there people where it's yeah it's arguably
different you know I think they're generally you know it'll house you know a subtle inclination
but this will be specific to her because we're trying to orient her this is the one that is close
not open to start with yeah so just start there till you get that and then they still however go
ahead and open wide and see how much it changes it doesn't change much because you're still going to
her commissure hey okay so one things I find him really helpful is when I'm palpating is a lot she
put my finger right there the inner trachis notch and then as I pull back then I'm kind of lining my
finger up and giving myself you know that that orientation oh yeah yeah you're actually you're
actually kind of seeing that for for yourself now with the angulation of your finger yeah because
otherwise you know I'm used to lining up this brain is going to take me here where I standard
ia but I want my brain to go with me up here no I used to actually seem to recall that people
actually put their finger in the patient's ear to to do it as ad not really necessary I dream I like
it I can appreciate the feel that might help them you know have a sense of where the condom right
same way if you do a check but you can't push the cut you're not pushing the condyle for well
anything if she opens wide you you can feel the articulation you can feel it move so I you know I
know it's about here yeah then my next sort of you know imaginary thing is then when I turn her back
around okay I know where my finger is and it's it's going to be a mental image as if I am aiming
for my finger my finger now is right next to the condyle okay so here you know over here where I'm
moving my finger you know that's my target height right so we're my penetration I just you know let
my brain try to yeah it's kind of like on yeah it's kind of like just having a finger here and
then you're going to start over here and you can't see it so you have to turn your head and
then try to bring your two fingers together get it exact like a roadside sobriety test yeah yeah so
when I come in I want to choose the height of my penetration in respect to the mesial-lingual cusp
of the molar okay and I'm going to be distal to the second molar okay still I'm coming in over the
bicuspid scre penetration will be there opens wide as you can for me slightly up till inclination and
again as if I'm able to track towards my fingers palpating on her Conda any idea why you would use
the mesial-lingual of the first molar versus the second molar since you're back behind the
second molar is it has to do with how the height of the condyle okay because if I'm using a tooth
up higher I'm going to be you know higher if I'm using the tooth down lower so that gives me a line
with the height of the client vial okay so it's good coming out over here the one other thing that
sometimes been used to our advantage is if you look at the flare mm-hmm of her tragus right here
and hers is fairly smooth it just flares out just a little bit mm-hmm but if someone has you know
quite a bit of flare out that can have to do with how far out there Ramos Flair's so if they have a
very narrow gym then the trades may be tucked in we've got a fair amount of flair so that's going
to help me decide how far over in relationship to the bicuspids I'm going to be they're going to be
you know really wide flare then I might be back closer to the molar okay they're much narrower
profile than I maybe a little bit closer to ya is the wider the jaw is the condyle is going to
be positioned farther laterally and therefore more ya flare because of that and so you swing around
more towards the molars okay we get that again Amy and there's probably room to swing over to
the molars because of the fact that the mandible is a little wider versus somebody's got a very
narrow one huh all right sounds good well I guess I get to do a dry run with the topical
anesthetic right so I'm going to start from over the bicuspids on the opposite side and go to the
height of the mesial-lingual cusp of the first molar and then move distal to the second molar
and place the topical there how does that look to you Cathy for it that looks good injection point
good you know and that's a good example how it's not a steep angle up you know given how
far she can open yeah I'm looking at that angle it looks pretty close to the angle my
finger like you mentioned before so and it's subtle it's not drastic right here it's not
pointed at me my worth okay so as you mentioned it it doesn't since we're going to be doing the
twizzle that you refer to and we're going to keep everything nice and straight it really
doesn't matter it really doesn't matter where we put the bevel in essence in fact we're not
exactly sure where the bevel might end up anyway but it almost doesn't matter because
we're going to have it just tracking straight because of the twizz lien that we're doing and
that's going to be with all the things that we do the wand it's we're doing by
rotational and so by rotation I'm going to grab it a little farther back because it's
for a block and not for an infiltration okay how you doing right there right here yep I'm
good right there if you can can you see that okay yeah okay I'll pinch here on a Maria
just go ahead and start your twizzle whenever you're ready and just keep your focus on you
know where that location is near the condyle so typically on a gal gates like this how much
of the car pill cap will you take getting back there to your target site you know
you've got about eight seconds before this is going to automatically start into crews
and I find that that's adequate to get there and I guess is I'm anticipating you're going
to have contact here short right there I do okay see and that's that's about 3/4 mm-hmm
you know its traditional for an ia and aspirate at this point yeah correct and I'm here things
that are so positive there so you want me to come back out and let's do okay how far right
about here maybe do you feel you can clear that yeah what direction would you like me to clear
it in um go and do a second aspiration and see if we've got anything well I'm gonna have to
okay that looks clear go and go back to site with yeah I'm going just twizzle the Eklund
and advance again and then ask for it again at your site and if we're clear on that one
will continue yeah we are looks good and that's one of the nice things you know from this view
you can't see it but you're clear right from the attachment through the entire thing so if you have
you know any positive aspiration it's really easy to pick up on the lawn well I'm really happy I got
a positive aspiration on my first one ate with you here and B you know just to see how to you
know just a little nice refresher on how to handle it well while you're there and so typically then
for a gal gates once we're in here and expressing it at the normal speed we you do a full the rest
of the car filled air cartridge okay and then that's it just that one cartridge and then sale
that the conversation we have this more you know because that the you know the soft tissue space in
there is will accommodate more many people will just choose to do two cartridges which is super
because we would just do our switch out you'd hold your position we'd reload at the base of
the sta unit and then go ahead and deliver the second cartridge at this point with me back all
the way would you ever take your thumb and put it on the occlusal table to kind of remind the
patient to open a little bit at this point you sure can but if an I feel like if I make contact
like I am now that you know with her that she must be open enough if I'm if I'm contacting the bone
is that is that correct to think that way or not necessarily is I feel like I'm against that part
of the you know as long as it's not changing your needle depth if she started to close oh they're
gonna see my needle sink away from you then you'd really tell that the copper hell anyway
but that's not a bad technique to just gently remind the you know I also have to say that this
is literally the first time I've ever used a 25 gauge we were taught all 27 gauges in school and
so that's what I always used I really liked how it felt and I really liked what the contact felt
like we talked about in the interview that little mm-hmm that little kiss and that's kind of what it
felt like whereas with a 30 gauge I can see how it might not feel so definite like I just feels
like I have a definite tactile feel because of the larger gauge yeah in our experiences
patients really aren't able to tell the difference between the needle gauges and if it's just like a
logical for us right and being able to maintain some control in those denser tissues you know
there's some reasonable logic to that mm-hmm yeah I've seen those studies too where they can't tell
the difference between 25 and 27 so why would we do it for us if we can get more effective ones all
the patient cares about is being properly anesthetized also it's our own psychology
do you ever speed up at all in these injections are you very patient with these or maybe if you
saw a patient starting to close and having trouble okay I tend to stay with the normal
rate on these I know that there's a turbo but it's like you know if you think about injection
hydraulics and the smaller the gauge of the needle higher the pressure will be at the needle tip the
faster you expel the greater the pressure so if you just think about your garden hose you know
putting your finger over and creating the spray when you're washing your car right we speed up
these smaller gauges and we're putting on a lot of pressure right that needle tip and the whole
mechanism of paresthesia they don't know it's a combination of things and and certainly the
injection of hydraulics has been discussed and looked at and can be part of that whole
mechanism so I think if we can control any of those factors why wouldn't we right all right
there we go that should make a drum tells you though guess you don't need to buy rotational
in the way out but it was it was fun to do and to practice it again Wow now if you would I remember
from you telling me this morning that we want the patient open for two minutes so I'm going
to make it easy for you there you go just relax against that Oh perfect and I will start the clock
for two minutes and we'll see if we have any anesthesia by the time that two minutes comes
with that all right it's been two minutes I'm going to go ahead and remove that you can go
ahead and close on a Maria actually it's been a little more than two minutes let me ask you and
I want you to be perfectly honest unless that's an answer I don't want to hear are you starting
to get upper and lower upper and lower Kathy what does that mean was I in the wrong spot if
she's upper remember that the maxillary branch of the trigeminal nerve is going anterior about the
same point that the mandibular branch is dropping down so we're up that height we can definitely get
collateral anesthesia people will often have their regular temporal nerve also anesthetized so not at
all uncommon to have the ear feel some numbness - alright thank you that was awesome thank you
you