[Sacamuelas]

The next teeth that need to be taken out are the canine/lateral & central incisors. These teeth are generally the easiest and least complicated extractions that you will face in the upper arch.

Things to note:

1. You can use a similar technique of anesthesia concerning local infiltration over the apex of the roots on the buccal mucosa. This will anesthetize the teeth and outside gingiva.
   
2. You will need to use a different palatal gingiva anesthesia technique on these three teeth however. These three teeth are innervated on the palatal gingiva by a nerve (nasopalantine nerve) that runs through the incisal foramen. This canal (incisive canal) is also labeled on the already posted/attached pic above on palatal bony anatomy.
   
3. The easy way to find this opening clinically is to locate the soft tissue "hump" immediately behind the central incisors on the palate. This marks the location of the incisive foramen and sphenopalatine artery/nasopalantine nerve that run through it.
   
4. The palatal injection is given with the following technique for maximum comfort during the process.

1. Technique for anterior palatal anesthesia
   
2. Use a cotton tipped applicator/or mirror handle to apply FIRM pressure on the actual hump just behind the centrals. Hold this pressure firm enough to cause blanching of the tissue in the area.
3. After approx. 10 seconds, inform the patient that you will now give them a quick pinch. While still holding pressure, insert the needle right beside your instrument applying the pressure. Do this quick and with intention as the tissue in this area is thickly epithelium and requires a little force to penetrate.
4. Now, release the pressure from the instrument and VERY slowly begin placing anesthetic into the area. I do this with a short burst type technique as the tissue is firm/tight and requires a lot of pressure on the plunger to get anesthesia to flow. The slow pumping then relaxing allows time for the anesthetic to begin working on the tissues as it expands out away from the needle. This vastly decreases the sensitivity to this injection.
   
   BTW- It really hurts if you just pump it in fast. It is by far the most sensitive injection to give when performing Sacamuelas activities.
5. FWIW, don't waste your time using topical on the palatal injections, as it does not work. The keratinized gingiva on the palate will not allow it to soak in like it will on the outside (buccal) mucosa. Use the pressure technique to cause slight local anesthesia properties from the ischemia produced from the pressure.

Back to a few things to note about these particular teeth:

1. These three teeth are single rooted and conical in root shape. This allows for an extraction technique that involves slow rotational force to be put on the teeth while placing firm upward force with the forceps. Take your time and they will generally come out with no problems.
   
2. Before forceps, use the same elevating techniques and gingival separation as described for the other maxillary teeth. Remember, a little time spent loosening the teeth (elevating and luxating) will save you a LOT of time chasing after root tips and fragments.
   
3. The maxillary canine has the longest root in the mouth. It also tends to be difficult to extract not because of root shape but because of the bony anatomy of the maxilla. If you feel with your finger on the outside of your lip that covers your upper canine's root you will feel a prominence or boney lump. This is an extra cortical bone thickness(canine prominence) that covers the canine root for added strength. It was nature's way to provide for chewing/tearing/shreading of meat back when we were cavemen and not loosing out canine teeth due to the forces.
   For this reason, when extracting on a patient like in NDD's example, I will take out the lateral incisor before attempting to take out the canine. The reason I do this is to create a hole/opening in the bone next to the canine so that I can luxate the canine towards/into this hole to help loosen it before I try to extract it with forceps. That extra cortical bone definetly makes an extraction of that tooth more difficult, and this technique allows you to luxate the canine in a direction away from that extra boney support on the outside.
   
4. A special helpful thing to remember when taking out all of an indig. patient’s dentition as in NDD's example pic:
   
   You can use the adjacent teeth themselves as a fulcrum to lever against each other with your elevator when you are taking out all the teeth in an area. You do this with your elevators (large straight) and it will really luxate them quickly. You can NOT use this technique if you are not removing the tooth that you are using as the fulcrum of the lever as it WILL loosen that tooth as well and put unhealthy forces on its support.