Clinical and surgical techniques
Simrit Malhi, Angus C Cameron and Rebecca Eggers
Extraction of teeth in children
The removal of teeth in children can be one of the most stressful procedures for both the operator and patient. While a tooth may be totally anaesthetized, the pressure felt during the extraction can be extremely upsetting and uncomfortable. As one of the most important aspects of clinical practice, dentists need to be skilled, efficient and sensitive in the removal of teeth in children. Teeth should be removed gently with good surgical technique rather than excessive force that may fracture roots or upset the patient.
General principles of tooth extraction in children
• If the child will be unable to cope with the extraction(s) then sedation or general anaesthesia should be considered. Ideally, the decision to sedate a child should be made at the assessment appointment NOT once the child has become upset during the procedure.
• Children tolerate the use of luxators or elevators much better than application of forceps. The alveolar bone in children is soft and teeth can be elevated easily to a high degree of mobility prior to a final delivery with forceps.
Figure 8.2 Extraction of primary anterior teeth. (A) The alveolus is supported and the upper lip retracted. (B) The beaks of the forceps engage the tooth root, not the crown. Notice the blanching of the attached gingiva. (C,D) The tooth should be delivered with a rotation movement and with minimal apical force that might damage the permanent tooth germ.
• The removal of premolars is usually required for orthodontic reasons and may be the first dental intervention for some children. Extraction of the upper first premolar should be addressed with great care as the root apices may be fine and easily fractured. Surgical removal of a retained root fragment usually involves loss of bone, and will have implications for orthodontic treatment and the ability to move adjacent teeth into this space.
Figure 8.3 (A) When extracting primary posterior teeth it is useful to free the gingiva from the tooth with a flat plastic or a similar blunt instrument to protect it from tearing. (B) Avoid excessive buccal movement that will damage the thin, buccal, cortical plate and the attached gingiva when delivering these teeth.
• Second primary molars are often difficult to remove due to the divergent spread of the roots. Sectioning the tooth vertically can facilitate extraction if the crown is considerably damaged or the roots encircle the crown of the underlying permanent tooth.
• Multi-rooted permanent teeth can be extracted by using alternating, slow, buccal and palatal/lingual force or a ‘figure of 8’ motion in order to expand the alveolar bone. While many oral surgery texts recommend the buccal delivery of lower molars, the most dense bone is found on the buccal aspect and excessive movement of a lower permanent molar buccally may result in root fracture, particularly in teeth missing significant amounts of coronal structure.
Figure 8.4 (A) Luxators are delicate and sharp instruments, designed to shear the periodontal attachment and enlarge the tooth socket. The application of the luxator should be vertical along the long axis of the roots. (B) Elevators should be used similarly to a screwdriver, so their application on the tooth root is more horizontal between the embrasure. (C) The index finger should run along the blade and serves to protect the patient if the instrument slips.
Figure 8.5 (A) ‘Cowhorn’ pattern forceps engage the bifurcation of a molar tooth (B). (C) As pressure is applied, the beaks are worked further apically and the tooth will rise out of the socket, usually with minimal rotation or buccal movements. These forceps are very useful for badly broken-down molars. While fractures of the crown may occur, the level of the fracture is more coronal and tends to section the tooth, allowing easy delivery of the roots with an elevator. Note the finger support of either side of the alveolus. (D) The beaks of the forceps engage the furcation.
Avoiding and managing root fractures
• Always assess where a permanent tooth germ is positioned prior to elevating roots of primary teeth. If a root is fractured when extracting an ankylosed primary molar, this can usually be left in situ, especially if it is below the interseptal bone.
• Cryer elevators are used to remove interseptal bone between mandibular permanent molar roots to gain access to the roots. Care is required during removal of interseptal bone surrounding primary molar roots so as to avoid damage to the permanent successor.
• If it appears impossible to deliver a tooth without a root fracture, then the procedure should be performed as a surgical removal. Ideally this assessment should be made prior to starting the procedure.
Following the extraction
Postoperative instructions following extractions for children
Always give clear and lucid instructions to the child and caregiver:
• The next day, the mouth may be gently rinsed with water. There is little evidence that warm saline or antiseptic mouthwashes are of any real benefit following tooth extraction in children, but good oral hygiene is essential and gentle toothbrushing can start the day after the extraction. Parents should be advised that halitosis often occurs following extraction or oral surgery.
Repair and suturing of soft tissue injuries
Generally, soft tissue wounds should be closed within 24 h. Good closure of wounds allows for more rapid healing by primary intention. Suturing may reduce the sequestration of displaced bony fragments and may prevent bacterial contamination of the gingival sulcus. Furthermore, there is much less pain from the wound if exposed bony defects are well covered with periosteum and gingival tissues. Deeper lacerations of the lip will involve the muscle layer and it is important to close this as a separate layer to prevent formation of a ‘dead space’ will easily become infected (Figure 8.6). It is essential that the wound is properly debrided and free of contamination from foreign bodies or bony spicules prior to apposition of tissues. Any wound involving skin, including those crossing the vermillion border of the lip, require precise and expert skill to facilitate the best possible result. Often, this requires timely referral to an appropriate surgeon.
Figure 8.6 (A) When closing any wound, it is essential not to leave a dead space. This laceration to the upper lip was closed only superficially, leaving the muscle layers open. A large abscess developed within 12 h, requiring reopening of the wound, drainage and debridement and reclosure including the muscle and the mucosa (B).
Cyanoacrylate (tissue glue) is now commonly used for closure of smaller soft tissue wounds on the face and scalp in children without having to give local anaesthetic. Currently, the literature is equivocal as to whether suturing or gluing produces better outcomes, although it is clear that gluing is far less traumatic for the child and much faster.
Choice of material (Table 8.1)
The choice of suture material and needle will depend on:
The type and location of the wound to be closed
Figure 8.7 (A) Surgical nylon 4-0 on a reverse cutting needle. This monofilament suture material has excellent tissue reaction and strength. The reverse cutting needle has its cutting edge on the convex surface, which avoids tearing. Cutting needles are used for thick, keratinized tissue such as attached gingiva or palatal mucosa. (B) Polyglactin is a resorbable, braided material. They also have good tissue reaction but tend to accumulate plaque and can become quite dirty in the mouth prior to their loss after 2 weeks. The taper needle is excellent for friable or thin alveolar mucosa.
• Suturing of torn or lacerated gingival tissues should be conducted using a fine suture, such as a 4-0 or 5-0 resorbable suture (Dexon/Vicryl). Polyglactin or polyglycolic acid sutures have good traction strength for at least 3 weeks and have far less tissue reaction than catgut. They are resorbable but because they comprise braided material, they are not nearly as clean as monofilament sutures. Where strength is required, and removal of the sutures is not an issue, monofilament nylon is preferable.
The required strength and length of time required
Whether the material needs to be removed – resorbable or non-resorbable
While each surgeon will have their own individual preference of surgical instrumentation, the following instruments are those commonly used in many oral surgical suturing situations.