8. Clinical and surgical techniques

Clinical and surgical techniques

Simrit Malhi, Angus C Cameron and Rebecca Eggers

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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

Molars

• Extractions should be clean and atraumatic.

• Avoid gingival injuries by freeing the gingival margin with a flat plastic, luxator or elevator (Figure 8.3).

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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.

• Luxation/elevation is essential, however first permanent molars can be difficult to elevate when the adjacent mesial tooth (a second premolar or primary molar) is absent.

• Support the alveolus on either side with fingers.

• 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.

• ‘Cow-horn’ pattern forceps are extremely useful in removing either upper or lower permanent molars, especially those with little or no crown remaining on the lingual aspect (Figure 8.5).

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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.

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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.

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.

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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:

Instruments

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.

Needle holders

Many different patterns of needle holders are available. The most convenient holders are around 15 cm in length with/>

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Related posts:

  1. 1. The philosophy of paediatric dentistry
  2. 16. Speech, language and swallowing
  3. 13. Children with special needs
  4. 7. Pulp therapy for primary and immature permanent teeth
  5. 11. Dental anomalies
  6. 10. Paediatric oral medicine, oral pathology and radiology

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Jan 14, 2015 | Posted by in Pedodontics | Comments Off on 8. Clinical and surgical techniques

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