Curette

After administration of local anesthesia, a sterile curette may be used to sever the gingival attachment (Figure 8.2). This first step of the procedure may predict the behavior for the remainder of the procedure, as a very anxious child will respond negatively to even slight pressure with the curette. Anxiety is the biggest predictor of poor pain control (Nakai et al., 2000).

Luxation

Luxation (loosening) is the most important step to facilitate extraction and avoid root fracture of a primary molar. The interproximal contacts of primary molars are broad, flat and without cervical constriction. The tip of the instrument for luxation should be narrow enough to be placed through the embrasures of the primary molars (Figure 8.3a and 8.3b). This step may not be necessary for primary incisors and canines with conical, single roots but may be helpful in some cases. Primary incisors may be luxated using straight forceps with a labiolingual movement. During luxation, use caution not to include adjacent teeth, causing mobility. If an adjacent tooth is mobile before the extraction, the parent/guardian should be informed of the possibility of an unintentional extraction.

The feeling of pressure during the luxation and extraction should be explained. Pushing on the child’s shoulder may demonstrate this sensation. If a previously cooperative child begins to cry, exhibiting pain during luxation, administration of additional local anesthesia is indicated. Injections through the mesial and distal papilla from buccal to lingual, along with injection into the gingival sulcus, are very effective. Palatal injection using the DentalVibe significantly reduces injection discomfort (Figures 8.4a, 8.4b, 8.4c, and 8.5).

Extraction