pediatric extraction forceps, pediatric surgery, oral surgery of children, pediatric oral surgery, extraction technique, elevators, surgery techniques, repair and suturing of soft tissue injuries, suture material, choice material, suturing technique, surgical removal of supernumerary teeth, removal of impacted teeth, removal of impacted canine, incision and drainage, lingual frenetomy, tongue frenetomy, lingual frenectomy, tongue frenectomy, biopsy, biopsy of soft tissue lesion, biopsy procedure

1. by Dr. Zainab Mohammed Al-Tawili 1

2. by Dr. Zainab Mohammed Al-Tawili 2
A selection of
pediatric extraction
forceps. It is
important to use the
appropriate size
forceps for the tooth
to be removed.

3. by Dr. Zainab Mohammed Al-Tawili 3
(A) (B)
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.

4. by Dr. Zainab Mohammed Al-Tawili 4
(C) (D)
Extraction of primary anterior teeth.
(C,D) The tooth should be delivered with a rotation
movement and with minimal apical force that might damage the
permanent tooth germ.

5. by Dr. Zainab Mohammed Al-Tawili 5
(A) (B)
(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.

6. by Dr. Zainab Mohammed Al-Tawili 6
The index finger should run along the blade and serves to protect
the patient if the instrument slips.

7. by Dr. Zainab Mohammed Al-Tawili 7
(A) (B)
(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.

8. by Dr. Zainab Mohammed Al-Tawili 8
(A) (B)
(A) ‘Cowhorn’ pattern forceps engage the bifurcation of a
molar tooth (B).

9. by Dr. Zainab Mohammed Al-Tawili 9
(C) (D)
(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.

10. Repair and suturing of soft tissue injuries
• 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.
by Dr. Zainab Mohammed Al-Tawili 10

11. by Dr. Zainab Mohammed Al-Tawili 11
(A) (B)
(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).

12. Choice of material
by Dr. Zainab Mohammed Al-Tawili 12
Some indications for the selection of suture materials in paediatric dentistry
Suture Indication Size Needl
e
Absorption Tissue
reaction
Notes
Surgical
gut
Extraction
suture
3-0 Cuttin
g
Completely digested by
70 days. Effective
strength for 2–3 days In
the oral cavity
Moderat
e
Used for tissue closure where
strength Is required for 1-2
days.
Chromic
catgut
General
closure
4-0 Taper Completely digested by
110 days, but in the Oral
cavity it has effective
strength for Up to 5
days.
Moderat
e
But less
than
plain
Gut
Excellent for oral tissue closure
when Longer life is required
compared with plain gut.

13. Choice of material
by Dr. Zainab Mohammed Al-Tawili 13
Polyglyco
c
acid
Polyglacti
Alveolar
mucosa
Attached
gingiva
Large
where
Strength
Required
but a
resorbable
suture is
desirable.
4-0
5-0
3-0
4-0
3-0
Taper
Cuttin
g
Cuttin
g
Completely absorbed
Hydrolysis after 90
Faster absorption when
exposed to the Oral
environment.
Good strength for
2 weeks
Mild Polyglycolic acid has great
advantages For use in the
cavity in children. It has
strength over 7 days & is
resorbable. It is often
for longer periods however,
has a tendency to
plaque due to its braided
nature Tapering?
Needles are useful where
tissues are friable

14. Choice of material
by Dr. Zainab Mohammed Al-Tawili 14
Some indications for the selection of suture materials in paediatric dentistry
Suture Indication Siz Needl
e
Absorption Tissue
reactio
Notes
Mono-
filament
Nylon
Large flaps
where
Strength is
required
(i.e. Palate)
3-0
4-0
Cuttin
g
Essentially a
nonresorbable material,
but degrades at 15–20%
per year.
Extreme
ly
Low
Excellent tissue reaction &
strength.
Monofilament material is
extremely clean & allows
good wound healing but
needs to be removed.
Skin 6-0 Cuttin
g
Skin closure must be
performed with 6-0.
Sutures should be removed
before 7 days.

15. Choice of material
by Dr. Zainab Mohammed Al-Tawili 15
Surgical
silk
General
closure of
Most oral
tiss -ues
where a
nonresorb
able
Suture is
required
3-0
4-0
Cuttin
g
Completely degraded by
2 years.
Modera
te
Traditional suture material,
used
Where strength was
required.
Its use has diminished with
the availability of materials
such as
Polyglycolic acid.
A braided material &
therefore not as clean as
monofilament.

16. Repair and suturing of soft tissue injuries
◦ The required strength and length of time required:
• Keratinized and thick tissue such as the palate require thicker suture material.
• Large but thin, friable flaps may still need the strength of a thicker material without the risk of the suture tearing the
mucosa.
• Whether the material needs to be removed – resorbable or non-resorbable:
• Resorbable sutures such as polyglactin/ Polyglycolic acid (4-0 or 3-0) are preferable for use in young children or where
behavioral issues are a concern.
• Clinical Hints:
• Prior to suturing a site, examine it thoroughly for tooth fragments. If in any doubt, radiograph the site.
• Remove any jagged, damaged and necrotic soft tissues tags and freshen up old wound margins with a scalpel.
• Suture with adequate stress and tension achieving complete haemostasis.
• Leave suture ends short if using resorbable materials, but longer if the material is to be removed. Very short tag ends
often become buried and are difficult to remove.
• Remove skin sutures on the face within 5 days to prevent scarring of puncture sites.
by Dr. Zainab Mohammed Al-Tawili 16

17. by Dr. Zainab Mohammed Al-Tawili 17
(A) (B)
Horizontal mattress suture. (A) A large wound is left following the extraction of teeth 74 and 75. (B)
The suture needle is passed through the interdental papilla on the buccal through to the lingual side.

18. by Dr. Zainab Mohammed Al-Tawili 18
(C) (D)
(C). Approaching from the lingual, the needle is then passed back to the buccal through the more
mesial papilla Approaching from the lingual, the needle is then passed back to the buccal through
the more mesial papilla (D).

19. by Dr. Zainab Mohammed Al-Tawili 19
(E) (F)
(E,F) The suture is tied on the buccal side and cut leaving short tag ends.

20. by Dr. Zainab Mohammed Al-Tawili 20
(G) (H)
The suture is tied on the buccal side and cut leaving short tag ends (G). The final
appearance showing good repositioning of the flaps and compression of the socket
(H).

21. Surgical removal of supernumerary teeth or impacted canines
• Identification of the tooth:
• Most maxillary supernumeraries lie in the palate or in the midline between the central incisors.
inverted, conical supernumeraries often lie adjacent to the anterior nasal spine and are best removed via a
labial approach. Tuberculate teeth are commonly palatal and inferior to the central incisor.
• Supernumeraries in the premolar region lie lingual and inferior to the premolars.
• Canines may be impacted buccally or palatally, although invariably, the root apex lies in close
to the floor of the sinus.
• Surgical technique:
◦ A local anesthetic with a vasoconstrictor will aid hemorrhage control at the surgical site. an appropriate sized flap
should be raised to ensure adequate access to remove the tooth.
• Postoperative care
• Provide adequate analgesia perioperatively and postoperatively. Depending on the amount of bone
removal and the size of the bony defect, postoperative antibiotics are often not required. If antibiotics are
required, a single perioperative administration is preferable.
• Give good clear oral hygiene instructions.
• Arrange an appropriate postoperative recall appointment.
by Dr. Zainab Mohammed Al-Tawili 21

22. by Dr. Zainab Mohammed Al-Tawili 22
(A) (B)
Surgical removal of a maxillary supernumerary tooth (A) Labial &
palatal anesthesia. (B) Crestal incision from at least the distal of
the canine to the contralateral side.

23. by Dr. Zainab Mohammed Al-Tawili 23
(C) (D)
(C) Elevation of a full-thickness mucoperiosteal flap.
(D) Removal of bone with bur. Note how the flap is protected by
the periosteal elevator.

24. by Dr. Zainab Mohammed Al-Tawili 24
(E) (F)
(E) Exposure of the supernumerary and elevation with a Warwick James
elevator.
(F) Removal of the supernumerary tooth follicle with a pair of hemostats.

25. by Dr. Zainab Mohammed Al-Tawili 25
(G) The socket is thoroughly irrigated and in this case, bone
overlying the impacted upper right central incisor is removed to encourage
eruption.
(H) Closure of the flap with a resorbable suture.
(G) (H)

26. Incision and drainage of abscess
• Any collection of pus requires drainage.
• The following cases represent surgical emergencies and require urgent and immediate care and/or referral:
• A floor of mouth swelling, particularly those that have crossed the midline.
• Dysphagia or respiratory obstruction.
• Trismus.
• A fluctuant enlarging swelling in the head and neck.
• A enlarging swelling associated with acute fever, particularly a spiking temperature.
• Clinical presentation:
• Cellulitis:
◦ A hard, brawny swelling. Diffuse and tender. Warm to touch.
• Abscess
• A soft, warm and painful swelling, usually fluctuant.
• Usually circumscribed, may be very well localized in the mouth or more diffuse if extraoral.
• Surgical technique:
◦ Local anesthesia injection block injections are preferable. Where there is a significant swelling either intra-orally or extra-orally, general anesthesia will
be required to adequately manage and protect the airway and to undertake the procedure. Extra-oral drainage is typically only required for mandibular
swellings.
by Dr. Zainab Mohammed Al-Tawili 26

27. by Dr. Zainab Mohammed Al-Tawili 27
(A) (B)
Management of an intraoral abscess.
(A) A large fluctuant swelling associated
with tooth 65.
(B) Elevation of a flap to drain subperiosteal pus.

28. by Dr. Zainab Mohammed Al-Tawili 28
(C) (D)
(C) Irrigation of the abscess cavity.
(D) Extraction of the offending tooth.

29. by Dr. Zainab Mohammed Al-Tawili 29
The swelling is
fluctuant and an
incision is made
into the abscess

30. by Dr. Zainab Mohammed Al-Tawili 30
Drainage is established with a pair of haemostats opening
into the cavity and exploring the tissue space
The cavity is kept patent
with a flexible drain.

31. Lingual frenotomy
• A lingual frenotomy (simple cutting of the frenulum) is a procedure indicated in those infants
where a significant tongue-tie is affecting breast-feeding. Local anaesthesia is usually not required.
by Dr. Zainab Mohammed Al-Tawili 31

32. by Dr. Zainab Mohammed Al-Tawili 32
(A) (B) (C)
Lingual frenotomy. (A) The tongue is retracted. (B) An incision is made in the frenum with blunt-
ended dissecting scissors. (C) There is minimal bleeding and the infant can commence breast-
feeding immediately.

33. Lingual frenectomy
• A frenectomy is normally carried out under local anaesthesia in older children and under
general anaesthesia in younger children.
by Dr. Zainab Mohammed Al-Tawili 33

34. by Dr. Zainab Mohammed Al-Tawili 34
(A) (B) (C)
Lingual frenectomy. (A) A severe tongue tie with the insertion of a short frenum into the tongue tip.
(B) A stay suture stabilizes the tongue and a haemostat is placed from the insertion of the frenum to
a point in the floor of the mouth superior to the submandibular duct orifice. (C) The frenum is cut
using the haemostat as a guide.

35. by Dr. Zainab Mohammed Al-Tawili 35
(E)
(D) (F)
(D,E) Closure of the wound with a 4-0 resorbable suture. (F) Haemostasis and final closure.

36. Biopsy of soft tissue lesions
• with younger children usually requiring general anaesthesia. There is a risk of damage to adjacent
structures, possible scarring and the excessive removal of tissue. Fortunately, life-threatening
pathology in the oral cavity of children is rare and there may be little benefit to the patient in
removing tissue, simply to confirm the diagnosis of a benign condition.
by Dr. Zainab Mohammed Al-Tawili 36

37. by Dr. Zainab Mohammed Al-Tawili 37
(A) (B)
Excisional biopsy of exophytic lesions.
(A) Multiple fibrous epulides in a 3 month-old infant.
(B) Administration of local anaesthesia for pain and haemostasis.

38. by Dr. Zainab Mohammed Al-Tawili 38
(D) (E)(C)
(C) Excision of the lesion with a border of normal tissue. (D,E) Wound
closure with a fine resorbable suture.

39. Reference:
by Dr. Zainab Mohammed Al-Tawili 39