159
4.3
Tooth Extraction
Hubertus van Waes
Clinic of Orthodontics and Pediatric Dentistry, Center of Dental Medicine, University of Zurich, Zurich, Switzerland
­Introduction
Due to the limited value of deciduous teeth,
the decision to extract them can be easier than
in the permanent dentition. One should always
keep in mind, however, that a deciduous tooth is
important for food consumption, aesthetics
and speech, and that it acts as a space main-
tainer for the permanent dentition. Loss of a
deciduous tooth can therefore cause a variety
of problems and create the need for further
treatment to enable a normal development of
the dentition. On the other hand, leaving an
infected deciduous tooth in situ can harm the
permanent successor. Accidental damage of
the permanent tooth bud is always a factor
when performing an extraction of a deciduous
tooth. For that reason, it is generally not indi-
cated to remove any granulation tissue after
the extraction of a deciduous tooth. Once the
origin of infection is eliminated, granulation
tissue will disappear, so there is no need to put
a tooth germ in danger by scraping in that area.
The same is true for fistulas.
In the case of multiple extractions, such as
in situations with early childhood caries, it
can be useful to apply sutures or haemostatic
sponges to eliminate the danger of postoper-
ative bleeding, which can be dramatic and
traumatising for the child. Extractions of
molars with very divergent roots may result
Management of Dental Emergencies in Children and Adolescents, First Edition.
Edited by Klaus W. Neuhaus and Adrian Lussi.
© 2019 John Wiley & Sons Ltd. Published 2019 by John Wiley & Sons Ltd.
Companion website: www.wiley.com/go/neuhaus/dental_emergencies
in a widening of the alveolar bone and some-
times in the disruption of the soft tissues. In
these cases, careful compression of the alveo-
lae and sutures may be indicated (Figure 4.3.1).
Prior to each intervention, an x‐ray of the
tooth is necessary in order to evaluate the
state and shape of root resorption and the
topographic relation to the permanent succes-
sor. Depending on these findings, different
approaches can be chosen, such as splitting a
molar in a mesial and distal part.
Anchylosed molars pose a special challenge.
Their roots are subject to replacement resorp-
tion with loss of the periodontal space and
failure of vertical growth of the alveolar
­process in this area. These teeth can be far
from the occlusal plane and can even be sub-
merged under the gingiva, which makes it very
difficult to grab them with extraction forceps
and mobilise them. Due to the replacement
resorption, it is very likely that root remnants
will stay in place after an extraction. It has
then to be decided whether they can be left
behind or if their complete removal is neces-
sary to allow orthodontic movement of neigh-
bouring teeth. Usually, such remnants will be
resorbed if a permanent tooth erupts in this
area, but will resist resorption and remodelling
in the case of orthodontic movements. In such
a case, orthodontic movement of a tooth into
the extraction site may be severely hampered.
160 4.3  Tooth Extraction
Figure 4.3.1  Resorbable sutures after multiple
extractions in a small child treated under general
anaesthesia.
­Extraction of Incisors
Because of their anatomic shape, extraction
of deciduous incisors is usually quite simple,
involving a rotary movement with a forceps
after cutting the superficial periodontal
fibres. Because of the close proximity to their
permanent successors, however, it is impor-
tant not to move the crown too far labially,
because this will result in a movement of the
root tip to the palatinal side, where the per-
manent tooth is located (Figure 4.3.2).
Figure 4.3.2  Danger of damaging the permanent
tooth by excessive labial movement of the crown.
­Extraction of Molars
Whilst the extraction of incisors is usually a
quick and easy task, deciduous molars can
be very difficult to extract (Van Waes, 2001).
Especially in young patients with minor
physiologic resorptions, the very long and
often divergent roots can be difficult to lux-
ate. Due to their relatively small diameter
and curved shape, fractures of roots are very
common.
Because molars with long or even anchy-
losed roots are so difficult to luxate, extreme
care should be taken when using elevators
placed between the deciduous molar and a
freshly erupted and not yet fully grown per-
manent tooth. With the interdental force
generated by the elevator, it is easy to unin-
tentionally luxate the permanent neighbour
instead of the deciduous molar (Figure 4.3.3).
Therefore, extractions of deciduous molars
are usually performed by using a forceps and
applying forces to move the tooth to buccal
and lingual. The force should be applied for
some time, in order to widen the alveolar
socket and create room for the large and
divergent roots to come out.
During the extraction of a deciduous
molar, the germ of the permanent successor,
which is often located between its curved
roots, can be accidentally damaged or even
extracted. This underlines the importance of
Figure 4.3.3  Elevators should not be used against a
freshly erupted tooth, because it might be luxated
instead of the target deciduous molar. Elevators
should always be supported by bone.

a preoperative radiograph and a careful
approach. Particularly in the lower jaw, it
may be necessary to split a deciduous molar
with a bur and then take out the mesial and
distal parts separately (Figure 4.3.4). The cut-
ting has to be done with care in cases where
the permanent tooth is very close to the
bifurcation of the deciduous molar. If the cut
is not deep and large enough, luxation of the
fragments may be difficult; if it is extended
into the furcation area, the permanent tooth
may be damaged (Figure 4.3.5).
This can also happen in cases with severely
destroyed crowns, where special forceps
Figure 4.3.4  Schematic procedure of splitting a
lower deciduous molar prior to extraction. The cut
has to go all the way down to the furcation, without
damaging the permanent tooth.
Figure 4.3.5  Radiograph of an ankylosed lower second deciduous molar. It was decided by the dentist to
split the tooth by slicing it with a bur. After eruption of the successor, damage to the buccal cusp caused by
the bur became evident.
 ­Extractions in Emergency Situation 161
which grab into the furcation of a molar are
used because there is no bone above the
permanent successor.
­Extractions in Emergency
Situations
Deciduous teeth with infected pulps (e.g.
due to profound carious lesions) can be the
­origin of local abscesses or oedemas. Unlike
in adults, incision is rarely necessary in
the deciduous dentition and is unlikely to
produce pus, because the visible and some-
times impressive swelling is primarily an
oedema. In the case of an abscess, extraction
of the deciduous tooth will solve the prob-
lem, because the source of infection is more
superficial than in adults. In general, the
extraction is technically easy, because the
bone of children rapidly disappears due to
inflammation and the teeth can become very
mobile. The main concerns for the dentist
are pain control and patient cooperation. In
order to gain time, improve cooperation and
improve conditions for local anaesthesia,
prescription of antibiotics and pain killers
may be indicated (American Academy of
Pediatric Dentistry, 2017).
162 4.3  Tooth Extraction
­References
American Academy of Pediatric Dentistry.
2017. Guideline on management
considerations for pediatric oral surgery and
oral pathology. Pediatric Dentistry, 39(6),
279–88.
Van Waes, H. 2001. Chirurgie bei Kindern und
Jugendlichen. In: Van Waes, H., Stöckli, P.
(eds). Kinderzahnmedizin, Farbatlanten der
Zahnmedizin Bd 17. Stuttgart: Thieme,
pp. 227–52.