through-and-through root fillings are unsatisfactory as the apex may be wider than the
bulk of the canal, thus some form of retrograde restoration is required. It is often
difficult to secure undercuts at the apex when dealing with a tooth that has an open
apex, but this can be overcome by placing a large retrograde filling and relying on
multiple microscopic undercuts to secure it.
15.5.5 Cysts interfering with eruption
Eruption and dentigerous cysts can interfere with the eruption of teeth. Eruption cysts
in the young child are simply incised (when occluding teeth are present this can be
achieved by the patient themselves on biting). Dentigerous cysts may be
marsupialized to the oral mucosal lining following the removal of any overlying
primary predecessor and the permanent tooth allowed to erupt. Some authorities
advocate more aggressive treatment involving enucleation of the cyst (with or without
removal of the tooth) to ensure that epithelial remnants are not left behind. Fissural
cysts (such as the nasopalatine cyst) are rare in children; when found they should be
enucleated.
15.5.6 Treatment of acute orofacial infection
At this point it is relevant to discuss the treatment of orofacial infection. The major
cause of this condition is dental in origin. The minor oral surgical treatments
discussed above may all be employed to definitively treat the source of an orofacial
infection. Alternatively, conservative treatments such as endodontic therapy may be
appropriate. A rapidly spreading extraoral infection, however, is a surgical
emergency. This merits immediate treatment and may require admission for in-patient
management. Two areas of extraoral spread are of special importance. These are the
submandibular region and the angle between the eye and nose. Swelling in the
submandibular region arising from posterior mandibular teeth can result in the floor of
the mouth being raised. This can cause a physical obstruction to breathing and spread
from this region to the parapharyngeal spaces may further obstruct the airway. The
advance from dysphagia to dyspnoea can be rapid. A submandibular swelling should
be decompressed as a matter of urgency in children. A child with raising of the floor
of the mouth requires immediate admission to hospital. The fact that trismus is
invariably an associated feature makes expert anaesthetic help essential for safe
management. Infection involving the angle between eye and nose (1061HFig. 15.28) has the
potential to spread intracranially and produce a cavernous sinus thrombosis. This is a
potentially life-threatening complication. The angular veins of the orbit (which have
no valves) connect the cavernous sinus to the face, and if the normal extracranial flow
is obstructed due to pressure from the extraoral infection then infected material can
enter the sinus by reverse flow. To prevent this complication, infection in this area
(which arises from upper anterior teeth, especially the canines) must be treated
expeditiously.
The principles of the treatment of acute infection are to:
(1) remove the cause;
(2) institute drainage;
(3) prevent spread; and
(4) restore function.