used in the mandible in the region of the mental foramen care must be taken to ensure
that the vertical relief is at least one tooth in front of the foramen (which will have
been localized from the orthopantomogram). The only problem with this type of flap
is that it may disrupt the gingival contour, but this is not a major long-term problem in
the child. The second design of flap for buccally placed teeth is a semilunar incision.
At least 5 mm of attached gingiva should be maintained at the narrowest point to
ensure a good blood supply to the marginal gingivae. This flap does not provide such
good exposure or orientation as the previous design, and it is easy at the end of
surgery to be left with a large part of the wound margin over a bony defect. This can
lead to wound breakdown.
FLAPS FOR PALATALLY/LINGUALLY PLACED TEETH
Palatally positioned teeth are best removed via an incision that follows the palatal
gingival margin (1047HFig. 15.24 (a)-(g)). Such an incision maintains the integrity of the
greater palatine nerves and blood vessels. It is often possible to raise this flap without
sacrificing the neurovascular bundle that leaves the incisive foramen. This bundle will
stretch to a certain degree; however, if access demands it should be cut. This rarely
results in any postoperative complications. The extent of the palatal gingival incision
depends upon the surgery involved. A flap extending between the mesial aspect of
both first permanent molars is not unusual for the removal of bilateral impacted
maxillary canines. Smaller flaps may be sufficient to remove palatally placed teeth or
supernumeraries near the mid-line. In the lower jaw adequate access to the lingual
side is obtained by raising the lingual gingiva and reflected mucosa via an incision run
around the lingual gingival margin.
BONE REMOVAL
When working close to buried teeth that are to be retained it is essential that bone is
removed with care. This may be carried out using a handpiece and bur very slowly.
The use of chisels with hand pressure (mallets are not used unless working under
general anaesthesia and are seldom required in children) is much safer because this is
unlikely to damage coronal tissue.
TOOTH REMOVAL
Once sufficient bone has been removed to allow identification of the tooth to be
extracted and exposure of the greatest diameter of its crown, the tooth should be
elevated. If this is likely to produce undue pressure on neighbouring erupted or buried
teeth then the tooth should be divided using a handpiece and bur and removed in
parts. Mandibular teeth that are impacted within the line of the arch are best removed
by the so-called 'broken instrument technique', in which pressure is applied from one
side of the tooth (e.g. using a straight Warwick James elevator) to force it out of the
other side.
SUTURING
Resorbable sutures should be used in children whenever possible: 3/0 or 4/0 softgut is
ideal.
DISCHARGE
Any bleeding should be arrested before the patient is allowed to leave the surgery.
The patient and parent should receive instructions on simple methods of haemorrhage
control. The patient is encouraged to maintain good oral hygiene and may be given an