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Lecture date: 20/02/2013 Lecture was given by: Dr. Arwa Owais

*** I didnt have the slides when I wrote this lecture, so if you find any mistake, please correct it from the slides. Enjoy reading the lecture!

Extraction in Pediatric Dentistry

o Preservation of primary teeth is important for maintaining arch length. So if the patient had premature/early tooth loss, we go for Space analysis or space management. o We want to maintain a healthy oral environment.

o Full occlusion. o Oral environment free of dental decays and periodontal diseases. o Keeping teeth is important for children, and extraction is harmful psychologically. Why do we prefer to preserve primary teeth? - For the psychology of the patient. Why do we do extraction? - To release pain. - Maintain good looking appearance. - Maintain function of teeth. When is extraction contraindicated? - In some cases the only option is extraction; in other cases pulpotomy/pulpectomy is preferred rather than extraction, like in certain systemic diseases. - Blood diseases. - Acute systemic infection. - Uncontrolled diabetes mellitus. - Acute oral infection/ Irradiated bone.

Steps of extraction (in the clinic):

1. Take consent from the parent. In case of primary teeth, verbal consent is ok. But if you are going to extract a permanent tooth, you need to get a written consent. So always take a consent either from the parent or the guardian. 2. Explain the sensation & experience to be encountered for both LA & extraction. If you talk to the child and explain the sensation and what he will really feel, you will have no problem. 3. When communicating with the child, use a language that he would understand and like. Avoid using words like Extraction and remove, and use words like move and wiggle

4. Children are afraid of two things, needle and extraction. So do not show needles or forceps to the child. Pass the forceps the same way you pass the syringe.

5. For the child, pressure and pain are the same. But sometimes the child might be feeling pain not pressure. So you have to differentiate between pain and pressure, and make sure the child is well anesthetized. 6. Its couldnt hear it aggravate anxiety. Even throwing the forceps in the examination kit can cause anxiety, so try to make the environment quite.

7. The forceps from the forceps should be firmly but gently applied. Extraction is done with two movements, palatal + buccal. The application of the forceps should be firm, strict, gentle, but with a continuous movement. Its not the same way when you extract permanent teeth. In permanent teeth you need to wiggle the tooth (palatal buccal palatal buccal...etc.) until you expand the socket. In children, you do it to the palatal or lingual side (to expand the socket), then buccally as much as you can. Its like you go 15 to the palatal/lingual side, and 80 to the buccal side, so you deliver the tooth in one time (not sure of this. Please re-check). 9. When doing extraction, you shouldnt hurry, but also do not take a long time.

10. Be aware of unintentional removal of permanent tooth bud. This happens if you use permanent teeth forceps to extract a primary tooth. Thats why when you open a clinic and want to treat children make sure to have special forceps for primary teeth. Ex. If you use lower 6 forceps for extracting a primary tooth, the grip of the lower 6 will go to the lower 4 and take the follicle with it. Because the forceps itself is longer that the root. 11. Always use gauze nets. Take the gauze and ask the child to take his tongue out, and then place the gauze on the tongue. The aim of using it is to block the airways when doing extraction (delivering the tooth), to prevent the child from swallowing or inhaling the tooth in case it slips from the forceps. Do that when trying or placing SSC too. 12. Remove the extracted tooth away, and dont show it to the child. Never show it to the child (especially when theres blood on the tooth) unless hes aware that you took his tooth out, and he wants it for the tooth fairy for example. But always rinse the tooth before giving it to the child.

These are the morphological differences between primary and permanent teeth.

Because of the difference in the shape and size of primary/permanent teeth, there are some differences in the process of extraction. 1. The most important thing is the flare of the roots. 2. The size of primary teeth is smaller. 3. The shape of primary teeth is more bulbous. The difference between primary/permanent teeth forceps: 1. The peaks and the handle of the forceps are smaller, because teeth are smaller. 2. Peaks are more curvedwhy? Because the crown is more bulbous and we need to go beyond the crown, to the CEJ. 3. Small forceps easily concealed. Most of the ones that we use fit into the palm of the hand, even the short ones, so use them.

4. Forceps and elevators that by (virtue..??) of their design and function (????) in the underlying developing teeth should be avoided. Unless you are practiced enough.

5. Large root elevators are contraindicated. 6. Narrow root peaks and mosquito-peaked forceps for root removal can damage successors, due to the deep location of furcation.

Fractured roots during extraction:

If the root is fractured during extraction, its sometimes better to leave small fragments inside, because primary roots will resorb. If you fracture the apical part of the root in a primary tooth, consult the supervisor, you may leave it, because itll either resorb, or be pushed up to the oral cavity. You dont need to damage the follicle of the permanent root. If the fractured root fragment is visible, it should be removed. Blind investigation of the tooth socket should not be performed, because you might take out the follicle of the permanent tooth.

Patients Position:
You should decline the chair 30 degrees vertically, when removing an upper or lower left primary tooth. And you have to be standing in front of the child. When removing lower right tooth, stand in front of the patient. When removing upper teeth, the patients mouth should be at a level just below the operators shoulder. When removing lower left teeth, the patients mouth should be at a level just below the operators elbow. When removing teeth from lower right, the patient should be as low as possible.

Function of the non-working hand:

- Retract soft tissues. - Allow visibility. - Protect the instrument if it slips. - Support. - Provide resistance to the extraction force to the mandible. - Gives information about resistance to removal.

Order of extraction:
If you want to do more than one extraction in the same visit, you have to follow this order: 1. Symptomatic tooth before balancing extraction for the opposite side. Sometimes, the pain is in the upper left teeth, and the parents do not want to put space maintainer, so balancing extraction is a choice in orthodontics, so you do extraction for the symptomatic side, before going to the other side in the same visit. Why? the child may get uncooperative after the first extraction. So do not do the balancing before the symptomatic. 2. Lower before upper. 3. Distal first for visibility. To have a clear field.

Extraction techniques:
*** You have to know the types of forceps and elevators. As you know, each forceps has: 1. Peak 2. Nick 3. Handle And the shape of the peak & handle will give you an indication of which tooth we are talking.

1. For upper primary anterior teeth, we use straight, closed peaks.

How do you extract upper teeth in adults? You go back and forth, or rotation movement. Whereas in children we prefer just to rotate. We do clockwise and anti-clock wise rotation movement along the long access of the tooth. Sometimes, when we have labially placed upper anteriors, we can use elevators to dislodge them, you insert it either mesially or distally. The most useful elevators in these situations are the straight and curved werwick and ( couldnt hear it) These are the types of elevators; you have to be very careful when dealing with children (check the picture in the slides). and do not use elevators in the clinic, unless you are directly supervised. The straight elevators are applied along the long the access of the tooth. The curved elevators are used either for left or right sided application, and you can use them mesially or distally. If the roots are flared, then we need more expansion for the socket. If the roots are resorbed, then less expansion is needed. Upper anterior molar forceps: There are the T/straight/S shaped forceps. The S shaped is the most commonly used one for upper molars. And the dr. wants you to use it in the clinic. The initial movement of the forceps is the palatal side, to expand the socket in that direction. Then the tooth is subjected to a buccaly directed force, which results in tooth delivery. Lower primary teeth forceps:

Lower primary anterior forceps: (Closed peaks with 90 angulation)

Lower primary molar forceps: (Open peaks with 90 angulation)

Rotate the forceps in a clock-wise and anti-clock-wise direction, the same as in upper anteriors.

Expand in lingual/buccal direction. But start with the lingual side first.

Post-operative considerations for children:

The most common complication after the extraction of lower teeth is lip biting (because of anesthesia not because of extraction). Dry-socket is less frequent. Post-surgical discomfort in negligible. Give the patient instruction to keep clean gauze after extraction for at least 15 minutes. Soft diet. Warn the parent about lip biting. Mouth rinse the day after extraction. Never show the tooth to the child.

Done by: Katreen Suleiman.