• The resorptive process may also be affected by endocrine disturbances or vitamin

deficiencies.
• Atypical resorption of a deciduous tooth root may cause it to be overretained.
Such an over retained deciduous tooth should be extracted to allow normal
eruption and alignment of the permanent successor.

Ankylosed Deciduous Tooth

Such tooh shall be extracted when the cessation of vertical alveolar bone growth is
absorved, as evidenced by deciduous tooth submergence, followed by the
placement of a space maintainer.

Cariously involved, Nonrestorable Deciduous Tooth (Fig. 13.22)

When caries has seriously involved the clinical crown of a tooth and is non
restorable, the tooth should be removed.

Natal or Neonatal Tooth

The natal tooth, which has erupted before birth, or the neonatal tooth, usually
erupting, within one month following birth, must be considered for extracting if :
• The tooth is mobile and there is a chance of aspiration
• The tooth is a source of mechanical irritation, causing ulceration on the
ventral surface of the lounge.
• There is interference with breastfeeding.
• The natal or neonatal tooth may be a supernumerary tooth.

Chronic Pathologic Involvement (Fig. 13.21)

A primary molar usually present with furcal radiographic changes, ant the deciduous
anterior tooth may have changes seen in the apical portion. This presents with a parulis
or a draining abscess. The risk for the normal development of the permanent tooth bud
due to the infective environment warrant the extraction of the diseased deciduous
tooth.

Over retained deciduous tooth

The deciduous tooth may be retained for several reasons such as :

• If the erupting succedaneous tooth is malposed, the resorptive process on

the deciduous tooth may be irregular.
Contraindications to Tooth Removal

The removal of a tooth is contraindicated where acute symptoms of oral or systemic

disease are manifested ¡n the child patient such as:

Acute Systemic Infections

After the acute stages of systemic infections, such as glomerulonephritis, congenital

heart disease, rheumatic fever, rheumatic heart disease, are reduced to chronicity,
regimens of chemoprophylaxis will be required before extractions.

Blood Diseases

The hemophilic or leukemic child will require a well trained general dentist, a pediatric
dentist, or an oral surgeon along with a hematologist to perform satisfactorily the
measures required during tooth removal

Uncontrolled Diabetes Mellitus

Tooth removals should be avoided. Surgical wounds heal poorly, and postoperative pain
can be extreme. Recurrent hemorrhages may result.

Irradiated Bone

Tooth removal should be avoided. If an extraction is necessary, it should be

accomplished before radiation therapy. Osteomyelitis usually develops following an
extraction in an irradiated patient because of osseous avascularity.

Acute Oral Infection

In the presence of oral infections, such as acute necrotizing ulcerative gingivitis, acute
herpetic stomatitis acute dentoalveolar abscess, and other acute forms of oral disease,
tooth removals are definitely contraindicated until the infections are eliminated.

Supernumerary Tooth (Figs 13.23A to D)

The supernumerary tooth, erupted or impacted, is capable of diverting eruption of a

permanent tooth from its normal path, impacting it, or delaying its eruption and Should
be removed.

Fractured or Traumatized Tooth

Trauma can result in various kinds of trauma to the anterior teeth. Such a deciduous
tooth that ¡mposes risk to the permanent teeth should be removed.

Impacted Tooth

The impacted tooth may be a supernumerary tooth, a malformed tooth, or an

unerupted, ectopically placed tooth

Special consideration while deciding whether a primary tooth has to be extracted or

retained:

• Child management: if the emergency is severe enough, the tooth has

questionable prognosis and treatment may require many appointments in a
child who is difficult to manage then the tooth is extracted followed by
placement of a space maintainer
• Degree of root resorption: If > ½ of the root ¡s resorbed and the tooth requires
pulp treatment then It is extracted
• Space problems: ¡f there is an existing space problem, early extraction of the
tooth may allow space closure. In such cases tooth has to be retained by pulp
treatment
• Degree of parental concern: If parents exhibit an obvious lack of concern over
the emergency situation related to the injured tooth, the tooth is removed
• Habits: Deleterious oral habits If present will enhance the rate of space closure.
In such cases tooth must be retained.
• Speech: Early loss of the anterior teeth may have a direct effect on the speech
patterns and this is another reason for maintaining the tooth in the arch
• Esthetic: For psychological purpose It is better to postpone the extraction.

Position of the Operator and the Patient (Fig. 13.24)

Patient position: The dental chair is positioned such that the back is about 45o to the
floor during extraction of the upper teeth and at about 90o while extracting the lower
teeth. The height of the chair is adjusted such that the operator does not need to bend
nor lift his/her arm above the shoulder. Practically the operator must be able to
perform the procedure without straining oneself.

The position of the operator is in front of the patient for extraction of teeth in all the
quadrants except the lower right posterior quadrant. During the extraction of the teeth
in the lower right posterior quadrant the operator sits or stands at about 11 o’clock
position.
TECHNIQUE FOR EXTRACTION

Precautions to be Taken

the dentist should explain to the child the sensations and experiences to be
encountered before administration of the local anesthetic. The child should also be
informed briefly the procedure of extraction in a simple language so that the child can
be prepared and be ready for the procedure. To the uninformed child the sensation of
pressure from the forceps during the extraction procedure can be interpreted as pain,
and extraneous noise and osseous sound conduction associated with luxation may
aggravate the anxiety. Explanation and demonstration to the child that pressures and
noises associated with tooth extraction need not be feared is very important as the
primary step.

When a mandibular tooth is removed, it is prudent to stabilize the mandible by

providing support under the mandible (Fig. 13.25).

During extraction of deciduous teeth extra care must be taken to avoid the
unintentional accidental removal of the permanent tooth bud.

Another measure of precaution is the use of a throat guard that acts as safety screen
over the oropharynx behind the tongue to guard against swallowing or aspiration of an
extracted tooth.
Primary incisors and Canines

Procedure

1. Periosteal elevator is used to free the attached gingiva from the cervix of the
tooth labially and lingually. The tooth can be luxated slightly with the same
instrument, especially if the tooth is mobile.
2. Firm apical pressure is maintained with the forceps. Gently direct the initial
luxative force lingually/Palatally and carefully apply the next toward the labial
side. A rotative force is applied along the tooth’s long axis, delivering it through
its path of least resistance.
3. Mold the labial and lingual or palatal plates of the alveolar bone into normal
conformity with digital pressure.
4. Fold and place a sterile gauze sponge over the wound to help establish
hemostasis. Immediately before patient dismjssal, place a fresh sterile gauze
over the wound with instructions to remove it after 10-20 minutes.

Primary Molars

Procedure

1. Periosteal elevator is used to free the attached gingiva from the cervix of the
tooth labially and lingually. The tooth can be lu.xated slightly with the same
instrument, especially if the tooth is mobile.
2. Firm apical pressure is applied with the forceps (Fig. 13.26). Initial luxation
movement is toward the buccal side. Hold pressure momentarily, permitting
buccal alveolar plate expansion. Return the luxating force lingually/palatally.
Hold pressure to permit lingual alveolar plate expansion. Alternate the buccal
and lingual/palatally movements to further expand the cortical plate. When
there is adequate freedom of movement, deliver the tooth to the buccal side,
exercising slow, firm, continuous pressure.
3. Mold the labial and palatal cortical plates into normal conformity with finger
pressure. Place a folded sterile gauze over the wound during the hemostatic
process.