Pedodontics

Oral Surgery for Children dr.Ali sahib

Indications for extraction of primary teeth are following:
1. Acute pathological involvement: This involvement represents an acute periapical infection of
carious primary tooth, the microorganism may be virulent enough to produce an infection that is
diffused and distended for example cellulites. The tooth is extracted if it is destroyed beyond
rehabilitation.
2. Chronic pathological involvement: A primary molar usually present with furcal radiographic
changes and the primary anterior teeth may have changes seen in apical portion this conditions
presents with draining abscess, there will be a risk for the normal development of the permanent
tooth bud due to the infective environment. This infected primary tooth is indicated for extraction.
3. The over retained primary tooth: Many causes may lead to atypical resorption of primary tooth
root, which cause over retention. This tooth should be extracted to prevent it’s interfering with the
normal eruption and aligment of the permanent successor.
4. The ankylosed primary tooth: This tooth in need for close supervision then it should be removed
in case of submerged tooth.
5. The cariously involved, non-restorable primary tooth: When caries has seriously involved the
clinical crown of a tooth and is non restorable, this tooth should be removed. And use of an appliance
to retain the space if need.
6. The natal and neonatal tooth: These teeth must be considered for extraction if:
A- The tooth is mobile and there is a chance of aspiration.
B- The tooth is a source of mechanical irritation causing ulceration on the ventral surface of the
tongue.
C- There is interference with breast feeding.
D- These teeth may be supernumerary teeth.
7. The fractured or traumatized tooth in toddler and preschoolers: May lead to exposed vital
pulpal tissue, if there is no chance to perform a restorative treatment, these teeth should be removed,
also traumatized primary tooth may imposes risk to the permanent tooth should be removed.
8. In case of pulp therapy are contraindicated: Such as in congenital heart disease, kidney
disorders and rheumatic heart disease.
9. The supernumerary tooth: 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, so it should
be removed.

Contra indications to extraction of primary teeth:

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 Many of the contraindications are relative and may be overcome with special precaution and
premedication:
1. Acute oral infection: Which should be, eliminated before an extraction is completed like in acute
infectious stomatitis, acute Vincent’s infection or herpetic stomatitis and acute dentoalveolar abscess.
2. Blood dyscrasia: Lead the patient susceptible to post operative infection and hemorrhage. So
extraction should be performed only after adequate consultation with hematologist and proper
preparation of the patient.
3. Acute or chronic rheumatic heart disease, congenital heart disease and kidney disease: Those
require proper antibiotic coverage.
4. Acute dentoalveolar abscesses and cellulites: Should be treated with preoperative and
postoperative antibiotic medication.
5. Malignancy: If suspected contraindicated dental extractions because trauma of extraction tends to
enhance the speed of the growth and spread of tumors.
6. Teeth which are remained in irradiated bone.
7. Diabetes mellitus: Also poses a relative contraindication, need consultation with the physician to
certain that child is under control.

Indications for extraction of permanent first molars:

Permanent first molar can be removed before the permanent second molar has erupted through the
gingiva, so there is a chance that this second molar will move mesially and occupy the space of
extracted first molar, and get good alignment of teeth.
But if the second permanent molar has erupted at the time of loss of first permanent molar, then
second molar will probably tilted forward into the space of the first molar causing condition
favoring periodontal disease and orthodontic problems such as closing of the bite. So practically
extraction of first molar should be done before age 10 years and if one or two first molars are
diseased beyond repair, they should be removed, but if three first molar are diseased, all four first
molar should be removed with the expectation that a more symmetrical dentition will result.
In cases the second molars have erupted, every attempt should be made to save the first molars. If
extraction is necessary, only the destroyed teeth should be removed and space maintainers should be
inserted.

Position of the operator and the patient:

Patient position: the dental chair is positioned such that the back about 45 degree to the floor

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during extraction of the upper teeth and about 90 degree while extracting the lower teeth. The
position of the dentist is in front of the patient for extraction of teeth in all quadrants except the
lower right posterior quadrant, which need operator stands behind the dental chair.
Technique for tooth removal:
Precautions: Immediately following the local anesthetic procedure the dentist should explain to the
child the sensations and experiences to be encountered. To the uninformed child the sensation of
pressure from the forceps during the extraction procedure can be interpreted as pain, and other noise
and osseous sound conduction associated with luxation seem to aggravate the anxiety of the
moment.
Explain to the child that pressures and noises associated with tooth extractions are not to be
feared. Undue pressure should never be placed on a tooth when it is luxated. The forces from the
forceps should be firmly but gently applied, the precautions necessary to avoid the unintentional
removal of a permanent tooth bud during the extraction of a primary molar.
Sometime the resorption of a primary molar root occurs half way between the apex and the cemento-
enamel junction. This weakens root considerably and cause fractures of such roots. If such root is
broken, the question arises whether it should be removed immediately or whether an attitude of
watchingful waiting should be taken. The decision depends on skill of operator and the condition of
the root tip. If the tip can be removed without trauma to the bud of the permanent tooth, it should be
elevated with small spear-point elevator. But sometimes many of broken root tips will be resorped or
more often brought to the surface and shed when the permanent tooth erupts. In some cases a root tip
may act as a wedge and prevent the eruption of the permanent successor which needs surgical
removal.

The removal of anterior primary teeth and roots: Is simple, usually requiring a steady rotation in
one direction which disengages the tooth from its attachment.
For mandibular teeth: first support the mandible with your free hand. Then move the tooth lingual
and carefully apply the next toward the labial side, then apply a rotate force a long the axis.
For maxillary teeth: apply firm apical pressure, then direct the initial luxative movement toward
the palate then labially, rotate the tooth on its long axis in one continues direction. Then mold the
labial and lingual or palatal plates of the alveolar bone into normal conformity with digital pressure.
Place sterile cotton or gauze over the wound to help establish homeostasis. With instructions to
remove it after 10 min.
Primary molars:
For mandibular teeth: Initial luxation is toward the buccal side. Hold pressure to permit buccal
alveolar bone plate to expand. Then return the luxation force lingually. Alternate the buccal and

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lingual movement for further expansion. Then when there is adequate freedom of movement delivers
the tooth to the buccal or lingual side.
For maxillary teeth: Initially apply the forceps and secure a positive apical pressure. The same
procedure used.

Extraction complications:
1. If a permanent tooth bud is moved during an extraction, it should be carefully pushed into its
original position and the socket closed with one or two sutures. Also the permanent tooth bud should
be reinserted immediately without disturbing the tooth follicle or dentinal papilla. Care should be
taken to orient the tooth in the socket in the proper buccolingual position. Then socket should closed
by sutures and pulp tests should be made of the tooth after eruption.
2. If an already erupted permanent tooth with an insufficiently formed root has been dislodged
during the removal of a primary tooth, it should be reinserted and immediately splinted then after
healing pulp tests should made.
3. Sometimes especially on lower molars, because of a lingual inclination of the crown and the
inability of a child to open his mouth sufficiently a difficulties in application of forceps may be
happened.

Post operative extraction complications:

1. Dry sockets are rarely occurring in children. So, if child under 10 years of age develops a dry
socket the operator should immediately think of unusual infection, e.g. actinomycosis or a
complicating systemic disorder (anemia, nutritional disturbance, etc).
2. Aspiration or swallowing of teeth or roots may occur, under local or general anesthesia especially
when the mouth forced open .if possible, most loose teeth should be removed before general
anesthesia is started or the endotracheal tube is introduced orally.
Radiographic survey of teeth to be extracted is of prime importance because:
v To observe the size and contour of primary roots.
v To see the amount and type of resorption.
v The relation of roots to the succedaneous teeth is seen.
v The extent of the disease is seen.

The forceps of primary teeth: The forceps of primary teeth are small in size, with small blades.
Forceps for upper primary anterior teeth and forceps for upper molar, forceps for lower primary
anterior teeth and forceps for lower primary molars.

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Infections manifestation and management
Infections in children are of special importance to the pedodontist, because he is often positioned
to prevent or intercept them. He can shorten their course and prevent their spread.

Infection in a young jaw:

1. May spread due to the wide marrow spaces.
2. May involve the buds of permanent teeth as in brown discoloration of enamel produced in chronic
infection (turner’s hypoplasia). Infection can also cause complete destruction of permanent tooth
germs.
3. May reach the growth centers of the jaw, especially the condylar region in the mandible, resulting
in disfigurement, (sequestration of large pieces of bone in any part of the jaws may have the same
effect).
4. May produce cellulites and abscess formation, which will require incision and drainage.

Alveolar abscess:
The primary tooth abscess is usually evident as a more diffuse infection, and the surrounding
tissue is less able to wall off the process. While the alveolar abscess associated with the pulpless
permanent tooth is usually specific lesion localized by fibrous capsule produced by fibroblasts that
differentiate from the periodontal membrane.

Antimicrobial agents commonly used are:

1. Semi-synthetic penicillins, ex., Amoxycillin.
2. Cephalosporins
3. Macrolides, ex., Erythromycin, Roxithromycin and Clarithromycin.
4. Nitromidazoles, ex., Metronidazole.