PEDIATRIC CONSIDERATIONS

IN ORAL SURGERY
Part 2
Extractions

Learning objectives
• Explain extraction of primary teeth and minor oral surgical
procedures among children. (C2)
Indications
Therapeutic
• Non-restorable caries
• Apical disease refractory
to endodontic Tx
• Fractures of crowns or
roots
• Prolonged retention of
deciduous tooth due to
improper resorption of
root/ ankylosis
• Impacted teeth
• Supernumerary
Contraindications
Prophylactic Prophylactic Relative Absolute Local
(General) (Local)
• Acute Oral Infection • Uncontrolled • Acute gingival and
• Prior to organ • Tooth in fracture line as stomatitis or pericoronal
transplantation to cleft/tooth in the region herpetic stomatitis diabetes
infections
prevent to prevent of an osteotomy line • Congenital heart • Renal failure • Extraction of
transplant rejection • Peri-coronitis disease, rheumatic
• Prior to radiation or • prevent a follicular cyst fever • Liver cirrhosis maxillary molars and
chemotherapy to prevent • risk of root resorption • Blood Diseases as • Leukemia premolars during
osteoradionecrosis acute maxillary
• Risk of caries hemophilia or
• Prior to heart-valve leukemia • Cardiac failure sinusitis
• Resorption of the alveolar
surgery
bone due to repeated • Uncontrolled • Hemangioma • Teeth related to
Diabetes Mellitus
infection
• Preventive measures • Renal disease
• Arteriovenous malignant tumors
against relapse • After radiotherapy fistula

How is it different from permanent tooth

Pre-op management extraction?
• Knowledge of eruption times and sequence
• Simple extraction requires minimal modification from that used in
• Delayed eruption that is asymmetric indicates abnormality adult
• Radiograph of the tooth to be extracted important-
• Important is child management
• Root size and contour of primary tooth
• Amount and type of resorption • Modifications dictated by:
• Relation of roots to succedaneous tooth • Proximity of the succedaneous tooth to the roots
• Extent of disease • Roots of non resorbed teeth are long, slender and potentially divergent
Armamentarium

• Pediatric forceps
• Reduced size allows easy placement in smaller mouth of child

• Easily concealed in operator’s hand

• Smaller working beaks more closely adapt to the anatomy of the primary
teeth

❖Cow horn forceps is contraindicated for use in primary teeth owing to

potential for injury to the developing premolars

Gripping the forceps

Principles of selecting forceps
Parallel to the long
axis

Right

Does not engage

the adjacent tooth Right

Engage the tooth Adapt to the root

firmly surface
Prior to extraction general considerations
Positioning of patient
Review of
Parental informed Preparation of
patient’s medical Prevent by:
consent the child Aspiration of objects due
history ***** to: - Patient position such that
upper jaw is at a angle not
- Reclining position
greater than 45 degree to
- Poor visibility as a result of the floor – Mx – 45 degree
small mouth and relatively
- Md – II to floor
large tongue
Demonstrate to - If greater angle preferred
- Unexpected movements
Ensure profound place a light gauze in the
child the pressure by the child
posterior oral cavity
anesthesia
he/she would feel

Important

• Should give easy control of instrument

Operator • Good visibility of surgical site
position: • Control child’s head

• to control patient’s head;

Use non • support jaw being treated;
dominant • retract cheek, lips, and tongue from surgical field
• Palpate the alveolar process and adjacent teeth
hand during extraction
General principles of extraction General principles of extraction
Apical pressure applied Apical end - minimal Tears the periodontal
such that center of translational movement ligament fibers
rotation is as close to → less chances of
root apex fracture of apical third

Periosteal elevator Placement of Catch the root not

appropriate forceps the crown’

• severe epithelial • Use appropriate • First lingual beak

attachment forceps then slide over
the buccal beak
into proper
position

General principles of extraction

Socket evaluated No scraping of

visually and with Check for any bony
extraction site after
curette sharpness
deciduous extraction

Evaluate for suture – rarely

indicated for deciduous Written post operative
Compress the socket to teeth extraction instructions and
original & explain to both parent
Obtain hemostasis and child
 • First palatal movement followed by buccal with slow continuous force
Primary molar extractions • Important to support the mandible with non dominant hand to
prevent injury to TMJ
• Max. and mand. deciduous molars differ from
permanent - height of contour is closer to
cementoenamel junction; roots are divergent
and smaller in diameter- root fracture
common

• Relationship of primary molar roots to

succeeding tooth – if roots encircle the
premolar crown , premolar can get
inadvertently extracted

Maxillary anterior extractions Mandibular Anterior extraction

• Incisors and canines- single
rooted
• Care that forceps does not place
any force on the adjacent tooth
as they can be easily dislodged
• Rotational force is used

• Incisors ( dec & perm), canines have single conical roots, fracture less likely
• Rotational movements
• Deciduous anterior should be luxated labially due to lingual position of
the permanent tooth****
 If pre-op evaluation shows that root fracture is likely,
Fractured primary roots alternative method of extraction to be used i.e. sectioning
Consider Common sense

If root visible remove

Aggressive removal -
root tips → damage to
succadenous tooth
If several attempts fail to remove, or tip
is very small,situated very deep, best to
leave it to resorb

Leaving it may lead to

postop infection, delay Notify parents
eruption of permanent
tooth, though most of
primary roots resorb
Reassure chances of unfavorable sequelae rare

Post extraction instructions Complications of extraction

• Bite on gauze for 30 minutes. Do not chew on the gauze
• Take soft cold diet, avoid hot food and drinks • Can occur:
• Take pain medication as directed • During anesthesia – syncope, allergy
• In case of increased pain or abnormal bleeding report to dental office • During extraction
• To prevent bleeding and swelling keep head elevated while resting or sleeping • Soft tissue laceration
• Broken tooth
• If bleeding starts again put a new gauze pad or a damp tea bag over the bleeding area • Oroantral communication
for1 hour, do not chew on it. • Luxation of adjacent tooth
• Do Not use straw to drink for 24 hours • TMJ problem
• Do Not rinse mouth on the day of extraction • Fracture jaw
• Tooth ingestion or aspiration
• Do Not spit and swallow saliva, otherwise it will cause bleeding • After extraction
• Do not eat anything till the numbness goes away • Bleeding
• Do not bite on the lip or cheek for 2 hours after extraction • Dry socket ( rare in children)
• Self inflicted trauma ( lip biting)
• Ice packs used immediately after surgery will reduce swelling. Keep ice pack on for 10
minutes and off 10 minutes.