EXODONTIA FOR CHILDREN

Introduction

Factors that will affect the extraction of teeth in children

Natal and neonatal teeth Infraocclusion Fusion/Germination : due to the abnormal shape, elevators should be used Damage to Permanent Successor: Do not use forceps with large beaks. A radiograph should be obtained. Dislocation of Mandible: It is very easy to dislocate a childs mandible during extractions under general anesthesia as the articular eminence is not pronounced yet. Always verify this situation before allowing patient to gain consciousness

If the teeth is decayed beyond possible repair; if decay reaches down into bifurcation or if a sound hard gingival margin cannot be established If infection of the periapical or interradicular area has occurred and cannot be eradicated by other means In cases of acute dentoalveolar abscess with cellulitis If the teeth are interfering with the normal eruption of the succeeding permanent teeth In cases of submerged teeth

If the primary second molar has not fallen and first molar has a severe caries, the first molar can be extracted so that the permanent second molar will drift into the space of the first molar. If the primary second molar has already fallen. The permanent first molar must be saved in any way possible. As drifting of teeth will not occur fully. Extraction to reduce the third molar impaction

Acute infectious stomatitis, acute Vincents infection or herpetic stomatitis and similar lesions should be eliminated before an extraction is contemplated. Blood dyscrasias render the patient susceptible to postoperative infection and hemorrhage. Extractions should be performed only after adequate consultation with a hematologist and proper preparation of the patient Acute or chronic rheumatic heart disease, congenital heart disease and kidney disease require proper antibiotic coverage

Acute pericementitits, dentoalveolar abscesses and cellulitis Acute systemic infections of childhood contraindicate elective extractions for the child because of a lowered resistance of the body and the possibility of secondary infection Malignancy. If suspected, contraindicates dental extractions. Trauma of extraction tends to enhance the speed of the growth and spread of tumors.

Teeth which have remained in irradicated bone should be extracted only as a last resort and only after the consequences have been fully explained to patient. It is very dangerous to extract teeth after exposure to radiation Diabetes mellitus patients

Clinic Clothing
Has

to be clean and appropriate

Hands and arms

Antibacterial soap is used and scrubbing hands is done approximately 5-6 minutes. These are the steps for washing hands before and after every dental treatment :

Remove all jewelry (rings, watches, bracelets) Nails must be short and clean Wet hands with running water. Apply soap and rub to lather well These steps should be done for 15-30 seconds

Rub palm to palm Rub the back of both hands Rub palms again with fingers interlaced Rub backs of interlaced fingers Wash back of thumbs Rib both palms with fingertips Wash your wrists

Rinse hands under clean running water until all the soap is gone Bloat your hands dry with a clean towel. Do not close the tap with your own hands

Triad Barrier

To prevent cross-contamination between dentist, staff and patient:

Gloves

Disposable gloves are the better option When sterility is needed eg; implant or aloplastic material to add ridge: sterile gloves can be used Face mask with strings is more practical compared to elastic ones to have better adaptability to the face. Made from plastic and light Provides eye protection from saliva, micro bacteria, debris and other foreign materials. Operator is also recommended to use surgical caps

Mask

Goggles

Immunization Mental Preparation

Understanding

the procedures of the treatment Able to overcome complications that may caries Postsurgical

Remove debris from instrument

A

separate area is needed to clean the instruments The brush used to scrub the instruments are deemed contaminated are cannot be used to wash hands The nurse in charge of washing the instruments must wear thick gloves All the saliva, blood and tissue must be cleaned before starting the sterilization and disinfection stage. It is recommended to use a ultrasonic cleaner

Packing the instrument

Packing the instrument using 2 layers of cloth Indicator tape which is sensitive to heat or vapor which will change color to indicate the packaging has been autoclaved is placed It is recommended the packaged instruments is also wrapped in clear plastic and the date which the instruments are autoclaved written on the packaging The instruments packaged in one layer of cloth must be autoclaved every 30 days if not used. The instruments packaged in 2 layers of cloth can last till 6 months without autoclave if not used

Instruments are categorized into

Critical instruments Semi critical instruments Non-critical instrument

Instruments that penetrate

Instruments that contact with

Instruments that contact with

soft tissue, contact bone,

enter into or contact the blood stream or other normally sterile tissue of the mouth

the mucous membrane but

will not penetrate soft tissue, contact bone, enter into or contact with blood stream or other normally sterile tissue of the mouth

intact skin

Processed by sterilization

Ideally by sterilization.
Disinfection

Disinfection

Example: injection needles, scalpel, elevators, burs, tangs, suture needle. 1. Sterile instruments must be checked weekly with a spore test

Example: handpiece, mouth Example: counter tops, mirror, bite block, retractors chair position controller, x-ray viewer

If contaminated with blood, should be wiped with towel and disinfected

2. When sterilizing, an
indicator sensitive to heat or vapor should be placed outside the packaging.

with antimicrobial
solution

To prevent contamination, we have to

Decontaminate
Decontamination is done on surfaces that have come into contact with patients mouth fluid (saliva, blood, etc.) Method: All the surfaces that are contaminated or have risk of contamination will be wiped with a clean towel and then disinfected with whitening solution (diluted Clorox 1:10 or 1:100 depending on the type of organic substance.

Surface protector
Use a waterproof paper, aluminium foil or clear plastic to cover the surfaces that are easily contaminated and hard to disinfect such as the light holder or the x-ray head. Change after every extraction to prevent cross contamination although there is no sign of contamination.

Mental Preparation
Minimize

anxiety and fear of patients to injections, wound pain, anesthetic action and the possibility of disability or death. Good communication with patient, if possible make patient feel at ease in any way possible depending on the patient.

Medical history and physical examination is the best screening method to detect a disease Even without signs and symptoms of a disease, the surgeon may request for a laboratory test as precaution

Radiology

and Histopathology examination

Physical Examination consist of

Anamnesis Inspection Palpation Percussion Auscultation

Physical Preparation
Observation
Blood

of the vital signs

Pressure (120/80) Pulse Rate Temperature (36degrees Celsius- 37.2 degree Celsius) Respiration Rate (12 -20 breaths per minute)

proper and accurate medical history is needed to determine whether a patient can undergo surgery Can be obtained from the patient or patients family Take note of:
Allergy,

especially to antibiotic Medication, whether the patient is taking steroids, insulin or anticoagulant Existing Disease such as diabetes mellitus, epilepsy, asthma, stroke or infarct and etc. Past surgery, normally heart surgery, organ transplant or cancer surgery. Ask whether there were any reactions or complication throughout the surgery.

 Specifically
Smoking

include the patients social habits and practices such as

history Alcohol intake Pregnancy status History of injecting drug abuse Sexual practices

Full Blood Test

Hemoglobin
Hematocrit Erythrocyte

Sedimentation Rate

Leucocyte
Thrombocyte

Bleeding Time and Clotting Time Blood Glucose

Medical Consultation
Formal

request to have input from other doctors on the surgery Purpose is to reduce the risk and increase the possibility of a successful surgery. Normally done with the anesthetist, internal medicine specialist and pediatrician

Nutrition
Consideration

of the need for proper nutrition based on the patient's clinical condition

Blood supply
Blood

reserves in the event of complications in patients Maintain hemoglobin levels before and after the operation no less than 10 g / dl

 Informed
It

Consent

is as effective way to provide enough information to the patient such as general status, therapy that will be done and alternatives, the pros and cons of the therapy, complications Communication between doctor, patient and parents or guardian must be accurate and clear when providing information. It should be a two way conversation. Information is given based on the education level, experience, age and other factors.

 Treatment
Patient

Options

and parents or guardian should be informed of their options, and should never be led to believe that there are no alternatives. There is an option of no treatment and its consequences must be discussed with the patient.

Written

or Verbal Consent

A written

consent is signed by both the patient (parents or guardian), dentist and a witness if available. All treatments especially one that will affect the patients level of consciousness should have a written consent.

 Medication

given in a 1-2hour period before

anesthesia Purpose of premedication

Reduce

anxiety and panic Induces calmness Reduce airway secretion Strengthen the effect of hypnotic drugs in general anesthetic Reduce nausea and vomiting Causes amnesia Reduce volume and increase the stomach pH Reduces vagal reflex

 Examples

of premedication : Benzodiazepine, Opoid, Anticholinergic Factors that determine the type of medication and dose:
Age Weight Health

status Mental Condition Anesthetic and Surgery Procedure Therapeutic medication

Factors that determine the type of anesthetic

Age
General

Condition of Patient ( past disease, vital signs, patients cooperation, physical ) Type of surgery Patients request

NERVE FOR MAXILLARY

Nerves at maxillary are nasopalatinal nerve (D) connects palate, canine region and incisor tooth Anterior palatine nerve connects to hard palate and molar region Anterior superior alveolar nerve connects to canine and incisor and buccal side of the teeth Superior alveolar nerve connects mesiobuccal root of deciduous teeth.

NERVE FOR MANDIBLE

Buccinators nerve connects cheek mucosa, buccal soft tissue from molar to canine Interior alveolar nerve connects mandible teeth until median line Lingual nerve connects 2/3 anterior tongue and lingual side of tooth until median line

PREPARATION FOR ANASTHESIA

Take Phenobarbital dose about half to one hour before appointment Sterilization needs for the operator and mucosa region that need to be

injected
Instruments needed are sharp needle, disposable and the size of needle for children less than adult Anaesthetic drugs for topical is chloroethyl which can be paste or spray using cotton For local anaesthesia, drug being used are esther (procaine) or non esther (lidocaine or prilocaine) added with vasoconstrictor

TOPICAL ANASTHESIA
A method that pain relief at the surface site by applying it directly Indications : incision abscess

extraction of mobile tooth

extraction of deciduous tooth to subtract pain when enter the needle for sensitive patient Side effects are dizziness, nausea or fainting

TECHNIQUE FOR TOPICAL ANASTHESIA

Dry the region that will be anaesthetised If hyper salivation happens at that region, use cotton roll for isolation Within 15 cm, spray chloroethyl until the surface looks pale We can also sprayed directly on cotton, then put on the gums two to four times Extraction can be done

Patient is advice to breath by using nose

INFILTRATION ANASTHESIA
Used for relief pain at certain region by injection Indications : extraction molar deciduous tooth that had been resorption till mobile extraction of deciduous tooth that persistent

TECHNIQUE FOR INFILTRATION ANASTHESIA

wiping muccobuccal fold with jodium Inject the needle at 45 at muccobuccal fold or one and a half of the tooth neck, bevel towards the bone, until reach the bone Withdraw 1-2 mm and parallel the needle until reach the bone at periapical tooth region nearby Release 1cc slowly because too rapid of releasing anaesthesia will lead to spreading to broad region and the effect will be too light For palatine region, injection at palatine mucosa 1/3 from dental gum edge distance that will be extracting Put a light pressure when inserted the needle and release 0.5cc of anaesthesia.

BLOCK ANASTHESIA
To relief pain at a certain region because of anaesthesia at central nerve system Two techniques :

Single path technique or straight line technique is directly given

Fisher technique is indirectly given to patient. Indications : extraction of molar deciduous tooth which its root not resorp yet extraction of permanent molars

TECHNIQUE FOR BLOCK ANASTHESIA

parallel mandible with floor Put your index finger at the occlusal of the molar tooth so that it will touch the occlusal angle The finger nail facing to the tongue, find retromolar trigone and lean the nail at internal linea oblique Insert the needle at near the tip of finger and the syringe is at first and second

molar at the opposite side

When already reach to the bone, withdraw a bit and put the syringe parallel to occlusal site which will be anaesthetise

Release 0.5cc for lingual nerve and placed syringe at the first position which situated in between canine and first molar Face it towards below of occlusal plane until reach mandible foramen Release 1cc of anaesthesia for inferior alveolar nerve To anaesthetise buccal side, infiltration anaesthesia is done with 0.5cc for buccinators nerve After five minutes, cheek, anterior tongue and lips will be numb at one side

Wound can happen certain time because children bite the anesthetise region

Instruments for Retraction of Soft tissue

Cheek

retractor

Types

Right-angle Austin retractor Offset broad Minnesota retractor

To

retract cheek and mucoperiosteal flap

Tongue
Mouth

retractor

mirror, Weider tongue retractor( wide retractor, heart shape with sharp teeth on one side till it can resist the tongue

Right-angle Austin retractor Weider tongue retractor Offset broad Minnesota retractor

Instruments to remove soft tissue from damaged bone

Periapical
Has

curette

a angled shape, with two ends Debridement of socket Used to remove soft tissue from damaged bone such as removing granuloma or small cyst from periapical lesions or removing granulation tissue debris from teeth socket

Instruments to Keep Mouth open

Bite

block

Used

to resist the patients jaw from closing, prevent the stress on the TMJ Made from rubber

Instruments for Suction

Used

as suction for blood, saliva and irrigation solution to be removed from the treatment site so that the view of the operator is not affected

Instruments for irrigation

Normally

used large plastic syringe with an 18 gauge blunt needle Uses: irrigation of treatment area with sterile saline

Instruments for hemostasis

Sterile square gauze

Applied with pressure to the area of bleeding

Cotton rolls
To stop bleeding by biting on it Can be placed between the tongue and teeth, and between the cheek and teeth to allow an area to remain isolated and dry

Elevators
Primarily

as levers Parts of an elevator

Handle:

this part is used for holding the instrument Shank: this part connects the handle with the blade and is at 90 degrees to the handle Blade: this part of the instrument engages the crown or the root to be removed

 Indications
To

reflect mucoperiosteum Luxate the tooth before applying the forceps for extraction To luxate and remove the tooth from its socket which cannot be engaged with forceps To remove a fractures or carious tooth which might fracture when engaged with beaks To remove inter-radicular bone To remove a fractured root when the fracture line is below the cervical line

Straight type

Triangle or Pennant shaped type

Pick type

Commonly used to luxate Broken root remains in the teeth socket and the adjacent socket is empty

Used like a lever to remove roots Tease small root tips from their socket

Blade has a concave

Provided in pairs, Left and

surface on one side that is right. placed toward the tooth Blade are triangle in shape

to be extracted

Example : No.301 which are used to displace tooth before forceps are used Larger elevators are used to displace roots from their sockets or when the smaller elevators are less effective Most frequently used: No.34S, No.46 and no.77R

Most common types are Cryers.

Two versions: Crane pick Root tip pick

Examples of angled shank elevators with the blades similar to the straight elevators is the Potts elevators and Millers elevators

Miller elevator Potts elevator Crane pick elevator

General use: reflection of the mucoperiosteum from the underlying bone before extracting of teeth, testing whether the anesthesia has worked, reflection of the gingival cleft Normally used is Molt periosteal elevator no.9

Has 2 ends : pointed-sharp and flat-wide Uses The pointed end is used to lift up the soft tissue. Usually used at the dental papilla The flat and wide end is pushed under a flap to separate the periosteum from the bone beneath it With a scraping motion the periosteum is separated from bone Used as a retractor

 General

use: removal of fractured root, impacted maxillary third molars and impacted cuspids. There are various types No.301 straight apexo elevators

Used for the removal of fractured roots( at the gingival line) of maxillary central and lateral incisors, bicuspids and cuspids

No.4(302)and

5 (304) elevators

Used when the mandibular root has fractured below the gingival line The blade is at 90 degree angle to the handle

 Mandibular
No.151

Forceps

Universal mandible forceps Has beak which form a nearly 90 degree to the handle The handle is slightly bent the beak is relatively small ,narrow and meets only at the tip, which helps the beak to adapt with the cervical line of the teeth and grip the root

 Maxilla

Forceps
S

No.150

Universal forcep The beak is almost parallel to the handle ( has a slight bent) The beak when seen from side, is slightly curved but seen from the top is straight

EXTRACTION TECHNIQUES FOR CHILDREN

 Patient position o Child seated in dental chair reclined about 30 degree to the vertical for extraction under LA o Removing upper teeth, operator stands in front of patient + straight back + patients mouth just below the operators shoulder. o Removing lower teeth, similar position for upper teeth + patients mouth just below the operators elbow.

 Non-working hand o Retracts soft tissue allow visibility and access o Protects tissues if instrument slips o Provides resistance to the extraction force on the mandibleprevent dislocation o Provides feel to the operator Order of extraction: when performing multiple extractions in all quadrants (especially in under GA) o Symptomatic teeth before balancing extractions o Lower teeth before upper teeth (eliminate bleeding interfering) o If symptomatic teeth in all quadrants, begin with lower right (minimizes number of changes of position of surgeon reduces GA time)

Upper Primary and Permanent Anteriors

When tooth in normal position: o apply forceps beaks to the root, using clockwise and anticlockwise rotation about the long axis (like screwdriver) o In older children, additional buccal expansion may be required for the removal of the permanent upper canine Malpositioned permanent anteriors: o Labially placed lateral incisors and canines little buccal support (easily removed) by using straight forceps applied mesially and distally + slight rotary movement or using elevators o Palatally positioned lateral incisors and caninesUsually not accessible with forceps elevators applied on palatomesial and palatodistal

Upper Primary and Permanent Anteriors

For labially placed upper LI and C Straight and curved Warwick James and Couplands elevators. Straight elevators applied along the length of mesial and distal surfaces of the root. With rotary manner towards the apex.

Upper Primary Molars

Primary molars has widely splayed roots considerable expansion of socket is required Upper primary molar forceps are used and applied to the roots with initial movement palatally (to expand socket) Continued with buccal directed force sometime, not adequately obtained due to gross caries on palatal aspect slipage of forceps beak on palatal side during buccal expansion. Overcome by continued palatal

Upper Premolars
1st premolar 2 rooted, removed by buccal expansion using upper premolar forceps 2nd premolar single rooted, attempt buccal expansion, then, rotation about its long axis Palatally displaced difficult to remove using forceps. Use elevators in a manner similar to palatally displaced canines

Upper Permanent Molars

Removed using left and right upper molar forceps Following application of the forceps to the roots of the tooth (pointed beak being driven toward the buccal root bifurcation) tooth is delivered by expanding the socket in buccal direction Palatal expansion not successful but can be attempt if buccal expansion fails. Problem fracture of palatal root

LOWER PERMANENT ANTERIORS LOWER PRIMARY ANTERIORS Same manner as their upper counterparts Rotation about the long axis using lower primary anterior or root forceps
Incisors: Not readily removed by rotation thin roots mesiodistally fracture Apply lower root forceps and expand socket labially Labially placed straight elevators Canine : Rotary movement about long axis or by buccal expansion Labially displaced similar to buccally displaced upper anteriors

Lower Primary Molars

Removed by buccolingual expansion of the socket. Extracted using either lower primary molar or lower primary root forceps. Lower primary molar forceps similar design to permanent molar forceps have 2 beaks which engage the bifurcation. Lower primary root forceps apply beaks to the mesial root of the primary molar. Lower 1st primary molars usually more easily removed with lower primary root forceps. Application of forceps + small lingual movement + continuous buccal force delivery of tooth

Lower Premolars
When fully erupted, simply remove by rotary movement around the long axis of the root using lower premolar forceps. Malpositioned (normally lingually): Difficult to remove with lower premolar forceps Extracted using straight elevators applied mesially, lingually and distally. Alternatively, if possible, apply beaks of upper fine root forceps mesially and distally to the crown when forceps are directed from the opposite side of the jaw. Gentle rotation of the tooth with forceps may effect the removal.

Lower Permanent Molars

Using lower molar forceps: o Has 2 beaks, applied in region of the bifurcation bucally and lingually. o Apply forceps move tooth buccaly (expand buccal cortical plate) if insufficient, forceps moved in figure-of-eight fashion (expand socket lingually as well as buccally) Using forceps with cowhorn design: o Has 2 beaks that taper to a point. o Points applied to bifurcation similar to above technique squeeze forceps together beaks approaching one another at base of bifurcation tooth displaced in occlusal direction extraction of

Lower Permanent Molars

Cowhorn design forcep. Choice of technique depends mainly on the preference of operator

 Bite down on gauze 20-30 minutes w/o chewing the gauze (Do not disturb the clot) Do not use straw Brush teeth as usual w/o using mouthwash on the day of extraction If swelling occurs ice pack If jaw stiff after swelling warm pack Eat soft and cool foods If there is stiches rinse with salt water Seek medical attention if pain after 48 hours or abnormal

POST EXTRACTION INSTRUCTION

It is important to explain to the child what to do after the extraction as well as to their parents or caregiver.

REFERRAL CASES
Supernumerary teeth Buried teeth Cysts in the soft tissue Abnormal lingual or labial frenulum Tumours Cysts caused by trauma to the apex of the tooth

Supernumerar y teeth

Buried tooth

Cys t

Abnormal frenulum

Tumour

Cysts on apex caused by trauma

EXODONTIA FOR DECIDUOUS TEETH

COMPLICATIONS DURING AND POST OPERATIVE EXTRACTION

DURING EXTRACTION
COMPLICATION MANAGEMENT

Aspiration or swallowing of teeth or roots may occur, especially under general anaesthesia with the mouth forced open
A tooth may be suddenly released from the bone and owing to its shape and wedging action of the forceps, may be squeezed out of the beaks of the forceps and aspirated or swallowed

controlled pressure on the handles of forceps and by using a 4 by 4 inch sponge as a curtain behind the tooth to be extracted radiographic examination of the chest and abdomen should request immediately if cannot encountered A tooth or part of it in bronchial tree must be removed as soon as possible by bronchoscopy to prevent serious complications If it is in alimentary canal, its elimination should be ascertained by having the stools examined for the tooth Consultation with physician should be obtained

POST EXTRACTION
COMPLICATION Dry socket rarely happens within children If having dry socket, operator should thought that as unusual infection such as actinomycosis or systemic complication like anaemia or lack of nutrition MANAGEMENT Advising patient to use 0.2% chlorhexidine mouth rinse may be helpful to avoid dry socket in suspect cases Cotrol pain by analgesics, advice warm saline rinse to remove food debris, dressing the cavity to protect & heal the socket Early stages - initiating fresh bleeding in the socket and giving a pack will resolve this condition Zinc oxide dressings also have been advised

Infections: May spread owing to the wide marrow spaces May involve the buds of permanent teeth, as in brown discolouration of enamel produced in chronic infection, can also cause complete destruction of permanent tooth germs May reach the growth centers of the jaw, especially condylar region in mandible, resulting in disfiguration May produce cellulitis and abscess formation which will require incision and drainage

Retention of a permanent anterior tooth is a paramount importance and should be attempted even if life span of the tooth may be retentively short after treatment If the tooth painful to percussion and elongated and presents spontaneous throbbing pain, the pulp chamber should be opened If anasthesia must be used, use inhalation especially in a well premedicated child Cotton prevents solid food particles from obstructing the drainage, root canal treatment may institute, followed by apicoectomy or periapical curettage Dentist may prescribe antibiotic to treat the infection Antibiotic is administered Also can give vitamin B and C

THANK YOU!