exodontia for children-final

7/31/2019 Exodontia for Children-Final

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EXODONTIA FORCHILDREN


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Introduction


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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


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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 areahas 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


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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 firstmolar.

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


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Acute infectious stomatitis, acute Vincentsinfection or herpetic stomatitis and similar lesionsshould be eliminated before an extraction iscontemplated.

Blood dyscrasias render the patient susceptible topostoperative infection and hemorrhage.Extractions should be performed only afteradequate consultation with a hematologist and

proper preparation of the patient Acute or chronic rheumatic heart disease,

congenital heart disease and kidney diseaserequire proper antibiotic coverage


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Acute pericementitits, dentoalveolar

abscesses and cellulitis

Acute systemic infections of childhood

contraindicate elective extractions for the childbecause of a lowered resistance of the body

and the possibility of secondary infection

Malignancy. If suspected, contraindicatesdental extractions. Trauma of extraction tends

to enhance the speed of the growth and

spread of tumors.


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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 toextract teeth after exposure to radiation

Diabetes mellitus patients


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Hands and arms

Antibacterial soap is used and scrubbing hands is done

approximately 5-6 minutes. These are the steps forwashing 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 isgone

Bloat your hands dry with a clean towel.

Do not close the tap with your own hands


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Triad Barrier

To prevent cross-contamination between dentist, staffand patient: Gloves

Disposable gloves are the better option

When sterility is needed eg; implant or aloplastic material toadd ridge: sterile gloves can be used

Mask Face mask with strings is more practical compared to elastic

ones to have better adaptability to the face.

Goggles

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


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Immunization

Mental Preparation

Understanding the procedures of the treatment

Able to overcome complications that may caries

Postsurgical


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Remove debris from instrument

A separate area is needed to clean the

instruments

The brush used to scrub the instruments aredeemed 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


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Packing the instrument

Packing the instrument using 2 layers of cloth

Indicator tape which is sensitive to heat or vaporwhich will change color to indicate the packaging has

been autoclaved is placed

It is recommended the packaged instruments is alsowrapped in clear plastic and the date which theinstruments are autoclaved written on the packaging

The instruments packaged in one layer of cloth mustbe autoclaved every 30 days if not used. Theinstruments packaged in 2 layers of cloth can last till 6months without autoclave if not used


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Instruments are categorized intoCritical instruments Semi critical instruments Non-critical instrument

Instruments that penetrate

soft tissue, contact bone,

enter into or contact the

blood stream or other

normally sterile tissue of

the mouth

Instruments that contact with

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

Instruments that contact with

intact skin

Processed by sterilization Ideally by sterilization.Disinfection

Disinfection


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Example: injection

needles, scalpel,

elevators, burs, tangs,

suture needle.

Example: handpiece, mouth

mirror, bite block,

retractors

Example: counter tops,

chair position controller,

x-ray viewer

1. Sterile instruments must

be checked weekly with

a spore test2. When sterilizing, an

indicator sensitive to

heat or vapor should be

placed outside the

packaging.

If contaminated with blood,

should be wiped with

towel and disinfected

with antimicrobial

solution


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To prevent contamination, we have to Decontaminate

Decontamination is done on surfaces that have come intocontact with patients mouth fluid (saliva, blood, etc.)

Method: All the surfaces that are contaminated or have riskof contamination will be wiped with a clean towel and thendisinfected with whitening solution (diluted Clorox 1:10 or1:100 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 todisinfect such as the light holder or the x-ray head.

Change after every extraction to prevent crosscontamination although there is no sign of contamination.


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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.


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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


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Physical Preparation

Observation of the vital signs

Blood Pressure (120/80)

Pulse Rate Temperature (36degrees Celsius- 37.2 degree

Celsius)

Respiration Rate (12 -20 breaths per minute)


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A proper and accurate medical history is needed todetermine 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.


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Specifically include the patients social habits and

practices such as

Smoking history

Alcohol intake Pregnancy status

History of injecting drug abuse

Sexual practices


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Full Blood Test

Hemoglobin

Hematocrit

Erythrocyte Sedimentation Rate

Leucocyte

Thrombocyte

Bleeding Time and Clotting Time Blood Glucose


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Medical Consultation

Formal request to have input from other doctors

on the surgeryPurpose is to reduce the risk and increase the

possibility of a successful surgery.

Normally done with the anesthetist, internal

medicine specialist and pediatrician


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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

patientsMaintain hemoglobin levels before and after the

operation no less than 10 g / dl


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Informed Consent

It 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.


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Treatment Options

Patient 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 discussedwith the patient.

Written or Verbal Consent

A written consent is signed by both the patient

(parents or guardian), dentist and a witness ifavailable.

All treatments especially one that will affect the

patients level of consciousness should have a written

consent.


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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

anestheticReduce nausea and vomiting

Causes amnesia

Reduce volume and increase the stomach pH

Reduces vagal reflex


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Examples of premedication : Benzodiazepine,

Opoid, Anticholinergic

Factors that determine the type of medication and

dose:Age

Weight

Health status

Mental ConditionAnesthetic and Surgery Procedure

Therapeutic medication


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Factors that determine the type of anesthetic

Age

General Condition of Patient ( past disease, vital

signs, patients cooperation, physical )

Type of surgery

Patients request


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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.


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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


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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


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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


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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


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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


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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.


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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


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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 obliqueInsert 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


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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


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Instruments for Retraction of Soft tissue

Cheek retractor

Types

Right-angle Austin retractor Offset broad Minnesota retractor

To retract cheek and mucoperiosteal flap

Tongue retractor

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

resist the tongue


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Right-angle Austin

retractor

Weider tongue

retractor Offset broad Minnesota

retractor


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Instruments to Keep

Mouth open

Bite block

Used to resist thepatients jaw from

closing, prevent the

stress on the TMJ

Made from rubber


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Instruments for Suction

Used as suction for

blood, saliva and

irrigation solution to beremoved from the

treatment site so that

the view of the operator

is not affected


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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 betweenthe tongue and teeth,

and between the cheek

and teeth to allow an

area to remain isolated

and dry

Elevators


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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 bladeand is at 90 degrees to the handle

Blade: this part of the instrument engages the crown

or the root to be removed


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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


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Straight type Triangle or Pennant shaped

type

Pick type

Commonly used to luxate

teethBroken root remains in the

socket and the adjacent socket

is empty

Used like a lever to remove

rootsTease small root tips from their

socketBlade has a concave

surface on one side that is

placed toward the tooth

to be extracted

Provided in pairs, Left and

right.Blade are triangle in shape


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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


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Miller elevator

Potts elevator

Crane pick

elevator


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General use: reflection of the

mucoperiosteum from the underlying bonebefore 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


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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


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Mandibular Forceps

No.151 S

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 teethand grip the root


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Maxilla Forceps

No.150 S

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


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EXTRACTION TECHNIQUESFOR CHILDREN

P ti t iti


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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 ofpatient + 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


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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 themandibleprevent dislocation

o Provides feel to the operator

Order of extraction: when performing multipleextractions 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


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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 rotarymovement or using elevators

o Palatally positioned lateral incisors and

caninesUsually not accessible with forceps

elevators applied on palatomesial and palatodistal



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Anteriors

For labially placed upper

LI and C

Straight and curved

Warwick James andCouplands elevators.

Straight elevators

applied along the length

of mesial and distal

surfaces of the root.

With rotary manner

towards the apex.

U P i M l


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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 onpalatal aspect slipage of forceps

beak on palatal side during buccal

expansion.

Overcome by continued palatal

U P l


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Upper Premolars

1st

premolar 2 rooted, removed by buccal expansionusing 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

U P t M l


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Upper Permanent Molars

Removed using left and right upper molarforceps

Following application of the forceps to the roots

of the tooth (pointed beak being driven towardthe buccal root bifurcation) tooth is delivered

by expanding the socket in buccal direction

Palatal expansion not successful but can beattempt if buccal expansion fails. Problem

fracture of palatal root

LOWER PERMANENT


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LOWER

PRIMARYANTERIORS

Same manner

as their upper

counterparts Rotation about

the long axis

using lower

primary anterior

or root forceps

LOWER PERMANENT

ANTERIORS Incisors:

Not readily removed byrotation 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

L P i M l


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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 whichengage the bifurcation.

Lower primary root forceps apply beaks to the mesial

root of the primary molar.

Lower 1

st

primary molars usually more easily removedwith lower primary root forceps.

Application of forceps + small lingual movement +

continuous buccal force delivery of tooth

L P l


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Lower Premolars When fully erupted, simply remove by rotary

movement around the long axis of the root usinglower 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 crownwhen forceps are directed from the opposite side

of the jaw. Gentle rotation of the tooth with forceps

may effect the removal.

L P t M l


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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


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o e e a e t

Molars

Cowhorn design forcep. Choice oftechnique depends mainly on the

preference of operator

POST EXTRACTION


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INSTRUCTION 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 ofextraction

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

It is important to explain to thechild what to do after the

extraction as well as to their

parents or caregiver.

REFERRAL CASES


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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


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Supernumerar

y teeth

1


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1

23

Buried tooth


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Cys

t

Abnormal


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Abnormal

frenulum

Tumour

Cysts on apex

caused by

trauma


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EXODONTIA FORDECIDUOUS TEETHCOMPLICATIONS DURING AND POST

OPERATIVE EXTRACTION

DURING EXTRACTION


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DURING EXTRACTIONCOMPLICATION MANAGEMENT

Aspiration or swallowing of teeth orroots may occur, especially under

general anaesthesia with the mouth

forced open

controlled pressure on the handles offorceps 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, itselimination should be ascertained by

having the stools examined for the tooth

Consultation with physician should be

obtained

A tooth may be suddenly released from

the bone and owing to its shape andwedging action of the forceps, may be

squeezed out of the beaks of the

forceps and aspirated or swallowed

POST EXTRACTION


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POST EXTRACTION

COMPLICATION MANAGEMENT

Dry socket rarely happens within

children

If having dry socket, operator should

thought that as unusual infection such

as actinomycosis or systemiccomplication like anaemia or lack of

nutrition

Advising patient to use 0.2%

chlorhexidine mouth rinse may be

helpful to avoid dry socket in suspect

cases

Cotrol pain by analgesics, advice warmsaline 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 conditionZinc oxide dressings also have been

advised


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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 treatmentIf 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 childCotton 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 administeredAlso can give vitamin B and C


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THANK YOU!

exodontia for children-final

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