8- child extractions

What does the success of a pediatric extraction depend on?

Procedure itself- loose tooth or surgical extraction

Child’s psychological conditions

Behaviour management techniques- motivation and anxiety control

LA or sedation techniques- pain control

As a general rule…

Surgical extraction is not necessary in temporary dentition

Must have informed consent and preop x rays

Indications for extractions in temp dentition

Large non restorable caries lesions

Traumatic lesions- dentoalveolar fracture, vertical fracture

Orthodontic reasons (serial extractions)

Periapical or inter-radicular infection- no other alternative

Medical reasons (lack of cooperation, disabled patient)

Acute dento-alveolar abscess with cellulitis

Temporary teeth which interfere with the normal eruption of the permanent successor (ectopic eruption, ankylosis)

Persistence of temporary roots

Serious delay of eruption of the permanent teeth

Temporary teeth related or close to cysts, tumors

Periodontal problems

Economic problem

What are some systemic contraindications of extractions?

Medical issues may delay- consult with paediatrician or specialist

Rheumatic fever in childhood

Congenital cardio disease

Renal disorder

Immunodeficiency

Blood dyscrasia, Hemophilia or other platelet disorders

Diabetes (if uncontrolled- affects healing process, due to weak immune system)

Patients on steroids.

Malignant disease is an absolute contraindication- Leukaemia, Lymphoma- Increased risk of infection and bleeding. Only indicated if maxillary bones need radiation because of a tumor

Local contraindications in dental extractions

Previous/ present radiation treatment in that area- ORN of the jaws is likely to develop (absolute contraindication).

Severe acute infection abscess, pericoronatis (relative contraindication, extraction is delayed)

Angioma

Other contraindications to consider?

Psychological and physical immaturity of child- assess social, emotional status and cognitive level

Nutritional facts

If no informed consent

What must you evaluate preop extraction?

Medical history, intraoral exam, radiogarph

Behaviour

Signed informed consent

Explain procedure to child and parent

Premedication if necessary (endocarditis)

Give post op recommendations and prescribe meds in advance

Instruments- forceps

Pediatric forceps- smaller and easier to hide in hand

Conventional forceps- bigger but easier to handle- more efficient for force

Instruments- elevators or luxators

Use if- retained roots, ankylosed teeth, very destroyed teeth

Caution if sharp

Control tip by placing finger close to it, hold handle with hand

Instruments- peristome, curette

Peristome- retracts mucoperiosteum

Sharp spooned curette- to remove connective and granulation tissue from bone- NOT FOR TEMP- damages perm tooth

Suture not freq

Anaesthesia technique for extractions?

Local

Start with topical- spray/gel- benzocaine gel 5 mins

1- Infiltration injection

2- Mandibular block- but may be uncomfy

Upper anteriors extraction technique

Easy and simple- good visibility

1 conical root

Cause- trauma or huge caries

Rotation with forceps

Roots require elevator then forceps

Respect permanent germ- in palatal apical area

Luxation movements of crown ALWAYS LINGUAL never buccal

When shouldn’t you extract upper anteriors?

If non visible radicular crest

Usually after horizontal fracture

Leave them to resorption

How to extract lower anterior teeth?

Due to lingual eruption of permanent

Careful luxation movements if atypical root resorption as the root will be long but extremely thin

How to extract upper posterior molars? (Why difficult to use forceps, first, what movements)

Crown convexity + cervical outline height + root convexity

Use the elevator to remove insertion

Start with palatal movements, and after buccal movements

Soft circular movements can be performed after that

What instruments to use/not for lower posterior molars, consider…?

Avoid cow horn forceps- damage perm germ

Use straight elevator

If difficult- odontosection- in L2M extract m and d roots separately

Support mandible to protect TMJ joints from injury

Maxillary and mandibular molars important points

Roots are shorter, thiner and much more divergent than permanent

Eruption of the successor weaken the roots

Root fracture common

Before extraction, assess with X-Ray of the relation between temporary roots and the permanent successor (how close)

Pressure should be avoided in the furcation area. maybe odontosection to protect the developing permanent tooth

Force has to be continuous palatal-lingual to buccal, allows for the expansion of the alveolar bone to reduce the risk of root fracture

What to remember if the primary tooth root is fractured?

If root tip can be removed easily- remove it

If small root deep in socket close to perm successor- leave to be resorbed- inform parents and monitor

Extraction of immature PD…

Usually premolars for orthodontic indication, or first molars (caries, MIH)

Less probability of root fracture

Bone is more spongy than the one in an adult

What must you do during the extraction?

Prevent swallowing extracted tooth by placing intraoral gauze behind it

If extracting after a resto- keep rubber dam on

Avoid periapical curettage

Post operative consideration

Show cleaned extracted tooth

Hold gauze for 15-30mins- change if bleeding continues to 60mins

Don’t eat until after anaesthesia effect gone

Don’t rinse or spit first day

Ice in wet cloth can be placed after 2-3 hrs- 10mins on, 20mins off

Soft cold diet , careful brushing

Rinse with serum + take painkiller

What is the most frequent complication after child extractions?

Mainly after inferior alveolar block (mandible)

Swelling as child suctions their lip- cerstaes edema- mistaken for abscess

Mild pain and discomfort

May scratch injury of chin

What are some complications averted child extractions?

Pain

Difficulty eating and drinking

Abscess

Temperature

Cellulitis

Septicaemia