Pediatric1.docx

CHAPTER

Pediatric Exodontia Nikhil Marwah

Chapter outline • • • •

Indication for Extraction of Teeth Contraindications for Extraction Preparation for Extraction Principle of Extraction Exodontia Techniques Procedure for Extraction Extraction of Permanent Maxillary Teeth Extraction of Mandibular Teeth Extraction of Roots Extraction of Deciduous Teeth Operative Complications Postoperative Care • •

The horrifying experience associated with the tooth extraction in the past is still to overcome by the layman. Even today the removal of a tooth is still dreaded by the patient almost more than any other surgical procedure. Many patients have extraction phobia, despite modern methods of anesthesia. Today dentists often consider tooth extraction a minor and unimportant procedure and without proper training, attempt difficult cases and land up in a mess. Before undertaking the extraction of a tooth, one should thoroughly evaluate the care involved. Further, consideration should be given to type of anesthesia used and a good radiograph should be secured to rule out any abnormalities that may make extraction difficult. So in this way we can avoid the

hasty use of forceps and the type of procedure can be selected that is most

likely to yield the best results. The ideal tooth extraction is the procedure of painless removal of whole tooth, or root with minimum trauma to soft tissue and hard tissue so that the wound heals uneventfully and with no postoperative problem. the instances, teeth are extracted because they are affected by disease or can cause ill health due to spread of the infection. Following are the main indications: . Teeth affected by advanced caries and its sequelae - Teeth affected by periodontal disease Extraction of healthy teeth to correct malocclusion . Over-retained teeth Trauma to the teeth or jaws may cause dislocation of a tooth from its socket (avulsion)

Extraction of teeth for prosthodontic reasons . Impacted and supernumerary teeth . Extraction of decayed 1st or 2nd molars to Extraction of teeth for esthetic reasons .

prevent

impaction of 3rd molars Teeth involved in fracture line . Teeth involved in tumors or cysts . Tooth as foci of infection

Teeth affected by crown, abrasion, attrition or hypoplasia Teeth affected by pulpal lesions e.g. pulpitis, pink spot or pulp polyp . Teeth in the area of direct therapeutic irradiation. INDICATION FOR EXTRACTION OF TEETH The value of a tooth should not be underestimated as they CONTRAINDICATIONS FOR EXTRACTION are important not only from an esthetic point of view but also help in proper digestion of food. There are many reasons why It is necessary for the well being of the patient to delay both deciduous and permanent teeth have to be extracted. extraction until certain local or systemic conditions can be Sometimes, normal teeth occasionally must be sacrificed to corrected or modified. Analgesics and antibiotics can be improve mastication and prevent malocclusion. In most of used to keep the patient comfortable. It is sometimes best to

Chapter 62 Pediatric Exodontia 7 treat the infection first and extract the tooth when the acute . If a tooth is to be removed by dissection symptoms subside. There are few absolute contraindications . Close relationship of tooth or root with to the removal of teeth when it is necessary for the well being - Maxillary sinus of the patient. - Inferior alveolar canal

• Presence of acute oral infections such as, necrotising - Mental nerves ulcerative gingivitis or herpetic gingival stomatitis. • All mandibular and maxillary 3rd molars, in standing Pericornitis (difficult surgical procedure involving bone premolars or misplaced canines removal is anticipated). Pulp less teeth with resorbed roots Extraction of teeth in previously irradiated areas (at . Teeth affected by periodontal disease least 1 year should be allowed for maximal recovery of Traumatic teeth circulation to the bone). . An isolated tooth There are number of relative systemic contraindications . Any partially erupted or unerupted tooth or retained root to the tooth extraction, e.g.

Retained deciduous tooth - Uncontrolled diabetes Submerged tooth - Acute blood dyscrasias

Conditions which predisposes to dental or alveolar Untreated coagulopathies abnormality, e.g. -

Adrenal insufficiency

- Cleidocrania ldysostolia — for pseudo-anodontia - General debilitation for any reason - Osteitisdeformans — for hypercementosed root Myocardial infarction (wait for 6 months period). Patient with therapeutic irradiation

- Osteopetrosia. PREPARATION FOR EXTRACTION

Choice of Anesthesia Preoperative Assessment Teeth may be extracted under either local anesthesia or A history of general

disease, nervousness, or previous general anesthesia and one should assess the indication difficulty with extractions, will govern both the choice of and contraindications of both before deciding which to anesthesia and procedure of tooth extraction. use in a particular case. Most extraction of tooth can be The general cleanliness of the patient's mouth and oral done with local anesthesia alone. hygiene are

observed. To decrease the nervousness, relieve tension and control Pre-extraction scaling

should be performed, especially in psychic behavior sedation can be used in conjunction neglected mouths, at least one week prior to surgery. with the local anesthesia. In young children, general Sick or fatigued should rest before operative procedures. anesthesia rather than local anesthesia may be indicated Highly apprehensive patient should receive some form of to facilitate patient management. sedation before the operation. All patients with general anesthesia or local anesthesia Patient undergoing

generalanesthesia should be instructed should be observed in a recovery area until they are able to omit the previous meal and to take nothing by mouth to go home unaided or should be accompanied by adult for at least 6 hours before extraction. and not permitted to drive. Patient with inflamed or infected gingival should use an antiseptic mouth rinse before the extraction. PRINCIPLE OF EXTRACTION Removable prostheses must be taken out of the patient's mouth. In routine practice, the following three time mechanical The administration of antibiotics is recommended as a principles of extraction should be followed for the well being prophylactic measure in all medical compromised patients. of the patients by doing atraumatic extraction.

Pre-extraction Radiograph The purpose of pre-extraction radiograph is to show the whole root structure and the alveolar bone investing the tooth with IOPA, lateral oblique view, OPG. The following are the main indication for preoperative radiographs:

• History of difficult or attempted extractions • A tooth which is resistant to forceps extraction

Expansion of the Socket The extraction of a tooth requires the separation of its attach ment to the alveolar bone via the crestal and principal fibers of the PDL which involves a process of expansion of alveolar socket. This is achieved by using the tooth as the dilating instrument with the help forceps, to permit the removal of the tooth.

738 Section 12 Oral Surgical Procedures in Children Use of a Lever and Fulcrum

Transalveolar Method (Open View Technique) This basic principle is used with elevators that force a tooth or root out of the socket along the path of least resistance.

The Insertion of a Wedge This method is used where roots are inaccessible to routine removal by forceps or by

an elevator, when they cannot be luxated with simple forces, or when the roots are covered by bone. This method is far less traumatic than when there is

prolonged use of forceps or elevator attempted root removal. This is done between the tooth root surface and the bony socket wall to help the tooth to rise in its socket.

EXODONTIA TECHNIQUES Odontotomy The following techniques may be used for tooth removal: • The forceps technique - closed method • The elevator technique - open • Transalveolar technique - open method • Odontotomy.

In this method, the extraction procedure may be simplified by cutting a tooth apart, e.g. in multirooted deciduous or permanent teeth with divergent roots, where crown is decayed. PROCEDURE FOR EXTRACTION

.

Forceps Technique It is the most commonly used method for the extraction of teeth. But, it should not be used in difficult cases, e.g. tooth with hypercementoid root or tooth with deformity of the roots. This forcep technique gives least amount of trauma to soft tissues and hard tissue of judiciously used. In multiple extractions the marginal gingival may have to be reflected to permit rounding and smoothing of the sharp prominences of the alveolar process. Care should be taken to preserves the height and breadth of the ridge for stability of a future denture. Proper use of this technique involves the application of several basic principles. • The beaks of the selected forcep should be sealed as far apically as possible without compression of the soft tissues after reflecting the cervical gingival. The placement of the beaks of the forceps should be as parallel as possible to the long axis of the tooth. The application of excessive force should be avoided so that the fracture of the alveolar process or tooth itself does not occur.

Instrumentation and Positioning Instruments are selected and arranged according to the need and according to the surgeon's preference. Position of the operator: - When extracting any

tooth except the right mandibular quadrant the operator stands on the right hand side of the patient. For the removal of

the teeth in right mandibular quadrant, the operator stands behind the patient. For maxillary teeth, the chair should be adjusted so that the site of operation is about 8 cm below the shoulder level of the operator. During the extraction of mandibular tooth the chair height should be about 16 cm below the level of the operator's elbow. When the operator is standing behind the patient the chair should be adjusted to enable him to have a clear view of the field of extraction. All these aspects combined with good illumination of the operative field is an essential condition for the successful extraction of the teeth.

Technique See Flow chart 62.1.

Elevator Techniques This technique is used in two ways: 1.

Elevator as a

lever: In this case, the alveolar crest serves as the fulcrum. The area of the compressed bone should be removed with a file or

rongeur to reduce the postoperative pain and infection. With elevators, one should avoid traumatizing the gingival and loosening of adjacent teeth. This method is used for the removal of whole or nearly whole roots. Elevator as a wedge: This principle is used for the removal of small root tips by way of displacement. If the root tip cannot be dislodged from the socket easily, an open view method should be used. EXTRACTION OF PERMANENT MAXILLARY TEETH (FIGS 62. I TO 62.3) Central incisors: These often have a conical root and rarely deformed or curved. They are grasped with straight wide beaked forceps and can be safely rotated first in one direction and then in the other direction until PDL attachment is broken and it can be

taken out with slight tractions.

Chapter 62 Pediatric Exodontia 75 Flow chart 62.1: Technique of tooth extraction Administer local anesthesia

Before attempts are made to extract a tooth the gingival tissue at the cervical region should be detached with

the

help of Moon's probe

After this, insert the beaks of the forceps under the gingival as far on the outer and inner aspects of the tooth as possible

1st molar: It usually has three divergent roots, strongest

and longest of

which is the palatal root. The buccal roots are often curved distally. For the safe

extraction of 1st molar, careful rocking of the tooth buccally with upper universal or bayonet forceps is used to loosen the palatal root, and buccopalatal traction aids in complete luxation of the tooth which is removed without

rotation. 2nd molars: It can be removed by a technique similar to that

used for 1st molar extraction. Buccopalatal rocking and traction may be used and even moderate torsion is permissible to detach and remove the tooth. 3rd

molars: 3rd molars may be removed with the same forceps that are used for

1st and 2nd molar. The long axis of the maxillary 3rd molar is such that its crown is usually more posteriorly placed than its roots. As a rule, teeth that are buccally inclined can be removed easily, those distally inclined may fracture. No attempt The forceps are carefully adapted and the root is grasped firmly with the beaks parallel to the long axis of the tooth

For maxillary teeth extraction, one hand is used to reflect the cheeks or lip and stabilize the patient's head in the head rest

For mandibular teeth, one hand supports the mandible and retracts the cheek or lip

To extract any tooth, the handles of the forceps are grasped with enough force to hold the tooth firming but not to crush it

Then the tooth is rotated or carefully socked, depending upon its shape and until PDL attachment is broken and the socket is dilated and tooth is taken out of the socket

Lateral incisors: They have slender roots which are often flattened on the mesial

and distal surfaces. A fine bladed

forceps is used for the extraction of lateral

incisors. Canines: These can be the most difficult upper teeth to remove because of the length and frequent apical curvature of their roots. Since great force is needed to dislodge these teeth, partial or total fracture of the labial wall of the alveolus is common. Forceps are placed as high as possible under the gingival margin, and the tooth is then rotated back and forth while upward pressure is maintained and traction is applied for its removal. 1st premolar: It has two fine roots which may be both curved and divergent and

fracture occurs readily during extraction. Buccopalatal rocking with upper universal forceps or bayonet forceps is used to locate the tooth and tooth should be removed in the direction of least resistance. 2nd premolar: These are much easier to extract than the 1st premolars because they have only one root.

Careful rotary motion with rocking to the buccal sides with gradual fraction will usually deliver the tooth.

Figs 62.1A and B: (A) Position of dentist for performing extraction of

teeth in

maxillary anterior segment; (B) Position of forceps for maxillary anterior segment

740 Section 12 Oral Surgical Procedures in Children

Figs 62.2A and B: (A) Position of dentist for performing extraction of teeth in maxillary first quadrant; (B) Position of forceps for maxillary first quadrant

Figs 62.3A and B: (A) Position of dentist for performing extraction of teeth in maxillary second quadrant; (B) Position of forceps for maxillary second quadrant

should be made to apply forceps to either a semi erupted maxillary 3rd molar unless

both buccal and lingual surfaces are visible. If more pressure is applied in an upward direction the tooth or root may be displaced into the maxillary antrum. bladed forceps should be used to grasp them, e.g. lower universal Canines. It is

long and bulky, firmly embedded and difficult to extract the apex is often inclined distally. A heavier bladed forceps should be used and movement in a buccolingual

direction is applied for extraction of this tooth. Premolars: They have tapering

roots and their apices may be distally inclined and surrounded by thick compact bone. A forceps with blades fine enough to give 'two point contact' on the root should be applied to the tooth. The first movement should be firm but gentle and torsion may EXTRACTION OF MANDIBULAR TEETH (FIGS 62.4 TO 62.6) Incisors: Lower incisors have fine roots with flattened sides. The supporting alveolar process is very thin, and it is easy to luxate the tooth when it is rocked labially. Fine

Chapter 62 Pediatric Exodontia 741 be employed freely, combined with buccolingual rocking as in the case of canines. Lower molars: These molars are best extracted with full molar forceps and often loosened by buccolingual pressure and are best delivered by secondary rotation. The extraction of 2nd and 3rd molars can often be facilitated by the mesial application of an elevator before the application of forceps if not malposed, impacted or unerupted, the mandibular 3rd molars can be quite easily removed with the forceps technique.

Figs 62.4A and B: (A) Position of dentist for performing extraction of teeth in mandibular anterior region;

(B) Position of forceps in mandibular anterior region

Figs 62.5A and B: (A) Position of dentist for performing extraction of teeth in mandibular third quadrant; (B) Position of forceps in mandibular third quadrant

742 Section 12 Oral Surgical Procedures in Children

Figs 62.6A and B: (A) Position of dentist for performing extraction of teeth in mandibular fourth quadrant;

(B) Position of forceps in mandibular fourth quadrant

EXTRACTION OF ROOTS

Roots may be extracted with forceps: If they are not decayed. Bayonet or universal forceps are used for roots in the upper jaw and forceps such as those used for premolars are used in the mandible. If forceps cannot be applied directly to the roots, an elevator technique may be used. In open beak technique, alveolar bone rather than the root itself is grasped with the forceps and crushed bone should be carefully removed after removal of the root. Mandibular molar roots can be removed by placing a straight elevator or cryer elevator between them and using the interradicular septum as a tulcorum to remove one root. If roots are attached, a bur is first used to separate them. Maxillary molar roots removed by simultaneously grasping the distobuccal and

palatal roots with the forceps and mesiobuccal root can be removed separately with forceps or a small elevator. Roots that are under the gingival margin or roots completely embedded in bone are removed by the open view method of extraction. The main consideration in the removal of deciduous teeth is to avoid injury to the developing permanent dentition. The most critical step in extraction of deciduous teeth is the administration of local anesthesia. If the child allows this step then he will be definitely co-operative for the next step, the extraction. This is because most anxiety

and fear is generated during this phase. Studies by most authors explain the

rise of pulse rate and blood pressure during this time. So it is critical to alleviate the fear of the child rather than increase it. It is most recommended to perform some behavior shaping of children prior to extraction and local anesthesia. Some methods are:

The first step: This is to make the patient comfortable. It is imperative that we do not proceed with the extraction immediately. It is best if we first engage in some friendly talk with the child and explain him the merits of taking out his carious teeth in a language that he can compre hend according to the developmental status of the child. Tell-show-feel-do: This modification involves describing the procedure from the application of topical anesthetic to postoperative reward. The patient is then showed an empty syringe without needle and made to feel it to dispel any fears of injections that he may have. However, during

the actual procedure it is best not to load anesthetic or bring the needle or

syringe in front of child so as to avoid anxiety. It is best to cover the child's eye with one hand and perform the task with other. Use of euphemisms: Like comparing the pinch of needle to mosquito bite or comparing LA solution to water to flush out bacteria from teeth have proven to be useful.

EXTRACTION OF DECIDUOUS TEETH • Before extraction of deciduous teeth, a thorough examina tion should be performed to minimize complications. As tooth crown and root structure differ from those of adult teeth, the use of specially designed pediatric instrument

is recommended.

Chapter 62 Pediatric Exodontia 74 - Audiovisual distraction: It is also a vital technique as it

Additional advisory in case of children allows multisensory distraction. Use of bite blocks: These are recommended for difficult • Parent is instructed to keep a check on the status of cotton so that the child does not swallow it inadvertently. patients

who have a tendency to close their

mouth Patient is instructed to keep the cotton for 30 minutes to 1 hour while the procedure

as they are helpful in opening the and avoid spitting out. mouth so as to avoid any injury during procedure. • It is best to give cold food stuff like ice-cream to children to aid in Modeling: This is especially useful in case of a close clot formation. friend or a sibling who can be observed performing Explain the effect of anesthesia will keep the area numb for the desired behavior. a specific time so as to avoid lip or cheek biting, especially in Physical

restraints: This is

the last and least preferred children. option with the dentist and is used in highly In case of pediatric exodontia it is best to allow the child to uncooperative or special

children. be seated in the dental chair for at least 10 minutes before The

technique of extraction

is the same as that used in the discharging him so as to avoid any shock symptoms. removal of permanent teeth. But it is

important to ensure Advise parents to keep children under close supervision that before application of

forceps that the blades are fine particular day and avoid sports of heavy nature. • Parents should use alternate methods to distract the child so as to

enough to pass

down the periodontal membranes and avoid his attention towards the wound. applied

to the roots. A firm lingual movement

usually causes the tooth to rise removed or necessary socket irrigation is performed. The in its socket and it can be delivered by moving buccally alveolar process then should be pressed together with the and rotated forwards. thumb and forefinger in order to reduce any distortion of The roots of the extracted deciduous teeth should be the supporting tissues; suturing should always be done after examined to ensure that they are complete. Fracture root multiple

extractions and if the gingival flaps are loose enough surfaces are flat and shiny with sharp margins, resorbed to be approximated. After extraction, a gauze pack is placed roots are with irregular margins. over the socket and patient is directed to bite on the pack In case of fracture of a root fragment the best option is to for 12 hour, exerting firm even pressure. This will prevent radiographically visualize it before attempting any kind bleeding

while the patient returns home and it allows a blood of retrieval. In case it is located superficially away from clot to form. Some postoperative instructions are: underlying tooth bud it can be safely removed by re- . The patient should be warned that sucking the wound, instrumentation. However, if it is close to the underlying

investigating the socket with tongue and rinsing during tooth bud it is advisable to let it remain there as it may the first day disturbs the blood clot and may cause dry undergo resorption or may appear with the erupting tooth. socket. Patient should be directed to remain quiet for several OPERATIVE COMPLICATIONS hours, preferably sitting in a chair or iflying down, keeping the head elevated. The most frequent operative complication that encounter .

Only liquids and soft solids should be advice on the first during the extraction of teeth are:

day. They may be warm or cold but not extremely hot. • Fracture of the tooth The teeth should be brushed as usual and on the day after

• Injuries to adjacent teeth surgery rinsing of the mouth should begin. A warm saline Fracture of the alveolar bone

solution is best for this purpose. Fracture of the tuberosity Some degree of postoperative pain accompanies many Extraction of the

wrong tooth exodontia procedures and begins after the effects of the Root displaced in the sinus anesthetic have left. So, it is better to take some analgesic Maxillary sinus perforation before the effect of anesthetic wears off. Root displaced in the submandibular space

Prevention of swelling after extensive or difficult opera Gingival and mucosal lacerations

tion adds to the comfort of the patient. The degree of Injury to the inferior alveolar nerve

swelling that occurs postoperatively is generally in • Hemorrhage and hematoma direct proportion to the degree of surgical trauma. The TMJ trauma application of cold to the operated site is beneficial in Damage to permanent successor. reducing the amount of postoperative swelling. Pressure dressings are also beneficial in limiting the postoperative POSTOPERATIVE CARE

swelling. Smoking should be avoided after tooth extraction as it After care when the tooth has been extracted the socket increases the incidence of alveolar osteitis and should be should be inspected and any loose fragment of bone is discontinued for five days.

744 Section 12 Oral Surgical Procedures in Children POINTS TO REMEMBER The ideal tooth extraction is the procedure of painless removal of whole tooth, or root with minimum trauma to soft tissue and hard tissue so that the wound

heals uneventfully and with no postoperative problem. Indications for extraction are teeth affected by advanced caries, periodontal disease, over-retained teeth, impacted and supernumerary teeth, teeth involved in tumors or cysts, teeth affected by pulpal lesions and teeth in the area of direct therapeutic irradiation.

Contraindications are presence of acute oral infections and systemic contraindications. Techniques used for tooth removal are forceps technique, elevator technique, transalveolar technique and odontotomy. Position of the

operator: When extracting any tooth except the right mandibular quadrant the operator stands on the right hand side of the patient. For the removal of the teeth in right mandibular quadrant, the operator stands behind the patient. For maxillary teeth, the chair should be adjusted so that the site of operation is about 8 cm below the shoulder level of the

operator. During the extraction of mandibular tooth the chair height should be about 16 cm below the level of the operator's elbow. The most important behaviour modification during extraction for pediatric patients are tell-show-feel-do, audiovisual distraction and modeling. Operative complications during extraction of teeth are fracture of the tooth or bone, root displacement, sinus perforation, laceration, nerve injury, TMJ trauma, damage

to succeeding tooth, cheek biting. QUESTIONNAIRE 1. What are indications and contraindications for tooth extraction? 2. Describe the

techniques of extraction. 3. Explain the principles of extraction. 4. What are the operating positions for extracting different teeth? 5. Write note on extraction of deciduous teeth. 6. Enumerate the postextraction instructions given to patient. 7. What are the complications associated with extraction in relation to children?

BIBLIOGRAPHY 1. Berman SA. Basic principles of dento-alveolar surgery. LJ, Editor: principles of oral and maxillofacial surgery, Philadelphia, JB Lippincott; 1992. 2.

Blakey GH III, Ruiz RL, Turvey TA. In: Fonseca RJ, Walker RV (Eds). Oral and Maxillofacial Trauma. Philadelphia, PA: WB Saunders. 1997;2(2):1003-41. 3. Byrd Dl. Exodontia: modern concepts. Dent Clin North Am.

1971;15:273. 4. Cerny R. Removing broken roots: a simple method. Aus Dent J. 1978;23:357. 5. Kaban LB. In: Kaban LB (Ed). Pediatric Oral and Maxillofacial Surgery. Philadelphia, PA: WB Saunders. 1990.pp.233-60.

63 CHAPTER Traumatic Injuries to Anterior Teeth

Nikhil Marwah, Prabhadevi C Maganur

Chapter outline • •

• Response of Oral Tissues to Trauma • Etiology Mechanism of Dental Injuries

• Classification of Traumatic Injuries • Examination and Diagnosis • Management of Traumatic Injuries •• Reimplantation Storage Media for Avulsed Teeth Periodontal Healing Reactions Splinting Effect of Traumatic Injuries on Developing Dentition Trauma to Primary Dentition •

that when parts of the dental follicle are removed an ankylosis is formed between the tooth surface and the crypt. Cervical Loop Tooth trauma has been and continues to be the common occurrence that every dental professional must be prepared to assess and treat when necessary. It has no perspective method for occurring, possesses no significant predictable pattern of

when dentists are least prepared or when the dental office is closed. The dynamic panorama of sporting activity worldwide and the significant increase in violence in our population, tooth trauma and its management loom as a major challenge to the dental practitioner. Cervical loop is highly resistant to trauma. Only profound contusion due to intrusion of primary incisor results in total arrest of odontogenesis. intensity or extensiveness and is occurring at times

Inner Enamel Epithelium RESPONSE OF ORAL TISSUES TO TRAUMA In case of total loss of ameloblasts in the secretory phase, no regenerative potential exists. In case of partial damage, enamel matrix formation and maturation may be affected. If there is total loss of the ameloblasts during the maturation stage hypomineralized enamel will develop.

An injury can be defined as an interruption in the continuity of tissues. The result

of this process can either be tissue repair, where the continuity is restored but the healed tissue differs in anatomy and function or tissue regeneration, where both anatomy and

function are restored. Dental tissues are unique in comparison to most other

tissues in the body due to their ability to completely regenerate. Injury and its squealae in some important structures of teeth are:

Reduced Enamel Epithelium Minor injury to the reduced enamel epithelium is repaired with a thin squamous epithelium whereas, larger area of destruction result in ankylosis and tooth retention.

Dental Follicle Traumatic injuries can be transmitted easily from the primary to permanent dentition. It has been shown in experiments

Enamel and Enamel Matrix Trauma to primary tooth may cause contusion of

the permanent matrix. Ameloblasts will also be destroyed thereby