د. وسام حامد عيدان Oral Surgery for Children All surgical procedures require anesthesia; if a patient properly premedicated and comfortable and if the tissues are handled gently, extensive operations can be performed with local anesthesia. when the fears of the patient uncontrolled, 'when an understanding of the situation is impossible, or when the procedure is complicated, general anesthesia is indicated. It should emphasized that no surgical procedure should be done without the permission of the parent or guardian who should have a
basic understanding ,of what is to be done, why it is being done, and what complication can occur.
before 10 years of age, when permanent second molar is not erupted, the direction of eruption is mesially angulated. So when second permanent molar start to erupt, it will erupt mesially but the presence of first molar prevent such drifting. So if the first molar extracted before I0 years, the 2nd molar will erupt in its place and it will be in a nice occlusion with opposing tooth, although there is little space between 5
and 7 in comparison to 5 and 6.
If the first permanent molar is very badly carious, X_ray should be taken to see if the bud of 2ndpermanent molar is present still unerupted in the jaw, we extract first permanent molar and have the second permanent molar to take its place.
when there is crowding in anterior teeth the sixes are extracted and all the teeth may retract posteriorly, so it will decrease the crowding.
If the first permanent molar a badly carious and the 2nd permanent molar erupted and the occlusion is in good alignment. If we extract the first permanent molar there will be space because the 2nd difficult to drift and fill the space. In such a case, the opinion of the orthodontist should be taken.
Contraindications of Extractions:
There are no contraindications but there is postponed the extraction as in the followings:
1. when there is cellulites because:
a. It cause spread of infection .
b. local anesthetic will not work .
2. in a case of uncontrolled systemic disease such as:
a. heart disease they need antibiotic cover.
b. diabetic patient, they should measure blood sugar before extraction.
c. hemophilic patient should be hospitalized for factor VIII and IX.
3. when the child has viral infection in his mouth such as viral stomatites so it is painful.
4. when the child allergic to anesthesia since it is very rare cases but the type of anesthesia should be changed.
Extraction Technique for primary Teeth.
The initial steps for extracting any tooth are the same. First having administered the local anesthetic, adequate time should be allowed for it to take effect. The adequacy of anesthesia is tested by reflection of gingival cuff from the tooth. The routine use of straight dental elevators as the next step has been over emphasized. In most cases proceeding with extraction forceps is preferable, smaller increments of pressure may be applied initially with the elevator. The first force exerted, prior to any attempt too luxates the tooth, isan apical direction. The low height of contour and small undercuts need this apical force to ensure good forceps seating to prevent slippage of the beaks, even during initial luxation there should be apical force. The maxillary primary incisors and canines have straight conical roots and can be removed easily with mesiodistal rotation.
1. In the primary maxillary molar region, the initial luxation force is palatal rather than buccal as is initially used with permanent maxillary posteriors. the palatal root of primary molar is straight, relatively bulky, and less prone to fracture than the spindly, curved buccal roots. Thus the
fulcrum point should be on this stronger root.
2- The maxillary primary molars lie toward the palatial side of the
alveolar ridge. The buccal plate is full in order to accommodate the erupting permanent teeth and as a result of normal lateral growth on the maxilla; there fore it is less easy to expand with buccally directed forceps. Once some movement has been gained the primary maxillary molar is now redelivered with gradual buccal palatal motion.
Mandibular primary anterior teeth have roots that are elliptical in cross-section. These teeth usually lie labial to the crowns of erupting permanent anterior. So the initial luxation force is toward the labial, Delivery of the tooth is made with gradual labial-lingual luxation. The primary mandibular molars are luxated initially to the buccal for similar reasons and delivered with bucco-lingual movement. A molar forceps are particularly suited to grasping the furcation area of these teeth.
Simple extraction of individual primary teeth do not usually require suturing for hemostasis, and a gauze placed under pressure for 15-20 minutes will cause a stable clot to form. When placing the gauze toward the buccal aspect of the teeth rather than the lingual, which might cause the patient to gag. When the bleeding is a problem, or when more than one tooth or multiple teeth in the same area are extracted, suture is best placed from the buccal to lingual interdental papilla. Again, it is best to use a resorbable suture to avoid a second procedure in very young anxious or physically ,or mentally handi-capped patients. In most other situations, black silk suture is perfect because it is soft, inexpensive, easy to see in the mouth, and easy to tie.
Tooth root or tooth tip fragments should be removed whenever possible. Any tooth root that is involved with periapical or periodontal infection must be removed, it serve as the nidus for recurring infection. Without exception, a tooth fragment that might interfere with normal succedaneous tooth eruption must also be removed. Often the apical position of a primary molar root will fracture off, and if the radiograph indicate it is curved down below the height of contour of the premolar crown, we always attempt to remove it through the existing socket using a fine root elevator. If this is not successful, we may leave the root tip alone rather than attempt the more involved surgical approach of intervention by reflecting a buccal flap and removing buccal bone to reach the root tip. This may effect the bone support of the permanent tooth.
Another case for surgical extraction is the fully erupted tooth that is unsuited to forceps extraction. If the crown fractures or crumbles 'or if excessive force must be used ,it will be kinder and time saving if initial plan is to raise a flap, divide the roots, and remove it in sections.
The forceps of primary teeth are small in size, small blades and small handle. There is forceps for upper anterior teeth, lower primary teeth, upper molar, lower molar.
Manifestation of Infection and its Management.
A child is susceptible to the same organism as an adult, inflammatory responses are the same and the same general principles of infection control and treatment apply.
Acute Dental Infections
An acute apical infection resulting from a non-vital or degenerative pulp may be confined to the alveolar process, may break through the cortical barrier and involve the periosteum, or may invade the surrounding soft tissue and result in cellulites. one of three results will become evident resolution, localization, or overwhelming infection. An immediate decision must be made whether to extract the tooth or treated endodontically. Fever, malaise, and oral pain result in low fluid intake and generalized acute illness, thus close observation is indicated antibiotic therapy is indicated, penicillin is the drug of choice, but erythromycin may be given and sedative.
One must not wait until the acute exacerbation has completely subside. A traumatic extraction that one performed at the time when the infection is most virulent may have local and systemic consequence.
If the pus seems to be localizing, heat should be applied intra-orally, extra-orally or in both ways to hasten localization. So that the incision and drainage may be performed, after that the antibiotic continue until the signs and symptoms of infection disappear.
Chronic Dental Infection.
Chronic infections are usually manifested by apical pathosis, (as shown by radiographs examination) or by sinus tract that is draining through the alveolar process into the mouth. Antibiotic therapy is not usually necessary in the treatment of this phase, since healing is rapid
after the removal of the source of infection. Gentle curettage should be done after extraction, but in the case of primary tooth, injury to the underlying tooth bud must be avoided. the path of drainage of chronic infection will find its way through the cutaneous surface of the face
especially the anterior portion of the mandible when such draining area results from an infected tooth. antibiotic therapy and extra-oral surgical closures will fail completely until the source of infection has been removed.