Pediatric Dentistry I Forth Year

1. Dr AZZA TAG ELDIN

2. EXTRACTION
It is the painless removal of the whole tooth
or tooth root with minimal trauma to the
investing tissues,
So that wounds heals uneventfully and no
post operative prosthetic problems.

3. PRINCIPLES
 Avoid injury to soft tissues such as the tongue lips,
gingiva and cheeks .
 Avoid injury to underlying developing permanent teeth
and other hard tissues such as bone and adjacent or
opposing teeth.
 Use radiograph to determine:-
 Size and shape of roots.
 Amount and directions of root resorption.
 Position and stage of development of underlying
permanent tooth.
 Any pathology.

4. DIFFERENCE BETWEEN PRIMARY &
PERMANENT TEETH
 Size:- Primary teeth are smaller in every dimensions
compare to their permanent counterpart.
 Shape:- Crown of primary teeth are more bulbous. The
furcation of primary molar root is positioned more
cervically than in the corresponding permanent teeth.
 Physiology:- Root of primary teeth resorb naturally where
as in the permanent dentition resorption is normally a sign
of pathology.
 Support:- The bone of alveolus is much more elastic in the
younger patient.

5. These difference means that there are some modification to
Extraction technique in children.
1. Type of forceps :-- the beaks & handles are smaller, & to
accommodate more bulbous crown the beaks are more curved
in forceps designed for removal of primary teeth.
2. The wide splaying of primary molars roots means
that more expansion of the socket is required.
3. Due to relatively cervical position of the bifurcation in primary
molars it is injudicious to use forceps with deeply plunging beaks.
4. Avoid blind investigation of primary socket.
5. Because of physiological resorption it is often preferable to
leave small fragments in situ if root fractures.

6. PROBLEMS PECULIAR TO CHILD PATIENTS
 Natal & Neonatal teeth.
 Infra Occlusion of teeth.
 Fusion Gemination of two teeth.
 Damage to Permanent successor.
 Dislocation of the Mandible.

7. Indication for extraction of deciduous teeth
 Badly carious can not be restored.
 Over retained primary teeth preventing
eruption of permanent successor.
 Infection of periapical area can not be treated
without extraction.
 For orthodontic purpose.
 Supernumerary teeth if not needed in dental
arch.
 In traumatic injury to teeth if vertical fracture
occur.
 Ankylosed primary teeth that have permanent
successor and fails to exfoliate normally.
 Impacted teeth.
 Ectopically positioned can not be brought into
function.

8. Contraindications for Extractions of teeth in
children
 Child having bleeding disorder.
 Acute infections like stomatitis and acute Vincent’s infections.
 Herpetic stomatitis.
 Acute pericementitis.
 Acute dentoalveolar abscess.
 Acute cellulitis.
 Malignancy.
 Teeth getting irradiation.
 Acute or chronic heart disease, congenital heart disease and kidney
disease.

9. PRE - OPERATIVE PREPARATION OF THE
PARENT AND CHILD
 PARENT-
1. PARENTAL CONSENT BEFORE THE PROCEDURE.
2. INSTRUCT THE PARENT NOT TO DICUSS WITH THE
CHILD WHAT THE DENTIST WILL DO.
 CHILD-
1. ARMAMENTARIUM SHOULD BE KEPT BEHIND THE CHAIR.
2. NEVER HOLD THE NEEDLE IN FRONT OF CHILD ALWAYS
HIDDEN BY FINGERS.
3. BEFORE GIVING THE LA, EXPLAIN TO THE CHILD THAT
SENSATION OF PINCHING OR AN ANT BITING MAY BE FELT.
4. CHILD REALIZES THE DIFFERENCE BETWEEN PRESSURE AND
PAIN.
5. EXPLAIN THE SENSATION OF NUMBNESS TO CHILD.

13. Extraction Technique
 Patient Position:-
The child should be seated in dental chair reclined about
30° to the vertical for extraction under local anesthesia,
under general anesthesia supine position.

14. Extraction Technique
Operator position:-
When removing upper teeth under LA the operator should stand in
front of the patient with straight back and the patient mouth at a level just
below the operator’s shoulder.
A right handed operator removes lower left teeth from similar
position in front of the patient except that the patient mouth is at height
just below the operator’s elbow.
When removing the teeth from the lower right , the right handed
operator stand behind the patient with the chair as low as possible to allow
good vision.

15.  The Non-working hand:-
1. It retract soft tissues to allow visibility and access.
2. It protects the tissues if the instruments slips.
3. It provide resistance to the extraction forces on the
mandible to prevent dislocation.
4. It provides feel to the operator during the
extraction and gives in formation about resistance
to removal.

17. Upper primary & permanent anterior
When these teeth are in normal position:
forceps used for primary teeth
– upper primary anterior
OR upper primary root forceps.
forceps used for permanent teeth
– upper straight forceps
force applied– applying the forceps beaks to the root &
then Using clockwise & anticlockwise rotating about long
axis.

18.  Labially placed upper lateral
incisor & canine have vary
little buccal support & are
easily removed, either by
using straight forceps .
Applied mesially & distally &
using a slight rotatory
movement or By the use of
elevator.
 Most commonly used elevator
are WARWICK JAMES &
COUPLANDS elevator.
 Palatally positioned lateral
incisors & canine are usually
not accessible with forceps &
thus elevator are used.

19. Upper primary molars
 These teeth display the
most widely splayed roots
so considerable
 Expansion of socket is
required.
 Forceps used– upper
primary molar forceps
 Force applied– initially
palatally to expand the
socket then continous
 Buccaly directed force.

20. Upper premolars
 Forcep used – upper premolar forceps
 Removed by the buccal expansion
Upper permanent molars
 Forceps– left & right upper molar forceps
 Removed by expanding the socket in the buccal
direction
Lower primary anterior
 Forceps– lower primary anterior or root forceps
 Extracted same as upper anterior.

21. Lower permanent anterior
Root of lower incisors are thin mesiodistally & rotation is
likely to cause root fracture so the most effective method of
removal:-
Is to apply lower root forceps & expand the socket labially.
Permanent lower canine may be delivered by rotatory
movement or By buccal expansion.

22. Lower primary molars
 Forceps– lower primary
molar forcep.
 Two pointed beaks
which engage the
bifurcation.
 Buccolingual
expansion of socket

23. Lower premolars
Forcep– lower premolar forceps
Removed by rotatory movement around the long axis of root
Lower permanent molars
Two designs of forceps used –1.lower molar forceps
-2.forcep of cowhorn design
Lower molar forcep have two pointed beaks which are applied in the
Region of bifurcation buccally & lingually.
Applied the forceps & move the tooth in buccal direction to expand
the buccal cortical plate.
When buccal expansion is not sufficient to deliver the tooth then the
forceps should be moved In a figure –of –eight fashion to expand the
Socket lingually as well as buccally.

24. Management of buried teeth
 Buried teeth (including supernumeraries) are
treated in children for several reasons -
1. Symptomatic (eg. pain)
2. Radiographic sign of pathology (eg.dentigerous cyst
formation)
3. Part of an orthodontics treatment plan

25. Extraction Of Buried Teeth
 Flap design
Flap should:-
1. be muco-periosteol.
2. Be cut 90º to bone.
3. Have a good blood supply.
4. Avoid damage to imp. Structures
5. Allow atraumatic reflection.
6. Provide adequate access and visibility.
7. Permit re-apposition of the wound margins over
sound bone.

26. Flap for buccaly placed teeth –
2 designs –
Ist Design-
Gingival margin as the horizontal component and a
vertical relief incision into the depth of the buccal
sulcus
2nd Design –
Semilunar incision, at least 5 mm of attached
gingiva should be maintained at the narrowest
point to ensure a good blood supply to marginal
gingiva.

28. Flap for palatally/lingually placed teeth –
Palatally positioned teeth are best removed via an
incision that follows the palatal gingival margin.
Such an incision maintain the integrity of greater
palatine nerve & vessels.
In the lower jaw adequate access to the lingual side
is obtained by raising the lingual gingiva &
reflected mucosa via an incision run around the
lingual gingival margin

30.  Bone Removal
this may be carried out using a hand piece and bur
or by the use of chisels.
 Tooth Removal
once sufficient bone has been removed to allow
identification of the tooth to be extracted &
exposure of the greatest diameter of its crown, the
tooth should be elevated.
 Suturing

31. POST OPERATIVE COMPLICATIONS
 Dry Socket
 Aspiration or swallowing of tooth.
 Post-operative Bleeding.
 Pain.
 Swelling.
 Infection.

32. POST OPERATIVE INSTRUCTION
 FOR CHILD-
1. The child should not be dismissed until blood clot is formed.
2. Hold a small cotton roll between his teeth for half an hour .
3. Not to bite his lip.
4. Do not disturb the area where tooth was removed.
5. Do not rinse mouth for 24 hours after extraction.
 FOR PARENT-
1. Reinforce the child for instructions that already given to him.
2. Light meal with no hard food.
3. Analgesics is prescribed if the extraction was traumatic and antibiotic
coverage is done if the area was infected.

33. CONCLUSION
For the young child who requires the removal of
primary teeth, the dentist should recognize the proper
sequence of all the procedures. The dentist prepares
the child by using a sensitive approach through his
selection of words that indicate to the child the nature
of the procedure.