Minor Oral Surgical Procedures in Children PDF, Yousra Spring 2023

MINOR ORAL SURGICAL PROCEDURES IN CHILDREN Dr Yousra Mohamed PEDO 2 1 Minor Oral Surgery in Children Some factors to be considered in oral surgery for children: 1. The oral cavity is small. 2. The jaws are in the process of growth and developmen...

MINOR ORAL SURGICAL PROCEDURES IN CHILDREN Dr Yousra Mohamed PEDO 2 1 Minor Oral Surgery in Children Some factors to be considered in oral surgery for children: 1. The oral cavity is small. 2. The jaws are in the process of growth and development. 3. The bone structure of a child contains higher percentage of organic material. Lower frequency of fractures needing repair in children; incomplete (green stick fracture) due: A- Developing bone is less calcified so less hard. B- Interosseus sutures are softer and more flexible C- Faster healing power, better tissue resistance, and greater remodeling capacity provided that correct positioning. Local Anaesthesia Consideration When infiltration anesthesia is used, the injection should be made close to apex of the tooth. Because the roots of the deciduous teeth are short, the injection is not made as deeply in the vestibule as in the adult. Penetrating too deeply at the area of the tuberosity can produce a hematoma due to injury of the pterygoid venus plexus or posterior superior alveolar artery. The ramus of the mandible is shorter vertically and narrower anteroposteriorly so the depth of penetration of the needle should be less in children. The ideal tooth extraction The painless removal of the whole tooth, or root, with minimal trauma to the investing tissues, so that the wound heals uneventfully and no post-operative problem is created. Extraction of teeth: Indications for extraction 1-Acute pathologic infection. 2-Chronic Pathologic Involvement. 3-Over Retained Deciduous Tooth. 4-Ankylosed Deciduous Tooth. 5-Cariously Involved, nonrestorable tooth. 6-Natal or Neonatal Tooth. 7-Supernumerary Tooth. 8-Fractured or Traumatized Tooth. 9-Impacted Tooth. 1 2 Contraindications to extraction : Many of these contraindications are relative and may be overcome with special precautions and premedication. 1. Acute infections. The acute phase should be controlled before extraction 2. Blood dyscrasis: These render the patient susceptible to postoperative infection and hemorrhage. Extractions should be performed only after consultation with haematologist and proper preparation of the patient. 3. Rheumatic heart disease, congenital heart disease and congenital kidney disease: require proper antibiotic coverage. 4. Malignancy: If suspected, on the other hand, extractions are strongly indicated if the orofacial areas are to receive irradiation. 5. Teeth which have remained in irradiated bone. 6. Diabetes mellitus: After proper medical consultation to make certain that the child is under control. Treatment planning for extraction of primary teeth: Removal of primary teeth should be included in the treatment plan along with restorative procedures or cementation of space maintainers. Radiographic surveys of teeth to be extracted are of prime importance. A tooth needs not be removed on the first appointment unless there is an acute infection or current toothache. When the placement of a space maintainer is scheduled, the appliance should be ready before the appointment 'and cemented after the removal of the tooth. Preoperative preparation: As the extraction of a tooth can be emotionally upsetting to the child and the parents, some preparations are necessary. a) Preparing the parents: A parental consent is important. discussion with the parents before treatment begins. Any possible medical condition that may require special precaution should be thought. b) Preparing the patient: The choice of words that the dentist uses is critical. Explain to the child what sensation may be experienced and what is expected from him. 2 3 It is extremely important that the patient realizes the difference between pressure and pain. Modifications to extraction technique 1.The forceps beaks and handles are smaller to accommodate difference in size. 2. Also the beaks are more curved to accommodate the more bulbous crown. 3.The wide splaying of primary molars roots mean that more expansion of the socket is required & the more elastic alveolus allow this to be achieved. 4.Owing to relatively cervical position of furcation area , it is injudicious to use forceps with deep plunging beaks as it could damage the underlying permanent successors specially with lower primary molars 6.Blind investigation of the socket should not be performed as there is danger for permanent successors. Techniques for the removal of primary teeth: Removal of some of the deciduous teeth with all or part of the roots present can be challenging. Armamentarium for exodontia procedures is much the same as for adult but as all anatomic structures are smaller, special forceps are available for primary teeth and offer some convenience. Large adult forceps such as the (Cow horn) forceps and large elevators are contra-indicated. When removing young permanent teeth, the young elastic bone structures and incomplete root development usually facilitate the extraction. Fracture of a slender root is common, especially when there is uneven resorption. These roots should be removed, provided that the permanent tooth buds can be avoided. A small spear point elevator or even a large spoon excavator can be used for removing the remaining fragments. Extraction of anterior teeth; Anterior teeth should be luxated to the labial during the extraction procedure - due to the lingual position of the permanent teeth - then rotated slightly and delivered to the labial. Extraction of maxillary primary molars: Because the palatal root is curved, it indicates the direction of the removal, and the initial direction of force is slightly to the lingual. Slight force is emphasized in order not to fracture the curved palatal root then in a single sustained force to the buccal the tooth is loosened, and a counterclockwise motion delivers the tooth out of the socket. Extraction of mandibular primary molars; 3 4 The cross-section of the mandibular first primary molar roots is flat mesiodistally. After it is loosened, a counterclockwise rotation delivers the tooth from the socket. During extraction the mandible is supported with the nonextraction hand to protect TMJ against any possible injury. Order of extraction The order of extraction is as follows:  Symptomatic teeth before balancing extraction on the opposite side.  Lower teeth before upper teeth (to eliminate bleeding interference with surgical field). If there are symptomatic teeth in all quadrants, a right handed operator should begin with lower right extractions (minimize changes in position of surgeon which will reduce general anesthetic time) Fractured primary tooth roots ⮚ Expert opinion suggests that if the fractured root tip can be removed easily, it should be removed. ⮚ If the root tip is very small, located deep in the socket, situated in close proximity to the permanent successor, or unable to be retrieved after several attempts, it is best left to be resorbed. ⮚ The parent must be informed and a complete record of the discussion must be documented. Indications for extraction of permanent first molars: 1. Permanent first molars erupt early and sometimes thought by the parents as primary teeth. 2. If a permanent first molar is removed before the permanent second molar has erupted through the gingiva the chances that the second molar will move mesially and occupy the space of the extracted first molars are very good. 3. When two first molars are diseased beyond repair, they should be removed. 4. But if three first molars are diseased beyond repair, all four molars should be removed with the expectation that a more symmetrical dentition will result. Balancing and compensating extraction A balancing extraction is a tooth from the opposite side of the same arch, designed to minimize midline shift. Compensation means of a tooth from the opposing quadrant to the enforced extraction to avoid overeruption of unopposed molar. Decision depends the condition of the 4 molars, the age of the child, presence of third molars and degree of malocclusion after orthodontic consultation. This is complicated by a number of factors : 1.Timing of first permanent molar extraction 4 5 2.Presence of an underlying malocclusion 3. Developmental status of the dentition (premolars & third molars) 4. The long-term prognosis of the remaining first permanent molar/s Guidelines for Extraction of First Permanent molar The ideal conditions for extracting first molars that have a poor longterm prognosis are: 1. Unerupted canines, 2. Premolars and second molars are visible on a radiograph and show no evidence of abnormality, 3. The occlusal relationship is class I, there is mild buccal segment crowding i.e there is insufficient space in the arch for the eruption of canines and premolars. 4. The patient is between 8 1/2 and 10 years of age If the first permanent molar is extracted before the age of eight years, the second premolar can drift distally into the extraction space, tip and rotate. If the first permanent molar is extracted during the later stages of second molar eruption, the second molar may tip mesially and rotate, producing spacing and poor occlusal contacts. ⮚ Immediate Complications after extraction in children ⮚ Fracture of the mandible. ⮚ Loosening or extraction of adjacent teeth. ⮚ TMJ dislocation. ⮚ Extraction of the permanent successor: ⮚ It should be replanted immediately with ligating the tooth into its normal position. ⮚ Recent extraction modalities ⮚ Physics Forceps® 5 6 ⮚ The extractions using the Physics Forceps are more predictable in time commitment, faster procedures, and most assuredly, less traumatic physically and psychologically to the patient. ⮚ Postoperative instructions: A. For the child: 1. Once the blood has clotted, the child is instructed to hold between his lips a small cotton roll until his lips "wake up". 2. The child may return to school or go out and play once the numbness has gone. 3. Child should be reassured that he will get a new tooth replaced with the one that was removed. B. For the Parents: 1.There is a need to tell the parents why the cotton roll is used and that they should not be concerned if there is slight oozing or blood from the socket or if blood is seen on the pillow the next day. 2.Light meal with no hard food is recommended. 3.The parents are further instructed not to ask the child how painful the area is or continuously ask how the child feels. 4- Simple written instructions are helpful. Post extraction problems Hemorrhage apply pressure and suturing Lip biting put cotton roll attached with floss Structural anomalies: 1-Supernumerary Teeth (hyperdontia): Terms used to describe an excess in tooth number. Mesiodens (a term restricted to supernumerary teeth in the midline of the maxilla), paramolar, distomolar, supplemental teeth. Frequency Occur in permanent more than primary teeth. Clinical significance or complications: a. Over-retained primary teeth 6 7 b. Delayed or ectopic eruption of permanent c. Development of midline diastema d. Displacement and rotation of adjacent teeth e. Root resorption of adjacent teeth. f. Crowding and cross bite g. Dentigerous cyst formation h. Prevention of orthodontic tooth movement Diagnosis: Usually may be asymptomatic and discovered on routine radiographic examination. Failed or eruption disturbance of permanent tooth The diagnosis of a mesiodens can be confirmed with radiographs, including occlusal, periapical, panoramic films, or CBCT. Natal and Neonatal teeth: Natal teeth: Teeth present at birth Neonatal teeth: Teeth present within the first 30 days Natal teeth are 3 times more common than neonatal teeth. More than 90% of natal and neonatal teeth are prematurely erupted deciduous series of teeth, whereas less than 10% are supernumerary. 85% of the natal teeth are mandibular incisors, 11% are maxillary incisors & 4%are posterior teeth. Complications: 1) Risk of Aspiration (if they are excessively mobile) 2) Interference of breast feeding. 3) Riga-Fede Syndrome: ulcer on ventral surface of tongue or in inner surface of lower lip caused by trauma of soft tissue from erupted natal or neo natal teeth. Management: The radiographic examination is essential to differentiate the premature eruption of a primary deciduous tooth from a supernumerary tooth. I-No complications: can be retained and follow up. II-Make complications: extract 1) Avoid extraction before the tenth day to prevent postoperative bleeding from newly born jaundice. (Rule of 10 for pediatric surgery; 10 days, 10 pounds weight, 10 mg hemoglobin). 7 8 2) Before 10 days: Administer Vitamin K before extraction ( 0.5-1.0 mg IM ) Abnormal maxillary frenum attachment: The origin: at the midline on the inner surface of the lip The most commonly observed types are mucosal and gingival. Infants have the highest prevalence of papillary penetrating phenotype. Best time for management: 1- After eruption of upper permanent canine (diastema could be self corrected by end of ugly duckling stage). 2- After orthodontic treatment to avoid relapse Complication: Breastfeeding difficulties Isolated gingival recessions and diastemas possible etiologic factors for a diastema should be ruled out before surgical correction of a prominent maxillary labial frenum. These include thumb sucking, tongue thrusting, supernumerary teeth, cystic lesions or due to peg shaped lateral incisor, congenital missing lateral incisor). Interfere with proper toothbrush placement Food accumulation, inflammation, pocket development between the labial surface of the tooth and the vestibular mucosa. 1. In mild cases, no specific treatment is required. 2. Frenotomy 3.Electrosurgery or CO2 laser can be used Ankylosed Deciduous Teeth :( Submergence or infraocclusion) Such teeth will interfere with the eruption of their permanent successor. Such teeth should be surgically removed at appropriate time to allow unhindered eruption of permanent teeth into normal position. Extraction or surgical removal is indicated in cases of severe infra occlusion or any change in the axial inclination of adjacent teeth. Ankylosed Permanent Teeth: (after replantation of avulsed tooth) If ankylosis occurs before the age of 10 or before the growth spurt, a high risk of developing severe infrapositioning. So decoronation should be performed within 2 years in early mixed dentition (age 7–10 years). 8 9 Decoronation: Removal of the crown just below the cervical bone margin, this prevents severe bone loss from extraction of ankylosed teeth. This is very important for successful implant insertion later. Pathology consideration pediatric patients: Tumors generally grow faster in pediatric patients and are less predictable in behavior. Children tolerate the trauma of surgery better and recover more quickly. Lesions of the newborn Oral pathologies occurring in newborn children include Epstein’s pearls, Dental lamina cysts, Bohn’s nodules, Epstein’s pearls are common, found in about 75% to 80% of newborns. They occur in the median palatal raphe areaas a result of trapped epithelial remnants along the line of fusion of the palatal halves. Dental lamina cysts, found on the crests of the dental ridges, most commonly are seen bilaterally in the region of the first primary molars on maxillary and mandibular ridges. Eruption cyst The eruption cyst is a soft tissue cyst that results from a separation of the dental follicle from the crown of an erupting tooth. Fluid accumulation occurs within this created follicular space. Eruption cysts most commonly are found in the mandibular molar region. Color of these lesions can range from normal to blue-black or brown, depending on the amount of blood in the cystic fluid. The blood is secondary to trauma. If trauma is intense, these blood-filled lesions sometimes are referred to as eruption hematomas. Because the tooth erupts through the lesion, no treatment is necessary. 9 10 Infection consideration: Younger than 5 years: upper face infections of nonodontogenic origin are more common. Older than 5 years, lower face infections odontogenic origin are more common. Most odontogenic infections can be managed with pulpectomy, extraction, or incision and drainage (for serious infections). Infections of odontogenic origin with systemic manifestations [e.g., fever, facial cellulitis, difficulty in breathing or swallowing, fatigue, nausea] can be life threatening and may require immediate hospitalization with intravenous antibiotics, incision and drainage, and referral/consultation with an oral and maxillofacial surgeon. Acute orofacial infection Major cause is dental in origin — Two areas are of special importance: Swelling in submandibular area Infection involving angles between eyes & nose Treatment : 1. Remove the cause 2. Drainage 3. Prevention of spread 4. Restore function 5. The child must be adequately hydrated Clinical Examination Check the Presence of systemic symptoms as Fever, Malaise, Chills, Anorexia and dehydration. Patient’s respiratory compromise, distress. Examination of the floor of the mouth, the retro-molar areas & the palate by visual examination and bimanual palpation. Involved swelling and its severity (localizaed or diffuse) Palpation of the tissues to discern their tenderness and consistency (cellulitic or fluctuant). Examination of the dentition. Indications for admitting a pediatric patient to the hospital include: 1. Fever, lymphadenopathy. 10 11 2. Elevated white blood cell count (WBC). 3. Poor oral intake. 4. Dehydration. 5. Involved fascial spaces, associated findings (e.g., dysphagia) 6. Compromised air way. 7. General appearance of the patient provides significant guidance. The appearance of being ill (i.e., looking sick). Ex: Deep neck infections 8. Patients who have some defense compromise, such as diabetes or immunosuppression. POST-OPERATIVE INSTRUCTIONS FOR EXTRACTIONS/ORAL SURGERY It is important to inform and give advice to the parent about the consequence after surgery. 1. Numbness: The mouth will be numb two to four hours. Watch to see that your child does not bite, scratch, or injure the cheek, lips, or tongue during this time. 2. Bleeding: Hold gauze with firm pressure against the surgical site until oozing has stopped. If bleeding continues for more than two hours, contact your dentist. 3. Surgical Site Care: advice child to not disturb the surgical site, or rinse vigorously, or probe the area with fingers. The day after surgery, your child can rinse with warm salt water (½ teaspoon salt with one cup water) after meals. 4. Sutures: Sutures may be needed to be removed at follow-up visit. 5. Daily Activities: your child should avoid any physical exercise in day of surgery. 6. Diet: After all bleeding has stopped, the patient may drink cool noncarbonated liquids but should not use a straw. Encourage fluids to help avoid dehydration. Cold soft foods (eg, ice cream, pudding, yogurt) are ideal the first day. Until healing is more established, avoid foods such as nut and popcorn that may get lodged in the surgical areas. 7. Oral Hygiene: Keeping the mouth clean is essential but avoid stimulating the surgical site. 8. Pain: Because some discomfort is expected, you may give your child or ibuprofen before the numbness wears off. Do NOT give aspirin to your child. 9. Watch for: Swelling: Slight swelling and inflammation may occur for the next two days. If swelling occurs, ice packs may be used for the first 24 hours (10 minutes on then 10 minutes off ) to decrease swelling and/or bruising. If swelling persists after 24 hours, warm/moist compresses (10 minutes on then 10 minutes off) may help. Fever: A slight fever (temperature to 100.5°F) is not uncommon the first 48 hours after surgery. If a higher fever develops or the fever persists, call your dentist. 11 12 Important points for revision All medically comprised conditions need consultation preoperatively. Blood Diseases: Systemic hemostatic agents preoperatively and sometimes postoperatively depending on the patient’s condition. Agents include factor infusion, cryoprecipitate or fresh frozen plasma. Local hemostatic agents and techniques such as pressure, surgical packs, sutures and surgical stents may be used individually or in combination and may assist in the local delivery of hemostatic agents, such as topical thrombin and vasoconstrictors. For patients taking warfarin, their international normalized ratio (INR) should be measured before a surgical procedure. The normal therapeutic range is 2.0–3.0. According to current recommendations, most oral surgical procedures can be performed without altering the warfarin dose if the INR is less than 3.0. If INR values are greater than3.0, physician referral is suggested. Patients taking heparin are often those who are on hemodialysis due to end-stage renal disease. Heparin has a short half-life (about 5 hours) and patients can often be treated safely on the days between dialysis. Cardiac disorders: A. Follow AHA infective endocarditis prophylaxis regimens for the high-risk patients like (prosthetic cardiac valve, prosthetic material used for cardiac valve repair, previous infective endocarditis, congenital heart disease (CHD) or cardiac transplantation recipients who develop cardiac valvulopathy) undergoing at-risk procedure like extraction or surgery. 12