DENTAL SCIENCE PROGRAM 8

Clinical Surgery of Hard and Soft Tissue

TOPIC 3

PEDODONTIC EXODONTIASubmission date : March 30th, 2011

GROUP ONE : NPM

1. LEONG LI-SHAN 1601100830152. ASHLEY ANN DECRUZ 1601100830163. TUN SHAFIQAH BT TUN MAJID 160110083017

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Table of Contents

CHAPTER ONE : INTRODUCTION............................................................................................................3

Definition of Exodontia......................................................................................................................3

CHAPTER TWO : LITERATURE VIEW.......................................................................................................4

INDICATIONS FOR EXTRACTION OF PRIMARY TEETH.........................................................................4

Indications for Extraction of Permanent First Molars....................................................................4

CONTRAINDICATIONS TO EXTRACTION OF PRIMARY TEETH.............................................................5

INSTRUMENTS USED FOR EXTRACTION OF MAXILLARY TEETH.........................................................6

Maxilla Teeth.................................................................................................................................6

Mandible Teeth...........................................................................................................................13

EXTRACTION TECHNIQUES OF MAXILLARY AND MANDIBLE............................................................16

Preparation for Anaesthesia........................................................................................................17

Topical Anaesthesia.....................................................................................................................17

Extraction procedures.................................................................................................................19

POST-EXTRACTIONS : INSTRUCTIONS TO GUARDIAN AND PATIENT................................................21

Reminders for the guardian.........................................................................................................22

Reminders for the patient...........................................................................................................23

COMPLICATIONS DURING EXTRACTION AND POST EXTRACTION COMPLICATIONS........................24

Complications during Extraction..................................................................................................24

Post Extraction Complications.....................................................................................................24

MANAGING COMPLICATIONS DUE TO TOOTH EXTRACTION...........................................................25

REFERENCES........................................................................................................................................26

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CHAPTER ONE : INTRODUCTION

Definition of Exodontia

A branch of dentistry dealing with the extraction of a tooth from its socket in the bone.

According to Jeffrey and Howe, an ideal tooth extraction is defined as painless removal of

whole tooth or tooth root with minimal trauma to investing tissues so that wound heals

uneventfully and postoperative prosthetic problems are minimal.

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CHAPTER TWO : LITERATURE VIEW

INDICATIONS FOR EXTRACTION OF PRIMARY TEETH

1. If the teeth are decayed beyond possible repair; if decay reaches down into the

bifurcation or if a sound hard gingival margin cannot be established.

2. If infection of the periapical or interradicular area has occurred and cannot be

eradicated by other means.

3. In cases of acute dentoalveolar abscess with cellulitis.

4. If the teeth are interfering with the normal eruption of the succeeding permanent teeth.

5. In cases of submerged teeth

6. Supernumerary teeth, if not needed in dental arch.

Before the indications are considered, a primary tooth that is firm and intact in the arch

should never be removed unless a complete clinical and radiographic evaluation has been

made of the entire mouth and the particular area.

Factors that should also be considered: occlusion, arch development, size of teeth, amount of

root, resorption of the primary tooth involved, the state of development of the underlying

permanent successor and adjacent teeth, presence or absence of infection.

Indications for Extraction of Permanent First Molars

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If a permanent first molar is removed before the permanent second molar has erupted

through the gingiva, the chances that this second molar will move mesially and occupy the

space of the extracted first molar is GOOD.

If the permanent second molar has erupted through the gingiva at the time of loss of the

permanent first molar, the second molar will probably tilt forward into the space of the first

molar causing conditions favouring periodontal disease and orthodontic problems.

If second molars have broken through, every attempt should be made to save the first molars.

Systemic condition of the patient should also be considered before the extraction of primary

teeth.

CONTRAINDICATIONS TO EXTRACTION OF PRIMARY TEETH

More or less the same as in adults. They may be overcome with special precaution and

premedication.

1. Acute infectious stomatitis, acute Vincent’s infection of herpetic stomatitis and

similar infections should be eliminated before an extraction is contemplated.

EXCEPTIONS: acute dentoalveolar abscesses with cellulitis, which demands

immediate extraction.

2. Blood dyscrasias render the patient susceptible to postoperative infection and

hemorrhage.

3. Acute of chronic rheumatic heart disease, congenital heart disease and kidney disease

requires antibiotic coverage.

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4. Acute pericementitis, dentoalveolar abscesses and cellulitis.

5. Acute systemic infections of childhood: lowered resistance of the body and secondary

infection

6. Malignancy: extraction tends to enhance the speed of growth and spread of tumors but

is strongly indicated if radiation therapy of the jaw and surrounding tissues are to

follow.

7. Teeth which have remained in irradiated bone: infection of the bone will follow

extractions because of avascularity.

8. Diabetes mellitus: must be under control.

INSTRUMENTS USED FOR EXTRACTION OF MAXILLARY TEETH

Maxilla Teeth

Dental Elevator

Functions:

To luxate teeth (loosen) from surrounding bone.

Minimize the incidence of broken roots, teeth and bone.

It also facilitates the removal of a broken root should it occur.

Elevators also expand the alveolar bone.

Remove broken or surgically sectioned roots from their sockets.

3 Components: Handle, Shank and Blade

Handle: to hold the instrument comfortably to apply substantial but controlled force.

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Shank: connects handle to working end.

Blade: working tip of the elevator and transmits force to bone, tooth or both.

3 Types:

1. Straight type

Most commonly used to luxate teeth.

Small straight elevator: No. 301 is used for beginning the luxation of an

erupted

Larger straight elevator: to displace roots from their sockets and also to

luxate teeth that are more widely spaces or once a smaller sized straight

elevator becomes less effective. Most commonly used: No.34S

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2. Triangle or pennant-shape type

Provided in pairs.

Most useful when a root remains in the tooth socket and the adjacent

socket is empty

The elevator is turned in a wheel-and-axle rotation with the sharp tip of the

elevator engaging the cementum of the remaining distal root; the elevator

is then turned and the root is delivered.

Cryer is the most common type but not popularly used in pedo because it

causes damage to the permanent teeth in development

3. Pick type

Used to remove roots

Heavy version: Crane pick used as a lever to elevate a broken root from

the tooth socket after a purchase point has been prepared with a bur.

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Purchase point is made by using a bur to drill a hole approximately 3mm

deep into the root just at the bony crest. The tip of the pick is then inserted

into the hole and with the buccal plate of bone as the fulcrum, the root is

elevated from the tooth socket.

Root tip pick or apex elevator. It is used to tease small root tips from their

sockets

Only the straight and pick type are used more commonly for elevating grossly carious

primary teeth and roots.

Extraction forceps

Instruments used to remove tooth from alveolar bone.

The forceps used in the extractions of primary teeth are the same as in adults.

Some operators prefer special child forceps because they can be hidden in the

palm. This is felt unnecessary because forceps with larger handles can be

controlled better.

The removal of anterior primary teeth and roots is simple. A steady rotation in one

direction disengages the tooth from its attachment.

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Components of the forceps

Handles, beaks and hinge

• Handles: adequately sized to handle comfortably and deliver sufficient pressue and

leverage

• Hinge: English type: vertical fashion

American type: horizontal fashion

• Beak: to adapt to the tooth root near the junction of the crown and root.

Maxilla: Anterior: Ash No. 37 straight forceps

Maxilla: Posterior: No. 150S or bayonet forceps

Mandible: No. 151 or Universal forceps. Similar in shape to No.150 but the beaks are

pointed inferiorly for the lower teeth

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Other armamentarium for extraction of primary teeth

Suction tip: A surgical suction tip has a very small opening that allows the dental assistant to

keep the area clean and free from blood so that the dentist has a clear view of the area being

treated.

Cheek retractor. The Minnesota retractor can be used to retract the cheek and a

mucoperiosteal flap simultaneously. Before the flap is created, the retractor is held loosely in

the cheek, and once the flap is reflected, the retractor edge is placed on the bone and is then

used to retract the flap.

Tongue retractor. The instrument most commonly used to retract the tongue during routine

exodontia is the mouth mirror. It can also be used as a cheek retractor. The Weider tongue

retractor shown below is a broad, heart shaped retractor that is serrated on one side so that it

can more firmly engage the tongue and retract it medially and anteriorly .

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Periosteal elevator. Most commonly used is the Molt periosteal elevator No.9. This

instrument has a sharp, pointed end and a broader flat end. The pointed end is used to confirm

the depth of the incision and reflect dental papilla form between the teeth. The broad end is

used to elevate the tissue from the bone.

Curette for debridement of the socket after extraction.

Gauze squares to aid in hemostasis

Syringe for administration of local anaesthetic for analgesia.

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Mandible Teeth

Basic instruments for Pediatric extractions:

1. Suction tip :

Used to suck out excess fluid or blood in the mouth.

2. Cheek and tongue retractor:

Retracts tongue and cheeks to aid in a proper visualization during extractions.

3. Periosteal elevator:

Reflexes the gingival cleft

4. Gauze square:

To stop bleeding and start hemostasis

5. Syringe and cartridge for local anesthesia: Cytojet

Administration of anesthetic

Figure: Shows the picture of cytojet used for administration of anesthetic.

Source: http://dentafiesta.blogspot.com/2009/01/wah-gawatcitoject-oh-citoject.html

6. Mandibular forceps:

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For pediatric extractions, the use of 151S (a modified version of the 151 forcep) is

sufficient for all mandibular extractions.

The beaks and handles of the of the forceps are smaller and more curved to

accommodate the more bulbous crown of the primary teeth.

Figure: Shows the 151S forceps

Source:

http://www.freeed.net/sweethaven/medtech/dental/dentsetups/lessonMain.asp?

iNum=fra0305

http://www.dental-forceps.com/blog/2010/12

7. Bein / Elevator

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Is used when the tooth intended for extraction is still in the alveolar process.

The bein or elevator is used to scoop out the teeth from the socket using light forces.

The elevator is sensitive to touch.

Figure:

Left: Straight elevator number 34-S.

Right: Straight Elevator Number 301. Similar in shape to but smaller than number 34-S.

Source: http://www.dental-forceps.com/blog/2010/12

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Figure:  Apical Fragment Root Elevators. These are used to remove apical root fragments 

Source: http://www.dental-forceps.com/blog/2010/12

EXTRACTION TECHNIQUES OF MAXILLARY AND MANDIBLE

Before making a decision about extraction, the oral cavity must be carefully examined. The

dentist collects medical and dental history and makes X-rays. Then the dentist assesses the

state of the tooth, its roots and root bone placed around.

Medical history helps to gather all medical information about the health of the patient to

determine the best methods and techniques for the forthcoming treatments. Other illness of

the patient, what medications the patient takes must be taken into concerns too. The fact is

some medications used by patients can cause complications during tooth extraction, for

example, aspirin slows blood clotting.

Before removal of the tooth, anaesthesia is used for the tooth and surrounding bone and

gums. In order for the patient does not experience discomfort associated with injection of

anesthetic solution during anesthesia, anesthetic gel (pain medication) of high concentration

is applied in the area of injection. After an adequate anesthesia, the dentist proceeds to

remove the tooth.

Anaesthetic techniques used for maxillary and mandible of a child : infiltration technique and

block technique.

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Preparation for Anaesthesia

For premedication, take Phenobarbital dose about half to one hour before appointment.

Sterilization needs for the operator and mucosa region that need to be injected. Instruments

needed are sharp needle, disposable and the size of needle for children less than adult.

Anaesthetic drugs for topical is chloroethyl which can be paste or spray using cotton. For

local anaesthesia, drug being used are esther (procaine) or non esther (lidocaine or prilocaine)

added with vasoconstrictor.

Topical Anaesthesia

Topical anaesthesia is a method that pain relief at the surface site by applying it directly.

The indications for topical anaesthesia are :

incision abscess

extraction of mobile tooth

extraction of deciduous tooth

subtract pain when enter the needle for sensitive patient

Techniques for topical anaesthesia begin with dry the region that will be anaesthetised. If

hyper salivation happens at that region, use cotton roll for isolation. Within 15 cm, spray

chloroethyl until the surface looks pale. We can also sprayed directly on cotton, then put on

the gums two to four times. Extraction can be done. Patient is advice to breath by using

nose. The side effects of using chloroethyl are dizziness, nausea or fainting.

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i) Infiltration Anaesthesia

Infiltration anaesthesia is used for relief pain at certain region by injection. The indications

for using this method are extraction molar deciduous tooth that had been resorption till

mobile or extraction of deciduous tooth that persistent.

The techniques begin with wiping muccobuccal fold with jodium. Inject the needle at 45º at

muccobuccal fold or one and a half of the tooth neck, bevel towards the bone, until reach the

bone. Withdraw 1-2 mm and parallel the needle until reach the bone at periapical tooth

region nearby. Release 1cc slowly because too rapid of releasing anaesthesia will lead to

spreading to broad region and the effect will be too light. For palatine region, injection at

palatine mucosa ±1/3 from dental gum edge distance that will be extracting. Put a light

pressure when inserted the needle and release 0.5cc of anaesthesia.

ii) Block Anaesthesia

Block anaesthesia is to relief pain at a certain region because of anaesthesia at central nerve

system. There are two techniques for block anaesthesia which are single path technique and

Fisher technique. Single path technique or straight line technique is directly given meanwhile

Fisher technique is indirectly given to patient.

Indications for using these methods are :

extraction of molar deciduous tooth without root resorption

extraction of permanent molars

The techniques start with parallel mandible with floor. Put your index finger at the occlusal

of the molar tooth so that it will touch the occlusal angle. The finger nail facing to the

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tongue, find retromolar trigone and lean the nail at internal linea oblique. Insert the needle at

near the tip of finger and the syringe is at first and second molar at the opposite side. When

already reach to the bone, withdraw a bit and put the syringe parallel to occlusal site which

will be anaesthetise.

Release 0.5cc for lingual nerve and placed syringe at the first position which situated in

between canine and first molar. Face it towards below of occlusal plane until reach mandible

foramen. Release 1cc of anaesthesia for inferior alveolar nerve. To anaesthetise buccal side,

infiltration anaesthesia is done with 0.5cc for buccinators nerve. After five minutes, cheek,

anterior tongue and lips will be numb at one side. Wound can happen certain time because

children bite the anesthetise region.

Extraction procedures

For maxilla teeth, the patient will be positioned more horizontally and the dentist will be at

the position of 6-9 o’clock ; whilst for mandible teeth, the patient will be positioned lower at

110 H and the dentist at 9-12 o’clock.

The dentist’s non-working hand is used to retracts soft tissues to allow visibility and access

and protects the tissues if the instrument slips. The other hand also provides resistance to the

extraction force on the mandible to prevent dislocation while providing the ‘feel’ to the

operator during the extraction and gives information about resistance to removal.

An elevator is used to wedge between the tooth and the bone surrounding it. This expands the

tooth's socket and separates its ligament.

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The extraction forceps will then be used, manipulating the tooth from side to side and rotating

it for further socket expansion and ligament separation. When properly prepared this way, the

tooth will be pulled upon to slide out of the socket in its entirety. The forcep used in the

extractions of primary teeth are the same as in adults.

The removal of anterior primary teeth and roots is simple, requiring a steady rotation in one

direction which disengages the tooth from its attachment. This can be accomplished in the

upper jaw (maxilla) with a No.150 or bayonet forceps and in the lower jaw (mandible) with a

No.151 forceps.

Figure : Paediatric forcep No.150

Figure : Paediatric forcep No.151

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Figures source : http://www.medical-supplies-equipment-company.com/lab-equipment-

supplies/product/pediatric-extracting-forceps.html

For posterior teeth, the same instruments are used. Upper and lower primary molars are

removed with a buccolingual motion with the motion towards the lingual aspect quite often

offers less resistance.

Note : difficulties in the application of forceps may be encountered in lower molars due to the

inclination of the crown and the inability of the child to open his mouth wide enough.

POST-EXTRACTIONS : INSTRUCTIONS TO GUARDIAN AND PATIENT

Bleeding is typical after a tooth has been extracted. This may last for only about a day.

A small piece of gauze will be applied to the area of the tooth extraction. This should be kept

in place for long enough for the blood to clot. It is important for the child's mouth to be kept

as clean as possible during the healing period. This can be done by rinsing the mouth with

salt water several times per day.

If any additional swelling occurs or if the child begins to feel additionally ill or comes down

with a fever, then be certain to call the dentist immediately in case of infection. This rarely

happens though.

Children's Tylenol or Ibuprofen should be purchased if the dentist did not already prescribe a

painkiller for the child to increase comfort after the extraction is complete. It is often best if

these not be used until the blood clot has formed.

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It may be good to apply a bag of ice to the outside of the child's jaw to keep swelling to a

minimum and to aid in numbing the pain.

Reminders for the guardian :

Mouth-rinsing

The child shall not rinse his mouth exactly after extraction. Wait until the bleeding

stops and ask the child to rinse mouth gently every 3 to 4 hours (especially after

meals) using warm salt water ( 1-2 teaspoon of salt to a glass of warm water).

Continue rinses for several days.

Bleeding

 If persistent bleeding occurs, place moist gauze pads over bleeding area and ask the

child to bite down firmly for one-half hour. Repeat if necessary. If bleeding still

persists, contact the dentist on call.

Soft diet

A liquid or soft diet is advisable during the first 24 hours. Make sure the child drinks

lots of fluids. Avoid drinking with straws for the first few days as this can result in

bleeding and delayed healing. The sucking action creates a negative pressure which

will cause bleeding. Advisable menu : Soup, mashed potatoes, milkshakes and

creamed vegetables make a good soft diet. Remember not to use a straw.

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Reminders for the patient :

Anaesthesia

The feeling of numbness will begin to wear off in 30 minutes to 4 hours. Until that

time, avoid all hot foods or liquids, and do not chew. This is to prevent accidentally

burning or biting the lips and cheeks.

Bleeding

When the procedure is completed, bite on the gauze that is placed in the mouth for at

least 1/2 hour. If there is more than slight bleeding, remove old gauze carefully and

place damp gauze over the bleeding area and hold in place for twenty minutes. Hold

firmly so that no blood escapes. Repeat this procedure as necessary.

Soft diet

Oral Hygiene

Clean the rest of the mouth as usual, however avoid bumping or brushing the

extraction site.

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COMPLICATIONS DURING EXTRACTION AND POST EXTRACTION COMPLICATIONS

Complications during Extraction

1. Causing hurt to the permanent tooth.

If by accident, the permanent tooth is removed during extraction, it should be

carefully replaced into the crypt or socket and the wound must be closed.

The patient is asked not to disturb that area till it has healed.

2. The use of curettes must be avoided to remove granulation tissue after extraction.

This is to avoid causing damage or hurt to the permanent teeth.

3. Extraction of submerged deciduous teeth caused by root ankylosis.

The alveolar bone develops around the root of the tooth and makes it appear

submerged. If the teeth are symptomless, no extraction is needed, however if

symptoms of pain or discomfort appear, the tooth should be removed.

Radiographic examination must be accompanied in these cases. Incision is done

through elevating the mucoperiosteal flap and burring around the root that is fused

to the bone. It is important to avoid fracturing thin roots as it is difficult to be

located.

Post Extraction Complications

1. Dry socket

Defined as postoperative pain in and around the dental alveolus. It delays the

healing process and usually happens when the newly formed clot in the extraction

site does not form correctly or is prematurely lost.

2. Aspiration or swallowing of teeth or roots.

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MANAGING COMPLICATIONS DUE TO TOOTH EXTRACTION

1. Dry sockets rarely occur in children. In cases of occurrence of dry socket in

children, the dentist should suspect for :

a) Unusual infection e.g.actinomycosis

b) Complicating systemic disorder such as anemia, or nutritional disturbances.

2. Most loose teeth must be removed before administration of general anesthesia or

oral introduction of endotracheal tube.

3. During forceful extractions, a tooth may be suddenly released from the bone and

squeezed out of the beaks of the forceps and aspirated or swallowed. This can be

prevented by using controlled pressure in the handles of the forceps and by sing a

4 by 4 inch sponge as a curtain behind the tooth being extracted.

4. If tooth goes missing during n extraction and it cannot be located, then a chest and

abdomen radiographic examination must be done immediately.

5. Absence of cough is not a prove that the tooth has not been aspirated.

6. A tooth in the bronchial tree must be removed immediately through

bronchoscopy.

7. If the tooth is located I the chest or abdomen area, a physician must be consulted

immediately.

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REFERENCES

Clinical Pedodontics. FINN. WB Saunders 2003. Page 394-396

Textbook of Oral and Maxillofacial Surgery by SM Balaji

Buku Ajar Praktis Bedah Mulut , Pedersen W.G

http://www.medical-supplies-equipmentcompany.com/product/ppf/id/26585/

new_prod_full.asp

http://www.ehow.com/how-does_4924301_how-tooth-extraction-performed-

child.html

http://www.sodental.com/images/extraction.pdf

http://www.jaharr.com/postextractionin.html

http://www.freeed.net/sweethaven/medtech/dental/dentsetups/lessonMain.asp?

iNum=fra0305

http://www.dental-forceps.com/blog/2010/12

http://www.dentalfind.com/info/forcepsMaxillary teeth (relating to the upper jaw or

jawbone)

http://dentalhandtools.com/dentalhandtools/maxillary-extraction-forceps/

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