Professional Documents
Culture Documents
Exodontia For Children-Final
Exodontia For Children-Final
Introduction
Natal and neonatal teeth Infraocclusion Fusion/Germination : due to the abnormal shape, elevators should be used Damage to Permanent Successor: Do not use forceps with large beaks. A radiograph should be obtained. Dislocation of Mandible: It is very easy to dislocate a childs mandible during extractions under general anesthesia as the articular eminence is not pronounced yet. Always verify this situation before allowing patient to gain consciousness
If the teeth is decayed beyond possible repair; if decay reaches down into bifurcation or if a sound hard gingival margin cannot be established If infection of the periapical or interradicular area has occurred and cannot be eradicated by other means In cases of acute dentoalveolar abscess with cellulitis If the teeth are interfering with the normal eruption of the succeeding permanent teeth In cases of submerged teeth
If the primary second molar has not fallen and first molar has a severe caries, the first molar can be extracted so that the permanent second molar will drift into the space of the first molar. If the primary second molar has already fallen. The permanent first molar must be saved in any way possible. As drifting of teeth will not occur fully. Extraction to reduce the third molar impaction
Acute infectious stomatitis, acute Vincents infection or herpetic stomatitis and similar lesions should be eliminated before an extraction is contemplated. Blood dyscrasias render the patient susceptible to postoperative infection and hemorrhage. Extractions should be performed only after adequate consultation with a hematologist and proper preparation of the patient Acute or chronic rheumatic heart disease, congenital heart disease and kidney disease require proper antibiotic coverage
Acute pericementitits, dentoalveolar abscesses and cellulitis Acute systemic infections of childhood contraindicate elective extractions for the child because of a lowered resistance of the body and the possibility of secondary infection Malignancy. If suspected, contraindicates dental extractions. Trauma of extraction tends to enhance the speed of the growth and spread of tumors.
Teeth which have remained in irradicated bone should be extracted only as a last resort and only after the consequences have been fully explained to patient. It is very dangerous to extract teeth after exposure to radiation Diabetes mellitus patients
Clinic Clothing
Has
Antibacterial soap is used and scrubbing hands is done approximately 5-6 minutes. These are the steps for washing hands before and after every dental treatment :
Remove all jewelry (rings, watches, bracelets) Nails must be short and clean Wet hands with running water. Apply soap and rub to lather well These steps should be done for 15-30 seconds
Rub palm to palm Rub the back of both hands Rub palms again with fingers interlaced Rub backs of interlaced fingers Wash back of thumbs Rib both palms with fingertips Wash your wrists
Rinse hands under clean running water until all the soap is gone Bloat your hands dry with a clean towel. Do not close the tap with your own hands
Triad Barrier
Gloves
Disposable gloves are the better option When sterility is needed eg; implant or aloplastic material to add ridge: sterile gloves can be used Face mask with strings is more practical compared to elastic ones to have better adaptability to the face. Made from plastic and light Provides eye protection from saliva, micro bacteria, debris and other foreign materials. Operator is also recommended to use surgical caps
Mask
Goggles
the procedures of the treatment Able to overcome complications that may caries Postsurgical
separate area is needed to clean the instruments The brush used to scrub the instruments are deemed contaminated are cannot be used to wash hands The nurse in charge of washing the instruments must wear thick gloves All the saliva, blood and tissue must be cleaned before starting the sterilization and disinfection stage. It is recommended to use a ultrasonic cleaner
intact skin
Processed by sterilization
Ideally by sterilization.
Disinfection
Disinfection
Example: injection needles, scalpel, elevators, burs, tangs, suture needle. 1. Sterile instruments must be checked weekly with a spore test
Example: handpiece, mouth Example: counter tops, mirror, bite block, retractors chair position controller, x-ray viewer
2. When sterilizing, an
indicator sensitive to heat or vapor should be placed outside the packaging.
with antimicrobial
solution
Decontaminate
Decontamination is done on surfaces that have come into contact with patients mouth fluid (saliva, blood, etc.) Method: All the surfaces that are contaminated or have risk of contamination will be wiped with a clean towel and then disinfected with whitening solution (diluted Clorox 1:10 or 1:100 depending on the type of organic substance.
Surface protector
Use a waterproof paper, aluminium foil or clear plastic to cover the surfaces that are easily contaminated and hard to disinfect such as the light holder or the x-ray head. Change after every extraction to prevent cross contamination although there is no sign of contamination.
Mental Preparation
Minimize
anxiety and fear of patients to injections, wound pain, anesthetic action and the possibility of disability or death. Good communication with patient, if possible make patient feel at ease in any way possible depending on the patient.
Medical history and physical examination is the best screening method to detect a disease Even without signs and symptoms of a disease, the surgeon may request for a laboratory test as precaution
Radiology
Physical Preparation
Observation
Blood
Pressure (120/80) Pulse Rate Temperature (36degrees Celsius- 37.2 degree Celsius) Respiration Rate (12 -20 breaths per minute)
proper and accurate medical history is needed to determine whether a patient can undergo surgery Can be obtained from the patient or patients family Take note of:
Allergy,
especially to antibiotic Medication, whether the patient is taking steroids, insulin or anticoagulant Existing Disease such as diabetes mellitus, epilepsy, asthma, stroke or infarct and etc. Past surgery, normally heart surgery, organ transplant or cancer surgery. Ask whether there were any reactions or complication throughout the surgery.
Specifically
Smoking
Sedimentation Rate
Leucocyte
Thrombocyte
Medical Consultation
Formal
request to have input from other doctors on the surgery Purpose is to reduce the risk and increase the possibility of a successful surgery. Normally done with the anesthetist, internal medicine specialist and pediatrician
Nutrition
Consideration
of the need for proper nutrition based on the patient's clinical condition
Blood supply
Blood
reserves in the event of complications in patients Maintain hemoglobin levels before and after the operation no less than 10 g / dl
Informed
It
Consent
is as effective way to provide enough information to the patient such as general status, therapy that will be done and alternatives, the pros and cons of the therapy, complications Communication between doctor, patient and parents or guardian must be accurate and clear when providing information. It should be a two way conversation. Information is given based on the education level, experience, age and other factors.
Treatment
Patient
Options
and parents or guardian should be informed of their options, and should never be led to believe that there are no alternatives. There is an option of no treatment and its consequences must be discussed with the patient.
Written
or Verbal Consent
A written
consent is signed by both the patient (parents or guardian), dentist and a witness if available. All treatments especially one that will affect the patients level of consciousness should have a written consent.
Medication
anxiety and panic Induces calmness Reduce airway secretion Strengthen the effect of hypnotic drugs in general anesthetic Reduce nausea and vomiting Causes amnesia Reduce volume and increase the stomach pH Reduces vagal reflex
Examples
of premedication : Benzodiazepine, Opoid, Anticholinergic Factors that determine the type of medication and dose:
Age Weight Health
Condition of Patient ( past disease, vital signs, patients cooperation, physical ) Type of surgery Patients request
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 ANASTHESIA
A method that pain relief at the surface site by applying it directly Indications : incision abscess
INFILTRATION ANASTHESIA
Used for relief pain at certain region by injection Indications : extraction molar deciduous tooth that had been resorption till mobile extraction of deciduous tooth that persistent
BLOCK ANASTHESIA
To relief pain at a certain region because of anaesthesia at central nerve system Two techniques :
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
retractor
Types
To
Tongue
Mouth
retractor
mirror, Weider tongue retractor( wide retractor, heart shape with sharp teeth on one side till it can resist the tongue
Right-angle Austin retractor Weider tongue retractor Offset broad Minnesota retractor
curette
a angled shape, with two ends Debridement of socket Used to remove soft tissue from damaged bone such as removing granuloma or small cyst from periapical lesions or removing granulation tissue debris from teeth socket
block
Used
to resist the patients jaw from closing, prevent the stress on the TMJ Made from rubber
as suction for blood, saliva and irrigation solution to be removed from the treatment site so that the view of the operator is not affected
used large plastic syringe with an 18 gauge blunt needle Uses: irrigation of treatment area with sterile saline
Cotton rolls
To stop bleeding by biting on it Can be placed between the tongue and teeth, and between the cheek and teeth to allow an area to remain isolated and dry
Elevators
Primarily
this part is used for holding the instrument Shank: this part connects the handle with the blade and is at 90 degrees to the handle Blade: this part of the instrument engages the crown or the root to be removed
Indications
To
reflect mucoperiosteum Luxate the tooth before applying the forceps for extraction To luxate and remove the tooth from its socket which cannot be engaged with forceps To remove a fractures or carious tooth which might fracture when engaged with beaks To remove inter-radicular bone To remove a fractured root when the fracture line is below the cervical line
Straight type
Pick type
Commonly used to luxate Broken root remains in the teeth socket and the adjacent socket is empty
Used like a lever to remove roots Tease small root tips from their socket
surface on one side that is right. placed toward the tooth Blade are triangle in shape
to be extracted
Example : No.301 which are used to displace tooth before forceps are used Larger elevators are used to displace roots from their sockets or when the smaller elevators are less effective Most frequently used: No.34S, No.46 and no.77R
Examples of angled shank elevators with the blades similar to the straight elevators is the Potts elevators and Millers elevators
General use: reflection of the mucoperiosteum from the underlying bone before extracting of teeth, testing whether the anesthesia has worked, reflection of the gingival cleft Normally used is Molt periosteal elevator no.9
Has 2 ends : pointed-sharp and flat-wide Uses The pointed end is used to lift up the soft tissue. Usually used at the dental papilla The flat and wide end is pushed under a flap to separate the periosteum from the bone beneath it With a scraping motion the periosteum is separated from bone Used as a retractor
General
use: removal of fractured root, impacted maxillary third molars and impacted cuspids. There are various types No.301 straight apexo elevators
Used for the removal of fractured roots( at the gingival line) of maxillary central and lateral incisors, bicuspids and cuspids
No.4(302)and
5 (304) elevators
Used when the mandibular root has fractured below the gingival line The blade is at 90 degree angle to the handle
Mandibular
No.151
Forceps
Universal mandible forceps Has beak which form a nearly 90 degree to the handle The handle is slightly bent the beak is relatively small ,narrow and meets only at the tip, which helps the beak to adapt with the cervical line of the teeth and grip the root
Maxilla
Forceps
S
No.150
Universal forcep The beak is almost parallel to the handle ( has a slight bent) The beak when seen from side, is slightly curved but seen from the top is straight
Patient position o Child seated in dental chair reclined about 30 degree to the vertical for extraction under LA o Removing upper teeth, operator stands in front of patient + straight back + patients mouth just below the operators shoulder. o Removing lower teeth, similar position for upper teeth + patients mouth just below the operators elbow.
Non-working hand o Retracts soft tissue allow visibility and access o Protects tissues if instrument slips o Provides resistance to the extraction force on the mandibleprevent dislocation o Provides feel to the operator Order of extraction: when performing multiple extractions in all quadrants (especially in under GA) o Symptomatic teeth before balancing extractions o Lower teeth before upper teeth (eliminate bleeding interfering) o If symptomatic teeth in all quadrants, begin with lower right (minimizes number of changes of position of surgeon reduces GA time)
Upper Premolars
1st premolar 2 rooted, removed by buccal expansion using upper premolar forceps 2nd premolar single rooted, attempt buccal expansion, then, rotation about its long axis Palatally displaced difficult to remove using forceps. Use elevators in a manner similar to palatally displaced canines
LOWER PERMANENT ANTERIORS LOWER PRIMARY ANTERIORS Same manner as their upper counterparts Rotation about the long axis using lower primary anterior or root forceps
Incisors: Not readily removed by rotation thin roots mesiodistally fracture Apply lower root forceps and expand socket labially Labially placed straight elevators Canine : Rotary movement about long axis or by buccal expansion Labially displaced similar to buccally displaced upper anteriors
Lower Premolars
When fully erupted, simply remove by rotary movement around the long axis of the root using lower premolar forceps. Malpositioned (normally lingually): Difficult to remove with lower premolar forceps Extracted using straight elevators applied mesially, lingually and distally. Alternatively, if possible, apply beaks of upper fine root forceps mesially and distally to the crown when forceps are directed from the opposite side of the jaw. Gentle rotation of the tooth with forceps may effect the removal.
Cowhorn design forcep. Choice of technique depends mainly on the preference of operator
Bite down on gauze 20-30 minutes w/o chewing the gauze (Do not disturb the clot) Do not use straw Brush teeth as usual w/o using mouthwash on the day of extraction If swelling occurs ice pack If jaw stiff after swelling warm pack Eat soft and cool foods If there is stiches rinse with salt water Seek medical attention if pain after 48 hours or abnormal
It is important to explain to the child what to do after the extraction as well as to their parents or caregiver.
REFERRAL CASES
Supernumerary teeth Buried teeth Cysts in the soft tissue Abnormal lingual or labial frenulum Tumours Cysts caused by trauma to the apex of the tooth
Supernumerar y teeth
Buried tooth
Cys t
Abnormal frenulum
Tumour
DURING EXTRACTION
COMPLICATION MANAGEMENT
Aspiration or swallowing of teeth or roots may occur, especially under general anaesthesia with the mouth forced open
A tooth may be suddenly released from the bone and owing to its shape and wedging action of the forceps, may be squeezed out of the beaks of the forceps and aspirated or swallowed
controlled pressure on the handles of forceps and by using a 4 by 4 inch sponge as a curtain behind the tooth to be extracted radiographic examination of the chest and abdomen should request immediately if cannot encountered A tooth or part of it in bronchial tree must be removed as soon as possible by bronchoscopy to prevent serious complications If it is in alimentary canal, its elimination should be ascertained by having the stools examined for the tooth Consultation with physician should be obtained
POST EXTRACTION
COMPLICATION Dry socket rarely happens within children If having dry socket, operator should thought that as unusual infection such as actinomycosis or systemic complication like anaemia or lack of nutrition MANAGEMENT Advising patient to use 0.2% chlorhexidine mouth rinse may be helpful to avoid dry socket in suspect cases Cotrol pain by analgesics, advice warm saline rinse to remove food debris, dressing the cavity to protect & heal the socket Early stages - initiating fresh bleeding in the socket and giving a pack will resolve this condition Zinc oxide dressings also have been advised
Infections: May spread owing to the wide marrow spaces May involve the buds of permanent teeth, as in brown discolouration of enamel produced in chronic infection, can also cause complete destruction of permanent tooth germs May reach the growth centers of the jaw, especially condylar region in mandible, resulting in disfiguration May produce cellulitis and abscess formation which will require incision and drainage
Retention of a permanent anterior tooth is a paramount importance and should be attempted even if life span of the tooth may be retentively short after treatment If the tooth painful to percussion and elongated and presents spontaneous throbbing pain, the pulp chamber should be opened If anasthesia must be used, use inhalation especially in a well premedicated child Cotton prevents solid food particles from obstructing the drainage, root canal treatment may institute, followed by apicoectomy or periapical curettage Dentist may prescribe antibiotic to treat the infection Antibiotic is administered Also can give vitamin B and C
THANK YOU!