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ORAL SURGERY IN
PEDIATRIC DENTISTRY

HOSPITAL PROCEDURE FOR

DENTAL PATIENT
Admission orders
Admission note
Chief complaint
Present illness
Past medical history
Physical examination

Medical check up
Operating room
Scrub technique
Drapes
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Post operative orders

Record BP, pulse, respiration every 15 min for
1 hour then every 30 min
Suction to bedside
Semi- fowler position
Antibiotics and Analgesia
Sedative
Diet liquids after nausea has passed
Post operative care
Short procedure: discharged same day
Long : every hour after operation

EXODONTIA
Def: Is the painless removal of the whole tooth,
or tooth-root, with minimal trauma to the
investing tissue, so that the wound heals
uneventfully and no postoperative prosthetic
problem is created.

DIFFERENCES BETWEEN PRIMARY

AND PERMANENT TEETH
Size :smaller
Roots are smaller they do form a
proportionately greater part of the tooth
Shape : crowns are bulbous
Roots are more splayed
Furcation is positioned more cervically than in
the corresponding permanent teeth
Physiology:- roots resorb physiologically
Support: alveolus is much more elastic in the
younger patient
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MODIFICATIONS :Type of forceps

Wide splaying of roots- more expansion of the socket
Cervical position of furcation:

cowhorn forceps

Blind investigation of primary socket should not be

performed
Blind investigation of distal root socket of first
permanent molar- unintentional elevation of second
molar
Curettes not used to remove periapical granulomas
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INDICATIONS
Hopeless carious and not restorable
Decay reaches bifurcation
Interfere with normal eruption..
Improper root resorption
Causing deflection of erupting tooth- lower Ant
Irregular resorption
Sinus opening
R/F : periapical pathosis poor prognosis
Root fracture- subsequent infection
Supernumerary teeth
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CONTRAINDICATIONSAcute infections- stomatitis, Vincents infection

Herpetic stomatitis
Acute dentoalveolar abscess with cellulitis
Dentoalveolar abscess
Malignancy
Tissue receive radiation therapy

Contraindications

Acute systemic infections-

resistance

Blood dyscrasias
Rheumatic heart disease, CHD, Renal diseases
Diabetes mellitus

Absolute contraindications
Haemangioma
Arterio venous fistula

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PREOPERATIVE PREPARATION:PARENT & CHILD

Parent

Parent consent.
Reassure that post- operative pain usually does not
occur
Not to discuss with child

Child
8 to 10 years old 4 to 7 days in advance
Younger child: on the day appointment
Armamentarium- kept behind the chair
Never hold the needle in front of the child
Difference pressure and pain
Explain sensation of numbness

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TECHNIQUE FOR REMOVAL OF

PRIMARY TEETH
Position of operator
Maxillary right and left quadrant
mandibular left quadrant :
-operator in front and to the side
of the patient
Mandibular right quadrant:
-operator in back and to the
side of patient

Position of child
Upper jaw no more than 450
Lower jaw parallel to floor
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ARMAMENTARIUM
BRITISH SYSTEM

AMERICAN SYSTEM

Usually employs a
standup
posture
Force applied via
whole forearm

Dentist usually is
seated
Force is delivered
wrist action

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ARMAMENTARIUM
#150 and 151- Universal forceps
#17- Mandibular perm molar
#53R and 53L- Maxillary molars
#23 cowhorn forceps: Mand. Molar with distinct
bifurcation

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TECHNIQUE FOR REMOVAL OF

PRIMARY TEETH
Maxillary molar extraction
Maxillary anterior teeth
Mandibular molar extraction
Extraction of Mandibular anterior teeth
Management of fractured primary tooth roots

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Maxillary molar extraction

Palatal movement is initiated first , b/L movement

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Maxillary anterior teeth

Rotational movement

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Mandibular molar extraction

Apical- labial in sustained action- clockwise
motion

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Extraction of Mandibular anterior

teeth
Apical- labial in sustained action- clockwise
motion

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SPECIAL CONSIDERATION

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SPECIAL CONSIDERATION

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POST OPERATIVE COMPLICATIONS

Dry socket rare in the children
Aspiration or swallowing of the teeth or rootControlled pressure on the handle of forceps
4 by 4 inch sponge curtain behind the tooth to
xtd
Absence of cough is not proof

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COMPLICATED EXTRACTIONS.
Anatomical abnormalities in the roots and
alveolar structures, breakdown of crowns,
ankylosis, and proximity to successor teeth

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POST OPERATIVE
INSTRUCTIONS

For the child

For the parent

Child should not dismissed

until a blood clot has
formed

A light meal with no hard

food should be recommended

Hold the small cotton roll

half an hour

Analgesia and Antibiotics

for the day

Blood can appear on the

Not to bite his lips and

tongue

pillow the next day

Do not disturb the

extracted site

symptoms develop

Call office if undue

Do not rinse mouth for 24

hours after extraction
Do not use straws for that
day

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ODONTOGENIC INFECTION
Pulpitis
Acute

chronic

Apical periodontitis

Periapical Granuloma

Periapical Abcess
Osteomyelitis

Periapical cyst

Periostitis
Cellulitis

Abscess

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ODONTOGENIC INFECTIONS:Most common- caries leading to pulpal exposure

Anatomical considerations:
Wide marrow spaces
Infections involve buds of permanent tooth(Turners hypoplasia)
Reach the growth site condylar region
May produce cellulitis and abscess formation
Depending on age and stage development of
root
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Odontogenic infections:Bifurcational or trifurcational infection often

precedes the periapical involvement
Differences in progress of infection (cuspid region
& molar region)
Facial planes are important anatomic pathways
for the extension and spread of infection
Cellulitis and abscess formation may be quite
exaggerated cavernous sinus thrombosis, brain
abscess,
septcemia, airway obstruction and mediastinitis
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ODONTOGENIC INFECTIONS:Subperiosteal abscess- hard, circumcumscibed

swelling, that can be palpated either in the
mucobuccal fold from external surface
Spread through alveolar spaces- gravity and
anatomical spaces
Important to recognize the pitting and fluctuation
of abscess progressing towards the skin

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Manifestation & Treatment

Fever especially high in small children- with rapid
pulse and rapid but shallow respiration.
General malaise, nausea and vomiting

Treatment :
Elimination of cause
Incision and Drainage
Antimicrobial therapy
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Ludwigs angina
Life threatening infection of sublingual
submental and submandibular spaces
Etiology : odontogenic infections, lacerations,
#mandible, foreign bodies and
immunocompromised statusC/F: Pan cervical brawny induration usually
accompanied by fewer, malaise, and leukocytosis
Mandible will be fixed with mouth half open,
tongue is elevated along with floor of mouth,
drooling due to inability to swallow.
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Ludwigs Angina- Treatment

Support of airway endotracheal intubation and
tracheostomy
Incision and drainage:
Purulent exudate is small
Decompression: cervical incision from angle of
mandible to other side
Thru this submandibular and sublingual spaces
connected with Penrose drains
Antibiotic therapy
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Soft Tissue Abnormalities

Prominent frenum
Maxillary labial frenum
Mandibular labial frenum
Lingual frenum-tongue tie
Mucocele
Ranula
Irritation Fibroma and papilloma or warts
Eruption cyst and natal teeth

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MAXILLARY LABIAL FRENUM

Labial frenum: band of fibroelastic tissue that
originates in the lip and inserts in to the attached
gingiva at the middle of the maxilla.

Prominent : inserting on the crest of the

alveolar ridge and incisive papillaRelocates apically with normal vertical growth of
alveolus

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Treatment- Frenectomy
Timing : If diastema has failed to close , after
the six maxillary anterior teeth
Standard Frenectomy
Laser Frenectomy

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Standard Frenectomy

Bell shaped defect

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Laser Frenectomy
Using CO2 laser
Advantages :
Less time, less swelling and less discomfort
No suturing required

Safety precautions:
Room closed with large sign warning
O2 and inflammable gases
Protective eye wear
Isolated field with protection of adjacent
structures
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MANDIBULAR LABIAL FREMUM

Attaches high on the interdental papilla btw the
lower incisors
Results : trapping of food and plaque
accumulation

Techniques
Excision
Excision and Z- Plasty closure
Laser Excision
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Excision

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Excision and Z- Plasty closure

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LINGUAL FRENUM TONGUE

TIE
Attached high on the lingual alveolar ridgecommonly seen in infant
Becomes less prominent during first 2 to 5 years
Children with mixed dentition complains of
difficulty moving tongue and speech
Technique :
Excision and V- Y closure
Excision and Z- plasty
Laser excision

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Excision and V- Y closure

Milder form of tongue tie
Straight line defect V

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Excision and Z- plasty

Excellent procedure- excision of band with single
or multiple Z- plasties to lengthen the ventral
surface of tongue
Improves tongue mobility without endangering
submandibular duct

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Mucocele
Most common benign salivary gland tumor
Mucous retention cyst- pseudocyst
Common location- lower lip
Pathogenesis extravasation of saliva from minor
salivary gland
Lesion not painful, clear bluish or pale and
fibrotic.

Treatment: surgical excision

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Ranula
Latin word: Ranula pipiens
Retention cyst appearing in infants and toddlers
congenital- as a result of dilatation of sublingual or
submaxillary gland ducts in the floor of the mouth
Older children post traumatic
Located in the sublingual space between the
mylohyoid muscle and lingual mucosa
Extends in to submental or submandibular space
by perforating through the mylohyoid musclePlunging Ranula
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Ranula- Marsupialization
Before marsupialization : mature (shows distinct
fibrous lining)
Roof of cyst excised
cavity drained
mature lining sutured to raw edge of the mucosa
Important to have the submandibular duct
identified and cannulated prevents injury and
subsequent obstruction

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Marsupialization

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Hard Tissue Abnormalities

Tumors

Odontoma
Most common odontogenic tumor
Asymptomatic, small and slow growing have
low recurrenceafter curettage
well encapsulated - Enucleated

Ameloblastoma fibroma
benign neoplasm associate with erupted teeth
Most common in children than adults
Treatment is enucleation and curettage
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Hard Tissue Abnormalities

Non odontogenic cyst
Hemorrhagic bone cyst
Most common traumatic cyst
Asymptomatic radiolucent lesion of
mandible in premolar region
Treatment exploration and curettage
Aneurysmal bone cyst
Common in children than adults
Females more common
R/F: soap bubble appearance
Treatment : curettage
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Treatment modalities
Enucleation and/
or curettage

Marginal / partial
resection

Complete
resection

Odontogenic tumors
Odontoma
Ameloblastic
fibroma
AOT

Ameloblastoma
CEOT
Ameloblastic
odontoma

Malignant
ameloblastoma

Fibrosseous lesions
Central ossifying

sarcoma

fibroma
Fibrous dysplasia
Cherubism
Aneurysmal bone
cyst
Osteoma
Others:
Hemangioma

Hemangioma

Lymphomas
Salivary gland

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Enucleation
Process by which total removal of a cystic lesion is
achieved

Def : it means shelling out of entire cystic lesion

without rupture

Indications :
Safely removed without unduly sacrificing adjacent
structures

Advantages:
Pathologic examination of the entire cyst
patient need not worry about marsupial cavity constant irrigations
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Marsupialization
Decompression/ partsh operation all refers to creating a
surgical widow in the wall of the cyst, evacuating the
contents of the cyst, and maintaining continuity between
the cyst and the oral cavity, max sinus, or nasal cavity.

Only portion of cyst that is removed

Intracystic pressure
Promotes shrinkage of the cyst and bone fill
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Marsupialization

Indications:-

Amount of tissue injury

Proximity to vital structures- Oronasal fistula

Surgical accessAll portion of cyst is difficult- recurrence

Assistance in eruption of teeth

Tooth dentigerous cyst

Extent of surgery
Unhealthy and debilitated pt

Size of cyst
Risk of jaw#
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Marsupialization

Advantages:
Simple procedure to perform
Spare vital structures from damage

Disadvantages:
Pathologic tissue is left insitu
Patient inconvenience
Kept clean to prevent infection
Several times irrigation

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