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ORAL SURGERY IN PEDIATRIC DENTISTRY

*HOSPITAL PROCEDURE FOR DENTAL PATIENTAdmission ordersAdmission noteChief complaintPresent illnessPast medical historyPhysical examination

Medical check upOperating roomScrub techniqueDrapes

*Post operative ordersRecord BP, pulse, respiration every 15 min for 1 hour then every 30 minSuction to bedsideSemi- fowler positionAntibiotics and AnalgesiaSedative Diet liquids after nausea has passedPost operative careShort procedure: discharged same dayLong : 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 TEETHSize :smallerRoots are smaller they do form a proportionately greater part of the toothShape : crowns are bulbous Roots are more splayedFurcation is positioned more cervically than in the corresponding permanent teethPhysiology:- roots resorb physiologicallySupport: alveolus is much more elastic in the younger patient

*MODIFICATIONS :-Type of forceps Wide splaying of roots- more expansion of the socketCervical position of furcation: cowhorn forcepsBlind investigation of primary socket should not be performedBlind investigation of distal root socket of first permanent molar- unintentional elevation of second molarCurettes not used to remove periapical granulomas

*INDICATIONS Hopeless carious and not restorableDecay reaches bifurcationInterfere with normal eruption.. Improper root resorptionCausing deflection of erupting tooth- lower AntIrregular resorption Sinus openingR/F : periapical pathosis poor prognosisRoot fracture- subsequent infectionSupernumerary teeth

*CONTRAINDICATIONS-Acute infections- stomatitis, Vincents infection Herpetic stomatitisAcute dentoalveolar abscess with cellulitisDentoalveolar abscessMalignancy Tissue receive radiation therapy

*ContraindicationsAcute systemic infections- resistanceBlood dyscrasiasRheumatic heart disease, CHD, Renal diseasesDiabetes mellitus

Absolute contraindicationsHaemangiomaArterio venous fistula

*PREOPERATIVE PREPARATION:- PARENT & CHILDParentParent consent.Reassure that post- operative pain usually does not occurNot to discuss with child

Child 8 to 10 years old 4 to 7 days in advanceYounger child: on the day appointmentArmamentarium- kept behind the chairNever hold the needle in front of the childDifference pressure and painExplain sensation of numbness

*TECHNIQUE FOR REMOVAL OF PRIMARY TEETHPosition of operatorMaxillary right and left quadrant mandibular left quadrant : -operator in front and to the side of the patientMandibular right quadrant: -operator in back and to the side of patient Position of childUpper jaw no more than 450 Lower jaw parallel to floor

*ARMAMENTARIUM

BRITISH SYSTEMAMERICAN SYSTEM Usually employs a standup postureForce applied via whole forearmDentist usually is seated Force is delivered wrist action

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

*TECHNIQUE FOR REMOVAL OF PRIMARY TEETHMaxillary molar extractionMaxillary anterior teethMandibular molar extractionExtraction of Mandibular anterior teethManagement of fractured primary tooth roots

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Maxillary molar extraction

Palatal movement is initiated first , b/L movement

*Maxillary anterior teethRotational movement

*Mandibular molar extractionApical- labial in sustained action- clockwise motion

*Extraction of Mandibular anterior teethApical- labial in sustained action- clockwise motion

*SPECIAL CONSIDERATION

*SPECIAL CONSIDERATION

*POST OPERATIVE COMPLICATIONSDry socket rare in the children Aspiration or swallowing of the teeth or root-Controlled pressure on the handle of forceps 4 by 4 inch sponge curtain behind the tooth to xtdAbsence of cough is not proof

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

*POST OPERATIVE INSTRUCTIONS

For the childFor the parentChild should not dismissed until a blood clot has formedHold the small cotton roll half an hourNot to bite his lips and tongueDo not disturb the extracted siteDo not rinse mouth for 24 hours after extractionDo not use straws for that day

A light meal with no hard food should be recommended for the day Analgesia and AntibioticsBlood can appear on the pillow the next dayCall office if undue symptoms develop

*ODONTOGENIC INFECTIONPulpitisAcute chronicApical periodontitisPeriapical AbcessPeriapical GranulomaPeriapical cystOsteomyelitisPeriostitisCellulitisAbscess

*ODONTOGENIC INFECTIONS:-Most common- caries leading to pulpal exposureAnatomical considerations:Wide marrow spacesInfections involve buds of permanent tooth- (Turners hypoplasia)Reach the growth site condylar regionMay produce cellulitis and abscess formationDepending on age and stage development of root

*Odontogenic infections:-Bifurcational or trifurcational infection often precedes the periapical involvementDifferences in progress of infection (cuspid region & molar region) Facial planes are important anatomic pathways for the extension and spread of infectionCellulitis and abscess formation may be quite exaggerated cavernous sinus thrombosis, brain abscess, septcemia, airway obstruction and mediastinitis

*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

*Fever especially high in small children- with rapid pulse and rapid but shallow respiration.General malaise, nausea and vomitingTreatment :Elimination of cause Incision and DrainageAntimicrobial therapy Manifestation & Treatment

*Ludwigs anginaLife threatening infection of sublingual submental and submandibular spacesEtiology : odontogenic infections, lacerations, #mandible, foreign bodies and immunocompromised status-C/F: Pan cervical brawny induration usually accompanied by fewer, malaise, and leukocytosisMandible will be fixed with mouth half open, tongue is elevated along with floor of mouth, drooling due to inability to swallow.

*Support of airway endotracheal intubation and tracheostomyIncision and drainage: Purulent exudate is smallDecompression: cervical incision from angle of mandible to other sideThru this submandibular and sublingual spaces connected with Penrose drainsAntibiotic therapyLudwigs Angina- Treatment

*Soft Tissue AbnormalitiesProminent frenumMaxillary labial frenumMandibular labial frenumLingual frenum-tongue tie Mucocele Ranula Irritation Fibroma and papilloma or wartsEruption cyst and natal teeth

*MAXILLARY LABIAL FRENUMLabial 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 papilla- Relocates apically with normal vertical growth of alveolus

*Treatment- Frenectomy Timing : If diastema has failed to close , after the six maxillary anterior teethStandard FrenectomyLaser Frenectomy

*Standard FrenectomyBell shaped defect

*Laser FrenectomyUsing CO2 laserAdvantages :Less time, less swelling and less discomfortNo suturing required Safety precautions:Room closed with large sign warningO2 and inflammable gasesProtective eye wearIsolated field with protection of adjacent structures

*MANDIBULAR LABIAL FREMUMAttaches high on the interdental papilla btw the lower incisorsResults : trapping of food and plaque accumulationTechniques Excision Excision and Z- Plasty closureLaser Excision

*Excision

*Excision and Z- Plasty closure

*LINGUAL FRENUM TONGUE TIEAttached high on the lingual alveolar ridge-commonly seen in infantBecomes less prominent during first 2 to 5 yearsChildren with mixed dentition complains of difficulty moving tongue and speech Technique :Excision and V- Y closureExcision and Z- plastyLaser excision

*Excision and V- Y closureMilder form of tongue tieStraight line defect V

*Excision and Z- plastyExcellent procedure- excision of band with single or multiple Z- plasties to lengthen the ventral surface of tongueImproves tongue mobility without endangering submandibular duct

*Mucocele Most common benign salivary gland tumorMucous retention cyst- pseudocyst Common location- lower lipPathogenesis extravasation of saliva from minor salivary glandLesion not painful, clear bluish or pale and fibrotic.

Treatment: surgical excision

*RanulaLatin word: Ranula pipiensRetention cyst appearing in infants and toddlers congenital- as a result of dilatation of sublingual or submaxillary gland ducts in the floor of the mouthOlder children post traumaticLocated in the sublingual space between the mylohyoid muscle and lingual mucosaExtends in to submental or submandibular space by perforating through the mylohyoid muscle- Plunging Ranula

*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 obstructionRanula- Marsupialization

*Marsupialization

*Hard Tissue AbnormalitiesTumors OdontomaMost common odontogenic tumorAsymptomatic, small and slow growing have low recurrenceafter curettage well encapsulated - Enucleated

Ameloblastoma fibroma benign neoplasm associate with erupted teethMost common in children than adultsTreatment is enucleation and curettage

*Hard Tissue AbnormalitiesNon odontogenic cystHemorrhagic bone cystMost common traumatic cystAsymptomatic radiolucent lesion of mandible in premolar regionTreatment exploration and curettageAneurysmal bone cystCommon in children than adultsFemales more commonR/F: soap bubble appearanceTreatment : curettage

*Treatment modalities

Enucleation and/ or curettageMarginal / partial resection Complete resectionOdontogenic tumorsOdontomaAmeloblastic fibromaAOTAmeloblastomaCEOTAmeloblastic odontomaMalignant ameloblastoma

Fibrosseous lesionsCentral ossifying fibromaFibrous dysplasiaCherubismAneurysmal bone cystOsteomasarcomaOthers:HemangiomaHemangioma LymphomasSalivary gland malignancy

*Enucleation Process by which total removal of a cystic lesion is achievedDef : it means shelling out of entire cystic lesion without ruptureIndications :Safely removed without unduly sacrificing adjacent structuresAdvantages:Pathologic examination of the entire cystpatient need not worry about marsupial cavity - constant irrigations

*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

Remaining cyst lining left insitu

Intracystic pressure

Promotes shrinkage of the cyst and bone fill

*Indications:- Amount of tissue injuryProximity to vital structures- Oronasal fistulaSurgical access-All portion of cyst is difficult- recurrenceAssistance in eruption of teethTooth dentigerous cyst Extent of surgeryUnhealthy and debilitated pt Size of cystRisk of jaw#Marsupialization

*Advantages: Simple procedure to performSpare vital structures from damageDisadvantages:Pathologic tissue is left insituPatient inconvenienceKept clean to prevent infectionSeveral times irrigation

Marsupialization

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