Exodontia in

pediatric dental
patient
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Extraction: is the pain less removal of
the whole tooth or tooth root with minimal
trauma to the investing tissue, so that
wounds heals uneventfully.

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 Principles of Exodontia
1-Avoid injury to soft tissues such as the tongue, lips,
gingiva and cheeks.

2-Avoid injury to underlying developing permanent teeth

and other hard tissues such as bone and adjacent or
opposing teeth.

PEDIATRICS FOR DENTISTRY 3

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 Con
3-use radiograph to determine:

- size and shape of roots.

- amount and directions of root resorption.
- position and stage of development of underlying
permanent tooth.
-any pathology.

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 Difference between primary &
permanent teeth
1-size: primary teeth are smaller in every dimensions
compare to their permanent counterpart.

2-shape: crown of primary teeth are more bulbous. The

furcation of primary molar root is positioned more
cervically than in the corresponding permanent teeth.

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 CON
3-Physiology:root of primary teeth resorb
natutrally where as in the permanent dentition
resorption is normally a sign of pathology.

4-Support:the bone of alveolus is much more

elastic in the younger patient.

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These difference means that there are some modification to
Extraction technique in children.

1. Type of forceps :-- the beaks & handles are smaller, & to
accomodate more bulbous crown the beaks are more curved
in forceps designed for removal of primary teeth.

2. The wide splaying of primary molars roots means that

more expansion of the socket is required.

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3. Due to relatively cervical position of the bifurcation in primary
molars it is injudicious to use forceps with deeply plunging beaks.

4. Avoid blind investigation of primary socket.

5. Because of physiological resorption it is often preferable to
Leave small fragments in situ if root is fractured.

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 Problems peculiar to child patients

1-natal & neonatal teeth

2-infra occlusion of teeth

3-fusion\ gemination of two teeth

4-damage to permanent successor

5-dislocation of the mandible

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 Indication for extratcion of deciduous
teeth
1-badly carious that can not be restored.

2-over retained primary teeth that preventing eruption of

permanent successor.

3-if there is infection of peri apical area & can not be

treated without extraction.

4-for orthodontic purpose.

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 Con..
5-supernumerary teeth if not needed in dental arch.
6-in traumatic injury to teeth if vertical fracture occur.
7-ankylosed primary teeth that have permanent
successor and fails to exfoliate normally
8-impacted teeth.
9-ectopically positioned teeth that can not be brought
into function.

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Contraindications for extractions
of teeth in children's
1-child having bleeding disorder.

2-acute infections like stomatitis and acute vincents

infections.

3-herpetic stomatitis.

4-acute pericementitis.

5-acute dentoalveolar abscess.

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 Con
6-acute cellulitis.
7-malignancy.
8-teeth getting irradiation.
9-acute or chronic heart disease, congenital
heart disease and kidney disease

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Preoperative preparation of the parent
and child
A-Parent-
1. Parental consent before the procedure.

2. Instruct the parent not to discuss with the child what the
dentist will do.

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 B-Child
1.Armamentarium should be kept behind the chair.

2. Never hold the needle in front of child, always hidden by fingers.

3. Before giving the LA, explain to the child that sensation of pinching
or an ant biting may be felt.

4. Child realizes the difference between pressure and pain.

5. Explain the sensation of numbness to child.

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PEDIATRICS FOR DENTISTRY 16
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PEDIATRICS FOR DENTISTRY 17
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PEDIATRICS FOR DENTISTRY 18
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 Extraction technique
Patient position:
The child should be seated in a dental chair
reclined about 30 degree to the vertical for
extraction under Local Anesthesia & under
General Anesthesia- supine position.

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 Cont..

Operator position:
When removing upper teeth under LA the operator
should stand in front of the patient with straight back
and the patient mouth at a level just below the operators
shoulder.

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 Con
A right handed operator removes lower
left teeth from similar position in front of
the patient except that the patient mouth is
at a height just below the operators
elbow..

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 Con
When removing the teeth from the lower
right, the right handed operator stand
behind the patient with the chair as low
as possible to allow good vision

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 The non-working hand:
1. it retract soft tissues to allow visibility and access.
2. it protects the tissues if the instruments slips.
3. it provide resistance to the extraction forces on
the mandible to prevent dislocation.
4. It provides feel to the operator during extraction
and gives information about resistance to
removal.

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PEDIATRICS FOR DENTISTRY 24
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Upper primary & permanent anteriors
When these teeth are in normal position:
Forceps used for primary teeth upper primary anterior
or upper primary root forceps.

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for permanent teeth upper straight forceps

force applied applying the forceps beaks to the

root & then Using clockwise & anticlockwise rotating
about long axis.

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 Labially placed upper lateral
incisor & canine have very little
buccal support & are easily
removed, either by using
straight forceps applied
mesially & distally & using a
slight rotatory movement or By
the use of elevator.

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 Most commonly used elevator are warwick
james & couplands elevator.

Palatally positioned lateral incisors & canine are

usually not accessible with forceps & thus
elevator are used.

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 Upper primary molars

These teeth display the

most widely splayed roots
so considerable
expansion of socket is
required.
Forceps used upper
primary molar forceps

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 Con
Force applied
initially palatally to
expand the socket
then continuous
buccally directed
force.

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 Upper premolars

Forcep used upper premolar forceps

Removed by the buccal expansion

Upper permanent molars

Forceps left & right upper molar forceps

Removed by expanding the socket in the buccal
direction

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 Con
Lower primary anterior

Forceps lower primary anterior or root

forceps

Extracted same as upper anterior.

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 Lower permanent anterior
Root of lower incisors are thin mesiodistally &
rotation is likely to cause root fracture so the most
effective method of removal

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 Lower primary molars

Forceps lower
primary molar forcep.
two pointed beaks
which engage the
bifurcation.
Buccolingual
expansion of socket

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 Lower premolars
Forcep lower premolar forceps
Removed by rotatory movement around the long axis of root

Lower permanent molars

Two designs of forceps used 1.lower molar forceps
-2.forcep of cowhorn design

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Lower molar forceps have two pointed beaks which are applied in
the region of bifurcation buccally & lingually.

Applied the forceps & move the tooth in buccal direction to expand
the buccal cortical plate.
When buccal expansion is not sufficient to deliver the tooth then
the forceps should be moved In a figure of eight fashion to
expand the socket lingually as well as buccally.

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 Management of buried teeth

Buried teeth (including supernumeraries)

are treated in children for several
reasons -
1. Symptomatic (eg. pain)
2. Radiographic sign of pathology
(eg.dentigerous cyst formation)
3. Part of an orthodontics treatment plan

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 Extraction Of Buried Teeth
Flap design
Flap should :
1. be mucoperiosteol.
2. Be cut 90 degree to bone.
3. Have a good blood supply..

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 Con
4. Avoid damage to important Structures
5. Allow atraumatic reflection.
6. Provide adequate access and visibility.
7. Permit reposition of the wound margins
over sound bone.

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Flap for Buccally placed teeth:
There are 2 designs:

Ist Design:
Gingival margin as the horizontal
component and a vertical relief
incision into the depth of the buccal
sulcus

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 Con
IInd Design :
Semilunar incision, at least 5 mm of
attached gingiva should be maintained at
the narrowest point to ensure a good
blood supply to marginal gingiva.

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PEDIATRICS FOR DENTISTRY 42
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Flap for palatally/lingually placed
teeth :

Palatally positioned teeth are best removed via

an incision that follows the palatal gingival
margin. Such an incision maintain the integrity of
greater palatine nerve & vessels.

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 Con
In the lower jaw adequate access to the
lingual side is obtained by raising the
lingual gingiva &reflected mucosa via an
incision run around the lingual gingival
margin

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PEDIATRICS FOR DENTISTRY 45
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 Bone Removal
this may be carried out using a hand piece and
bur or by the use of chisels.
Tooth Removal
once sufficient bone has been removed to allow
identification of the tooth to be extracted &
exposure of the greatest diameter of its crown,
the tooth should be elevated.
Suturing

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 POST OPERATIVE COMPLICATIONS

dry socket(infection of socket)

aspiration or swallowing of tooth

postoperative bleeding

pain

Swelling

infection

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 POST OPERATIVE INSTRUCTION

for child-
1. the child should not be dismissed until blood clot is formed

2. hold a small cotton roll between his teeth for half an hour

3. not to bite his lip.

4. do not disturb the area where tooth was removed.

5. do not rinse mouth for 24 hrs. after exraction.

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 Con
For parent-
1.Reinforce the child for instructions that already given to the child.

2. Light meal , no hard food.

3. Analgesics is prescribed if the extraction was traumatic and antibiotic

coverage is done if the area was infected.

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 CONCLUSION
For the young child who requires the
removal of primary teeth, the dentist
should recognize the proper sequence of
all the procedures.
The dentist prepares the child by using a
sensitive approach through his selection of
words that indicate to the child the nature
of the procedure.

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