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ORAL SURGERY IN
PEDIATRIC DENTISTRY

Dr. Santhosh Challa

PG in pedodontics
 Contents
Introduction
Hospital procedure for dental patient
Exodontia and Impaction
Odontogenic infection
Ludwig Angina
Minor surgical procedures
Soft tissue abnormalities
Hard tissue abnormalities
Conclusion
References

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‘CHILD IS A NOT A MINATURE ADULT’

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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

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 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.’’

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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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 CONTRAINDICATIONS-

Acute infections- stomatitis, Vincents infection Herpetic

stomatitis

Acute dentoalveolar abscess with cellulitis

Dentoalveolar abscess

Malignancy

Tissue receive radiation therapy

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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 13
 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 Dentist usually is seated
standup Force is delivered – wrist
posture action
Force applied via whole
forearm

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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 root-

Controlled 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 A light meal with no hard food

until a blood clot has formed should be recommended for the
Hold the small cotton roll – half day
an hour Analgesia and Antibiotics
Not to bite his lips and tongue
Blood can appear on the pillow
Do not disturb the extracted the next day
site
Call office if undue symptoms
Do not rinse mouth for 24
develop
hours after extraction
Do not use straws for that day

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 SUPERNUMERARY TOOTH
Frequently –Mesiodens
Cleidocranial dysostosis and the Gardner Syndrome

Supernumerary teeth causes…

Delay in eruption of permanent tooth
Dentigerous cyst and primordial cyst
Root resorption- pulp damage
Impaction and malposition of tooth
Formation of diastema
Ectopic eruption
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 SUPERNUMERARY TOOTH
Considerations:
Location: Lies lingual to normal tooth
Timing : Condition of apices of the adjacent
permanent tooth
Procedure :palatal approach
Important to leave a collar of bone on the teeth- if
adjacent tooth support is compromised (splinting)
Impacted supernumerary tooth

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 IMPACTED TOOTH
Fail to erupt because they are mechanically obstructed
by a supernumerary tooth, cyst, or odontogenic tumor or
because there is insufficient space in the dental arch,
either of skeletal or dental origin.
Order of frequency : maxillary canine, mandibular
second premolar, and maxillary incisor
Syndromes :cleidocranial dysostosis, craniosynostosis
Hypothyriodism and Hypopituitarism

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 IMPACTED MAXILLARY CANINE..

Dewell explained:
Long distance traveled
Root completely formed than other..
Delayed resorption of primary cuspid- deflection

Sequence of eruption
Erupts after lateral incisor and premolars
Same time with second molar

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 CHOICES OF MANAGEMENT..
Surgical exposure of the tooth-followed by orthodontic
movement
Teeth will not erupt naturally – (Ideal time extraction)
Autotransplantation
Ideal treatment: prevention by close observation of the
child’s eruption pattern and jaw and dental development
Before any procedure:
Othodontic status - deeply impacted canine
Root development of canine
Apex closed: less chance of movement
Incomplete : spontaneous movement occur

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 TREATMENT
Radiographic evaluation

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EXPOSURE TECHNIQUE- PALATALLY
IMPACTED

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EXPOSURE TECHNIQUE-
LABIALLY IMPACTED

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 ATTACHMENT OF WIRE TO THE
TOOTH
A 26- guage circumferential wire passed around the

cervix

Clear Long TMS pin

Enamel adhesive

Crowns forms with or with wire ligation

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ODONTOGENIC INFECTION
Pulpitis
Acute chronic

Apical periodontitis

Periapical Abcess Periapical Granuloma

Osteomyelitis Periapical cyst

Periostitis

Cellulitis Abscess

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Percementitis

Subperiosteal abscess (throbbing pain)

Pus breaks thru barrier of periosteum

Sudden swelling of soft tissue of face appears

- pressure is relieved and pain decreased integrity

Spread thru alveolar structures

-Gravity
-Anatomical pathways
-Fascia of facial planes

Formation of abscess accompanied by cellulitis

-mucobuccal fold
-sublingual
-palatal region

Skin

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ODONTOGENIC INFECTIONS:-
Most common- caries leading to pulpal exposure
Anatomical considerations:
Wide marrow spaces
Infections involve buds of permanent tooth-
(Turner’s 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 status-
C/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 papilla-
Relocates 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 ridge-
commonly 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 muscle-
Plunging 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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Irritation Fibroma and papilloma or
warts
Fibroma :
Benign and slow growing
Recurrent trauma – ulceration, bleeding, and pain

Papilloma :
Pale to whitish in color, exophytic surface texturewith
numerous fingerlike projections
Removed by: Electrocautery

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 Eruption cyst & Natal teeth
Natal teeth :Recommended to observe- extract them
only if they are extremely mobile

Eruption cyst: crest of the alveolar ridge as clear or

blood- tinged , fluid- filled masses.
Not painful- feeding problems

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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 Marginal / partial Complete resection
curettage resection
Odontogenic tumors Ameloblastoma Malignant
Odontoma CEOT ameloblastoma
Ameloblastic fibroma Ameloblastic odontoma
AOT

Fibrosseous lesions sarcoma

Central ossifying
fibroma
Fibrous dysplasia
Cherubism
Aneurysmal bone
cyst
Osteoma
Others: Hemangioma Lymphomas
Hemangioma Salivary gland
malignancy
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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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 Enucleation
Disadvantages:
Large cyst: fracture of jaw
Devitalization of teeth
Cyst associated teeth –not saved

Enucleation.
Enucleation and primary closure.
Enucleation and packing.
Enucleation of small cystic lesions from an inta oral approach
Enucleation of large, inaccessible mandibular lesions from an extra
oral approach.
Enucleation and primary closure with reconstruction/bone grafting.

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 Enucleation -Technique
Anaesthesia. (GA, LA, CS)
Incision :
Around the necks of involved and teeth adjacent on either side.
Flap rests on sound teeth.
Releasing incisions are given on either ends which ends at the
buccal sulcus.
Reflection of the flap.
Bone is removed to expose the cystic lesion.
If a window in the bone is already present it is enlarged using
rounger.
If the bone is thick holes are drilled with bone bur and they
are connected to fragment the bone.
Thin layer of bone may be seen adhered to the flap which is
peeled off.
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 Enucleation -Technique
Cystic lining is separated.
Curved curette or periosteal elevator.
Concave surface of the instrument should face the
cyst lining.
Care should be taken to prevent rupture of the cyst
lining.
In areas where the cystic lining is adherent, a peanut
gauze is held in the beaks of hemostat and it is
inserted b/w the lining and the bony bed.
Cystic contents can also be aspirated so that lining
shrinks and the visibility is improved.

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Bleeding points are arrested.
Wound is flushed with normal saline and antiseptic
solution such as 2% povidone-iodine.
Cavity is left to heal or various packed with graft
material.

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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

Remaining cyst lining left insitu

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 access-
All 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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Marsupialization…

Surgical procedure
Partsch I. Incisions. Partsch II or Waldron’s method:
2 stage procedure
Removal of bone. combining marsupialization and enucleation
Thin bone.
Thick bone.
Removal of cystic lining.
Visual examination of residual cystic lining.
Irrigation of the cystic cavity.
Suturing.
Packing.-white head’s varnish for 10 to 14 days
Maintenance.
Use of plugs.
Healing.
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Marsupialization…

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Marsupialization…

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 References
Pediatric dentistry- Stephen wei
Clinical pedodontics – Finn
Pediatric oral surgery- kaban
Textbook of pedodontics – Shoba Tandon
Pediatric dentistry – Stewart
Pediatric dentistry – Pinkham
Pediatric dental medicine – Forrester
Oral maxilofacial surgery - Peterson

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