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Pedia oral surgery

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Pediatric Dentistry I …

Pediatric Dentistry I
Forth Year

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  • 1. 1)Odontogenic infections & its complications 2)Extraction of erupted and unerupted teeth 3)Management of fractured primary tooth roots 4)Management of unerupte; impacted& supernumery teeth 5)Management of oral lesions in the newborn as Epstein's pearls, dental lamina cysts, Bohn's nodules, and congenital epulis (Neumann's tumor) 6) Surgical opening of eruption cyst 7) Surgical excision of mucocele. 8) Oral structural anomalies as maxillary frenum, mandibular labial frenum, mandibular lingual frenum. Frenuloplasty and frenectomy (for ankyloglossia)
  • 2. • It is a localized, purulent form of apical periodontitis. • A fluctuant buccal or palatal swelling, with or without a draining fistula. • Regional adenopathy is usually present. • If pus is draining, pain usually is not severe. 1. Antibiotics are not necessary unless concurrent cellulitis is present. 2. Acute incision and drainage of a fluctuant area. 3.Definitive therapy is root canal treatment or extraction.
  • 3. •Cellulitis follow apical periodontitis •Diffuse, tense, painful swelling of the affected tissues occurs. •Regional lymph-adenopathy, fever. •The infection can spread into the major facial spaces of the head and neck, with the attendant risk of airway compromise.
  • 4. • Maxillary infection spread to the periorbital area, increasing the risk of serious complications that include loss of vision, cavernous sinus thrombosis, and central nervous system involvement
  • 5. • It is inflammation of the soft tissues surrounding the crown of a partially erupted tooth (wisdom tooth). • Bacterial plaque and food debris accumulate beneath the flap of gum covering the partially erupted tooth. • Inflammatory edema, as trauma from the opposing tooth, leads to swelling of the flap, pain, tenderness, and a bad taste caused by pus oozing from beneath the flap. • Regional lymph-adenopathy is common, and cellulites and trismus can occur.
  • 6. EXTRACTION • It is painless removal of the whole tooth or tooth root with minimal trauma to the investing tissue, So that wounds heals uneventfully without post operative problems. • Avoid injury to soft tissues as tongue, lips, gingiva & cheeks. • Avoid injury to underlying developing permanent & other hard tissues as bone& adjacent or opposing teeth. • Use radiograph to determine:- • Size & shape of roots. • Amount & directions of root resorption. • Position & stage of development of underlying permanent tooth. • Any pathology.
  • 7. Differences between Primary and Permanent Teeth • Size primary teeth are smaller in every dimensions than permanent. • Shape- crown of primary teeth are more bulbous. The furcation of primary molar root is positioned more cervically than permanent. • Physiology- root of primary teeth resorb naturally where as in the permanent resorption is normally a sign of pathology. • Support- the bone of alveolus is much more elastic in the younger patient.
  • 8. Modification to Extraction technique in children • Type of forceps :- the beaks & handles are smaller, & to accommodate more bulbous crown the beaks are more curved in forceps designed for removal of primary teeth. • The wide splaying of primary molars roots means that more expansion of the socket is required. • Due to relatively cervical position of the bifurcation in primary molars it is injudicious to use forceps with deeply plunging beaks. • Avoid blind investigation of primary socket. • Because of physiological resorption it is often preferable to leave small fragments in situ if root fractures.
  • 9. Indication for extraction of deciduous teeth • Badly carious can not be restored. • Over retained primary teeth preventing eruption of permanent successor. • Infection of periapical area can not be treated without extraction. • For orthodontic purpose. • Supernumerary teeth if not needed in dental arch. • In traumatic injury to teeth if vertical fracture occur. • Ankylosed primary teeth that have permanent successor and fails to exfoliate normally. • Impacted teeth. • Ectopically positioned can not be brought into function.
  • 10. Contraindications for extractions of teeth in children • Child having bleeding disorder. • Acute infections like stomatitis& acute Vincent’s infections. • Herpetic stomatitis. • Acute pericementitis. • Acute dentoalveolar abscess. • Acute cellulitis. • Malignancy. • Teeth getting irradiation. • Acute or chronic heart disease, Congenital heart disease & Kidney disease.
  • 11. Pre - Operative Preparation of The Parent & Child • PARENT- 1. Parental Consent before the procedure. 2. Instruct the parent not to discuss with the child what the dentist will do. • CHILD- 1. Armamentarium should be kept behind the chair. 2. Never hold needle in front of child always hidden by fingers. 3. Before giving the LA, explain to the child (sensation of pinching or an ant biting felt). 4. Child realizes the difference between pressure & pain.
  • 12. Extraction Technique • Patient Position The child should be seated in a dental chair reclined 30° to the vertical for extraction under LA & under GA- supine position.
  • 13. Operator Position When removing upper teeth under LA the operator stand in front of the patient with straight back & the patient mouth at a level just below the operator shoulder. 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 operator elbow. When removing the teeth from the lower right , the E RIGHT handed operator stand behind the patient with the chair as low as possible to allow good vision. Extraction Technique
  • 14. • The non-working hand 1. It retract soft tissues to allow visibility & access. 2. It protects the tissues if the instruments slips. 3. It provides resistance to extraction forces on the mandible to prevent dislocation. 4. It provides feel to the operator during the extraction & gives information about resistance to removal.
  • 15. Upper primary & permanent anteriors When teeth are in normal position: forceps used– for primary teeth– upper primary anterior OR upper primary root forceps. for permanent teeth– upper straight forceps force applied– applying the forceps beaks to the root then Using clockwise & anticlockwise rotating about long axis.
  • 16. • Labially placed upper lateral incisor & canine have vary 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. Most commonly used elevator are WARWICK JAMES & COUPLANDS elevator. • Palatally positioned lateral incisors & canine are usually not accessible with forceps & thus elevator are used.
  • 17. Upper primary molars • These teeth display the most widely splayed roots so considerable • Expansion of socket is required. • Forceps used– upper primary molar forceps • Force applied– initially palatally to expand the socket then continous • Buccaly directed force.
  • 18. 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 Lower primary anterior • Forceps– lower primary anterior or root forceps • Extracted same as upper anterior.
  • 19. • A gauze sponge is partially unfolded & placed over the tongue and gently covering the oro-pharynx as a protective screen against swallowing or aspirating an extracted tooth.
  • 20. Lower permanent anterior • Root of lower incisors are thin mesiodistally & rotation is likely • To cause root fracture so the most effective method of removal • Is to apply lower root forceps & expand the socket labially. • Permanent lower canine may be delivered by rotatory movement or • By buccal expansion.
  • 21. Lower primary molars • Forceps– lower primary molar forcep. • two pointed beaks which engage the bifurcation. • Buccolingual expansion of socket
  • 22. 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 Lower molar forcep 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 to expand the
  • 23. • The No. 301 straight elevate‘ is inserted into the cleft and rotated slightly splitting the tooth in half. One-half is removed with the No. 151 forceps. • A No. 330 FG bur is placed adjacent to the buccal groove to initiate buccal to lingual sectioning. • The cleft extends from the buccal groove through the lingual groove, dividing the crown in half bucca-lingually. Its depth is to the floor of the pulp chamber extending buccally and lingually into the free gingival space. • The remaining half of tooth is removed.
  • 24. ROOT AS THE RESIDUUM OF A SEVERE CARIOUS PROCESS • Root remnants of a seven destructive carious process. The radiograph indicates the roots supported in inflammatory tissue. • Straight elevator is used to elevate the distal root remnant of a right mandibular second primary molar.
  • 25. Management of impacted teeth • Impacted 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
  • 26. • Impacted central incisors either “simple” the tip of the impacted tooth is near the adjacent cemento-enamel junctions or “complex” where the impacted tooth is positioned high in the vestibule.  Central incisors usually are impacted labially.
  • 27. Extraction Of Impacted Teeth  Flap design Flap should – 1. be mucoperiosteol. 2. Be cut 90 degree to bone. 3. Have a good blood supply. 4. Avoid damage to imp. Structures 5. Allow atraumatic reflection. 6. Provide adequate access and visibility. 7. Permit reapposition of the wound margins over sound bone.
  • 28. • If the incisal edge of the maxillary central incisor is positioned coronal (incisal) to the mucogingival junction, • an apically positioned flap, • flap/closed eruption technique, or • a gingivectomy procedure. • If the patient has insufficient attached gingiva, an apically positioned flap is chosen. • If sufficient gingiva is present, a gingivectomy uncovering may be appropriate. • If the incisal edge is positioned apical to the CEJ, a flap/closed eruption technique should be employed.
  • 29. Flap for buccaly placed teeth 2 designs– Ist Design- Gingival margin as the horizontal component and a vertical relief incision into the depth of the buccal sulcus 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.
  • 30. 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. 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
  • 31. 1. Maxillary Canine-Labial Impaction 2. Maxillary Canine- Intra-Alveolar Impaction 3. Maxillary Canine- Simple Palatal Impaction 4. Maxillary Canine – Complex Palatal Impaction is oriented horizontally . • A full-thickness palatal flap is reflected from the molar through the midline. • Bone is removed from the crown of the impacted tooth, being very careful not to damage the roots of the central lateral incisor, especially around the apices of these teeth. The area is isolated to achieve a dry field for bracketing. 5. Mandibular Canine 6. Mandibular Second Premolar
  • 32. Flap/Closed Eruption Technique • A crestal incision is made and buccal and/or lingual flaps are reflected. • Appropriate bone removal is accomplished, • A bracket or chain is attached to the impacted tooth. • The flaps are returned to their original location for complete closure. • The chain passes under the flap, exits at the mid- crestal incision area, and is attached to the arch wire. This technique is best used with high labially impacted teeth and teeth that are impacted in the mid-alveolar area.
  • 33.  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 Palatally /lingually placed teeth
  • 34. POST OPERATIVE COMPLICATIONS • DRY SOCKET • ASPIRATION OR SWALLOWING OF TOOTH • POSTOPERATIVE BLEEDING • PAIN • SWELLING • INFECTION
  • 35. POST OPERATIVE INSTRUCTION • FOR CHILD- 1. The child should not be dismissed until blood clot formed 2. Hold a small cotton roll between his teeth for ½ 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 hors after extraction. • FOR PARENT- 1. Reinforce the child for instructions that already given to the child. 2. Light meal with no hard food. 3. Analgesics is prescribed if the extraction was traumatic & antibiotic coverage is done if the area was infected.
  • 36. Structural Anomalies Maxillary Frenum A high or prominent maxillary frenum in children, associated with a diastema. Recent trends significantly fewer frenectomies. Treatment is necessary when the attachment exerts a traumatic force on the gingiva or it causes a diastema remain after eruption of the perm canines. • Treatment delayed until the permanent incisors and cuspids have erupted and had an opportunity to close naturally. • If a frenum is present and the papilla blanches when the upper lip is pulled, removal. • Frenectomy performed after orthodontic treatment is completed and the diastema is closed.
  • 37. Labial frenuloplasty • Local anesthesia. • Curved hemostat placed close to the lip. • Frenulum is cut along the hemostat. • Lateral incisions for removal of fibrous frenulum.
  • 38. A high frenum present on the labial aspect of the mandibular ridge. This is most in the central incisor area and frequently occurs in individuals where the vestibule is shallow. The mandibular anterior frenum, as it is known, occasionally inserts into the free or marginal gingival tissue. Movements of the lower lip cause the frenum to pull on the fibers inserting into the free marginal tissue, can lead to food and plaque accumulation. Early treatment is indicated to prevent subsequent inflammation, recession, pocket formation, and possible loss of the alveolar bone and/or tooth.
  • 39. Mandibular Lingual Frenum/Ankyloglossia Ankyloglossia is a developmental anomaly of the tongue characterized by a short, thick lingual frenum resulting in limitation of tongue movement. 2types. Total ankyloglossia is rare& the tongue is completely fused to the floor of the mouth. Partial ankyloglossia is variable A short lingual frenum can inhibit tongue movement and create deglutition problems. Frenectomy for functional problems should be considered on an individual basis. If evaluation shows that function will be improved by surgery, treatment should be considered.
  • 40. Ankyloglossia also can lead to problems with breastfeeding, speech, malocclusion, and potential periodontal problems. When indicated, frenuloplasty to facilitate breastfeeding. Improving tongue mobility and speech. Therapy by a qualified speech therapist have been completed. Ankyloglossia also has been associated with Class III malocclusion. The abnormal tongue position may affect skeletal development.
  • 41. Lingual frenuloplasty • Lingual frenulum restricting the movements of the tongue. • Local anesthesia. • Curved hemostat is placed close to the tongue. • Frenulum is cut.
  • 42. It is important to observe the eruption of these permanent teeth. Occasionally they will erupt out of position if the primary tooth is retained. To prevent the mal- positioning of the permanent tooth it might be necessary to remove the retained primary tooth. Retained primary tooth
  • 43. Supernumerary teeth and hyperdontia are an excess in tooth number. Supernumerary teeth are thought to be related to disturbances in the initiation and proliferation stages of dental development. Or syndrome associated (cleidocranial dysplasia) or familial. Supernumerary teeth can occur in either the primary or permanent dentition. In 33% of the cases, a supernumerary tooth in the primary dentition is followed by the supernumerary tooth complement in the permanent dentition. The permanent dentition being affected 5 times more frequently than the primary dentition and males being affected twice as frequently as females.
  • 44. 90% of single tooth supernumerary are in the maxillary arch. The anterior midline of the maxilla as a mesiodens. A mesiodens suspected if there is an asymmetric eruption pattern of the maxillary incisors, delayed eruption of the maxillary incisors with or without any over-retained primary incisors, or ectopic eruption of a maxillary incisor. The diagnosis confirmed with radiographs including occlusal, periapical, or panoramic films. 2 periapical radiographs or the tube shift technique (buccal object rule or Clark's rule).
  • 45. Complications of supernumerary teeth can include:_  delayed and/or lack of eruption of permanent tooth,  crowding, Displacement  resorption of adjacent teeth,  dentigerous cyst formation,  pericoronal space ossification, and  crown resorption. A mesiodens that is conical in shape and is not inverted has a better chance for eruption than a mesiodens that is tubercular in shape and is inverted.
  • 46. Surgical management depend on the size, shape, and number of supernumeraries and the patient's dental development. The treatment objective for a non-erupting primary tooth mesiodens differs in that the removal of these teeth usually is not recommended as the surgical intervention may disrupt or damage the underlying developing permanent teeth. Erupted primary tooth mesiodens typically are left to shed normally upon the eruption of the permanent dentition
  • 47. • Extraction of an unerupted primary or permanent tooth mesiodens is recommended during the mixed dentition to allow the normal eruptive force of the permanent incisor to bring itself into the oral cavity. Waiting until the adjacent incisors have at least two thirds root development will present less risk to the developing teeth but still allow spontaneous eruption of the incisors. • In 75% of the cases, extraction of the mesiodens during the mixed dentition results in spontaneous eruption and alignment of the adjacent teeth. • If the adjacent teeth do not erupt within 6 to 12 months, surgical exposure and orthodontic treatment may be necessary to aid their eruption.
  • 48. Oral pathologies occurring in newborn children include Epstein's pearls, dental lamina cysts, Bohn's nodules, and congenital epulis. Epstein's pearls are common and found in about 75 to 80% of newborns. They occur in the median palatal raphe area, as a result of trapped epithelial remnants along the line of fusion of the palatal halves. Dental lamina cysts, found on the crests of the dental ridges, most commonly are seen bilaterally in the region of the first primary molars. They result from remnants of the dental lamina. Bohn's nodules are remnants of salivary gland epithelium and usually are found on the buccal and lingual aspects of the ridge, away from the midline. Epstein's pearls, Bohn's nodules, and dental lamina cysts typically present as asymptomatic 1 to 3 mm nodules or papules. They are smooth, whitish in appearance, and filled with keratin. No treatment is required as these cysts usually disappear during the first 3 months of life.
  • 49. Natal teeth have been defined as those teeth present at birth, and neonatal teeth are those that erupt during the first 30 days of life. The occurrence of natal and neonatal teeth is rare The teeth most often affected are the mandibular primary incisors. Although many theories exist as to why the teeth occur, The superficial position of the tooth germ associated with a hereditary factor seems to be the most accepted possibility. If the tooth is not excessively mobile or causing feeding problems, it should be preserved and maintained in healthy condition if at all possible. Close monitoring is indicated to ensure that the tooth remains stable.
  • 50. This baby was seen because of early exfoliation of teeth. A biopsy of the gingiva adjacent to the mandibular incisors rendered the diagnosis of Langerhans's cell histiocytosis. This child developed the acute disseminated variety.
  • 51. Riga-Fede caused by the natal or neonatal tooth rubbing the ventral surface of the tongue during feeding and causing ulceration. Failure to diagnose and properly treat this lesion result in dehydration & inadequate nutrient intake for the infant. Treatment is smoothing rough incisal edges or placing resin over the edge of the tooth. or, extraction. when deciding to extract a natal or neonatal tooth is the potential for hemorrhage. Unless the child is at least 10 days old, consultation with the pediatrician regarding adequate hemostasis may be indicated prior to extraction.
  • 52. Congenital epulis of the newborn, also known as granular cell tumor or Neumann's tumor, is a rare benign tumor seen only in newborns. This lesion is typically a protuberant mass arising from the gingival mucosa. It is most often found on the anterior maxillary ridge. Patients typically present with feeding and/or respiratory problems. Congenital epulis has a marked predilection for females at 8-10:1. Treatment normally consists of surgical excision. The newborn usually heals well and no future complications or treatment should be expected
  • 53. Eruption Cyst (Eruption Hematoma) The eruption cyst is a soft tissue cyst that results from a separation of the dental follicle from the crown of an erupting tooth. Fluid accumulation occurs within this created follicular space. Eruption cysts most commonly are found in the mandibular molar region. Color of these lesions can range from normal to blue- black or brown depending on the amount of blood in the cystic fluid. The blood is secondary to trauma. If trauma is intense, these blood filled lesions sometimes are referred to as eruption hematomas. Because the tooth erupts through the lesion, no treatment is necessary. If the cyst does not rupture spontaneously or the lesion becomes infected, the roof of the cyst may be opened surgically.
  • 54. Dentigerous cyst associated with mesiodens Dentigerous Cyst (Follicular Cyst) An odontogenic cyst that surrounds the crown f an impacted tooth; caused by fluid accumulation between the reduced enamel epithelium and the enamel surface, resulting in a cyst in which the crown is located within the lumen and root (s) outside
  • 55. Radicular Cyst (Periapical Cyst, Apical Periodontal Cyst) An odontogenic cyst of inflammatory origin that is preceded by a chronic periapical granuloma and stimulation of rests of Malassez present in the periodontal membrane.
  • 56. Calcifying Odontogenic Cyst (Gorlin Cyst, Odntogenic Ghost Cell Tumor) A rare, well-circumscribed, solid or cystic lesion derived from odontogenic epitheliium that resembles follicular ameloblastoma but contains "ghost cells" and spherical calcifications.
  • 57. The mucocele is a common lesion in children and adolescents resulting from the rupture of a minor salivary gland excretory duct with subsequent spillage of mucin into the surrounding connective tissues that may later be surrounded in a fibrous capsule. Most mucoceles are well-circumscribed bluish translucent fluctuant swellings (although deeper and long-standing lesions may range from normal in color to having a whitish keratinized surface) that are firm to palpation. Local mechanical trauma to the minor salivary gland is often the cause of rupture. At least 75% of cases are found on the lower lip, usually lateral to the midline. Mucoceles also can be found on the buccal mucosa, ventral surface of the tongue, retromolar region, and floor of the mouth (ranula). Superficial mucoceles and some mucoceles are short-lived lesions that burst spontaneously, leaving shallow ulcers that heal within a few days. Many lesions, however, require local surgical excision with the removal of adjacent minor salivary glands to minimize the risk of recurrence.
  • 58. Accessory accumulation of thyroid tissue that is usually functional within the body of the posterior tongue. ٍSurgical excision with possible thyroid replacement therapy
  • 59. Periapical radiograph of complex composite odontoma Resorption of the roots of the maxillary central and lateral incisor caused by complex composite odontome
  • 60. This infant had a neuroectodermal tumor of infancy. The radiograph shows a large osteolitic lesion which is displacing teeth germs. Surgical treatment of this neoplasm also implicated ablation of those germs with permanent loss of the primary and permanent teeth affected.
  • 61. SOFT AND HARD TISSUE NEOPLASMS. A vast number of either benign or malignant neoplasms as well as several tumor like conditions developing in the soft or hard tissues in the vicinity of teeth can be responsible for the partial loss of teeth either by directly interfering with tooth development or as a consequence to therapy. Examples include: neuroectodermal tumor of infancy, central giant cell granuloma, fibrous dysplasia, sarcomas, etc
  • 62. LANGERHANS' CELL HISTIOCYTOSIS is possibly a neoplastic proliferation of Langerhans' histiocytes which is presently classified as follows: ACUTE DISSEMINATED (Letterer-Siwe disease) it exclusively affects infants and it manifests clinically with hepatosplenomegaly and diffuse radiolucent bone lesions. The bone lesions in the jaws produce alveolar bone resorption with consequent teeth and/or teeth germs exofoliation. Radiographically this finding has been described as "floating teeth". There is also marked gingivitis and soft tissue necrosis. This type is generally fatal
  • 63. Surgical Procedures for handicapped Ensure that patients with congenital heart disease receive antimicrobial prophylaxis before dental procedures Consider surgical correction of gingival hyperplasia (overgrown gums) as a result of phenytoin Refer for surgical correction of cleft lip and palate at age 2-3 months Consider bone grafting to enhance jaw size and dental arch stability  Control body movement in mentally handicap
  • 64. Electrical burns of the oral cavity are acquired most commonly through direct contact with a live wire, plug, socket, or household appliance. In young children, this typically occurs when a wall socket is explored with the mouth or a wire is chewed upon.
  • 65. 1. Early treatment of electrical burns includes tetanus prophylaxis and the administration of both systemic and topical antibiotics to provide coverage against a broad spectrum of microorganisms. 2. The wounds are left open to the air to allow the formation of a hardened, dry eschar. Creams, salves, and dressings are contraindicated. 3. Instead, saline or chlorhexidine is used to cleanse the wound just prior to application of a topical antibiotic. 4. Though not universally accepted, removable appliances often are fabricated to apply lateral force at the commissure to prevent tissue contraction and assure normal width and contours.
  • 66. 5. Nutritional maintenance is essential and, while naso-gastric tubes may serve as a vital aid until normal oral function is restored, there is no evidence that immediately resuming normal masticatory function and oral feeding increases the risk of infection. 6. Intralesional steroid injections along with vitamin E creams and massage therapy are used in the later stages of burn management to prevent microstomia and retraction of the orbicularis oris muscle .
  • 67. Complication expect after surgery:- 1. There may be bleeding from the mouth if teeth have been removed child may nausea and vomiting may occur . 2. The child may experience discomfort in the mouth, jaw or neck. 3. There may be a slight rise in temperature for 24 hours. 4. The child may be sleep for several hours after returning home. Rest and quiet activities are important after surgery. The child may be unsteady for a while due to the medication given. It is important to closely supervise any activity for the remainder of the day. Limit the day to indoor activities.