Pedodontic Fifth-year First semester By Lama El Banna Al Azhar University Gaza Palestine

1. ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
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2. College of Dentistry
Pedodontic II
Extraction of Teeth in Children
Management of Traumatic Injuries in
Children
Dr. Hazem El Ajrami
Master Degree in Orthodontic & Pedodontic
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3. Indications for extraction of permanent
first molars:
Permanent first molars erupt early and
sometimes thought by the parents as primary
teeth. If a permanent first molar is removed
before the permanent second molar has erupted
through the gingiva, the chances that the
second molar will move mesially and occupy
the space of the extracted first molars are very
good.
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5. • When two first molars are diseased beyond
repair, they should be removed. But if three
first molars are diseased beyond repair, all four
molars should be removed with the expectation
that a more symmetrical dentition will result.
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6. Treatment planning for extraction of primary
teeth:
Removal of primary teeth should be included
in the treatment plan along with restorative
procedures or cementation of space maintainers.
Radiographic surveys of teeth to be extracted are
of prime importance. A tooth needs not be
removed on the first appointment unless there is
an acute infection or current toothache. When the
placement of a space maintainer is scheduled, the
appliance should be ready before the appointment
and cemented after the removal of the tooth.
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7.  Preoperative preparation:
As the extraction of a tooth can be
emotionally upsetting to the child and to
parents, some preparations are necessary.
A. Preparing the parents:
A parental consent is important before the
operation is performed on a minor. If there is
doubt whether a carious primary tooth can be
restored, the possibility of its being removed
should be discussed with the parents before
treatment begins. Any possible medical
condition that may require special precaution
should be thought.
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8. B. Preparing the patient:
The choice of words that the dentist uses is
critical. Avoid the use of technical words and
words suggesting fear or pain. Explain to the
child what sensation may be experienced and
what is expected from him. It is extremely
important that the patient realize the
difference between pressure and “pain”.
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9. Techniques for the removal of primary teeth:
• Although extraction of a deciduous tooth with
completely resorbed roots is a simple task,
removal of some of the deciduous teeth with all
or part of the roots present can be challenging.
• Armamentarium for exodontic procedures is
much the same as for adult, but as all anatomic
structures are smaller, special forceps are
available for primary teeth and offer some
convenience. Large adult forceps such as the
(Cowhom) forceps and large elevators are contra-
indicated.
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11. • When removing young permanent teeth, the
young elastic bone structures and incomplete
root development usually facilitate the
extraction. Fracture of a slender root is
common, especially when there is uneven
resorption. These roots should be removed,
provided that the permanent tooth buds can be
avoided. A small spear point elevator or even a
large spoon excavator or sealer can be used for
removing the remaining fragments.
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12. Extraction of anterior teeth:
Anterior teeth should be luxated to the
labial during the extraction procedure due to
the lingual position of the permanent teeth-
then rotated slightly and delivered to the labial.
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13. Extraction of maxillary primary molars:
Because the palatal root is curved, it
indicates the direction of the removal, and the
initial direction of force is slightly to the lingual.
Slight force is emphasized in order not to
fracture the curved palatal root then in a single
sustained force to the buccal the tooth is
loosened, and a counterclockwise motion
delivers the tooth out of the socket.
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14. Extraction of mandibular primary molars:
The cross-section of the mandibular first
primary molar roots is flat mesiodistally and
elliptical. Therefore, any rotary motion is
contraindicated. The initial force is slightly to
the lingual; then a single sustained force to the
buccal until the tooth is loosened. After it is
loosened, a counterclockwise rotation delivers
the tooth from the socket.
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15. • During extraction, the mandible is supported
with the non-extraction hand to protect TMJ
against any possible injury.
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16.  Postoperative instructions:
For the child:
1. The child should not be dismissed until a
blood clot has formed, once the blood has
clotted, the child is instructed to hold
between his lips a small cotton roll until his
lips "wake up".
2. The child may return to school or go out and
play once the numbness has gone.
3. A child should be reassured that he will get a
new tooth replaced with the one that was
removed.16

17. For the Parents:
1. There is a need to tell the parents why the
cotton roll is used and that they should not be
concerned if there is slight oozing or blood
from the socket or if blood is seen on the
pillow the next day or so. Light meal with no
hard food is recommended.
2. The parents are further instructed not to ask
the child how painful the area is or
continuously enquire how the child feels.
Simple written instructions are helpful.
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18. Management of Traumatic Injuries
in Children
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19. • An injury to both the primary and permanent
teeth and the supporting structures is one of the
most common dental problems seen in
children. The extent of injury may vary from
mild chipping of the enamel to severe
maxillofacial injury.
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20. • Besides physical trauma it also has a great
psychological impact on both the parents and
the child since these fractures may affect the
child's appearance. Trauma should always be
considered an emergency situation and the
dentist's responsibility is to act objectively and
efficiently in such a situation.
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21. • Epidemiology:
About 30% of school children suffer
traumatic dental injury in the primary
dentition, and 22% in the permanent
dentition.
Studies in Egypt have shown that 9.8% of
school children suffer traumatic dental
injury in the permanent dentition.
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22. The prevalence of traumatic dental injury among
boys and girls does not differ to a great extent
until the age of 9 years. After this age, boys show
higher prevalence than girls. The ratio was found
to be 1.5 : 1; this is probably because of active
participation of boys' in contact sports.
The majority of injuries to the dentition occur to
the anterior teeth and in particular the maxillary
central incisors of both primary and permanent
dentition. Injuries usually affect only one tooth;
and 25% of the patients treated for dental trauma
will very likely repeat the experience.
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24. • Predisposing factors to dental trauma:
Sports activities as contact sports, bicycle or
horse riding.
Falls or road accidents.
Mentally handicapped individuals or children
suffering from repetitive seizures where
violent contact with objects may be
unavoidable.
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25. A Class II, division 1 malocclusion with
protruding upper incisors and incompetent lips.
Dental trauma is as twice as frequent in those
children. Early orthodontic treatment may
prevent a great deal of traumatic injuries.
Hypoplasia, extensive caries or any defects of
enamel that results in weakening of the tooth
structure, can cause fracture of the crown under
even slight trauma.
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27. • Classification of trauma to anterior teeth:
Several classifications have been advocated
by several authors.
Ellis and Davey classification:
Class 1: simple crown fracture with little or
no dentin.
Class 2: extensive crown fracture involving
considerable amount of dentine without pulp
exposure.
Class 3: extensive crown fracture involving
considerable amount of dentine with pulp
exposure.27

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29. Class 4: non-vital traumatized tooth with or
without loss of crown structure.
Class 5: loss of the tooth.
Class 6: root fracture with or without crown
fracture.
Class 7: tooth displacement without crown or
root fracture.
Class 8: fracture of crown en-mass.
Class 9: traumatic injuries of deciduous teeth.
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31. Descriptive classification:
• Injuries to the tooth:
Crown
Crack or craze of enamel.
Fracture of crown involving enamel, dentine or
pulp.
Fracture of crown and root involving
cementum which may or may not have pulp
involvement.
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32. Root
• May be horizontal or oblique:
Apical third fracture.
 Middle third fracture.
Coronal third fracture.
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34. • Involving the whole tooth:
Concussion: sensitivity of the tooth due to
trauma without abnormal loosening or
mobility. The tooth may be sensitive to
percussion usually caused due to mild blow.
Subluxation: loosening of the tooth without
displacement, due to a more severe blow
resulting in injury to periodontal ligament.
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35. Displacement/luxation:
Intrusion: displacement of a tooth in an apical
direction. Tooth is pushed into the socket,
causing fracture of the bone at the floor of the
socket in most of the cases.
Extrusion: displacement of a tooth in a coronal
direction. Tooth is seen extruded partially of the
socket.
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37. Labial/lingual/palatal: displacement of a tooth
in a labial or lingual direction.
Lateral: displacement of a tooth in a mesial or
distal direction.
Avulsion: loss of tooth, where the entire
tooth is out of the socket.
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38. Thank You
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