2. 1. Introduction
2. General Considerations; Preoperative, perioperative
and postoperative.
3. Recommendations and Management of various
conditions
◦ Infections
◦ Exodontia( Erupted, Unerupted/Impacted teeth
◦ Maxillofacial fractures
◦ Emergency management
4. Pediatric oral pathology
◦ Biopsies
◦ Lesions of the Newborns ie natal and neonatal teeth
◦ Lesions occurring in children and Adults
Outline
3. Preoperative evaluation:
◦ History of presenting complaint
◦ Medical history E.g – mother’s obstetric history, teratogens
during pregnancy
◦ Dental History
◦ Examination; both intraoral and extraoral
Behavioral Assessment
Consider:
◦ Psychological development
◦ Physical development
◦ Dental development
BACKGROUND
4. Keep in mind that:
◦ Jaws are in the state of growth and development.
◦ Resorption of deciduous teeth and eruption of permanent
teeth are taking place.
◦ Jaws have developing tooth buds.
◦ Bones of children contain more organic material – soft and
less mineralized.
◦ Small mouth opening – procedures involving posterior oral
cavity will be difficult.
5. 1. Informed consent
Before any surgical procedure, informed
consent must be obtained from the parent or
legal guardian.
2. Medical evaluation
obtain a thorough medical history, and
appropriate medical and dental history, to
anticipate and prevent emergencies, and to be
prepared to treat emergencies.
Preoperative considerations
6. 3. Dental Evaluation
clinical examination of extraoral and intraoral soft
tissues
Radiographic evaluation including IOPAs, OPGs,
etc
To minimize the negative effects of surgery on
the developing dentition, careful planning using
radiographs, tomography, CBCT, and/or 3D
imaging techniques is necessary to provide
valuable information to assess the presence,
absence, location, and/or quality of individual
crown and root development.
7. 4. Growth and Development.
Traumatic injuries in the maxillofacial region
affect growth, development, and function.
Therefore, a thorough evaluation of the growing
patient must be done before surgical
interventions are performed to minimize the risk
of damage to the growing facial complex
5. Behavioral evaluation
Special attention to assessment of the social,
emotional, and psychological status and cognitive
level of the pediatric patient before surgery
sedation or general anesthesia
8. Metabolic management of children following
surgery frequently is more complex than that
of adults.
Special consideration should be given to
caloric intake, fluid and electrolyte
management, and blood replacement.
Comprehensive management of the pediatric
patient after surgery is best accomplished in a
hospital or a well-equipped dental facility with
a specialist.
Peri- and postoperative
considerations
9. Systemic considerations:
◦ URTI
◦ Asthma
◦ Endocrine disorders – diabetes
◦ Congenital cardiac defects
◦ Hematologic disease
◦ Familial risk for susceptibilty to malignant hypothermia
Anatomical considerations:
◦ Small mandibles
◦ Large tongues
◦ Large tonsillar/ adenoid tissues
◦ Smaller glottis
◦ Supple, pliable larynges
Anesthesia considerations
10. Opening the patient’s mouth and maintaining
its opening can be facilitated with a bite block
or a Molt mouth prop.
Commonly used retractors in oral surgery
include:
◦ Austin retractor – cheek and surgical flaps
◦ Minnesota retractor – cheek and surgical flaps
◦ Weider retractor – tongue retractor
Fraser suction tip
13. Indications for extraction of deciduous teeth:
◦ Nonrestorable caries
◦ Apical disease
◦ Fractures of crowns or roots
◦ Prolonged retention of primary teeth because of
improper root resorption or ankylosis
◦ Impacted teeth
◦ Supernumerary teeth.
Special considerations:
◦ Proximity of the deciduous tooth to the succedaneous
tooth
◦ Roots on primary teeth with nonresorbed roots will be
long, slender and potentially divergent.
Recommendations in Simple
exodontia
15. Causes of impacted teeth:
◦ Insufficient space in dental arch
◦ Mechanical obstruction secondary to oral pathology e.g
odontomas
◦ Supernumerary tooth
◦ Malposed tooth germs
Reasons for disimpaction of impacted third molars:
◦ Limit progression of periodontal disease
IMPACTED TEETH
16. Impacted Canines
◦ 2nd most impacted tooth
◦ Treatment is by extraction of the primary canine (normal
space and no incisor resorption)
◦ No improvement in canine position in a year, surgical and
orthodontic treatment
Mesiodens
◦ Most common supernumerary
◦ Treatment
●No surgery for non-erupting primary mesiodens (damage to
succedeneous tooth)
●Mixed dentition extract the mesiodens ensure 2/3rd of root
formation of incisor
●Allow erupted primary mesiodens to shed
18. Management of an impacted tooth may include:
◦ Observation
◦ Extraction of the impacted tooth
◦ Surgical exposure and assisted eruption
◦ Surgical uprighting
◦ Autotransplantation
Factors affecting management of impacted teeth:
◦ Age and health of the patient
◦ Potential pathology associated with the impacted tooth
◦ Location and angulation of the impacted tooth
◦ Benefit of surgery
◦ Frequency and severity of the risks of surgery
◦ Risks and consequences of no surgical intervention
◦ Economic consequences of surgical versus nonsurgical
◦ Intervention and the quality of life associated with each of these
decisions.
19. Vary according to age:
◦ < 5 yrs Upper face infections: non-odontogenic
◦ >5 yrs lower face infections : odontogenic
Treatment
Non-odontogenic infections: Broad spectrum
antibiotics and hydration
Odontogenic infections: Antibiotics,
hydration, drainage, treat underlying dental
pblm
Considerations in Maxillofacial
infections
20. ◦ Management:
●Present illness, past medical and surgical history.
●History of the present illness must include
●Onset
●Rate of progression
●History of preceding odontogenic pain, upper respiratory
infection, sinus pain, otitis media
●Airway compromise (dysphagia, dyspnea, change in voice),
●Trismus
●Ophthalmic complaints (e.g., photophobia, changes in visual
acuity)
●Examine patient:
●Patient’s respiratory compromise, distress, or lack of
distress
●Involved swelling and the severity of the swelling
●Palpation of the tissues discerning their tenderness
●Consistency (cellulitic or fluctuant)
●Assessment of maximal mouth opening
●Examination of the dentition.
21. The components of intervention include:
◦ Determining whether the infection should be treated in an
outpatient or inpatient setting
◦ Establish appropriate antibiotics to use
◦ Undertaking surgery (incision and drainage and removal of the
etiology).
Indications for admitting a pediatric patient to the
hospital include:
◦ Fever (temperature 101.5F)
◦ Lymphadenopathy
◦ Elevated white blood cell count (WBC)
◦ Poor oral intake
◦ Dehydration
◦ Involved fascial spaces
◦ Associated fi ndings (e.g., dysphagia),
◦ Appearance of being ill (i.e. looking sick).
22. Injuries may have adverse effect to growth
E.g. Injuries to the mandible:
◦ Ankylosis
●Limited mandibular functions
●Restricted growth
Surgery for acquired/congenital anomalies
may tamper with growth.
◦ Cleft Palate repairs cause palatal scarring resulting
in maxillary constriction
Considerations in Growth and
development
23. Mandibular fractures are the most common facial
skeletal injury in pediatric trauma patients.
Young bone possesses unique physical properties
that coupled with space occupying developing
dentition give rise to patterns of fracture not seen
in adults.
Bone fragments in children may become partially
united as early as 4 days and fractures become
difficult to reduce by seventh day.
This results in need for different forms of
fixation as early as possible for comparatively
shorter duration of time
Considerations in Paediatric
maxillofacial fractures
24. Nonunion or fibrous union rarely occurs in
children and excellent remodeling occurs under
the influence of masticatory stresses even when
there is imperfect apposition of bone surfaces.
The management of mandibular fractures in
children differs somewhat from that of adults
mainly because of concern for possible disruption
of growth.
In children the final result is determined not
merely by initial treatment but by the effect that
growth has on form and function.
25. Growth abnormalities may occur as result of
fracture dislocation of condyle due to
elimination of ‘functional matrix’ of lateral
pterygoid function, trismus or ankylosis.
Between 2-4 years sufficient number of fully
formed deciduous teeth are present
facilitating application of arch bars or eyelet
wires.
5 to 8 years age old group may present with
some difficulty owing to loss or loosening of
deciduous teeth.
26. The shape and shortness of deciduous crowns
may make the placement of circumdental
wires and arch bar slightly more difficult in
children.
However the narrow cervix of tooth in relation
to crown and roots provides better retention
of wires as in Ivy loops or stout wires
Mandibular cortex is thinner in children so
care must be taken to avoid pulling a wire
through the mandible when placing
circummandibular wiring for splints
27. While doing open reduction and fixation
presence of tooth buds throughout the body
of mandible must be a consideration as
trauma to developing tooth buds may result in
failure of eruption of permanent teeth and
hence narrow alveolar ridge
28. The emergency management of facial trauma in
pediatric population also needs extra-
consideration.
Clinical signs of shock may occur with even
insignificant amounts of rapid blood loss due to
small blood volume
Because of small size of airway laryngeal edema
or retroposition of base of tongue may produce
sudden obstruction
Tracheostomy if required should be done using
vertical incision avoiding first tracheal ring and
high lying left innominate vein.
Considerations in Emergency
Management
29. Earlier most of the pediatric cases were
treated with conservative measures or closed
reduction techniques.
Only recently have the distinct advantages of
accurate primary repair and the stable fixation
of facial fractures been applied to the
rehabilitation of injuries in children too.
Also, resorbable materials have been made
available as a fixation option for pediatric
craniomaxillofacial fracture management
30. Mandibular fractures in children most commonly
occur in condylar region, followed by
parasymphysis and angle.
The fractures tend to be minimally displaced and
in majority of cases can be treated conservatively.
Significantly displaced mandibular fractures are
reduced and immobilized using rigid internal
fixation according to principles used in adults.
Fractures in condylar region usually are treated
using nonoperative therapies as in most cases
fracture heals and condyle is remodeled with
successful anatomic and functional results.
31. According to Peterson with the exception of
mandibular condyle fractures judicious use of
ORIF is preferable to the closed reduction and
immobilization techniques with splints when
treating fractures in the deciduous and mixed
dentition
33. ODONTOMAS:
◦ Most frequently occurring odontogenic tumors in
pediatric patients.
◦ Discovered mostly when patient comes for evaluation of
an unerupted tooth during radiographic examination.
◦ 2 types: compound and complex
◦ Rx: simple enucleation and curettage
HARD TISSUE LESIONS
34. ODONTOGENIC CYSTS:
◦ Most common: dentigerous cyst
●Usually asso with an unerupted permanent tooth or a
supernumerary tooth.
◦ Traumatic cysts – also common
●Unilateral and solitary
◦ Eruption cyst: caused by eruption trauma
●Erupting molar areas
●Color range from normal to blue-black or brown
●Resolves spontaneously with eruption of tooth.
◦ Management:
●Biopsy before definitive treatment.
●Initial step: Aspirate cystic contents
●Enucleation
35.
36. NATAL AND NEONATAL TEETH:
◦ Natal teeth: teeth present at birth
◦ Neonatal teeth: erupt during the first 30 days of life
◦ Teeth most affected:mandibular primary incisors.
◦ In most cases they are part of the normal complement of
the dentition
◦ Treatment
●Reassure parents
●Preserve and maintain in a healthy condition unless
excessively mobile or causes feeding problems
●Monitor Closely
37.
38. Commonly seen soft tissue pathologic conditions:
mucocele, ranula, fibroma, and pyogenic
granuloma. Lingual and labial frenectomies.
Soft tissue Lesions
39. MUCOCELES AND RANULAS:
◦ Benign pathologic lesion
◦ Result of the extravasation of saliva from an injured minor
salivary gland.
◦ Nonpainful, soft, doughy, and fluctuant to palpation.
◦ Overlying mucosa may have the same coloration as the lower lip
or have a bluish hue.
◦ Rx: remove the fibrous capsule and any associated minor
salivary glands.
◦ A ranula in a young pediatric patient needs to be differentiated
from a lymphatic malformation
40. EPSTEIN’S PEARLS
◦ Found in the median palatal raphe area
◦ Due to 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 seen bilaterally in the region of the first
primary molars.
◦ From remnants of the dental lamina.
They are both asymptomatic 1 mm to 3 mm
nodules. Smooth, whitish in appearance, and
filled with keratin.
42. CONGENITAL EPULIS OF THE NEWBORN/ GRANULAR
CELL TUMOR / NEUMANN’S TUMOR
◦ Rare benign tumor seen only in newborns.
◦ Protuberant mass arising from the gingival mucosa.
◦ Found on the anterior maxillary ridge.
◦ Patients typically present with feeding and/or respiratory
problems.
◦ Treatment: surgical excision.
43. RIGA-FEDE DISEASE:
Caused by the natal or neonatal tooth rubbing
the ventral surface of the tongue during feeding
leading to ulceration.
Treatment :
◦ Conservative :Create round, smooth incisal edges
◦ If it does not correct: extraction is the treatment of
choice to avoid ‘failure to thrive’
44. AAPD. Management Considerations for
Pediatric Oral Surgery and Oral Pathology,
2020.
Cawson R.A. and Odell E.A. Essentials of
OralPathology and Oral Medicine. 8th Edition.
Churchill Livingston Publishers. 2008.
McDonald and Avery
Shoba Tandon
REFERRENCES
