Extraction pf primary teeth

Announcements:
1) Please know what are the procedures steps for what you do in
the clinic like PRR or extraction or FS because the mark on the
practical work and your knowledge.
2) Please don't bring your things to the clinic especially money
leave them in the lockers.
3) The doctor said that the last day of the clinics will be on 7/5 so
try to finish your requirements before that.

Today' lecture is about primary tooth extraction, the doctor is certain that
the majority know about extraction from surgery but the difference that
we are talking about primary teeth.
Picture # 3: what is your treatment plane for 74, 75? Extraction what is
the problems about these teeth? (1) Root resorption. (2) Extensive caries
beyond restoration. (3) Abscess (4) eruption of the successors (5)
furcation radiolucency (6) internal resorption in 75.

Tooth extraction requires careful planning so before you do extraction

you should plane ahead: why we have to extract, what are the
indications? And how?? Then if you decide to do it: is the pt cooperative?
Does he need special behavior management technique? Or require GA?
And after the extraction what are the consequences that might happen?
How I can avoid them if they are bad? Do I need a space maintainer or
analysis ……etc.
You start thinking and plane your extraction you don't just remove the
tooth it is very easy to remove it but you have a plane ahead. The general
goal in pediatric dentistry is to maintain the teeth not to extract them but
if we have to in some specific situations then we will.

The best space maintainer all the time is the tooth itself, as long as we
keep the tooth it will maintain its own place but when we remove it then
we have to insert special oral appliances to maintain the space for us, the
premature loss of primary teeth can lead to many problems one of which:
loss of space, impaction, delayed in eruption or accelerated eruption in
some cases so in general malocclusion problems.
Rational "indications" of tooth removal:
1) Extensive dental decay : if you have primary tooth which is
extensively
Broken and not restorable you need to extract it.
2) Pulpal pathology:

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  In cases where you have pulpal necrosis or irreversible
pulpitis you can make pulpectomy in these cases but sometimes
the behavior does not allow you or the cost.
 Pulpal therapy is not indicated due to medical problems
for example: in patient with immune suppressive disease we
prefer to extract rather than doing pulpectomy cause the risk of
bacteremia and infections.
 Teeth with root canal morphology which prevent the endo
treatment because if you rotated root it is hard to do filing
inside the canal then you might to extract.
 Teeth with failed endo treatment: you did endo but the
lesion is not healing so you need to extract.
Slide # 6: this is 51 and there is Pulpal necrosis and abscess in it, pt has
bad OH pulpectomy is not indicated we usually do it in pt with low to
moderate risk patients where it is very important to keep the tooth but
when you look to the rest of this pt teeth you see many non restorable
teeth and the parent were not seeking any treatment so we are not really
concern keeping 51 for aesthetic reasons and his family did not concern
so this is the dental attitude in general.
3) Advanced periodontal disease: this disease in general is rare in
children we don’t see very often except in some certain medical or
genetic conditions like:
a- Diabetes. b- Gingival fibromatosis. C- Ehlers-Danlos
syndrome (type Vlll) d- Chediak-Higashe syndrome. E-cyclic
neutropenia. F- Immunoglobulin’s deficiencies.
4) Teeth with acquired or developmental defects: in cases of
enamel hypoplasia or dentinogensis imperfecta we might need
extraction.
Slide# 20: this is perio disease you can see how deep the bone
destruction up to the apex, it is so loose it can’t be held in the mouth so
we need to extract it.
Picture not found in the slides: dentinogensis imperfect you can see
the teeth are worn out and had reached the gum they are non restorable
and need to be removed, you noticed the SSC on the 6’s they had been
put to save them because if there were not any crowns the 6’s will end up
like the others.
5) Natal or neonatal teeth: in some not all the cases you might
need to extract them especially if they are causing trauma to the
tongue or the lips and if the pt is trying to bite himself. Like in the
picture also not found in the slides: this is the “riga fede” this injury
to the tongue and lips is called riga fede . Sometimes the child will
hurt himself because of psychological problems; of course he is old

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enough to understand the concept of hurting himself.

6) Orthodontic treatment: in some cases we need to extract sound

tooth just to make space for another tooth because of the
impaction or mal alignment this is called extraction for orthodontic
reasons some time you get referral from the orthodontic “please
extract the upper c’s for ortho treatment”.
7) Some teeth are malpositioned or rotated in this case we will
extract and the ortho will align the rest.
8) Cracked tooth: if there was trauma to a tooth this would crack it
“vertical crack” this is very hard type of injury especially if it
extend all the way to the apex then we have to extract.
9) Teeth as foci of infections especially in pt with medical history
or immune suppressed which make them more prone to infections
for example pt with immunoglobulin deficiency if he gets abscess in
one of his teeth it will put him in danger because the toxins and
abscess might travel in the blood causing severe infections and
that make him go to hospital to get IV antibiotics where as health
person like us can have abscess and swelling for a week and
survive so according to the medical history you decide when to
extract. So in cases of disease that may be related to focal
infections as in endocarditis, rheumatic fever, glomerulonephritis or
prior to chemotherapy having an abscess is very serious in these
pts. consider prophylactic antibiotics might be indicated, some of
them live their lives on prophylaxis. Do you know what the
immunoglobulin deficiency is? Where the body can’t produce
antibodies so the pt is very immune suppressed and usually these
come in sub classes of immunoglobulin deficiency sometime it is
IgG or IgE deficiency according to the sub class we get different
types of the disease so if IgE is deficient they will get a lot of
allergies and parasitic infections while IgG deficiency will lead to
more bacterial and viral infections.
10) Preprosthetic treatment: sometimes before you do prosthesis
or removable partial dentures you might need to remove some
teeth to create the path of insertion or proper alignment of the
teeth

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 11) Impacted teeth were teeth are unable to erupt to their correct
position then you have to open the bone and extract these teeth.
12) Over retained primary teeth: do you know when these cases
can occur? if we have missing successor we will get submerged
teeth or infraoccluded teeth and they stay for a long time in the
mouth until they are shed but sometimes they don’t shed if you
want to place a prosthesis (a bridge) in its place you need to
remove them but in other cases when you want them to remain
and preserve the place just leave them.
13) Supernumerary teeth: we always remove them because they
can develop cyst or impact or divert other teeth from their path of
eruption and many problems.
14) Teeth associated with pathology: if we have a tooth which
associated with abscess or cyst we remove it.
15) Pre-radiation therapy: as soon as they diagnose the case
usually the medical doctor want to rush to give him the radio or
chemo therapy to save his life so sometimes especially if you work
at the hospital he will call you and ask you to do an emergency GA
to that patient so you can do complete oral rehabilitation to that
patient in this case any teeth needs pulp therapy you have to
extract even if they are restorable because they are focus of
infection in this case then you do all the FS and FG and all what the
patient needs in that session so we can start radio therapy in the
next day.
16) Teeth involved with trauma: some cases with injury they
require you to extract the teeth because they aren’t restorable.
17) Teeth involved in jaw fracture: sometimes the jaw fracture will
involve the teeth with it so you have to remove the teeth when you
correct the fracture.
18) Aesthetics: sometimes in some cases for aesthetics reasons
you extract the tooth especially if it is severely discolored and you
cannot fix the problem.
19) Economy: when the patient cannot pay to treat the tooth and
this is bad.

Contraindication for tooth extraction:

No absolute contraindication but we can summarize them into two

types: 1) local 2)systemic.
Systemic ones which we have talked about, like when the patient at
risk of infection in diabetes mellitus, leukemia, lymphoma, cardiac
disease, bleeding problems and patient on medication causing
immune suppression for them.
Local contraindication: 1) irradiated bone because of the risk of
osteomyelitis because when irradiation begins the vessels become
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 constricted and the blood supply to bone is decreased which put the
patient at the risk of osteo-radionecrosis so even osteomyelitis may
occur because of the poor blood supply, bacteria get in that socket in
the bone so there will be reduced immune response and the result
will be osteomyelitis. So always the tooth should be extracted before
radiotherapy.
2) Teeth located with a tumor: in some cases if a tooth is located
within a tumor and you remove it some of the cells will escape and
get disseminated into other tissue and that helps in the spread of the
tumor.

Slide # 32: this is a case of tumor in pediatric patient came to doctor

clinic, she was 8 years old, her anterior teeth were mobile at the
beginning they thought it was periodontitis because she had deep
pockets due to bone resorption when they took this x-ray “mandibular
occlusal view” the pattern of resorption for the roots was not normal
and was not periodontitis, then they took bone aspiration it turned out
to be a tumor, it is a rare but you should not neglect these cases.
3)the presence of acute dentoalveolar disease : pt who has abscesses
with acute swelling in most cases you hear that they went to the dentist
and he told them that he cant extract due to infection is that true? Is
there any medically or systemically wrong if you remove it? Are there any
medical threats if you remove the tooth? There are no threats on the pt
health if u remove the tooth and if you can get profound local anesthesia
and open the pt mouth properly you better to remove the tooth in the
same day "if you can" but if the pt is tired and lethargic and has
temperature u can postpone it giving him antibiotics and pain killer and
let him rest and to come back and remove it.
This is one option the other as we said if the pt cooperative you can
remove it on the same day and in some cases we put the pt under GA
giving him IV antibiotics and we remove the tooth, so in conclusion:
"acute infection is NOT contraindication by it self but it is inability to open
the mouth, to get effective local anesthesia these are the problems
associated with it."
So as we said we need a good planning so we need a good preoperative
assessment: spend enough time to do proper assessment for the pt so
as we do in the clinic history, examination, special investigation which
might include X-ray or even further that that, then the diagnosis, the
treatment plan and you always get an informed consent, you always tell
the parent that you are going to extract the child tooth.
Clinical evaluation: is to note
1) The access to the tooth: as we have been talking about in acute
infection the access in difficult specially if it is lower 6 and the pt has
cellulites or Trismus or abscess and cant open his mouth in some cases
the crowding and mal alignment of the tooth makes it really difficult to
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get access to have to think an consider how am going to remove this
tooth.
2) The presence of the infection: what is the nature of the infection? Is it
drainage, abscess or cellulitis, the sight of infection and its relation to the
tooth.
The potential for local anesthesia is it going to work and is there any
systemic involvement to give antibiotics.
3) Mobility of the tooth: is it mobile or locked in its space or any chance
ankylosis and hypercementosis.
Slide # 29: In this case the D is ankylosed, look at the occlusal level of
the D it is way below the E this is class 1 ankylosis, class 2 when it is at
the contact point and class 3 below the contact point. then we can see
the X-ray of the case because it is ankylosed you might think of
sectioning the tooth cause removing it with the forceps might break it or
remove part of the bone with it. Keep this in mined and also you may
have to work with the surgeon with it.
4) Condition of the crown: you need to assess it if the is big carious lesion
or large restoration, are you going to break the crown or there is any risk
on the adjacent tooth and
5)make sure the permanent tooth is present like don’t extract the E
without making sure that the 5 is there because some time you have to
hang up on it for a long time if the permanent tooth is missing.
Relationship to associated vital structures: avoid them specially nerves or
blood vessels, some pt have Heamangiomas like sublingual
heamangiomas, and if it is close to a tooth then you'll have big bleeding
that you cant stop and don’t forget the sinus in case of upper 6`s.
Slide# 32:"this is X-ray showing missing 5 so we have 2 keep the E`s as
long as possible trying your best to save the tooth by doing pulpectomy".
6) Relationship of primary root: some peaces of primary tooth roots are
very close to permanent tooth bud it is locking them, so if u try to remove
it you`ll remove the tooth bud with it this is rare but can happen.
7) Configuration of the root.
8) Condition of the surrounding bone.
Bone density and presence of apical and furcation pathology and dental
treatment should never be given until you get certain diagnosis.
If you don’t know what you are doing or what is the diagnosis it is better
not to do anything. Don’t ever be ashamed if you are not sure you can
say that you have u check and consult with your colleague so never give
cretin diagnosis until you are really sure in you in doubt seek a2nd
opinion.

Treatment:

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Preoperative assessment should include the level of anxiety as we said
the behavior management and then if you think it is difficult refer it to
specialist.
Principles of extraction:
Expand your boney socket and always have a fulcrum or lever and insert
a wedge in which cases is the beak of the forceps or the elevator.
Extraction technique:
• You always need a good access so your instrument can move in
and out easily.
• Vision: you have to see clearly have a good light inside the
mouth
• make sure of your position
• Light.
• The height of the dental chair: in surgery clinic you do the
extraction standing up but in pedo clinic you do it setting down,
have the chair at the level of your hand because it’s much more
relaxing for you and the pt. When you do extraction "the working
hand" will hold the forceps and “the non-working hand“ will
retract the soft tissue and hold the boney buccal and lingual for
support and protection if the instrument slips you should have a
very good grip and it will provide resistance the extraction force
on the mandible and prevent its dislocation and it will provide
feeling so you can feel the bone while removing the tooth and
support for the head and the jaw cause dislocation could happen
on children.
Instruments and the gauze should be sterile and if your
instruments have not been used for long time they should be re-
sterilized every six months.

Picture slide# 42: this is the forceps you know they have a beak, a shank
and a handle. We have maxillary, mandibular, anterior and posterior.

Picture slide# 43: from left to right: mandibular lower molar, lower
anterior, upper molar, upper anterior.
So maxillary forceps are usually straight for anterior teeth or curved for
posterior or very angled for the 8’s, mandibular forceps usually have the
blades at 90˚ . the blades are usually sharp in order to catch the tooth
properly they are wedge shape “like a triangle” in order to be narrow at
the beak to hold as much as possible and dilate the socket, the more you
dilate the more the forceps can go down, try to go down as much as you
can and if you grip the furcation area then you have an excellent grip and
remove the tooth in one piece. The inner surface of the beak is hollowed
so it can be griped at the convexity of the tooth. The angles are designed
to drive the forces along the long axis of the tooth.

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Extraction with the forceps:

You cut the soft tissue and tear the periodontal ligament and dilate the
socket then the tooth become loosens to be removed.

Slide# 52: show how to apply your forceps, many do the wrong technique
“left pic” and that’s why the tooth will never come out this is doing
nothing you have to hold and grip it properly and do the proper
movement “right pic”.
You have to know how to hold the forceps in case the upper forceps the
handle is concave like an arch and this should face the palm of the hand,
never put your middle finger between the handles because when you
extract the tooth you will press your finger ”slide# 53”.
Conical root are extracted by rotation movement and these are the
anterior teeth, in case of canine and premolars you need buccal and
lingual movement, in case of molars you need figure (8) movement an din
all these cases you need a little bit of rotation even in molar and canine
at the end rotate the tooth then pull it. In case of molar you remove it
toward the buccal direction, you can not remove it in the lingual side so
during movement you can move it lingually but the last movement is
buccally.
Common errors in forceps extraction:
1) Failure to grip the roots correctly.
2) Continued attempts to extract with out movement
“also the grip”
3) Gripping the crown not the root
4) Use of one blade contact
5) Incorrect alignment of the forceps to the long access
of the tooth
6) Working with hast, not caring or consideration so you
end up extraction of the wrong tooth if you are in hurray.
Difficulties with extraction:
A. Small mouth: some people have congenital problems or
microsomia or had burns so their mouths are very scared so they
can’t open them properly, this is hard to deal with.
B. Difficulties with good forceps due to bulbous crowns: cause
some crowns are very big “bulbous” and the roots are very slim
so it is hard to get the forceps to go beneath the crown catching
the root in the furcation area and you end up fracturing the crown
unless you are careful.
C. Remaining roots, complications due to ankylosis.
D. Damage to permanent tooth bud.

Elevators:

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 In slide # 60 you can see the warwek James elevator, they
usually come in pairs one for mesial or distal or right or left.
Coplant elevators which could be serrated in some cases or be in different
sizes 1, 2 or 3.
Why we use elevators? We use them as a fulcrum to take the tooth out.
So from its name it elevates the tooth from the socket and when you
apply it you put it as a wedge next to the mesio-buccal or the disto-buccal
aspect of the tooth then rotate it as a screw driver. And use them to
provide a point of application for the forceps, to dilate and expand the
socket or to dislodge the whole tooth.
It is also composed of a handle, shank and blade. The types we use in
pedo clinic are the warwek James elevators because they are safe, blunt,
small suitable with children teeth.
They are always held with the palm of the hand as you see in slide #68,
so you hold it in your hand and use your index finger to move it around to
use it as fulcrum or wedge. As lever then rotate it in order to get the
tooth out, as a wedge to dilate the socket, so you loosen the soft tissue
attachment around the tooth with the elevator.
Clinical information from the doctor”The approach to extract a tooth
“
 Tell the parent that you are going to extract
 Give pt anesthesia and do all the behavior management
for anesthesia
 After the tooth is numbed you will tell the pt that you will
extract his tooth cause it is badly broken or it’s painful
 We explain that he won’t feel any thing except the
pressure how? You press on his hand genteelly and tell him that
is what you will feel.
 Then hold the tweezers and press on the buccal mucosa
and show him that this is only pressure not pain “if good
anesthesia was provided
 Hold his thumb and move it back and forth then tell him
that you going to hold his teeth and move like this, or tell him
the tooth will dance but it wont be painful
 Then the tooth will pup out by itself
 You should make it very easy and talk to the child by his
language to have good communication with him and making it a
relaxing procedure for him
Functions of elevators:
1) Luxation of the tooth from surrounding bone before the application of
the forceps
2) Expansion of the alveolar bone before you apply excessive force and
that for preventing fracture of the tooth.
3) Removal of broken, remained roots

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Please make sure that the instrument won’t slip inside the pt mouth and
in order to do that have good grip, good light and good fulcrum and
maintain them properly, the blades should be sharpened and if you
extract with elevators please do debridement for the socket by irrigation
with normal saline especially with the 8’s.

Complications of extraction:
So after you do the extractions what harm might happen?
1) Difficulty of access
a) Trismus
b) Dislodgment of TMJ
c) Reduced oral aperture it will make the extraction difficult
d) Crowded or miss displaced tooth also makes the extraction
difficult
2) Failure to obtain local anesthesia due to:
*technique
*presence of infection
*insufficient dosage
*anatomical variation
 Problems related to local anesthesia:
• Blanching of facial skin in case you hit facial artery but it is
now rare because the usage of aspirating syringes
• Trauma to soft tissue : if you give id block always tell the
pt not to bite on his lips because if they do they will get
serious injury and swelling which last for two weeks to be
resolved
• The management is to avoid these problems and always
give your warnings about local anesthesia
3) Failure to remove the tooth: you just can’t remove it in cases of
ankylosis or hyper
Cementosis or variation in root morphology in these cases stop
and think why the
tooth is not coming out? So stop to review and re-assess and
sometime you need
to consult with the surgeon or may do minor oral surgery.
4) Damage of other teeth while you the extraction cause you might
damage the adjacent restoration and even extract the wrong tooth.
5) Fracture of the crown
6) Fracture of the roots
7) Loss of the tooth: if you are excited about extraction don’t let the
tooth slips away because if you don’t find it around on the floor you
have to check if it is inside the t mouth. What will happen if he
inspires it? It will cause aspiration pneumonia and you should take
chest x-ray to check, this is a serious condition because the bacteria
the live in our oral cavity are really dangerous elsewhere and that’s
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 why the human bite is more dangerous than the dog bite. But if it
goes to the GI ”ingestion” it is not as serious as aspiration
8) Dislodgment of tooth into the antrum this is bad cause it will
lead to infection
9) Oro-antral communication: here you will injure the sinus and cause
communication with the oral cavity so when the pt drinks it will go
up to the sinus and its secretions go into the mouth. It has to be
treated by suturing or by oral surgeon depend on the severity of the
case. This is rare in children because the roots don’t reach up to the
sinus but might happen if the sinus had expanded to be close to the
roots apexes especially in premolars area.
10) Damage to soft tissue: for example if the elevator slips or the
temperature of the instrument is high especially if you are in hurray;
you took them form the autoclave and applied them immediately on
the pt
11) Damage to hard tissue: if you fracture any bone
12) Dislocation of the TMJ: it happens easily in children because the
articulare eminence isn’t high”big” enough to prevent it, do is could
happen if you press too long on the mandible. For correction just
open the pt mouth and put it back.
13) Hemorrhage: primary or secondary:
Primary: if you have systemic disease which predispose to it.
Secondary: usually due to infection or inflammation, in all cases you
have to stop it and you might to give antibiotics if it was caused by
infection
In some cases we use haemostatic agent especially with bleeders, we
place “surgicel” or “gel foam” it is very thin piece of gauze which has
haemostatic agent, eugenol, anti bacterial and sedative agent; we place
it inside the socket and leave it because it’s absorbable.
So it will help in clotting and minimize the infection.
14) Dry socket: it is infection of the bone due to poor blood supply
and healing and it’s painful. It is rare to happen in children because
they lack the predisposing factors like trauma for elevators,
smoking, and diabetes. The management is to apply local anesthesia
then irrigate with normal saline.
So you know what is “alveogel”? It has sedative agent, eugenol, anti
microbial agent “tetracycline” and analgesic component

Long term complications: loss of space, poor contact between the teeth
and you always consider space maintainer.
So you always need excellent knowledge prior to treatment, have a plane
to know what you are doing, know your limitation; if you can’t do it refer
it or consult.
After the extraction press the socket and apply the gauze, wait until the
primary haemostatic happens then tell him to bite on the gauze for 15
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min, don’t dismiss the pt unless you are sure that every thing is ok then
you give him the post operative instructions.

The end

I just want to say thanx to lamiya for the lap top and to every one who
helped me typing this lec and to shefa2

Done
by:
Muna Koro

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