Part 12

Extraction of primary teeth

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 Extraction of primary teeth
The ideal tooth extraction is the painless removal of the whole tooth or tooth-
root, with minimal trauma to the investing tissue so that the wond heals
uneventfully and no postoperative problems are created.
Many oral surgical procedures are similar in adults and children and thus the
fundamental principles are no different. But there are certain, anatomic,
metabolic, and physiologic differences such as :
a. Bone is soft and elastic.
b. maxillary sinus is small and mandibular canal is lower in relation to the teeth.
c. Healing tissue resistance and rapid.
d. Better tissue resistance and greater remodeling capacity.
e. Drugs prescribing.
f. The time of the extraction is critical

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Indications for extraction of primary teeth
1. Decayed teeth not amenable to restorations.
2. Severe periodontal disease.
3. Orthodontic considerations.
4. Primary teeth with furcal involvement.
5. Severe periapical infection.
6. Interference of deciduous teeth with eruption of permanent
successor.
7. Teeth involved with eruption tumors.
8. Impacted and supernumerary teeth.
9. Over retained deciduous teeth.
10. Tooth involved in fracture.
11. Odontoclastic resorptive lesions.
12. Fractures of teeth, beyond repair.

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Contraindications
There is not absolute contraindication for extraction of teeth. The relative
contraindication are:
1. Acute stomatitis.
2. Acute narcotizing ulcerative gingivitis.
3. Acute dentoalveolar abscess.
4. Pericoronitis.
5. History of recent irradiation.
6. Blood dyscrasias.
7. Adrenal insufficiency.
8. Uncontrolled diabetes.
9. Patient on anticoagulants.
10. Severe debilitating diseases.
11. Hemoglobinopathies.

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Factors to be considered during extraction of primary teeth
1. Age of child.
2. Arch development.
3. Amount of resorption of roots of primary teeth.
4. Development of the underlying permanent teeth.
5. Presence or absence of successor.
6. Amount of bone over lying the permanent tooth bud.
An internal radiograph is essential prior to extraction to assess the above factors.

Technique of anesthesia:
1. Aspiration needles are used for most injections, these are 2cm. Or 2.5cm in length.
Long needles (3.0cm) are used for inferior alveolar nerve blocks. Fine needles
(gauge 30) are recommended for infiltrations and thicker (gauge 27) needles for all
other injections.
2. 2% lignocaine with 1:80000 adrenaline is the most recommended combination.
Prilocaine (3%) with felypressin (0.31 iu/ml) is the alternative in cases where
adrenaline is contraindicated.
3. Topical anesthetics to reduce the pain of injection may be used in patients if they do
not object to its disagreeable taste. Ethyl aminobenzoate or 15% ligocaine spray
may be used. It is advisable to wait for at least 4 min for the topical anesthetic to act
before starting the injection. 5
4. Site: due to the less density of bone and rapid diffusion, most of the areas can be
anaesthetized by infiltration except for inferior alveolar block. Thr lesser height of the ramus
in children can be compensated by inserting the needle a few mm nearer to occlusal plane
than adults.
< 6 years: below occlusal plane
6-12 years: at occlusal plane
>12 years: above occlusal plane
5. Child must be informed about the symptoms of local anesthesia either before giving the
injection or just after it. Wait at least 5 min before checking for anesthesia or starting the
procedure.

Precautions:
1. When using an infiltration technique, solution should be deposited slowly to avoid
pain by distention.
2. Injection into an infected region can lead to its spread. To avoid this, the injection
should be given well a way from the area of inflammation.
3. Disposable sharp needles should be used to avoid breakage and spread of
infection.
4. Parents should watch their child carfullt till the sensation returns to avoid biting
his/her lips or to burn the mucosa with hot foods.
5. The injection is given at the reflection of the labial\buccal mucosa with the
alveolus, avoiding the contact with bone to minimize pain. One ml of the
anesthetic solution is administered slowly over a period of 30 sec. it is not
necessary to administer a full dose of 1.8ml.
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Methods of tooth extraction:
Basically two methods of extraction are available. The first method, which is commonly
employed is the “forcep extraction”. This involves the removal of a tooth or tooth root
using a forcep, which is placed between the tooth and the bony soket wall. This method is
known as “intraalveolar method”.
The other method of extraction is to dissect the tooth or root from its bony attachments. This
technique is commonly called “surgical method” or “transalveolar method”
Primary tooth extractions are generally carried out with intraalveolar method.

Mechanical principles of extraction:

1. Expansion of the bony socket.
2. Use of lever and fulcrum to force a tooth out of the socket.

Tooth movement in extraction:

There are three possible movement by which tooth may be loosened.
1. Rotation along the long axis of the root. This movement is applicable to teeth with single,
circular roots. Most central and lateral incisors, a few canines, the palatal roots of upper
molars and many lower premolars can be extracted by this technique.
2. Lateral dislocation. This involves removal of all bonds on three sides of the tooth, together
with the breaking of the thin socket wall. This principle is applicable to any tooth, whether
single or multirooted. If the root is curved, it may be necessary to remove them in the 7
direction of the curvature.
3. Direct thrust towards the mouth of the socket. This is done with an elevator introduced
along the side of the root.

Specific consideration in extraction.

Local anesthesia:
• Maxilla: from birth to adolescence the bone of the maxiila remains relatively porous.
Hence, it permits the use of simple infiltration techniques to secure anesthesia. This remains
until the permanent molars appear. The cortical bone of the posterior maxilla becomes
progressively denser. This bone necessitates the use of nerve block as it serves as barrier to
diffusion of the anesthetic agents.
• Mandibule: as the child approaches ado;escence the entire bony structure of the mandible
becomes quit dense. So it needs block and the height of the occlusal plane of mandibular
teeth should be used as a guide to indicate the point of needle insertion.

Extraction of primary maxillary anterior teeth:

After adequate anesthesia, the soft tissue attachment may be separated with an elevator
or a periosteal elevator. For anterior teeth, the tooth is gripped with the forceps in a
labiopalatal direction.
Rotational movements and a labiopalatal motion are used to extract the tooth.

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Extraction of primary maxillary molars:
primary maxillary molars differ from there permanent cunterparts in that the
height of contour is closer to CEJ and the root tend too diverge.
These roots are farther weakened by the eruption of the permanent tooth.
Hence its quite common one to encounter root fractures in primary maxillary
molars.
The extraction can be done with a universal maxillary forceps. Palatal movement
is initiated first, followed by alternating buccal and palatal motion with slow
continuous force.
Extraction of mandibular anterior:
The mandibular primary and the permanent central and lateral incisor and
canine, as well as mandibular premolars are all single rooted.
Hence rational movement with alternating labial and lingual movement will
Enable the teeth to be removed easily.

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Extraction of mandibular molar
When extracting mandibular molars, the dentist should support the mandibular so as to
prevent injury to the TMJ.
A no. 151 forcep used to extract the tooth
The tooth id is gripped with the beaks and alternating buccal and lingual movement is
used to remove the tooth.
Maxillary primary molars may have extremely flared roots; extreme care should be
taken while applying force. For extracting mandibular primary molars, no. 151 is
used. Use of cowhorn forcep is an inappropriate choice for primary mandibular
molars.
After and instruction.
 When tooth has been extracted the socket should be inspected for any loose
fragment of bone and necessary socket cleaning is performed.
 The socket should then be squeezed in order to reduce any distortion of supporting
tissues.
 Patient is instructed to bite firmly on the gauze-pad until the blood clot is formed.
 Parents should be told about the effect of anesthesia in order to prevent biting of
anesthetized tissue inadvertently.
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 Medications may be required.
Complications in exodontics:
Operative complication:
1. Fracture of the tooth:
This is very common, especially when the forceps is used extraction. Devitalized teeth
are particular prone to fracture. Sudden movement the child can also cause
fracture. In either case, the root fragment should then remove. However, small
uninfected fragments within the bone are well tolerated.
2. Injuries to adjacent or succedaneum teeth:
This includes loosening or avulsion of adjacent teeth, generally attributed improper
technique. While extraction deciduous tooth, trauma may occur if the underlying
permanent successor. This is especially true if a forceps is forced through the
furcal area of the deciduous molar. Application of a proper technique can prevent
this mishap.
3. Gingival and mucosal lacerations:
The improper bracing of instruments can lead to accidental perforations or lacerations
of the oral tissues. Sudden movement of patient may also cause such lacerations.
The wound should be cleaned of foreign material and irrigated with isotonic
saline. The tissues should then be approximated layer by layer.
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4. Hemorrahage:
Mucosal lacerations may cause excessive hemorrhage. Excessive hemorrhage may also
be seen in systemic disease like blood dyscrasias, thyroid disorders, diabetes or
use of anticoagulants. In majority of the cases, hemorrhage can be controlled by a
pressure pack using gauze. In special cases, bone wax or haemostatic sponge may
have to be used.
5. TMJ problems:
A considerable a mount of tension is placed on the TMJ ligaments during mandibular
molar extractions. This can result in post-operative pain and limitation of jaw
movement. This can be avoided by supporting the mandibule and by using rubber
biteblocks.
Post operative complications:
1. Hemorrhage:
Slight oozing of blood after extraction for several hours is considered normal but
persistent bleeding which cannot be controlled by pressure packs or the use of an
ice bag needs definitive.

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Management:
In such cases, a through general evaluation should be preformed. The excess clots
should be removed and a small amount of local haemostatic agent may be applied
when it is not possible to approximate the tissue, a gelatin sponge should be
packed in the socket if the bleeding still does not stop, and a specialist should be
summoned for help.
2. Swelling:
After any surgical procedure, the appearance of simple inflammatory edema is
common. However, laceration of soft tissue, trauma to the periosteum,
careless retraction of flaps, irritation by bony fragments are the most
common causes excessive edema.
Warm isotonic saliva mouth rinses every 3 to 4 hrs. are helpful in resolving the
edema.
3. Pain:
Post extraction pain longer than 3 to 5 days is suggestive of infection. It usually
involves the alveolar bone (alveolar osteitis or dry socket)

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3. Dry socket:
Alveolar osteitis is a condition in which there is a loss of blood clot from socket.
Suppuration and a foul odour accompany the severe radiating pain. The
symptoms start 3-5 days after extraction.
Therapy is directed towards relief of pain. Curettage is strictly contraindicated
as this predisposes the patient to infection and also destroys previous
attempts of healing.
Local therapy consists of warm saline mouth rinses or a dilute solution of H2O2.
Topical applications of an obtundent (eugenol) or a local anesthetic
(benzocaine) are useful.

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