1. Oral Surgical Consideration in Children
Dr Lamis Elsharkasi

2. Consideration in mind
Surgery performed on paediatric patients involves a number of special considerations unique to this population.
These include:
preoperative evaluation;
a. medical
b. dental
2. behavioural considerations
3. growth and development
4. developing dentition
5. pathology
6. perioperative care

3. Consent Informed consent Before any surgical procedure
Informed consent must be obtained from the parent or legal guardian.

4. Preoperative evaluation
Dental
It is important to perform a thorough clinical and radiographic preoperative evaluation of the dentition as well as extra-oral and intra-oral soft tissues.
Radiographs can include intra-oral films and extra-oral imaging

5. Preoperative evaluation
Medical evaluation:
Important considerations in treating a paediatric patient include obtaining:
Thorough medical history
Obtaining appropriate medical and dental consultations,
Anticipating and preventing emergency situations,
Being prepared to treat emergency situations

6. Preoperative evaluation
Behavioural considerations
Behavioural guidance of children in the operative and perioperative periods presents a special challenge. Many children benefit from modalities beyond local anaesthesia and nitrous oxide/oxygen inhalation to control their anxiety

7. Odontogenic infection
Odontogenic infections In children, odontogenic infections may involve more than one tooth and usually are due to carious lesions, periodontal problems, or a history of trauma.
Untreated odontogenic infections can lead to pain, abscess, cellulitis, and difficulty eating or drinking. In these children, dehydration is a significant consideration; prompt treatment of the source of infection is imperative.

8. Odontogenic infection
Most odontogenic infections can be managed with pulp therapy, extraction, or incision and drainage
Infections of odontogenic origin with systemic manifestations [e.g., elevated temperature, facial cellulitis, difficulty in breathing or swallowing, fatigue, nausea, require antibiotic therapy.

9. Odontogenic infection
Severe but rare complications of odontogenic infections include cavernous sinus thrombosis and Ludwig’s angina. These conditions can be life threatening and may require immediate hospitalization with intravenous antibiotics, incision and drainage, and referral/consultation with an oral and maxillofacial surgeon.

10. Differences between primary and permanent teeth
Size:
Primary teeth are smaller in every dimension compared with their permanent counterparts.
Shape:
The crown of primary teeth are more bulbous than the crowns of permanent teeth.
The roots of primary molars are more splayed than the roots of permanent teeth
The furcation of primary molar roots is positioned more cervically than the permanent teeth

11. Differences between primary and permanent teeth
Physiology:
The roots of primary teeth resorb naturally, whereas in the permanent dentition, resorption is normally a sign of pathology.
Support:
The bone of the alveolus is much more elastic in the younger patient

12. Extraction of anterior primary teeth
Most primary and permanent maxillary and mandibular central incisors, lateral incisors, and canines have conical single roots. In most cases, extraction of anterior teeth is accomplished with a rotational movement, due to their single root anatomies.

13. Extraction of primary molar teeth
Maxillary and mandibular molars Primary molars have roots that are smaller in diameter and more divergent than permanent molars.
Root fracture in primary molars is not uncommon due to these characteristics as well as the potential weakening of the roots caused by the eruption of their permanent successors.
Prior to extraction, the relationship of the primary roots to the developing succedaneous tooth should be assessed.

14. Extraction of primary molar teeth
In order to avoid inadvertent extraction or dislocation of or trauma to the permanent successor, pressure should be avoided in the furcation area or the tooth may need to be sectioned to protect the developing permanent tooth.
Extractions are accomplished by using slow continuous palatal/lingual and buccal force allowing for the expansion of the alveolar bone to accommodate the divergent roots and reduce the risk of root fracture.

15. Extraction of primary molar teeth
When extracting mandibular molars, care should be taken to support the mandible to protect the temporo-mandibular joints from injury.

16. In case of root fracture!!!
Fractured primary tooth roots
The presence of a root tip should not be regarded as a positive indication for its removal.
The dilemma to consider when managing a retained primary tooth root is that removing the root tip may cause damage to the succedaneous tooth, while leaving the root tip may increase the chance for postoperative infection and delay eruption of the permanent successor.
Radiographs can assist in the decision process.

17. In case of root fracture!!!
Expert opinion suggests that if the fractured root tip can be removed easily, it should be removed.
If the root tip is very small, located deep in the socket, situated in close proximity to the permanent successor, or unable to be retrieved after several attempts, it is best left to be resorbed.
The parent must be informed and a complete record of the discussion must be documented.
The patient should be monitored at appropriate intervals to evaluate for potential adverse effects.

18. Extraction of permanent molars
Upper permanent molars are removed using forceps , its extracted by expanding the socket in buccal direction
The use of palatal expansion is not as successful. It may cause palatal root fracture.
Lower permanent molar are extracted by moving the forceps in buccal direction to expand the socket and then to move it in a figure-of-eight direction to expand the socket buccally and palatally

19. Managing impacted canine
Ectopic maxillary canines occur in about 2% of the population, 85% of these canines are palatal
An impacted canine can frequently resorb adjacent incisor roots with a risk of 48%

20. Managing impacted canine
Panoramic radiogragh
Position of the canine an asymmetries
When appears large on x-ray …..palatal position
Parallax technique
Two views of the area taken with x-ray tube in two different positions
Cone beam computed tomography

21. Managing impacted canine
Early treatment:
Extraction of the primary canine gives a >70% chance depending on these factors:
Early detection <12 years
Adequate space for permanent canine to erupt
Mild/moderate canine displacement
Once primary canine has been extracted, the tooth position should be reassessed at 1 year. If no improvement is noted, other treatment options should be considered.

22. Managing impacted canine
Late treatment:
Treatment options:
Leave and monitor
Remove impacted canine +/_ space closure with orthodontic appliance
Expose the canine and align it with orthodontic appliances
Transplant the canine

23. Soft tissue surgery Labial fraena.
A prominent midline fraenum in the maxilla may be present in association with diastema
Excision of a midline maxillary fraenum is often requested as a part of orthodontic treatment plan
This procedure is simple and performed under local anaesthesia
Before surgery x ray should be taken to exclude any other causes of diastema ( supernumerary tooth)
Frenectomy should be performed after the eruption of permanent canine as the diastema may close spontaneously when these teeth erupts.

24. Soft tissue surgery Lingual fraena
A prominent lingual fraenum should be excised if it is interfering with speech or oral hygiene.

25. Soft tissue surgery Mucocoeles
Most common in the second decade of life, although they occasionally occur in younger children including new-born
If cause functional or emotional problems they should be excised.
An incision is made next to the lesion, which is removed by blunt dissection under the epithelium.
Ranula is better to be removed by a specialist

26. Soft tissue surgery Incisional biopsy Excisional biopsy
Are performed to confirm a diagnosis by removing part of the lesion.
Excisional biopsy
Small lesion of oral mucosa are removed by excisional biopsy, which involves the removal of an ellipse of tissue including the lesion
All tissue surgically removed should be placed in a solution of 10% saline.

27. Suturing
Resorbable sutures should be used to close soft tissue wounds in children whenever possible; however, in mobile structures such as the tongue and the lips these may lost shortly after surgery as their knots may be less secure than those obtained with black silk