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patients under the age of five may not be suitable for orthopantomographic imaging due to the behavioural requirements of this form of radiograph, but it can be useful for examining the overall dentition and the stage of dental development.

B.1.3  Consent

In many jurisdictions worldwide, consent for treatment concerning patients under the age of 18 falls to the patient’s parent or legal guardian. The consent process should nonetheless involve obtaining informed consent from all parties, taking care to explain the procedure, indications, risks, benefits, and alternatives to the patient as well as their carer. Patients under the age of 18 may be deemed to be ‘Gillick competent’; that is, sufficiently able to understand the treatment being provided and its attendant risks and expected outcomes. The surgeon must be well versed in local laws and regulations regarding medical treatment of minors and the consent process involved.

B.1.4  Local Anaesthetic

In paediatric patients, local anaesthetic serves primarily to manage intraoperative pain during dental extraction, but it also acts as an important behaviour-modification strategy in eliminating any external response or resistance to dental treatment. Local anaesthetic strategies in the paediatric population differ significantly from those used with adults:

●●Dose. The relative low body mass compared with adults corresponds to a lower total dose of local anaesthetic that may be administered. Whilst the dose per kilogramme of body weight remains the same between child and adult, the absolute volume of any given concentration of anaesthetic will be much lower.

●●Duration of Anaesthetic. Long-acting local anaesthetics are not recommended in younger paediatric groups. Uncontrolled lip biting after local anaesthetic administration can lead to significant soft tissue trauma and is commonly seen after the use of long-acting agents such as bupivacaine. Therefore, only short-acting agents such as lignocaine should be used in the paediatric patient, in order to avoid this complication.

●●Techniques. Due to the porous nature of maxillary and mandibular bone in children, buccal and palatal/lingual infiltration may be sufficient to obtain anaesthesia for deciduous dental extractions in patients under the age of six. Use of inferior alveolar nerve blocks may be required for the removal of mandibular teeth in patients older than this.

B.1.5  Use of Sedation

In addition to local anaesthetic, a ladder of anaesthetic interventions is available to improve a child’s tolerance of a dental procedure. Conscious sedation, employing nitrous oxide administered via a nasal hood, is commonly available in the dental clinic setting and is a safe method of obtaining patient comfort without loss of consciousness or pharyngeal and laryngeal reflexes. Oral sedation, intravenous sedation, and general anaesthesia may also be utilised, depending on the level of behaviour modification required and the complexity of treatment. Whilst a further discussion on the merits, indications, and techniques of sedation is outside the scope of this manual, provision of these services must be made by appropriately trained personnel, in a setting which is sufficiently prepared to manage any associated complications.

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Table B.1  Options for space maintenance after deciduous tooth extraction.

Band/crown-loop

Distal shoe

Lingual holding arch

Palatal/transpalatal arch

Nance appliance

Removable appliance

Bonded space maintainer

B.1.6  Extraction Technique

The extraction technique for deciduous extractions differs from that for adult teeth:

●●Generally, less force is required to rupture the periodontal ligament.

●●Adjacent teeth are more likely to be inadvertently luxated or avulsed if elevators or forceps are applied incorrectly.

●●Paediatric bone is more elastic than adult bone, and expansion of the socket is easier.

●●Root anatomy is more predictable (incisors and canines have straight, conical roots; deciduous molars have a mesial and distal root).

●●Deciduous tooth roots are thinner and root fracture is more likely.

●●Retrieval of fractured roots carries the risk of damage to the crown and follicle of the developing succedaneous tooth.

●●Submerged or ankylosed deciduous teeth in adults will almost always require surgical methods for extraction, due to fusion of thin roots to the underlying bone.

B.1.7  Outcomes Following Extraction

Extraction of a deciduous tooth generally occurs before that tooth has reached the appropriate timing for exfoliation. There are a number of potentially negative sequelae that may follow early loss of a deciduous tooth, including arch asymmetry, reduced arch length, ectopic eruption of permanent teeth, and midline discrepancies. In conjunction with specialist paediatric dentists, a clear plan must be put in place for space maintenance following tooth extraction, to facilitate continued normal dental development and avoidance of complications (Table B.1).

●●Premature loss of anterior teeth (incisors and canines) can cause loss of space due to a lateral shift of the other anterior teeth, causing a midline discrepancy. This is most pronounced if a primary canine tooth is extracted or lost early. Loss of space does not tend to occur after removal of a primary incisor, so long as the primary canine is fully erupted.

●●Premature loss of posterior teeth can cause distal movement of the primary canine and incisors, as well as mesial eruption of the first permanent molar. This space loss is greatest if the first permanent molar has not completed eruption, and tends to be worse in the maxilla than the mandible.

B.2  Techniques­ of Paediatric Dental Extraction

B.2.1  Deciduous Incisors and Canines

1)Difficulty Assessment. Deciduous incisors and canines are straight-rooted teeth. It is extremely rare to require surgical techniques for extraction of teeth in this category. Root

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resorption due to eruption of underlying permanent teeth generally reduces the amount of force required to extract a deciduous incisor or canine.

2)Consent. General risks of dental extraction apply. Damage to underlying permanent teeth is always a risk of deciduous tooth extraction and must be explicitly included in the consent process. Space maintenance plans should be included in the consent process.

3)Basic Equipment. Paediatric upper straight forceps are used for maxillary incisors and canines, and paediatric lower universal forceps for mandibular ones. A straight elevator should be available to expand the periodontal ligament prior to forceps placement.

4)Final Check. The tooth number and location must be confirmed on radiograph.

5)Local Anaesthetic. Infiltration of the buccal vestibule with localised palatal (for maxillary teeth) or lingual (for mandibular teeth) infiltration will provide sufficient anaesthesia for the soft tissue and periodontal ligament.

6)Positioning. The patient should be positioned lying almost flat, with the patient’s head and headrest slightly raised.

7)Elevation. A straight elevator should be applied to the mesial and distal areas of the periodontal ligament. Using a wheel-and-axle motion, the periodontal ligament should be gently expanded until a small amount of mobility is noted in the tooth. Care must be taken to elevate between tooth and bone only, and not against adjacent teeth. The thumb and finger of the nondominant hand should be used to support the alveolus of the tooth being extracted, to guide the application of force to the tooth socket only, and to prevent instrument slippage.

8)Delivery. The forceps should be applied to the cementoenamel junction. Initially, apical pressure is used to slide the beaks as deep on to the root as possible. Rapid, small clockwise–coun- terclockwise rotational movements should then be used to continue tearing the periodontal ligament. Finally, the buccal part of the crown should be rotated towards the midline.

9)Assessment. The tooth root should be assessed to ensure it has been removed complete. The socket must be examined for bleeding, alveolar bone fracture, or soft tissue trauma, which should be managed as appropriate. Instrumentation of the socket should be avoided, as the underlying permanent tooth may be damaged.

B.2.2  Deciduous Molars

1)Difficulty Assessment. Both maxillary and mandibular deciduous molars have a predominantly mesial and distal root configuration. Depending on the stage of dental development, there may be significant resorption of the tooth roots due to eruption of the underlying permanent tooth. This can increase the likelihood of root fracture during extraction. In general, root fracture is common during removal of a deciduous molar tooth.

2)Consent. General risks of dental extraction apply. Damage to underlying permanent teeth is always a risk of deciduous tooth extraction and must be explicitly included in the consent process. Space maintenance plans should be included in the consent process.

3)Basic Equipment. Paediatric upper molar forceps are used for maxillary molars, and paediatric lower molar forceps for mandibular ones. Adult forceps are not recommended for use in paediatric populations as there is poor adaptation of the forceps beaks to the teeth, increasing the risk of root or crown fracture. A straight elevator should be available to expand the periodontal ligament prior to forceps placement.

4)Final Check. The tooth number and location must be confirmed on radiograph.

5)Local Anaesthetic. Infiltration of the buccal vestibule with localised palatal (for maxillary teeth) infiltration is sufficient for maxillary teeth. For mandibular molars in patients under

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four years of age, buccal and lingual infiltration anaesthetic is sufficient for extraction. A combination of an inferior alveolar nerve block with localised buccal infiltration is required for mandibular teeth in patients over four years of age.

6)Positioning. The patient should be positioned lying almost flat, with the patient’s head and headrest slightly raised.

7)Elevation. A straight elevator should be applied to the mesial and distal areas of the periodontal ligament. Using a wheel-and-axle motion, the periodontal ligament should be gently expanded until a small amount of mobility is noted in the tooth. Care must be taken to elevate between tooth and bone only, and not against adjacent teeth. The thumb and finger of the nondominant hand should be used to support the alveolus of the tooth being extracted, to guide the application of force to the tooth socket only, and to prevent instrument slippage.

8)Delivery. The should be applied to the cementoenamel junction. Initially, apical pressure is used to slide the beaks as deep on to the root as possible. Slow, sustained buccolingual movements, with a predominant buccal force, should then be used to continue expansion of the socket. It is not uncommon to encounter fracture of one of the roots at this stage. Finally, the tooth should be delivered with a large buccal movement.

9)Assessment. The tooth root should be assessed to ensure it has been removed complete. Any remaining root fragments are likely to be loose in the socket, and can be gently removed with a straight elevator. The socket must be examined for bleeding, alveolar bone fracture, or soft ­tissue trauma, which should be managed as appropriate.

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