SPECIAL CONSIDERATIONS FOR ORAL SURGEY IN PEDIATRIC PATIENTS- GROUP B.pptx

SPECIAL CONSIDERATIONS FOR ORAL SURGERY IN PEDIATRIC PATIENTS- GROUP B.pptx

1. SPECIAL CONSIDERATIONS FOR ORAL SURGERY IN PEDIATRIC PATIENTS GROUP B

2. Introduction General Considerations; Preoperative, perioperative and postoperative. Recommendations and Management of various conditions Infections Exodontia( Erupted, Unerupted/Impacted teeth Maxillofacial fractures Emergency management 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. 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

11. Recommendations and Management.

12. 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

13. Contraindications for exodontia: Bleeding disorders Acute infection – stomatitis Herpetic stomatitis Acute pericementitis Acute dentoalveolar abscess Acute cellulitis Malignancy Teeth getting irradiation Diabetes mellitus

14. 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

15. Impacted Canines 2 nd 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 2/3 rd of root formation of incisor Allow erupted primary mesiodens to shed

16. Mesiodens

17. 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.

18. 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

19. 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.

20. 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).

21. 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

22. 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

23. 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.

24. 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.

25. 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

26. 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

27. 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

28. 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

29. 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.

30. 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

31. Pediatric Oral and Maxillofacial Pathology

32. 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

33. 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

34. 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

35. Commonly seen soft tissue pathologic conditions: mucocele, ranula, fibroma, and pyogenic granuloma. Lingual and labial frenectomies. Soft tissue Lesions

36. 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

37. 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.

38. Treatment: Reassure parents Disappear during the first 3 months of life.

39. 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.

40. 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’

41. AAPD. Management Considerations for Pediatric Oral Surgery and Oral Pathology, 20 2 0. Cawson R.A. and Odell E.A. Essentials of OralPathology and Oral Medicine. 8 th Edition. Churchill Livingston Publishers. 200 8 . McDonald and Avery Shoba Tandon REFERRENCES

42. THANK YOU