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Jani Mira U et al.: Minor Oral Surgery in Pediatric REVIEW ARTICLE

Minor Oral Surgery in Pediatric Dentistry

Jani Mira U1, AbhayMani Tripathi2, Sonali Saha3, Gunjan Yadav4, Kavita Dhinsa5, Apurva Mishra6 1 -Post Graduate Student, Sardar Patel Post Graduate Institute Of Dental And Medical Sciences , Uttar Pradesh. 2-Professor And Head, Sardar Patel Post Graduate Institute Of Dental And Medical Sciences, Uttar Pradesh. 3-Professor, Sardar Patel Post Graduate Correspondence to: Dr. Jani Mira U, Sardar Patel Post Institute Of Dental And Medical Sciences, Uttar Pradesh. 4- Professor, Sardar Patel Post Graduate Institute Of Dental And Medical Sciences, Uttar Pradesh. 5-Reader, Sardar Patel Graduate Institute Of Dental And Medical Sciences, Uttar Pradesh. Post Graduate Institute Of Dental And Medical Sciences, Uttar Pradesh. 6-Senior Lecturer, Contact Us: www.ijohmr.com Sardar Patel Post Graduate Institute Of Dental And Medical Sciences, Uttar Pradesh. ABSTRACT

Minor oral surgery comprises of those surgical procedures, which can be comfortably completed by an operator in not more than 30 minutes. Minor surgical procedures will include carrying out complicated surgical extractions (a combination of sectioning, mucoperiosteal flap reflection, removal prior to the use of a forceps or elevators), elimination of small in the oral cavity, which are in the hard or soft tissues. It also comprises of oral surgical procedures of short duration which are carried out under local . Oral surgical procedures in children are endeavors that demand expertise and skill. They involve unique consideration regarding behavior management, growth, and development, developing dentition, wound healing, and postoperative care. KEYWORDS: Odontogenic , Unerupted and Impacted teeth, Supernumerary teeth, Lesions of the . detailed history of the general health status and medical AINTRODUCTIONASSSAAsasasss history of the patient is taken, which may or may not be related to the chief complaint, the management of the Pediatric patients deserve quality dental care of the patient, and the outcome of the treatment. The brief highest standards. Thus, in this respect, a pedodontist medical history questions / interview should include a strives to establish positive treatment experiences during detailed history of the following: an individual’s developmental years to help shape a 1. Cardiovascular disorders include hypertension, favorable outlook towards future dental and medical rheumatic heart disease, myocardial infarction, care.1 ischemic heart disease, angina, valvular septal defect, and congestive cardiac failure. Pedodontist can do a large number of surgical 2. Diseases of the include bronchial interventions in the cases.. The term "Minor oral surgery" asthma, chronic obstructive pulmonary disease, refers to smaller operations and include removing pleuritis, bronchitis, pneumonia, and upper wisdom teeth, impacted teeth, and severely broken-down respiratory tract infections. teeth, as well as apicectomies, biopsies and other 2 3. Neurologic conditions such as and past history of procedures. head injury epilepsy, hemiparaplegia(also known as Brown-Sequard’s hemiplegia, Brown-Sequard’s PRE- AND POST-OPERATIVE paralysis, hemiparaplagic syndrome), and any CONSIDERATIONS TAKEN FOR medications taken for the same. 4. Endocrine system disorders including thyroid MINOR ORAL SURGERY disorders, adrenal pheochromocytoma, diabetes, and Metabolic management of children for surgery is more multiple endocrine neoplasias. complex and different than adults. That required special 5. Hematological disorders like anemias, leukemia, consideration like caloric intake, fluid and electrolyte hemophilia, platelet count abnormalities, etc. and the management, and blood replacement. Complete last available blood reports pertaining to the management of the pediatric patient for minor oral condition. surgery is accomplished by expertise and experience in 6. The bleeding tendency after the trauma the management of young patients.3 7. Tuberculosis, syphilis, viral hepatitis, herpes, and other sexually transmitted Infectious diseases that Taking Proper Personal And Family History: A adversely affect outcomes of surgery. detailed history of the personal habits as well as patient’s 8. Peptic ulcer, acidity problems, vomiting, and family taken. It include age, general health status, diarrhea are Gastric disorders. medical ailments (epilepsy, cardiac disorders, diabetes, 9. Glomerulonephritis, patients on dialysis, renal bleeding disorders, and tuberculosis), cause, and age at 4 failure, and nephrotic syndrome are Renal the time of death of any deceased member is recorded. . Taking Proper Past/Present Medical History: A 10. Liver Disorders such as alcoholic liver disease,

How to cite this article: Jani MU, Tripathi AM, Saha S, Yadav G, Dhinsa K, Mishra A . Minor Oral Surgery in Pediatric Dentistry. Int J Oral Health Med Res 2019;6(4):29-32.

International Journal of Oral Health and Medical Research | ISSN 2395-7387 | NOVEMBER-DECEMBER 2019 | VOL 6 | ISSUE 4 29

Jani Mira U et al.: Minor Oral Surgery in Pediatric Dentistry REVIEW ARTICLE

hepatitis, and cirrhosis. It includes the red blood cell count, white blood cell 11. Autoimmune disorders including systemic lupus count, differential white blood cell count, platelet erythematosus, scleroderma, and patient long term number, and a description of blood smear.4 corticosteroid therapy.

12. Psychological disorders and treatment taken for the VARIOUS MINOR SURGICAL same. 13. Digestive system disorders including loss of appetite, PROCEDURES loss of weight, excessive thirst (polydipsia), and Minor surgical procedures will include carrying out the frequent urination (polyuria). elimination of small lesions in the oral cavity, which are 14. Drug allergy. in the hard or soft tissues. They include 15. Illness and trauma related to birth and childhood. 16. Detailed history of previous hospitalization, blood 1) Management of Odontogenic infections: Infections transfusions, and surgeries. of orofacial region may be odontogenic or non 17. Any medications (current/past) were taken. odontogenic in nature, and the most of odontogenic infections are caused by the endogenous bacteria present Any of the above conditions can alter the patient’s in the oral cavity. Odontogenic infections include response to surgical procedure, and influence both the periapical, and periodontal infections. In dentistry, anesthetic, and surgical management of the patient as odontogenic infections are one of the most difficult to 4 well as postoperative recovery and wound healing. treat and manage. These infections may range from low Dental Evaluation: It is important to perform a to high grade, and welllocalized infections that require only minimal treatment to severe life-threatening facial preoperative clinical and radiographic evaluation of the 6 dentition as well as soft tissues. Due to the presence of space infections. developing tooth follicles Surgery involving the Principles of treating the : To predict and of young patients is complicated. Careful pathways of spread of infections and to drain these spaces evaluation and treatment planning carried out using proper knowledge of anatomy, anatomical landmarks and radiographs, tomography, cone beam computed vital structures of the face and neck is necessary. The tomography, and/or 3-D imaging techniques. It is cause should be removed (i.e. extract the tooth, open & important to minimize the negative / adverse effects of extirpate the ). To drain pus incision & Drainage 3 surgery on the developing dentition. performed. For treating the infections antibiotics use.7 Investigations: 2) Management of Unerupted and Impacted teeth: A) Radiological Examination Most commonly impacted teeth is third molars followed 1. Conventional radiography by permanent maxillary canines. Visual inspection, a) Intraoral Radiographs palpation, and radiographic examination are used for b) Extraoral Radiographs early detection of an ectopically erupting canine, and  Orthopantomogram assessed abnormal angulation of cuspids. The treatment of choice is extraction of the impacted canines.3,8  Lateral oblique view of mandible  Posteroanterior view or Water’s Position 3) Management of Supernumerary teeth: The  Posteroanterior view of mandible additional teeth in to the normal dentition. Result from  Lateral cephalogram view disturbances during the initiation and proliferation stages  Posteroanterior view of skull of dental development. Supernumerary teeth can occur in  Lateral skull view both primary or permanent dentition. Mesiodens is a  Submentovertex view (Jug Handle view)— supernumerary tooth present in the midline between the 2. Specialized imaging two central . Followed by the maxillary  Magnetic Resonance Imaging area, known as a paramolar tooth. Complications of supernumerary teeth can include delayed the eruption of  Sialography the permanent tooth or displaced the tooth from its  Angiography 5 original position, crowding, resorption of adjacent teeth,  Arthrography formation (), pericoronal space B) Routine Hematological Investigations: The use of infection, and crown resorption. To prevent complete blood investigations before any minor surgery complications early diagnosis and treatment are is important for evaluation to determine fitness for pre- important. Depending on the size, shape, and number of anesthetic, anesthesia, and identify patients at high risk of supernumeraries Surgical management will vary. 9 postoperative complications. 4) Lesions of the Newborn: Complete Blood Count: Complete blood count (CBC) help to determine the nutritional status, detect the a) Epstein’s pearls, dental lamina , and Bohn’s presence of infection, detect/rule out bleeding disorders, nodules: Epstein pearls are whitish-yellow cysts. It and decide whether the patient’s immune response will be occurs on the and roof of the mouth in a newborn adequate to facilitate postoperative recovery. baby. Dental lamina cyst, also known as a

International Journal of Oral Health and Medical Research | ISSN 2395-7387 | NOVEMBER-DECEMBER 2019 | VOL 6 | ISSUE 4 30

Jani Mira U et al.: Minor Oral Surgery in Pediatric Dentistry REVIEW ARTICLE

of newborns, are raised nodules on alveolar ridges of iv. A sharp rise in the temperature, particularly if infants, derived from the rests of the dental the patient is having antibiotics. lamina which consist of keratin producing epithelial 2. Where the involved compartment is inaccessible, lining. Bohn’s nodules are found on the buccal and such as the pterygomandibular and lateral lingual aspects of the ridge, away from the midline. No pharynxgeal spaces, and in the case of submasseteric treatment is required, as these cysts disappear during the and infratemporal fossa infections where it may be first three months of life.3 impossible to elicit the classic signs of suppuration. b) Congenital of the newborn: Congenital 3. With Ludwig’s angina and other serious and rapidly epulis is a proliferation of cells occurring on the alveolar evolving infections of the floor of the mouth ridge at birth. The tumor is typically pedunculated and and upper neck, immediate incision and drainage of varies in size from 0.5 cm to 9 cm. The is typically the relevant tissue compartments is essential.13,14 painless and does not increase in size. Small lesions may 10 7) Apicoectomy: regress over time. Treatment is surgical excision. Apicoectomy is the surgical procedure for the root apex c) Eruption cyst (eruption hematoma): An eruption to treat the apical infection. It is the removal of the apical cyst is an eruption hematoma, and bluish color portion of the root and curettage of periapical necrotic, swelling occurs on the soft tissue over an erupting tooth. granulomatous, inflammatory or cystic lesions.15 Management includes the cyst roof may be drained with its fluid to allow spontaneous tooth eruption.11 8) Marsupialization and Enucleation: d) Mucocele: is also termed as mucous Epithelium lined may be treated in one extravasation cyst, mucous retention cyst of the oral of two ways: mucosa. Local trauma cause a ruptured salivary a) By marsupialization, which may be performed after gland duct result in Mucocele. The most common site removal of part of the lining or after enucleation of inner surface of the lower , on the buccal mucosa, on the whole cyst sac. the anterior ventral , and the floor of the mouth. b) By enucleation and primary closure3 Some mucoceles spontaneously resolve on their own. 3 a) Marsupialization: Where a substantial area of Others are chronic and require surgical removal. mucoperiosteum covered alveolar process is expanded a 5) Management of Anatomical Structural anomalies: simple window may be made, removing an oval of the mucosa, bone, and underlying cyst wall. The opening a) / restrictive mandibular lingual must be made as large as possible compatible with the frenum: Ankyloglossia, also known as tongue-tie, may preservation of adjacent structures, and the cavity packed. decrease the mobility of the tongue tip. It is caused short, thick lingual frenulum. Ankyloglossia can affect speech. About two-thirds of the cyst lining on average is left in For example, the problem in making sounds such as s, z, situ by these techniques, which raises the possibility that t, d, l, j, sh, ch, th, dg. surgical treatments for more serious disease may be overlooked if the whole cyst ankyglossia include frenectomy. 3 sac is not submitted to the pathologist. Some form a single large cyst with the more b) Maxillary frenum: The high labial frenulum often obvious tumor tissue in one or more nodules. In all cases attaches to the center of the upper lip and between two before the cyst is packed the cavity is irrigated and maxillary cental incisors. The maxillary labial frenal aspirated dry, and the inner surface of the lining inspected attachment can be classified with respect to its anatomical for mural nodules. If one is seen it should be removed for insertion level. section.16  Mucosal  Gingival b) Enucleation: Where enucleation of the cyst lining is  Papillary undertaken but the previous infection in a large cyst  Papilla penetrating suggests that primary closure of the wound would not be successful, a flap is turned in, and the cavity packed. The Surgical removal of maxillary midline frenum to correct cavity heals with granulation tissue until epithelialization presence of midline diastema followed by orthodontic 12 is complete. Reduction in size takes place after treatment to correct midline diastema. marsupialization with retention of the deeper part of the 6) The surgical drainage of Abscesses: lining. Loose packing after enucleation is also used as a secondary measure where the wound breaks down after Immediate incision and drainage are required: an attempt at primary closure.16 1. Where there are signs of pus beneath the deep fascia: i. A localized dusky redness is appearing in the 9) Natal and general redness of the firm swelling. Natal teeth are present at birth. Neonatal teeth are erupt ii. A localized area of tenderness over the center within 30 days. Etiology includes the superficial position of the swelling. of the tooth germ, hormonal stimulation, and heredity iii. Pitting edema in the middle of a previously eruption. Associated syndromes a) chondroectodermal firm swelling. dysplasia or Ellis-van Creveld syndrome, b) Mandibulo-

International Journal of Oral Health and Medical Research | ISSN 2395-7387 | NOVEMBER-DECEMBER 2019 | VOL 6 | ISSUE 4 31

Jani Mira U et al.: Minor Oral Surgery in Pediatric Dentistry REVIEW ARTICLE

oculo-facial dyscephaly with hypotrichosis or Oral Surgery and Oral . Reference manual 2015; Hallermann-Streiff syndrome, c) pachyonychia 37(6): 279-288. 4. Anil MN. Art of Diagnosis. In Anil MN, editor. Textbook congenital or Jadassohn-Lewandowski syndrome d) Riga rd fede syndrome. Treatment includes etraction of natal and of Oral and Maxillofacial Surgery, 3 edition. New Delhi: Jaypee Brothers Medical Publishers; 2012. p. 5-18. neonatal teeth.17 5. https://en.wikipedia.org/wiki/Dental_radiography 6. Seow W. Diagnosis and management of unusual dental POSTOPERATIVE MEDICATION abscesses in children. Australian Dental Journal 2003; 43(3): 156-168. Postoperative antibiotic such as a combination of 7. Dodson T, Perrott D, Kaban L. Pediatric maxillofacial amoxicillin 500mg and clavulanic acid 125mg should be infections: A retrospective study of 113 patients. Journal of the drug of choice for soft tissue management and should Oral and Maxillofacial Surgery 1989; 47(4): 327-330. be given for 5-7 days. And NSAIDS with potent 8. Manne R, Gandikota SC, Rao JS, Reddy MRH, Anche S. analgesics and anti-inflammatory properties such as a Impacted Canines: Etiology, diagnosis, and orthodontic combination of cyclo group + paracetamol + management. Journal of Pharmacy and Bioallied Sciences serratiopeptidase should be prescribe for 3-5 days with 2012; 4(2): S234–S238. the addition of multivitamin and PPI (proton pump 9. Seward GR, Harris M, Megowan DA. Unerupted and inhibitors). impacted teeth. In Seward GR, Harris M, Megowan DA, editor. Killey and Kay’s Outline of Oral Surgery, part-1, 2nd edition. England: British Library Catalogaing in CONCLUSION Publication; 1987. p. 52-92. 10. Eghbalian F, Monsef A. in the newborn, Minor surgery can be performed in a variety of settings review of the literature and a case report. Journal including primary care offices, hospital ambulatory of Pediatric Hematology/Oncology 2009; 31(3): 198-199. clinics, and the operating room. Previous research has 11. Moore UJ. Treatment of cyst of the jaw. In Moore UJ, recommended that a hospital-based minor surgery unit is editor. Principles of Oral and Maxillofacial Surgery, 6th more cost - effective than procedures undertaken in either edition. New Jersey: John Wiley & Sons, Ltd., Publication; the operating room or in general practice. Furthermore, a 2011. p. 225-243. prospective trial published in 2008 showed that the 12. AL- Najjim A, Sen P. Are Upper Labial Frenectomies In quality and safety of minor surgery performed by Children Aged 11 And Under Appropriate? Is It Time To specially trained hospital physicians is higher than those Change Practice And Agree Guidelines? Faculty Dental Journal 2014; 5(1):14-17. carried out in primary care practices. 13. Siqueira JF. Microbiology and Treatment of Acute Apical In past years, surgeons have often hesitated to perform Abscesses. Clinical Microbiology Reviews Journal 2013; minor surgery in children <10 or 11 years of age. 26(2): 255–273. However, a significant proportion of our pediatric 14. Seward GR, Harris M, Megowan DA. Pyogenic Infection of the Soft Tissues. In Seward GR, Harris M, Megowan population younger than this underwent successful DA, editor. Killey and Kay’s Outline of Oral Surgery, Part- procedures in the ambulatory clinic. Minor surgery is 1, 2nd edition. England: British Library Catalogaing in feasible in children as young as five or six years of age Publication; 1987. p. 121-174. and can be an appropriate and positive treatment option. 15. Anil MN. Minor Oral Surgical Procedures. In Anil MN, editor. Textbook of Oral and Maxillofacial Surgery, 3rd Hospital outpatient clinics may become the preferred edition. New Delhi: Jaypee Brothers Medical Publishers; vehicle for the delivery of minor surgery services. These 2012. p. 138-165. clinics, regularly available, offer the ability to form 16. Seward GR, Harris M, Megowan DA. Soft-tissue swellings personal relationships with staff and surgeon, which may of the oral mucosa. In Seward GR, Harris M, Megowan contribute to the high degree of patient satisfaction. DA, editor. Killey and Kay’s Outline of Oral Surgery, Part- 1, 2nd edition. England: British Library Catalogaing in REFERENCES Publication; 1987. p. 297-312. 17. Wray D, Stenhouse D, Lee D, Clark AJE. Introduction. In 1. https://www.eastgeorgiaoralsurgery.com/pediatric-and- Wray D, Stenhouse D, Lee D, editor. Text book of General st adolescent-oral surgery/(Last Accessed-05/11/2019) and Oral Surgery, 1 edition. London: Churchill 2. https://wellingtoncosmeticclinic.co.nz/orthodontic- Livingstone; 2003. p. 3-4. cosmetic-dentistry/minor-oral-surgery/ (Last Accessed- 05/11/2019) 3. American Association of Oral and Maxillofacial Surgeons. Source of Support: Nil Conflict of Interest: Nil Guidelines on management considerations for Pediatric

International Journal of Oral Health and Medical Research | ISSN 2395-7387 | NOVEMBER-DECEMBER 2019 | VOL 6 | ISSUE 4 32