A thought on extraction planning

I would argue that the preoperative planning and post operative complication management are aspects of surgery that are just as important to learn as the procedure itself. One thought that has come to mind lately about planning an extraction is to start planning with the patient, not the tooth. Look at their age, gender, medical status. Young, females will have lower density bone on average and extractions that at a glance appear difficult may prove simpler. As a guide, as we grow older, over the age of 25, our bone will increase in density and the teeth will become more brittle due to increased mineral content in the dentine. After the age of 50, we are dealing with glass set in concrete.

When planning from the xray, I like to imagine what would happen with the tooth if we were dealing with a dry skull. If the periodontal ligament was gone, would the tooth drop out from gravity? If so, it is likely to be a straight forward extraction. If not, then there are tooth or bony undercuts that are holding that tooth on. To an extent, the bone in the maxilla and anterior mandible can expand to allow teeth that are locked in to be removed but largely what we are doing when we luxate teeth and apply forcep pressure is stretching and severing the periodontal ligament. If the tooth won't drop out in a dry skull, often what we need to do is make modifications to the structures to allow this to happen and allow an unimpeded path of withdrawal.

This may involve sectioning the tooth, removal of the crown, removal of bone. Without these strategies, severing of the periodontal ligament alone will not result in the extraction of the tooth and excessive forces will cause something to break be it the tooth, the buccal bone or the jaw.