Difficult extraction today

Today I had a very difficult extraction case which I struggled with. I knew it would be from the preoperative xray and by looking at the patient. My recognition of the difficulty of cases is improving but I do find myself looking at most of the extraction cases and judging them as difficult. This is partly a reflection of my wary nature. I think it is useful to analyse the case properly beforehand and recognise the difficulties for the purpose of planning contingencies. I don't think that planning should produce fear of the procedure but instead reinforce that things can go wrong and that when they do you will be prepared for it. It is also useful to recognise when a case may beyond your skills and referral or guidance is warranted.

In this case, a lower 6 had curved roots and the patient had a massively thick jaw and tongue. The large tongue is always a difficulty with the administration of a IDN block. Getting the patient to relax their tongue is useful but not always possible. Holding a mirror at the injection site and pushing the tongue out of the way can give access to the site. Using the syringe over the ipsilateral molars can allow needle penetration without the barrel being pushed by the tongue. Once the tip of the needle is inside the tissues, you can safely swing the barrel of the syringe over to the other side and pushing it against the tongue to get the angle required, advance the needle into the tissues till bone is contacted. Alternatively, an Akinosi block can be used as this doesn't have the tongue as an obstruction.

At the end of the appointment I had my fingers on the buccal and lingual bone to "compress the socket" and I realised then how thick the buccal and lingual bone plate was. This is another thing I will keep an eye out for especially for large built males. The thickness of the bone plate determines the amount of expansion that the bone will undergo with force applied with thicker plates expanding less. The ratio of cortical bone to cancellous bone matters as well to expansion but is not possible to determine without raising a flap and removing bone but in general thicker bone will have thicker cortical plates. A lack of bone expansion means that any variation of root anatomy from straight will lock into the bone and be difficult to remove. Thick and dense bone is a dead giveaway that bone removal is required before applying force to the tooth. The dense and thicker the bone, the more I am tending to gutter further down towards the apex.

In this case, I sectioned the tooth pretty soon after starting. One thing I will question about my technique is that perhaps I should be rounding the buccal and lingual edges of the tooth which are normally sharp after sectioning the roots apart. This is because the root forceps curve around these edges and may contact them first. Stress may be concentrated and increase the risk of crown fracture. By rounding off the tooth structure that is normally at the mud buccal and lingual either side of the section line, it may take pressure off these weak spots and allow the forceps to seat properly on the root structure at the centre of the root.

Eventually I got the tooth out after repeatedly fracturing the tooth chasing it apically. After doing this a few times I knew that I should start a surgical removal but was too stubborn to do so. Having a rule or point in time when to decide when you proceed to a more involved procedure would be good to have before the procedure starts. In this case I may have decided prior to raise a flap once the root broke subcrestally. Once you make this rule, stick to it.

All in all, the appointment was an extremely tiring one for myself and the patient. It challenged me physically and mentally and I would hope that I would learn from the mistakes made and continue to recognise difficult cases but plan my attack a bit better in the future.