A case of dense bone during extraction

A male patient of age 59 presented to the oral and maxillofacial surgery department with a fractured and carious tooth #36. Tooth was fractured mesiodistally and was extending sub-gingivally separating crown into buccal and lingual cusps. This was the initial difficulty. 

Extraction Procedure Overview: The extraction of the tooth presented a challenging scenario, primarily attributed to the initial condition of the tooth, the patient's age, and anatomical factors. The tooth exhibited a mesiodistal fracture, which extended subgingivally, leading to the separation of the crown into distinct buccal and lingual cusps. This subgingival extension posed an initial difficulty, which required a careful approach. 

Initial Crown Fracture: To address the subgingival extension and facilitate the extraction, an intentional crown fracture was performed using forceps. This step allowed for better access and manipulation of the tooth during the extraction process.

Furcation Management: A straight elevator was strategically placed in the furcation area, and a wedging technique was employed to break the furcation. The application of controlled wedging forces aimed to create a separation and weaken the connection between the roots and surrounding bone, making the subsequent extraction steps more manageable.  

Mesial Root Removal: The mesial root was successfully removed using a straight elevator, taking advantage of the previous crown fracture to aid in the process. This portion of the extraction proceeded relatively smoothly. 

Challenges with Distal Root Removal: The distal root, however, presented a greater challenge. Initial attempts to remove it using a straight elevator were unsuccessful. The difficulty arose due to several factors, including increased bone density, a thin periodontal ligament (PDL) space, and potentially the patient's age, if it falls within a category where dense bone becomes more prevalent. 

Impact of Bone Density and Age: In older patients, especially those over the age of 40, dense and sclerosed bone can be encountered, particularly in the lower teeth. This dense bone can pose a significant challenge during extractions, as it resists luxation and increases the risk of tooth fracture. In contrast, younger patients often have more elastic and expandable bone, which generally eases the extraction process. 

Adaptation and Technique: To overcome the difficulty presented by the dense bone, a Cryer was employed to remove interradicular bone in the area surrounding the distal root. This technique allowed for better access and visibility, facilitating the subsequent removal of the distal root. It's worth noting that the removal of the distal root was more challenging than the mesial root, emphasizing the impact of the anatomical and patient-specific factors on the extraction difficulty. 

Contributing Factors to Difficulty: In this particular case, multiple factors contributed to the overall difficulty of the extraction. These included the dense bone on the distal side of the tooth, the poor compliance of the patient due to anxiety, and the initial fractured crown, which necessitated careful manipulation to ensure a successful extraction. 

In conclusion, the extraction was a complex procedure due to the specific circumstances surrounding the tooth's condition and the patient's age. The extraction process required a combination of strategic techniques and adaptability to overcome the challenges posed by the fractured crown, dense bone, and anatomical factors. 

This case was done with Dr. Muhammad Ahmed, at Farooq Hospital Westwood Branch, Lahore.