See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/323678166

Evaluation of a new ergonomic position for the operator/clinicians for the

extraction of mandibular right posterior molar teeth

Article · January 2018

DOI: 10.4103/jioh.jioh_259_17

CITATIONS READS

4 335

5 authors, including:

Srikanth Gadicherla Kalyana Pentapati

Manipal Academy of Higher Education Manipal Academy of Higher Education
28 PUBLICATIONS 59 CITATIONS 129 PUBLICATIONS 636 CITATIONS

SEE PROFILE SEE PROFILE

Evit Rajan John

University of Texas Health Science Center at Houston
5 PUBLICATIONS 4 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Relationship of Oral Hygiene Practices and Dental Caries among School Children of Sullia Taluk, Karnataka, South India View project

Incidence of second primary lesion after surgical excision of indexed first primary lesion View project

All content following this page was uploaded by Evit Rajan John on 05 July 2018.

The user has requested enhancement of the downloaded file.

6SLQHPP

,661

œÕÀ˜>ÊœvÊ
-RXUQDORI,QWHUQDWLRQDO2UDO+HDOWK‡9ROXPH‡,VVXH‡-DQXDU\)HEUXDU\‡3DJHV

˜ÌiÀ˜>̈œ˜>Ê
"À>Êi>Ì Ê
˜ÌiÀ˜>̈œ˜>Ê-œVˆiÌÞʜvÊ*ÀiÛi˜ÌˆÛiÊ>˜`Ê œ““Õ˜ˆÌÞÊ i˜ÌˆÃÌÀÞ


6œÕ“iÊ£äÊÊUÊÊÃÃÕiÊ£ÊÊUÊÊ>˜Õ>ÀއiLÀÕ>ÀÞÊÓä£n

ZZZMLRKRUJ
 Original Research

Evaluation of a New Ergonomic Position for the

Operator/Clinicians for the Extraction of Mandibular Right
Posterior Molar Teeth
Srikanth Gadicherla1, Kalyana Chakravarthy Pentapati2, Anupam Singh1, Evit Rajan John1, Komal Smriti3
Department of 1Oral and Maxillofacial surgery and 2Public Health Dentistry, Manipal College of Dental Sciences, Manipal
Academy of Higher Education, Manipal, Karnataka, India, 3Department of Oral Medicine and Radiology, Manipal College of Dental Sciences,
Manipal Academy of Higher Education, Manipal, Karnataka, India

Abstract
Aims: This study aimed to assess and compare the feasibility of this new ergonomic position (2’o clock or left rear position) with conventional
(12’o clock) position in the exodontia of the mandibular right posterior (MRP) teeth (second and third molars) among right‑handed operators.
Materials and Methods: An observational questionnaire study was conducted among dental students, faculty, postgraduates, and private
practitioners. A self-administered questionnaire which evaluated eight domains, namely, posture of the operator, visibility of the teeth being
extracted, fatigue to the operator, accessibility to the teeth being extracted, grasp of the molar teeth, delivery of force, retraction of cheeks, and
difficulty in extraction were distributed to the operators. All the items in the questionnaire were based on visual analog scale. Results: A total of 63
operators have completed the study out of which 60.3% were females. The mean age of the participant was 25.63 ± 6.41 years. All the parameters
have shown that the mean scores were significantly higher for 2’o clock than 12’o clock positions (P < 0.001), respectively. Conclusion: The
new operator position (2’o clock) was more acceptable among the dentists for the extraction of MRP molar teeth.

Keywords: 12’o clock position, 2’o clock, ergonomics, extraction, teeth

IntroductIon Essentially, there are two schools of thoughts for performing

Exodontia is the most common technique that all dentists are
taught to perform in dental school and used by most general
clinicians in their practice. The positions of the dental chair,
patient, and operator are crucial for carrying out tooth extraction
effectively.[1] The correct posture of the operator is essential not
only to have good visibility and accessibility of the oral cavity
but also to allow the operator to have the utmost control over the
force being delivered to the patient’s tooth through the forceps.[1]
The appropriate working position would lead to an acceptable
posture which in turn reduces fatigue, physical strain, and
onset of musculoskeletal disorders for operators. Work‑related
musculoskeletal disorders in dental care providers are reported
in the literature with symptoms affecting various regions of the
body including neck, shoulders, upper extremities (elbows,
hands, wrists, and fingers), and back.[2] Ergonomic studies had
established that safety and management should begin on time
before musculoskeletal injuries become persistent.[3]
Access this article online
Quick Response Code:
Website:
www.jioh.org
the exodontia based on the operator stature, namely, operator
either practicing exodontia in seated or orthostatic postures.[4]
Dentists usually stand during exodontia, and the correct position
allows them to provide stability and support and to keep the
wrists and elbows straight enough to deliver the force with the
arm and shoulder, and not with the fingers or hand.
Extraction in the lower arch requires the backrest of the dental
chair and the patient positioned in a more upright position so
that when the mouth is wide open, the mandible and occlusal
Address for correspondence: Dr. Komal Smriti,
Department of Oral Medicine and Radiology, Manipal College of Dental
Sciences, Manipal Academy of Higher Education,
Manipal- 576 104, Karnataka, India.
E-mail: komalmds1@gmail.com
This is an open access article distributed under the terms of the Creative Commons
Attribution‑NonCommercial‑ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non‑commercially, as long as the author is credited and the
new creations are licensed under the identical terms.
For reprints contact: reprints@medknow.com

How to cite this article: Gadicherla S, Pentapati KC, Singh A, John ER,
DOI: Smriti K. Evaluation of a new ergonomic position for the operator/clinicians
10.4103/jioh.jioh_259_17 for the extraction of mandibular right posterior molar teeth. J Int Oral Health
2018;10:36-9.

36 © 2018 Journal of International Oral Health | Published by Wolters Kluwer ‑ Medknow

 Gadicherla, et al.: New ergonomic position for dental extraction

plane are positioned in a parallel line with the floor.[5] A the exodontia of MRP teeth of the single patient [Figures 1
right-handed operator conventionally stand at the right rear and 2]. Before performing the exodontia with new proposed
position (11’o clock) or direct rear position (12’o clock)[6] for position, a brief interactive personalized session was conducted
exodontia of the mandibular right posterior (MRP) teeth. It is by the principal investigator to familiarize the operator
fair to believe that these positions provide good visibility and positions and contents of the questionnaire. Any clarifications
maximal accessibility to the oral cavity for MRP molar teeth. and queries were clarified before conducting the study.
However, many operators have reported reduced accessibility
The inclusion criteria were operators who practiced right-handed
while extracting the MRP molar teeth with these positions.
dentistry for exodontia of MRP teeth, especially molars in
Hence, to overcome this problem of reduced accessibility, the
standing position. The exclusion criteria were operators with
operator tends to bend forward which results in unnecessary
a history of myalgia, osteoarthritis, operated wrist of the right
curvature of the spine or slumping of shoulders leading to
hand with guarded prognosis, and operators preferring to do
physical strain during the procedure and also the operator
the exodontias in sitting posture. Permission to conduct the
tends to lean over the patient and put his/her face close to
study was obtained from the Institutional Ethics Committee
the patient’s mouth. To overcome this problem faced due to
of Kasturba Hospital, Manipal (IEC 488/2016). Prior informed
awkward postures, a new ergonomic position was proposed
consent was sought from patients and the operators. All
which involves the operator to stand at 2’o clock position
the analyses were done using SPSS version 18 (SPSS Inc,
while performing extraction of teeth in MRP region.[7] Hence,
Ill, Chicago, USA). P < 0.05 was considered statistically
we aimed to assess and compare the feasibility of this new
significant. Data were evaluated for normality using Shapiro–
ergonomic position (2’o clock or left rear position) with
Wilk test. Comparison of mean VAS scores was done using
conventional (12’o clock) position in the exodontia of the MRP
Wilcoxon signed‑rank test between both the operator positions.
teeth (second and third molars) among right-handed operators.

materIalS and metHodS reSultS

A total of 63 operators have completed the study out of which
This observational questionnaire study was conducted among
60.3% were females. The mean age of the participant was
dental students, faculty, postgraduates, and private practitioners
25.63 ± 6.41 years. A total of eight parameters were evaluated
in the field practice area of Manipal College of Dental Sciences,
on VAS scores for both the operator positions (12’o clock
Manipal from January to April 2017. A self-administered
and 2’o clock). All the parameters have shown that the mean
questionnaire which evaluated eight domains, namely, posture
scores were significantly higher for 2’o clock than 12’o clock
of the operator, visibility of the teeth being extracted, fatigue
positions (P < 0.001, respectively). This implied that the 2’o
to the operator, accessibility to the teeth being extracted, grasp
clock operator position was more acceptable for the eight
of the molar teeth, delivery of force, retraction of cheeks, and
domains that were evaluated for exodontia of MRP molar
difficulty in extraction were distributed to the operators. All
teeth [Table 1].
the items in the questionnaire were based on visual analog
scale (VAS) which ranged from “not acceptable” (0) to “highly
acceptable” (10). The questionnaire was pilot tested to evaluate dIScuSSIon
the feasibility. Each operator was asked to evaluate both the Working posture of the dentist is the most debated subject
proposed 2’o clock and conventional 12’o clock positions in when principles of ergonomics were applied to the field of

Figure 1: Operator position for conventional exodontia of mandibular Figure 2: New proposed position for exodontia of mandibular right
right posterior molar teeth posterior molar teeth

Journal of International Oral Health ¦ Volume 10 ¦ Issue 1 ¦ January-February2018 37

 Gadicherla, et al.: New ergonomic position for dental extraction

Table 1: Comparison of mean scores for the 12’o clock and 2’o clock positions
Domains Mean±SD 95% CI df P
12’o clock 2’o clock Difference
Posture of the operator 6.14±1.50 8.22±1.08 2.08±1.95 1.59-2.57 62 <0.001; significant
Visibility of the teeth being extracted 5.25±1.56 9.33±0.84 4.08±1.74 3.64-4.52 62 <0.001; significant
Fatigue to the operator 5.83±1.71 7.92±1.83 2.10±2.57 1.45-2.74 62 <0.001; significant
Accessibility to the teeth being extracted 5.41±1.64 9.24±1.01 3.83±1.76 3.38-4.27 62 <0.001; significant
Grasp of the molar teeth 5.98±1.48 8.48±0.98 2.49±1.63 2.08-2.90 62 <0.001; significant
Delivery of force 6.17±1.60 8.21±1.32 2.03±2.09 1.50-2.56 62 <0.001; significant
Retraction of cheeks 6.27±1.82 7.71±1.30 1.44±2.44 0.83-2.06 62 <0.001; significant
Difficulty in extraction 5.75±1.75 8.41±1.03 2.67±1.51 2.29-3.05 62 <0.001; significant
SD: Standard deviation, CI: Confidence interval, df: Degree of freedom

dentistry. The specific consideration is justified by the widely
documented and recognized fact that posture is the key to
prevent the musculoskeletal disorders. The dentist’s posture
evolved from the orthostatic posture to a seated posture,
especially on the account of adopting the concept of four
hand dentistry.[8] Orthostatic posture is often adopted despite
its many disadvantages, especially while performing the
exodontia.[9]
The essence of ergonomics has often been overlooked
while performing minor oral surgical procedures which
progressively lead to various musculoskeletal disorders as
well as compromises on the quality of work being delivered.
Work‑related musculoskeletal disorders are considered as
one of the major health hazards for the dentists[10,11] and have
been attributed as the leading cause for early retirement of
the dentists.[12]
It is observed that when performing minor oral surgical
procedures such as tooth extraction, dental graduates especially
in their early career; when they start, dental clinics usually
stand and perform exodontia. However, inexperienced
operators may require more duration to complete the
procedure, which involves unfavorable standing posture
particularly for exodontia of MRP teeth with conventional 12’o
clock position. A recent study had reported a high prevalence
of knee disorders in students performing alveolar surgeries in
an unfavorable standing posture.[13]
Exodontia of MRP teeth requires a controlled force. The
operator tends to stoop or bend their shoulders when standing
at the conventional position for gaining visibility and
accessibility for exodontia of MRP teeth which might lead
to neck pain or back pain and compromises on the ability to
deliver the controlled force. To an extent by the posture in the
conventional position might lead to breakage of root apices,
increased appointment time, elevated unwanted stresses on the
mandible or even can affect the operator due to the awkward
posture.
A previous report proposed the use of 2’o clock position
for exodontia of MRP molar teeth in orthostatic and seated
positions. However, in our study, we evaluated this new
operator position only in orthostatic position as it was widely
followed in our institution. To date, there were no studies
which compared the conventional 12’o clock position with
the 2’o clock position.[3] Hence, a comparison of the results
with previous studies was not possible.
We have compared the results of the 12’o clock position with
2’o clock position on various parameters pertaining to the
operator’s ergonomics as well as the difficulty in extraction in
carrying out exodontia of MRP molar teeth in standing posture.
In ergonomics, both the parameters, i.e., posture and fatigue,
had a P < 0.001 which signified that the operators were more
comfortable in performing the exodontia of MRP molar teeth
with a 2’o clock position rather than the conventional 12’o
clock position. The operators reported muscle fatigue of much
lesser degree while working at 2’o clock position. Our results
indicated that 2’o clock position was easier, acceptable, and
ergonomic for the operator for the exodontia of MRP molar
teeth.
Improving the ergonomics for the delivery of dental services
while accounting for working conditions in dental offices
enhances the well-being and safety of patients, staff, and
practitioners. It might be difficult for the well‑established
clinician/operators to adopt to this new working position.
We propose that this 2’o clock position can be incorporated
into the curriculum so that the dental trainees can be
trained to this ergonomic and acceptable posture, without
compromising on the quality of work. The ideal posture of
an operator should give effective working conditions (access
and visibility) as well as the corporeal and psychosomatic
well‑being during the execution of the clinical procedure. A
suitable posture is not a comfort, and it does not need major
expenses but reorganizing the way of working. The strength
of this study was that the same operators have evaluated
both the positions in the same individuals for the extraction
of teeth. Further studies have to be done to evaluate the
long-term effect of this new position which can also be
assessed in seated position.
concluSIon
Our results indicated that new ergonomic position (2’o clock
position) was easier, acceptable, and ergonomic for the operator

38 Journal of International Oral Health ¦ Volume 10 ¦ Issue 1 ¦ January-February 2018

 Gadicherla, et al.: New ergonomic position for dental extraction
for the exodontia of MRP molar teeth in comparison to the
conventional position.
Declaration of patient consent
The authors certify that they have obtained all appropriate
patient consent forms. In the form the patient(s) has/have
given his/her/their consent for his/her/their images and other
clinical information to be reported in the journal. The patients
understand that their names and initials will not be published
and due efforts will be made to conceal their identity, but
anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
referenceS
1. Hupp JR. Principles of routine exodontia. In: Hupp JR, Ellis E,
Tucker MR, editors. Contemporary Oral and Maxillofacial Surgery.
6th ed. St. Louis, Missouri: Mosby Elsevier; 2014. p. 88-118.
2. Finsen L, Christensen H, Bakke M. Musculoskeletal disorders among
dentists and variation in dental work. Appl Ergon 1998;29:119‑25.
3. Ranney D. Work‑related chronic injuries of the forearm and hand: Their
specific diagnosis and management. Ergonomics 1993;36:871‑80.
Journal of International Oral Health ¦ Volume 10 ¦ Issue 1 ¦ January-February2018
View publication stats
4. Pîrvu C, Pătraşcu I, Pîrvu D, Ionescu C. The dentist’s operating
posture – Ergonomic aspects. J Med Life 2014;7:177-82.
5. Saker M, Ogle OE, Dym H. Complex exodontia and surgical
management of impacted teeth. In: Fonseca R, editors. Oral and
Maxillofacial Surgery. 2nd ed., Vol. 1. Philadelphia: Elsevier; 2009.
p. 185-211.
6. Robinson PD. Tooth Extraction: A Practical Guide. 1st ed. Oxford:
Wright; 2000. p. 34-5.
7. Kumaresan R, Pendyala S, Dhanavel J. The most compatible position
of the operator for mandibular right posterior teeth extraction. Plast
Aesthet Res 2016;3:257-8.
8. An Introduction to Ergonomics: risk Factors, MSDs, Approaches, and
Interventions – A Report of the Ergonomics and Disability Support
Advisory Committee (EDSAC) to Council on Dental Practice (CDP).
Available from: https://www.cdn.shopify.com/s/files/1/1171/2566/files/
topics_ergonomics_paper_2.pdf. [Last accessed on 2017 May 14].
9. Anghel M, Argesanu V, Talpos-Niculescu C, Lungeanu D.
Musculoskeletal disorders (MSDs) consequence of prolonged static
posture. J Exp Med Surg Res 2007;4:167-72.
10. Brown J, Burke FJ, Macdonald EB, Gilmour H, Hill KB, Morris AJ,
et al. Dental practitioners and ill health retirement: Causes, outcomes
11.
and re-employment. Br Dent J 2010;209:E7.
Hill KB, Burke FJ, Brown J, Macdonald EB, Morris AJ, White DA, et al.
Dental practitioners and ill health retirement: A qualitative investigation
into the causes and effects. Br Dent J 2010;209:E8.
12. Burke FJ, Main JR, Freeman R. The practice of dentistry: An assessment
of reasons for premature retirement. Br Dent J 1997;182:250-4.
13. Yi J, Hu X, Yan B, Zheng W, Li Y, Zhao Z, et al. High and specialty-related
musculoskeletal disorders afflict dental professionals even since early
training years. J Appl Oral Sci 2013;21:376-82.
39