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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

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Srikanth Gadicherla Kalyana Pentapati


Manipal Academy of Higher Education Manipal Academy of Higher Education
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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


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

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

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Journal of International Oral Health ¦ Volume 10 ¦ Issue 1 ¦ January-February2018 39

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