wvr ^ Columbia Wini)itx^itv \^^2^ in tfje Citp of J^eto gorfe ' C< £^ g>£f)ool ot ©ental anb (2^ral ^urgerp J^eference Hibrarp V Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/manualofdentalsuOOcole MANUAL OP DENTAL SURGERY AND PATHOLOGY. BY ALFRED COLEMAN, L.R.C.R, F.R.C.S. EXAM. L.D.S., ETC., SENIOR DBSTAL fiURUEON AND LECTURKR ON DENTAL SUROERY TO ST. B ARTHOLO.M U VV' HOJJPITAI, ; SENIOR DENTAL SURGEON AND LECTURER ON DENTAL SUROERV TO THE DENTAL HOSPITAL OF LONDON ; ME.MBER OF BOARD OF EXAMINERS IN DENTAL SURGERT, ROYAL COLLEGE OF SURGEONS ; FORMERLY PRESIDENT ODONTOLOGICAL SOCIETY OF GREAT BRITAIN. THOROUGHLY REVISED AND ADAPTED TO THE USE OF AMERICAN STUDENTS AND PRACTITIONERS. BY THOMAS C. STELLWAGEN, MA.,M.D.,D.D.S. PROFESSOR OF PHYSIOLOGY AT THE PHILADELPHIA DENTAL COLLEGE. P H I L A D E L P II I A : HENRY C. LEA'S SON& 1882. CO Entered according to Act of Congress, in the year 1882, by HENRY C. LEA'S SON & CO., ill the Office of tlie Librarian of Congress. All rights reserved. COLLINS, I' K I N r E K PREFACE TO THE AMERICAN EDITION. In introducing Mr. Coleman's 3Linual of Dental Surgery raid Pathology to the American profession the [iretiice furnished by tlie antlior rendei's it nnnecessarv for the editor to say more tlian will suffice to indicate very briefly his own share in its preparation for publication. The care which Mr. Coleman has bestowed upon liis work has left but comparatively few additions to be supplied. In no direction, perhaps, has the ingenuity of the American mind been more actively exercised than in the [iroductlon of an immense variety of instruments for the use of the dental surgeon. The difficulty experienced by the student in making proper selections from these lias seemed to justify the insertion of a special chai)ter devoted to their choice. A chapter on the present greatly improved methods of crown- ing teeth, has been added in view of this being generally performed by the operative dentist, and because of its bearing U[>oii the efforts now made for the ])reservation of the natural teeth and roots. Throughout the work have been inserted many notes descriptive of certain modes of treatment demanded by the peculiarities of our climate, or indicative of the latest and most approved systems of operating adopted on this Con- tinent. To accommodate the one hundred and twelve added illustra- tions, delineating some three hundred and twenty instruments and appliances, an increase in the size of the page has been iv PREFACE TO THE AMERICAN EDITION. rendered neeessnr}'. The original text has been preserved with but few alterations, and all additions, amounting to about f)ne hundred pages, have been distinguished b}^ inclusion in brackets [ ]. In conclusion, the editor desires to acknowledge his indebt- edness to Drs. James W. White and Wilbur F. Litch for their assistance in [)reparing this work for publication. No. 1637 Chestnut Street, Philadelphia, February, 1882. PREFACE. If illustration Avere wanted to show that immense advances have been made in tlie science and practice of Dental Surgery during the last tliirty or forty years, no better one could be fur- nished than the circumstance that most of the leading works on the subject at the commencement of that period comjire- hended, and within very modest limits, all its branches, viz. : Dental Anatomy, Physiology, Surgery, Pathology, Therapeu- tics, Materia Medica, and often even Mechanics. The establishment, in this and several other countries, of a defined and systematic course for the student of Dental Science, including distinct courses of lectures u[)on Dental Anatomy and Physiology, Dental Surgery and Pathology, and Dental Me- chanics, Ijas, perhajis more than anything else, led to a demand for sejiarate and more complete treatises on these several depart- ments. In some of these subjects this want has been coujpletely sup- plied, and the Dental Student can have nothing more to desire than the recent admirable treatise on Dental Anatomy, Human and Comparative, wliich has appeared from the hands of my talented colleague, Mr. C. S. Tomes. Another subject, viz.. Dental Mechanics, has been separately and successfully treated upon in the manual of Mr. Oakley Coles, and the English student desirous of fuller information can obtain the same in his own language, in " A Practical Treatise on Mechanical Dentistry," by Dr. Joseph Richardsox, of Ohio, U. S. VI PREFACE. On the subject of Dental Surgery— and to my lot has follen the privilege of lecturing tliereon at the largest Medical School in London consecutivel}' for fifteen years — it can hardly be said that any work perfectl}- suitable as a text-book has yet been produced. The excellent works of Mr. John Tomes, and of that gentleman in conjunction with Mr. C. S. Tomes, which have been so much employed and valued for that pur[)Ose, include also Human Dental Anatomy and Physiology, which by many, and especially the general medical student, whose requirements I have endeavored to bear in mind, may not be needed. On the other hand^ Mr. Salter's much appreciated work, though chiefly confined to Dental Pathology and Surgery, is, as the author states, "a digested collection of all my previous essays and papers, arranged in the foi-m of chapters; and several more chapters have been added to }>reviously published matter," rather than a systematic treatise upon the subject. * It is therefore hoped that the present work may supply a want which I believe to exist, although I cannot venture to presume that it will satisfy the requirements of the student as fully as the work of Mr. C. S. Tomes accomplishes its object; nevertheless, I trust that the large amount of experience which has fallen to my lot, as a consequence of holding hospital ap- pointments for nearly a quarter of a century, niay not have been lost upon me, and that the results may in these [tages be rendered profitable to others. One of my chief desires has been to make the work as sys- tennitic as possible, associating under the same head a variety of subjects wiiich bear upon one another, rather than isolating them under distinct chapters, and to avoid as much as possible the recording of cases, even though rare and interesting, which could not be considered appro[)riately under any [)roper classi- lication. In attempting to make the work a jiractical treatise, I have laid njyself under heavy obligation to those who have so kindly PREFACE. Vll assisted me. To Mr. C. S. Rouers, the demonstrator at the Dental Hospital of London, my best thanks are due for the chief contents of the pages devoted to the descri^jtion of tillino; with cohesive gold. To Messrs. C. Ash & Sons, of London, my warmest thanks are due for the valuable loan of some 250 illus- trations of instruments, appliances, etc. ; as they are also to the eminent practitioners by whom many of the latter were in- vented, and whose iiiimes I have endeavored always to insert in the foot-notes referring to them. To the Council of the Odontological Society I am indebted for permission to copy the illustrations which have appeared m my papers published in their " Transactions." To Mr. iSToBLE Smith I owe much for tlie pains and skill that he has besto\ved upon the original woodcuts which illustrate the work. To very many authors I am largely indebted for material collected from their works, which, I fear, I have on some occasions, omitted to acknowl- edge. Finally, I am under heavy obligations to Mr. E. Har- rison, barrister-at-law, for his kindness in undertaking the tedious and uninteresting work of revising my pages. A. C. CONTENTS. CHAPTER I. PAGE The First Dentition. Order and Periods of Eruption. Xorm'il and Ab- normal Conditions occurring during Teetliing 17 CHAPTER II. Irregularities in the Temporary Teeth. Diseases of the Temporary Teeth. The Second Dentition • 38 CHAPTER III. Irregularities in the Permanent Teeth, in Size, in Form (Odontomes), in Number, in Position — Class I. Accidental and Avoidable (Fractures of the Jaws) 54 CHAPTER lY. Irregulai-itiesin the Permanent Teeth in Position, continued — Class II. Con- genital and Unavoidable ... ..... 88 CHAPTER V. • Injuries to the teeth. Concussion, Dislocation, Fracture . . . .108 CHAPTER YI. Dental Caries. Description of the Disease, Microscopical Appearances. Theories of Dental Caries . . . . . . . . .114 [ C H A P T E R Y 1 1 . Selection of Instruments ......... 134] CHAPTER YIII. Treatment of Dental Caries (Anticipation and Prevention), by Excision, by Stopping, Filling, or Plugging. Pi'eparation of the tooth for Filling, Materials Employed, and the Processes of their Manipulation . . IGl X CONTENTS. CHAPTER IX. PAOE Treatiiu'iit of Dental Carios, coiitimu'd. Dllliciilties and Complications UK-t with in the OiK-ratlon of Filling Tc-etli ...... 21(; C H A P T I<: Ft X . Pi-rioilontitis. Synijitoms, Pathology, and Treatment .... 235 CHAPTER XI. Xeeroiis. Absorption of Permanent Teeth. Exostosis .... 2.')0 [CHAPTER XII. Fitting Artificial Crowns to Roots of Natm-il Teeth .... 257] CHAPTER XIII. Extraction of Teeth, General Directions. Extraction of Individual Teeth 264 CHAPTER XIV. Extraction of Roots of Teeth, with the Forceps, with the Elevator, etc. Extraction of Temporary Teeth ........ 290 CHAPTER XV. Difficulties and Complications occurring in Extraction, due to Malformed Teeth, Contraction of the Jaws, Impacted Teeth, Alveolar Hemon-hage, etc 302 C H iV P T E R XVI. Aneesthesia, History of, by Nitrous Oxide Gas, by Ether, by Chloroform . 3l;> CHAPTER XVII. Tiie Replantation and Transplantation of Teeth ..... 345 CHAPTER XVIII. Congestion of the Gums. Salivary Calculus. Ulcerations of the Gum. Necrosis of the Jaws .......... Sii'.i V 11 A PTER XIX. Cicatrices closinif the Jaws ........ 37<» CONTENTS. XI CHAPTER XX. PAOE Tumors of the (Jiiins mid upuu the Jaws . . . . . . . 372 CHAP T J-: 11 XXI. Uuntigerous Cysts . . . . . . . . . . .379 C H A r T E R X X I I . Diseases of the Antrum .......... 38C C H A P T E R XXIII. Nervous and Mnscuhir Affections dependent upon Dental Irritation . . 391 INDEX 399 LIST OF ILLUSTRATIONS. FIO. 1. 2. 3. 4, 5. 6. [9. 10. [11 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. [28, 29. 30. The temporary teeth of the right side in the upper and lower jaws Dental pocket hineet ....... Upper secondary temporary molar with four fangs Lower second temporary molar with three fangs Gemination of a temporary lateral incisor and cuspidatus of the lowe jaw . . . . . . Upper jaw of a child in which the lateral incisors arc absent . Lower jaw of a cliild in which all the incisors are absent Upper jaw containing a supernumerary lateral incisor on the right sidi Protrusion of the superior incisors (Dental Cosmos) Chin retractor as applied ..... Another ibrm of chin retractor .... Uj^per jaw with portions of the roots of temporary central incisor: exposed ....... Lower jaw with one root fully and one partially exposed Upper maxilla with portions cut away to exhibit the developing per manent teeth ...... Upper permanent teeth of the left side Lower permanent teeth of the right side Permanent teeth of unusually large dimensions Permanent teeth of unusually small dimensions Honeycombed teeth of the upper jaw .... Syphilitic teeth in upper and lower jaws as they appear when recently erupted ....... Syphilitic teeth in upper and lower jaws which have been erupted some time . ... Supernumerary permanent tooth of the most common type Supernumerary tooth not unirecpiently met with in the region of the upper central incisors ..... Three specimens of gemination .... Supernumerary teeth in the upper jaw of a } outh Su])ernumerary bicuspid of the upper jaw, riglit side . L^pper jaw in which the lateral incisors have not been erujited The positions of the developing permanent teetli and the fangs of the temporary teeth (White) ..... Side view of the jaw of a cliild with permanent teetli forming Lower jaw in which tlu; permanent central incisors have been crupti'd behind the temporary central incisors .... PACE 19 26 39 39 39 40 40 40 40] 41 41] 42 42 45 49 50 54 54 57 58 58 58 61 61 62 64] 65 67 XIV LIST OF ILLUSTRATIONS. no. PAOB ol. Tlie condition toriiu'd partially nndcrliung . . , .67 [32. Improssion c'\ip for wax, upper jaw ....'. 68] [33. Impression rup lor wax, lower jaw ..... 68] [34. Impression cup for plaster, lower jaw . .... G9] [35. Impression cup for plaster, upper jaw .... 69] SG. Plate adapted for pressing out the central incisors . . .70 37. Plate adapted for drawing inwards the front teeth of the upper jaAV . 73 38. Right central incisor of the upper jaw erupted at an angle to the dental arch from want of space . . . , .73 [39. The half hitch . . . . . . .'75] [40. The square knot . . . . . , .7.5] [41. The surgeon's knot ....... 75] [42. The clove hitch . . . . . . .75] [43. Drawing a tooth forward into the arch by an elastic ligature . . 75] [44. Rings cut from rubber tubing ...... 75] [45. McQuillen's cap to prevent occlusion of the teeth (Dental Cosmos) . 7G] [46. McQuillen's bar for drawing teeth forward (Dental Cosmos) . 76] [4 7. A method of drawing a tooth into position by an elastic ligature (Dental Cosmos) . . . . . . -7'] [48. Flagg's method of tying ligature for torsion . . . • '^'] [49. A case of torsion and retraction of central incisoi's by a plate with pins and elastic ligatures (Dental Cosmos) .... 78] [50. Guilford's torsion apparatus ...... 79] [51. Mode of applying the above ...... 79] [52. Represents position of teeth before treatment by Guilford's apparatus 8(»] [53. Represents position of teeth after treatment by the same . .81] [54. Represents peculiar formation of teeth in Avhich the same treatment can be followed . . . ,. . . .81] 55. Fracture of the lower jaw treated by means of a metallic cap . 83 5C. A'ertical fracture of the lower jaw between the left euspidttus and first bicus]>id . . . . . . . .84 57. Ada]jtation of the fractured parts l)y a plaster cut . . .84 58. Gunning's interdental splint for fractures of either jaw . . 85 .^9. Hammond's splint in situ . . . . . .86 60. Well-developed' upper jaw in a youth aged about twelve years . 89 61. luijK'rfectly-develojjcd up])er jaw with irregular dental arch. The lateral incisors art; bitt«'n over by the lower ciispiduti . . 90 62. Imf)erfcctly-develo])ed up])er jaw, and when; the dental arch assumes the V-shaped form . . . . . . .91 63. Imperfectly and ill-developed u])per jaw, a case suital^lc for trt'atmcnt by expa)ision of the dental arch . . . . .92 64. CofTin's method for expanding the contracted dental arch liy means of a divided ))late and sjiring formed of pianoforte wire, the back teeth heing capj)e 114 'IIG ;ii7 ;ii8 ;ii9 ;f2o, il21, ;i22 123, ;i24, ;i25. ;i2c, 127. ;i28. ;i29. ;i3o. "131, ;i32. "133. 134, 135 ;i3G 137 ;i38 ;i39 ;i4o ;i4i ;i42 ;i43 144 145. 14(;, 150. 151. 152. [15.-^, . Hoes ...... , Diamond-shiipod points .... , Auger drill. — Kouiid burs. — Odd or acorn burs . AVhcei burs ...... . Oval burs ...... , I'almcr's norvc-canal instruments . ,115. Retaining-point drills, spade, and spear-points , Stump files and corundum wheels, for pivoting . Round burs ...... , "Wheel burs ...... , Inverted-cone burs ..... , Fissure burs ...... , Pointed fissure drills .... , Spear-pointed drills .... , Five-sided drills ..... , Fine-cut round burs ..... Fine-cut pear-shaped burs .... , Sugar-loaf drills ..... Dr. Holmes' engine-bit oiler , Screw-head mandrels with and without .shoulder Northrop' s corundum points Arkansas-stone polisliing points. — Diamond-disk wheel , Flexible rubber disk for polishing j)roximate surfaces , Diamond disk ibr separating teeth . ICUis' pluggers. — New York set of pluggers. — Lord's pluiriiers and burnishers ...... Jack's matrix. — Set of Jack's matrices. — Matrix plugger, magnifiec — Set of matrix pluggers. — Pliers for adjusting matrices. — Sectiona views of cavities on ])roximate surfaces Hand or mallet pluggers. — S. S. W. burnishers. — Darby's burnishers — Engine burnishers .... Flagg's condensing forceps. — Weston's amalgam pluggers Palmer's metal tube with lead filling, for nudlet-head . Cutting pliers ..... , Wedge pliers. Palmer's pattern Forms of enamel chisels or cutters . , Paraboloid and gouge chisels of Jack and Forbes . , The S. S. Wliite dental engine , The S. S. White water motor apjjlicd to the dental engine , Corundum points used with the denial engine Typical form of a cavity when prepared for receiving a filling 14 7, 148, 149. Various forms of mandrel or handpiece for the denta engine ...... Flexiljle Jni)en that a cliild may be said to die directly from it, and independently of any of its com[»lications, A weak child may be so exhausted by the process as to sink under it. A marked case came under the notice of the writer: — a male infant, which had tiie misfortune to lose its niother at the birth, and, with her, that means of nourishment most adapted for a weakly child, did fairly well up to the usual period of teething, when tooth after tooth, irrespective of group, rapidly made its THE FIRST DENTITION. 25 appearance; the appetite fell off, yet the food taken, though small in quantity, was fairly digested; the little sufferer's rest was hroken, and it gradually lost strength from day to day, and week to week, until it finally sank, exhausted. Now, had this weakly child erupted its teeth in grouiis, with the proper periods of repose hetween each, instead of en masse, so to speak, there is fair reason to believe that it might have gained suffi- cient strength in the intervals to enable it to pass through the trials as they arrived. In this case there was no disease, and therefore there could be no actual treatment, and this may be said of teething in general. [Sometimes lancing freely seems to restore the normal conditions, and delay teeth that are prema- turely erupting.] But, whilst there is no specific for teething, much may often be done to allay symptoms, care being taken, however, that they are not mistaken as arising from this cause, when they have in fact another and a more serious origin. When the process is naturally conducted, the less nature is interfered with the better; but we may inculcate on those having charge of infants the importance of their being especially guarded, particularly dur- ing the erup)tion of a group, from things in respject of which there is less necessity for care when the process is completed. Thus, at such periods, the following matters should be especially avoided; weaning, or other important changes in diet, exposure to changes of temperature by alteration in clothing or situation, the chance of infection of zymotic diseases, etc., and vaccina- tion. If called to children whose symptoms are confined to local ones, we may, if we find the gums somewhat swollen and con- gested, though not tender, afford some relief by lightly scarify- ing them with a sharp lancet; — we lay much stress ori sharp, as it then causes very little pain, and, by cleanly dividing the superficial vessels, affords greater relief through freer bleeding ; — but, should the gums be very tender, as evidenced by the cry or altered cry of the infant when it is commenced, it should at once be discontinued, for an inflamed surface is mostly acutely sensitive, and the less cruel method of applying a leech at the angle of the jaw should be adopted. We doubt whether much relief, or relief of an}- duration, is attained by the operation of scarifying the gums; yet that it does afford relief, and cause but 20 MANUAL OF DENTAL SURGERY AND PATHOLOGY. little pain, is evidenced by the fact that we have occasionally been asked by children, old enough to do so, to perform it, from their recollection of the relief which they had experienced on former occasions. [One of the writer's children, before she was nineteen months old, insisted upon the lancing of her gums, and persevered until eight incisions were made over the four erupt- ing molars, when, with an embrace and a kiss as recompense for the relief afforded, she immediately fell into a tranquil sleep.] In case, however, of other conditions than the merely local ones prevailing, should we find the gums elevated at certain points, and, on inquiry, ascertain that certain teeth of a group have Fis:. 2. Three forms of lancet useful in dental surgery ; the blade in a line with the handle is that best suited for lancing the gums. been erupted, and should the gum, moreover, appear stretched over such spots as correspond to other members of such group, we may then with advantage freely divide the gum until the tooth is reached, which should be but a short distance from the surface. In performing this simple operation, especially in the front of the month, care should be taken to incise upon the anterior rather than upon the posterior asi)ect of the gum ; as it niight be possible, in the latter case, for the lancet to slide down the posterior surface of the tooth and injure the germ of its permanent successor. The operation, however, should be quite exceptional; its general employment, as was the case some half- century ago, was undoubtedly cruel and uncalled for; yet there is a danger, in the present day, of a really valuable and simple means of allaying serious symptoms being for fashion's sake discarded. [By many, with whom my own experience has universally agreed, it is still deemed best to comjiletely sever all the bands of overlying tissue, thus entirely freeing the underlying for- mative pulp and nervous tissue from the irritation of pressure. The bleeding relieves even deep-seated congestion, and the THE FIRST DENTITION. 27 cicatrix that may form over the tooth is much more readily pene- trated than the original tissue.^ There is also less liability to other symptoms of a general and serious nature such as are enumerated in the next paragraph.] In respect of the diarrhcea accompanying teething, and re- garded by some as an effort of nature to relieve or prevent local inflammations, and therefore not to be actively dealt with, the greatest circumspection on the part of the practitioner is requi- site; processes natural in themselves at the outset may yet become habitual, and continue after the cause of their existence has disa[»peared ; and diarrhoea, simply the result of the reflex action of a cutting tooth, may soon result in symptoms alarm- ing, and conditions difficult of control. It is not always easy, in cases of diarrhoea occurring at the period of teething, to diagnose its true cause, and therefore it will be the more pru- dent, at all events, to try and restrain it within moderate bounds, even though our suspicions strongly point to a dental origin. Our conclusions upon the subject may, however, be much assisted by our learning whether, in case of teeth having been previously erupted, such conditions then prevailed, and passed oft' when the process was accomplished. Our attention should also be directed to ascertaining, whether other portions of the mucous membrane are likewise aftected, as shown by catarrhal S3'mp- toms generally ; and the condition of the alvine ejections, and the circumstance of a group of teeth being, or about to be erupted, should also be ascertained. Above all, we must inquire into the conditions under which the child is receiving its nutri- ment: if from the breast, then whether circumstances have occurred which could alter the character of the milk, or whether the child be allowed the breast too frequently or at irregular intervals; if by hand, then whether any changes have been made in the character of the food, or in its consistency. The milk, if that has been employed, may have been obtained from another source or supplied in too large quantity, or not suffi- ciently diluted — both very common errors in the nurture of infants. A child may often do well by hand, on milk and water [' See "Paget's Surgical Pathology," Lindsay aud Blakistou, Phila., 1865, pp. 88, 158, 159, 194. For example, a lip once split by chapping, will after heal- ing open again upon the slightest stretching.] 28 MANUAL OF DENTAL SURGERY AND PATHOLOGY. (the best food for ninety-nine out of a hundred children for the first year) until the period of teething, when the digestive organs appear less capable of digesting the casein of cow's milk, espe- cially when too little diluted with water. As in the milk of cows casein exists in larger quantity than in that of the human species, a certain dilution, especially in the case of delicate chil- dren at this period, is essential ; but there is no douht also that it exists in the former in a less digestible form ; " the casein of cow's milk coagulates in large clots, whilst woman's milk pro- duces only small flocculent coagula." Should the casein be not digested, w^e usuallj^ at first find symptoms of constipation ; the motions are voided with diflficulty and pain, and are much of the consistency and appearance of dry putty; the action of the liver appears almost suspended, and the napkins are scarcely soiled. If this condition of things be allowed to continue, diarrhoea, often culminating in so-called infantile cholera, espe- cially in hot seasons, maj" soon occur; but this is not the diar- riioea of teething, though it may be greatly incited and aggra- vated thereby. [It has been the writer's practice always to examine personally the condition of the feeding-bottle and appliances. Of these the simplest and most easily cleaned are the best — an ordinary smooth, strong, wide-mouthed bottle, free from thin scales of glass and sharp edges or corners, either within or without, and a thin, black, elastic, vulcanized rubber nipple. The former should be scrupulously scalded, and both washed with soda and water immediately after using, and after thorough rinsing be kept in clean, cold water that is unclouded by aii}^ residue of milk, until the time to feed arrives, which is probably shown by the dis- quiet of the child. Then, tasting and being assured by critical examination tiiat the milk is sweet and good, fresh from an ice chest or cold s[)ring-house, it may, if cow's milk, be slightly warmed by the addition of one-third part of boiling water. To this iriixture (or less advantageously to the milk imme- diately upon its being received from the dairyman), add of lime water one or two teaspoonfuls for each pint of milk. Sweeten with a small quantity of sugar of milk, say two teaspoonfuls to the pint. As the child advances in age the amount of water may be decreased uj)til about the beginning of the period of dentition, when the milk may be used pure from the cow, except THE FIRST DENTITION. 29 where feverish conditions point to the desirability of dilutinir it with water. The rnles for proper nourishment for young infants and animals have probably been more the result of empirical domination than those for any other age in life; this is the natural sequence of the timidity of the young mother, the dicta- tion and ignorant confidence of the so-called experienced nurse, together with the utter helplessness of the little sufferer and the impossibility of its making known its wants. To form arbitrary and invariable rules with regard to the time of feeding and amount or kind of nourishment to be given to babes, is as unrea- sonable as it would be to dress them in clothes made according to one pattern and of one uniform material. Disquiet and a peculiar rooling movement of the nose and head are generally the signs of an infant's hunger, and invite attention to its need. Many of man's morbid appetites come of eating and chewing various articles to temporarily relieve the discon)fort of hunger. There is but little danger of the young of any animal being over- fed, so long as the food furnished is perfectly healthy and free from condiments and unnatural constituents. Carbonaceous food, such as candy, sugar, molasses, cake, and sweets, is too often resorted to as placebos until a pernicious appetite is formed by the child, which destroys the value of the craving or desire for aliment as a guide to its administration. Sydenham is credited Avith the proposition that the more nearly a medicine approaches a food the better, but the modern developments of knowledge in the direction of physiology and pathology seem to warrant the broader assertion that probably in the modification of the diet is to be found the greatest power to control or modify the entire animal economy, and the mind is often in such sympathy with the body as to be likewise affected by the regimen. The im- portance of proper food is such that no parent can be said to have performed his or her duty, in the cultivation of the highest capabilities of the bodies or the minds of their children, if the strictest attention is not paid to their diet. For most infantile troubles, as already intimated, proper air, food, ajid clothing, and thorough lancing when indicated, are aU-sufficient when the child has no marked inherited disease. The diarrhoea of our warm summer weather often, however, requires, where the babe is artificially nourished, some special modification of the milk. A good plan is to boil flour in a bag 30 MANUAL OF DENTAL SURGERY AND PATHOLOGY. for four hours; then, removing the outside crust when required for use, tlie interior may be grated to powder and added to the preparation above mentioned to form pa[t.] Here our attention must be directed to diet almost exclusively ; goat's milk maj' be substituted for cow's, and should this not prove ettective, ass's milk, which more nearly approaches the human than an}' other available, will often be digested;^ or, where these are not accessible, the valuable suggestion of form- ing a corajtound analogous to human milk may be adopted.^ [Where so situated as to be unable to get or keep cow's milk pure and sweet, children thrive for a time upon condensed milk ; this in the absence of goat's or ass's milk (both kinds very rare in this country) has done great service in furnishing a healthy ' Buttermilk has been much commended in some parts of the Continent. * To a friend and former teacher — Dr. Frankland, of the Department of Sci- ence and Art, — we are indebted for the following plan, slightly altered at our suggestion with liis concurrence, for preparing a food for infants, closely resem- bling in its composition human milk. Take the cream furnished by a pint of milk and add it to | pint of new milk. Into the skimmed milk from which the cream is taken, put a piece of rennet about one inch square, and set the vessel containing it in warm water, until the milk is fully curdled, which should occupy about 5 to 15 minutes. The rennet, being removed, washed, and then kept in salt and water, will be serviceable for a month. Next break up the curd, and carefullj' strain it from the whey, which latter should be heated to the boiling point, and then again strained from the casein formed during the boiling "feelings." Add to the hot wliey 110 grains of milk-sugar, and when dissolved mix the whole with the f pint of new milk and added cream. The artificial milk thus prepared should be used within twelve hours of its preparation, and all vessels employed should be scrupulously clean. Analyses of milk, from " Frankland's Experimental Researches:" Woman. Ass. Cow. Artificial. Casein . . 2.7 1.7 4.2 2.8 Butter . . 3.0 1.3 3.8 3.8 Milk-sugar . . 5.0 4.5 3.8 5.0 Salts . . .2 .5 .7 .7 It is not impossible also, that a portion of the milk having been acted on with pepsine, the casein of the fresh milk added may undergo some beneficial change : at all events, the food has in most cases appeared to answer quite as well as Iiuman milk. Tlie trouble, however, of preparing it is by no means inconsid- erable, and would lead most to seek the more simple yet morally doubtful expedient of a wet nurse. In large institutions, such as foundling hospitals, etc., this process might no doubt be adopted, and willi great advantage. THE FIRST DENTITION. 31 and nonrislnng temporary substitute. But persons who desire to raise healthy children, and who arc compelled to make use of artificial food, must be prepared to seek such localities as aflTord pure fresh cow's milk. Who would expect to become a success- ful grazier and raiser of cattle where the food had to be imported? Yet parents give less thought on this matter with reference to their children than to their stock. In this country n)Ost physicians have, from English authori- ties and training, been more or less forgetful of our extremes of temperature and the modifications of dress demanded by them. In winter the child should live in roomsonly moderately Avarmed (during the day) by direct radiation of heat from a stove, or bet- ter by an open fire, and be clad in heavy woollen material. The sleeping a[iartments should ofl:er free admission of the outside air through large open windows, and during the arctic waves fur covering at night is advisable. The summer, however, often requires the tropical dress of simple, flowing, loose night shirts of cotton stuff for even a week or more at a time during the prevalence of our hot waves. Many weak children have been and will continue to be sacrificed — the unreasoning prejudice of tlieir sliould-be protectors tormenting them to a sure but painful death during the heated terms by flannel clothing, or inviting the horrors of croup in winter by the sudden changes from a tropical atmosphere in the nursery to a polar one with- out.] In our treatment of these cases, it will make little difterence whether the cause be teething or otherwise; though, as before stated, we shall of course treat it, the diarrhoea, in the former less actively ; next to a correction of any errors which w'e may have discovered, as regards diet or exposure to cold, a common factor in the diarrhoea of infants, we may with much advantage administer, for three or four successive days, a small teaspoon- ful of an emulsion, composed of equal parts of castor-oil and gum-syrup, which may in some cases be repeated more than once in the day, but should be discontinued on the cessation or moderation of the diarrhoea; in severe cases, a small quantity, one to three drops at most, of vinum opii may be added, and this opiated form should be especially employed in cases of relapse. [While, as a rule, opium is a most pernicious drug for infants, 32 MANUAL OF DENTAL SURGERY AND PATHOLOaY. it may be occasionally of use in extreme cases of diarrhoea, under the familiar form of camphorated tincture of opium, of which ten to thirty drops may be administered after the prima via has been cleared of its contents by a purgative dose, say one to two teas[)0()nfuls, of aromatic syrup of rhubarb. AVithout attempting to pass into a discussion of the physi- ological action, it may here be stated that some of the obstinate cases of this com[»laint in both adults and children have been cured apparently b}- a teaspoonful or tublespoonful of pure cider vinegar, the former amount, diluted with water, for children.] When the cliild is found to be much exhausted and emaciated, great benefit often ensues from adding to its food a little brandy, "lij or iT\^iij at each of its meals, but not in the whole exceed- ing 8 to 10 drops in the day. If there be much vomiting, the same quanity of sal volatile may be substituted. The food must be greatly diminished in such cases, and perhaps only a tea- spoonful should be given at a time, but at more frequent inter- vals. Great benefit is also often experienced from the application of a large but light linseed-meal poultice, apjilied warm over the abdomen, and covered over with oil silk, a very small pro- portion of mustard only being added, the surface being pre- viously slightly oiled. Enemata of starch and laudanun), about "ij to "iv of the latter according as they are retained, may at times be usefully employed. [This raw starch injection, with from a half drop to three drops of liquid extract of opium, cannot be too highly recommended in cases of dysentery, where the irritated surface of the rectum causes intense pain and keeps up the disease at a point so remote from the mouth that drugs administered by that orifice cannot reach their destination without undergoing change and causing deleterious action, both constitutionally and upon surfaces trav- ersed in their course.] When called to an infant in whom the symptoms, however slight, indicate that the nervous system is affected, we must never omit a careful inspection of the mouth; and, should there be the smallest evidence for believing that the symptoms may depend upon the cause now before us, the gum-lancet should be freely used; for little harm can be done by incising, though unnecessarily, a healthy gum, compared with the mischief which may result from overlooking this cause of infantile convulsions. THE FIRST DENTITION. 33 « The symptoms may be slight, such as mere restlessness, light and uneasy sleep, with the thumbs slightly contracted on the palms; or there may be more restlessness accompanied by mus- cular twitchings, the child sleeping with the eyelids but partially closed, moaning in its sleej», and waking Avith a start, and cry- ing violently ; or the symptoms may be the still more severe ones of active convulsive movements, succeeded after a time by complete unconsciousness. Should the movements be unilateral, they would of course most probably point to another cause than dental irritation. Even in the severest cases, the simple opera- tion of lancing the gums has, under our hands, often allayed in a marvellously short time the symptoms which have continued more or less for twenty- four and even thirtj'-six hours. But it would never be right to depend upon this alone: tlie warm bath, to which a handful of mustard is a valuable adjunct, should be likewise employed. To the head if hot, cold should be applied, whilst the feet on removal from the bath should be wrapped in hot flannel. Should the face be flushed, the pulse full and in- compressible, and the fontanelles prominent, a few leeches applied at the occiput and removed directly an eifect is produced, will often prove of great service: when these cannot be obtained, an ounce or two of blood according to age may be taken from • the external or anterior jugular veins, and, when required, an aperient must never be omitted. But it is most necessary, in treatino; cases of infantile convulsions from teethino;, not to mistake for these symptoms somewhat similar ones arising from a wholly difterent cause, viz., the convulsions of aneemia ; as the above-mentioned treatment would most probably be attended with a fatal result. They arise from the same cause as do the convulsions witnessed in those who have suffered from severe liemorrhage in parturition, and we well know what would be the likely result of a depleting course in such condition. The following symptoms — a pale though occasionally flushing face, a dry skin with hair of head somewhat erect, conspicuous veins and sunken orbits but prominent eyeballs, fontanelles depressed, and pulse rapid and almost imperceptible, and quick respiration, with occasionally a loud, shrill, and distressing cry, often the precursor of a fatal termination, — call for stimulants, warmth, and nourishment, rather than depletion or depressants, to arrest the convulsions, of which the cause is not in any such instance 3 3-i MANUAL OF DENTAL SURGERY^ AND PATHOLOGY. the tectli, but is probably an exhaustive diarrlioea, or imperfect nutrition. [The thorough use of the lancet has, accordincr to \ny own experience, been an almost invariable relief and ever valuable remedy in reducing the nervous symptoms of teething children, that add so seriously and often fatally to the complications of the conditions of many of the diseases of that age. It is a sheet anchor of hope in moderately healthy constitutions, and it is urged upon the profession as an instrument whose strokes, if properly made, equal the reputed power of the passes of the magician's wand in fairyland. The difficulties that obstruct its use are overcome without much trouble by those who are determined to succeed, and are really less than those attending the forcing of a medicine down the little patient's throat. Let the child be held firmly and immovably from the waist up by a seated attendant, who holds the infant in his lap, facing the operator and the light, with its back against the assistant's breast, and the right arm of the latter over the child's arms, grasping them above the elbows, while the left hand over the forehead and eyes holds the child's occiput under the attendant's chin. The surgeon, with a sharp curved bistoury, guarded by a strip of cloth wound around the blade, allowing only an eighth to a quarter of an inch of the latter to be exposed, will make a sin- gle cut for incisor teeth in the line of the arch, and two cuts, forming the ISt. Andrew's cross, for the other teeth — in these cases the cuts crossing the tooth diagonally, "^i'o do this, the lancet should be inserted perpendicularly through the gum, until the distal corner of the tooth is distinctly felt, and then, taking care to hold it down u[)on the tooth, draw it forward from the disto-lingual or palatal to the mesio-buccal or labial angle, and from the disto-buccal to the mesio-palatal or lingual ant'le, com[)letely severing all the tissues above the teeth. Another and simple method of holding the child, is to seat both the operator and the attendant face to face. Lay the child u}ion the hitter's lap upon its back, with its head firndy grasped between the knees of the operator, the wrists of the child being held by the hands of the attendant. Without nerve, firm conviction, and confidence in the im- mense value of the lalicing, sufficient to im[)ress those attend- TUB FIRST DENTITION. 35 ins;, and enable the surgeon to operate deliberately, the results have so often been vexatious as to have caused many to con- demn the operation, when in reality the failure was due to their own inefficienc}',] Witii regard to the cutaneous eruptions often seen during the period of teething, which anxious parents so urgently solicit the practitioner to cure, a palliative treatment only is the best course to pursue, as active interference is often attended by severe and |)ermanent injury to other organs, especially the re- spiratoiy. The removal of the crusts, when large, by poultice, and scrupulous attention to cleanliness, with perhaps the em- ployment of some mild astringent and cooling lotion, form the best treatment. [Starch mixed with cold water to a creamy consistency as for eneraata, but without the opium, unless there is great pain, Avill prove a marvellous remedy to apply to these surfaces of irrita- tion. When on the head, anointing w'ith castor oil, and w^ash- ing with dilute solution of borate of sodium in water, is a very safe and cleanly treatment.] A disease has been described under the appeUation, " odontitis infantum," in which the gum over an erupting temporary tooth becomes swollen, congested, and finally ulcerated, when the tooth has penetrated it. The examples we have met with,?, e., if they be thedisease in question, were certainly, in our opinion, no other than cases of ulcerative stomatitis, moditied to some extent hy the condition of the parts during the [)rocess of denti- tion, which readily yielded to the specific for that disease, viz. chlorate of potash. [Sage tea and hone}' are very highly recommended also in these cases, but for cliildren or adults a simple touching of the ulcers wnth a crystal of alum, the mucous membrane surround- ing the parts immediately affected having been previously dried, will generally produce the most speedy and effective cure.* In stubborn cases, Avhere the white ulcerated surfaces indicate the presence of the oidium albicans (a parasitic vegetable growth giving the appearance of a dead and soaked piece of skin, or curd, or layer of starch covering the bottom of the ulcer), a saturated [' Nitrate of silver has been recommended by Dr. J. Win. White, " Holmes's System of Surgery," vol. ii. p. 517. 1881.] 36 MANUAL OF DENTAL SURGERY AND PATHOLOGY. tincture of iodine is invaluable, and ma}' be applied bj^ dipping tbe end of a piece of wood, like a match stick, in the solution, and then applying to the ulcer, previously dried to prevent spreading of the medicament to the surrounding surface.] In very delicate children, especially those who may have suf- fered from hooping-cough, measles, etc., the mucous membrane covering an erupting tooth may completely slough ; for this we l)ave found no remedy so efficient as strong carbolic acid. Another condition that may be witnessed at this period is the formation of a small sac containing serous fluid above the summit of a coming tooth, which is doubtless, as suggested b}' J. Tomes, an abnormal secretion of serum into the space between the enamel of the tooth and the remains of the enamel organ. In descrii)ing some of the untoward conditions which occur during teething, and how they ma}' best be met, the limits and objects of this work enable us only to give but a brief and con- sequently imperfect outline, and the student desirous of more information will do well to consult the writings of West, Trousseau, and Dickinson, also an excellent article in the "Journal de Therapeutique" for July 25, 1877, on the Diarrhoea of Infants, by M. Blache, translated in the 'Lancet' of Se[)tem- ber 15, 1877, from which works we have occasionally quoted verbatim. [In our extreme warm weather I cannot too highly recom- mend the laying of the child in grass or open network ham- mocks, instead of the arms of the nurse or upon the bed, to admit of the freest circulation of air about it, together with frequent ablutions in water of a temperature of 85^ to 90-' Fah., to keep down the accumulation of caloric and the subsequent danger of heat fever, or, as it is commonly called, sunstroke or insolation. "VVrajiping the child in a sheet and then sprinkling it with water of the above temperature Avill ra[>idly cool and reduce feverish conditions where there are dryness of the skin and lieat exhaus- tion. A little brandy diluted with water may be administered internally in antemia. In all febrile conditions, to sip a tea- spoonful of cool water, say 50 to 60° Fah. every quarter or half liour, is most grateful, and, by keeping the mucous surfaces moist and replacing the loss of water by evaporation from the body, it will do more to relieve suftering, reduce the temperature. THE FIRST DENTITION. 37 and effect a cure than any drug ever known. With young babes cotton bird-eye diaper is always preferable to linen, it being less likely to chill, and it is equally useful as an absorbent, while only about one-fourth the price. The diapers should always be changed the moment they are soiled, then waslied and dried in the sun upou the grass, or hung out to be aired until they have the freshness of smell that is characteristic of clean washed material. Under all circumstances the abominable contriv^ances of water-proof stutfs to protect the child's dress while feeding, and the nurse's lap, should be regarded as the enemy of health, inasmuch as they retain the heat and the imperceptible perspi- ration and poisonous effluvia arising from the body.^J [' See p. 520 to 52G, Prin. of Human Phj'siology, by Wm. B. Carpenter, with notes and additions by Prof. Francis G. Smith, M.D. Phihxdelphia, Henry C. Lea, 1876.] 38 MANUAL OF DENTAL SURGERY AND PATHOLOGY. CHAPTER II. IRREGUI.ARITIES IX THE TEMPORARY TEETH. DISEASES OF THE TEMPORARY TEETH. THE SECOND DENTITION. The temporary teeth have but few abnormal conditions, and ]:>robal)ly no diseases peculiar to themselves, which are not also common to them and the permanent teeth ; so that, whilst we now point out some of the former, we shall reserve a description of the latter till we treat of the diseases of the permanent teeth. In the temporary, as in the permanent series, we may meet with irregularities in size, form, number, and position. In regard to abnormality in size, the temporary teeth differ less than the permanent, but occasionally cuspidati, and second molars, are met with so developed that they might readily be mistaken for those of the second series. As it is important, especially in the treatment of irregularities in position, that such an error should be avoided, we may point out that, inde- pendently of size, the teeih of the first series may be generally recognized by their more delicate and translucent color, by the enamel at their necks terminating in an extended and abrupt manner (see Fig. 1, p. 19), and, at a time when they could be so mistaken, by their masticating surfaces exhibiting more or less evidences of wear: in tiie case of the cuspidati, they would l»robably be sliglitly loose to the touch at a time when they could be mistaken for their successors, and in that of the second temporory molars their position in the dental series ought gene- rally to determine their true class. In fornj, likewise, the temporaiy teeth are more constant than are the peru)anent ones. With regard to the number of their roots they do not often vary, but observation on this point cannot be so certainly determined, as in the natural course of events they are lost by absorption, at the period of eruption of the [lermanent teeth. We have in our possession four upper cus[»idati, each bifurcated at the radical extremity, and a lower IRREGULARITIES IN TEMPORARY TEETH. 39 molar with three and aii iiitpei' molar with four fajigs. A more common departure is where two teeth are united (geminated) together; the union may occur in the cementum only, or in the Fi- 3. Fis?. 4. Upper second terapov:uy molar with four fangs. Lower second temporary molar witli three fangs. Fit dentine and enamel. In the latter case a pulp cavity may be common to both : union of teeth by cementum only may take place after the teeth are developed as a pathological process. In number also, the temporary series are more constant than the permanent. Absence from the series is rare, although the writer has under observation a family in which one member is deficient in the four laterals, another in all the incisors excepting the upper centrals, and a third in W'hom again the lateral incisors are absent. In these three cases, all females, it could be almost certainly prognosti- cated, from the want of development of the jaw at birth, tliat such teeth would be ahsent. In this family there is the history of the mater- nal grandmother and a great-uncle having had a deficiency in the second series.^ [A case similar to Fig. 5 occurred in the mouth of one of the writer's children, involving only the right lower cus|)id and lateral incisor.] Excess in number is, though rare, probably more common; the writer lias met with eight or nine cases of an additional lateral incisor of the upper jaw, and almost ahvays well formed, like teeth of the same class. As the temporary teeth are erupted in the line of the position Gemination of a tem- porary lateral incisor and cuspidatus of the lower jaw, left side. ' The writer has recently met uith a case of a little girl, in ■whom was want- ing one of the temporary incisors of the lower jaw, but who now has not only the full number of permanent teeth, but also a well-formed supernumerary lower lateral incisor. 40 MANUAL OF DENTAL SURGERY AND PATHOLOGY, of their development, whicli is not so in the case of the perma- nent teetli, they are, as we should naturally expect, much less Fii^. 6. Upper jaw of a child in whicli the lateral incisors are absent. Fiff. 7. Lower jaw of a child in which all the incisors are absent. liable to deviation from the normal arrangement. Irregularities in position of the temporary teeth are comparatively rare, the most common being a slight overlapping of the upper central Fia;. 8. Upper jaw containing a supernumerary lateral on the right side. incisors at their mesial extremities; occasionally an edge to edge bite, that is, when the cutting extremities of the front teeth of each jaw meet each other, instead of the upper slightly overlapping the lower teeth, as is natural ; and more rarely this is extended to what is termed underhung, i. e.^ when the lower teeth overlap the upper when the mouth is closed. We have noticed this latter taking place some years after the teeth have been erupted, their original position having been normal. Tumors, by their pressure, will of course also produce [Fig. 9. Protrusion of tlio Hupnrior inei.sors, a frcr|uont result of thumb or finger sucking. (From the Dental Cosmos.)] this class of irregularity. Thumb-sucking, likewise, may occa- sion a deformity. We have a case now under observation DISEASES OF TEMPORARY TEETH 41 where the teeth and alveolar process of the right side of the upper jaw are considerably pressed outwards hy this habit always practised on that side. [It is not uncommon for this habit, unless cured, to be the cause of a deformity in the perma- nent teeth, producing a disfigurement giving an almost idiotic expression by the protrusion of the upper incisors fiir beyond the lower. (See Fig. 9.)] With regard to treatment, we have never seen occasion to interfere in the case of supernumerary temporary teeth, which are sometimes followed, and sometimes not, by permanent suc- Fig. 10. [Fig. 11. Chin retractor as applied. Another form of chin retractor which by the lower bandage draws the chin directly backwards, and by the buckles the tension may be altered at pleasure. Both bandages may be made of elastic webbing, and pads may be put under the buckles.] cessors. In the cases, however, where there is an increasing tendency to become underhung, due doubtless to some excess of development in the lower jaw, or imperfect development in its ascending ramus, an applinnce for drawing back the chin, by means of an elastic band attached to a cap for the head, may quite prevent, at an early age, the occurrence of this unsightly irregularity. The temporary teeth cannot be said to be liable to any diseases special to themselves which are not common to both series. 42 MANUAL OF DENTAL SURGERY AND PATHOLOGY. Caries, the most common of all, appears to arise from the same causes, and run much the same course; still, there are slight difterences which may be briefly noticed. It often appears in a very superficial form, attacking all the front teeth at once, and giving them an appearance of having been eaten away by an acid solvent. In its more ordinary forni, its progress appears somewhat mote rapid, and attended by necrosis at an earlier period, which may perhaps arise from the temporary teeth con- taining a larger proportion of organic constituents than do the permanent ones.^ The result of this loss of vitality is usually alveolar abscess, or gum-boil, appearing generally on the labial aspect of the gum: the bone lost by the process at this portion of the jaw leads to the necrosed fangs of these teeth becoming exposed at such points during the eruption of the permanent teeth, where they are not unfrequently mistaken tor small ex- foliations of bone; or, if overlooked, they may penetrate into the adjacent cheek, setting up considerable ulceration and swell- ing, followed often by cicatrices which bind the cheek at those points to the jaw. When this occurs, they should of course be removed, and the operation may be eftected in a very easj' manner. "Where the fang is not exposed in its whole length, i. e., where on]y a portion of its apex penetrates the gum, the latter — the isthmus-like portion — should be divided by the lan- cet, and then, a pointed elevator being placed a little aijove or below (as the ease may be) and behind the apex of the fang, a downward or upward and slightly inward movement will ■ The temporary teeth also being more rapidly developed should, we might naturally expect, show less power of resistance than their more slowly developed Fig. 12. Fig. 13. Upper jaw with portions of the roots of tcni- Lower jaw witli lower second lomporary porary central incisors exposed. molar having one root fully and one root partially exposed. successors, whilst a proportionately larger pulp cavity would result in an earlier exposure of its contents, and an earlier death of the tooth. DISEASES OF TEMPORARY TEETH. 43 speedily detach the tooth ; witli the removal of the tooth the ulceration and swellino^ soon disappear, although the small cicatrix above mentioned ma}' result. [Excision of the exposed ends of the roots, and their subsequent smoothing by a file, have resulted in very happy healing and restoration of the utility of such teeth in the writer's }>ractice.] The treatment of caries of the iirst teeth will be conducted upon much the same princij)lcs as will be detailed when we treat of that disease in the permanent set: we cannot, however, too strongly inculcate an early employment of the tooth-brush, especiiiUy at night: parents are commonly disposed to imagine that practice unnecessary with children, and the latter suffer accordingly. In the case of superficial caries, where the opera- tion of filling cannot be resorted to, the cleansing process be- comes imperative: it should be performed after each meal, and a few drops of a mixture of sal volatile and alcohol^ applied at the conclusion. When this is persevered in, the progress of the caries seems to be generally arrested, and the teeth affected are often preserved until the ordinary time for shedding them arrives. Moreover, the teeth, which, when affected with the superficial decay, are usually very sensitive to bite ui)on, become with this treatment free from tenderness and useful in masti- cation. [Lime-water diluted with three or four parts of water makes an excellent local aj)plication or mouth-wash ; and pre- pared chalk, rubbed around these teeth with the finger, and allowed to remain during the night, will afford relief, and often by neutralizing acid conditions effect a cure.] The temporary teeth, having fulfilled their ofiice, retire from active service in favor of their more durable successors. "Whe- ther the act of their departure jiertains more to themselves or to their successors has been for some years a moot point. An ancient view was tliat the permanent teeth in their advance absorbed and assimilated for their own benefit their temporary predecessors, and in this cannibal view perhaps a modicum of truth existed. A more recent view regards the temporary ' ^. Spiritus ainmonife aromat. ,5J ; Spiritus vinse, ^iij ; M. ft. applicatio. About 10 drops of the above to a teaspoonful of water to be applied ou the tooth-brush after cleansinE: the teeth. 4i MANUAL OF DENTAL SURGERY AND PATHOLOGY. teeth as subject to that condition which appertains to all tissues of the body — cells, fibres, and their combinations, even to the whole body itself, viz., in having a fixed period of existence, which includes the stages of development and growth, of main- tenance and maturity, and of degeneration and decay, in wdiich last they undergo changes which involve their being cast off from the surface like hair, epithelia, etc., or breaking up and being carried away in the circulatory system, as are all sub- cutaneous tissues in the body ; and to this rule the fangs of the temporary teeth form no exception : they also undergo, at fixed periods of their existence, ramollissement, and are removed amongst the products of metamorphosed tissues. Whilst we are full}' prepared to admit the truth of this doctrine, in so far as that a change in the condition of a temporary tooth precedes its absorption, it is yet evident that the process is closely in relation with that which eft'ects the eruption of its successor; for, should the latter be absent, the process often does not take place for many years later ; indeed, it is not uncommon to see temporary teeth in the mouth and firm after maturity has been attained. The writer once filled a lower second temporary molar with gold, in the person of a gentleman above sixty. As this process of absorption is so closely connected with the eruption of the permanent teeth, we may here give our views upon the latter process, which were first expressed in a course of lectures delivered at St. Bartholomew's Hospital in 1867, and published subsequently, but certaiidy not until after almost similar views had been exi)ressed in an admirable paper in the '• Vierteljahrsschrift," by the pen of Herr Robert Baume.^ To account for the eruption of the teeth, two views have until re- cently been advanced : one, in which the process is attributed to the growth of the fangs of tlie teeth causing their crowns to be raised out of their alveoli ; and the other, in which that pro- cess is attrihuted to a growtii of bone at the lower portions of the alveoli, srpieezing, as it were, the teeth out of their sockets. The first is still the view entertained by some,^ but its inaccu- ' Trtinslatf'd in tlip Montlily Review of Dental Surgery, vol. i. 2 " The erui)tion of the teeth is a process of gradual elongation of the teeth on the one hand, and of simultaneous absorption of the superimposed tissues on the other. The absorption commences, first in the overhanging margins and front -walls of the alveoli, which gradually disappear until room is afforded THE SECOND DENTITION. 45 racy is readily verified upon the examination of preparations at various periods in the second dentition. In the woodcut helow, taken from a normal prepara- „. ^ , Fiff. 14. tion in tlie Museum of the Odontological Society, will be seen a bicuspid tooth, with the fang fnlly formed, yet not erupted, and other teeth, the fangs of which are nearly com- pleted, also not erupted, but which undoubtedly would have been so in due course had the individual survived. For the second and later assigned cause there is actually no ground, as it cannot be shown that there is greater development of bone taking place during the erup- tion of the teeth at the apices of the alveoli than at other parts of that district of the maxillae. [A remarkable case was exhib- ited by Dr. George W. Neidich, before a meeting of the Pennsylvania State Dental Society, of a young gentleman with a central incisor presenting a corner of its cutting edge under the mucous membrane of the gum near the freenum of the lip, and its root at the length of the tooth back in the palate. It was treated by him, and the tooth brought down to a normal position, save that it was con- siderably twisted upon its longitudinal axis and presented the mesial face to the front. A cliange of residence, by removal of the family, caused him subsequently to come under the writer's care, and the tooth gave every evidence of being sound and for the free passage of tlie advancing tooth. The growth of the tooth keeps pace witli this absorption, and the crown at length pressing against the mem- branous coverings, these undergo atrophy, and, becoming by degrees thinner and at last transparent, give way and disclose the advancing crown." — The Student's Guide to Dental Anatomy and Surgery, by Henry Sewell, M.Ii.C.S., 187G, p. 27. Upper maxilla of the right side, -nith por- tions cut away to exhibit the developing per- manent teeth. It will be observed that the fang of the first bicuspid is fully developed, and the fangs of the cuspidatus and second bicuspid are nearly so, while no portion of the crown of these teeth has been erupted. The platform of bone spoken of in the text is se^n supporting the first temporary molar. 46 MANUAL OF DENTAL SURGERY AND PATHOLOGY. healthy, altliono-h tlie apex had traversed one-half to three- quarters of an inch through the bone. This remarkable opera- tion, aside from the wonderful perseverence and endurance on the part of both the dentist and the patient, with the consum- mate skill and intimate knowledge of the former, shows that it is possible for the nutrient vessels and nerve filaments of the apex of the root to follow it through the bone and accom- modate themselves to new positions widely distant from their original ones. The final history was confirmative of the above diagnosis. The patient preferred to take the risk, of immediate torsion detaching the vessels and devitalizing the pulp, rather than the slow and almost sure but more painful methods; indeed it was the only operation to wdiich he would submit, although the danger to this [larticular tooth was fully explained to him. The tooth was then, by several o[)erations of immediate torsion with forceps, as recommended by Tomes, brought into proper position, but, as already intimated, the pulp died and was treated accordingly. With but slight change of brilliancy it remained at his last visit to me })erfectly serviceable, although several years had elapsed since devitalization of the pulp. I may add that tliis is the only case of death of pulp following that operation in my practice, although I have repeatedly per- formed it.] The only probable explanation which it appears to us can he oftered, is in the general growth and advance of the bone towards the surface, carrying with it the contained teeth. This assertion consequentlj' im|»lies a continual growth of bone (as is the case with epitlielia, cartilage, etc. etc.) from its nutrient centres towards its circumference, and also that at the latter aljsorption must be frequently taking place, as we have evidence of its occasionally doing during the process of absorp- tion of the temporary, and advance of the permanent, teeth, where portions of bone — platforms, as they might be called, supporting the former— are often seen extending much beyond the general level, as represented in tiie woodcut; which plat- forms become absorbed as soon as the sustained teeth fall out. To which tissue or structure this power of absorptioji pertains, we will not venture to decide; thougli we are inclined to the conclusion that it is effected by the osteo-blastic layer of the THE SECOND DENTITION. 47 periosteum assuming an osteo-clastic function. But that such power exists, none we think can deny from the foi'egoing con- siderations, as also wlien we take into account those conditions of loss at certain })arts and gain at others which take place in the inferior maxilla between childhood and manhood ; more- over, it affords a more rational explanation of the exfoliation of teeth and roots, when unopposed by pressure, also of sequestra of bone, than the assertion that nature casts such off because use- less. In the treatment of irregularity in position by mechanical appliance, we often see certain teeth, wliich have been relieved from opposing pressure by such means, become unduly elon- gated ; whilst in cases where a tooth, from loss of its comrades, becimies subjected to undue pressure, it will be found often more deeply imbedded in the jaw than is natural. According then to the views advanced, a tooth developed in the maxilla is carried with the growth of that bone towards the surface. Arriving at the surface, the bony c(wering becomes absorbed, and the more so as the tooth advances, until the crown, project- ing above the surface, meets with some 0[)position to its further advancement, and is retained in position,^ when the bone imme- diately surrounding it — its alveolus — becomes more dense in character, and less ra[)id in growth, than the surrounding can- cellous interalveolar portions. The^^e harder portions of bone being more stationary, we have, doubtless, so to speak, bone currents continually existing in the maxillfe, but more especially during the periods of the first and second dentitions, when these bones are in a condition of more than ordinary active develop- ment.^ If we now apply these views to the question before us, viz., the absorption of the temporary teeth, we shall understand that the bone, carrying with it the permanent teeth, advances to the surface, where it becomes absorbed ; and, as this process of absorption must at these times be very active and extensive, ' Besides the operation of opposing teeth in effecting sucli retention, we may take into consideration the retaining power exercised by tlie mucous membrane firmly attached to the necks of the teeth, which attachment, when lost by disease, is almost invariably followed by their exfoliation. 2 These views have been more fully expressed in a contribution to the St. Bartholomew' s Ho^piUd Reports, p. 91. They have met Avitli the approval of Professor Owen, who has kindlj' pointed out to the writer a similarity of idea in his description of the development of teeth in the elepliant, OdontograpJii/, p. 639 ; but C. S. Tomes still regards the process as obscure and unexplained. 48 MANUAL OF DENTAL SURGERY AND PATHOLOGY. ns indeed we know it to be, it seems probable tbat the periosteal covering to the temporary teeth meets the same fate, or becomes 80 altered in character that its osteo-blastic elements may become active and osteo-clastic agents. In either way, it so happens that the fangs of the teeth come into contact with these ele- ments, which are found in collections about their roots, and constitute the "absorption-organs of Tomes." la confirmation of the position taken above, we have the fact that there is no ai>pearance of periosteum where the process of absorption is taking place. These cells, the elements of absorption, are in no wise difterent from those of actively-growing bone ; indeed, J, Tomes shows that the process of absorption is often alter- nating with that of formation, but, the balance being in favor of the former, the greater part of the dentine, and generally some portion of the enamel, eventually disappears. It is not uncommon to see a temporary tooth, esj»ecially a molar, at the period of its being shed, appearing of a pink color, owing to its transparency, showing through it the vascular and proliferating bone-elements beneath it. The condition termed necrosis, in which a tooth or bone has undergone changes other than a mere loss of vitality — which is not the case with simply dried teeth or bone removed from living or recently-killed animals, where chemical change or decomposition has not ensued — is a barrier, and fortunately so, to the i)roces8 of absorption, such tooth or sequestrum being got rid of by the general advance of bone to the surface; but, where, through resistance by obstacles, etc., necrosed temporary teeth or roots are retained m situ, they form a common cause of irregularity in their permanent suc- cessors. [Sometimes, however, a process of erosion of these dead roots takes place, and they are removed or exuviated with but little irregularity as to time or manner.] But, whatever be the means, the absorption of the temjiorary teeth is so far effected that they lose their hold upon the mucous membrane, and fall, or are rubbed off, from it: the order of their disappearance is usually that of tlie appearance of their successors. The process is happily a gradual one, otherwise animals would be left for a time in an unpleasant predicament, and it usually occupies about ten to twelve years or even longer. [Generally, in this country', the eleventh or twelfth year finds the process completed so far as the replacement of the THE SECOND DENTITION. 49 deciduous teeth is concerned.] In most cases, the falling out of a tooth is followed by the a[)pearance of its successor within a few days ; in some, the successor api>ears before the predecessor has departed, and then in an abnormal position ; and in some it does not ap[)ear for months or even years after. The teeth of the permanent set are thirty-two in number: they therefore contain in their series twelve more than the temporary set. They are arranged in the same manner, viz., an equal number in each jaw, and symmetrically on each side of the mesial line of the month. Their formula is incisors |, cuspidati ^, bicuspids |, molars f ; the cuspidati are also called canine and eye teeth, and tlie bi- cuspids premolars. [The cuspids of the lower jaw are frequently called "stomach teeth," in contradistinction to those of the upper.] The first permanent tooth that makes its appearance is the first molar,^ and it is generally the largest in size of all. When Fis:. 15. Upper permanent teeth of the left side. «, central incisor ; 6, lateral incisor ; c, cuspidatus; d, first bicuspid ; e, second bicuspid ; /, first molar ; g, second mular ; k, third molar. the second temporary molar has been ei'upted, it almost wholl}' occupies the space between the first molar and the coronoid l)rocess of the lower and the tuberosity' of the upper jaw ; but, as the period of tlie second dentition approaches, considerable ' This tooth holds a somewhat sin2;ular position in the dental series. In regard to its development, it is closely allied to the temporary series, in having its formation from a special duplication of the mucous membrane, and in not being any offshoot from a temporary tooih, and also in its furnishing the off- shoots for the second and third molars. From the age at which it is erupted, and from its not undergoing absorption, and its iiot having a successor in its place, also from its position, etc., in the series, it is classed amongst the second or permanent teeth ; its claim, however, to permanency in another sense, especially in the present day, is a very doubtful one. 4 * 50 MANUAL OF DENTAL SURGERY AND PATHOLOGY. space will be found to exist posterior to those teeth, which is produced in the lower jaw by an absorption or loss of bone at the anterior and inferior portions of the coronoid processes, with corresponding increase at the posterior and inferior por- F\ "Warty teeth," Salter. 60 MANUAL OF DENTAL SURflERY AND PATHOLOGY. which distension consequently takes place at parts as yet not calcified. In these, certain portions of the tooth, especially its coronal ones, bear their normal appearance, or nearly so. This class is b}' far the most frequently met with of an}^, especially if we include, as some have done, those malformed teeth, usually supernumerary, which appear as if a flattened tooth-pulp had been folded upon itself, and often, previously to a section being made, appearing like a tooth developed within a tooth. We think, that if these should be classed at all as odontomes, they belong rather to Broca's second class than to the third. In the fourth class, odontomes radicidaries^^ are comprised those rare cases where hypertrophy has arisen after the calcifi- cation of the crown of the tooth. Here the components will be dentine and cementum, or the latter only: the mass may be of very considerable size, and be readily mistaken for an immense exostosis. Teeth may also occasionally be found with small nodules of enamel on the portions of their surfaces otherwise covered with cementum, or there may be distinct cusps covered with enamel, which project above the gum and may readily be mistaken for distinct and supernumerary teeth, the error only being dis- covered when their removal is attempted ; the main portion of the tooth from which they spring being seen to move with them. With our more accurate knowledge of the development of teeth, the occurrence of these nodules and offshoots is more readily explained. [There would seem to be a tendency to proliferation (but yet not a fully completed formation of distinct sacs and teeth in these cases) somewhat similar to the development of the three molars.] 3. Irregularity as regards number. We have spoken of super- numerary teeth in the last section ; they may be found iti con- siderable number, even to four or Ave in the same mouth, and upon almost all portions of the alveolar and palatal processes of the maxillae; we recently saw one, discovered lying horizontally between the articulations of the latter processes, the crown pointing backwards. They are more common in the upper thari in the lower jaw, and, when in the latter, are generally met ' "Ilernia of the fiuvj;'' Salter. IRREGULARITIES IN PERMANENT TEETH, 61 with in the neighborhood of the tliird nioljirs. Whilst all excess above the ordinary number nmst be regarded as supernumerary, we may also class as such, irrespective of the proper number present, additional teeth occurring in positions where they Fis;. 25. Fi- 26. Supernumerary teeth iu the upper jaw of a youth. Copied from a cast iu our possession. Supernumerary bicuspid of the upper jaw, right side. partake of the same type as their neighbors ; thus, we should regard as supernumerary a third well-formed bicuspid, or a fourth molar, though its presence might cause no actual excess in the proper number. [There are, however, puzzling exceptions to this rule. Among the writer's patients is a young gentleman, now a student of medicine, who had six superior incisors so well formed as to defy attempts to indicate which were supernumerary. There are now remaining tive of these teeth well formed, and so regularly arranged as to escape notice except when attention is particularly called to them.] Deticiency in number is b}' no means unusual, and we may venture to express the opinion that it is more common now than formerly. The teeth most commonly absent are the lateral incisors of the upper jaw, and when one of these is wanting, that present often assumes, as before noticed, the small pointed form characteristic of a supernumerary tooth. Next in order of de- ficiency we would reckon the lateral incisors of the lower jaw, and following these the second bicuspids of the same. The 62 MANUAL OF DENTAL SURGERY AND PATHOLOGY, second bicuspids of the lower jaw are often impacted between the iirst bicuspids and first molars, and therefore may be present without showing themselves at all, or until later in life, when they present an appearance usually internal to the dental arch. [Cases of retention of the bicuspids have been presented in the writer's practice where they did not come up to the line of occlusion with their antagonists until after the fortieth year. In these instances they were generally held down by the inclina- tion towards each other of the two adjacent teeth, the removal of either of which permitted the eruption of the retarded tooth to be completed. The retention of the deciduous teeth may likewise be a fre- quent cause of irregularity as to the time of eruption as well as to position of the permanent set.] We might perhaps have placed earlier in the list the third molars, but the evidence of their absence is in many cases ren- Fiff. 27. Upper jaw in wliich the lateral incisors have not been erupted. dered difficult by the fact that the first permanent molar is often regarded as a tem[)orary tooth when it is removed at an early age, and the space so afibrded being quite occupied by the second molar, the third is not uncommonly regarded as the second. IRREGULARITIES IN PERMANENT TEETH. 63 Still they are sometimes erupted at so late a period in life that they may be present when not suspected.' [The writer has recently seen two of the wisdom teetli but partially erupted through the gum in the mouth of a patient fifty years of age.] Another form of excess in number is where a third set of teeth is supposed to have been erupted. Although every case we have investigated, and they have been numerous, has turned out to be the eruption of retarded or missing teeth, of true super- numerary teeth, or of portions of fractured roots of teeth which become in time carried to the surface in the manner described at page 46, yet cases have been narrated by authorities whose accuracy and candor must compel us to accept the fact that a third set of teeth is a possibility. 4. Irregularity in position. To the dental surgeon this divi- sion of the subject is by far the most important and interesting. It is moreover one which often largely taxes both his ingenuity and his patience; sometimes to be attended by the disappoint- ment of failure; but, when successful, bringing the reward of almost unspeakable satisfaction, for to restore to symmetry and beauty so important a feature as the mouth, when out of harmony with the rest, is certain to insure for the practitioner the lasting gratitude of the patient and the patient's friends. To attempt to describe the various forms of irregularity which occur under this head would be almost impossible, but we may, we trust, aid the student by pointing out their most common causes and the general principles on which they may be treated. With this object we shall somewhat arbitrarily divide them into two classes, viz., those which we shall term 1, accidental and avoidable, and those which we shall term 2, congenital and unavoidable. 1. Accidental and avoidable. This form most commonly arises from the persistence of temporary teeth which from some cause have not undergone absorption of their roots commensu- rate with the advance of the permanent teeth, or from the reten- tion of necrosed roots which do not undergo absorption. The ' In a communication recently made by Professor Flower to the Odontologi- cal Society, vide vol. xii. p. 32, that high autliority classes the third molars as the teeth that are most frequently absent in man. 64 MANUAL OF DENTAL SURGERY AND PATHOLOGY. tootli in coDsequence assumes an abnormal position sometimes anterior or external to the proper dental arch, but more com- monly internal to it. To clearly comprehend this portion of our subject, it is necessary that we should understand tlie relative positions of the permanent and the temporary teeth, about the age when the second dentition commences. If we take the skull of an individual \vho died at the age of, say, six years, and before any of the temporary teeth have been shed, and pare away the anterior surfaces of the alveolar processes, we shall iind the following arrangement and condition of the teeth to prevail. Commencing with the upper jaw, we shall find the crowns of the permanent central incisors situated on a higher plane than the temporary teeth, with an inclination directed more outwards, forming with the latter an angle of fifteen degrees or thereabouts, and, when they are erupted, placing them Fiff. 28. View of the uppor and Icnvorjaws of a child aged about 63^ years. The external portions of the bones have been removed to show the positions of the developing permanent teeth and the fangs of Ihe temporary teeth. The bifurcation in the fangs of tlie upper cuspidati is abnormal. [From "The Mouth and the Teeth," liy .1. W. White, M.D., D.D.S.] in a more prominent and consequently a wider dental arch cora- metisurate with tlieir larger dimensions; they are also situated behind the roots of the temporary central and lateral teeth, which show some slight indication of absorption at this period, and the imjierfectly developed extremities of their fangs abut closely upon the thin os-eous floor of the nares, whilst their IRREGULARITIES IN PERMANENT TEETH. 65 cutting; cd2;es reach to about tlie middle of tlie roots of the temporary incisors. The cuspidati, the crowns of which are but barely developed, are situated on a much higher level than the last-named, viz., about J of an inch below the floors of the orbits (hence [»ro- bably their designation eye-teeth), and at the sides of the outer walls of the nares, the floor of which is level with the centre of their crowns. The infra-orbital canals are about I in. above and external to their uiidevelo[)ed extremities. Posterior to these latter in the dental arch, l)Ut situated on a lower level and more external, are the first bi(;uspids, and between these and the central incisors, and on nearly the same plane, are the lateral incisors, placed however internal in the dental arch to the cuspidati and central incisors. The crowns of the first and Fis?. 29. Side view of the jaw of a child with permanent teeth forming'. second bicuspids not fully developed are seen placed directlv above and embraced by the fangs of the first and second tem- porary molars respectively. The first permanent molars, the crowns of wiiich nearly meet their comrades of the lower jaw, and which must have been erupted some weeks, have their fangs about one-half developed, whilst the second molars, or rather the small developed portions of their crowns, hold a position above, and posterior to, the first molars, with their masticating sur- faces looking downwards and backwards towards the lower i)or- tions of the external pterygoid processes; little crypts on a still 66 MANUAL OF DENTAL SURGERY AND PATHOLOGY. hiirlier level in the tuberosities of the bone show the position of the future dentes sapientife of the upper jaw. In tiie lower jaw, the central permanent incisors, the fangs of which are about one-fourth developed, occupy a more vertical position, in a narrower circle, than do the corresponding teeth of the upper jaw ; and this holds good generally with all the teeth of the lower jaw, but es[)ecially the six front ones. They are situated directly behind the partial Ij^ absorbed roots of the temporary centrals, and partiall}^ behind the temporary laterals, their cutting edges having but a very thin layer of bone inter- posed between them and the surface. The cuspidati occupy a lower plane in the same arch, their developing roots resting upon the thin dense portion of bone which forms the inferior surface of the body of the lower maxilla, the roots of their temporary predecessors being directly in front of them. Between and partially behind, the cuspidati and the centrals are the lateral permanent incisors, having directly in front of them the roots of their temporary predecessors.^ The bicuspids^ occupy relatively' the same .position in the lower as they do in the upper jaws; as do likewise the first molars. The second molars have their developing crowns on a higher level than that of the bicuspids, with their masticating surfaces looking upwards and forwards. Small crypts in the coronoid processes denote the position of the future dentes sapientias, or third molars of the lower jaw. From this description of the relative positions occupied b}^ the permanent and temporary teeth prior to the eruption of the former, we readily learn how a persistency in the latter through an unabsorbed root will effect deviation, and the direction which it will cause a permanent tooth to take, when in the process of eruption ; thus, persistence in the lower temporary incisors will of necessity, under the above-mentioned conditions, cause these teeth in the permanent series to occupy a position within the ' In a prcparalioa before us, small round holes in the jaws, immediately above the summits of the lateral incisors, show absorption of the roofs of their bony crypts to iiave taken place in advance of any other of the six front teeth. 2 The first bicuspids lie immediately internal to the mental foramina, which, remaining but little changed in position during life, constitute, as shown by J. Tomes, valuable fixed points for estimating the various alterations which the inferior maxilla undergoes. IRREGULARITIES IN PERMANENT TEETH. 67 dental arcli. If it be a temporary lateral tooth or root, the per- manent successor must appear behind the permanent central and the temporary cuspidatus, the temporary cuspidati will have the same effect upon the permanent ones, whilst persistence of the roots of the temporary molars will cause the bicuspids to deviate to positions either internal or external to the dental arch. The treatment of these cases will be evident, viz., removal of the obstructing teeth or roots. In the lower jaw we fre- quently meet with cases where the permanent incisors are erupted behind the temporary ones; and, by the removal of the latter, the former are soon brought by the pressure of the Fig. 30. tongue into proper ])Osition ; and, in considering the treat- ment of irregularities in posi- tion, we must ever bear in mind the continual beneficial action of this member, as well as that of the lips, in causing the teeth to assume their nor- mal positions. The former is constantly pressing the lower teeth outwards, until they be- come arrested by the upper teeth which bite in front of them ; whilst the latter, by their elasticity, are continually acting u[)on the upper teeth in the opposite direction ; it therefore happens that by these means great irregularity is reduced to symmetry wdien simply oppos- ing obstacles are removed. But it may chance to happen, in the case of the upper jaw, that we are not con- sulted until the njisplaced tooth or teeth have been so far erupted that they are bitten over l)y the lower teeth wheiiever The couduion termed par- the mouth is shut, resulting, in the case of tiaiiy underhung: itwiube , . observed that the four inci- one or two teeth, in the subjects being par- sors of the lower jaw bite in tially, and in tiie case of the six front ones, ^'■°°' °^ '^« "''"■^^ '""^"'"^ ■^ ^ _ ot the upper jaw. in their being wholly underhung. It will here be apparent that removal alone of the temporary obstruc- tives will be unavailing: a new and more serious impediment Lower jaw in which the permanent central incisors have been erupted behind the tem- porary central incisors. Fig. 31. 68 MANUAL OF DENTAL SURGERY AND PATHOLOGY. exists, and the ease, if left to itself, can only become worse and more disfiguring as time advances. The lower jaw becomes gradually drawn forwards, the angles at the union of the body and rami forming more obtuse angles than the natural ones, and the features characteristic of that species of dog in the com- pany of which it was at one time considered disgraceful to be seen. Besides removing the temporary teeth, we must employ means which will obviate the closing of the lower in front of the upper ever}^ time that the mouth is shut, and at the same time we may greatly accelerate the process by applying pressure behind the misplaced teeth. The following, we believe, will be found the simplest and most effective manner of accomplishing our object. We first [Fig. 33. Upper jaw. Impression cup for wax.] [Fig. 33. Lower jaw. Impression cup for wax.] obtain an accurate model of the mouth, by means of an im- pression or mould taken in wax, plaster of Paris, gutta-percha, or the conif)Ounds known as .Stent's and Hind's compositions — IRREGULARITIES IN PERMANENT TEETH. 69 we recommend the two latter — and from this a casting is made in plaster of Paris. To describe this more fully, we obtain a metal tray of the size that will roughly adapt itself to that of the upper dental arch of the patient, and be inserted without much stretching of the mouth. Into this tray we put a suffi- ciency of the Stent's or Hind's composition, which has been Lower jaw. Impi. s^i.m cup for jUaster.] [Fig. 35. Upper jaw. Impression cup for plaster.] thoroughly softened in almost boiling water, then dried and kneaded in the hands to render it quite consistent ; a spirit lam}) aiding the latter process, and causing it to attach itself to the tray, which should be filled evenly to the level of its sides. The surface being just rubbed over with a little olive oil, we insert the tray, which we are careful to see is not hot enough to hurt the lips, into the mouth, one side before the other being 70 MANUAL OF DENTAL SURGERY AND PATHOLOGY Fie:. 36. attended with tlie least stretching, and then press it with its CO itents steadily upwards in an almost vertical direction, and high enough to obtain an impression of the surfaces of the teeth above the gum and also of the whole of the hard palate. We allow it to remain in its position for from two to four minutes, as the patient can submit, then bring it vertically downwards, feeling for and following the direction in which it comes the most readily ; and, when it is below the level of the teeth, remove it from the mouth, and thus we obtain an accurate impression of the portion of the mouth required. Into this impression, when hard, is poured plaster of Paris of line quality, mixed bj- carefully adding the plaster to the water, until, when, well stirred, it is of the consistence of tliick cream. [The im- pression may be previously covered with a thin coat of olive oil, by means of a camel's-hair brush, to prevent adhesion of the model.] We tap the tray at every addition, in order to allow the plaster to go into all the smallest depressions in the impres- sion, and to get rid of tlie air-bubbles, and, as the plaster becomes thick enough, we build u[) the model to the height of one or two inches in order to give it strength and solidity. After a few hours, and when the plaster has firmly set, it may be liekl tray-side downwards in a vessel of nearly boil- ing water until the composition is so softened that it is readily removed from the plaster. The model is, after being trimmed, now transferred to an oven and dried until it almost ceases to steam, when, to render it hard, it is immersed in a vessel of melted stearine, and boiled in it about half a minute, and then removed to dry. We have dwelt upon this process of taking impressions of the mouth becau^e it is not merely apjdicable in dental cases, but may also be of use in many ordinary surgical ones. We have found it very useful, when watching the progress of certain tumors, or obtaining represen- tations of them before removal, or estimating the extent of clcft-jialate, ^. e., whether the case be more suitable for surgical Plate adapted to the upper jaw suitable for raising the bite and pressing out the central incisors ■when bitten over by the teeth of the lower jaw. Behind each cen- tral incisor is shown the dovetail cut into the plate in which the pieces of compressed deal are in- sorted, and which by swelling, when they become moist, press forward the teeth they are in con- tact with. IRREGULARITIES IN PERMANENT TEETH. 71 or for mechanical treatment, and in cases where a second opinion at a distance may be sought for without a journey. The model is now placed in the hands of the mechanical dentist, who constructs a plate of metal — gold, i)latina, silver, or dental alloy — or vulcanite, which last we prefer in ordinary cases. The plate should cap over the bicuspids and such molars as are erupted, and may be made to keep up securely, by our having scraped away the model slightly round, a very little below the necks of the teeth capped, and on their outer surfaces, where consequently the plate grasps them ; the thickness of the plate over these teeth should just prevent the front ones from meeting. Behind each tooth to be pressed out should be sawn a space, of dove-tail form, to be filled up by a piece of soft deal firewood which has been greatly reduced in size by pressure for some hours in a strong vice, the compressed surface of the wood being opposed to the tooth. The plate is intro- duced into the mouth, to which it should attach itself firmly, and then the compressed wood by absorbing moisture swells, and the upper teeth, having now no obstruction from the lower biting in front of them, are pushed rapidly outwards, often in the space of a week, though generally longer, and are carried beyond the lower, so that on removal of the plate they bite in front of them and cannot return to their abnormal position. In the place of the wood a loop of India-rubber, drawn through a small hole in the plate behind the tooth to be pressed out, may be employed ; and is perhaps better where patients are unable to pay frequent visits, but under ordinary conditions we prefer the wood. The patient should be instructed to eat with the plate in the mouth, and to remove it only for cleansing, which should be done thoroughly after every meal. In no case do we recommend plates being tied or fastened in, as injur}"^ may be done to the teeth in even a few days when they cannot be removed for cleansing. In cases amongst the poor, and where the above-mentioned treatment cannot be resorted to, success is occasionally attained by continually holding a paper knife or thin piece of wood so that it rests in front of a lower tooth, and behind an upper that is bitten over; this method requires great perseverance, and probably succeeds only where the patient sleeps with the mouth open. In a few hospital cases we have, by the aid of a thin elastic rubber band, extended 72 MANUAL OF DENTAL SURGERY AND PATHOLOGY. round the head and across the face, where it is padded witli wool to prevent uneven pressure, and then curried behind the misplaced tooth, succeeded in drawing^ it forwards as desired ; in this and the last-mentioned treatment tliin India-rubber, drawn between some of the posterior teeth on each side, will, b}' keeping the mouth from closing, much aid the process; but the irritation thus occasioned cannot be long tolerated. The same retention of the teeth or roots ma}', when the permanent upper incisors, for instance, are erupted anterior to them, which occasionally occurs, cause the latter to project. When the pro- jection is slight, the pressure of the upper lip will generally, after the removal of the obstruction, bring matters right; but, when it is more prominent, they come to rest upon the lower lip, and thus meet with a continual agency, in the form of an elastic cushion, to further projection. For such cases we may employ a somewhat similar j^late to the last, and, by attaching to its palatal surface a small India-rubber ring, draw the [)romi- uent teeth backwards into position : the plate must of course be cut away at the backs of such teeth to enable it to do so. It must be borne in mind that teeth so moved have not, as in the underhung cases, a barrier to prevent their return to the ab- normal positions — there will be nothing but the elasticity of tiie lip; the plate must therefore be worn much longer, namely, until the vacancy in the anterior portions of the alveoli caused by the movements of the teeth have become tilled up with bony material. In the movement of teeth by mechanical means, it is important to bear in mind the fact that the earlier it is attempted after their eruption the more easily it will be otlected,as at that time the teeth are not closely surrounded by bone as they become afterwards. A detained root or tooth may also have the effect of causing an erupting permanent tooth to become twisted on its long axis, 80 that its inner and outer edges become placed in the antero- posterior direction, and its cutting or masticating edge at right angles to the opjiosing tooth of the opposite jaw. When this condition has occurred in an upper central or lateral incisor or cusj»idatus, it has been recommended that where there is a suffi- ciency of room the case shouhl be treated by what nnxy be termed immediate torsion, i. «., by grasping the tooth near its neck with a iiair of forceps, guarded witli tliin leather or other substance IRREGULARITIES IN PERMANENT TEETH. 73 to prevent injury and give firmness, and then steadily but forci- blv rotating it into position. Against such practice when lirst advocated we urged a protest, on the ground of injury likely to occur to vessels and nerves upon which the vitality of a tooth Fiting. Where lateral crowding is threatened, it is rarely desirable to remove the deciduous teeth on either side of tiie erupting per- manent one. It seems probable that the wedging into position tends to enlarge the arch. It not infrequently occurs that from want of room the canines erupt outside of the arch, and the bicuspids are so far into position as to interlock their cusps with those of the o{)posite jaw when occluded. Rather than attempt to jump the bicus- pid cusps over their antagonists, it will generally be best to ex- tract the first bicuspids and allow the canines to fall back into the spaces vacated Ijy the extraction. This avoids the irritation of the tissues and the initiation of abnormal blood currents, which might ultimately induce hypertrophy, or otlier trouble, about the roots. IRREGULARITrES IN PERMANENT TEETH. 83 It has lono; been a rule with dentists to preserve the decidu- ous canines, for their position in the arch is important; they act somewhat like keystones, tending to preserve the regularity and beauty of the curve described by the teeth of the perma- nent denture.] Another cause of irregularity of the permanent teeth in posi- tion, is stated to be the habit of thumb and tongue sucking. It is probably, in such cases, due to some peculiarity in the manner in which the habit is practised ; for we may have, as in the family of the writer, a member who was subject to a con- siderable projection of both temporary and permanent upper incisors, j^et who never had the habit: whilst the next in age, a most inveterate thumb-sucker, has the most perfectly formed arch of a large family. On the other hand, we have under observation a child about five years of age, who invariably sucks the right thumb, and in whom not only the front teeth, but the alveolar process of that side, are abnormally prominent. The treatment, of course, will be the prevention of the habit, and the wearing of a coarse worsted glove will generally effect the object: if not, the continual a]»plication of aloes to the favorite thumb will probably do so. The treatment of irregularities which are the result of tumors will of course consist in attention to the latter. Irregularity in position of the teeth, the result of fracture of the jaw, although coming more under the province of the general than that of the dental surgeon, may, however, in the majority Fiff. 55. Case of fracture of the lower jaw, transversely through the hody, treated by means of a metallic cap, which fits tightly over teeth on each side of the fracture, and thus holds tho fragments in firm apposition. of cases be treated most successfully by the means and appliances which are best known to the latter, and especially in cases where many of tlie teeth are not wanting. To put up a fracture of the lower jaw, where much distortion exists, with a well-adapted 84 MANUAL OF DENTAL SURGERY AND PATHOLOGY. gutta-percha splint, moulded to the chin, and retained by a four-tailed bandaoje, appears to us about as good a means for perpetuating a deformity as would be the jipplication of a plaster-of-Paris bandage to an unreduced fracture in a limb. A simple form of treatment of a fracture in either jaw will Fio-. 56. Model taken from a vertical fnicturo of the lower jaw between the left cuspidatus and first bicuspid. The dotted line, which indicates the fracture, is the line to be sawn through in order to bring the model into the normal position of the jaw. consist in constructing a plate of metal that will cap and securely hold several of the teeth on both sides of the injury. To effect this, wax or plaster impressions are taken of both jaws, the fractured one in its abnormal position ; from these plaster Fig. 57. The engraving nhows how, by means of a cast of the tipper jaw, the two fragments of Fig. r>6 can be placed in precisely the normal position of the lower jaw before the fracture occurred. models are obtained, and that representing the injured jaw sawn through in tlic line of the fracture. The two divided portions arc now fitted by the crowns of the teeth to their corresponding places with the crowns of the teeth in the model of the uninjured jaw, and the relative positions of both — the IRREGULARITIES IN PERMANENT TEETH. 85 bite or articulation — as they existed before the injury are tljus obtained, and the divided portions are again united by plaster. To the model representing the fractured jaw a metal or vul- canite plate is constructed, capping three, four, or more teeth on both sides of the injury as the case may admit. To obtain a good hold, the plate may be lined with gutta-percha, which, at the time of its application, is made warm and retained until cold ; or small screws may, as adopted by Barrett, pass through the sides of the plate and between the teeth at their necks. If, however, a little care be taken in the construction of a metal plate, so that it fits accurately and firmly at the necks of the teeth, the gutta-percha or screws may be dispensed with. Small holes are sometimes drilled in the plates, to admit of syringing and the egress of discharge, but in a plate that merely caps the teeth these will not be required. A double interdental Fio;. 58. Gunning's interdental splint for fractures of either jaw, and in which the sound jaw assists in retaining in position the fragments of the fractured one splint has been devised by Gunning, and is especially adapted to cases in which more than one vertical fracture through the body of the bone exists. It is best constructed of vulcanite, .and consists of an interdental splint for each jaw, constructed in one piece. By it, the two jaws act upon each other, the sound one assisting in holding the injured one in position. The jaws are kept a short distance apart, and an opening between the two splints in front of the mouth admits of the introduction of fluid food without movement of the jaws. The plates may be retained by the screws, but with adults this is not as a rule necessary, as a bandage round the head will keep the two jaws together. But of all appliances devised to this end, and especially for fractures of the lower jaw, the splint of Hammond certainly, in 86 MANUAL OF DENTAL SURGERY AND PATHOLOGY our opinion, appears the most efficacious. It consists of a stout piece of iron wire, bent so as to include the whole dental arch on both sides of it, and soldered at its terminations. When applied to the dental arch, it should just rest upon the gum on Fig. 59. Hammond's splint in situ. either side at the level of the necks of the teeth. When so placed, it is firmly secured to the jaw by passing fine silver or iron binding wire between the teeth at their necks, and attach- ing it to, and twisting it tightly upon, its inner and outer portions. It is a somewhat tedious and unpleasant process, but such labor is well repaid when, as in a case recently treated at St. Bartholomew's Hospital by our esteemed colleague, I. Lyons, the patient within half an hour of its application had eaten a mutton-chop and smoked a pipe with much satisfaction. In the case of edentulous jaws, vulcanite splints may be adapted, but even if lined with soft rubber, a material about as hard as leather, their pressure on the soft mucous membrane can be but ill tolerated, and especially when in the lower jaw they are secured to the chin, by connecting the splint with a gutta- percha cap fitted over the latter. [As a temporary splint for fractures of the jaws, two or three IRREGULARITIES IN PERMANENT TEETH. 87 sizes of silver, or gold, plates struck up like lower impression cups, without handles, might he kept on hand. Cut these open at the incisors to attbrd feeding space, and drill holes to pass wire for binding them together; fill with gutta-percha rendered plastic by heat. They should tiien be pressed upon the teeth, after the fractures are reduced, and wired together to hold the jaws and the parts in jiosition, until more elaborate splints are made, if necessary. This splint, suggested and used by the writer, has been found sufficient, and actual practice on frac- tured jaws has demonstrated that often no other was required.] 88 MANUAL OF DENTAL SURGERY AND PATHOLOGY. CHAPTER IV. IRREGULARITIES IN THE PERMANENT TEETH {continued). II. Congenital and Unavoidable. — The irregularities which we have classed under this head are the result of an undue rela- tionship between the teeth and the maxillse, i. e., w^here the lat- ter are developed in excess as regards the former, and vice versa. The former alternative, by far the less common in the present day, may result in the teeth having abnormal interspaces, and most commonly between the two central incisors of the upper jaw; or, as is not unfrequently the case, a bicuspid may have been erupted so that its lateral surfaces become placed in the reverse position, viz., externally and internally. That, how- ever, which is certainly more common in the present day is where the reverse of the above prevails, and the maxillse, especially their alveolar portions, are not developed commen- surately with the teeth. That such condition prevails to a greater extent now than some generations since, and is apparently on the increase, is, we believe, the unvarying opinion of practi- tioners who have Inid the opportunity of having under observa- tion the mouths of three and often four generations of the same families; and such opinions are confirmed by the comparison of old skulls with those of persons of the present age. The examination of some 200 skulls in the crypt of the church at Hythe, when measured from the anterior fang of one fi.rst upper molar near its neck to tlie same jiortion of the corresponding tooth upon the opposite side of the jaw, gave — greatest width, 2| inches; least width, 2|- inches; average width, 21- inches: which, com})ared with the average in recent skulls, gives an excess in favor of the former, whilst the teeth appeared to be about the same average size formerly as now: "In no single instance was there anything seen approaching to that which under the term 'contracted arch' so commonly exists in the present day ; they all presented an architecture characteristic of IRREGULARITIES IN PERMANENT TEETH. 89 the church that contained them ; tlie Gothic architecture of a more retined period in them also had not as yet made its ap- pearance."^ But what was still more conspicuous in these old skulls was the inclination outwards of the teeth and alveolar Fitr. CO. t f Well-developed upper jaw ia a youth aged about twelve years. processes, of especially the upper jaw, which gave a more promi- nent and consequently more capacious dental arch ; so much so that in many the third molars occupied the position which we now see occupied by the first molars. There can be no doubt but that the chief cause for this departure is that assigned by Darwin^ and Wallace, viz., those altered conditions in the food of man, with tlie less necessity for exercising his teeth and jaws, in an age of advanced civiliza- tion. Together with this explanation must also be considered the effect of a sexual selection or breed ing-in,'' which tends per- petually to continue, and further develo[» an ai)proved type. [Tonsillitis^ has likewise been pointed out as a cause of the contraction of the arches at the bicuspids. The labored breath- ing, from the filling up of the fauces by these swollen glands, ' "Remarks upon the Collection of Skulls in the Crypt of Hythe Church, Kent," by Samuel Cartwright and A. Coleman, Trans. Odont. Soc, vol. iv. p. 221, old series. 2 The Descent of Man, by C. Darwin. * " Reflections on the Cause and Treatment of some forms of Irregularity," by S. Cartwright, Trans. Odont. Soc, vol. iv. p. 114, old series. [* See p. 11, "Oral Deformities," by Norman W. Kiugley, M.D.S., D.D.S., D. Appleton & Co., New York, 1880.] 90 MANUAL OF DENTAL SURGERY AND PATHOLOGY. causes tlie cheeks to be compressed over the lateral parts of the mouth.] One of the characteristics of this type will be a more vertical development of the teeth and alveolar processes, as well as a greater prominence of forehead and chin, so that a straight line would fall nearly parallel with forehead, base of nose, lips, and chin ; whereas in an opposite type, such for instance as is seen in the native of Australia, a line drawn parallel with forehead, base of nose, and upper lip would form an angle with one parallel with lower lip and chin : in the former arrangement a much smaller dental arch exists than in the latter. As man- kind become more refined in their perceptions, the forms most indicative of refinement attract chiefly their admiration; and thus those the most abounding in such characteristics are the most likely to marry, and those the most deficient in them the least likely to do so. In other states of society we see the reverse of this picture: the savage who possesses the greatest physical strength (which is usually met with in a form most wanting in those characteristics of which we have just spoken), becomes usually a chief among his people, and receives the greatest marks of favor from the females of his tribe; and, where polygamy exists, numbers more wives than does he whose Fig. Gl. Imperfectly developed upper jaw with irregular dental arch. The lateral incisors are bitten over by the lower cuspidati. tendencies to refinement render him an object of contempt, and doubtless exclude him from female association. Thus the savage races preserve for ages the characteristics of their class with far IRREGULARITIES IN TERMANENT TEETH 91 less deviation from them than do those in civilized communi- ties ; there being some limits to physical strength and barbarism, there being none to intellectual and moral progress, save in perfection. Whatever may be the causes of a less perfect development of the maxillae, and especially of a more vertical position in the teeth and alveoli, the result must be obvious, supposing the teeth to be normal in regard to size; viz., the dental arch must be irregular, and the most common form which such irregularity will assume will be what our acquaintance with the positions of the permanent teeth just prior to eruption would indicate; Fiij. 62. Imperfectly developed upper jaw, aud where the dental arch assumes the V-shaped form. thus, the central incisors and cuspidati will be unduly prominent in the dental arch, whilst the lateral incisors will be within the dental arch, and, in the upper jaw, most probably bitten over by the inferior cuspidati. In another variety of this form of irregularity we have the teeth fairly in line, but the incisors, especially of the upper jaw, are forced out, often overlapping at the mesial line, and o-ivino; to the arch a V-like form.^ We ' A praiseworthy attempt has recently been made to classify the various forms of normal and abnormal maxillfe that are met with in the present day, by J. Okley Coles, Trans. Odont. Soc, vol. xii. p. 103. The subject, however, requires much careful consideration before any classification of so intricate a subject can be adopted. 92 MANUAL OF DENTAL SURGERY AND PATHOLOGY have regarded this type as caused by the eruption of the cuspidati before the bicuspids, so that they assume earlier a position in the arch at the expense of the incisors, which are driven forwards, although it may of course result as a conse- quence of the position in which the frout teeth are originally developed. Fiff. 63. Imperfectly and ill-developed upper jaw, a case suitable for treatment by expansion of the dental arch. C. S. Tomes has pointed out how this form of irregularity may be explained. Thus, if the cornua of the foetal upper jaw are not in the first Instance divergent, the subse- quently added portions which support the three permanent molar teeth will form an angle in the bicuspid region with that previously existing. The matter is interesting from another point of view viz., in regard to idiocy. Langden Down has pointed out that, in regard to congenital Idiots, there is almost always a diminution of space between the bicuspids, with abnormally high vaulting of the palate. [This cannot be an invariable rule, for repeated examination by Drs. J. "W. White and 'N. W. Kingsley,' of the mouths of the inmates of two large institutions in this country, for the treatment and care of the feeble-minded, has demonstrated that generally the entire digestive apparatus is almost abnormally developed. The jaws and teeth show a perfection of adaptation that corresponds with the Avell-known capacity and the alimen- tary capability of these unfortunates.] [' See Dental Cosmos, April, 1872. "Tlio Tlolalion between the Develop- ment of tlie Mouth and Teeth to Systemic and Mental Development." By Dr. J. W. White. See Kingsley's Oral Deformities, pp. 30-^7, where Drs. White, Peirce, and the writer are quoted as concurring in the above view.] IRREQULARITIES IN PERMANENT TEETH. 93 To such form of irretrularity two methods of treatment present themselves by which the teeth and maxillaj may be brought into harmonious relationship, viz., an expansion of the alveolar and dental arches, or a diminution in the number of teeth. The first naturally commends itself as rational and conservative, especially where the teeth appear sound, and should be attempted where there is not excessive crowdins;, and particularly where one dental arch may be perfectly developed whilst the other is narrow and contracted, and the more so should the ill-developed arch be the upper. The process of treatment will consist,. in the upper jaw, of constructing a plate adapted to the palate and internal surfaces of the teeth ; a removal of a small quantity of the plaster from the model at the necks of the teeth, and between each, will generally insure the firm attachment of the plate, and then, by means of the wedges previously described, the dental arch may be in a few weeks expanded. As the tendency to return to the abnormal condition will be considerable, a plate should be made, adapted to the perfected arch, in order to retain the teeth for several months in their altered position. The same process in the lower jaw is much more difficult to carry out, and generally not nearly so successful in its results; fortunately the teeth in the lower jaw are less seen than in the u|'per, and therefore its treatment by expansion is seldom attempted, unless to improve mastication by a more perfect antagonism of the two dental arches. If attempted, the process will be best eifected by a metallic plate, made to cap the teeth and capable of being expanded by a spring. A more elegant but less rapid process for expanding the upper dental arch than that suggested above consists in con- structing a plate as described — although it will generally be found necessary to cap the teeth in this case — dividing it into two halves in the line of articulation of the palate, and then vulcanizing into each a portion of a spring constructed of piano- forte wire, of the form shown in Fig. 64.^ The objection to the constant breakage of the spring from rusting may be greatly ' For this ingenious device, we believe, we are indebted to Coffin, of London, and the latter suggestion, we are informed, to Kingsley, of New York. J. S. Turner tins his steel springs. 94 MANUAL OF DENTAL SURGERY AND PATHOLOGY. overcome by inserting in the vulcanite a very small piece ot zinc in contact with the wire. The dilatation of the dental arch by this apparatus, though less rapid than by wedging, is one requiring far less constant attention on the part of the Fig. 64. Fio;. 65. Contracted dental arch. CofKii's method lor expanding the same by means of a divided plate and spring formed of pianoforte wire, the back teeth being capped. practitioner, and the most suitable for patients who reside at a distance from him. In the place of the wire spring the jack- screw may be employed. It is vulcanized into a plate of similar construction to that just described, or it may be used Fig. 66. Fig. 67. Til"' f'XpanH'on of a V-shapod arch by means of Codii plate. The back teeth not capped. Tlio jack-screw, three sizes. without any plate at all, viz., by attaching its extremities against the palatal surfaces of two 0[>p08ite teeth. By inserting a small ])in into the central portion and turning it in one direction the jack becomes elongated, and tiiusthe teeth are pressed outwards IRKEGULARITIES IN PERMANENT TEETH. 95 ill the dental arch. There is probably no appliance to equal it in the rapidity with which it effects its object, and it is readily under control of the patient or the patient's guardians. But in the treatment of these cases our attention must not be exclu- sively restricted to the condition of the dental arches; these may be brought into the most perfect symmetry, and yet the result may be anything but gratifying; and this is a matter •which, we think, has not received its due share of attention at the hands of the dental practitioner. Our views on the subject can perhaps be best explained by narrating the history of a very instructive case. About the period when tiie writer entered upon practice, a great deal was written and said on the unjustifiable procedure of removing sound teeth for the purpose of regulating the dental arch, and expansion of the arch to efiect that jturpose was stated to be, under almost every condition, the correct and legitimate treatment. Adopting the views of his seniors, the writer had the opportunity of putting them into practice in the case of a young lady of prepossessing appearance, niuch marred, however, by the irregularity of her teeth, which presented the type tirst described ; thus, as shown in Fig. 61, the upper centrals and cuspidati were unduly prom- inent, whilst the lateral incisors were bitten over by the cus- pidati of the lower jaw. In consequence of this arrangement, Fio;. G8. The same case as Fig. 61 after troatmoiU by expansioa. the chin appeared elongated and unduly prominent, partially underhung. The result of the treatment was an undoubted improvement, the upper front teeth were brought into perfect 96 MANUAL OF DENTAL SURGERY AND PATHOLOGY. regularity, the face shortened, and the chin no longer prominent. In a dental point of view the result might have been considered perfect, but not so in a facial point of view, as the mouth had been rendered undulj' large in proportion to the other features, giving it somewhat of a plebeian aspect. After a year or two, the lower first molars became carious and were removed, as were also the two upper first bicuspids : the effect was, that the dental arches became reduced in size, and the mouth assumed harmony with respect to the other features. Such, then, will be found, in a large number of cases of irregularity by crowding, to be the proper treatment, viz., lessening the number of teeth, which, it has already been stated, are in the present day so often found in excess of development in relation to the maxillae, even when the latter are not out of proportion to the other bones of the cranium. In other points of view, this latter has greac advantage over the former plan, inasmuch as the teeth are less pressed upon by their neighbors, whereby a very fruitful cause of decay is removed ; and also from the considera- tion that plates are less frequently needed, or, if required, are seldom necessary for so long a period. But, if we decide to treat a case of irregularity in position by the removal of teeth, the important questions arise, At what age is it best attempted ? and what teeth shall be selected ? With regard to the age, much must be left to the discretion of the [)ractitioner, and no hard and fast rule can be laid down ; at the same time, we express our conviction that in many cases the practice of removing teeth is adopted much too soon, prob- ably from a disposition to lean to tlie wishes and persuasions of anxious parents ; and the result is, that the spaces thus created fill up too soon from the vis a tergo of the developing molars, which latter, in finding abnormal room in their eruption, fail to effect that full development in the posterior portions of the maxillae which is so dependent upon their presence in the nor- mal situations. We well remember the case of a youth whose age did not exceed fourteen, but who had had the four bicuspids removed from the upper jaw, as well as several teeth from the lower, to afford space. In the upper jaw the first molars were pressing against the cuspidati which were still unduly promi- nent, and the general expression of the individual was quite ruined liy the absence of proper development in the region of IRREGULARITIES IN PERMANENT TEETH. 97 the mouth. In another case, of wliich we give an illustration (Fig. 70), in the lower jaw on the left side one, and on the right both, of the bicuspids had been removed at an early age, and the spaces had quite closed up, but a defective development of the angle between the ramus and the ascending portion of the jaw had resulted, so that the front teeth did not meet when the mouth Avas closed. Other things concurring, we believe the best period for les- Fi.tr. no. Result of an early removal of all of the bicuspids in the upper jaw. selling the occupants of the dental arch will be when the indi- vidual has just erupted, the second molars; and later still if it Fis. 70. Result of an earlv renn dcuspids in the lower jaw. be decided to remove the first molars, and apply mechanical means for devoting the space which they occupy to the benefit 7 98 MANUAL OF DENTAL SURGERY AND PATHOLOGY. of the anterior of the arch, as the second molars will be neces- sary as points of traction. [Dr. Louis Jack has shown that deformities of the month from the injudicious extraction of the first molars are twofold. First, when removed before the second molars are presenting through the gum, the necessity for chewing, and the loss of the grinding faces of these teeth, cause undue use of the anterior teeth ; with unnatural development of the alveolar processes of Fio;. 71. Deformity from too early extraction of sixth year molar. (From Dental Cosmos.) this region, the curving of the lower jaw, by the contraction of the cicatrix, and tension of the anterior portion of the masseter Fiff. 72. Deformity from extraction of sixtli year molar after the eruption of the twelftli year molar. (I'roui Dental Ccsmos.) muscles, and projection outwards of the superior incisors. Secondly, if the extraction be delayed until the second molars have fully erupted, these latter teeth rnny lean towards the IRREOULARITIES IN PERMANENT TEETH. 99 bicuspids, and in many cases the edges of the grinding surfaces of their crowns meet, impairing their use for mastication and favor- ing the retention of food in tlie trianguhir space between the proximal surfaces of tliese teetli and the gum, until decay may add complication to the trouble alread}^ existing.'] With regard to the teeth which ought to be removed, it is even more difficult to lay down any Hxed rules, except, of course, that we should, if it can possibly ettbct our object, take by pre- ference teeth of abnormal form, or teeth so affected by disease that there is no certain prospect of their being permanently saved ; and, indeed, in not attempting removal too soon, we may often have ground for satisfaction in finding that disease has set in, in members which it was not our intention to sacrifice. On the other hand, a very early manifestation of disease would no doubt lead us to prompter treatment. Suppo-^ing that all the teeth appear sound, and tiiere is no urgent reason for our selecting certain teeth in preference to others, we may be satis- factorily guided to our selection by a consideration of the com- parative liability of the teeth to disease, and information on this subject has been provided for us by J. Tomes, whose valual)le table we copy.^ Central incisors 25 Lateral " 63 Canines 36 First bicuspids 227 Second bicuspids B03 First molars 1 090 Second molars 575 Third molars 230 Other practitioners have collected somewhat similar statistics, which in the main agree with that given, and the information gathered therefrom would lead us to sacritice a first molar in preference to any other tooth, provided that in so doing our object could be equally well accomplished, and in like manner a second in preference to a first bicuspid. Cuspidati we should be very loath to remove on the ground also of their being char- acteristic teeth in the dental arch. [' See proceedings of Odontographic Society of Pennsylvania., in Dental Cosmos for May 1874, pp. 252 and 253.] 2 "Analysis of 2638 cases of extraction on account of caries," by J. Tomes, F.R.S., Lectures on Dental Surgery and Anatomj'. 100 MANUAL OF DENTAL SURGERY AND PATHOLOGY The only way in which we can pretend to aid the student in this matter is, by taking: a few tj-pical cases, and the manner in which we should treat them. In case 1 (Figs. 73, 74), where both jaws are generally over-crowded, our best course would no Fitr. 74. i'igs. 73 and 74 represent case 1, in which tlie removal of the first molars from each jaw would be beneficial. doubt be to remove the four first molars. In case 2 (Figs. 75, 76), where the lower arch, though rather imperfectly developed, contains the teeth in a fairly even position, but the upper 'arch is Y-shaped, and the front teeth are unduly prominent, but not resting on the lower li[» when the mouth is closed, we should Fiar. 75. Fiff. 76. KigB. 7i5 and 70 n-jiresent case 2, in which the removal of the first bicuspids of the upper jaw only is advisable. remove the ujipor first bicusi)id8 only, and the action of the lips would ] robably biing tlie projecting teetli into good position. IRREGULARrTIBS IN PERMANENT TEETH, lUl Should the incisors rest upon the lower lip, we must in addition make use of the plate shown in Fig;. 37, p. 73, for drawing them Fig. 78. Figs. 77 and 7S represont case 2, before and alter treatment. The dotted lines show the distance the front teeth have beeu drawn backwards. In 79 the second permanent molars have been erupted. backwards. In case 3 (Fig;^. 79, 80,) we should in the upper jaw remove the second bicuspids, which we should always select in preference to the first, when any suspicion may exist that the space made may not wholly till up, as well as from their greater Fiff. 79. Fi£r. 80. ' ,J %j:^ iK3s*^l Fi^'s. 79 and 80 represent case 3, in which the remova' of the two second bicuspids from the upper and the right laterel incisor from itie lower jaw is to be recommended. [The principal difficulty attending this treatment has been alluded to on page 82] liability to caries; we should also adapt a plate to press out the lateral incisors bitten over by tlie lower cuspidati, and probably also to drawback the upper cuspidati; in the lower jaw we should remove the right lateral incisor. In case -4 (Fig. 66, p. 94), where we have not onl}' prominent incisors resting upon the lip when the mouth is closed, but also a considerable nar- 102 MANUAL OF DENTAL SURGERY AND PATHOLOGY. rowing of the dental arch at its sides, causing the bicuspids and first molars to close more or less within the lower dental arch, we should, the lower arch being well-developed, expand the upper by pressing out the bicuspids and first molars, and, when this is accomplished, draw backwards the front teeth. The cases which we have taken as illustrations could each of them no doubt be satisfactorily treated in the manner suggested, as many almost similar ones daily are, but there are many com- plications which arise, rendering the treatment much more diffi- cult and tedious, and sometimes wholly defeating our efforts, and a few of which we may point out ; thus, in the case of a patient's being underhung, we may without difficulty press out tlie upper front teeth beyond the cutting edges of the lower, but yet the shortness of the former may, after the discontinu- ance of the plate, allow of their return to their old position, and the same thing may occur from the back teeth meeting too soon. In the first case little can be done bej^ond wearing a plate adapted to the palate only for a long time in order to try and retain the teeth in proper p)Osition, and trust that they may drop somewhat after a time when not bitten upon; in the second case we have often found the chin-retractor (Figs. 10 and 11 p. 41), which elevates it as well, of great service, it being of course most applicable in very young subjects. We know how the constant tension of a contracting cicatrix in the neck of a young person will distort the growing inferior maxilla, and on the same principle an effect in the contrary direction may be pro- duced. But perhaps the greatest obstacle to success exists in the cii'cumstance, that the very means which we employ for overcoming one evil is productive of another not less serious in character, and that the constant wearing of plates is a most fertile source of the production of caries. Much may be done by tlie j)atient no doubt to prevent this; thus, the plate, which should never be so attached but that the patient can remove it, should be scrupulously cleansed with soap and precipitated chalk after every meal, as well as the teeth themselves, and the plate and mouth finally rinsed in a weak solution of spirit and water. In one very obstinate case we were tempted to secure in the mouth a plate, having the soft deal wedges before spoken of, by ligatures for about ten days, when it was seen that the enamel had become defective on all the teeth in contact with IRREGULARITIES IN PERMANENT TEETH. 103 the we(lo;e9; an immediate discontiiinance of the plate, and the application of salvolatile to the siiots six times in the day, happily arrested all further mischief, at least so far as it was possible to determine. The same thing has occurred where a platina band went in front of tiie upper incisors, but which the salvolatile treatment appeared also perfectly to arrest. We now generally recommend, that, after thorough cleansing of the plate, all bands should be wiped over with that compound. The mischief is no doubt due to the decomposition of the food which lodges in such places. A question of no little importance is whether, by the timely removal of temporary teeth in contracted arches, more space may be afforded for their successors. It is a subject to which we have long both given and called attention,^ having had reason to believe that thousands, perhaps millions of unhappy children have submitted to operations about as necessary as we now re- gard those of bleeding and gum-lancing as practised some half century ago. To take very common cases, in the lower jaw for instance: when that bone is well developed, we shall observe Fig. 81. • Results of an early removal of the temporary molars in an ill-developed lovrer jaw; the first permanent molars having advanced into an abnormal position. that, as the period of the second dentition approaches, the tem- porary teeth, especially the six front ones, become more promi- nent in the dental arch, and also separated, laterally, from each other, 80 that, as each drops out, room is afforded for its successor (see Fig. 30, p. 67> In imperfectly developed maxillse such prominence and separation do not occur, so that when the first incisor is erupted, it will appear behind its predecessor and par- • Vide Trans. Odont. Soc, old series, vol. iv. p. 237. 104 MANUAL OF DENTAL SURGERY AND PATHOLOGY. tiallj behind the lateral incisor of that side: in like manner the permanent lateral incisor will appear behind the temporary and cuspidatus teeth. [To aid in the expansion and normal development of the jaws, the late Prof. McQuillen always urged the importance of pre- serving the deciduous teeth, by filling and treating them so that their use would be unattended by pain, and he further recom- mended that food requiring considerable force for mastication be given to children — such aliment being seemingly demanded from the well-known tendency of children to gnaw or chew wood, roots, gum, etc.] The treatment was, and is unhappily still, very commonly adopted of removing all interfering temporary teeth, to afford the ijermanent ones room in the dental arch. It did not occur, we think, to those who thus acted, that the limits of the dental arch are almost entirely determined before such treatment commences; that there are fixed points to its limits in the two already erupted permanent molars, which, especially in crowded arches, are ever ready to usurp any room afforded to them in an anterior direction, as shown in Fig. 81 (p. 103), where an early removal of the two second temporary molars is followed by an eruption of the first two permanent ones in abnormally advanced positions. The same advance is always met with in normally developed jaws : the two temporary molars occupy a larger space in the dental arch than do their successors, the two bicuspids, but, as soon as the former are shed, tiie excess of space is usurped by the advance of the permanent molar; a fact which has been generally overlooked, as it has been stated that such space is accorded to accommodate the permanent euspidati. Figs. 82 and 83, drawn from normal pre[)arations, clearly illustrate this point. In well-developed maxillie the earlv removal of the temporary teeth will have little effect up(^n the permanent dental arch. Cases, where all have been removed before the eru[)tion of one permanent tooth, are taken to illustrate this point, but it is certainly very different in the case of a defective maxilla. Thus, as in the cut (Fig. 84) of a case which we treated un- fortunately in this way very man^'" years ago, where the incisors and euspidati of the first series were removed to accommodate the four incisors of the second series, and where everything IRREGULARITIES IN PERMANENT TEETH, 105 looked very satisfactory up to the eruption of tlie euspidati, when two bicuspids had to be removed, and a plate worn to Fia:. 82. Fis;. 83. Figs. 82 and 83 show when compared the usual advance of the first permanent molars after the shedding of the temporary molars ; and that no room is afforded to the teeth anterior to the first molars by the difference in size between the temporaiy molars and the bicuspids. accommodate the euspidati ; it would have been far better for the case, and much more ao;reeable to the patient, had we done nothing farther than remove, if necessary, any temporary teeth whose successors had appeared, when, as in the illustration (Fig. 85), one incisor would eventually have assumed a position ante- rior or posterior to the dental arch, and its removal alone would have effected all that could be desired. It must be distinctly borne in mind that these remarks apply solely to the treatment of the lower jaw, and to the rule that we would lay down — if it 106 MANUAL OF DENTAL SURGERY AND PATHOLOGY be safe to lay down any rule at all in the treatment of irregu- larities in position — viz., simply to remove each temporary tooth as its permanent successor a]^pears: and this indeed not as a Fig. 84. /. yf EesiTlt of the common treatment of removiuy the temporary incisors and cuspidati to give room for the permanent incisors. The incisors appear to be in good position, but no room is left for the permanent cuspidati. matter of great urgency, the tongue always pressing forward the teeth into any space available for them. In the upper jaw this rule cannot apply, as it would often occur that teeth would Fiff. 85. Method of treatment by removing from tho lower jaw tlie temporary teeth only as their succes- sors appear. Hero the removal of the right lower central incisor will be the only treatment nece««ary. be kept within the arch, and bitten over by those of the lower jaw. The temporary teeth must be removed which prevent the permanent ones from assuming their right position; also the IRRE(3ULARITIES IN PERMANENT TEETH, 107 Fiir. 85a. difference in size of the upper incisor teeth with regard to each otlier would, as a rule, forbid our removing one of these to afford space, and we therefore generally select bicuspids or molars. We willingly confess to the imperfect manner in which the important subject contained in this chaj)ter has been treated; but to have done it more justice would have involved a larger space in the volume than we can afford to allot to it. The student desirous of investigating it more deeply may with advantage consult the excellent work of Norman Kingsley on Oral De- formities.' [Dr. M. II. Cryer has exhibited an ingenious device for protect- ing the teeth from injury when undergoing pressure, by means of the jack-screws figured on page 94. It consists of thin platinum bands, encircling the teeth, to protect them from in- jury where the ends of the screw impinge. The bands are fitted and the ends soldered or held together by a small screw passing through and binding them some- what after the fashion of Dr. Farrar's device. Then by burnishing down to the inequalities of the teeth, and filling the spaces between the band and the tooth with a quick setting amalgam, it is made immovable. Into one of these bands a hole is drilled to receive the point of the jack-screw, and upon the other small lugs may be soldered, between which the crotch ends of the jack-screw may fit tightly, and thus be prevented from slipping.] ^•^'mfit Bauds for protecting teeth, to be moved by jack-screws, after model by Dr. M. H. Cryer. ' A Treatise on Oral Deformities as a branch of Mechanical Surger}', by Nor- man W. Kingsley, M.D.S., D.D.S., etc. D. Appletou & Co., New York, 1880. 108 MANUAL OF DENTAL SURGERY AND PATHOLOGY, CHAPTER V. INJURIES TO THE TEETH. Concussion.- — From violence caused by a blow or fall, or where the lower jaw has been driven forcibl}^ ao;ainst the upper, one or more of the teeth may suffer. If slight, it may merely result in tenderness and discomfort for a few days; if more severe, it may result in the death of a tooth, under which circumstance' the tooth after a time usually assumes a pale fawn color, due to extravasation of the vessels of the pulp, and consequent staining of the dentine by the hsemato-globuline of the blood: with this exception, the tooth often continues for years' other- wise quite unimpaired, but occasionally a small gum-boil forms over the apex of its root. Or, again, a tooth so injured may never become quite lirm, and is usually lost at an earlier period than the rest. For such cases, rest for the organ, so far as it can be obtained b}' soft food, and soothing fomentations within the mouth, of which camomile and poppy are the best, will be the only treatment. Dislocation, partial. — The same cause may result in a tooth being loosened in, and partially detached from, its socket, in which case the" alveolus is usually more or less injured, the })eriosteum lacerated, and the vessels and nerves, which enter ' It was our opinion until recently that recovery of its proper color in a tooth Ihat had once lost it, in consequence of a blow, was impossible ; but a case came under our observation in which there was undoubted evidence to the contrary, the brown tint was gradually disappearing from the cutting edge of an upper central incisor towards its neck. In such case we appreliend that extravasation of blood had occurred, but not death of the pulp, and that the blood was being absorbed. [The writer had a patient who, in the lowered vitality from a dangerous attack of typhoid fever, had a lower incisor lose its translucency and present tlie appearance of a dead tootli, which, as she regained her strength and gene- ral tonicity, regained its color until no visible difference existed between it and its healthy fellows.] INJURIES TO THE TEETH. 109 at the radical extremity of the tooth, generally severed. In such cases the moutli should he washed with tepid water until bleeding has ceased, and the tooth or teeth pressed carefully between the finger and thumb, and steadily but forcibly back into their proper positions, whilst the same members of the other hand should simultaneously reduce any displaced portions of alveolus. The above-mentioned applications for concussion may be employed, but great tenderness mny be often relieved by the ai)}»lication of one or two leeches to the neighboring part. [Dr. C, a graduate of both dentistry and medicine, several years since had liis lower incisors and tiie anterior plate of the alveolar process pulled over the lower lip by a liorse stumbling while the rider was putting on gloves, and tem[)orarily holding the reins in his mouth. The teeth were immediately pushed back into their proper position, and now appear as natural as the adjacent ones.] Dislocation, complete. — Should this result of violence occur, the mouth should be washed until bleeding has ceased, when the alveolus is cleared of coagula by cotton, and afterwards by the syringe and tepid water, to insure removal of any i)articles of cotton, tartar, etc.; and the tooth or teeth, as the case may be, which should be freed from all foreign substances and kept immersed in tepid water during the interval, carefully but firmly replaced in their sockets, and the alveoli, probably more injured tlian in the former cases, moulded to their sides as before. In almost all the cases now under consideration, the teeth thus treated will, after a day or two, appear elongated in their sockets, and looser than when replanted, but this, the result of effusion, generally passes oft" in the course of a few days. If the alveolar process has not been much injured, the operation is generally successful, and we should not despair of success even where a tooth has been out of the mouth for several hours. We shall again refer to this subject in the chapter on Replantation and Transplantation. [Dr. H. E. Pfliiger reports having known teeth with extirpated jiulps to again have the cavities filled with sensitive vascular tissue resembling the original. Prof. McQuillen exhibited before the Odontographic Society and Academy of ^'^atural Sciences, in Philadelphia, a pigeon whose cerebrum he had 110 MANUAL OF DENTAL SURGERY AND PATHOLOGY. four-fifths extirpated, and which regained the lost functions. The cranial cavity was refilled with tissue that, on microscopic examination, presented the appearance of typical nerve cells. ^] As the result of violence, an accident almost the reverse of dislocation may occur, viz., where a tooth is driven into and beyond its alveolus. It is more likely to occur to the teeth of the upper than to those of the lower jaw, and in some cases has even effected a perforation of the floor of the nares. The treatment here will be to brin;^ the tooth down to its proper level by the aid of forceps; and in this case a ligature attached to an adjoining tooth or adjoining teeth, to retain it in situ, may be essential ; and there can be no objection to the employ- ment of a ligature, as plenty of space in the alveolus will exist for any exudation to occupy. In the case of ordinary disloca- tion, as we have described it, we do consider the ligature of the replaced tooth to its neighbors, as generally recommended, objectionable, as it prevents the effusion of lymph into the alveolus, which fornis the medium of union between the severed portions of the alveolo-dental membrane. [The writer has a child, who fell and drove the crowns of both superior deciduous central incisors up into the gum, one almost out of sight. They were at once drawn down by forceps to their original position, A few weeks after, the one most displaced by the first accident, was again driven up by a similar fall. This tooth was a second time drawn down, but never recovered com))letely, as it soon showed unmistakable signs of death of the pulp and was shed a year or so afterwards, in advance of its fellow and the presentation of the permanent teeth — which latter, however, came properly into position, and now, as when erupted, are to every test normal.] Fracture of the teeth may be another consequence of violence, and may vary in amount from slight chipping of the enamel to conijtlete division at the neck or elsewhere. Where very slight, it may be attended with no further result than its unsightli- ness. Should, however, a portion of the dentine be involved, it will be generally very sensitive when touched, and also to heat and cold for some time; l)ut, if fractured so as to expose the [' Prnccodings of Odontographic Socii-ty of Pennsylvania and Proceedings of Academy of Natural Sciences of Philadelphia, Feb. 4, 1878, p. 343.] INJURIES TO THE TEETH. Ill pulp, there will be considerable pain on the slightest contact of even soft substances. Fracture may, of course, be complicated with partial or complete dislocation. Treatment. — In the first simple cases we may, by a judicious employment of the file, often lessen the unsightliness; thus, if the chip be at the cutting edge of an incisor, we may, by round- ing it oif, and slightly shortening the tooth, render it scarcely conspicuous. When the dentine lias been exposed, especially in a young subject, we must wait until the sensitiveness has passed off (which may be accelerated by the application of salvolatile or solution of zinc chloride) before the file can be employed, and we may often with advantage sacrifice a little of the enamel of the contiguous teeth. When, however, the tooth has been much fractured, and especially if the pulp has been exposed, one of two alternatives must be adojited, — either the destruction of the pulp, or the removal of tlie tooth, — our decisions as to which, will depend upon the nature of the fracture, the age at which it occurs, the crowding or otherwise of the teeth, and their relative sizes. Should the fracture include more than a small portion below the neck of the tooth, or be accompanied with much injury to the alveolus, we should without hesita- tion at once extract. Should it occur in a patient over fifteen years of age whose teeth are not crowded, and should the frac- ture not extend obliquely below, or much below, the surface of the gum, we should adopt the former plan, the process for which we shall hereafter describe, and 8U[)ply the patient with an arti- ficial tooth to be attached to the root of the fractured tooth. Should, however, the patient be under fifteen, when the fang of an incisor or cuspidatus is not fully developed, and also when there exists no very marked difference in size between the various front teeth, with es[)ecially a tendency to crowding, or, at all events, to the teeth not being separated from each other, we shall then do best to extract, as we may feel pretty sure that without, but alniost certain that with, mechanical aid, the space will in time be quite filled up. We removed, about two years ago, a large upper central incisor from the mouth of a little girl aged ten, and a year afterwards its fellow: the lateral incisors now meet closely together, and the mouth looks far better than it did at first, as the teeth in question were abnor- mally developed. The}- were removed on account of caries. 112 MANTAL OF DENTAL SURGERY AND PATHOLOGY. [This recalls, of two cases bearing upon the subject, one of u young lady who had lost the left central incisor at lifteen, Avhich space was completely obliterated, and the mouth and teeth were comely and shapely ; the other of a lad of eleven years, whose central incisor was broken by a stone thrown against the tooth, s[)litting the root longitudinally, and completely destroying the crown. Acting ujjou the experience of the first case, wdjich was originally under the care of another dentist, this Avas similarly treated and the remains of the root were at once removed. Within four years the space lias almost closed.] The uniting of the portions of a fractured fang is so very rare an event that we can hardly ever look for its occurrence ; nevertheless, as cases have been recorded, we should at all events be in no great hurry to extract where such event has occurred. The favorable cases would no doubt be in young persons, where, of course, the vitality of the pulp has not been destroyed or the periosteum much injured. The medium of union in such cases appears to be cementum, but the pulp in the region of the fracture had in one case recorded become calcified. Teeth fractured by violence in their fangs may be retained with moderate firmness Iw the periosteum for some time, but they sooner or later become a source of inconvenience, and the crown portion either has to be removed, or becomes loose a)id drops out; still we. have seen them so retained for several years. Two cases are recorded where a ^ ■ tooth had been fractured by violence, and the crown portion removed, but the pul[» left had been converted into secondary dentine of more than normal dimensions; also another, where the same accident occurred, but where the surface of the retained portion became coated with cemen- tun].^ The only recorded case of impacted ■", . fracture of a tooth is, we believe, one we com- Ca»c of im- ' imcted fracture muuicated to the Odoiitological Society.^ The )n an upper inci- ^^ interesting, inasmuch as the existence wor tooth. llie o" two fragment of thc tVacturc was uot discovcrcd until after the (love-tail into , ,, ^ ^ i •. ^ i .•arh other. tootl) was cxtractcd ; it was an upper central ' A System of Dental Snrgeiy, by John Tomes, F.R.S. '^ Trans. Odont. Soc, vol. xi. p. 140. INJURIES TO THE TEETH. llo incisor, and one practitioner of eminence had even drilled through the crown, and j)arlially removed the contents of and filled the pulp-cavity to relieve periostitis, without jterceiving the mischief. It occurred in the person of a youth of fourteen, and was certaitdy a most favorable case for re-union, as the two fragments were immovable and kept in accurate position for three years, but the violence of the shock had caused death of the pulp. Under the term "dilaceration" J. Tomes has described a con- dition supposed to be due to violence, in which the crown of a tooth is found bent at a considerable angle to its fang ; a section in such a case will exhibit the dentinal tubules abruptly bent or deviated at such angle. We have ever been inclined to regard sucli deviation as more deiiendent upon the ordinary lines of development having become abruptly altered ; and this view has been entertained by others:^ at tlie same time, a blow or other violence might readily determine an altered course of development, which we can readily comprehend if we adopt the views already given with regard to the growth of bone resulting in the eruption of the teeth ; thus, in a tooth, the crown of which is just or nearly develojied, any condition that would cause tlie surrounding growing bone to advance to the surface in an altered direction would naturally alter the relationship of that portion of the tooth to the rest. In a very well marked case of this de- formity, a central incisor of the upper jaw, which we handed to J. Tomes, and which, we believe, he has figured in one of liis works, there was a distinct history of violence at the period when the crown of such tooth would have been nearly calcified, but the character of the violence rendered it difficult to imagine that its results could have affected one tooth only, or have affected it 80 as to cause its being so much bent upon its fang. ' The Pathology of the Teeth, by Carl Wedl. 114 MANUAL OF DENTAL SURGERY AND PATHOLOGY, CHAPTEE VI. DENTAL CARIES. To the dental practitioner there can be no subject more im- portant or interesting tlian the disease which bears the above- mentioned designation, for of the cases which come before him some ninety per cent, will most probably be more or less depend- ent upon its presence or its results. Its interest, too, is enhanced by the fact that it is a disease much more common to civilized than to uncivilized communities, and is undoubtedly, but le?s happily, like civilization, greatly on the increase. That such is the case, we accept again the experience of those who have had under observation the mouths of several generations in the same families, as well as avail ourselves of the results of our own practical examination of the skulls of past generations as com- pared with those of individuals now living.^ There is, probably, no disease so common to the civilized portion of the human race in the present day as dental caries; so much so, that it is rare to find a mouth in which some manifestation of its ravages is not present, or an individual so fortunate as to have never ex- perienced the pain which commonly accompanies it. IlTeverthe- less, it is remarkable that no one amongst its numerous and talented investigators has yet offered for a disease so common and ap[>arently so favoral)le for observation an explanation of its causes or nature that has been at all generally accepted by dental practitioners. The most diversified and opposite views have been i)Ut forward, and to the speculative here are theories to the heart's content. It will be our duty to notice the most important of these, but we shall first attempt to describe what actually takes place if we watch the disease from its commence- ment to its termination. According to our own observations, made when it has com- ' Trans. Odont. Soc, vol. iv. p 227, old series. DENTAL CARIES. 115 menced in positions favorable for observation, the first mani- festation of its existence bas been a small whitish o[)aque spot on the enamel as contrasted with the yellowish and somewhat A section of tooth affected with caries. On the upper part at the ri{,'ht side will be seen a small piUtion of enamel involved ; the rods appear more distinct than when normal, and also exhibit the transverse markings. In the affected dentine the tubuli appear more distinct, with tendency to separate from each other ; the di.seased portions are seen dipping down amongst the healthy structure in the direction of the pulp cavity. That portion situated between the diseased and healthy tissue, and where the markings of the tubuli are less distinct, is the translucent zone of Tomes. (From a section in possession of the author.) opalescent appearance of that structure. In its progress it gene- rally assumes a somewhat darker, light brown, or fawn color, though this much depends ujion the rate of its progress, for where tins is very rapid, a light color is maintained through- out. Microscopical examination at the earliest stages, which it is difficult to conduct owing to the friable nature of the enamel,^ shows this structure to possess an orange-brown hue in the parts affected, especially in the basis-substance of the enamel rods, which latter have their outlines more distinct than when nor- mal : they also present transverse markings which are seldom seen, or seen distinctly, in the perfect tissue. In the interstices ' Dr. Frank Abbott, Dental Cosmos, vol. xxi. p. 59, recommends the follow- ing method as emplo3-ed by Dr. Bodccker, viz. : — A section sawn frcmi a carious tooth perfectly fresh should be ground by a corundum wheel under the surface of water, and, when sufficiently thin, im- mersed in a dilute solution of chromic acid, viz., | per cent., for tAventy-four hours : it should be then stained in carmine solution and mounted in a mixture of glycerine and water, two parts of the former to one of the latter. lllj MANUAL OF DENTAL SURGERY AND PATUOLOGY. between the enamel rods some investigators^ have discovered delicate beaded fibres, which may be stained by carmine, whilst on the outer surface appear fiat epithelial-like bodies, supposed to be the remnants of ll^asmyth's membrane. At the earliest stages, when only the enamel is aft'ected, we find no traces of lejitothrix or micrococci, to the presence of which in causing or promoting dental caries some writers have attached much im- portance. [A theory has been advanced that these parasites, which may be found in mouths where the teeth are perfectly sound and without any unfilled cavities of decay, have lodged in the carious places simply as locations where they are partially pro- tected from dislodgment by the breath, drink, or food, as fissured rocks will sui^port vegetable or animal life in the crevices, while the smooth surfaces, exposed to the winds and rains, are bare (^f vegetation.] As the disease advances, the subjacent dentine becomes in- volved, and, it being a much less dense and less homogeneous structure than the enamel, the disorganization takes place in it more rapidly, the lime-salts disappear, leaving the gelatinous basis-substance much in the same condition as it was when its calcification took place. In some cases, those of so-called chalk}' decay, it would ai>pear as if the calcified structure broke down at once. In both the enamel and dentine the greatest destruction appears at the outer surfaces, z. e., the part first attacked, for dental caries arises from without, not from within, a tooth, and this will give to th-e parts atfected cone-like forms; in the enamel one having its base at the surface whilst its truncated apex is in apposition to the base of that of the dentine, which is a larger and more [lerfect representation of tliis figure. In the dentine it imrsucs its course in the direction of the dentinal tubuli, i. c, towards the pulp-cavity into which they open, ^^licroscopical examination at this period^ shows the enamel more broken up ' Dr. Frank Abbott, Dental Cosmos, vol. xxi. p. 62. 2 Dr. Frank Abbott, op. cit., recommends the following process : The carious tooth, or a suitable portion of it, sliould be immersed for two months in a 1 per cent, solution of chromic acid, to wliich a few drops of dilute hydrochloric acid should be added every other day, the mixture being changed weekly ; at the •end of the two months the tooth should be embedded in warm paraflfine, to which a little beeswax has been added, and, when it is cold, sections should be cutoff with a razor, stained with carmine, and mounted in the glycerine solution. DENTAL CARIES 117 and disorganized than in the former case, and the subjacent dentine of a yellowish color, having; festoon-slinped boundaries sei)arati!ig it from the healthy structure; whilst, especially in acute cases, portions having the j-ellow color are seen dipping down at some distance from the principal centre of the disease towards the |)ulp-cavit3'. At the margin of the diseased struc- ture the dentinal tubuli ajipear less distinct than they do in the l>erfectl3^ healthy tissue nearer the i)ul})-cavity ; viewed with a low power this portion has a zone-like form, the zone of Tomes, who regarded it as a consolidation of the contents of the tubuli, an effort of nature, in fact, to put a barrier between the healthy and diseased structures ; other and later observers have, however, regarded it as a result of diseased action producing an absolute exclusion of air from the tubuli, thus rendering them invisible when viewed hy transmitted light, but amongst several living authorities the views of J. Tomes are still adopted. [Fig, 89 Fig. 88. [Fig. 89. The tobacco-pipe-stem appearance(Tonies) ; the drawing is made from a specimen of the chalky decay. was drawn from a microscopical sec- tion made from a tooth where the translucent zone was found beneath a gold filling. Prof. McQuillen had a section where this zone was shown to have formed under a retaining pit in a tooth that had been successfully filled with gold.] At the more aftected portions, i. c, nearer to the surface, we observe the tubular structure of the dentine to be more apparent than in the healthy tissue, and for the reason, doubtless, that the in- tertubular substance is the first to be attacked, the walls or external portions of the tul)uli appearing to possess a e:reater power of resistance. When the disccised portion is seen in Translucent zone in a tooth that had been filled with guld] 118 MANUAL OF DENTAL SURGERY AND PATHOLOGY. transverse, or in partially transverse, sectioii, its appearance reminds us of a bundle of tobacco-pipes when broken short off in their stems, as described and ligured by J. Tomes.^ But a section, cut so as to exhibit the results of the disease at various distances from the surface and viewed by a very high power,^ Fis;. 90. ^^' Cross-section of carious dentine magnified 1000 diameters, copied from Dr. Frank Abbott's ex- ceHent paper in the Dental Cosmos (vol. xxi. p. 117) ; a, canaliculi, with radiated offshoots, in the healthy tissue ; 6, the same enlarged by extension of disease and exhibiting granules and threads which take up carmine ; c and d, the same more affected by disease ; e, canaliculi enlarged to ten or fifteen times their ordinary diameters, and filled with partly-nucleated protoplasm ;/and g, confluence of two or more canaliculi ; h, basis substance entirely disappeared, and beyond this a disintegrated mass composed probably in great part of micrococci. shows, at its neighborhood to the healthy tissue, the canaliculi unaflected ; but as the decayed surface is approached, these are enlarged, and tilled apparently with granules and threads, which receive the staining of carmine; still nearer to the surface they are enlarged to two or three times their normal diameters, exhibiting within them a network of living matter, and occa- sionally, where more enlarged, nuclei also. Further outwards ' System of Dental Surgery, 2cl edit. p. 29R. * Dr. Frank Abbott, Dental Cosmos, vol. xxi. p. IIG. DENTAL CARIES, 119 they are so extended that several become confluent; as this increases, the hasis substance disappears, the outern)ost layer consisting of a disintegrated mass of tissue mixed up with micrococci and liptotlirix. Fio;. 91. Fragment of dentine covered on its surface, and interstices with leptotlirix and micrococci. The drawing must be regarded as diagrammatic rather than accurate. If a portion of carious dentine be tested with litmus-paper, it will be found to possess a strong acid reaction, wliilst in a healthy tooth the dentine — probably the contents of the cana- liculi — yields a decidedly alkaline reaction. The acid reaction of carious dentine we have accounted for by the neutral phos- phates of lime which are incorporated with the basis substance becoming converted into the soluble acid phosphate, the hypo- phosphate of lime. To revert to our general observation of the process, we next, probably, get the eflects of mechanical strain on the enamel, which is imperfectly supported by the subjacent soft- ened dentine, and breaks down, leaving a more or less exposed cavity. Where the disease has been very rapid and interstitial, I, e., occurring between teeth, the breaking of the enamel is often the first intimation to tlie patient of what has existed, he not unfrequently attributing the fracture to an accident in mastica- tion, and the decay as sequence to and result oi the accident : where it has been less rapid, the enamel disintegrates in minute particles. In both cases the progress of the disease 120 MANUAL OF DENTAL SURGERY AND PATHOLOGY. becomes more rapid when an actual cavitj' exists, one at least that can readily retain portions of food, and ere long in the natural order of events the pulp-cavity becomes invaded. Such, however, is not always the case, for it may happen, and this is more likely where the disease advances very slowly, that the pulp becomes calcified — converted, that is, into Avhat has been termed secondary dentine; and, indeed, in almost all cases, even in the most rapid, we shall find that some attempt, the result no doubt of irritation, has been made by the pulp in this direction. The consequence of exposure of the pulp is usually its inflammation, and, owing to the attendant effusion into a structure surrounded with unyielding walls, the pain set up is generally most acute; in many cases, however, we find the pulp exposed in the progress of caries where pain has never been experienced, except, perhaps, when pressed upon by food, and where we may doubtless rightly infer that severe inflamnjatory action has never set in. Pain is, however, often felt before the pulp is actually exposed ; sometimes in the very earliest stages, and, indeed, in a few cases, before any actual manifestation of the disease is discernible, but where, at the spot referred to, the disease after a time makes its appearance. Exposure of the pulp is usually attended with ulceration of its surface, and with such ulceration more or less exudation of serous or sangui no- serous fluid. Tliis has generallj^ been spoken of as suppuration of the pul[t; but, althougli actual pus may occasionally be formed by the pulp, it is very dift'erent from the first-named fluid, and contains only a small proportion of the debris of the white corpuscles. The crimson surface of an exposed pulp is most comparable to that of the "irritable ulcer," and the fluid exuded not dissimilar, exce})t that it decomposes more rapidly, emitting a most otfensive cadaverous smell. Tlie reaction of this fluid is alkaline, and it certainly tends to neutralize the acid condition of the dentine at least at the surface, for we have found it acid a short distance below, and thus probably, as lias been pointed out, to some extent retards the progress of the disease, whilst the pulj) gradual!}' sloughs away more or less rapidly. The pulp being lost, the dentine softens ra[)idly, the enamel breaking away as its support is withdrawn from it, until tiie carious surface becomes level, or nearly so, with tiie DENTAL CARIES. 121 surroundiiio: sjnni, wliere, from protection of surface hy the latter, aided probably by that other protection aojainst decom- position which livinor substances exert towards organic bodies in their immediate vicinity, the softening of the dentine of the fang or fangs advances much more slowly. Still the residue, gradually carried to the surface by the process which we have described, becomes continually diminished until its hold on the mucous membrane is so slight that it falls away under the friction of tlie tongue or in mastication. Such, then, is the ordinary career of a carious tooth from its commencement to its end. Many variations in the process occur, but the conditions above described may be considered typical ; and now the far more difficult task devolves upon us of attempting to describe briefly, and with justice to tlie authors, the various theories whicl) have been propounded to account for it. Hunter, who, amongst modern pathologists, was one of the first to investigate dental diseases, and give to them the promi- nence which they deserved, denominated this as "the decay of the teeth arising from rottenness;" but that he implied something difterent from what we now generally comprehend by slow chemical decomposition of animal or vegetable substances is evident from his statement " that such decay would appear to deserve the name of mortification;" and still something more, for " the simple death of the part would produce but little effect," and he suspects that during life there is some operation going on which produces a change in the diseased part. When it attacks the bony part of a tooth, it appears first to destroy the earth, as the bony part becomes softer and softer. It begiiis sometimes in the inside of a tooth, although but rarely: if it always so commenced, it might have been supposed to arise from a deficiency of nourishment from some fault in the vascular system, but, as it most commonly begins externally, where the teeth in their most sound state receive little or no nourishment, it cannot be referred to that cause. It does not arise from external injury or from menstrua, which have a power of dissolving part of a tooth, for such could not act so partially ; and it is reasonable to su[)pose that it is a disease arising originally in the tooth itself, because, when once the shell of the tooth has given way to the cavity, the cavity itself soon becomes 122 MANUAL OF DENTAL SURGERY AND PATHOLOGY. diseased in the same way: in a sound tooth broken by accident no such quick decay ensues. From a perusal of Hunter's work,' it can scarcely be gathered that that great man held any very distinct theory or definite views upon the causes and nature of dental caries ; although with regard to it, and what is observed duringi its progress, he writes with a clearness which is a characteristic of all his works. Fox,2 who wrote about a quarter of a century later than Hunter, alludes to the disease as "caries, or, as it is most coni- monly called, decay," showing that it had received the former designation, — though by whom we have not been able to ascer- tain, — since the period in which Hunter's work was published. He states, in opposition to Hunter, that the disease originates from within the tooth, i. e., "the bony part of the crown of the tooth," and "that when it has made some progress internallj', a small opaque spot appears on the enamel," etc. "The proximate cause of caries appears to be an inflammation in the bone of the crown of the tooth, which, on account of its peculiar structure, terminates in mortification." Again, the cause of the mortifica- tion in the bone of the tooth is inflammation occurring to the dental pulp, "occasioned by any excitement that produces irregular action," and which, " when inflamed, separates from the bone, and the death of the tooth is the consequence," in the like manner " that a caries of other bones is caused by a sepa- ration of those membranes which cover them and which are attached to them." It is evident, from what is stated above, that Fox attempted to show the similarity of dental caries to that disease in bone, adopting the theories respecting the latter prevalent in his day. The next writer of eminence is Thomas Bell,^ whose work ap[)eared about thirty years after the last-named, and whose views do not so very materially difl:er from his. During the period just mentioned more correct views had come to be enter- tained in regard to diseases in bone generally, the structure of ' The Natural History of the Human Teeth, by John Hunter. 2 Tlie Natural History and Diseases of the Human Teeth, by Joseph Fox. * Tlie Anatomy, Physiology, and Diseases of the Teeth, by Thomas Bell, F.Il.C.S., etc. DENTAL CARIES. 123 that tissue being; better understood. Bell commences bj severe strictures on the name " caiies," which he considers " is totally misapplied," and desires to substitute for it "gangrene of the teetli," "as the disease has not the slightest analogy to true caries in bone." "Its proximate cause is inflammation in the bony structure of the tooth, set up by cold or any other cause, and the part which suffers the most severely is unable, from its possessing comi)aratively but a small degree of vital power, to recover from the effects of the inflammation, and mortification of that part is the consequence." Roots that have lost their vitality, owing to the destruction of the pulp, " are no longer the subject of disease, and often continue for years in nearly the same apparent state." Robertson, of Birmingham, in a work almost exclusively devoted to this subject, and published in 1835,' adopts a wholly different view from either of the foregoing, believing the disease to be essentially the result of a chemical action U[ion the teeth. " The only cause capable of explaining the partial operation and the particular situations of decay is the corrosive or chemical action of the solid particles of food which have been retained and have undergone a process of putrefaction, or fermentation, in the several parts of the teeth best adapted for their reception," At the time when Robertson wrote, the true structure of den- tine was but little understood ; he held that the sole object of the pulp was to supply' additional bone to the tooth when worn by mastication ; but, if so, why a pulp-cavity at all? Even wiien the researches of J. Tomes with regard to the contents of the dentinal tubuli had been made known, this writer still held that the office of the pulp or bloodvessels was not to supply' nutriment to the bone of the tooth, but for the object above mentioned;^ but then he avows himself a disbeliever in the value of micro- scopic research in throwing light upon either the cause or the nature of dental caries. John Tomes,^ w^hose opinions have generally received the appellation of the Chemico-Vital Theory of Dental Caries, and ' A Practical Treatise on the Disease;; of the Teeth, in which the Origin and Nature of Decay are Exphiined, etc., b}' William Robertson. 2 Trans. Odont. Soc, vol. i. p. 101. ' A Course of Lectures on Dental Physiology and Surgery, by John Tomes, 1848. 124 MANUAL OF DENTAL SURGERY AND PATHOLOGy. are a happy combination of the two very opposite views which had been advanced, believes that it " may be defined as the death and subsequent progressive decomposition of a part or a whole of the tooth ;" that with the loss of its vitality the dentine loses also its power of resisting chemical action, and tliat consequently the dead part is, under favoring circumstances, decomposed by the fluids of tlie niouth; "that there njust be a concurrence of dead dental tissue and of a condition of the oral fluids capable of decomposing the dead [lart before the phenomena of caries can be developed;" that in the course of its progress there are dis- tinct evidences of vital action, to wit, the transparent zone, the formation of secondary dentine in the pulp, and the occurrence of pain in a tooth often long before the disease has encroached upon the pulp-cavit}'. The manner in which the decomposition of the dead dentine is brought about is by the chemical solution of its earthy ingredients, the solvents being probably furnished by the saliva in abnormal condition, especially when containing excess of acid mucus. It is also suggested in a note that the decomposition of the gelatine may furnish an acid of sufiicient strength to rob the contiguous dentine of its lime. The pre- disposing causes of dental caries have for the most part a struc- tural origin, they are faults in the development of the dental tissues, and especially of the enamel : such are the pits in honey- combed teeth, abnormal depth in the fissures on the masticating surfaces of teeth, imperfections in the enamel fibres themselves, and imperfections in their union with each other, and in the dentine an imperfect calcification of that structure. Fevers, a scrofulous diathesis, salivation, indigestion, a low damp situation, are amongst the general predisposing causes. "Circumstances which favor the chemical decomposition of the dental tissues may lead also to the loss of vitality which renders them sus- ceptible of decomposition. Thus caries may, no doubt, be ex- cited by the local application of numerous substances, such as the mineral acids, either when incautiously taken in medicine or in sweetmeats, and also by the presence of the gastric acids eructated during a fit of indigestion." In a later work' than that from which we have quoted, the same views are maintained, though more stress is laid upon the ' A System of Dental Surgery, by John Tomes, F.R.S., 1859. DENTAL CARIES. 125 influence of acid mucus in the process; hut the saliva or even the stomach may supply the necessary acid hy whicii the vitality of the part is destroyed and decomposition succeeds the loss of life. In the latest work of this author, edited also hy his son, C. S. Tomes,' the leaning is evidently towards the views of Rohertson, which have recently received some confirmation at the hands of Masjitot, Leher and Rottenstein, and Wedl, all of whom more or less avow that the conditions observed in carious teeth are to be met with in human teeth and hippopotamus ivory which have been emploj^ed as artificial substitutes in the mouth. Thus, accordini^ to this author, "there is an over- whelming body of evidence to show that caries — in so far as it is a process of disintegration — has no relation whatever to the connection of the teeth with the living body." The translucent zone of the earlier works is in this no longer an evidence of a vital action occurring in the progress of the disease, but a result of chemical decomposition of the dentine, as adduced by Wedl and Leber and Rottenstein, but in opposition to Magitot and Salter. Finally, the conclusion is, " that, inasmuch as no characteristic appearances can be found to distinguish caries as occurring in living from that attacking dead teeth, it seems that the hypothesis of vital action in any way modifying the disease must be abandoned in (olo, and dental caries cannot, strictly speaking, be said to have any ' pathology.' " Bridgman, who "^vas the successful candidate for a prize essay on dental caries,^ attributes the phenomena witnessed in that . disease to purely electrical conditions. He compares the mouth to an electrolytic apparatus, in which the crowns of the teeth represent under ordinary conditions the positive electrodes, whilst their roots, with the cutis, etc., represent the negative electrodes, the saliva of course being the electrolyte. When certain abnormal conditions in the saliva or vascular system exist, then electrical action is set up with such intensity that the positive pole, the crown of a tooth, yields up its lime salts, which pass to the negative pole represented by the root, where > A System of Dental Surgery, by John Tomes, F.R.S., etc., and C. S. Tomes, M.A. 1873. " Tiaus. Odont. Soc, vol iii. p. 369. 126 MANUAL OF DENTAL SURGERY AND PATHOLOGY. they are at times deposited as tartar. It is impossible in a short statement to do justice to a theory which, although at variance with certain facts as we now know them to exist, is nevertheless maintained by much ingenious argument. Spence Bate, of Plymouth, attributes dental caries^ chiefly to the presence of carbonic acid in abnormal positions and in abnormal quantities. A death and decomposition of the mem- brane covering the enamel will furnish this acid in a nascent state, in which condition it will act readily upon the lime-salts of the subjacent structure, especially if tliat structure be imper- fectly developed. When the disease has reached the dentine, the dentinal tubuli become opened, and empty tlieir contents into the carious cavity, wliich likewise decomposing furnish further sui>plies of nascent carbonic acid to continue and aug- ment the process. Finally, Leber and E-ottenstein^ advocate the view that the disease in question is mainly due to the presence of the lep- tothrix. As this cryptogamic growth is not met with in the earlier stages of caries, when confined to the enamel only, they apprehend that portion of the process to be due to the solvent action of an acid ; but, when the subjacent dentine becomes ex- posed, then the leptothrix, finding its w^ay into the dentinal canals, etiects a rapid disintegration of the dentine. Of the various opinions advanced, that which most accords with our own views is the so-called chemieo-vital theory of J. Tomes, notwithstanding that, as stated in the last edition of his work, the editors have followed the opinions of certain Con- tinental writers, who, judging from the comparison of micro- scopical preparations obtained from carious teeth, and teeth softened and acted upon by food and oral fluids when attached to artificial dentures, have adopted ap[)arently the purely chemi- cal theory of Robertson. Tiiat the conditions prevailing in the progress of dental caries are dissimilar to those which take place in the inflan)mation of most soft structures, which are hyper- femia, ettusion, cell-migration, softening, fatty degeneration, etc. etc., we can readily admit, without denying to the process a pathological character. ' The Piithology of Dental Caries, by C. Spence Bate, F.R.S., Trans. Odont. Soc., vol. iv. p. 40. 2 Kecherches sur la Carie Dentaire, par Leber et Roltenstein, Paris, 18G8. DENTAL CARIES. 127 The teeth of every person must in the mouth, like every other portion of the body — the hair, nails, and skin included — be continually exposed to conditions, which, but for a i)revailing something, would ere long subject them to those chauges which all highly com[)lex nitrogenous bodies undergo when removed from its s[ihere or influence. It is this jirevailing something, ceasing or changing with the loss of life in an individual, that immediately permits the existence of those affinities, or no longer opposes their action, which tend to break u[) into simpler forms the more complex chemical com})Ounds of which an animal or vegetable body consists, and to which consequently we apply the vague term " vital force," which, if actually a force, is probably not more distinct from the chemical than the latter is from the electrical, or any of the so-called forces ; indeed, it may be only one manifestation of the chemical force. Whilst this exists or remains unchanged, the teeth are, so to speak, protected from conditions, viz., moisture, warmth, action of acids, and bodies themselves undergoing change and decom- position, which Avould otherwise certainly allow the exercise which those affinities are ever exerting to break up complex organic compounds. We are prepared to grant that such affinities may when strong overcome that resistance, as well as have their full action when it is weakened, changed, or withdrawn, but this would in our eyes constitute it a pathological process.^ If we follow its course as we have described it, we shall find, as a rule, that the disease continues to be more circumscribed and limited 1 That the microscopical appearances as exhibited in the decay that occurs in teeth employed as artificial substitutes should closely resemble the same in teeth naturally attached in the mouth is rather what we should look for, and, to our mind, is no evidence that the process is not a patliological one, both having been brought into the same or nearly similar condition by pathological processes ; tiie former by probably tlie death of the whole individual of whom the tooth formed a part, the latter by the death of the portion of the tooth attacked, the conditions of the subsequent decomposition being almost precisely the same. If we are bound to assert that the loss of vitality in the dentine of a living tooth is a result of inflammatory action, then we must admit that our evidences of its existence are very small ; recent research would rather tend to show that it might be so, and, in the case of affected cementum, there is every ground for believing it to be so ; but the loss of vitality in a part may occur independently of iiitlammator}' action, and yet, we presume, deserve the ap- pellation of pathological. 128 MANUAL OF DENTAL SURGERY AND PATHOLOGY. SO long as the pulp retains its vitality; with the loss of vitality a much more general softening of the surrounding dentine ensues, which is more comparable to tliat of natural teeth attached to artiticial dentures. Our views, which on the whole differ but little from those of J. Tomes, are that the disease arises from the action of particles of food, or mucus, or the com- bination of both, undergoing decomposition in contact with the teeth at parts where, owing to certain conditions, that influence which protects living structures is weakened or absent. The favoring conditions will be imperfection in development, either in the structure itself, or in the form of the teeth, whereby a greater opportunity for the lodgment and retention of food and mucus is afforded. This latter alone, we are ])repared to admit, may in time be al)le to overcome the resisting force where otherwise the development may not be imperfect. To the acids formed in such decomposition of food and mucus has been generally assigned the entire agency in the work; but, whilst admitting the great importance of the part they piny, we cannot but believe that another condition is largely concerned in it, viz., that arising from the contact of bodies undergoing molecular change u[)on bodies in a stable condition. This, tliough no longer allowed to be the potential agency in fermentation, is still admitted to exist in the case of bodies in a state of putrefac- tion. Fermentation, in which the leptothrix may play no un- important part, probably does take pl^ce to some extent in the food collected in a carious cavity, and may produce the acids which certainly assist in the process. Experiments which we made some years ago,^ where carious teeth, from which all softened dentine had been removed, were exposed to the action of different kinds of food contained in loosely covered vessels, and mixed some with water and some with water and saliva, and kept at about 100° F. for twenty days, showed that the greatest amount of change was not always in proportion to the greatest amount of acid geneiated, or even to the character of the acid. Ordinary baker's bread in a solution of water and saliva was the most active, although the solution was far less rich in those acids which are known to decompose most readily the pliosphates of lime than was the case in a similar experi- ' "On tlie Nature of Dental Caries," Trans. Odont. Soc, vol. iii. p. 80. DENTAL CARIES. 129 ment with cane-sugar, water, and saliva. The appearance, too, of the softened dentine in the bread and saliva experiment cer- tainly more closely resembled that obtained from a carious tooth than in any other. In the case of teeth exposed under the same conditions in vessels including; meat and water, and meat, water, and saliva, no softening whatever took place, but it must be admitted that the liquids at the end of the experiment were strongly alkaline. [This starchy deposit of the remainder of bread or biscuit or cracker, which hangs like a sour pulp or paste around or at the necks of the teeth, is apparently the active cause in many mouths of labial or buccal surface decay ; for teeth that are freed from this, by their shape or the movements of the soft tissues over them, will escape, while those where lodgment is allowed, in the same mouths, afford notable examples of the ravages of the disease.] In considering the question before us, we have laid no stress upon the existence of the zone of Tomes as evidencing a vital action iu the process, its nature having been disputed by high authorities ; but, putting aside this phenomenon, we may cer- tainly see in those cases where very superficial caries has existed and become arrested, as frequently witnessed upon the coronal surfaces of tirst molars, a hardening, which, as compared with the subjacent structure, can, we think, hardly be explained as wholly the result of friction and polishing. Here we must leave the subject, and with the same remark as when we entered upon it, viz., that no explanation of the causes or nature of dental caries has yet been offered which has been generally acceptable to dental practitioners. The question may now be considered — is the disease which we have been describing, and which presents at times different features, one disease, or may we be comprehending in our de- scription more than one? Some authorities incline to the latter view, and divide dental caries into soft and white decay, and hard and dark decay, in which latter condition the structures affected are at times almost black. Most authorities, however, are agreed that the disease is precisely the same, the conditions being varied by the former being rapidly, the latter slowl}', progressive. A variety of caries termed chalky, and met with most frequently in the third molars esjiecially of the upper 9 130 MAXnAL OF DENTAL SURGERY AND PATHOLOGY. jaw, would, from the appearance which the affected portion presents, give the idea that its disintegration had not been pre- ceded by a solution and removal of the lime-salts, but that the calcified structure had itself broken down. If we take some of the chalky powder, which upon the finger-nail appears to resemble whitning, and examine it under the microscope, we shall find it to consist of fragments of dentinal tubuli and inter- tubular substance (see Fig. 88), in which the tobacco-pipe ap- pearance noticed by J. Tomes is very conspicuous : a little hydrochloric acid added to the specimen liberates abundant bubbles of gas. Another condition is where a loss of substance occurs gene- rally at the necks of the teeth, giving the appearance of a por- tion of the tooth having been removed by a file, and the place highly polished. This form has been termed "decay by denu- dation," or "erosion." It is most commonly seen upon the labial aspects of the teeth, especially the bicuspids, but it also does occur, though less frequently, upon their lingual surfaces, and in other spots inaccessible to the tooth-brush, which proves that it does not arise from the friction of that appliance, as some have supposed : it is also stated to be met with in some of the lower animals. [It has, however, frequently been noticed that the canines where prominent seem to suffer most, and the left one in right-handed people is generally more S- 93. deeply grooved, which would look as if the tooth-brush may play an important, if only an auxiliary and secondary, part in removing the partially softened enamel and dentine, while it may also add to the irritation that may be the prime cause of the acid secretion from the firum.l It appears, however, almost A cnspidatns oi the o j i. x ' lower jaw worn on its perfectly identical in appearance with the lingual surface by the ^.g^,,^^ ^way of a tooth at its neck by the friction of a plate. a J •/ friction of a clasp to support a denture ; such clasps invariably retain small portions of food, bread-substance especially, so that tiie rapid loss of substance they occasion is probabl}' something more than friction. It is stated to be more common to the upper than to the lower teeth, and we believe this to be correct. Although most frequently met with at or below the termination of the enamel at the neck of the tooth, DENTAL CARIES. 131 it occasionally, i. e., on the assumption that it is the same affec- tion, attacks the enamel itself. We have cases on record where the two upper central incisors have so suffered, and in persons of undoubtedly good constitutions. In one case, which we had under observation for more than twelve years, the disease had appeared on the labial surface of the enamel, midway between the cutting surface of the tooth and the gum. As it progressed, there was no discoloration, and the surface presented was highly polished, and intensely hard and sensitive. [In a number of cases of this kind, treated by cutting retaining grooves and fill- ino- with srold, there seemed relief sufficient to warrant its recom- mendation in almost every case that has progressed to a depth much below the enamel.] Eventually one of the teeth broke off, the pulp having become dentinified in the progress of the disease; the other has remained in much the same condition for a number of years, the patient, a lady, aged now about thirty-five, having most assiduously kept the cavity sealed with white wax, which almost completely hides the deformity. We feel inclined to attribute the condition which we have described to the solvent action of an acid secreted by certain labial and other mucous glands. It is by no means uncommon for dental caries in its ordinary form to appear upon the eroded portions of the necks of teeth, when the difference in the two conditions is very manifest. Cases are recorded where the teeth generally, but especially the six upper front ones, have undergone a gene- ral loss of substance above the gum ; such loss has been too general to be accounted for in any other way than that they have been attacked by some solvent which has acted upon them generally. [Pressure, if continued, upon the soft tissues will produce absorption, and even the bony structure will after a time yield to the same cause.] Allusion has been made to the greater frequency of dental caries in the present day than formerly, and we may probably investigate this question more profitably, and with more hope of a satisfactory solution, than the former one, viz., its patho- logy. One of the chief causes of this degeneracy we believe to be the change, both in character and mode of preparation, which the food of man has undergone during the last few centuries. Take, for instance, his bread ; this, as compared with that of the present day, was imperfectly ground and contained a larger 132 MANUAL OF DENTAL SURGERY AND PATHOLOGY. proportion of husk of the grain, and, in consequence, a larger proportion of phosphates. Baked into a hard mass, it required no small amount of force to bite and reduce it to a pulp Avith the saliva; yet this was readilj'' accomplished by the well- developed javva and strong teeth of bygone ages. His meat, cooked soon after the death of the animal that provided it, was presented to him in a condition which would sorely tax both teeth and jaws of the present generation : it was not then the custom to hang meat until upon the eve of putrefaction, or render it so soft by culinary art that it can be almost sucked into division, rather than brought to that state by laceration and pounding. But further than this condition of his food, let us remark his manner of devouring it. The meat was torn from the bone by the grasp of the incisors and cuspidati, whilst in the present day by appliances indispensable in civilized life, the knife and fork,^ the office of those teeth has become almost a sinecure. Organs or structures not properly exercised undergo, after, it maj' be, many generations, some form of degeneration, and it is only reasonable to conclude that the teeth and jaws follow that same law ; the former unprotected, losing their power of resisting external agencies ; the latter protected, appear- ing in diminished size and incapable of aftbrding capacious den- tal arches, and hence also results a crowding of the teeth with pressure, which is an acknowledged predisposer to caries. The evidence of the injurious effects of soft food upon the teeth of dogs is strong su[)port of the foregoing conclusion. Another result arising from too soft a food is the unhealthy condition of the gums. From loss of a natural stimulus they become hy[)erpemic, soft, and spongy, not only causing, by absorption of the alveoli, premature shedding of the teeth, but secreting an abnormal quantity of acid-forming mucus. To the above must be added all conditions unfavorable to the perfect development and health of the body ; the preservation of the weak and feeble, such as in a less civilized state would never attain to manhood, and consequent matrimony with progeny ; the depressing effects due to over-exertion of mental and nerv- ' Perhaps there was loss ahsunlity in a bishop in tlie reign of Queen Eliza- beth preaching a sermon against the use of the fork, than has been commonly attributed to him in our time. DENTAL CARIES. 133 ous energies; and the far too great indulgence in the luxuries of the table, especially stimulants,' which weaken the digestive organs and vitiate the saliva. The mixing of breed also appears to have an unfavorable influence generally upon the physique of a nation, and especially upon their teeth. The effects of administering medicines, especially acid ones, have by some been considered important factors in producing dental caries. We believe that it has been overrated ; at the same time, the long continuance of acid medicines renders such secre- tions as the saliva abnormally acid ; and the direct contact of such acids as phosphoric, hydrochloric, and nitric may no doubt in time affect the teeth, as they certainly do certain kinds of metallic fillings in them. As sulphuric acid has but a very slight action upon the dental tissues, from the circumstance that an insoluble sulphate of lime is formed as soon as it touches them, it may well be, where possible, substituted for any of the former. The common practice of employing a tube when taking acid medicines is of but small advantage compared with a thorough rinsing of the mouth with a solution of bicarbonate of potash or soda afterwards. ' Amongst the various classes of mankind whose teeth we have had the opportunity of inspecting, few have surpassed in beauty those of the Bedouin of the Arabian desert ; and their much greater freedom from caries, as com- pared with the Arab of the town, is, by "Waller Bey, of Cairo, who is able to speak from large experience, attributed to the former being total abstainers from alcoholic beverages. Their purity of breed, and the very perfect sanitary conditions of their surroundings, must not, however, be left out of the account. [The less the conditions of natural selection and survival of the fittest are disturbed, the greater the likelihood of a healthy race. The writer's observation of the Bedouin confirms the universally received rule, that under adversities of life the bold and hardy survive, and beget children who inherit the physical endurance of their parents, or else, if delicacy of constitution be their lot, death soon weeds them out. The law may be laid down that the teeth are equally valuable guides as to savage man's chances of life as they are to an ani- mal's. It must, however, be recognized sooner or later that children, who are reared in the free open air of a healthy climate, are better qualified for the battle of life than those raised under the enervating influences of house or institute training. Children with decay running riot in their systems have been so frequently saved by a change to open-air life, as to make the fact no longer disputable. Dental caries has so frequently yielded to a change from an in-door to an out-door life, that it must be admitted that the Greeks with their open-air gymnasia understood and reaped the benefits of pure air. The tendency now is to a better ventilation of school-rooms, and even to open-air sessions during the summer season.] 134 MANUAL OF DENTAL SURGERY AND PATHOLOGY. [CHAPTER VII. THE SELECTION OF INSTRUMENTS.' The selection of instruments is one of the most important duties of the dental preceptor or teacher, and the varieties of sets recommended by ditierent operators seem to be limited only by the number of the recommeuders. For some years the set selected by the writer, and about to be mentioned, has been the source of much satisfaction in its adaptability to the various demands made upon it, and is the standard upon which or from which sets have been selected and used by many students. The only objection has been as to its expense, which at first sight may seem considerable, but, after some years of study of the peculiarities of dental students, it may be safely said that they rarely enter practice with less than the amount here spoken of, and often more, much of which is after trial discarded as un- handy and useless. In the first place, true economy will be practised by the pur- chase of a case, in order that each instrument may have a sepa- rate and appropriate place ; for misplacement and loss will try the temper of the patient, the operator, and the instrument. If thrown loosely together, the edges are impaired or destroyed on each other, and this, although not always understood by the young operator, makes a wonderful ditierence in time and re- muneration in practice. Beyond all else the points of the instruments are to be con- sidered. As to the handles, it is more a question of taste; yet the balance and shape have much to do with the dexterity of the operator. The new models of milled socket handles, made by the S. S. White Dental Manufacturing Company, seem to answer much that is desired in this direction, while they ofter a ready and ' [Acknowledgment is due to The S. 8. White Dental Manufacturing Co., for the courtesy in permitting the use of illustrations of a number of the instru- ments in this chapter.] THE SELECTION OF INSTRUMENTS. 135 expeditious means for renewing the points that may be broken, to say nothing of the cleanliness and sightliness of the set when 1 Mi Fiff. 93. Wew socket handles. Ul spread upon a snow-white linen napkin ready for use. If clean- liness is considered next to godliness by our patients, they certainly appreciate it in anything designed for use in their mouths. There are always enough disagreeable and painful associations connected with dental offices to make it highly 186 MANUAL OF DENTAL SURfiERY AND PATHOLOGY, desirable that thej should be, as far as possible, relieved of every unpdeasant feature. The recent demonstrations of Pasteur be- fore the world's medical congress show, that many diseases are liable to propagation as ferments and infusoria, which from minute particles will propagate, grow, and increase to immense numbers under conditions favoring their development, as in the inoculation or vaccination from an infected animal's fluids. This would seem to make an additional reminder necessary that anything short of the most exacting and scrupulous care on the part of the dentist or surgeon is an offence against the health of the community, that will be classed as criminal, and before many years, — if not already — it may be punished as such. Fig. 94. student's iDstrament case. Tlje student will do well to provide himself with a case like that shown (Fig. 94), which may have four trays for the instru- ments, or, what is perhaps better, have the separate smaller cases such as are made for the socket handles. For the tray for instruments for examination of the mouth, removing salivary calculus, and finishing fillings: first, obtain two fine probes for examination of cavities. These should be soft and capable of being bent into convenient shapes for passing around or between the teeth, and a little thicker than heavy bristles. THE SELECTION OF INSTRUMENTS. 137 For scalers, use the S. S. W. Nos. 10 and 8 (Fig;. 95), which may be supplemented with a pair of the right and left. In the I i i Fiflc. 95. Scalers. 3 O Dr. Forbes' gouge. Operation of scaling we can also be greatly assisted by a selection from tiie ordinary excavators ; the scoops presently to be spoken of being invaluable and almost universal in their application (Fig. 106). For opening cavities and removing overhanging walls, Dr. Forbes' Nos. 1 and 2, and Dr. Head's Nos. 20, 12, 4, are desirable, and later on may be added as required !N'os. 18 and 21 of the latter set. ]N"ext a curved sickle-shaped lancet will be desirable for opening abscesses, lancing the gums of children, or around the wisdom or such other teeth as have the 138 MANUAL OF DENTAL SURGERY AND PATHOLOGY, Fio;. 96. gums attached — generally only those that have stood alone in the mouth for some time. Fig. 96 represents a scaler that may be sharpened on both edges, and made to answer the purpose. The foil carrier and j^lugger combined, Fig. 97, the writer has made so curved as to meet only at the point, in order to prevent the possibility of catching the mucous membrane of the lips or cheeks, and allowing the attention to be concentrated on the points of the instrument. Foil shears will be useful for cutting the gold foil, but they may be dispensed with at first, and a pair of curved scissors (Fig. 98) for use both in and out of the mouth may be procured. For a mouth mirror the magnifying is to be pre- ferred, and, in selecting it, it should be held up close to the eye, so that its image may be examined for imperfections. Those with the wooden back and handle (Fig. 99) are less 5 Scaler, to be sharpened on both edges for ffum lancet. Fig. 97. Combined foil carrier and plugger. Fis: 98. Curved scissors. expensive and very serviceable, but the nickel-plated back and carefully-fitted water-tight mirrors (Fig. 100) are the best, and probably the most economical, all things considered. The syringe may be of glass (Fig. 101) or hard rubber; lately a pattern of nickel-plated brass has given much satisfaction. Hickory pivot wood, cotton and box-wood strips, are useful for cleansing, wedging, cauterizing, and pivoting teeth. Provide also a strip of Scotch or Ilindostan stone, celluloid polishing strips, a box of pulverized pumice, and one of peroxide of tin. THE SELECTION OF INSTRUMENTS. 139 Fis. 99. Fig. 100. Fig. 101. Magnifying mouth mirrors. Glass syringe. 140 xMANUAL OF DENTAL SURGERY AND PATHOLOGY. Dr. Louis Jack's enamel chisels. Fis. 103. ^'' ,^ Prof. D. D. Smitli'H plug finisher. I|ie' Dental files. THE SELECTION OF INSTRUMENTS. 141 Dr. Jack's chisels (Fig. 102) are often put into this tray as convenient for opening cavities and for cutting separations between the proximal surfaces of the teeth. The writer has his made with a heavier handle and single point, as he believes they are less ruil)le to be injured by a fall. For plug finishing, the various bur drills may be used, par- ticularly when the student has a dental engine. Ey some, however, the hand cutting is preferred ; or, as is generally recommended, the student may learn without the engine, and after acquiring the necessary strength and dexterity of the hand the engine may be employed. Files, Nos. 14, 19, 20, and 33, together with Prof. D. J). Smith's plug finishers, iN'os. 4 and 5, will be of value. A Kseber saw frame. Fig. 105, for carrying watchmakers' fine saws, will be handy in starting an opening between the Fiij. 105. Kseber saw frame. teeth, where permanent separation is desired. The passage of the saw first between the teeth, will make the use of the tile or disk much less unpleasant and laborious to both patient and operator. The second tray may contain the excavators proper; and here, as in all dental instruments, the shapes that resemble the human hand should be the most highly prized. Foremost in the rank — the very poetry of points in steel — stands a set of six finger-shaped instruments, devised by Dr. Corydon Palmer. Unfortunately they cannot be recommended to every tyro, any more than a genuine Cremona violin should be placed in the hands of a sawyer. But for the light and skilled hand of the maestro, to have once made their acquaint- ance is to be ever thankful with and unhappy without them. To a child who knows the principles of digging sand holes 142 MANUAL OF DENTAL SURGERY AND PATHOLOGY. these instruments will show their adaptation. All that is neces- sary is to remember that the cutting edge is the linger nail and the instrument the finger. A wood-cut will not convey the idea, and, therefore, attempts to illustrate them have not been made. Next will follow the regular scoops, which resemble the open hand, and are nearly as universal in their application. They should be made with the palmar side flat instead of hollowed, as the latter shape weakens the edges for cutting the more solid portions of the teeth, and particularly for cutting down over- hanging walls of enamel — a use for which they are well calcu- lated. Fig. 106, ISTos. 67 and 68, are the most useful, but larger Fiff. 106. ^ ^ ff ^ Scoops. sizes may he required, and as they are worn down in sharpening they will approach these favorite numbers. Some curved, as the last four, for rights and lefts, may be likened to the hand, arm, and elbow ; they are useful to reach down between teeth upon the floors of the approximal surface cavities, cutting that portion near the necks of the teeth, the sides may best be finished by the plain scoops or hoes. They may be used also upon the mesial walls of molar crown cavities. For hatchets, there may likewise be no ex[)lanation of their use required, beyond the reminder that there is great tempta- tion to cut with them in lines parallel to the dentinal tubuli ; a thing to be avoided, except where the tooth-substance is dead or its connection with the pulp cavity severed. The first two. THE SELECTION OP INSTRUMENTS. 143 Nos. 14 and 16, may be well recommended, of the others it may be said that they are ottered as guides to select from. Fiff. 107. ( -.- "^ 1l 1l n Tl "11 Hi) ijO Hatchets. Of hoes, no description as to the method of their use will be required. The first, ISTo. 27, is the one that should be provided at the outset, and of the others the same may be said as above of hatchets. Fi?. 108. Fisr. 109. 27 60 a^ 58 57 IMunioud-shaped poiuts. The diamotid-shaped points, Fig. 109, ISTos. 58, 60, 59, 57, are gradually going out of use since the introduction of the engine points. They are, however, very useful in opening cavities, particularly upon the deeply-fissured crowns of molars. With the above we may fill another tray, or, by selection and 144 MANUAL OF DENTAL SURGERY AND PATHOLOGY. combining with the next, they, with part of the following, may be put into one tray. In the full set of instruments the third tray is devoted almost exclusively to drills, which are used, generally, in the last step of excavation — namely, shaping, smoothing, and surfacing — - while in the formation of retaining points they are almost in- dispensable. After the overhanging walls are cut down, the auger drills. Fig. 110, ]^os. 3, 2, 6, 8, may be used to round and deepen the cavity, or they may be made to drill at the outer end or point of Fig. 110. Auger drill. Round burs. Odd or acorn. each fissure of a large star-shaped cavity, or to unite the ra^^s of a small one and make a plain, round cavity. In this the round burs, Nos. 2, 3, 7, 14, 9, 12, will be particularly useful to assist the first named, or with the engine they become the principal working tools, enlarging, shaping, undercutting, grooving or guttering, rounding or curving, smoothing and preparing the floors and walls; also in finishing the concave surfaces of fillings upon the masticating surfaces of teeth. The student may here be reminded that fillings should partake of the general shape externally of tlie parts of the teeth in which they are placed. Being designed to replace, to a certain extent, the lost tissue and protect the remainder of the tooth-snbstance, the fillings should rarely project as full as the original material, and over- hanging edges, except where the cavities are countersunk ex- pressly for the purpose, arc not to be recommended, as the thin edges may turn uj), break off, or become defective. THE SELECTION OF INSTRUMENTS, 145 Wheel burs, Nos. 1, B, 5, 7, 12, 15, and 18, are auxiliary to the above, and are excellent for flattening floors and enlarging the interior of cavities, serving to make them slightly larger within than at their openings, giving them a shallow-jar or pomatum- pot shape. Sometimes they can be made of service in cutting out Assures, grooving, and rounding, but they are invaluable in Fii?. 111. EM Fisr. 113. Wheel burs. bfi S9 90 91 92 93 Oval burs. Fiar. 113. shallow places upon labial or buccal surfaces to undercut grooves for the retaining of the filling. For the latter purpose, Xos. 88| to 93, Fig. 112, as shown for the engine points, are slightly ovoid, as if the edges of the tire of the wheel had been worn by use. Palmer s root or pulp canal drills, Fig. 113, are of great value, Nos. 2, 3, 5, 15 ; they may be made to enlarge, straighten, and open or ream the canals to admit of the treatment and filling with the least difliculty ; and with care in their use they will follow the canal rather than cut a bole through the side of the root — an accident to be strictly guarded against. The best form of retaining-point drill is the spade, Fig. 114, Nos. 121 to 124, in the cuts for the engine- 10 2 3 5 15 Palmer's nerve, canal instruments. 146 MANUAL OF DENTAL SURGERY AND PATHOLOGY. FijT. 114. Fig. 115. Fig. 116. 121 to 124 161 162 163 Retainiug-point drills, spade, aud spear-poiuts. r^) Sturap files and corundum p^ ^ wheels, for pivoting. points, but a spear-point drill, Fig. 115, may occa- sionally be used for this jiurpose where the corner of the spade would endanger opening into the pulp chamber. These are also useful when we desire to cut to considerable depths, on entering the alveolus at the apex of the root, to form an artificial fistula for the relief of an abscess. For pivoting, a nearly round file, as in Fig. 116, ISTos. 41, 42, and 40, will be required for the old- fashioned method of pivoting, but the wn-iter had the stump corundum wheels for the engine made for this purpose, and with these latter at hand the use of the above files has almost been discarded. The dental engine is now so generally used, that it will be necessary to supplement the above-described excavators with a set of points that will be suitahle for the many uses to which this invaluable addition to the dentist's apiiliances is [»ut. Nos. J to 11, Fig. 117, represent the sizes of round bur drills. Nos. 11^ to 22, Fig. 118, are wheel burs. The uses of the above points have already been described with the hand instruments. The inverted cones, Fig. 119, l^os. 2>^ to 37, enable tlie operation of enlarging the fioor,or base of the cavity, to be performed readily and expeditiously. Fig. 120, Kos. bb\ to 59, is a set of fissure drills that enable the operator THE SELECTION OF INSTROMENTS. 147 to cut down the walls and round out the points, or ends, of the stellate cavities, avoiding the jar and danger of slipping, which Fis. 117. Fifr. 118. 503 "'"'^ fFTTTTJ lU 12 13 14 1.5 16 17 IS 19 20 21 22 Wheel bur.s. 335 34 3.) 36 37 Invevtecl-fone burs. Fiir. 121. 5.)i 56 57 58 59 Fissure burs. 66i 67 68 69 70 Pointed fissure drills are such drawbacks to the cutting of tliese by hand. The square ends will make a tiiiish of the same kind on the floor. Some- times it is desired to enter and enlarge a somewhat smaller fissure, and after cutting away the enamel, as should be done with the chisels and points already referred to, p. 137, Fig. 95, the pointed fissure drills ^6^ to 70, Fig. 121, may be of service. The oval burs Fig. 112 are also employed in the finishing of the surfaces of the fillings. 148 MANUAL OF DENTAL SURGERY AND PATHOLOGY, Fig. 122, ISTos. 100 to 108, shows a set of spear-point drills which enable the operator to open into the pulp cavities of dead teeth, remove old fillings, or enlarge or deepen the cavities to be filled. Fig. 123. Fiff. 133. 100 101 102 103 104 lOo 106 Spear-point drills. 142 143 144 145 146 147 148 Five-sided drills. Fig. 114, ISTos. 121 to 124, are the spade drills before mentioned for cutting retaining-pits or points. Fig. 128, Nos. 142 to 148, is a set of five-sided drills for enlarg- ino; and makino; true round holes in the roots of teeth designed to be pivoted. Fig. 124, N^os. 200 to 204, are finer cut round burs for finishing fillings, or preparing, and finishing smoothly, round cavities. Fig. 125, ISTos. 230 to 234, are the useful pear-shaped burs for the same purpose as 'Nos. 200 to 204. Fiff. 134. Fi2:. 135. Fig. 126. 200 202 204 230 232 234 Fine cut round liiirs. Fine cut pear-sliaped burs. 242 243 244 245 246 247 Sugar-loaf drills. Fig. 126, Nos. 242 to 247, called the sugar-loaf drills, were first shown to the writer by Dr. Louis Jack, whose idea they embody. These points have a variety of uses between the teeth for making the now well-known V-shajied o|)enings with curved faces; to remove proximate surface 8U[)erficial decay, and finish fillings in the same situations. THE SELECTION OF INSTRUMENTS, 149 Fig. 127, Dr. A. W. Holmes's engine-bit oiler, is a neat con- trivance for keepino; tlie sockets and bits clean and oiled to pre- vent rusting, and obviate annoyance in making the necessary changes expeditiously. Fiij. 127. FiL^ 128. Dr. Holmes's engiue-bit oiler. Screw-head mandrels with and without .shoulder. Fig. 128 represents the screw-head mandrels; the first one was invented by Dr. Robert Huey. Their use for carrying disks for cutting, or the various points for polishing, is so well suggested by their form that further description is unnecessary. Fig. l'.:9 is a portion of a very complete set of corundum points, recommended by Dr. A. L. ISTorthrop, of I^ew York. They may be fashioned from broken corundum wheels, or disks, by warm- ing slightly and revolving against a piece of wood. Fia;. 130. J K Arkaiisas-stoue wheels. Diamond-disk wheel. Fig. 130, Hindoostan or Arkansas stone points, for polishing fillings and surfaces of teeth. J and K are figured as the most serviceable, but there are man}' other shapes made and figured in the catalogrues. 150 MANUAL OF DENTAL SURGERY AND PATHOLOGY. Soft rubber disks (Fig. 131), of somewbat similar forms, for carryiijo; tbe polisbing tut ty, from tljeir pliabilit\^ may be brougbt into contact Avitb many forms of curved surfaces. The diamond disk, Fig. 132, is of great value for sligbtly Fi!?. 131. Fia:. 132. Flexible rubber disk for polishing proximate surfaces of te'^tli or fillings. Diamond disk for separating teeth. separating teetb tbat are unduly crowded and defective on tbeir proximate surfaces. Tbese are manufactured of very thin plates of nickel with the diamond powder imbedded on their surfaces. Somewhat similar wheels of celluloid and corundum are like- wise very useful, and from their flexibility can be conformed somewhat to the surfaces of the teeth. JSTon-cohesive gold should be packed as a lewis is put into a stone for hoisting it, or much as damp cigars may be packed into a tumbler, pressing a wedge into the middle, and forcing the cigars against the sides and putting fresh ones in the centre until full. For fillings of this description the gold may be pre- pared in cylinders by rolling upon a watchmaker's fine broach. The three-sided are preferred. To accomplish this Abbey's jSTo. 6 non-cohesive gold foil ma^' be twice folded in the book by turnincr the outside edge of the leaf to the centre and then making this, by a second folding in the same manner, one-quarter of the original size, and of four thicknesses, like a miniature folded newspaper or quarto. This folded sheet is then cut into strips or ribbons or tapes, in width equal to about one-third more than the depth of the cavity. The end of the tape is laid upon the index finger of the left hand, the broach put across the extreme end, and the thumb of the same hand then laid on this. By drawing the thumb over the broach and rib- bon toward the free end of the latter, the gold is wound tightly on the steel broach, and then, by guiding the ribbon straight THE SELECTION OF INSTRUMENTS. 151 with these fingers, the handle of the broach may be twirled between the thumb and index tinger of the right hand, making tlie gold into a tightly rolled (-3 linder, the ends of which are formed by the edges of the ribbon, and appearing something like a diminutive block of the kind used by milliners, a true cylin- der, not bulging like a barrel in the centre. The back of the thumb-nail of the left hand may be pressed against the end of the cylinder as it is finished, and the edge of the nail held upon the broach while the latter and the cylinder are revolved. After this the cylinder may be carefully pushed ofi' the broach by the thumb-nail f)f the right hand or a pair of [>liers, taking care not to unwind the gold. Ropes are made by folding the same foil into strips or ribbons one-fourth or one-sixth the width of the sheet, taking care that the edges are inwards, and then twisting the ribbon tightly between the forefingers and thumbs, making it unitbrm in den- sity. To finish a rope neatly it may be rolled between two pieces of plate glass until a degree of density is obtained that is uniform and the rope smooth surfaced. The rope, as first recommended, may be made of half or quarter sheets for very small cavities, and it is generaly best cut into short pieces from one-sixteenth to one-fourth of an inch in length. These may be used much like the cigars above mentioned, or as cylinders, being stood upon their ends upon the fioor of the cavity and allowed to project in tight cylinders equal to one third of the depth, or in loose ropes rather more than the depth of the hole. They should be shajied to the w^alls by pressure at a right angle to the latter, or in the direction of the spokes of a wheel toward the rim. The last cylinder or piece of rope, will be the key piece to the whole, acting like the hub of a wheel to press out- wards toward the walls. The softest cylinders are used against the walls, and the hardest for the centre or key pieces. In such operations, the last stage of filling consists of con- densing upon the ends of the cylinders or ropes, pressing the projecting gold into the cavit}-, and finishing up by filing or burring and burnishing alternately, until the whole surface is flush with that of the tooth, and uniforndy hard, and capable of a high polish, which latter is desirable as preventing the lodgment of food or any deleterious matter about the edges or surface. 152 MANUAL OF DENTAL SURGERY AND PATHOLOGY. Tapes may be made of tlie same gold by folding or cutting into strips as before described, and these may be packed in alternate foldings and refoldings, so that the layers when finished will run perpendicularly to the floor of the cavity. Long tapes and ropes are in danger of being moistened and ruined by the saliva of the mouth. They are best cut into pieces as described, one-sixteenth to one-fourth of an inch long. The condensation of the filling should be commenced with coarse and heavy points and finished with smaller ones, testing the density by boring with a slight brad-awl-like movement of the instrument's point, and if found to penetrate, enlarging the opening to its utmost and filling the hole made by another pellet or cylinder. Cohesive gold should be prepared by folding as above, using Abbey's 'No. 4 foil, and cutting or tearing with instrument points into pieces havingfrom four to eight thicknesses, and about one-thirty-second to one-fourth of an inch square. The greatest pains must be taken to preserve it free from moisture, from breath condensation, or any cause ; also from all other foreign substances, as grease, saliva, dust, etc., as they will impair its working property, which depends upon the cohesion. Unlike the former gold, which was recommended to be worked like piling to fill a cavity, this operation should be commenced by anchoring the gold in retaining points, except in very small cavities, on the floor, and building up like masonry, laying the pieces so as to break joints with each other, carrying each layer parallel to the floor, or horizontally with the general direction of the floor, or at right angles to the axis of the cavity. The general princii>les of architecture and engineering, the arch and buttresses, trussing, bolting, screw piles, etc., must be followed upon a very minute scale. Sometimes, in moderately small cavities, say one-eighth to one-fourth of an inch in diameter, with smooth rounded walls, cohesive gold may be [)acked against them, a little higher than in the centre, by using Dr. Benj. Lord's plug- gers presently to be described. But in larger cavities there is always danger of the gold bridging over, causing defects and hollow spaces, which impair the value of the filling. From the difierence in the manner of using non-cohesive and cohesive gold, it may be inferred that a set of instruments specially designed for each will be required. The first being THE SELECTION OF INSTRUMENTS, 153 wedged into the cavity, will require slightly tapering points, and often deep serrations, to prick the gold pellets one into the other. (See Fig. 133.) Nos. 9, 99, 101, 1, 4, 127, and 128 of the Fiff. 133. 10 n 12 127 Ellis's pluggei's. 9 99 101 4 3 New York set of pluggers. Dr. Lord's pluggers and burnishers. ISTew York set are selected, together with (Fig. 138) JSTo. 3 of Prof. E. T. Darby's set ; also a bayonet packer and condenser. Dr. a. W. Ellis's, JS'os. 11, 1 2, and 10, Fig. 133, may be used foreither kind ofgold,asalso may Dr. Benj. Lord's (Fig. 133.) 154 MANUAL OF DE^;TAL SURGERY AND PATHOLOGY. The latter are remarkable from their general resemblance to the linger or hand of man, and render packins^ almost so easy of accomplishment with them as to need no further description. The two on the right of the cut are for burnishing. These j>oints are on unpolished handles and shafts, which afford a better grasp, without being so roughened bj' file cutting as to make the corn-like callous spots upon the hand and fingers of the operator. Dr. Louis Jack's matrix pluggers (Fig. 134) are designed by him for use with his matrices, as shown hy the Fig. 134. They are principally useful on proximate surfaces, the matrices being wedged into position by pressing between the teeth, using wooden wedges if necessary. The latter are recommended to be made of boxwood, which is now obtainable at the dental depots, cut into thin strips of different sizes appropriate for the purpose. The cavities are prepared by cutting away the over- haugins; crown-surfaces so as to obtain a full view of their inte- rior. After the removal of the decay, the floors are flattened or rounded, aud a retaining point cut on either side, clear of the pulfHchamber. These may be united by a shallow groove if desired, aud grooves running from them to the cutting or masticating face will hold the filling material in position. The filling is accomplished by wedging a cj^linder or pellet of non- cohesive gold into either retaining point, with its side against the floor, and one end abutting againt the tooth and the other against the matrix, which is [)laced in position after the cavity has been prepared. A third piece of gold is driven between these two, as in the lewis, to wedge and hold them in position, and the whole layer is now thoroughly condensed against the walls. The filling is to bo finished up to near the masticating face b\' successive la^'ers, as just described, taking care to drive the gold with the long serrations of the pluggers tightly against the walls and the polished surfaces of the steel matrices, and over each retaining-point making a \nt in the gold b}'^ driving a plugger in each layer to leave a corresponding pit for anchor- age of the next. The filling may be finished with cohesive foil at the top, where the wear of mastication is greatest. If properly made, when the matrix is removed, but little work will be required to finish the filling, as the smooth steel THE SELECTION OF INSTRUMENTS, Fig. 134. I C ^---J ^ l)r. Jack's matrix. loo Dr. Jack's matrices. Dr. L. Jack's matrix plagger, maenified. 5 liiacnces. 156 MANUAL OF DENTAL SURfiERY AND PATHOLOGY I surface of the matrix leaves the gold almost ready for the ^ burnisher. A set (Fig. 135), called in the catalogues after the writer, but really only selected and arranged by him, 'has been designed for hand or mallet pressure, and may be used for cohesive gold when the serrations are new and sharp, they being shallow and of the patterns most gene- 5 6 7 S Hand or mallet pluggers. 1 S 2 S. S. W. burnibliers. 9 10 Prof. E. T. Darby's burnishers. E H J Engine biirnishors. THE SELECTION OF INSTRUMENTS, 157 rally used. As the instrnmeiits become worn by use, they will serve nicely to condense the surfaces of fillings. Fig. 135 gives patterns of the most useful shapes of burnishers — Nos. 1, 8, and 2, of the S. S. W. set, for general use, and Prof. Darby's, ISTos. 31 and 32, for proximate surfaces and fissures. Fig. 135, l^os. E, H, J, give the smooth-pointed burnishers for the dental engine. Fig. 136 represents Prof. J. Foster Flagg's patterns of 1)1 ug- ging forceps, which, for non-cohesive gold, afford a very easy Fig. 136. Prof. J. F. Flagg's condensing forceps. Weston's amalgam pluggers. but powerful means of getting desirable density and finish. The plain beak is put upon the side of the tooth, which may be protected by some intervening substance if desired, and, using this as a fulcrum, the other beak is pressed upon the gold. Fig. 136, Nos. 6 and 8, Dr. Weston's patterns of amalgam pluggers, may be added. The bottom of the case will serve as a general receptacle for gold, polishing powders, napkins, four and six inches square, for keeping the cavities dry, amadou, bibulous, blotting, and test 158 MANUAL OF DENTAL SURGERY AND PATHOLOGY. papers. Rubber dam and punches, clamps, holders, and wedge- cutters for use with the same, may here be kejtt. A hand magnifying-glass is useful to examine debris in exca- vating, surfaces of fillings, etc. An ivory paper-folder will be of service for folding the gold, and may be kept here. Fig. 187. Dr. Corydon Palmer's metal tube with lead fllllug fur iiiallet-head. THE SELECTION OF INSTRUMENTS. 159 The mallet (Fig. 137), as designed by Dr. Corydon Palmer, is best kept in the tray with the plugging instruments. This pattern of mallet has the lead run into a i)iece of metal piiie to Fii?. 138. Fi?. 139. Cutting pliers. Wedge pliers. Dr. Corydou Palmer's i)atterii. 160 MANUAL OF DEXTAL SURGERY AND PATHOLOGY. prevent its spreading at the ends or faces by use. This mallet may weigh half a pound, and is best used with a dead or push- ing blow. A cutting plier, Fig. 138, will also be of service for cutting off woodeu wedges in separating teeth, or projecting spiculas of the septum of bone between the alveoli after extraction of the teeth ; also a pair of pliers. Fig. 139, for removing the wooden wedge after finishing the operation.] TREATMENT OP DENTAL CARIES. 161 CHAPTER VIII. treatmi:nt of dentai. caries. The first consideration with regard to any disease should certainly be, if possible, its anticipation and prevention ; and it', in Chapter VI., we have at all rightly comprehended the nature of dental caries, or the conditions which favor its exist- ence, we may approach the subject with some confidence of success. [Exercise, of an earnest and even laborious character, has long been looked upon as a safe, sure, and sensible tonic treatment to bring about a normal appetite for normal food. The Greeks liad their palfestra and gymnasia, in the open air, or for bad weather under colonnades ; the moderns have substituted the ill- ventilated gymnasium. But a ride on horseback, or a game of ball, or any exercise with the stimulus of an object to be attained, far outweighs in benetit derived the mere labor for labor's sake.] First, with regard to food, we can now generally obtain bread made from the whole-meal flour, which, if not quite so palatable at first, becomes to children brought up on it preferable to any other. With regard to meat we can say little. Some attribute the early loss of the teeth to eating too large a proportion of it; but, if so, surely the Esquimaux ought to suffer considerably, whereas they have probably the finest teeth of any nation under the skies; on the other hand are tribes having excellent teeth who are almost entirely vegetable feeders. For children we would request the indulgence, viz., that during the period of their nurseryhood they bo freely supplied with bones on which to exercise their teetli and gums. A child's invariable predilec- tion for a bone to suck and gnaw must be some strong dictate of nature, and the freedom of a bone from all else than bone, after it has been in a child's possession, proves that nature most successfully fulfils her own demands. We have spoken of the knife and fork, which we believe 11 162 MANUAL OF DENTAL SURGERY AND PATHOLOGY. have nineh to answer for; or, perliaps, rather the civilization wliieh has introduced them, and holds them too dear to think of ever giving them up. But the same civilization has to some extent atoned by the introduction of the tooth-brush, a thorough employment of which latter -will to a great extent counteract the evils of the former, as well as those arising from many other causes. The Chinese are and have long been a civilized nation, and as a rule have excellent teeth ; but every house has its family tooth-brush, as well as its comb and its tongue-scraper, and the teeth are scrupulously cleansed after every meal. At the head of his boat, where would in England be seen a short jjipe, the Canton boatman fixes his tooth-brush, read}' for use after every meal; and in like manner do most Indian tribes of both the new and old worlds who live on soft food carefully cleanse their teeth after eating, with a species of cane root or even hard wood. Thorough brushing after every meal is strongly to be recommended, and, if this were practised, water alone would suffice ; still there can be no objection to the occa- sional emplo^'ment of a dentifrice, of which none can be better than a mixture of pure soap and precipitated chalk; in some cases an antiseptic may be added, such as tinely powdered puri- fied charcoal, but these are generally best used separately, and a pleasant and effective one is Eau de Cologne diluted with water, to which, when the secretions of the mouth appear acid, a little salvolatile ma}'- advantageously be added. [Charcoal, while unsurpassed as a purifier in the form of a dentifrice, has, like all insoluble materials, the insuperable objection of being liable to work up between the teeth and the free margins of the gums, w^here the spiculfe initiate a disease, the absorption of tiie alveolar processes, which may continue throughout life and eventually eflect the loss of the teeth by loosening their attach- ments.] Cases in which the foregoing reconmiendations have been scrupulously followed sjieak for themselves when com- pared with those where no such care has been exercised, and this especially is the case with children. It is a very common error to argue, that, because animals employ no tooth-brush and yet have excellent teeth, that appliance cannot be necessary. An animal's tooth-brush is its proper food, which, if changed for an improper one, will often result in injury to the teetb. But we must now direct our attention to cases in which the TREATMENT OF DENTAL CAKIES. 163 disease has actually made its appearance, and first we take those cases in which it has either very recently commenced or advanced very slowly and superficially, and for such cases the operation of excision is often the most suitahle. In performing this opera- tion it is essential that the surface or part excised shall become free and exposed to the action of the tongue or lips, or, in other words, so left that food shall no longer be able to lodge or re- main in contact with it. The cases the most suitable for excis- ion then are those in which the disease has made its appearance on the ajiiiroxiraal surfaces of the upper front teeth, and more towards their posterior than their anterior ones, for there it can be cut away without any observable disfigurement and shelved oft" into the posterior surface of the tooth, where the movements of the tongue will prevent the lodgment of food. When the disease is quite superficial, and situated on the crown of molars, bicuspids, or cuspidati,or on the approximal surfaces of the two former at or near to their masticating surfaces, which when cut out, will leave a V-shaped space between those teeth, excision may also be well employed. The operation will be best per- formed by first cutting away all overhanging enamel with small highly-tempered chisels, termed enamel-cutters, the force being employed as far as possible in the line of the enamel-fibres, as the structure yields most readily in that direction. To prevent the instrument from slipping and iiijuring adjacent parts, it should be held near" to the cutting edge and governed by the thumb f)f the hand grasping it, the thumb resting upon that operated on, or an a(ljf)ining tooth. Having removed most of the overhanging enamel, the ojierator will next do well to scrape away with an excavator, — a smaller description ot" cliisel to be firesently described, — all softened dentine, as tliis will aftbrd him a certain knowledge of the dei)th of the diseased structures, and perhaps lead him to discover that the operation of excision is not suitable for the case before he has advanced too far in it. The softened dentine being removed, the enamel-cutter is again employed until the surface is rendered level, or nearly so, when, Avith tiles curved and bent so as to reach otherwise inaccessible places, a perfectly smooth surface is obtained, and may be finally polished by rubbing it with finely pcnvdered pumice and water applied on a pointed piece of wood. [To obtain a more highly ]iolished surface, many operators then use polishingputty or 164 MANUAL OF DENTAL SURGERY AND PATHOLOGY, Fig. 140 f <^ I n A variety of forms of enamel chisels or cutters. The forms given will, we believe, be found the most useful in practice. tuttj (the peroxide of tin), which is applied in a similar man- ner. For approximal surfaces it may be placed upon tape, or probably better, the old-fashioned oil lamp-wick, that has been TREATMENT OF DENTAL CARIES, Fisr. 141. Fiff. 142. 165 I I I I Fig 141. Very serviceable paraboloid and gunge oliisels of Dis. J;ick all- aiid-8ocket JMiiit lor placing it at varii>us [Punch for tnaklog holes In the lubbcr dam.] unglex. TREATMENT OF DENTAL CARIES. 175 the patient, in conjunction with the saliva-punij). As tliis ap- pliance has become so important a feature in the present day, we shall describe its mode of application, admitting at the same time that in common with many of the older practitioners we have used it much less, and therefore probably can apply it with less dexterity, than man}' of our juniors. The material employed is thin sheet India-ruljber : in sub- stance it should not be so thick as to occupy much space when placed between the teeth, nor so thin as to tear. Of this a size is selected, varying according to the position of the tooth to which it is to be ap[)lied, being necessarily larger when back teeth are included. By means of a punch (Fig. 153) circular holes are cut in the rubber: thus, if we were about to apply it, say, to a central incisor of the upper jaw, we should make three holes so as to include the tooth in question and its two neigh- bors, and about -jV inch in diameter, and i inch from each other. For bicuspids we should do much the same, but for molars we should make rather larger holes, jV ^'^ch, and at rather greater distances from each other. In place of the punch we may draw the rubber tightly over the extremity of the steel handle of an ordinary excavator, and on its being touched a short distance from the extremity with a penknife, a small quite round disk will fly otf from it; a little practice will enable an operator to control its size. The next proceeding will be, to place the dam in position, and this is often anything but easy to do. It is best accomplished by holding the dam by the thumbs and fingers of both hands, the hole nearest to the operator being stretched over the tooth nearest to him ; then the next in order is in like man- ner included, and, finally, the third tooth: this arrangement may, however, be altered as convenience dictates. Where the teeth are arranged closely together, difficulty will be experienced in passing the rubber between them : to facilitate this an instru- ment (Fig. 155) carrying a tensely stretched piece of silk or thread will l)e found very convenient, and the thread or silk may be detached and employed for tying round the teeth adjoin- ing the one to be filled. Floss silk rubbed with beeswax will be found the most suitable material for tying with, from its smaller liability to slip. In cases where teeth stand alone, or where, even when the dam can be tied on to adjoining ones, it cannot be carried so far 176 MANUAL OF DENTAL SURGERY AND PATHOLOGY. Fig. 156.] Fia:. 155 [Fig. 157.] vy Fig. LO.j. Instrnmcnt for applying tlio rofTi'r-dam. Silk or tliro.-ul is iiiiHMod into tlio grooves oT the fork end, and tightened by windins,' it idiind tlie steol l)uttoii. By i:iidl3^, no time must be lost in con- veying it to the cavity, and its introduction into the cavity is facilitated by the pi'essure of a highly polished steel burnisher: a platina one would no doubt be preferable. Its qualifications and disqualifications are so similar to the oxychloride above mentioned, that we need only say that it differs from it in proving far more durable, especially when applied at the necks of the teeth. With both these, compounds it is essential that they should be employed when recently made; exposure to air, especially in the case of the pyrophosphates, causing considerable deterioration. It is unfortunate, therefore, that they are not vended in smaller quantities and in hermetically sealed vessels. The pyrophosphate, to which our remarks are referable, is that sold as Pulson's: other varieties may require somewhat modified manipulation. 18(3 MANUAL OF DENTAL SURGKRY AND PATHOLOGY. [Fla2fg's,Gnillois',Weston's, acme and agatecement, and cement plonibe have their friends in this country, and it seems that, although some may be better capable of resisting solution in certain mouths than others, doubtless one of the principal causes of ditierence of success, resides in the variation of manner of mixing and inserting. Although at first sight these plastics would seem to be readily managed, it is now conceded that great exf)edition and expertness are demanded for thorough mixing and use before setting has progressed so far as to impair their value.'] Of the alloys of mercury with other metals, termed amal- gams, those which become hard after mixture have long enjoyed a reputation amongst the substances employed in tilling teeth. As they possess no direct property of adhesion to the walls of a tooth, it is necessary, in preparing a cavitj'- for their reception, that there be some undercutting, or dove- tailing, to retain them. [Sharp angles, grooves, undercuts, and pits, are contraindicated from the well-known tendency of the amalgam to assume the spheroidal shape.^] Two classes of these compounds apparently exist, viz., where the combination is a binary one, and appears something more than a mere mixture or solution of one metal in the other, heat being evolved in the union; and the result is, probably, a definite chemical compound, dissolved in either metal which may be in excess of atomic quantity — analogous, probably, to the mixtures of sulphuric acid in water — at all events, the resulting alloys, as in the cases of mercury and palladium, or silver, or copper, are admitted to undergo less change in bulk after their mixture and application than do any of the other compounds consisting of more than two metals and which comprise the second class. Unfortunately, the first class pos- sesses one great drawback, viz., unsuitable color; and the silver and cop[)er compouuds the additional one of staining the teeth, the silver a bluish-black color, and the copper a greenish ; of the second class, some are now prepared which, when properly manipulated, keep their white silvery color for many j-ears. In applying the amalgams, certain precautions are necessary, according to the description employed ; thus, with palladium, its compound sets very rapidly, so much so that we have found [' See Fliigg's "Plastics and Plastic Filling."] [2 Seepage 191.] TREATMENT OF DENTAL CARIES. 187 some specimens, and probably the purest, almost useless ; also, when mixed in largish quantities at a time, say enough for a Fiff. 1G9. i r Polished steel burnishers of various forms. Four useful forms of amalgam stoppers. 188 MANUAL OF DEXTAL SURGERY AND PATHOLOGY. good-sized cavity, it evolves so much heat as to explode with emission of light. About as much mercury as would fill the cavity to be treated is placed in the palm of the hand, and the palladium powder very gradually added. It requires some care- ful rubbing with the forefinger before the two become incorpo- rated, when it should be divided into smallish pellets, and these rapidly carried, one after another, to the cavity, each piece being well compressed and rubbed into the inequalities of its walls by a burnishing or compressing instrument, and with a rotary movement of the hand. This is continued until the cavity is quite filled, or even, if necessary, to some slight extent built out, the surfiice being rendered smooth and polished with the burnisher until it has quite set, which is generally in a verj' little, too short a time. This is probably the most dur- able of all the amalgams, but the most difiicult to manipulate. Its surface changes to a black color, but, as' a rule, it does not stain the structure of the tooth. The circumstance of its set- ting so soon has one advantage, viz., that the patient is less liable to displace it at the next meal. The silver compound is prob- ably quite equal in durability to the palladium, but its staining and discoloring properties are so objectionable that it is very rarely employed. It sets almost as rapidly as the last named, and must, therefore, be worked with the same x>i'ecautions. Some experiments we have lately made with this compound entitle it, we think, to be more employed than it has been, and especially in cases where the cavity can be partially lined with the pyrophosphate cement. The copper amalgam* is supplied in a difterent form from any other, viz., copper already in combination with mercury, and is commonly known as Sulivan's, the name of a maker who has long prepared it. It is probably the easiest to employ of all amalgams. One of the little egg-shaped pieces, in which form it is vended, is placed ' The compound now generally supplied under tbe name of Sulivan's is, we believe, prepared 1)y precipitating copper from a solution of the sulphate, with mercury at the bottom of the vessel that contains it, by means of stirring the fluid with a piece of zinc. A much better preparation is that obtained by sub- stituting iron for zinc. The latter as so prepared was employed many years ago, and we occasionally now recognize it by a coppery lustre on portions most subjected to friction ; it is, wc believe, harder and more durable than the zinc- prepared material. TREATMENT OF DENTAL CARIES, 189 in a small iron spoon or ladle (Fig. 171), and orently lieated over the flame of a spirit-lamp, until minute globules of mercury Fis. 171. Iron spoon or ladle with wooden handle for heating, over a spirit-lamp, the copper (Sulivan's) amalgam. exude upon its surface, with generally a slight hissing noise; it 18 tiien transferred to a glass or agate mortar (Fig. 172), broken up, and rubbed into a smooth paste; it should then be well washed with a weak solution of sul})buric acid; some recommend Fi?. 173. Pestle and mortar for breaking up the copper amalgam when heated. For this purpose thev should be constructed of either agate or glass, as the compound adheres to Wedgwood's com- position. soap and water, until no longer any black fluid can be obtained from it, when the acid or soap should be removed with clean water, and if the latter quite dissolved out with alcohol, and the amalgam thoroughly dried between folds of soft linen. [It has been some years since well-known amalgam workers have objected to washing as likely to make a less perfect filling, from the impossibility of removing the water or fluid in time to employ the amalgam. It is even claimed that the discoloration under an amalgam tilling, is in a measure preserva- tive, tending to till up the dentinal tubuli ; particularly is stress laid upon this in very soft teeth with marked porosity of the dentine.] A quantity of mercury may generally, after the amalgam is dried, be squeezed out through wash-leather, leaving it in an almost powdery condition, which, on being rubbed in the palm of the hand, will soon become coherent and soft, when still more mercury may be squeezed out. The drier it can be employed 100 MANUAL OF DENTAL SURGERY AND PATHOLOGY. the better, provided it will cohere in the cavity of the tooth, Avhicli cohesion will be favored by the warmth of the mouth, and this also admits of drier portions being added to those first employed. The patient should be strictly enjoined to avoid eat- ing upon it for several hours, or be restricted to a soup diet for that day. Under the above-mentioned conditions a moderately hard and durable stopping can generally be effected ; but its black color, together with staining of the tooth, are objections to its employment ; doubtless it will always be useful for certain cases, such as the almost inaccessible cavities near to the gum between back teeth. Those varieties in which the compounds are apparently more of the nature of mixtures than the foregoing, are generally composed of silver and tin, to which ma}'' be added small quantities of either gold or platina, or both,^ mixed in certain proportions by the various makers, by whose names they are designated, melted into ino-ots, and then cut into the conve- nient form of filings. Their mode of application is as follows: a small quantity of mercury should be shaken from the drop bottle into the palm of the left hand, and to this is added by degrees the til- ings, which are thus dissolved in the former until the mass is scarcely coherent ; it should then be transferred to the mortar and thoroughly mixed The moicury j^,-,(j incorporated ; it may then be again rubbed in drop liottle from '- , , •■ • t i which the metal the palm of the hand until it exhibits a slight con- Fisr. 173. can be shaken in fine globules. sistency ' One formula is, gold one part, silver three parts, tin two parts. 2 T. Fletcher, of Warrington, has introduced a very perfect and efficient Fiff. 174. Balance for weighing out Fletcher's filiiji^s and mercury in proper proportions. The arrange- ment admilH of two varieties be'n^.' woiglied ; tlius mercury Is put into the most distant of tlie two cups and counterbalanced by filings at the opposite extremity for his platinum amalgam, but put Into the other cnp and In like manner counterbalanced for liis e.xtra plastic amalgam, nietl)od of manipulating his amalgam (plafina and gold alloy). By a simple form of balance, the right proportions of filings and mercury are obtained, and TREATMENT OF DENTAL CARIES, 191 This mixture is can-led in small portions to the cavity of the tooth, where it must be patiently rubbed and pressed, and any Fia;. 175. Fis;. 176. Fletcher's mixing-tabe for shakiiiir together the filings and the mcrcnry. appearance of free mercury be met by the addition of portions containing smaller and smaller quantities of that metal, keeping np the pressing and rubbing until indications of setting are becoming evident; and this pro- cess may be necessary for a considerable time, its object being to avoid that condition which fluid and semifluid bodies have a tendency, by attraction of their particles, to assume, viz., the spheroidal form, which we believe we were the first to point out in regard to amalgams, as one cause of their separation from the margins of a cavity. To ensure a more perfect result in regard to both durability and appearance, all amalgam fillings after a few days should have Fletcher's mortar their surfaces carefully polished. It often hap- andpianger for com- , . , . , . . pressing his platiDum pens that in smoothing over their summits some amalgam into disks of the compound is spread over the surrounding p"'"' '° insertion in ^ _ ^ " the tooth. tooth, and this thin layer breaks aAvay, leaving slight irregularity and imperfection ; if filing be not feasible, such superfluous portions may be wiped off, when the fillino- is completed, with a piece of soft amadou. As it is very difficult to carry out an amalgam filling in a powdery condition, with a cavity in which one of the sides is wanting, considerable assistance is attbrded by the emjiloyment these are incorporated bj- agitation in a test-tube until thoroughly mixed, wlien the powderj'^ mass is transferred to an ivory compressor, -nhich reduces it into small cakes of cheese-like form : these are divided into smaller fragments and introduced into the cavity of a tooth, and worked into a consistent mass by a broad plugger pressed upon by the hand or the action of a mullet. Ot" both the preparation and the mode of its manipulation we can speak most highly. 192 MANUAL OF DENTAL SUKGERT AND PATHOLOGY. of a thin metal clamp applied round the tooth so as to supply during the process a temporary wall, and which is removed when tlie filling is completed. In cases where it is desired to huild up the lost crown of a tooth upon a surface almost level with the gum, and which will alibrd a vevy uncertain hold for the amalgam, we may greatly Ficr. 177. Fis. 178. Thin metal clamp (Pinnev's) suit- able for passing round a tooth and forming a temporary wall for snstain- ing an amalgam during the process of filling. An arrangement for giving support to an amalgam fill ing upon an almost flat surface by screwing pieces of gold wire into the substance of the tooth or its fangs. The free extremity of the wire is sawn, and the sections can be bent outwards after the insertion of the wire. increase the latter hy screwing pieces of gold wire into the root- cavities ; the projecting portions of the wire being previously sawn across with a hair saw, they may be opened and pressed outwards like the petals of a flower (Fig. 178). As some practi- tioners have believed that they have sutfered from mixing these mercurial compounds in the hand, the mortar may be employed throughout. Some few general precautions in regard to amalgam fillings may here be insisted on; thus, they should never be placed in cavities where pulps are almost exposed, without some inter- vening body of less heat-conducting properties. They are less suited f(U' the teeth of young people, such, for instance, as have large cavities in the first permanent molars at the ages, say, of seven to fourteen ; in this, as in the former case, there is great liability to death of the pulp. They are never to be inserted, without special precautions, upon surfaces of sensitive teeth, where they may come into contact with the gold clasps of arti- ficial dentures, as severe pain will be experienced bj'' an electrical action set up by the two metals coming in contact. Near the front of the mouth they must be used, if at all, very sparingly ; but we cannot lay down the law that the whitest varieties shall never be inserted into the front teeth. We have even seen palla- TREATMENT OF DENTAL CARIES. 19-3 (lium inserted in the back portions of front teeth, the presence of which we shouhl never have detected but for tlie mouth-mir- ror; but here the thickness of tooth-substance between the cavity and the surface was considerable. We have met with some varieties of palladium which have stained the teeth quite as badly as the copper compound.^ The next and last of the materials which we shall describe as used for filling teeth are the metals in their unalloyed state; they are employed either in the form of thin sheets, or in a finely precipitated condition, but much more commonl}' in the former. Those thus used are gold, platina, and tin, of which gold only has been as yet supplied in the precipitated form.^ Of all the materials employed in filling teeth, gold has cer- tainly enjoyed the greatest reputation, but we fear that its popu- larity has not been wholly free from an element of vulgar pre- judice, at least on the part of some patients. However this may be, there can be no doubt but that a metal so little afltected by chemical reagents is admirably adapted for occupying a position in the oral cavity. The modes of its application are by no means easy, and undoubtedly require a long and careful training before excellence can be attained, such as, it must be confessed, our American brethren have exhibited. To build up, as it were, from little more than a fragment of a tooth, a golden crown of corresponding anatomical form to the structure lost, requires no little skill and experience on the part of the operator, and must be met with an amount of patience and endurance on the part of the patient not always to be obtained, even at the prospect of such a reward. [Many cases of so-called building up of gold upon the teeth have l)een conducted with such disregard of the patient's general health as to produce injury to the whole system.] ' Sorae years ago a readily fusible metallic compound was occasionally em- ployed for filling purposes ; it appeared to make a durable stopping of good color, but the heat necessary to soften it was more than could be generally borne, even in dead teeth. 2 Within the last two years a preparation has been introduced, termed Sladen's compound, which consists of an amalgam in a ver}' finely divided condition, and which is consolidated by pressure in much the same way as precipitated gold, to be spoken of presently. It seems to be capable of making a stopping of good color, with little liability to change its dimensions, but sufficient time has not yet elapsed to enable us to speak with any confidence in regard to its true value. 13 194 MANUAL OF DENTAL SURGERY AND PATHOLOGY. As the operations of filling teeth with gold, especially when em- ployed in the cohesive form, are lengthy and fatiguing ones, we counsel the heginner to make early attempts to conduct them in the sitting posture, and to this end we believe he will find no appliances so valuable as a Wilkerson's operating chair and a Lyon's stool. The numerous movements of the former, so easily Fig. 179. The Wilkorsoii operating chair. The various movements of the seat, back, head-piece, foot- hoard, and of the whole chair itself upon its pedestal, are as perfect as it is possible to imagine, and are carried out with a patient seated, rapidly and with a very small amount of force. effected with the patient in the cliair, and the suitable angles at which the latter can be placed, are only fully a[)i)reciated by those who have learned to operate in a sitting posture. The gold, prepared in sheets or leaves, is technically termed foil, each sheet being usually about four inches square, and vary- ing in weight from 2 up to 240 grains; of late years the makers TREATMENT OF DENTAL CARIES. 195 have conveniently attached the ■'^^"j.!^" number to each represented by their V^ weight in grains. In the employ- • ""~~"^ ment of difierent numbers there is much variety of opinion, some pre- ferring the lower and some the higher ; if there be any rule, it would be the obvious one of the former being selected for small and the latter for large cavities. Which- ever be selected, one rule does pre- vail, and that is, to endeavor to insert the foil in folds parallel to the side walls of the cavity, i. e., vertically to the base and orifice of the cavity, as there will then be less liability in the metal to flake • /-> n • ^ Lion's adjustable stool ; the seat fiiu oil than if some of its layers were be raised to any necessary height and arranged parallel to the bottom ^^i^o placed at various angles. and orifice of the cavity: the following methods to this end are adopted : — 1. By tape or ribbon. — A sheet, say, of No. 5 foil is divided by a long clean pair of scissors (Fig. 181) into three or four even strips, and each of these folded n{)on itself until the re- duced width is about the diameter of the cavity to be filled. Fiff. 181. Scissors suitable for dividing the sheets of gold and other foil. The folding may be best accomplished with a gilder's knife (Fig. 182), as the ribbon or tape so formed will be more uniform in size, and less fingered, than if folded by the hand. If the cavit}'- be protected from moisture by a napkin kept in position by the forefinger and thumb of the left hand, one end of the tape is 196 MANUAL OF DENTAL SURGERY AND PATHOLOGY. seized by the foil forceps (Fig. 183) or attached to the end of a serrated-pointed plugger, by pressing on the foil laid upon cloth or velvet, and so conveyed to the cavitj^ where it is best to com- mence at the most distant or most inaccessible part. In the case Fiff. 182. Knife suitable for folding gold or other foil. Fig. 183. A suitable form of tweezers to be employed in plugging teeth. of rubber-dam protection, where both hands are at liberty, the foil is taken up by the forceps in the left hand, wdiilst by a suit- able instrument held in the right it is pressed down into folds parallel with the sides of the cavity, each fold being made a little longer than the cavity is deep, thus projecting slightly above its oritice. After a few folds are thus arranged, the forceps are gently removed and the folds jDressed against one side of the cavity, where, with a little management, they will be held with sufficient force to support the remainder of the tape. The instrument for forming the folds in the cavity should be flat, thin, and serrated, but not so sharp as to cut the gold (Fig. 133); that for com- pressing them, called from its shape a foot-plugger (Fig. 135), should be slightly roughened on the surface which exerts the pressure, but not so rough as to adhere to the foil and tear it away.^ One length of tape being exhausted, another is in like manner introduced, and usually with less difficulty than the first, and the process continued as before, care being taken to compress each thoroughly with the foot-plugger with as much force as the walls of the tooth can safely withstand. Having thus introduced as many lengths of tape as possible, a sharp wedge-shaped instrument should be forced into the centre of the tilling, parallel with the folds, and moved backwards and for- wards, but with much caution, as the leverage thus exercised ' Mfiny other form.s of plugger will be found necessary ; those shown in Fig. 133 are amongst the most useful. TREATMENT OF DENTAL CARIES, 197 Oil the walls of the cavity is considerable. Into the space thus made more tape is inserted, and this process continued until the wedge is with moderate force unable to penetrate the surface. The last added portions not being easily accomplished by the tape arrangement, it may be effected according to the plan which we shall next detail. If the above be carried into effect as described, we shall then have a cavity filled with gold foil, in layers parallel with each other, and held firmly by mutual com- pression, so that any dragging action on the surface will be re- sisted by the whole depth of the foil ; whereas, were the paral- lelism of the folds reversed, the layer at the surface would be sustained only by the narrow portion forming its first fold. Tiie process, how^ever, has yet to be completed, as at this stage the gold should project slightly above the orifice of the cavity. With instruments terminating in somewhat broad extremities, and file-cut, to prevent their slipping (Fig. 133), the surface is condensed by considerable pressure, greatly augmented by a slight rolling movement being given to them at the same time. Fvr 184. Hand mallet, the head of which is consti-uctcd of hard wood filled with lead, which lessens the amount of vibration when used. Fiff. 1S5. Automatic mallet (Snow and Lewis). The bit or plugger is inserted at the small end of the instrument, and when pressed upon raises a mallet against the resistance of a spring, and which at a given height is liberated by a trigger and strikes the bit. The amount of force can be regu- lated by the screw at the head of the instrument. [Such movement being very like the carpenter's u.se of the brad awl]. In the place of hand pressure, force may be conveyed to plugging instruments by a mallet (Fig. 184), the substance form- ing the head being a soft metal, which occasions less vibration 198 MANUAL OF DENTAL SURGERY AND PATHOLOGY. Fii?. 186. Prof. Flagg's condensing forceps. than does hard wood. The mallet may be an automatic one and then its employment necessitates only the use of one hand. The first of such instruments was devised by J. Tomes, but the American contrivances of Sahnon and Snow, in which the force is regulated by a screw, are certainly preferable. [With these mallets the short period of time, between the pressure of the point upon the filling and the blow from the automatic hammer, is with nervous people a seemingly much prolonged stage of dread, and many will change their dentist rather than be forced to submit to a repetition of this agony of anticipation. The pneumatic mallet of Williams gives most excellent, quick, and following or squeezing strokes. It is an instrument readily kept in order, being simple and neat in its construction. The use of the electric mallet has been abandoned of late by many who formerly advocated its employment, anating (annealing) gold foil. Spirit-lamp suitable for heating (annealing) gold foil. before placing it in situ. In annealing the gold, care should be taken not to over-heat it, as in that case the gold becomes harsh and brittle, losing all the beautiful softness that it possesses: if this be avoided, a degree of heat considerably below redness is all that is necessary ; indeed, for very small pellets a single wave over the spirit-flame will be found sufiicient. The gold having been thus prepared, we proceed to fill each retaining pit with the pellets, conveying them by means of the foil-carriers and thoroughly condensing each pellet as it is put in its place. This is best done with pluggers having fine serrated points (Fig. 199), which may receive their force from the hand, from the ordinary mallet (Fig. 184, p. 197), from the automatic mallet (Fig. 185, p. 197), from the pneumatic mallet (Fig. 200), which is worked by the foot, from a very ingenious mallet which can be attached to the dental engine (Fig. 201), or from the electro-magnetic mallet (Fig. 203). [A following or dead blow, as from the pneumatic or the lead mallet, is desirable; the efi'ort being to imitate the squeeze of a vice as much as possible, 80 that the gold is laid in its place gently but firmly and held TREATMENT OF DENTAL CARIES. 207 there by a momentary persistence of the pressure.] The retain- ing pits being filled, the gold is carried over from one to the Fiff. 198. Rich's tweezers suitable for carrying cohesive foil to the retaining points or grooves. Fig. 199. /' Three forms of plugger suitable for condensing cohesive foil. FlV. 200. F\robably two kinds of action when applied to soft living tissues; one, escharotic, in which it destroys vitality by forming com- pounds with their albuminous constituents; and the other, as a powerful irritant, exciting severe inflammation; and it is generally believed that it is chiefly the latter action, which, terminating in sphacelus, causes destruction of vitality in the dental pulp. Arsenious acid has also, as is well known, a powerful antiseptic action, and is unequalled in preventing for lengthened periods the decom[»osition of animal substances ; hence the pulp, though destroyed, is seldom found putrid after its action, and this property may, as we shall see, be turned to good account in certain troublesome cases. To resume: the fang-cavities being cleared out, — no easy matter in the case of lower molars, — they should be filled up, and, though gold may be employed in certain easy cases, it is better to use the oxy- chloride of zinc, mixed rather fluid, and incorporated with finely- chopped cotton-wool; this must be worked into the fangs by a 228 MANUAL OF DENTAL SURGERY AND PATHOLOGY. sort of pumping action, by which means the air is pressed out and the stopping pressed in ; the oxychloride being powerfully antiseptic, little hurt is likely to accrue if any small particles of soft tissue be left in the fang-cavities. If gold be used, it is well to wash out the fang-cavities with carbolic acid or creasote Fi-. 215. Fiir. 216. I Form of instruments for remov- ing the disorganized concents of a pulp-cavity. Pluggers of a delicate form for filling the fang cavities with foil. before attempting to insert it. [At this stage of the operation there seems to be no question that the use of pure carbolic acid in crystals is the best means of disposing of the fine filaments and the vessels within the apex of the root.] Occasionally, though rarely, and more especially in single-fang teeth, we may find that the pulp has undergone a species of dry gangrene, and on removal appears free from unpleasantness, and of a pithy consistency ; the tooth has not changed color, and the periodontal membrane appears perfectly healthy, showing that the tooth, though possessing no vitality except probably at its cementum, is no cause of irritation to surrounding tissues. In other cases we may find that the whole of the dental pul[) has sloughed away, leaving the surrounding dentine softened, but not putrid, both of which classes of cases we should treat precisely as if we had removed the pulp. It may, however, happen that, whilst the pulp has sloughed away, the canal-cavi- ties are filled with puriform t^uids, the dentine itself being moist and very ofi'ensive; and it is rare to find, in such cases, freedom from periodontal irritation, caused no doul)t by the presence of septic substance. Such cases have been usually treated by the TREATMENT OF DENTAL CARIES. 229 frequent application of strong antiseptics, carbolic acid and creasote, alone, or mixed with iodine, being the favorites ; but for some years we liave employed arsenious acid, as with one application we have obtained more certain results than with ten or twenty applications of those above mentioned : we sim- }ily clear out the pulp-cavity, wash out with carbolic acid, and apply the arsenic precisely as if for destruction of a pulp, laying the application over the orifice or orifices of the fang-cavities, and then filling over with oxychloride of zinc. If the latter be removed after two or three months, the pulp and fang-cavi- ties will generally be found dry and perfectly sweet; indeed, we believe that there is really no necessity for fang-filling in these cases, as the arsenic effectually renders their contents in- capable of further decomposition ; but upon this point we would speak with reserve. [Prof. Flagg has recommended that the arsenical paste (p. 226) be pricked into the canals by slow movements of a fine broach toward the a]»ex, and even at one sitting the contents may be removed with little more pain than an occasional pin-scratch would give. To impress upon the reader the difference of action of the two classes of antiseptics, the following extracts from a paper on the subject by Prof. Wilbur F. Litch are here offered.^ "All antiseptics, when applied in sufiicient strength, have the power of destroying minute organisms, and of thus arrest- ing fermentative and putrefactive changes ; but a careful dis- crimination must be made between the powers respectively of such antiseptics as carbolic acid, creasote, oil of cloves, etc., and such other antiseptics as chlorine, bromine, iodine, etc., Avhich, in addition to their antiz^anotic power, are true chemi- cal antagonists of those sulphuretted hydrogen compounds of which putrefactive gases are constituted, such gases being immediately decomposed by them, their hydrogen element going either to tiie chlorine, bromine, or iodine, to form respect- ively hydrochloric, hydrobromic, or hydriodic acid, the suljihur Ijeing in each case [)i'ecij)itate on a few occasions, and on the whole with l)enefit to the j)atients, thereby no doubt relieving the tension of the organ. In most cases, how^ever, where pain is set uj) in a tooth that has been filled, especially if it be con- stant and increasing, we shall do best to remove suitable for drui- , . , ^ . .p ., , . ing into the pulp- the stopping, and ascertain, it possible, its cause, cavity of a tooth. We may find that exposure of the pulp at a cer- tain spot existed, and has been overlooked, for it is quite possi- ble for a pulp to be exposed and yet excrete no unpleasant dis- charge, as we have occasionally found to be the case. It may prove, as in the case of amalgams especially, that changes of temperature readily conducted through them have led to irrita- tion of the not far distant pulp; or even, in the case of an amalgam which ex[>ands slightly in setting, the adjoining dentine may have thus sutfered from [iressure. In the two latter cases, the substitution of a gutta-percha filling, for a time, in the place of the metallic one, will be the safest course to [lursue. Pain, of a moderate amount, may come on at intervals in a tooth in which we maj' have good reason to believe tluit none of the above-mentioned causes exist. Coming into a warm room, suddenly moving the head, as in stooping or going down stairs; Drills to be em- ployed with till' dental engine, — ' An operation more than a century old, and now most readily accomplished by the bur-engine. 232 MANUAL OF DENTAL SURGERY AND PATHOLOGY. and also being exhausted or fatigued, especially during fasting, may seem to excite it. Under such conditions we may surmise that the .pulp is subject to occasional congestions, the explana- tion, we presume, of what is termed an irritable pulp. For the relief of these cases we have found no class of remedies so serv- iceable as counter-irritants, and that which we most employ is a saturated solution of chloride of ammonium in water, rubbed upon the surrounding gum. Experiment has shown that for a considerable distance below the spot at which a blister has been applied the various structures, and not essentially all of those which receive their blood from the same source, are more anaemic than normal, which explains the action of counter-irri- tants in relieving congestion. [Saturated tincture of iodine will blister nicely. The gum should be dried, and a pellet of cotton saturated with the tincture applied on the part over- lying the root of the tooth.] Many other conditions not enumerated will at times crop up, to interfere with or even defeat the best and most patient elibrts of the operator. Cramp in the jaws, from wide distension, is a trouble from which some patients suffer much, at times relieved by their having a prop to bite upon, which is often a comfort also to those whose mouths are kept long open. Very small mouths, or rather mouths Avith very small openings, con- siderably obstruct an operator ; but that which is perhaps worse than any of the above-mentioned peculiarities, is the tendency of some patients to faint as soon as an operation is attempted: we have best succeeded with these at an early period of the day, i. e., soon after breakfast and the night's rest. The teeth of very young people, however carefully filled, have a strong tendency to an extension of the mischief around the fillings. We have seen some of the most excellent fillings fail thus, though made by operators of the highest reputation. We believe that it will be found good practice to fill the teeth of these first with either the zinc-chlorides or zinc-phosphates, which, probal)ly from their making perfectly water-tight fill- ings, have a tendency to harden the tooth in the neighborhood of the filling. In strong teeth, though it be very desirable, it is not absolutely iniperative that a filling should be perfectly water-tight. If we select from amongst the teeth which we have removed some which have been filled with gold or anialgam TREATMENT OF DENTAL CARIES. 233 for a number of years, and in which the fillings still appear quite perfect, and immerse them for some time in a colored fluid which is a chemical compound, i. e. not merely a colored body held in suspension, — Draper's ink answers the purpose very ^vell, — we shall, on removing the teeth, and splitting them across the filled spots, almost invariably find that the color has penetrated between the stopping and the cavity. It would seem, therefore, that the presence of more solid substance is essential, in strong teeth at least, to the progress of caries, which favors the opinion we have expressed with regard to it (see p. 128). [There must be some allowance made in this experiment for the shrinkage of the tooth from drying, and of the filling from difference of temperature.] In those whose teeth have on the whole stood well, changes in the constitution may have a great effect for the worse, and amongst these pregnancy is undoubtedly the most common. "Women who have had excellent teeth up to the period of a first ])regnaney, often lose them one after another, and usually with considerable suffering, especially if a family come very fast. Various explanations have been offered, none of which appear to us 80 satisfactory as that the secretions of the mouth are altered in character, and the teeth have their power of resist- ance lessened. Again, we have seen teeth in young persons, which we have pronounced excellent, become completely' altered in character after an attack of one of the exanthemata, especially scarlatina. Great mental strain is another cause of teeth taking on sudden and rapid decay, and this is well illustrated in the case of those who have been working for some time for severe competitive examinations. A visit abroad, notwithstanding the general good done to the system, often has a deleterious infl.uence upon the teeth, and a short residence in Switzerland is so marked in this respect, that we cannot but believe it to be due to certain local conditions, probably the water. On the other hand, a residence in some countries lias the opposite effect, and we believe we may say without contradiction, that residence for a time in India or China, the former especially, proves beneficial to these organs. In treating teeth which have sufi'ered from the above-mentioned causes, we shall find the ordinary metallic fillings most unsatisfactory, and we shall em- ploy to most advantage the zinc-phosphate or gutta-percha, until 234 MANUAL OF DENTAL SURGERY AND PATHOLOGY. we can conclude that the ahnormal conditions have to a great extent passed off. A most careful employment of the tooth- brush after every meal must he inculcated, and the ammonia and spirit-mixture spoken of (see p. 43) may be used with ad- vantage. [Chalk ma}^ be freely applied by the finger around the teeth on retiring, and lime-water used to wash it away in the morning. This will at least modify the local conditions, but the general health and appetite should never be lost sight of. Fresh air, exer- cise, regular meals of healthy, substantial food, such as bread made from unbolted flour, fresh meat, particularly that of small birds, the bones of which should be eaten ; lobsters, crabs, oysters, and every form of food containing lime, together with milk and lime- water, will bring about an improvement in the tooth-structure.] In the present chapter we have incidentally spoken of almost all the abnormal conditions which may occur to the dental pulp. Some writers have considered it desirable to attempt to classify them, and to define each at some length. We believe such at- tempt to be more likely to confuse the dental student than to aid him, at least in his practical work ; his treatment of a tooth will probably never be influenced b}' his considering the ques- tion, — is the pulp in this case in a congested condition onlj^ or may it be in a state of chronic inflammation? He can obtain but at most a very imperfect knowledge of its condition, en- closed as it is in its bony surroundings, unless it be at some s[>ot exposed to view, and he will then act, in nine out of ten in- stances, according to the appearance that it presents, whether for its preservation or for its destruction. If for the purposes of an examination such knowledge be deemed requisite, we would simply remind the student that the dental pulp is very liable to all those conditions and stages that are to be met witli in delicate structures largely supplied with nerves and bloodves- sels, comprehended under the general designation of inflamma- tion, which we shall dwell upon in connection with the subject of the following chapter. [Tliere has come to my knowledge at least one case of threat- ened apoplexy, which was aggravated if not induced by i)ulp cap[iing and which was averted by extraction of the tooth. Operatiojis performed without due regard to the general health of the patient, are not infrequently the cause of serious disease.] PERIODONTITIS. 235 CHAPTER X. PERIODONTITIS. Inflammation of tlie periosteum of the tooth — tlie periodontal or alveolo-dentaP membrane — is, as has been already pointed out, a very common sequence to caries, and therefore a descrip- tion of its symptoms, pathology, and treatment naturally fol- lows that of the latter disease. It occurs in both the acute and chronic forms, sometimes commencing in the former and termi- nating in the latter, and vice versa. Although by far most frequently the result of dental caries, it at times appears with apparently perfectly sound teeth ; it is also a concomitant of stomatitis, whether of idiopathic, rheumatic, syphilitic, or mercurial or other medicinal origin. As a concomitant of den- tal caries its origin is probably due to the presence of septic matter generated by a decomposing pulp, which may come into direct contact with the membrane itself, or may, through the dentine and cementum, so influence it; or may, as some have supposed, aflect it through the vessels which supply both the pulp and the alveolo-dental membrane. It is possible, when occurring to a perfectly sound tooth without any conditions which may account for it, that it may arise from embolism of the nutrient vessels of the pulp; when due to rheumatism or syphilis, it no doubt arises from depositions, the result of those alfections which have a predilection or aflinity for such fibrous structures. Cold or violence may in this, as in any other struc- ture, be tlie proximate cause of inflammation. The symptoms of acute periodontitis are generally of the following character, as we have ourselves experienced it, which agrees in the main with the description given by other writers. In the first place, a tooth becomes the subject of attention on ' The Latin term lias been adopted by C. S. Tomes, as it explains more cor- rectly the true nature of this structure. 236 MANUAL OF DENTAL SURGERY AND PATHOLOGY. account of peculiar and uncomfortable, rather than of painful, sensations. It soon appears to be sliirlitly elongated, i. e., ex- truded from its socket, and also slightly loosened, which is the case, for, on closing the mouth, it can be felt to be pressed into its socket, and on opening the mouth it seems to part from its antagonist with a sensation of stickiness. Biting on the tooth at this stage appears to offer comfort, although it probably by no means improves the condition of matters. It may happen that recovery takes place at this, the first stage, although the disease more frequently runs on to another, in which the result of pressure is anything but agreeable; and this tenderness in- creases until even the slightest attempt to close the mouth, and even contact with the tongue, becomes intolerable. Indepen- dently of that caused by pressure, pain of a constant character, varied only by an aggravation at each pulsation, is experienced, which generally continues, it may be for some days, until a swelling appears in the neighborhood of the tooth, or some adjacent part, when, as a rule, there is considerably mitigation. Subsequently the swelling becomes more defined and prominent at one part, — the pointing of an abscess, — which bursts and evac- uates the matter it contains, when a still greater mitigation of all the unpleasant symptoms is experienced. It is generally some little time before the swelling entirely disappears, or the discharge ceases to be secreted : often for years afterwards a small fistulous opening remains, through which small quantities of pus, increased through cold, gastric disturbance, etc., find their way to the surface. Of all the teeth, the lateral incisors of the upper jaw appear the most liable to attacks of acute periodontitis. The fact has been pointed out, but the reason not explained. When it at- tacks these, the upper lip usually becomes considerably swollen, as does also the facial depression formed by the myrtiform fossa, and the tissues to the outer side of the nasal i)rocess of the supe- rior maxilla ; the swelling often extending up to the lower eyelid, with considerable ecchymosis at this [lart. There may, on the other hand, be little or no swelling on the anterior i)ortions of the jaw, but there may be considerable in the palate, extending quite as far as the limits of the hard palate. No teeth are, we believe, so likely to cause the palatal swellings as the upper lateral incisors, which swellings often exist for a considerable PERIODONTITIS. 237 time, when the cause of their existence has apparently been removed. Swellings in the same positions may arise from any of the upper six front teeth, and pus may evacuate itself ante- riorly over the apices of their roots, or in the palate, or into the nares, and more rarely ui)on the surface of the face. In the case of the bicuspids and molars, the matter generally points over the roots on the external alveolar wall, where the bone is thinnest; occasionally it appears on the inner surface of the cheek opposite to the tooth, and not far from Stenon's duct; it probably takes this course when the matter is formed above the inner fibrous covering to the buccinator muscle. From these teeth also pus may evacuate in the palate, especially when the mischief pertains chiefly to the palatine fangs of the molars. [Prof. Garretson had an unusually interesting case of this character, where perforation of the salivary duct occurred, causing a persistent opening upon the external face of the cheek, a diagnosis being thereby very much obscured. Somewhat like the above was the case of Mr. R., in whom a diseased lateral incisor excited inflammation and abscess opening into the antrum, and thence into the nares, resulting in Fisr. 218. Fis;. 219. From cast of mouth showing a cystic tumor. The same after treatment. a huge sack, dependent from the roof of the mouth. This was treated by making an opening from the mouth through the ex- ternal alveolar plate into the tumor, and introducing stimuli, principally tincture of iodine. The bony palate was absorbed at one point, admitting the finger to press up the mucous tis- sues through the jjalatal process of the superior maxilla. In time the opening in the bone was filled by a cartilaginous ma- 238 MANUAL OF DENTAL SURGERY AND PATHOLOGY. terial, -wliicb when last seen bad probably been ossified, as it was hard and resistant. It ma}' be added that the first figure (Fig. 218) is taken from an impression made after the size of the cyst had been ranch reduced by emptying it through the opening in the alveolar plate, and the tissues were no longer distended by their fluid contents. Attention is called to the dropping inward of the right cuspid, from the loss of the bone and the contraction of the cicatrix of the palatine process of the superior maxilla.] In the lower jaw, such abscesses, occurring from incisors and cus|:)idati whilst generally opening near the apices of their fangs on the external alveolar surface 0[>posite to the lower lip, occasionally point on the outer surface under the chin; more rarely they do so on the inner surface of the alveolus about the root of the tongue. Abscesses from the bicuspids and molars most commonly open on the external alveolar surface, about the apices of the roots, but also very frequently on the external sur- face, not far from the angle of the jaw ; and these, if permitted to continue, give rise to an unsightly puckered scar, not unfre- qnently resembling and mistaken for the result of a strumous abscess. The abscesses set up by the lower third molars are the most severe and formidable in their character and results. We have witnessed, as such, a mass of brawny tissue extending from the angle of the jaw to the clavicle, the structures matted together, and infiltrated with pus flowing from several orifices, all characteristic of well-marked phlegmonous erysipelas. Occa- sionally, but happily rarely, such abscesses open into the pharynx or oesojihagus ; and a case of evacuation into the tra- chea, attended with a fatal result, has been recorded by G. Pol- lock. The pathology of periodontitis has been variously described, but we believe that the following account of its nature and [iro- gress, which n)ay difler in some respects from the views of otliers, will be found, upon the whole, in accordance with the conditions as they present themselves. Owing to the causes already alluded to, viz., cold, violence, the extension of previous inflammation in adjacent parts, the presence of obnoxious ma- terial in the form of rheumatic or syphilitic deposits, but more especially of septic material, the alveolo-dental n)embrane suf- PERIODONTITIS. 239 fers irritation at certain spots. This irritation results in those changes which have heen so industriously studied in the web of the frog's foot, wing of tiie bat, mesentery of the frog, tail of the fish, etc. Tiie vessels at the irritated sjiot, whether pri- marily contracted or not, become dilated, whilst the blood which they contain becomes retarded in its flow, with complete stagna- tion at certain points: without the limits of the area of irrita- tion the vessels are dilated, and the circulation more than nor- mally active. This probably constitutes the stage of congestion of tlie alveolo-dental membrane, which becomes enlarged in consequence, and this enlargement can only be effected by an elevation of the tooth in its socket : hence also the apparent looseness of the tooth. Pressure on the tooth at tliis period forces the blood from the dilated vessels of the membrane, and hence no doubt the comfort experienced by this act. In the next stage, at the stagnant parts, the vessels become crowded and finally blocked up with the red corpuscles which adhere to their walls, whilst the white corpuscles, in like manner adher- ent, are seen in increased quantity: these latter put forth pro- cesses which penetrate the walls of the vessels, and, enlarging Fig. 320. Diagram to Illustrate the passage of the white blood-corpuscles through the walls of a blood- vessel, and their subsequent migration between the fibres of the surrounding connective tissue. The red and white blood-cells are not represented in their due proportions, as this would ob- scure the chief point we desire to illustrate. on the outer sides of the vessels, and diminishing on the inner, thus transport their contents or substance through them (Fig. 220): when free, the cells travel towards the irritated spots by aid of their amoeboid contractility, the changes in the surround- ing connective tissue, by the softening and fusion of its fibres, 2i0 MANUAL OF DENTAL SURGERY AND PATHOLOGY. rendering their passage more easy. Besides the passage of the white blood-cells, serum, more or less considerable in quantity, has passed out of the vessels into the surrounding tissue, and probably by its presence and pressure gives rise to the pain ex- perienced at this stage, when biting on the tooth can no longer simply empty the vessels of their surplus quantity of blood, but causes abnormal pressure on the hyperfesthetic nerves. In the next stage, we get a rapid cell-proliferation at the spots of chief irritation, accompanied also no doubt by a similar proliferation of the cells of the adjacent connective tissue, and these formations, taking place within hard and unyielding sur- roundings, account for the constant pain, increased by the further pressure of each pulsation before alluded to. But the ever-present connective tissue of the body, not excluding bone itself, shares in the process of suppuration, until finally the ex- ternal surroundings become involved: we discard the idea of a pyogenic membrane, which on the one side possesses a property of secreting pus, and on the other a property of absorbing adja- cent tissues. When the bone is lost, the pressure of the mass of cells with the products of their fatty degeneration — pus — readily distends the softer tissues of the mucous membrane, and with this swelling and lessening of pressure comes a general relief from pain. A continuance of the process causes a like breaking- down towards the surface; in such direction probably because the tissues most remote from their blood-supply possess the least power of resistance until only. the epithelial covering is left, which speedily gives way and the matter is evacuated. The amount of matter formed in an alveolar abscess varies con- siderably, about half a teacupful being sometimes evacuated at the first opening, whilst, for some days following, the discharge may be considerable: after a time it may heal up by granula- tion, but its doing so raj>idly, or otherwise, will much depend upon the nature of its first cause: thus, if it has been due to the presence of septic matter, the result of a necrosed tooth, so long as this remains so long will pus in smaller or greater quantities be secreted. When such abscesses open externally, as in the case of the lower molars especially, an opportunity is afforded for seeing for how long a time after the opening of the abscess pus continues to exude, drop l)y drop, from the fistulous orifice, which consists of a mass of granulations of nipple form, PERIODONTITIS. • 241 whilst the surronnditio; structures are twined to tlie bone loy adhesions which have undergone contraction, presenting a most unsiglitly spectacle.^ The general symptoms are those which are included under the term pyrexia; such as an elevation of the temperature, a quickened, full, and incompressihle pulse, a dry tongue, tliickly coated with brown fur, thirst, head-ache, absence of appetite, nrine scanty and high-colored, and bowels usually constipated. The treatment will of course be local and general. In the early or first stage, when the act of biting upon the tooth gives a sense of comfort, the application of continued warmth, which is best accomplished by means of popjiy or chamomile decoctions, a little warmer than the tem[ierature of the mouth, and held within it, will often atibrd relief and occasionally arrest further progress. Cold, no doubt, might effect the same result, and probably more expeditiously, but it is almost im[)0ssil)le to ap[ily cold continuously to the mouth, and a frequent alterna- tion of temiterature is worse than useless. Cold, most probably, by causing a contraction of the vessels at the part congested, as well as a lessening of the active vital changes, restricts the pro- cess ; warmth, on the other haJid, has the opposite tendency, viz., to promote and augment those changes and conditions which are a part of inflammatory processes, especially of cell-activity and proliferation ; but then it encourages a more healthy circula- tion in the stagnant vessels, and thus lessens the congestion and tendency to exudation and cell -migration. Cold, to be effect- ive, must be applied very early, and continuous!}' maintained, until a cure is effected. In a small burn, such as the dropping of ignited sealing-wax u['on the finger, which ordinarily pro- duces a blister and painful sore, if the part be immediately ' A rare consequence of a dental fistula may be a salivary fistula. A case of this kind came under our notice many years ago, in the person of a male adult, and when we were attached to the Metropolitan Free Hospital The dental fistula which arose from the root of a lower tooth had been in existence for some time, and, when the root was removed, the opening remained patent and the saliva continually flowed through it. A probe introduced through the opening in the cheek passed readily into the open alveolus of the tooth. By freeing the surroundings of the opening from the bone to which they were adherent, and paring its edges, the opening was readily closed by a silver wire suture, and healed up without trouble. It) 242 MANUAL OF DENTAL SURGERY AND PATHOLOGY. plnnored into cold water, intense relief is experienced; and, if it be kept there ]ougr enough, no blister will appear, or other usual consequences of such an injury. [The cold may be ap- plied by the ether spray apparatus, care being taken not to carry it to the point of [)roducing a frost-bite.] In the second stage, where we have reason to believe that exudation is taking place, the application of one or two leeches to the gum over the external alveolus, corresponding to the apex of the fang of the tooth, is often productive of great relief, the tooth generally appearing to recede again into its socket ; indeed, the same remedy may be employed with benefit, if it be considered worth the trouble, in the first stage. [Holding hot water in the mouth, although it produces an exacerbation of pain at first, will almost invariably be followed by relief after persevering in its use for half an hour or more, the result of the reaction from continued hot applications.] The bleeding should be encouraged, after the leech has ceased sucking, with warm water, within moderate limits, and when it has quite ceased, the poppy or chamomile fomentation may be continuously used. It is never well to apply the fomentation or poultices to the external surface, for, although they undoubtedly afford relief, they render the tendency greater for an abscess to open on such surface. In the second stage, if it has not been seen to in the first, the bowels should be well opened; the whole trouble having probably arisen as much from a systemic as from a local cause. We often remove teeth in which there has never been other than the inflammation which would have been caused by the simplest irritants, yet not only the pulp-cavity and den- tine are in a highly offensive condition, but also the alveolo- dental membrane ; the latter a mass of apparently noxious sep- tic material, exuding fluids of the same character. We can therefore only account for those severer forms of erysipelatous character as being due to a peculiar state of the system, or to an altered condition in the surrounding vessels. [Extraction is now only resorted to in rare cases, and should not be per- formed duriiig a high state of inflammation, as it is likely to add greatly to the irritation already existing.] The former is probably the more correct view, and for the reason that we find these attacks generally associated with some debilitating con- dition, such as probably conduces, as Simon points out, to an PERIODONTITIS. 243 accumulation of those products of disintegrated tissues in the blood which in liealth are eliminated from it by imiiortant ex- creting organs of tlie body. A sudden chill appears a very common forerunner of these attacks, and nothing is more likely to affect the excreting organs ; great mental strain and overwork is another, and probably also by their indirect effects on the same organs. [A chill is a very valuable diagnostic sign of the formation of pus in an^' part of the body, and it is not excep- tional when pus forms at the root of a tooth. It may be indefi- nite, as a mere crawl or cree[»ing of a cool sensation, generally down the back, or it may be so pronounced as to be quite evident to others than the patient.] Aperients and diuretics are there- fore certainly indicated in the early stages of acute periodon- titis. When these have exhibited their desired effects, we may with much advantage prescribe tonics, the best of which, in our exi)erience, are bark and sulphuric acid.^ Nothing appears so readily to remove the fur from the tongue as this does ; and, though it may be said to favor suppuration on the one hand, it undoubtedly strengthens the system to bear it on the other, and may even enable the sj^stem to dispose of the products of cell- formation without permitting them to degenerate into pus. We witness this in certain rare cases where the disease is arrested in the second stage, the products of inflammation be- coming organized and remaining as a swelling, which after some time entirely disappears. [These cases are frequently annoying from the persistence of the swelling ; they are at times bene- fited by deep lancing and treating the interior with iodine. Constant pressure, by a pad of cotton wool or carbolized flax or oakum laid between the gum and cheek, will reduce them gene- rally with the least trouhle and pain.] In the later stages, when suppuration is inevitable, the patient should be well sup- ported with soft nutritious diet, and, if necessary, a liberal amount of stimulant. During tl>e jteriod of the acutest pain, when it is more than probable that matter has formed, it is a question whether much relief might not be afforded by treating ' U. — Acidi sulpliurici dil. 3ij- Decoct, ciachonse, §viij. M. ft. liaust. An eighth part twice or thrice in the day 244 Manual of dExNtal surgery and pathology. as for abscess in hone, i. e., by trepbinino; ; an anaesthetic might be employed during the process. Could we always insure hit- ting upon the exact spot, it might be safely recommended ; but, as these abscesses often form at no inconsiderable distance from the tooth, failure would probably add much to the patient's sufterings; the lower jaw would probabl}^ be safer so to operate on than the upper. [An ordinary spear point drill (No. 163, Fig. 115) in the engine will penetrate in a moment and give relief in a large percentage of cases within half an hour.] Bell, in treating upon alveolar abscess, makes a distinction between those which occur in the immediate neighborhood of a tooth and those which occur at some distance; believing, however, the cause of both to be one and the same we see no object in drawing such distinction. Should the disease occur in teeth apparently sound, and with- out any previous debilitating or otherwise predisposing con- ditio!is, we may suspect, in those who are the subjects of rheu- matism, that it is of such origin, and we have found it yield readily to an alkaline treatment. In those who are the subjects of syphilis, iodide of potassium is doubtless the best remedy ; and, should it occur as the result of mercurial treatment, chlo- rate of potash, both internally and as a lotion, appears to give the most speedy relief. In describing the treatment of periodontitis we have presumed that the tooth or teeth affected have been sound, or at all events serviceable ones ; should it be otherwise, and not the result of extended inllammation,or occurring from the causes eimmerated in the foregoing paragraph, we may cut the matter short by ex- traction. [Since the introduction of Dr. Richmond's gold and the Gates-Bonwill porcelain crowns, the facility with which roots are used for supporting their share of masticatory pressure, adds to the duty of persistent efforts to save the roots and delay extraction.] In former days it was not the custom to remove teeth the surroundings of which were greatly inflamed ; Ave know of no objection to so doing other than the i)ain occurring at the time, and generally for some hours after. A surgeon would surely never refuse to withdraw a splinter from the flesh, how- ever severely inflamed, provided he could readily grasp the same ; in each case the removal of the foreign body, the cause of the mischief, would, if practicable, be tlie right course ; at the same PERIODONTITIS. 245 time no positive rule on the subject can be laid down ; there are, for instance, those forn)s of" inflammation liavini; the tendency to ulceration of surface, in which an open wound would be a most undesirable condition. With regard to opening the abscess by the knife, or allowing it to open spontaneously, much will depend upon its position and condition; if it ap[)ear to be point- ing in a suitable position and without hindrance, it may be left alone, but we may by a somewhat bold incision prevent its opening on the external surface ; where it appears bagging, and discharging at one or more small openings, we may with advan- tage make a free incision at the most dependent part. [When the tissue overh'ing the pus is over one-eighth of an inch thick lancing may be delayed without much prolongation of the pain until the pus finds its way nearer the surface ; otherwise a tent, saturated with carbolic acid or iodine to keep open the fistula, may be necessary, but when used it often adds to the smarting pain.] Chronic periodontitis is not unfrequently the condition left after the acute form has passed oflf, whilst, on the other hand, as before noticed, the chronic may suddenly take on the acute form. It may and generally does occur to a greater or lesser extent with teeth the vitality of which has been lost through violence, or destroyed by the employment of escharotics in the process of filling, especially where the fang-cavities have not been carefully cleansed and filled, as before described ; also with teeth that are much injured by caries wnth discharging pulps. It is, we believe, a fact that such teeth become much freer from chronic periodontitis after the whole of their pulps have sloughed away, and the place of their former occupation is found sweet and inoffensive. A tooth that has been long affected with chro- nic periodontitis is generally much discolored, which gives it the appearance of having been filled with a dark amalgam; it is usually more or less coated with salivary calculus, as are also, not only its immediate neighbors, but the corresponding teeth of the opposingjaw. If pressed upon laterally it is seen to move slightly in its socket, and when tapped gives more or less pain, and yields a duller and less clear sound than in the case of a healthy tooth. The mucous membrane covering that portion of the alveolar pro- cess, on the external surface especially, which corresponds to the situation of the apices of its root or roots, will be seen to be 246 MANUAL OF DENTAL SURGERY AND PATHOLOGY. cono^ested and of a deep purple color, whilst in the same region will occasionally he seen a small pustule, which at times enlarges and discharges itself: in the latter case the tooth is generally less sensitive to pressure, and ^vill often hear hiting on. [The line of demarcation hetween the deep color of the gum under the lip and the light ])ink color of that around the teeth has been called the health line. In proportion as it is distinct and clear it is a sio;n of health of the teeth-roots and of freedom from in- flammation ; as this line falls toward the free margin of the gum, or becomes indistinct, the condition of disease is more pro- nounced.] The discharge has been considered by some to he the ■fluid generated by the pulp, w^hich, especially in the case of tilled teeth, thus makes its way to the surface ; an error palpable from the fact that the tw^o fluids have hardly any similarity, the former being ordinary inotiensive pus, but which, however, may arise in consequence of the presence of the latter. If we remove a tooth, the subject of long-existing chronic peri- odontitis, we shall generally find that it will require less force than a healthy one. It mostly brings with it a considerable portion of its alveolo-dental membrane, wdiich w^e find consider- ably hypertrophied, of a dark-red color, and emitting a most ott'en- sive odor. The apices of the fangs are generally bared of membrane. In some cases the tooth comes away free from any of the membrane, moist, and glistening with purulent fluid ; this is generally in the severer cases. If we examine the hypertro- phied alveolo-dental membrane, w^e find that it sei)arates much more readily from the root, especially near the apex, than when healthy, being firmer as we approach the neck of the tooth, where it is less attected. We have accounted for the separation of the membrane at the apex of the fang as due to the large amount of cementum there, w^hich, no doubt, is in these cases necrosed. The membrane is found liighly congested and infiltrated with lymph and serum, and at the portion attached to the apex of the fang there is often a small amount of pus, and, as its form when folded together somewhat resembles a sac, it has often been re- garded as the sac of an abscess. Small abscesses situated in the thickened alveolo-dental membrane, as well as small cysts, do occasionally come away entire with the tooth. Under the micro- scope the fibrous tissue of the meml)rane appears less compact and discernible than in health; we perceive amongst its meshes PERIODONTITIS. 247 Ficr. 221. abundant cells and nuclei ; many of the cells are nucleated and oat-sha{)ed, elongated at their extremities to form fibres; and some of the cells appear in an active state of proliferation, whilst others appear to be undergoing fatty degeneration. The treatment of chronic periodontitis will much depend upon the condition of the tooth affected ; if its origin be that of violence, and in a sound tooth, a leech may be applied, followed by fomentation ; or, when tiie ^\ disease is very slight, and has occurred from time to time, a small piece of toasted fig, or a little warm bread and milk, may be placed in the sulcus formed by the gum and cheek before the patient retires to rest. [There has been so much objec- tion to the effect of the fig or raisin upon th.e adjoining teeth that they may be said to be almost if not entirely substitu . ted by hot water, cotton, or tow as recommended (pp. 242, 243.)] In like manner we may treat a tooth wdiich has been filled, and which at times gives evidence of periodontal irritation ; but in such cases counter-irritants appear more effectual, and we would recommend what we have suggested and found very serviceable, viz., a saturated solution of chloride of ammo- nium,^ which is especially ap- plicable in cases where pain comes on in a tooth after entering a hot room, or when the in- Aa alveolar-abscess syriage (Farrar's), for injectintr stimulating and antiseptic fluids til rough the fangs of teeth, for the treatment of alveolar-abscess and chronic periodontitis. ' ^^. — AmmonifB bj'droclil. 3iij. Aquse, SJ.— M. To be applied to the gum with the finger when pain comes on. 248 MANUAL OF DENTAL SDRGERY AND PATHOLOGY. dividual is over-fatigued. If in eitlier condition we have reason to suppose tliut it de[>ends upon the presence of a diseased or devitalized pulp, or an}^ portion of it, in the one case, viz., that of a sound tooth, an opening should be drilled through the crown into the pulp-cavity ; in the other, the stopping should be removed, and all the diseased substance carefully cleared out. The pulp-cavity should be dressed with antiseptic substances until there is reason to believe that the dentine is free from decomposed material before the fangs are filled and the cavity again sealed up. When it occurs in a tooth that is carious and has not been filled, esi^ecially one situated near to the front of the mouth, in which the mischief has existed for some time, besides clearing away all the decomi)Osed pulp-substance, it may be well to perforate the fang, so as to enlarge the foramen at its apex, and also to drill a hole through the external wall of the alveolus to meet this. That we have accomplished tliis, will be evidenced by syringing through the fang and seeing the fluid exude at the orifice in the gum, which should be of moderate size, and kept open by a tent. The treatment will then consist in thus syringing daily, oftener if possible, with some strong antiseptic fluid, — a solution of iodine and creasote is probably the best ; the tent should likewise be dipped in the same. Where a small gumboil exists, it will be only necessary to see that tiie passages are patent. The rationale of this treatment is the attempt to correct the impurity of the necrosed dentine and the cementum about the apex of the root of the tooth. When no gum-boil has existed, the simple removal of the contents of the pulp-cavity, and the application of arsenious acid, about -^^ of a grain, to the contents of the fang-cavity, covering with zinc oxychloride, has, under our hands, afforded very satisfactory results, and has the merit of saving a long, tedious, and dis- agreeable process. The treatment is on the same principle as that described above, viz., a correction of an existing septic condition. As a final resort, extraction and replantation, to be described hereafter, may be en)i)loyed. If the tooth attacked be 80 imperfect that it would be of little or no value if retained, we may then speedily effect the cure by its removal ; and how this operation should l>e i>est performed will shortly occupy our attention in a subsequent chapter. PERIODONTITIS. 249 [Arsenic cannot safely be applied if there be inflammation and pain already existing, as it is a searching, powerful, and dangerous irritant, which may so increase the pain as to make it excruciating. It is better to apply first for a day the simple morphia paste, so as to relieve the pain and quiet the inflamma- tory action.] 250 MANUAL OF PEMTAL STEGEET ASP PATHOLOGY. CHAPTER XI. ^'ECROSIS. ABSOEPTIOK OF PEE.MAXEXT TEETH. EXOSTOSIS. Xeceosis. — Of this we have already epokec on sereral occa- sions, but more particDlarl}' in the chapter treating upon inju- ries to the teeth. Though it is, no doubt, in sound teeth by far most frequently the result of an accident, yet we sometimes find teeth losing their vitalitj' without any apparent cause, those most liable being the front teeth, and in the upper jaw, the lateral incisors especially. When arising spontaneously, it not improbably results from embolism of the nutrient artery sup- plying the pulp, which structure undergoing change allows the coloring matter of the blood to stain the dentine or the contents of the dentinal tubuli, giving to the tooth a fawn color, which as time progresses changes to a darker hue. The vitality of the dentine is lost, but that of the cementum may be retained, and the tooth then remains serviceable though unsightly. It is rare, however, for the cementum not to suffer to some extent, and, in consequence, the alveolo-dental membrane. As we have before pointed out, we may have a living pulp with more or less necrosis of the cementum ; this latter most frequently occurs in cases of absorption of the alveoli. "We have met with a ease in which the irritation, caused by a patch of necrosed cementum on the anterior surface of a third lower molar, gave rise to so much pain that the tooth had to be removed; when split oi»en, the pulp appeared perfectly healthy. "With regard to treatment we may, in the first class of cases, drill into the pulp cavit}-, — if a front tooth, through the pos- terior surface of its crown, — and clear out the whole of its con- tents: this will lessen the chances of the cementum snffering, and, if dc»ne early, also probably lessen the discoloration ; indeed, we may attempt to bleach the tooth, oxalic acid having been found the most effective agent, and finally fill up the pulp- NECROSIS. 251 cavity and hole in the crown. In the second class of cases, where the ceraentura only is affected, little, likely to be of benefit, can be suggested. Could we accurately diagnose that only a small portion of cementum had suffered, and at a givea 8{>ot, we might open down upon it, and excise it, or subject it for a time to the action of creasote and iodine. [Bleaching teeth — To be successful in bleaching teeth it is im- portant to remember that the stain may be due to various chemical agents, and that each group will require a different bleaching material. Thus the stain from fruits and vegetable matter generally has hydrogen for its base, and therefore chlo- rine, from the affinity between them, is the proper applicatiou to make. For this purpose nothing will answer better than fresh chloride of lime, which may be purchased in small air-tight packages, and applied as a putty or like a temporary filling. Labarraque's solution is also very good, but a trifle more expen- sive. In the use of this and other chemicals for bleaching, the rubber dam should first be applied to save the unaffected teotb and the mucous membrane of the mouth and lungs from irrita- tion by the fluids or gases. For the liquidation of blood clots, ammonia water is valuable. AVhere a tooth is discolored from this cause it should first be washed out thoroughly ; then a crystal of oxalic acid dissolved bj a drop of water in the tooth, to remove the iron or ink stain, carefully washing again, and as a precaution neutralizing any remaining acid by alkalies, as ammonia, etc. Nitric acid will dissolve out amalgam residue, but it must be used with caution, by dipping in it the extreme tip of a small pointed stick and touching it for a few moments to the discolor- ation ; then plentiful syringing with water, taking care to finish by applying ammonia water to neutralize any remaining acid. The deadly poison, cyanide of potassium, may be used as a solvent for the metallic dyes, applied like oxalic acid only with exceeding caution. All bleaching to be permanent will, however, depend upon a thorough removal of the discoloration, even if considerable tooth substance has to be taken with it, and if leakage is liable to occur again through the apex of the root or pulp canal, the latter is best filled solidly with gold — indeed, it is generally the first step in the treatment after the recovery of the apical tis- 252 MANUAL OF DENTAL SURGBRY AND PATHOLOGY. sues, and essential to prevent irritation of the apical pericemen- tal tissue, !)}• the l^leachini^ material ; even the fumes are ordi- narily sufficient to cause trouble. This preparatory canal fillint;; should not come down quite to the point at which the dentinal tubuli leave the canal for the neck of the tooth, as it is through these that the bleaching is accomplished in the dentine under the enamel. Fisr. 223. Hot air-syringe. A, Entrance valve ; B, Valve to prevent the heated air from passing back into the rubber bulb. Finally, complete drying by the hot air syringe will be fol- lowed in most cases by the greatest improvement. The filling may be made to subserve a good purpose in those cases where the tooth still remains slightly darker, as by inserting oxychlo- ride of zinc we may obtain the advantage gained from a white reflecting surface under the dentine.] Absorption of permanent teeth. — This condition, which we re- gard as normal and necessary in the case of the temporary teeth, is a pathological one when occurring in the case of the perma- nent teeth, although at times the two processes are not very dissimilar: thus it is not very uncommon to find the fang of a lateral incisor more or less absorbed where an uneru[)ted or par- tially erupted cuspidatus has approximated abnormally to it ; or, again, a second molar of the lower jaw may in like manner be found to have undergone absorption at the point impinged upon by the crown of an erupting wisdom tooth (E'ig. 223). [This is a not infref4uent predisposing cause of decay, and mouths will be found otherwise almost free from the disease, except at the points where lodgment of food has caused almost irreparable injury.] Teeth which have suffered from violence often undergo more or less absor[>tion at their fangs; a tooth subjected to immediate torsion, as we have narrated, was found to have lost nearly the whole of its fang. Transplanted dried NECROSIS, 253 teeth almost invariably suft'er in the same manner. But the condition of ahsorjition in the permanent teeth is most com- monly witnessed wliere for a loni;: time a more or less congested or inflamed periosteum has existed. In attempting to account for the various phenomena met with in ahsorption of the teeth, the dijfficulties have, we think, been augmented by our looking for special organs capable of eftecting the process. Altered con- Fisr. 223. Fi?. 224. Unerupted wisdom tooth, which by pressure has caused absorption of the approximal surface of a sec- ond molar. Absorption of the roots of three permanent incisor teeth. (Copied from specimens in the author's possession). ditions in their surroundings have no doubt the greatest influ- ence in efl:ecting either their hypertrophy or their atrophy ; an undue determination of blood may stimulate the osteoblastic layer of the ceraental portion of the alveolo-dental membrane, and so produce hypertro])hy of the cementum. On the other hand, stimulation of the osteohlastic layer of the alveolar por- tion of the same membrane may induce growth of the alveolus inwards. The result of this latter may be pressure upon the osteohlastic layer of the cemental portion of the membrane, and in consequence induce the osteoblasts to take on an ahsorptive action, in fact to become osteoclasts, and effect more or less the destruction of the fangs of the teeth. The absorption of bone brought about by the pressure of an aneurism is no doubt ef- fected by the same agency. The condition of absorption may attack teeth singly, or seve- ral at a time, and we have seen a case where the whole of the upper six front teeth were thus lost, one after another. In the way of treatment we fear we can suggest but little that will prove of beneflt. To endeavor to preserve the raucous mem- brane of the gums as free from hyper?emia as possible, is of course indicated, but when the teeth become loose and trouble- some, we can only suggest their removal and sul stitution by 254 MANUAL OP DENTAL SURaERY AND PATHOLOGY. artificial ones. In cases in which it results from the pressure of an iinerupted tooth, and is usually accompanied by consid- erable pain, the same treatment is the only one which presents itself. Exostosis. — This is the reverse of the condition which we have last described, and consists in an augmentation to the cemental layer covering the fangs. When it is pretty evenly distributed over the surface of the fang or fangs we may with advantage adopt the term hyperostosis, and confine the former term to cases where the deposit is circumscribed and nodulated. It occurs most frequently in the case of teeth which have suf- fered by wear upon their masticating surfaces, and this, no doubt, has determined an irritation, with increased flow of blood, and consequent augmented supply of nutrition to the region of their roots. By this means an abnormal energy is given to the odontoblastic layer of the cementum, causing an increase in the latter, sometimes to a very considerable extent. Such struc- ture, when examined, will be found to approach ordinary bone in its character ; thus we often have Haversian canals, and irregularly formed Haversian systems, which are rare but not impossible to meet wiih in ordinary cementum. The conditions of dental hyperostosis have been examined and ably described by Hubert Shelley, but we think that his descriptions apply rather to cases where more inflammatory action accompanies Fig. 235. Cases of hyperostosis and exostosis in the fanps of teeth. (Copied from specimens in tlie author's possession.) the process than to the more gradual and more characteristic ones. In most cases, but not in all, — nor even in marked ones, — there is more or less of pain attendant on tlie process, attributable, no doubt, to a want of due correspondence between the eidargement of the cementum and a complementary en- largement of the alveolus, with consequent pressure upon the EXOSTOSIS. 255 nerves of the intermediate tissue. If this be the right explana- tion, it is not difficult to account for the process occurring at times without pain, at other times with moderate pain of even and persistent character, and again at times with pain of an excruciating character. The pain also is not unfrequentl}- re- ferred to other parts than the ones aitected, occurring in the head and face, about the ear, indeed, at any of the terminal branches of the fifth pair. Many supposed cases of neuralgia have their origin in this cause, which is often, before the re- moval of the teeth so afiected, very obscure. Such teeth may be free from tenderness when percussed or bitten on. The margin of the gum around teeth which are the subjects of hyperostosis may present, but not invariably, a line of congestion said to be characteristic of this condition. In such cases the electric mouth-illuminator of Hart might prove valuable, as the roots of teeth are distinctly seen when the apparatus is placed within the mouth. As may well be expected, the removal of such teeth is often attended with much difficulty, especially where the deposition has been greatest towards the extremity of the root or roots. We shall infer this to be the condition, when, after separating a tooth from its membranous attachments, we find it loose, yet having a strong impediment to its removal : a curved fang would likewise offer the same resistance. AVe must here very cautiously and patiently continue the loosening moven)ents, until we have so dilated the uj'per portion of the alveolus as to permit the enlarged or twisted root to come out. From this cause, lower bicuspid teeth or roots are not uncommonly very difficult to remove, even when not so considerably enlarged at their radical apices. Our museums show to what an extent the cementum may increase in rare cases, at times even uniting together the roots of contiguous teeth, but cases of a moderate amount of increase are extremely common. With regard to treatment, we again fear that little more can be oftered than the radical one of extraction; but, before we resort to this extremitj', iodide of potassium, in somewhat large doses, should have a trial. [It is always of service to place such teeth in a normal con- dition, by having them meet their antagonists properly ; this may require modification of their shape by filing, or grinding 256 MANUAL OF DENTAL SURGERY AND PATHOLOGY. with corundum wheels on the dental engine; sometimes cap- ping the adjoining ones to relieve undue pressure, and at others, where no antagonizing tooth is present, inserting an artificial one. Counter-irritation, as a blister over the root, by painting the gum with the saturated tincture of iodine, is also serviceable. These remedies may be quite ettective if applied early; but after the disease has progressed to the extremit}' described, benefit might be derived from cutting away the iiypertrophied portion with a point in a burring engine.] It is not a very uncommon occurrence to meet with the two conditions ju:^t spoken of existing together, and to find the fang of a tooth in one portion hyperostosed and in another more or less absorbed. FITTING ARTIFICIAL CROWNS TO TEETH. 257 [CHAPTER XII. FITTING ARTIFICIAL CROWNS TO ROOTS OF NATURAL TEETH. In all cases the roots should have been treated and filled a sufficient time to insure against danger from inflammation or abscess. Often, a root whose surrounding tissues have been tender, and threatening chronic inflammation, will be re- stored to a comfortable condition by regaining the normal stimulation of pressure in mastication. Pivot teeth are made of porcelain, in a great variety of shapes, sizes, and shades, to suit the difl:erences of teeth they are re- quired to replace. The old fashioned teeth, with the plain hole in the centre, to be made continuous with the pulp cavity of the natural root, have been in satisfactory use, and are likely to continue so for the oral teeth for many years. Natural teeth crowns were at one time in vogue, but their liability to putrefac- tion in themouth, their scarcity, and the difliculty of getting those that were satisfactory, has pretty nearly driven them out of use. In selecting a tooth, as a general rule, it may be accepted that the less prominent it is, and the less likely to attract attention, the better. Hence, of two shades, one a little too dark and the other as much lighter than the original, or adjoining teeth, the former is to be preferred. As to size, much depends upon the space to be filled, and a slight exaggeration of the breadth of the tooth will generally be less noticeable than wide spaces intervening between it and its neighbors. Care must be taken, that the hole for the pivot is well shaped, and in such position as to be continuous with that of the root, and while sufficiently large to admit a pivot strong enough to sup- port the pressure it will be required to bear, yet it should not be so large as to seriously weaken the crown or root, and thereby defeat its object. In such case it may be necessary to fit a plate tooth and back it with gold, or thin platinum with gold 17 258 MANUAL OF DENTAL SURGERY AND PATHOLOGY, Fig. 226. I IMUU Pivot files and wheels. flowed upon it, to which the pivotof gold wire maybe soldered after having been fitted and secured in situ upon the crown by wax or cement, so as to admit of investment in sand and plaster while the process of soldering is completed. The root of the natural tooth should be filed with a lialf-round pivot file (Fig. 226, Nos. 40, 41, or 42) to a curve corresponding with the festoon of the gum, and so short as to allow the joint hetween it and the crown to be covered by the gum after the latter heals. This may be done very nicely by tlie stump wheels on the burring engine. The porcelain crown is now fitted by grinding until the joint between it and the root is perfect, and as nearly at right angles to the force of mastication as p>ossible. The crown may then be tried with a temporary pivot, made of a soft piece of wood, but not so tightly fitted as to prevent its ready removal when in place and moistened. The articulation with the opposing teeth should then be studied, and it is always well to make the artificial tooth a trifle short, particularly if a wooden pivot is used, as it may elongate when moistened. The pivot may be made of hickory wood, well seasoned and dried. The spoke of a sound old wheel will furnish choice material. It is split into small [»ieces, and these drawn repeatedly through a wire draw-plate to the sizes desired, and about three inches in length. The size of the hole in the root and in the crown is then measured with a steel wire or a wooden match- stick, drawn in the same manner, only that it may be slightly moistened. After fitting it as to the length and diameter, it will serve as a pattern for the permanent liickory pivot. FITTING ARTIFICIAL CROWNS TO TEETH. 259 The latter must be inserted into the carefully dried porcelain crown, and then pressed into the hole made by previously ream- ing out the pul[» canal. The moisture of the mouth, or, if desired, a few syringefuls of water thrown around the neck of the tooth, will cause the wood to swell and hold the ci'own firmly and at the same time with an elasticity rarely equalled by more modern methods. There has been much said against the wooden pivots, but the writer has seen them, when cut off in the root and exposed for years, serve as a filling, and protect the cavity quite successfully. If properly made, they cannot be very porous, and will not be such receptacles for putrefaction as those who oppose their use would have us believe, while their elasticity and softness pre- vent injury to the dentine of the root from chafing or wearing. When it is desired, a gold or platinum wire may be fitted into the crown and held there by packing a few pieces of gold foil around it and then flowing solder into the joint. Taper- ing the wire slightly, warming and covering it with gutta percha, it may be pressed up into the root. Sometimes the wire pivot will be better if barbed. Several roots may thus be pivoted at once by a plate with teeth crowns soldered to it ; or one root, with the assistance of gold clasps around adjoining teeth, or wire projections into them, may be made to sustain two or three crowns. The cavities in which the projections are fitted should be filled, the spaces being completely obliterated by gold or gutta-percha. The Richmond Croivns. — Dr. C. M. Richmond some years since devised the means of rendering roots serviceable by fitting gold crowns upon them, by the use of a band which encircles the necks or parts of the roots above the alveolar processes like ferrules. These seeming slight attachments have proven sufli- cient under severe use in a great number of cases. Holes may be made by enlarging the pulp canals, and gold or platinum screws or bolts may be passed through the crowns down to the roots to serve as additional stays. The process of making these crowns may be briefly described as follows: — The gold should be of the fineness of coin — for convenience and economy the five dollar gold piece is the best — and should be 260 MANUAL OF DENTAL SURGERY AND PATHOLOGY. of the dark ricli color of the recent U. S. coinage, the alloy of which is mostly copper. The coin is passed through the rolling mill until reduced to about No. 27 gauge, which makes it of an elliptic shape, about 3 J inches long, and perhaps a trifle wider than the original coin. The ends and sides are now pared off to bring the plate to a rectangular shape, and, after weighing, the parings are melted upon a piece of jeweler's charcoal, and one-fifth of their weight of fine brass wire, cut into pieces about half an inch in length, is added. Care must be taken that the melted gold is well covered with flux (borax) to prevent the burning of the brass, which latter may be added piece by piece at a time, so as not to chill the button too rapidly, one end of each being pushed into the molten button. This forms the solder, which is rolled df)wn to about the thickness of the plate, and cut into small pieces as wanted for use. The root is prepared by filing or grinding with the stump cor- undum wheels or tiles to flatten the exposed end. A strip of the plate is cut, wide enough to reach from the alveolar process to a little above this end of the root, and long enough to encircle the same; for this a pattern of soft lead or tin foil may be tried and made as a guide. This strip of gold plate is now bent and filed so as to make a close fitting ferrule; indeed, it may be made a trifle smaller, say two or three times the thickness of the plate, as it is liable to stretch, the ends abutting edge to edge, and these soldered together. A piece of [)late large enough to cover the upper or crown end of the ferrule is now cut, and a small piece of the solder flowed over one side of it, when it is laid, with the soldered side down, upon the end of the ferrule, properly covered with borax ground in water to the consistence of cream, and by heating to the melting point of the solder, the blowpipe flame being thrown down u[»on it, this lid or end is united with the ferrule proper. With the file the edges of tlie lid are dressed down level with the ferrule, the outside is smoothed, and the end next the bone has the proximate surfaces cut away with a round file to correspond with the festoons of the gums and septa of bone between the teeth, where they hang lower. The edge next the gum is then slightly beveled from the outside, making a chisel or gouge-like edge to pass up around the root and in the closest contact with it. The ferrule is now placed upon the root and pushed or driven home, and the [)oints for putting on the FITTING ARTIFICIAL CROWNS TO TEETH. 261 cusps of the crown are marked. Buttons, made by melting scraps of the coin, are first sliojhtly flattened by the blows of a hammer, while they are lying upon a smooth steel surface, then tried as to size and shape, allowing; a very slight thickness for grinding off, to perfect the occlusion or biting against the an- tagonizing teeth, after the crown is finally placed. The part of the ferrule that is to be next the lip or cheek may have a slight mark scratched upon it for the sake of convenience in replacing the crown, and the ferrule may then be drawn off from the root by working it down with a dull hoe excavator, being careful not to nick the edge of the gold or scratch the tooth. The ferrule should now be solidly filled with moistened sand, to which a little plaster has been added, as for investing plates and artificial teeth for soldering, and the whole, excepting the top or lid, should be embedded in a slightly conical mass of the same. The buttons to form the cus|)S should be placed in posi- tion on the lid of the ferrule as soon as the plaster has dried, the solder piled up around the buttons, and the whole covered with the borax flux. To attach the mass it must now be heated by the blowpipe until the solder is melted and flows freely, forming a perfect crown in shape ; but care must be exercised not to flake ott' the plaster investment and expose to the flame the soldered portion of the work already finished, lest the ferrule come out from this heating defective, or with a hole burned through it. The crown is now shaped, smoothed, and afterwards polished upon a felt wheel, it being held in contact with the latter by a stick fitted into the open end of the ferrule. Care must be taken that we may be able to recognize readilj" the buccal or labial side either by the cusps or by allowing the scratched mark to remain. In cases where the {ippearance of the gold is objection- able a plain porcelain tootli of pro[)er shade may be fitted, backed, and soldered on in the place of the outside cusp or cusps, and in such teeth it is best that the ferrule should not come below the free margin of the gum upon the labial face. A small hole may now be drilled into the hollow portion at a convenient point of entrance from the outside, affording escape for the cement when the crown is being pressed into position. The root and surrounding gum being well wiped and kept thorougiily dr}^ by means of a folded napkin, the interior of the ferrule is filled with some plastic filling materials, oxy-chloride 262 MANUAL OF DENTAL SURGERY AND PATHOLOGY. or oxyphosphate of zinc, mixed rather thinner than usual for insertion into cavities. The crown is then to be pushed upon the root and a bite taken by the patient to force it to its place be- fore the cement filling has set, where it should be held im- movable until the plastic filling has hardened. The overflow opening may then be filled with gold. The crowns may then be ground with the corundum points on the dental engine until the articulation is perfect. The writer has worn with great satisfaction for nearly three years two teeth made as described, and with them he breaks up the hardest substances ordinarily used as food, preferring to risk the gold crowns rather than frail natural ones. Drs. Grates and Bonwill's crowns are made of porcelain. After being ground to fit the previously smoothed stump, and articulate properly with the antagonizing teetli, they are held in position by three-cornered barbed platinum wires, which have been secured in the roots by driving them in, and filling around them. The spaces left between the platinum, the crowns, and the roots are filled with a quick-setting amalgam or gutta- percha. Gates-Bonwill crowns. The Flagg pivot is explained in the following terse descrip- tion in his own words:' — "Select plate-tooth, fit it to root, and bevel it from near the pin — cervical — or pins, if cross-pins, to the labio-cervical edge. tSolder a platinum pin to it as a backstay and pivot combined, leaving it rou£i;li or grooved on both sides of the pin for a retain- COO i- ing hold to the finishing palatal amalgam. '' Fill the root, which is treated, prepared for strong mainte- nance of filling, and ' bell-muzzled,' or ' open-mouthed,' with a good usual or contour alloy, quick setter, non-shrinker, good edge, strength. I prefer to give this a day to iiarden thoroughly, [' See p. 129, Plastics and riaslic Filling.] FiTTINQ ARTIFICIAL CROWNS TO TEETH. 263 but in case of need it may, with care, be worke-l in an hour or two. "Into the root filling drill a hole rather larger than the platinum pin, as near to the pdatal portion of the filling as possible, and directed slantwise to the a[>ical centre of root-fill- ino-; then fissure-drill the hole towards the labial portion of the filling, trying the tooth until it sets just right, with the pivot- pin pressing hard against the labial side of the now oval pivot hole. B>/ this method the tooth is accurately placed in position and easily held firmly in place while the pin is secured by filling the pivot hole with amalgam. "Let this harden for half an hour, and then add amalgam in contour to the root filling and palatal face of the porcelain tootii. It is at this point of the operation that the need for ' bevelling' the cervical portion of the tooth is demonstrated, for, by this bevel, one is enabled to make, by filling, a perfectly tight joint at the labio-cervical junction of tooth with root, and also to secure a strength of amalgam equal to the entire surface of root-filling." There yet remains for notice an ingenious practice described, by Dr. Bing, of Paris, for filling or restoring large portions of crowns. A thin plate of pure gold is struck up to the shape desired to be placed upon the tooth, and upon the under side is soldered by the ends two pieces of wire shaped like staples. After fitting this gold cap or cover, the tooth is filled with gutta-percha, and while it is yet soft, the cap is warmed and pressed into place, and burnished down to fit tightly and pro- tect the edges of the tooth and the wiiole filling. The cavity in the tooth may be rounded in contour, the edges smoothed and polished, so as to enable the operator to burnish the gold, to form a tight and close-fitting joint.] 264 MANUAL OF DENTAL SURGERY AND PATHOLOGY. CHAPTER XIII. EXTRACTION OF TEETH. The operation of extraction bears an analogy to that of am- putation, inasmuch as it is the removal of a useless or obnox- ious member for the welfare of the rest. As no conscientious surgeon would ever think of resorting to the latter so long as any well-grounded hope existed of a limb or member being again restored to a state of usefuhiess, so no intelligent dentist will ever think of extracting a tooth as long as there remains a fair prospect of its also being restored to a state of usefulness. On the other hand, the surgeon knows that an artificial limb, however limited its capabilities, is yet infinitely better than a painful and useless one ; and the dentist likewise knows that an artificial tooth is infinitely better than a useless and painful one. In another point of view, however, the two operations widely differ, viz. : — in their effects upon the individual, the one being comparatively safe and almost momentary in point of duration, the other being severe in character, and highly dan- gerous in its results ; at the same time, this ought in no way to lessen a due consideration before sacrificing so useful though humble a member as a tooth, and this consideration becomes of still more importance when the tooth or teeth to be removed happen to be sound ones. The teeth, about the removal of which we hesitate the least, are those which have become so loose from absorption of their alveoli as to be quite useless, indeed impediments to mastica- tion ; those long affected with chronic periodontitis, whose tartar-crusted crowns are evidence of their long season of useless- ness, as well as that of their immediate neighbors ; teeth erupted in abnormal jiositions, incapable of being brought into position, and interfering with movements of the tongue or lips; also the roots of teeth causing unhealthy gums or secreting offensive ■fluids. [The method of fitting artificial crowns has, however, EXTRACTION OF TEETH. 265 rendered the preservation of roots a matter of much importance, and to-day many such are in constant and highly satisfactory use.] Having convinced ourselves of the expediency of resorting to extraction, we must in its performance carefully observe three conditions: first, to carry it out completelj', in other words, to remove the tooth in its entirety; secondly, to accomplish it with the least possible injury to surrounding parts; and thirdl}^ to inflict as little pain as possible. Usually carefully pursuing the second condition, we fulfil the third. The form of articula- tion of the teeth to the jaws has been classicall}' termed gom- phosis, but this gives an erroneous idea of the exact attach- ment; the teeth are not retained in their sockets as are nails in wood, by their elastic surroundings. In a dried skull the teeth will be felt loose in their alveoli ; some will, itideed, drop out by their own weight; the rest are retained by tlie dovetailing of their fangs in their sockets. It is a strong periosteum, the alveolo-dental membrane, which is the true medium of attach- ment of the teeth and maxillae, and it is the sundering of this which, in normal cases, necessitates the amount of force that must be employed, and which should occupy our chief atten- tion, the thin alveolar walls in the moist condition yielding more readily. \_Extraction. — The peculiar nervous condition into which most patients find themselves brought by the suffering which precedes and often compels the operation of extraction, entitles them to the most sympathetic consideration of the dentist and to his most gentle efforts for their relief. Weak children, delicate women, and sturdy men alike succumb, and lose all self-control in the face of the expected torture, and no amount of ordinary faith or courage will suffice to keep down their agitation and quiet their expressions of dread. To deal with such conditions requires peculiar gifts on the part of the dentist, which are so rare as to make their possessor both well known and successful. lie must have confidence, which can only be well founded by a thorough knowledge of his subject; his movements must be rapid but easy ; his manner firm but patient; above all his symjiathy must be genuine. The anatomy of the teeth and surrounding j^arts. — In this study we first note the insertion of their roots (for description of which 266 MANUAL OF DENTAL SURGERY AND PATHOLOaY. see pages 49 and 50) into a more or less spongy bone, with an ex- ceedingly tough membrane uniting the two, and which may be slightly thickened about the necks of the teeth, forming the so- called ligamentiim dentis, which, however, is of so slight im- portance from an operative standpoint that we may remind the student that its existence is doubted by some. Fiff. 228. The teeth of the left side of the mouth. i A little below the bottom of the cavity in which the tooth fits, which is called the alveolus, we find in the living bone an artery which gives oft" minute filamentary branches to enter the apex of each root, and with this passes also a nerve and vein of like proportions. At the back part of the upper jaw-bone, im- mediately behind and above the last tooth, is a tuberosity which is richly supplied with blood from several branching vessels of the alveolar artery, entering by small holes or foramina, the largest is the superior dental artery. Traversing the body of the bone almost per[)endiciilarly is a branch of the infra-orbital ar- tery, which it leaves in the canal under the orbit and descending sends small twigs to the upper incisors and antrum, a cavity in the bone connecting with the nose and formed immediately above the molars, whose roots, covered with a thin layer of bone and mucous membrane, often project into it. This cavity may be ' From "Tlie Mouth ami tlic Teeth." By Dr. Jas. W. White, Philadelphia. EXTRACTION OF TEETH. 26T opened into by the extraction of one of these teeth, or it may be diseased and involve them, but lined with mucous membrane like that of the nose, its .being opened by accident in extrac- tion is not of necessity a serious matter. In disease such opening serves as an avenue for treatment, and is often purposely made. Two bloodvessels, one on either side, are to be found running forward from the posterior part of the palate, nourishing that portion between the teeth which is commonly called the roof of the mouth ; they pass upward to the nose through the anterior palatine canal which is in the anterior portion of tlie upper jaw immediately behind the central incisors. In the lower jaw the inferior dental artery, a branch of the internal maxillary, enters the bone on the inside of the ramus by the inferior dental foramen, the opening of a canal in the bone through which it passes forward to the neighborhood of the root of the second bicuspid where it divides. One branch, the inferior incisor, passes forward to nourish the anterior part of the bone and oral teeth ; the main stem, diminished in size, and now called the mental artery, finds an exit on the labial side of the bone to nourish the lower lip and gums. The tongue is a highly vascular organ, having two arteries, the ranine, running parallel from its base on the underside to- ward its tip, and two above, the dorsali lingupe. The arteries above named anastomose toward their terminations.] In proceeding to consider the operation of extraction, it is desirable that we should first describe the instruments employed, and in tlius doing we shall merely allude to one, which, though serviceable in its day, should now possess only historical interest. The key (Fig. 229), so largely employed for many years, is now, or at least should be, entirely superseded by other and more efficient instruments. It formed, when in action, a most powerful lever of the first order, and therefore became, especially in inexperienced hands, a dangerous instrument ; moreover, when it was once ap- plied to a tooth, the force exerted could be in only one given direction, and this might happen to be that in which the greatest resistance was offered ; and lastly, as the fulcrum of the instru- ment was apitlied upon a soft tissue — the gum ; this, although it might be relieved by padding, had to bear the force necessary 268 MANUAL OF DENTAL SURGERY AND PATHOLOGY. for removing the tooth, mostly bruising it, sometimes lacerating it. [Some operators were, however, quite expert in its use, by placing the fulcrum upon the tooth, and thus avoiding the in- jury to the gum.] To the great improvements in the forceps is due the retire- ment of the key, which was not an improper instrument so long as the forceps employed was not adapted to be accurately Fis:. 229. Key instrument for extracting teeth. The upper portion represents, on the ri^ht hand, tlie bolster or fulcrum, and on the left hand a claw which revolves upon a screw shown at quite the extremity. The steel bar, which connects this portion with the handle, is bent, so as to permit it to clear the front teeth. The detached claws represent different widths for application to larger or smaller teeth. applied to each tooth, and, therefore, touching only at a few points, acted mostly like a cutting instrument, either slipping oft" from, or fracturing, the crown. The point is well illustrated in the case of the litters of gas and water [tipes, whose pincers or tongs, being segments of circles at their grasping points, securely hold the circular pipes, which ordinary pincers would only slide upon or crush. Changes in apjiliances, as in ideas, are mostly gradual; many practitioners, knowing the disad- vantages of the key, endeavored to rerned}' the evil by adapt- ing the existing forceps, as far as })0ssible, to certain teeth, l)ut the key received its death-blow when J. Tomes took in hand not only the construction of forceps ada[)tablc to every tooth. EXTRACTION OF TEETH. 269 but conferred tlie greater benefit of enabling practitioners to obtain the same, a privilege of which every dentist of the present day should not be unmindful ; and the public may also rejoice that from the time he did so the excruciating " key note" has gradually faded from the surgeries of dentists. The forceps is a modified pair of pincers (Fig. 230), and con- sists essentially of the same parts, viz., a pair of blades or jaws Fi?. 230. Forceps for extractiiii,' upper incisor and ciispi. George, now generally seen, has the latter advantage to per- fection, but it fails, we think, in not affording a little lateral 270 MANUAL OF DENTAL SURGERY AND PATHOLOGY. movement. In cojistructing the adapted forceps, it is usual, after forging and filing the blades as nearly to the required shape as possible, to fit them still more perfectly by applying them to the neck of a normally formed tooth, colored with pig- ment ; the spots marked by the pigment are cut away, and the process continued until an almost perfect adaptation is attained, after which the blades are tempered. Thus constructed, the blades should accurately fit upon the external and internal sur- faces about the neck of the tooth ; but, as these do not always bear the same relative position to each other, it is well to have a little play at the hinge, which will allow of the blades accom- modating themselves to this departure. The handles should be strong, broad, and roughened, long enough to aftbrd a firm grasp, but no more, for although length in the handles gives greater leverage, they make the instrument cumbrous, and interfere with delicacy of movement. [Forceps for the ojieration of tooth extraction should be gene- rally straight, or so nearly so as to make the force applied to be in a direct line with the axis of the tooth. Manufac- turers are still compelled to satisfy a demand for various tAvisted and curved implements which remain in favor with many. Hooked handles on forceps is an example of the power of conservatism ; except the hooks be upon both handles, the tendency is to cause the force exerted to press to one side, chang- ing the direction to an oblique one with the axis of the tooth. Forceps cannot be selected ready made without these cumber- some contrivances, and therefore the student must pardon their appearance in the illustrations. The beaks of the forceps as now sold are generally good as regards their shape, but in selecting it may not be amiss to test them upon typical teeth of the kind for which the forceps are designed. By many the joints are preferred of an oval form, being stronger and likewise less liable to wound the lips or cheeks, if the patient struggles. In indicating what may be called a set of forceps it has been the endeavor to name them in the order of their relative value. Fig. 231 is an incisor forceps, which has the qualities de- scribed, being straight in its axis, and although not shown in the cut, can be purchased with oval joints and straight ban- EXTRACTION OF TEETH, 271 dies. This instrument is of use often as far back as the bicuspids, and although intended for incisors only, it is used by many even Fiff. 231. Xo. 13. Superior incisor forceps. for molars, but in all cases except for the teeth for which it is desi!ij;ned, the danger of fracturing the crowns must not be over- looked. Fig. 232 is designed for lower bicuspid teeth, but may serve well for incisors by grasping the tooth upon the lip and tongue sides and making the motion forward and backward, instead of from right to left as in the bicuspids. Molars may in like Fiff. 232. No. 21. Inferior incisor, canine and bicuspid forceps. manner be extracted with it if not too firm in their sockets and by turning the beaks up the suj^erior molars and wisdom teeth may be grasped with it. Fia;. 233. Xo. tS. UppiT molar forceps for either sidr Fig. 233 and Fig. 234 are, better adapted to all upper and lower molars, except perhaps the wisdom teeth. The 272 MANUAL OF DENTAL SURGERY AND PATHOLOaY. former (Fig. 233), having one beak with a point for passing be- tween the buccal roots, and, being perfectly straight, may be used Fi?. 234. No. 17. Lower molar forceps for either side. upon either side by placing the pointed beak outward or next the cheek. The latter (Fig. 234) can be seen at a glance to be adapted to pass its pointed beaks between the two roots of a lower molar on either side. Fig. 235 is well designed for upper roots, being often service- able all around, occasionally even in the lower jaw. Fig. 235. No. 7. Root forceps. Fig. 236, in cases of upper second molars and wisdom teeth, will complete the set of six that are most useful and essential, Fig. 236. No. 10. Upper molar and wisdom teetli. and without which one need hardly hope to gain a very ex- tended practice, if any other dentist be accessible, unless he too is poorly provided. To the above set might well be added Fig. 237, a forceps designed by the writer for cutting out the roots without remov- EXTRACTION OF TEETH. 273 ing a portion of the bone; for separating hooked roots, so tliat they may be extracted separately ; also to use as elevators for wedging between wisdom teeth and second molars. In the latter use care must be taken to support the fulcrum tooth, Fisr. 237. No. 66. Forceps for cutting out the roots. if there be no tooth immediately in front, by placing a small piece of w^ood to impinge on it and the next one to the front. A little caution will likewise be necessary to prevent the turn- ing of the wisdom tooth so completely out of its socket as to liave it pushed back into the fauces ; particularly should this be observed if the patient be under an anaesthetic. To these forceps may be added with great advantage some few others, which, although not so frequently required, will well repay the first cost by the satisfaction of having them at liand when wanted. Extraction is an operation that must be performed with confidence on the part of the operator, and no better rule has been given for it than that of Tomes. "The whole of the tooth should be removed with as little injury as possible to the surrounding structures and the least pain ne- cessary to the case," Digging out a tooth piece-meal, or other barbarities, such as are practised by the African, who relieves his companion of an aching tooth by means of a spear-head for an instrument,^ cannot come under the classification of dentistry. Blacksmiths' tongs, cold chisels, and hammers have been used for the purpose successfullv, but are no more to be reprehended than some of the methods the writer has seen and heard of as adopted by dentists. [' It was related to the writer by Dr. Visick, of England, that one of his relatives had actually witnessed such an operation.] 18 274 MANUAL OF DENTAL SURGERY AND PATHOLOGY. Therefore, as auxiliary to the above list of seven instruments, every practising dentist will do well to furnish himself with the following : — Fig. 238, upper molar forceps, right and left. In these are found a deviation from the straight line so urgently recommended, Fiir 238. No. 18. R. & L. upper molar forceps. but to enable the operator to reach well back in mouths with a small opening, they w^ill very frequently be found desirable, if not absolutely necessary. Fig. 239, root forceps. The cut represents a pair, rather heavy for the purpose designed. For the operator who is content to FijT. 239. No. 1. Koot lurceps. consider the possible fracture of an instrument as of more im- portance than the pain inflicted by forcing up the beaks between the root and gum, it may do. There are, however, more deli- cate instruments made than the one figured, and if specially ordered, they can be made so light as to be capable of passing between the root and bone with a surety of success in the re- moval of the root. Fig. 240, right and left, is the cut of a pair of instruments that, although rarely used, are very valuable in extreme cases where the crowns are so far crumbled away or weakened as to EXTRACTION OF TEETH. 275 l)e incapable of resisting a force sufficient to remove the teeth. The horn-like beak passes between the buccal roots, and should Fi,-;. 241). No. 20. II. & L. ujiiier nicjlui- forceps. either bring them away or divide them so that with the curved or universal root forceps, Fig. 235, they may be susceptible of removal. Fig. 241 is the low^er forceps designed for the same purpose in the lower jaw. It is not an unfrequent experience that the Fiir. 241. No. 2.3. Lower molar forceps, either side. mere closure of the beaks between the roots will wedge the whole tooth out of its socket, and to complete the operation it is only necessary to lift it out of the mouth. Fig. 242 is a cutting forceps for the upper jaw, corresponding in its use to that of Fig. 287, adapted, liowever, by the curve, to reach back to the upper molars, and, b}^ cutting through the bone, seizing and removing their roots. The gum may be di- vided first by the lancet upon either side of the root ; an unneces- sary operation if the patient is anaesthetized. The advantage of these instruments over those that have double cutting edges on each beak is, that the healing is much more promptly eiiected than when a mass of bone is removed, 276 MANUAL OF DENTAL SURGERY AND PATHOLOGY. and at the same time the alveolar process is not lost — a great de- sidenitum when the patient is to wear an artificial substitute. Fiir. 243. No. 67. Cutting forceps. Fig. 243 is a smaller size of incisor forceps, which will answer in case of laterals or very small teeth. As mentioned before, it Fiff. 343. No. 48. Lateral incisor forceps. is often desirable to have more than one size, as the incisors var}- so much that one pair of forceps cannot be relied upon to fit all cases with accuracy sufficient for their removal without acci- dent or fracture. Fiff. 344. No. 40. Lower iiici.sur and rucit forceps. Fig. 244 represents a lower forceps, which may be used alike for incisors or canines; of this the same may be said as of the pair previously described.] EXTRACTION OF TEETH. 277 In employing the forceps, the student cannot do hetter than follow the excellent directions laid down by J. Tomes,' who divides the process into three stages, insisting most properly upon eacli being [jcrfectly accomplished before the succeeding one is attempted. The stages are — "first, the seizure of the tooth ; second, the destruction of its mend)ranous connection with the socket ; third, the removal of the tooth from the socket." In the first stage the instrument sljonld be taken lightly in the palm of the hand, the blades pointing upwards or down- wards, according to the jaw operated on, the thumb being em- ployed as a stop or regulator, to govern the amount of separa- tion of the handles and consequently of the blades. In applying it to the tooth, it is well first to adapt one blade to the side most obscured from the view of the operator, and then to close the other upon the opposite side, but only so lightly as just to touch the tooth at the point of its connection with the gum. This done, the thumb is now gradually withdrawn, and steady but forcible pressure made in the direction of the root of the tooth. The force employed should be regulated by the amount of resistance experienced, commencing gently and increasing as the case demands, and often accompanied to advantage by a very slight rotatory movement at the same time. Experience will enable the operator to tell when this has been accom- plished to the proper extent, but we fear that some have read too literally the injunction, to " push the jaws of your forcejo into the socket, as though you intended they should come out at the top of the head or under the chin," as we have seen it fulfilled on teeth which needed no such roughness, caus- ing unnecessary pain. The operator must judge, as he pro- gresses, how much force is required, commencing gently, but continuing to increase the force until the object in view, viz., a firm grasp of the tooth at or above its neck, as the state or diseased condition may indicate, is obtained. Perhaps more judgment is required in this portion of the operation than in any other; and it must be admitted that, if it be unskilful to use unnecessary force in it, it will prove more unfortunate to err on the other side, and cause the fracture of a tooth by era- ploying too little. The tooth being grasped at the right spot, ' Lectures, etc., p. 326. 278 MANUAL OF DENTAL SURGERY AND PATHOLOGY. it must be retained by a force sufficient to prevent the instru- ment from slippinsj, but not so great as to endanger the some- what fragile object; and then the second stage of the operation, the severing of it more or less from its membranous attach- ment, is commenced. This will consist in either a slightly ro- tatory movement in the long axis of the tooth, as in the case of one having a conical fang, or an inward and outward one, %. ?., between the adjoining teeth to and from the mesial line of the dental arch, when the fang is not conical, or there are more fangs than one. In making these movements, we should follow certain general directions to be presently mentioned ; but, if we fail with moderate force to cause the tooth to yield, we may © Fig. 245. Fig. 246. /TT) (5^ r^ Transverse sections of the teeth of the upper Transverse sections of the teeth of the lower jaw made at their necks. .iaw made at their necks. These figures will be fiequently referred to in the present chapter. employ it in others, gradually increasing it as we find our efforts availing. The yielding of the alveolo-dental membrane gives a sensation which we can readily perceive, and, when it is suffi- ciently severed, we may connect with our movements of de- tachment those more truly extractive, the third stage of the operation. Judgment must be exercised here too; for, if the extractive force be put on too soon, fracture, or too great a resistance, will be experienced ; if put on too late, much unne- cessary pain is inflicted : error in the former alternative is likely to be attended with the unwelcome exhibition of portions of alveolar process. The extractive force should, as a rule, be ex- erted chiefly in the direction of the long axis of the tooth ; but it is a rule with many exceptions. The skilful operator will EXTRACTION OF TEETH, 279 jutlge in which direction the loosened tootli is coming most readily, and in the direction of least resistance he should exert the traction. It is in this respect that the forceps is so superior to the key or other instruments, viz., in its enabling the ope- rator to vary the direction of the force that he employs. Having described the mode of applying the forceps in general, we now proceed to explain its application in the case of individual teeth, and must, in so doing, take it for granted that the reader is conversant witii dental anatomy, and fully acquainted with the forms wliich the teeth in man present. He must know that horizontal sections of upper incisors and cuspidati (Fig. 245), made at or a little below their necks, present at the divided sur- faces an almost circular form, the anterior and posterior aspects of which will be arcs of a circle — the anterior a rather larger one than the posterior. The blades of the forceps must be con- structed to correspond to such forms, and to cover, when applied, rather more than a third of the surface of the tooth grasp)ed. In the perfect instrument the inner blade should represent a less obtuse angle with the inner handle than the outer blade does with the outer handle, in accordance wMth the form presented by the roots of these teeth (Figs. 247, 248, 249). Whilst the Fio-. 247. Fia:. 248. Fiir. 249. Central incisor of upper jaw, front and side views. Lateral incisor of upper jaw, front and side views. Cuspidatus of upper jaw, front and side views. same instrument may be employed for all the above-mentioned teeth, a pair with narrower blades (Fig. 243) may be desirable when very small lateral incisors have to be dealt with. The operation of extracting these teeth is thus performed : the patient should be seated and facing a good light, and, if a proper dental chair be not at hand, an old-fashioned easj^ one, provided with a cushion, to raise the body so that the head may recline steadily on the top of it, will answ^er sufficiently well. If such a chair be not procurable — for these operations have often to be per- 280 MANUAL OF DENTAL SURGERY AND PATHOLOGY. formed at patients' houses — the following may be adopted : The patient is seated upon an ordinary chair, whilst a second chair is placed at the back; on this latter the operator firmly places his left foot, and covering his knee with a towel, makes it a soft but firm support for the patient's head. The foregoing sugges- tions are, of course, available also with all the teeth of the upper jaw. In applying the forceps to the teeth in question — upper incisors or cuspidati — the operator should stand rather in front, and on the patient's right side ; with the thumb of the left hand the lip should be raised, whilst the fingers of the same resting upon the patient's forehead afibrd steadiness to both patient and operator: if preferred, the operator may apply the finger and thumb of the left hand to each side of the alveolar process ad- joining the tooth ; this latter has the advantage of affording some knowledge of the yielding of the tooth to the force applied. [The concave portion of the palm of the left hand wmU be over the cheek and the prominence made by the zygomatic arch. The prominence near the wrist or the fingers may rest lightly upon the orbital process or temporal region of the head.] The forceps, held as before directed, should be applied to the neck of the tooth, to its posterior surface first, and then closed gently upon it by the thumb being withdrawn : the instrument is now forced upwards in the direction of the long axis of the tooth, until tlje edge of the alveolus, or, if the tooth be much decayed, a point beyond, is reached. The tooth being firmly grasped, a slight rotation in one direction is attempted ; but, if much resist- ance be encountered, the rotary movement is reversed, and, if still resisted, it may be exchanged for an inward and outward one, i. e., to and from the centre of the palate, coupled with a return to the rotary. [Generally the rotary movement should be very slight for all teeth save the superior central incisors.] As the tooth begins to yield from its attachments, the force may be gradually changed to a doAvnward one in the direction of the long axis of the tooth, but it should be steady and guarded, in- clining to the direction in which the tooth seems the most willing to yield. It is not elegant or agreeable to witness the tooth l^arting from its socket with a sudden jerk, although it not un- frequently shoots from it, owing to its sliding along the double inclined plane formed by the hlades of the forceps ; an occurrence not always possible to avoid, but one which we should do our EXTRACTION OF TEETH. 281 utmost to prevent, as tlie tooth ma}' disappear into the throat or even larynx under such circumstances. More force will be necessary in the removal of the cuspidati than in that of the central incisors, and more in the case of the latter than in that Fitc. 350. Fig. 251. Upper first bicuspid, front and side views. Upper second bicuspid, front and side views. of the lateral incisors, [The apices of the roots of the latter teeth very often have a sharp turn or crook, which will be broken by a hasty movement in the wrong direction. These crooked por- tions of all teeth roots that curve have a general inclination away from the mesial line toivard the distal face, requiring the motion to be backward, or such as to unhook it.] We now pass on to the bicuspids of the upper jaw, sections of which at their necks (Fig. 245) are of a less circular form than is that of the teeth just considered, which, instead of having an almost conical root, have a somewhat flattened one (Fig. 250), the teeth being broadest between their external and internal surfaces. In the place of one fjing there may be two or very rarely three, this being more common in the first than in the second bicuspid (Figs. 250, 251), although some works on anatomy give the re- verse. For these teeth we must have an instrument (Fig. 243), the blades of which must be segments of the circle presented by the external and internal surfaces of these teeth at their necks, and for all practical purposes segments of the same circle will suffice; otherwise we should require a pair for each side of the mouth, as the handles are bent at an angle with the blades, to prevent the former from pressing against the lower lip during the operation. The breadth of the blades should be about the same as in the instrument for the central incisors and cuspidati. The operator assuming much the same position as that just described, which is generally best suited to the removal of all the upper teeth, the instrument is applied and forced upwards, as before directed. The severing movements must be accom- 282 MANUAL OF DENTAL SURGERY AND PATHOLOGY. plished by force exerted to and from the palate — we prefer it in that order i. ted than the form suitable for the first and sec- Third moiar or wisdom ond molars; consequently such an instru- tooth of t&e upper jaw. [' See pp. 4 and 13, "A Practical Guide to Operations on the Teeth," by James Suell, Dentist ; Carey & Lea, Phila. , 1832.] 284 MANUAL OF DENTAL SURGERY AND PATHOLOGY. ment may be employed for eitlier side, whereas for the latter in- struments for the right and left side are necessary. The liandles ought to form a considerable angle with the blades, otherwise it will be impossible to adjust them accurately, and in the di- rection of the vertical axis of the tooth. Except from the in- accessibility due to their position, the third upper molars are not, as a rule, very difficult to remove ; their roots, if not agglu- tinated, are generally but slightly divergent ; and the bone in which they are placed is soft and spongy. From the direction of their long axes, the movements of detachment and removal may be combined in an outward and downward one from first to last, it often being necessary to make the latter considerable ; indeed, a circle passing from the crowai of the tooth, downwards, outwards, and upwards in the direction of the zygomatic pro- cess ; an exaggerated curve corresponding to that which the fang of the tooth often assumes in its alveolus. AVhen we operate upon the teeth of the lower jaw, the patient may conveniently be seated in an ordinary easy chair, the head being in a line with the body, i. e., in the usual sitting posture, or nearly so. As horizontal sections of incisor teeth of the lower jaw at their necks represent an ovoid figure, flattened laterally (see Fig. 246), the anterior and posterior surfaces of which are segments of a circle much smaller than that presented by the upper incisor teeth, the blades of the instrument to be employed for their removal must be narrower and arcs of a smaller circle, than in the case of the upper incisors, and in re- lation to the handles, curved as in Fig. 244. In employing the instrument, the operator may stand on the right of the patient, steadying the lower jaw with the fingers of the left hand, whilst the thumb depresses [the tongue, and the index finger] the lower lip, rendering clear to view the teeth upon which he is lookijjg down. The instrument being well pressed down, tlie severing or detaching movements, which can only be inward and out- ward in direction, must be very cautiously performed, as the fangs of these teeth are very slight (Figs. 255, 256, 257), and consequently easily fractured ; they will be found to yield most readily in the outward direction, in which, combined with an upward direction also, the final extractive force should be ex- erted. EXTRACTION OF TEETH. 285 For the lower cuspidati not only should the blades of the instrument be somewhat broader, but they should represent segments of a larger circle; still in practice the same as that suitable for the incisors is found to answer very well. The Fi":. 255. Fiff. 256. Fi-. 257. Central incisor of the lower jaw, frontand side views. Lateral incisor of the lower jaw, front and side views. Cuspidatas of the lower jaw, front and side views. severing movements, as suggested from a lateral view of their roots (Fig. '257), must be in the same directions, viz., to and from the centre of the dental arch, but they will require more force in their removal than the incisors usually do. [This motion should be generally toward a point re[»resenting the centre of the arc in which the teeth are arranged, or, in other w^ords, in and out on a line corresponding to the radius of the curve which is formed by the teeth.] In removing the tooth of the left side, the operator should stand almost in front of the patient, or the patient's head should be turned towards the operator. For the bicuspids of the lower jaw (Figs. 258, 259) we shall Fi-. 258. Fin;. 259. First bicuspid of the lower jaw, front and side views. Second bicuspid of the lower jaw, front and side views. best employ an instrument differing little from that last de- scribed, except that [it may be slightly heavier] ; these must be employed more from the front of the mouth. In operating with the straight forceps on the right side of the mouth, the best position is, to stand almost in front of the patient 286 MANUAL OF DENTAL SURGERY AND PATHOLOGY. whilst for the left side we should recommend a position at the back of the patient, bending over towards his head, but in both cases employing the finger and thumb of the left hand for sepa- rating the lips and tongue from the gums, in order to enable him to see clearly where to apply the instrument, and avoid in- cluding in it a fold of the loose mucous membrane which forms the floor of the mouth. It may be carefully noted, that sections of lower bicuspid teeth at their necks (see Fig. 246) present an almost circular form, and that their roots generally are conical. The forceps should be firmlj'^ pressed vertically downwards in the direction of the tooth, and the severing process attempted by a slight rotatory movement, first in one direction and then in the opposite; but it often happens that detachment is felt at the first movement, and then force applied in a direction up- wards and a little outwards will remove the tooth. The lower bicuspids are, however, very uncertain teeth to deal with ; occa- sionally parting from their surroundings with but little persua- sion, yet at times presenting very great resistance; we must, therefore, apply our rotatory force with discretion, changing it for an inward and outward one, or even combining the two, rather than risk a force greater than that which holds the parti- cles of a tooth to each other, viz., its cohesive attraction. The roots of these teeth, normally conical in form, and eminently suitable for the rotatory movement,^ are very liable to be curved or twisted, or to have enlargements at their extremities, thus opposing obstacles to such and other movements for their detach- ment ; and very often also, when they are detached from their immediate surroundings, they are yet dovetailed into their alveoli, from which they may, if care be not exercised, come away very suddenly, causing the instrument to strike against, and, perhaps, damage the teeth of the upper jaw ; but this is more liable to occur in the extraction of the teeth which we next consider — the lower molars. For the first and second molars (Figs. 260 and 261) the position of the operator in regard to the patient will be much the same as in the case of the teeth last mentioned. ' It should be distinctly borne in mind, that the bicuspids are the only teeth of the lower jaw to which a rotator movement in extraction is admissible. EXTRACTION OF TEETH. 287 A horizontal section of a lower molar tooth at the neck (Fig. 246) shows hoth its external and internal surfaces, of much the same form as the external surface of the first upper molar, viz., two segments of circles touching each other at one extremity, of which the anterior segment is the larger. The blades of the instruments must, therefore, be made to correspond in like manner; and, in order to insure the greatest accuracy, there should be an instrument for each side of the mouth ; practically, however, the difference between the sides of the tooth is so small Fig. 260. First molar of the lower jaw. Fiff. 261. Second molar of the lower jaw. that one instrument may suffice (except in the case of the addi- tional curve spoken of), provided the hinge possesses a little play. It is essential, too, that the angle between the blades and handles should be nearly a right angle. In using these forceps, the operator should stand in the same positions as those recommended in the case of the bicuspids, and employing the left hand in the same manner; but he may with advantage, in employing the instruments applied at the front of the mouth, after separating the lips and tongue from the gum, and placing the forceps on the tooth, place the fingers under the chin to support the jaw, and employ the thumb to press the forceps well down. Slight inward movement may first be attempted, but the tooth will generally yield most readily in the outward direction, where the alveolus is less thick; ajid, in raising the tooth, it wnll also be found to come most readily in the same direction. The two large and dense fangs (Fig. 260), anterior and posterior, especi- ally of first lower molars, often occupy more space than does the tooth at its crown, where it is in contact with its neighbors. To raise it vertically, without injury to the latter, would be impos- sible : and, where the fangs spread to any extent, the tooth be- comes locked, and then it is necessarj' to continue for some time 288 MANUAL OF DENTAL SURGERY AND PATHOLOGY. the lateral movements in order to dilate the alveolus, varying them with extractive force in a direction considerably outwards, but taking evevy care that the instrument in coming upwards does not strike and injure the upper teeth: the left thumb, in such cases, may be well retained on the upper part of the for- ceps. A pinch of the thumb may result, but the operator will smart less from this than if he fractured his patient's sound tooth. For a tooth which happens to be locked in the manner above mentioned, the lateral movements are no doiibt best performed by the instruments which are applied from the front of the mouth. On comparing a horizontal section of a lower third molar, made at the neck (see Fig. 246), with a similar one in a first or second molar, it will be observed that the depressions on each side marking the union of the two fangs are much less distinct. In making the lateral severing movements, we shall generally experience great resistance, the cause of which will be evident if we examine such a tooth in situ, by removing the external alveolar plate of the maxilla. When it is thus exposed, it will be noticed that the fangs incline backwards (Fig. 262), i. e., towards the angle of the jaw, a curving wdiich Fig. 262, is seen to increase from the first to the third molar tooth; the greater such curve is, the greater obviously will be the resistance to lateral movement, as a larger surface is impinged upon. The form of the curve also indicates the direc- tion in which such a tooth will most readily yield to force, viz., upwards and backwards. Third molar of the "^ '■ ci i lower jaw right side, towards ths coronoid proccsscs. buch a move- it will be observed ^^^^^^ -^ ^g almost impossiblc to effect with the how much the fangs ^ incline in the direc- forccps, but it is tlic prccisc oue which an in- tion of the coronoid gti-uniciit, virtually one-half of a pair of forceps process of the jaw. ' ■' _ ■"• . / — the elevator — can readily effect; and this in- strument, which we shall presently describe, we recommend for removing third molars, especially when the second molars re- main in situ. [The cutting forceps (Fig. 237) may be used to divide the roots 60 that tiiey may be separately removed, es[)ecially if they should EXTRACTION OF TEETH. 289 curve toward each other, cnibraciiii-; as they oi'ten do a portion of the bone, whicli otherwise would require to be broken ott* in the removal of tlie tooth. The same force]is miiy be uned as elevators as described before.] AVe have endeavored to tiibulate tlie foregoing instructions, as we ho[ie by so doing to make them more available to the student. Teeth of Upper Jaw. Patient seated raised and with head resting backwards [and tnrned to the left for extraction of teeth from the right side of the mouth]. Teeth. F