New yfft^ff ^ ' Columbia tlnibetsiitp mtijeCitpofi^etoi^orfe ^t|)ool of ISental anb (J^ral ^urgerp Eeferente Hi&rarp Lf ^=7-^ TA . ■ 0' '^ A TEXT-'QOO^ew York. OF Operative Dentistry. BY THOMAS FILLEBROWN, M.D., D.M.D., PROFESSOR OF OPEKATIVE DENTISTRY IN THE DENTAL SCHOOL OF HARVARD INIVERSITY MEMBER OK THE AMERICAN DENTAL ASSOCIATION, AMERICAN ACADEMY OF DENTAL SCIENCE, ETC. WRITTEN BY INVITATION OF THE NATIONAL ASSOCIATION OF DENTAL FACULTIES. THREE HUNDRED AND THIRTY ILLUSTRATIONS. PHILADELPHIA: P. BLAKISTON, SON & CO. IOI2 WALNUT STREET. 1889. f4^ Copyright, 1889, by P. Blakiston, Son & Co. Press of Wm F. Fell &. Co., 1220-24 Sansom St., philadelphia. PREFACE. For many years the author has felt that there was need of a text-book on Operative Dentistry, that should be confined more especially to the descriptions of the manual operations required for the preservation of the natural teeth. This volume is the result of this feelinf^, quickened by the invitation of the National Association of Dental Faculties to undertake the work. With what success it is accomplished, the future will deter- mine. The author hopes that it may at least serve as one step toward the production of something that shall serve the pur- pose fully. The effort has been made to avoid unnecessary detail and to leave out all that could be dispensed with, con- sistently with clearness. Hence History has not been attempted, and only enough of definitions, etiology and symptoms of diseases given to make clear the description of the operation to be performed. While intending to include the principles involved in all ways of per- forming each operation, repetitions under the heads of different methods have been avoided, and authors' names have been generally omitted from the text. The work is not intended as a substitute for larger works, but as an epitome of the practical application of the principles discussed at length in more extensive volumes, and to these the student is referred for exhaustive discussion. The most advanced nomenclature has been adopted as far as professional sentiment would sustain the author. Canine has been left for dogs and cuspid constantly used. Tartar has been discarded as unscientific, and calculus sub- stituted. Hyjiercementosis seems to fully express the con- iii / IV PREFACE. ditions of the cementum so long called exostosis, which seems applicable only to affections of true bone. Phagedenic pericementitis has been adopted as the scientific name of the condition known as Riggs' disease ; this has been pointed out as the one condition that obtains throughout the progress of the disease and seems eminently suitable and correct. The author desired to substitute lingual for palatal as applied to the upper teeth, but so many expressed dissent that the latter term is sustained. There has been so much change in respect to nomenclature, it was thought best to insert articles on anatomy and physi- ology, so that those parts of the subject should correspond with the nomenclature used in the subsequent pages of this book. Similar reasons apply to the writing of several other portions of the work. With few exceptions, all of the first and second parts have been written expressly for this work. The third part on Crown and Bridge work is necessarily largely a com- pilation. The introduction of this work is too recent, and the methods of construction too diversified, to make possible any definite system which should appear unquestionably better than all others. This work is classed as Operative Dentistry as it is all dependent upon the natural teeth for support, and may all be done at the operating chair, and almost all of it is much better done with the patient present. All Operative Dentistry is mechanical, and crown work is no more so than filling a cavity, applying a medicine or injecting an abscess. It was the opinion of a large majority of the Dental Faculties that it should be properly considered as belonging to Operative Dentistry, and in dental societies it has been by common consent considered as such. The limited time the author could devote to writing of this work would have been found entirely inadequate for the task, but for the clerical and literary assistance rendered by his professional friend and former pupil, Dana W. Fellows, m. d. PREFACE. V The portions treating of the Anatomy and Physiology of the teeth and contiguous parts and deciduous and permanent dentition were written entirely by him, and much critical assistance rendered throughout the book. Prof Frank Abbott, m. d., also gave the author valuable help b\' making careful and extended notes on the manuscript. Important suggestions were made also by Profs. S. H. Guilford, a.m., d.d.s.; E. T. Darby, m.d., d.d.s.; C. N. Pierce, D.D.S.; A. H. Fuller, .m.d., d.d.s.; T. E. Weeks, d.d.s.; Edmund Noyes, d.d.s.; H. W. Morgan, m.d., d.d.s.; S. W. Dennis, m.d., d.d.s.; T. H. Chandler, d.m.d., and Wm. H. Atkinson, m.d. Thanks are due to the S. S. White Dental Manufacturing Co. for the use of so many of their electrotypes for the ex- cellent illustrations appearing in these pages, also to the pub- lishers of the "American System of Dentistry," and to Claudius Ash & Sons, of London, for like favors. THOMAS FILLEBROWN. Boston, December iji/i, 1888. A CONTENTS. PACB The Alveolar Processes and Articulation of the Teeth, 9 Occlusion of the Teeth 10 The Dental Tissues, n Dentine, 11 ; Enamel, 11 ; Coinentum, 12 ; Pericementum, 12. The Deciduous and Termanent Dentitions, 12 Eruption of the Teeth, 13; Periods of Dentition, 13; Classes of Teeth, 14; Anatomi- cal Divisions of a Tooth, 14 ; Description of the Permanent Teeth, 15 ; Teeth of the Lower Jaw, 20; The Deciduous Teeth, 23. Dental Caries — Clinical History, 24 Working Steel 27 Making Instruments from Piano Wire, 29; Drawing Swiss Broaches to a Spring Tem- per, 29; Rendering Swiss Broaches Soft, 29. Instruments, 3° Instruments for Pulp Canals, 33 ; Instruments for Cleaning Teeth, 34 ; Instruments for Filling, 36; Pluggers for Gold, 37; Clamps, 38 ; Burnishers, 42; Finishing Instruments, 43; The Dental Engine, 43. The Dentist Himself, 46 Manner of Holding Instruments, 47 Examination of the Mouth, 5° Deposits on the Teeth 5^ Cleansing Teeth 54 Separating Teeth, 5^ Opening Cavities, 59 Removal of Decayed Dentine, .- 60 Formation of Cavities for Filling, 60 Exclusion of Moisture, 62 Gold for Filling, 6S The Adams Roller, 69 ; The Mat, 70 ; The Block, 70 ; The Compact Cylinder, 71 ; Rolled Gold 73; Cryst.-il Gold, 75 ; Annealing Gold, 76. The Dental Matrix, 76 Use of the Mallet, 79 Plastic Fillings, 84 Gutta Percha, 86 Cements, 87 Combination Fillings, 88 Porcelain Disk Fillings, 89 Erosion, 9° Sensitive Dentine, 9' Secondary Dentine, 9^ vii Vlll CONTENTS. PAGE The Dental Pulp 94 Sensitive Pulp, 94 ; Exposed Pulp, 94; Irritation, 95 ; Congestion and Inflammation, 95 ; Devitalization of Pulp, 96; Removal of Pulp, 97; Extirpation of Pulp, 98 ; General AnKsthesia in Removal of Pulp, 98 ; Preparation of Roots for Filling, 99 Filling Roots of Teeth 100 Gold, Gutta Percha, 100; Oxychloride of Zinc, Oxyphosphate of Zinc, loi. Bleaching Discolored Teeth, loi Treatment of First Molars, 102 Tliird Molars, 104. Treatment of the Temporary Teeth, 104 Hypercementosis, 106 Pericementitis, 106 Necrosis of Teeth, no Replantation of Teeth, no Alveolar Abscess, in Extracting Teeth, 116 Syncope, 119; Hemorrhage, 119. Instruments for Extracting Teeth, . 121 Position of Patient and Operator, 132 Extracting Roots, 135 Elevator, 139 ; The Key, 139. Anaesthesia, 142 Nitrous Oxide, 143 ; Ether, 145 ; Conditions unfavorable to Anaesthesia, 146 ; Chlo- roform, 146 ; Rapid Breathing, 147 ; Local Anassthesia, 147 ; Unfavorable Symp- toms, 147. Crown Work, 149 Preparing the Roots, 154; Richmond Crown, 155; Gold Cap Crowns, 158. The Mandrel System, 166 Crown with Metal Post, without Band, 176 ; the Logan Crown, 177; the Parmly Brown Crown, 181 ; the Collar Crown, 182 ; the Bonwill Crown, 190; the How Crown, 193 : Baldwin's Crown, 199 ; Low's Crown, 201 ; the Improved Richmond Crowns, 206 ; Meriam Crowns, 207; the Mattison Crown, 211; Dr. Kirk's Crown, 214; the Leech Crown, 216 ; the Stowell Crown, 217. Bridge Work, 221 Low Bridge, 241 ; Parmly Brown Bridge, 250 ; Cryer's Bridge, 253 ; Melotte's Bridge, 254; Richmond Removable Bridge, 258 ; Starr's Removab'e Bridge, 258. Repairing Crown and Bridge Work, 262 Appendix, 265 Formulas for Alloys, 265 ; Medicaments used in Operative Dentistry, 267. Index, 271 OPERATIVE DENTISTRY. THE ALVEOLAR PROCESSES AND ARTICULATION OF THE TEETH. For a description of the bone.s of the face the student is referred to works on anatomy. By the form of articulation known as gomphosis, the teeth are implanted in the alveolar processes, portions of the max- illary bones, which in regard to their development, form and duration are entirely subservient to the teeth. These portions of the maxillary bones, with which the teeth have so intimate a connection, and which have so many important relations to operative dentistry, should receive special attention. These are best described as consisting of two plates of bone, an outer and an inner plate, the alveoli being formed by septa passing across between the plates. The outer plate, continuous with the facial surface of the maxillary bone in the upper jaw, is very thin, and marked by eminences corresponding to the alveoli which contain the roots of the teeth, that over the cuspid being specially promi- nent, and known as the canine eminence, behind which is the canine fossa, and in front the incisive or myrtiform fossa. The inner plate is much thicker and stronger and merges into the palate processes. After extraction of the teeth of the upper jaw, the thin external alveolar plate is absorbed more quickly and to a greater extent than the inner. In the lower jaw the external plate is thick and strong, except in front, and after extraction of the teeth the absorption of the two plates is nearly uniform. The socket for each tooth conforms exactly to the root or 9 lO OPERATIVE DENTISTRY. roots which it contains, and consists of a thin shell of dense bone, which is surrounded by spongy tissue, and is continuous at the free margin with the dense cortical bone of the jaw. The walls are perforated by numerous foramina, and at the bottom of each alveolus or each division is a larger foramen for the transmission of vessels and nerves to the dental pulp and pericementum. The bony septa between the alveoli rise tD a higher level on the teeth in both jaws than the outer and inner walls. This should not be forgotten in the fitting of bands and crowns to the roots of teeth. OCCLUSION OF THE TEETH. In the normal human denture the teeth are arranged in a parabolic curve; every tooth touches those at each side, and the cusps and cutting edges of all are on nearly the same level. The plane of the grinding surfaces of the molars rises a little, however, from the first to the third, so that, viewed from the side, a gentle curve is seen, with the concavity directed upward. The arch of the upper denture is a somewhat larger curve than that of the lower, and in normal occlusion the upper front teeth shut over and in front of those of the lower jaw. The bicuspids and molars of the upper jaw also project beyond the corresponding lower teeth, so that the buccal cusps of the latter, in the closure of the mouth, come between the buccal and lingual cusps of those above. It will be seen, also, that no tooth in either denture is exactly opposed to any one in the other, but that in normal occlusion each tooth comes in contact with two in the opposite jaw, except the upper third molar, which, being smaller than the lower third molar, occludes with the posterior two-thirds of this tooth, and the inferior central incisor, which is opposed to the superior central incisor only. By the arrangement thus briefly described the cusps of the bicuspids and molars of either jaw shut into the depres- sions between the cusps of the teeth in the opposite jaw, thus securing a firmer occlusion and greater efficiency in mastica- THE DENTAL TISSUES. II tion than could otherwise be obtained. Moreover, if any one tooth be lost, those in the opposite jaw will still retain a par- tial occlusion with the contiguous teeth. THE DENTAL TISSUES. Three kinds of calcified tissue — dentine, enamel and cemen- tum — enter into the structure of a human tooth, and these, though not absolutely peculiar to the teeth, are appropriately called dental tissues. Dentine incloses the pulp chamber and makes up the greater part of the tooth. That portion above the neck is invested with a layer of enamel of varying thickness, and is described as the crown of the tooth, while a layer of cementum covers the root and usually overlaps the enamel to a slight extent. If the two last-named tissues be entirely removed, the dentine will still show the general form of the tooth, reduced in size and with the extremities of the roots and cusps quite thin and pointed. As to its physical properties, dentine is hard, dense and highly elastic, yellowish-white in color and somewhat translucent, frac- tured surfaces showing a silky lustre. Chemical analysis of perfectly dry dentine shows it to con- sist of about 28 per cent, animal and 72 per cent, mineral matter, the latter being mostly phosphate of lime. About 10 per cent, of the fresh tooth is water. The constituents vary, not only in different individuals, but probably in the same individual at different ages and under different conditions. The structural elements of dentine are the matrix, richly impregnated with calcareous salts, the dentinal tubes, and the soft fibrils. Each tube passes, with some variation in direction and curvature, from its opening on the wall of the pulp cavity toward the surface of the dentine. These tubes contain the soft fibrils, which are prolongations of the cells at or near the surface of the pulp. Enamel. — Well-formed enamel is by far the hardest of all animal tissues, containing also the smallest proportion of or- 12 OPERATIVE DENTISTRY. ganic constituents — from 3>^ to 5 per cent. Nearly 90 per cent, is phosphate of lime. Human enamel is translucent, pearly-white in color, with often a tinge of yellow. In structure it consists of enamel fibers or prisms, hexagonal in shape and in very close apposition, if not in actual contact. The course of these is, in a general way, from the dentine outward, at right angles with its surface. Enamel has a defi- nite cleavage, the line of fracture passing not between the prisms, but through their centres. Cementum. — This tissue is in all respects very much hke true bone. It differs from bone in having lacunae more vari- able in size and form, and canaliculi in greater number and of greater length. When the cementum is very thin, as at the neck of a tooth, it is apparently structureless. Pericementum. — This membrane covers the root of the tooth, lying between it and the bony socket. It serves as a means of attachment and a medium of nutrition to the ce- mentum, and also acts as a cushion to lessen the shock of occlusion. It consists of fibrous connective tissue, and is richly supplied with vessels and nerves. It is thicker near the neck of the tooth, where it is continuous with the gum and periosteum of the alveolar process. It is also thicker nearer the apex of the root. The direction of the fibers is obliquely across from the alveolar wall to the cementum, and, although the membrane varies histologically in different parts of its thickness, it is probably but a single membrane. THE DECIDUOUS AND PERMANENT DENTITIONS. Man, in common with most mammals, is provided with two sets of teeth, known as the deciduous and the permanent set. The deciduous teeth, which are adapted to the requirements of childhood, are fewer in number and, as regards teeth of the same class, smaller than their successors. They constitute the dental apparatus of the child from the time of their eruption to the age of six years, when the first permanent molars ap- THE DECIDUOUS AND PERMANENT DENTITIONS. 1 3 pear. The teeth last named are thus accessory, as regards function, to the deciduous dentition, though anatomically they are quite distinct, and have relations entirely with the perma- nent set. Formula of the deciduous dentition — d i I, d c |, d m § = }g = 20. The ten anterior permanent teeth in each jaw replace the deciduous teeth, while the twelve molars appear posterior to these and have no predecessors. Formula of the permanent dentition — i |, c ^, p m |, m f = -}«. = 32. In both deciduous and permanent dentitions the teeth are symmetrical on the two sides of each jaw, and equal in number though not symmetrical in the two jaws. Eruption of the Teeth. — The time of eruption of the deciduous and permanent teeth is subject to great variation, hence tables prepared by different observers do not agree. It is believed that the following tables are correct for the usual or average age at which the several classes of teeth appear : — DECIDUOUS. PERMANENT. Incisors, inferior and First molars, .... 6 years. superior, .... 5 to 8 months. Incisors, 7 to 8 " First molars . . . . 14 to 16 " Bicuspids, 9 to 10 " Cuspids, 17 to 20 " Cuspids, II " Second molars, . . . 20 to 30 *' Second molars, ... 12 " Third molars, .... 16 to 25 " The lower teeth in each dentition appear a little earlier than the upper. Periods of Dentition. — A comparison of the above tables will show that the first dentition is completed at the age of two and a half years. These twenty teeth exercise their functions during the three or four years that follow ; at six years of age the first permanent molars appear, and the child then has twenty-four teeth ; during the six years between this period and the age of twelve the deciduous teeth are all replaced by their permanent successors, and the second permanent molars 14 OPERATIVE DENTISTRY. are erupted, so that during the next six years the mouth con- tains twenty-eight teeth ; finally, at eighteen, often not until much later, the second dentition is completed by the eruption of the third molars. Classes of Teeth. — The teeth in each set are classified and named with reference to their form and relative position in the mouth. Thus, the permanent teeth are divided, with reference to their form, into four classes, namely, incisors, cuspids, bi- cuspids and molars. Those in the upper jaw are described as the superior or upper teeth, and those in the lower jaw as the inferior or lower teeth. They are further designated as right or left, according to the position they occupy with respect to the median plane of the body. In each of these divisions, namely, superior right and left and inferior right and left, are two incisors, one cuspid, two bicuspids and three molars. The incisors are usually distinguished as central and lateral, but first and second incisor is better, as with the bicuspids which are known as the first and second, and the molars as the first, second, and third, the first being in all cases the anterior tooth of the class, or, in other words, the one nearest the median plane following the line of the dental arch. Anatomical Divisions of a Tooth. — For description each tooth is divided into crown, neck and root. The crown is that part which is covered with enamel, and which in a normal tooth fully erupted is seen above the gum. The neck is a slight constriction immediately below the margin of the enamel which is closely embraced by the free margin of the gum. This anatomical division of the tooth merits careful study on account of the important relations it bears to the operation of extraction and to the fitting of bands and porcelain crowns. The root is implanted in the bony socket and includes all below * the neck. * The terms above, below, etc., have reference to the crown and root extremi- ties of the tooth ; thus, the term above, signifies toward the cutting or grinding surface of a tooth, and below, toward the apex of the root. THE DECIDUOUS AND PERMANENT DENTITIONS. 1 5 Surfaces of Teeth. — The surfaces of teeth are named from their relations in the mouth to each other and to other parts. Labial and buccal surfaces are those which present toward the Hps and cheeks, the term labial being applied to incisors and cuspids, and buccal to bicuspids and molars in either jaw. Litigual surfaces are those on all the teeth in both jaws presenting toward the tongue or the cavity of the mouth. This surface on the upper teeth is more commonly called palatal. The labial and buccal surfaces are sometimes called cxtcr- fial and the lingual internal. Proximal surfaces are those which are next to each other in adjoining teeth of the same jaw. Mesial surfaces are those proximal surfaces which present toward the median line of the dental arch. Distal surfaces are those on the opposite side of the tooth to the mesial, or presenting from the median line of the arch. As applied to bicuspids and molars, anterior is synonymous with mesial and posterior with distal. Cutting edges pertain to incisors and cuspids and grinding or occluding surfaces to bicuspids and molars. For more accurate description, combinations of the terms given above are used. Their form will explain their significa- tion, as labio-mesial angle, the angle formed by the union of the labial and mesial surfaces. These terms are properly employed with reference to the roots as well as to the crowns of teeth. Description of the Permanent Teeth. — Superior Central Incisor (Fig. i, a, p. 22). — The crown of this tooth is chisel- shaped. The cutting edge, which is the broadest part, is nearly straight across, but is a little more rounded at the distal angle than at the mesial. In recently-erupted incisors the cutting edge is divided into three nearly equal parts by two slight notches, which soon disappear by wear when the tooth comes into use. The middle point of the cutting edge is on a line with the lone axis of the tooth. l6 OPERATIVE DENTISTRY. The labial surface is somewhat quadrangular in outline, convex in all directions and usually quite smooth, though sometimes two shallow grooves run from the cutting edge to the cervical border. The cervical border is formed by the curved edge of the enamel at the margin of the gum, the con- cavity of the curve looking toward the crown of the tooth. The palatal surface is concave and often somewhat grooved longitudinally. The cervical border is formed by the cingule, a more or less prominent ridge of enamel which is continuous at each side with the proximo-palatal borders, and near the cingule on the palatal surface there is frequently a pit or other imperfection in the enamel. The proximal surfaces are triangular, having the base of the triangle at the cervical border and the apex at the cutting edge. The enamel border on these surfaces is somewhat V-shaped with a rounded angle, the latter being directed toward the cut- ting edge of the tooth. The distal surface is a little more convex than the mesial, and a little shorter. The neck of a central incisor is nearly cylindrical, with a tendency toward a triangular form, broader toward the labial side, and the root nearly conical and usually quite straight. Superior Lateral Incisor (Fig. i, b, p. 22). — The crown is similar in form to that of the central, but it is in every respect smaller. The form of the cutting edge is less constant, but the angle at the mesial side is usually acute, and the distal side much rounded off. This gives to the labial surface an irregular outline, with the mesial border longer than the distal ; this sur- face is slightly convex in all directions, with the cervical border curved like that of the central. The palatal surface is a little flatter than that of the central, but the cingule is usually more pronounced, and the pit near it is more constant and deeper. The proximal surfaces correspond in general form to the same surfaces of the central, but the mesial surface is less convex and the distal rather more so. The neck is much flattened mesio-distally, and the. same form THE DECIDUOUS AND PERMANENT DENTITIONS. J 7 is retained throughout the whole extent of the root, which is often bent near the apex toward the distal side. The root is slender and longer in proportion to its siz.e than that of the central. To determine to which side a superior incisor, either central or lateral belongs, let the student hold the tooth with the crown downward, and looking at the labial surface, if the longer border and more acute angle of the cutting edge be toward his right, it is a right tooth, if toward his left, it is a left tooth. Superior Cuspid (Fig. i, c, p. 22). — The superior cuspid is the longest tooth in the entire series. The crown is thick and strong, having a single rounded cusp in a line with the long axis of the tooth. The slope from this to the mesial surface is shorter than on the distal side. The labial surface is convex, especially from side to side, with a rounded, longitudinal ridge running its entire length, and on each side of this a slight depression. The palatal surface has a similar ridge with a depression at each side, or it is irregularly convex, with the cingulc thick and often prominent. The distal surface is a little more prominent and a little more rounded than the mesial. The form of the neck in section is triangular, with angles much rounded, the root becoming somewhat more flattened, with a groove at each side. The root is also thick and considerably longer than the roots of the incisors. Hold the tooth as directed for an incisor, and the shorter slope from the point of the cusp to the proximal surface will indicate the side to which the tooth belongs, the shorter side being the mesial. Superior Bicuspids (Fig. i , d, e, p. 22). — By some writers these are called premolars. The grinding surface supports two cusps of nearly equal length, that on the palatal side being regarded as the cingule before mentioned developed into the prominence of a cusp. The buccal cusp is thicker and stouter. This surface presents 16 OPERATIVE DENTISTRY. an outline somewhat quadrilateral in form ; the palatal border, however, is much rounded, while the buccal portion is broader and the angles distinct, giving to the tooth, at the base of this cusp, its greatest diameter from the mesial to the distal surface. The two cusps are separated by a distinct fissure which is nearly straight, and is limited at each end by ridges of enamel at the mesial and distal borders, the mesial border being higher than the distal in all the bicuspids. The buccal surface is strongly convex in all directions and similar in outline to the corresponding surface of the cuspid. The palatal surface much resembles the buccal, but it is not as broad and is more rounded from side to side. The proximal surfaces slope toward each other from the grinding surface, so that at the neck these surfaces are nearly or quite flat, or even concave. A cross section at the neck shows an elongated outline, often a little constricted at the middle by the beginning of the grooves which pass down the mesial and distal surfaces of the single flattened roots. More frequently, however, the first superior bicuspid has the root divided into two for one-third of its length. Sometimes the root of the second, also, is divided to some extent. The crown of the second bicuspid is usually a little larger than that of the first, the palatal cusp being more fully developed and often as long as the buccal. To determine to which side a bicuspid belongs, hold the tooth horizontally with the buccal surface, which may be known by its greater breadth, upward, and looking at the grinding sur- face, the higher proximo-grinding ridge and the closer prox- imity of the cusps, especially the lingual cusp, will indicate the side to which it belongs. Superior Molars (Fig. i, f, g. p. 22). — These have large, square-shaped crowns specially adapted for crushing and grind- ing. The following description will apply to the first and second molars, but while the first is quite constant in form, the second is more variable. The grinding surface has a rhombic outline with rounded THE DECIDUOUS AND PERMANENT DENTITIONS. I9 angles. The niesio-buccal and disto-palatal angles are acute and the meslo-palatal and disto-buccal obtuse. On the surface are four cusps, one at each angle, the mesio-palatal being con- siderably the largest, the mesio-buccal next in size and the linguo-distal the smallest. The linguo-mesial cusp is con- nected with the disto-buccal by a thick, oblique ridge, and between this ridge and the mesio-buccal cusp is a deep depres- sion, from which a fissure extends toward and often through the buccal border. Another extends toward the mesial bor- der and a third runs into the oblique ridge. Between the mid- dle portion of the oblique ridge and the linguo-distal cusp is another deep depression, with a fissure extending frequently through the lingual border, while the other extremity of the fissure rarely extends far enough to divide the distal border. The linguo-distal cusp thus separated is to be regarded as the cingule, the other three being true cusps. The buccal surface is divided nearly in the middle by a per- pendicular groove which is continuous with that on the grind- ing surface. The mesial portion of this surface is much more prominent than the distal, which slopes backward. The lin- gual surface is similarly divided, the distal portion being the more prominent. The proximal surfaces are broad and convex, becoming flat at the cervical portion. A section at the neck shows an outline similar to that of the grinding surface, four-sided with unequal angles. The root is divided into three, one large and nearly conical, diverging inward, and called the palatal root, and two buccal, the mesio-buccal much larger than the distal, and both much flattened mesio-distally. Frequently the disto-buccal and palatal roots are united throughout their whole extent. The superior third molar sometimes conforms to the descrip- tion above given, but usually the crown is smaller and of very irregular form, and the roots united into one throughout the whole or greater part of their extent. 20 OPERATIVE DENTISTRY, If the student hold an upper molar with the crown down- ward and the two buccal roots next to himself, the larger and broader root will be toward the side to which the tooth belongs. Teeth of the Lower Jaw. — The inferior central incisor (Fig. I, I, p. 22) is the smallest tooth in either denture. The lateral incisor (Fig. i, j, p. 22) is a little wider and the root considerably longer. The width of these two teeth is about three-fourths as great as that of the two corresponding superior incisors. The cutting edge of an inferior incisor is straight and nearly at right angles to the long axis of the tooth, though the distal angle is usually a little lower than the mesial. The labial surface is widest at the cutting edge and narrow- est at the neck, the proximal borders converging equally from the cutting edge downward. The enamel border at the neck is not prominent, and the surface is but slightly convex from above downward. The lingual surface is flat from side to side at its upper part, and rounded below and slightly concave from above downward. The cingule is not developed. The proximal surfaces are nearly equal, flat and triangular, with the cervical border of enamel quite thin. A cross-section at the neck is elliptical and quite narrow mesio-distally, and the root much flattened in the same direc- tion. Tlie Lower Cuspid {Y\^. i, k, p. 22). — This tooth, compared with the upper cuspid, is smaller and less specialized in form, resembling somewhat the conical teeth of the lower orders of animals. The crown is narrower and more elongated than that of the upper tooth. The labial surface is rounded and rather more prominent near the mesial border than elsewhere, and quite strongly con- vex from above downward. The lingual surface is flat or slightly concave, and the proximal surfaces triangular, the mesial somewhat the larger. THE DECIDUOUS AND PERMANENT DENTITIONS. 21 A transverse section of the neck is oval in form, witli the labial portion wider. Inferior Bicuspids (Fig. i, i., m, p. 22). — The first bicuspid is smaller than the second, the buccal cusp is prominent and the lingual small and often very short. The two cusps are united by a stout ridge of enamel passing across with a pit at each side. The buccal surface is prominent below and slopes rapidly away toward the grinding surface. From side to side it is moderately convex. The lingual surface is more prominent at its upper portion, making the tooth appear bent inward at the neck. The proximal surfaces are smoothly convex from side to side and most prominent near the upper border. A transverse section at the neck is nearly circular, the root nearly round and often but slightly tapering. The inferior second bicuspid corresponds to the description just given, except that the crown is larger and the lingual cusp more fully dev^eloped, with a tendency to the formation of two lingual cusps. A like ridge connects the two cusps and all the surfaces are similar, though the lingual surface is larger. The inferior first molar (Fig. i, n, p. 22) is usually the largest tooth of the lower jaw. The broad, grinding surface supports five cusps, three buccal and two lingual, or they may be de- scribed as two buccal, two lingual and one distal. The mesio- buccal cusp is the largest and the disto-buccal the smallest, the other three are subequal. A fissure extends across this surface from a point near the mesial border to the disto-buccal cusp, and from this point two fissures run, one between the middle buccal and the disto- buccal cusp, the other between the disto-buccal and disto-lin- gual cusps. A fissure running from the one first mentioned passes nearly to the lingual border dividing the two lingual cusps, and another passes toward and often through the buccal border behind the mesio-buccal cusp. The buccal surface is broad and much rounded off at its 22 OPERATIVE DENTISTRY. upper portion. Across this surface from above downward passes a groove, near the middle of which a pit is often found. The hngual surface is more prominent near the grinding surface and usually smooth. The proximal surfaces are broad and rounded above and flattened below. The transverse section at the neck is nearly square with rounded angles. There are two roots, a mesial and a distal ; the latter being subcylindrical, while the mesial is very much flattened and grooved, and both are usually curved backward. Inferior Second Mo/ar(Fig. i, o, p. 22). — This has a grinding surface which is very nearly square, with four cusps nearly equal in size. The groove which separates the mesial and distal cusps sometimes passes through the border to the buccal sur- face, but this is less frequent than in the first molar. Occa- sionally the second molar has five cusps, the conformation of the crown being similar to that of the first molar. The buccal THE niXIDUOUS AND PERMANENT DENTITIONS. 23 surface recedes toward the grinding surface, but not to an equal extent witli that of the first molar. The lingual rises abruptly to its angle with the grinding surface. For the proximal surfaces and roots the description given for the first molar will apply to this tooth. Inferior Third Molar (Fig. i, p, p. 22). — This varies very much in regard to its size and form, but usually the crown is large in comparison with the root, and frequently, also, in comparison with the crowns of the first and second molars. The grinding surface is generally of an irregular outline, having from three to five cusps. All the other surfaces are Fig. 2. rounded and receding toward the neck, the outline of which, in transverse section, is more nearly circular than that of the two preceding teeth. The root is usually single, grooved on each side, short and curved backward, often to a considerable extent. The Deciduous Teeth (Fig. 2). — In general terms, these teeth have the same forms and characteristics as the corres- ponding teeth of the permanent set. The six anterior teeth of each jaw are succeeded by those of the same classes as themselves, while the deciduous molars are the prototypes, not of the bicuspids which succeed them, but of the permanent molars. The deciduous teeth are, in all respects, smaller than the per- 24 OPERATIVE DENTISTRY. manent, the crowns are thick and short, and the roots of the molars are much flattened and strongly divergent. The enamel of these teeth terminates abruptly, which gives the effect of a strongly-marked constriction at the neck. So constant is this characteristic that retained deciduous teeth may always be recognized by passing an instrument under the free margin of the gum. In structure they are ordinarily less firm and dense than the permanent, and the pulp cavity is larger in proportion to the size of the tooth. In their position and arrangement there is seldom any irregu- larity, the arches being even and rounded. DENTAL CARIES. Dental caries was formerly supposed to be identical with caries of bone, hence the use of the term. This name is now in almost universal use. It has a recognized signification and cannot well be changed, especially as our present knowledge of the pathology and causation of the disease cannot furnish an expressive and significant name. Decay is another term in common use to express the same condition. The disease involves the hard tissues of the teeth and results in the destruction of a part or the whole of the organ attacked. In every country of the world and in all ages the human teeth have been thus destroyed, and to the prevalence of this disease alone operative dentistry owes its rise and progress, and at the present time, while other diseases of the teeth and con- tiguous parts require attention, dental caries claims a much larger share of the skill and labor of the dentist than all other affections of the dental apparatus. Clinical History. — As, in a perfectly normal condition, enamel is the only tissue exposed to external influences, this must necessarily be first destroyed and removed at some point before the dentine is reached by the destructive agencies, which are always external. If, however, a portion of the dentine is DENTAL CARIES. 2 5 exposed, as a result of imperfect calcification, fracture or wear, caries may have its beginning in this tissue, and, in cases of recession of the gum exposing the cemcntum, this maybe first attacked. For convenience of study the progress of caries is divided into three stages, superficial, simple and complicated. Super- ficial caries affects only the enamel. Simple caries may advance to any depth and extent consistent with the health and safety of the pulp, while complicated caries implies a diseased condi- tion of the pulp as a result of the carious process. Incipient caries of the enamel is marked by an opaque, whitish spot, which to the touch of an instrument will be found soft and friable. This soon becomes discolored by the deposit of extraneous coloring matter, and if, as is sometimes the case, a change in the conditions or surroundings of the tooth should cause the decay to be spontaneously arrested, the enamel, and if the decay has penetrated the dentine, this also, will usually become very dark or almost black. Some believe that the color of the disintegrating tissue depends mostly or wholly upon the kind of acid which has acted upon it. Three kinds of caries are described; first, black, caused by sulphuric acid. This is not as frequent as the other varieties. Its progress is very slow in all cases, the blackened tissue remaining quite hard, and often it is spontaneously arrested. Second, brown decay, the result of the action of hydrochloric acid, which destroys the lime salts of the tooth, leaving the organic portion of a brown color, and elastic, leathery consist- ence. This progresses more rapidly than the preceding, and it is seldom arrested spontaneously. Third, white decay, produced by nitric acid, which rapidly destroys both the mineral and the organic constituents of the tooth so that they are readily washed away, the cavity being usually filled with extraneous matter. Recent researches by Dr. Miller seem to show lactic acid to be the principal agent in the production of caries. 3 26 OPERATIVE DENTISTRY. In practice, tissue that has been partially or wholly decalci- fied will be found of all possible variations of color and con- sistency ; these variations being the effect of the combined action of the destructive agencies, or of other conditions, as length of time, quality of the tooth- substance, condition of the mouth or habits of the individual. As caries progresses, the cavity assumes one of two gen- eral forms, becoming either broad and shallow, with no well- defined walls or orifice, or else narrow and penetrating, enlarg- ing within the dentine and extending toward the pulp, while the opening in the enamel remains comparatively small. Certain surfaces of the teeth are specially liable to be attacked by caries, this liability, in each case, depending mostly upon the form of the tooth and its relation to other teeth. Of the incisors and cuspids the proximal surfaces are the most frequently affected, and next the labial surface at the mar- gin of the gum. If a pit exists on the palatal surface, this is frequently the seat of caries. The bicuspids are also most frequently attacked on the prox- imal surfaces; secondly, in the pits or fissures on the grinding surface ; and, thirdly, the buccal surfaces at the margin of the gum. The molars decay most frequently in the fissures of the grinding surface; secondly, on the proximal surfaces; and thirdly, on the buccal, in the pit upon this surface, or at the gum margin, and lastly on the lingual surfaces. Decay upon any point of the surface of a tooth may result from defective structure, or from special causes. The tooth most subject to decay is the lower first molar of either side, and next to this the upper first molar. The lower incisors and cuspids are the least liable to decay. Present knowledge of the subject does not warrant any definite statement respecting the relative liability to decay of the other teeth. Causation. — The predisposing causes are both general and local. The former have reference mainly to systemic condi- WORKING STEEL. 2/ tions, as impaired health from any cause, especially affections of the nervous and digestive systems, and the state of the bodily functions at different periods of life. Local causes have reference to organization, calcification and environment of the teeth, these depending largely upon the food, occupation and habits of life of the individual. Acids undoubtedly act as the primary exciting cause of decay of the teeth, though many other factors are concerned, especially microorganisms and inflammation, or a process closely allied to this. For the discussion of the " theories of decay " the student is referred to larger treatises and the periodical literature of the subject. WORKING STEEL. Very often an instrument of peculiar form is needed for a special case; it is therefore very important that every operator should be able to make such instruments as necessity requires, and the following directions will enable him to do so. A worn excavator is the ever-ready material for this purpose. Heat to a cherry red, and hammer it upon the anvil toward the form desired only as long as it will readily yield. Repeat the heating and hammering until the desired form is obtained. Heating hotter than a cherry red or hammering when too cool injures the steel. Bend the point to the form desired and reduce to proper size; form the edge by filing and grinding. Smooth and polish with emery, stone, pumice and rouge ; the instru- ment is then ready for the process of hardening and tempering. To obtain the proper temper for a good cutting edge, the instrument must first be heated to a bright red heat and sud- denly cooled by plunging into cold water or other cold liquid. This will give to the steel a silvery whiteness, and render it so hard that a sharp corner will readily scratch glass; this should be the test of the hardening. Make the part to be tempered clean and bright with fine emery or by other means ; heat the instrument slowly well up on the shank, and allow the heat gradually to approach the point; the blue and straw colors will 28 OPERATIVE DENTISTRY, be seen to run down on the shank as the heat progresses. There will be all the shades of blue from very dark to very light, and joined to this a dark straw color which will terminate in a very light straw. The dark blue represents a soft steel, the medium and light blue a spring temper; the dark straw shows a soft cutting edge and the pale straw a very hard cutting edge. When the instrument is tempered, the position of the colors should be as marked in Fig. 3. A thick edge will bear a much harder temper without break- ing than a thin edge, consequently the thick edge may be left a very pale straw, while the thin edge must be a little darker. For drawing the temper of small instruments, the flame of a, Point where heat is applied. /-, Dark lilue. c, Light blue. d, Dark straw. e, Light straw. the annealing lamp is sufficient. For hardening, a greater heat is required. The shank of the instrument should be of spring temper, and some practice will be necessary to obtain a good spring temper throughout the length of the shank and avoid reduc- ing it too low in some places. A weak solution of sulphuric acid will in a few moments remove from the instrument all of the coloring caused by tempering. Sharpening Instrjuncnts. — The rough grinding may be done with a fine corundum wheel well moistened, to avoid heating the in.strument, after which an Arkansas oil stone should be used for giving a fine edge. WORKINc; STEEL. 29 " Instructions for Making Instruments from Piano- Wire for the Removal of the Contents of Pulp-Canals. — Tlic very best (juality of piano-wire, of No. 20 or No. 22 standard wire or jilatc gauge, should be used. " It should be cut into lengths of three inches, and should then be filed down to the required size and taper. The wire should commence to taper at one and one-half inches from the point, while the last half inch should be of nearly uniform size. " Three sizes of these instruments are all that are needed, and they should measure, at the smallest diameter, 0.007, o.oio, and 0.013 of an inch, respectively, before the hook is made; with the hook they should measureo.oio, 0.014, and 0.0 17 of an inch. "When the wire is reduced to the required size, the hook is to be formed by placing the wire on an anvil, or other smooth hard surface, and holding the smooth edge of a thin knife blade upon it, near the end of the wire, when the wire is to be drawn up sharply and tightly, making a hook with a somewhat acute angle. The hook can then be honed down to the desired length. " The instruments should then be fastened in small handles, which can be procured of dealers in watchmakers' supplies for twenty-fiv^e cents a dozen, or they can "be easily made from any soft or hard wood. " Piano-wire should never be heated, and should be filed lengthwise." *' Method of Rendering Swiss Broaches of Spring Tem- per. — To draw Swiss broaches to a spring temper they should be placed on a steel, iron, or brass plate, one-eighth of an inch in thickness and three inches square. This should be held by phers or forceps over the flame of a spirit lamp, and be kept continually moving over it, so as to keep the plate as uniformly heated as possible. The broaches should be watched very carefully, and when they become of a dark-blue color they should be dropped in cold water." " Method of Rendering Swiss Broaches Completely Soft. — A piece of tin may be cut and bent so as to make a rough 30 OPERATIVE DENTISTRY. box, two and one-half inches long by one inch square. This should be filled half full of slaked lime, and the broaches — one, two, or three dozen — placed in the middle of the lime, and the box then filled over them. This should then be heated to a red heat, either with the blowpipe or in a stove fire, and then allowed to gradually cool. They can then be polished by holding them flat on a hard smooth surface and rubbing them lengthwise with oo emery paper. " Broaches rendered soft in this manner are very tough and can hardly be broken, and are safer for use in places difficult of access than those of spring temper. "They should be fastened in small handles, or used in the universal broach holder."-* INSTRUMENTS. The number and variety of dental instruments now manu- factured is so great that it would be impossible to describe or name them in this work, and a description of important classes only will be attempted. Fig. 4. Excavators are made in great variety of form, the principal of which are hatchets, hoes and spoons. We have the following in various siz^s : — The right-angle hatchet (Fig. 4), the obtuse-angle hatchet (Fig. S), the acute-angle hatchet (Fig. 6), hoes of the various * « Management of Pulpless Teeth." Chicago, 1887. INSTRUMENTS. 31 sizes (Fig. 7), spoons (Fig. 8). Fig. 9 shows a style of exca- vator in which the cutting edge is brought on a hne with the handle, thus working with much greater ease and steadiness than the ordinary style. Fig. 6. Fig. 7. Fig. All these instruments are also made with two angles in the shank. (Fig. 10.) They are also made in pairs, curved to cut right and left. Fig. 10. Fig. 9. Chisels of various sizes and forms are useful in breaking down the edges of cavities, dressing down the exposed edges of enamel and removing decayed dentine. A class of these instruments, known as Head's Excav^ators 32 OPERATIVE DENTISTRY. — shown in Fig. ii — gives a variety of forms which enables the operator to cut in every direction. Fig. II. (f i e r\ fTo /^ /\ n Another class are known as hard bits, the cutting edges of which are right angles, and the temper very hard. They are very effective in dressing away enamel, as they cut smoothly and evenly without chipping. They are shown in Fig. 12. Fig. 12. Fig. 13. Fig. 14. Each has eight cutting edges, and each edge will cut in two directions. Two forms of drills are illustrated : the flat, square-pointed and the spear-pointed. The flat, square -pointed are especially useful for drilling retaining pits (Fig. 13). The spear-pointed (Fig. 14) are INSTRUMENTS. 33 adapted for drilling enamel and dentine, to reach the pulp chamber, and for other purposes. These are made in various sizes — some quite small, and with long, spring-tempered shanks, which allow them to be used in canals inaccessible to straight instruments that are not flexible. Burs are made in great variety of forms and sizes, as shown in Fig. 15. They are known as round, wheel, cone, inverted cone, bud, fissure and oval. These are made both for use as hand instruments and for the engine. Via. 15. Instruments for Pulp Canals. — These consist of broaches, drills, reamers and pluggers. Broaches for removal of the Fig. 16. pulp are of various forms, as the barbed broach (Fig. 16), the fine, spring-tempered hook broach (Fig. 17). 34 OPERATIVE DENTISTRY. Fine hook broaches are also made of fine piano-wire, by fihng down without changing the temper. Broaches are also made of an alloy of platinum and iridium, which are useful for medication, as they do not corrode. Drills for use in the pulp canals should be of small size and flexible. The points may be square, spear-pointed, or enlarged in the form of a bud and with sharp edges for cutting, as shown in Fig. i8. Reamers for nerve canals are made pointed and in the form of a square, triangle, or half cone (Fig. 19). Fig. 18. Fig. Fig. 20. ^ l^ The smaller instruments should have flexible shanks. Those made from piano-wire are excellent. Pluggers for pulp canals should be of long taper, spring- tempered and small enough to reach the deepest portion of the canal. Both straight and curved are needed (Fig. 20). Instruments for Cleaning Teeth. — Instruments for the removal of calcareous deposits from the teeth are called scalers. They are of various forms, which may be best un- derstood by reference to the following cuts : — The essential part, of the instrument is a sharp edge for scraping the deposit from the teeth. INSTKLMENTS. 35 Fig. 21 illustrates the Abbott set of scalers. Fig. 22 shows the Gushing scalers, which arc formed for removing the deposit by pushing. Fk;. 21. Fig, 22. Fig. 23. The right-angle edge, which is found on the hard bit and on the sickle-shaped scalers of several sets, is effactive for this purpo.se. Fig. 23 represents a modification of one of Riggs' instru- 36 OPERATIVE DENTISTRY. merits. It should be made very hard, with square, sharp edges, like the hard bits. It is a universal instrument, cutting in all directions. Instruments for Filling. — Instruments for filling are made in such variety of form and style that it would be quite im- possible to describe them all. The essentials which all should possess are described, leaving the choice of form and style of instrument to the operator. Instruments for filling with cements consist of a flexible spatula for mixing (Fig. 24), thin, flat instruments for inserting the filling (Fig. 25), and some broader and smooth, as well as thin, for finishing (Fig. 26). Fig. 24. Fig. Fig. 26. Fig. 27. Fig. 28. Fig. 29. Ball burnishers are sometimes useful for packing the cement and for finishing. For packing amalgam, instruments of various forms and sizes, with smooth ojr serrated oval surfaces, are best adapted (Figs. 27, 28). INSTRLMKNTS. 37 Flat burnishers of different sizes, some thin, some bent on the edge and some on the flat (Fig. 29), are also useful. These two classes of instruments will be sufficient for all cases. Pluggers for Gold. — For packing non-cohesive gold, instru- ments acting upon the wedge principle are ftsed. The points are long and tapering in form, terminating in a wedge-shaped edge (Fig. 30). Fk;. 30. These are used entirely with hand pressure. In finally condensing the surface of the filling, a larger instrument is used, with a broad, flat surface. For packing cohesive gold foil, pluggers having either flat or oval surfaces are used. These instruments are made in great variety to meet the requirements of cavities of all sizes and in all positions. The faces are serrated to prevent slipping and to keep the surface of the gold a little roughened. Two grades of serrations are used, the very fine and the medium. The coarse serrations formerly used have been discarded. These instruments are made suitable to be used either with hand pressure or the hand mallet, and also with the automatic and electric mallet. The following figures illustrate a variety of forms in common use : — Fig. 31. 38 OPERATIVE DENTISTRY. Fig 32. Frc. 33. Clamps are an important auxiliary in the use of the rubber dam. They serve to hold the rubber upon teeth which have very short crowns or which are far back in the mouth, so that the strain of the cheek or tongue is likely to draw it off, or in any situation in which it is impracticable or undesirable to apply the ligature. They also serve to hold the rubber away, and thus afford a better view of the tooth operated upon. Very many different forms have been devised for the differ- ent classes of teeth and of cavities, and the student must select such as will best serve his purpose. INSTRUMENTS. 39 The following figures show several sets of the more desir- able forms Fig. 34. ^m- Fig. 34 rtpresents How's cervix clamp. Its purpose, con- struction and adjustment are plainly shown in the cuts. Fig. 35. Dr. W. W. Evans' lieaked Molar. Fig. 36. Fig. 37. Dr. E. C. Moore's. Fig. 38. Original Allan — Plain. 40 OPERATIVE DENTISTRY. • Fig. 40. Dr. Delos Palmer's Set. INSTRUMENTS. 41 42 OPERATIVE DENTISTRY. Fig. 43. Fig. 45. I. Inferior six-year molar and canine. 2. Cavities of decay. 3. The rubber dam applied. 4. The clamps holding the dam in place, making visible and keeping dry the cavities while impacting the gold. Fig.s. 43, 44, 45 show Dr. D. B. Freeman's cervix clamp. Fig. 42 shows the Brewer universal forceps, which is adapted to all clamps, with few exceptions. Other forceps may be obtained for clampfi of special form. Burnishers for use upon gold fillings are sufficiently de- scribed by the illustrations. Fig. 46. Fig. 46 represents three of the most important general forms. INSTRUMENTS. 43 Finishing instruments consist of files and burnishers. Fig. 47 shows Smith's proximal trimmers. Numerous appliances, in addition to these, are used, which are mentioned under accessories. In some cases the thin, flat, separating file is useful. A Ku;. 47. Fig. 48. thin instrument, with a sharp knife edge (Fig. 48), is useful to dress away the overhanging gold at the cervical wall. A chisel or hard bit is also often effective. Finishing burs, corundum points, wood, leather and rubber points and disks are used almost exclusively with the engine. Fig. 49 shows a few sizes of the more important forms of finishing burs. The Dental Engine. — The dental engine has become an almost indispensable aid to most operators. The essential parts of the engine are the hand-piece and the arm, the latter 44 OPERATIVE DENTISTRY. either flexible or jointed, making it possible to use a bur or drill in any direction. The S. S. White* engine has the flexible arm, and the Bon- will and the Shaw engines have the jointed arm, the last having a flexible portion next the hand-piece. This arm is attached by suitable mechanism to a foot-power or to a water or electric motor. The Morrison suspension engine is also in use. The power for operating this is transmitted by a long belt over pulleys to Fig. 50. the engine, which is suspended over the operating chair. When used, the hand-piece is drawn down to the mouth of the patient, and when not in use it is raised by weights or springs, so arranged as to hold it suspended. There are two forms of hand-piece. One is the universal chuck, which will carry any instrument of the size ordinarily used for the engine. For the other form of hand-piece, in- struments must be especially fitted. Improvements and changes are being constantly made in Fig. 51. Fig. 52. ■HEQ engines and hand-pieces, and it is impracticable to describe or mention them all. In addition to the instruments already described for use with the dental engine. Dr. Robert Huey's screw-headed mandrel (Fig. 50) is useful for carrying disks of rubber, corundum, or sand paper, and also Klump's screw-clamp porte polisher (Fig. 51) for carrying points of wood or corundum for grind- ing or polishing. Fig. 52 shows a mandrel useful for leather disks. INSTRUMENTS. 45 The right-angle and acute-angle attachments render the bur or drill applicable in m^ny places inaccessible to the straight hand-piece. The disk carrier (Fig. 53) is also a valuable attachment, the fixed angle of the instrument giving different directions to the disk as the hand-piece is turned, thus 'making the disk appli- FlG 53. cable in many places which could not be reached by the straight mandrel. The general forms of disks are shown in Fig. 54. Small wheels for the engine are now made of corundum specially prepared and baked in a furnace at a very high tem- perature. They are so hard as not to be perceptibly worn in grinding the teeth, and they are not affected by any heat Fig. 54. arising from friction. Small stones for the engine are also made of the same material. Disks of hard and of soft rubber are also used for carry- ing powder for polishing the natural teeth and for finishing fillings. Points of corundum, stone, wood, rubber and leather are made in great variety of forms for finishing and polishing. 46 OPERATIVE DENTISTRY. Many other instruments and appliances are indispensable, and are mentioned in connection with the operations requiring them. As they may be so readily seen at dental depots, any description of them here seems unnecessary. THE DENTIST HIMSELF. The appearance of the operator and his treatment of the patient are very important, and largely promote or hinder his success. Remember that " order is Heaven's first law," and " cleanli- ness is next to godliness." Be master of yourself Control the temper under all circum- stances. Be kind and sympathetic but firm and self-respecting, dignified but not distant, and tolerant of human weakness, both mental and physical. The operating room should be neat, orderly, well-lighted and airy. The north gives the steadiest and clearest light, the south- erly aspect is the most healthful, while the western sky affords the longest day. ' When operating by direct sunlight, a white Holland shade will so soften the light as to make it agreeable, and yet it remains effective. If the shade be placed outside the window, it affords circulation of air between it and the window, and thus keeps the heat from the room. A white awning serves the same purpose, but shuts out more light. The operating case should be conveniently placed and of sufficient size to allow of a convenient arrangement of the instruments, each instrument or class of instruments in its place. Every instrument should be kept clean, free from rust and well polished. Observe scrupulous cleanliness about the spittoon. Wash frequently, deodorize and disinfect. A weak solution of sul- phate of copper is an inexpensive and effective disinfectant. MANNER OF HOLDING INSTRUMENTS. 47 Other excellent disinfectants are Piatt's chlorides or perman- ganate of potash. Give careful attention to personal cleanliness, especially the hands. Wash them frequently, using the best toilet soap. Keep the nails pared short and scraped clean. When a grimy, rough or chapped condition of the hands obtains, give them a thorough washing in soft water with the free use of carbonate of soda ; partially dry the hands and apply glycerine and rose-water, rubbing well ; then rinse in clear, cold water and wipe dry. This leaves the hands perfectly clean and soft and promotes healing. MANNER OF HOLDING INSTRUMENTS. A few general principles which the student should fully comprehend, are concerned in the holding of instruments. First, the instrument should be grasped firmly, so as to be fully under control. Second, the hand should have some firm support to render the motions of the instrument accurate and steady. This sup- port is best obtained by resting the thumb or the third or fourth finger upon such teeth or other parts as will best accom- modate the operation. The instrument is held either between the thumb and the first and second fingers, as a pen is held, as in Fig. 55, or grasped in the palm of the hand, as shown in Fig. 56. When held like a pen, the fingers which hold the instru- ment should be kept free from the third finger, which forms the support, so that the motion may not be impeded by contact. The student is advised to practice a wide range of motion, so that he may operate with ease in any part of the mouth. Fig. 57 shows an effective range of six inches, with the point of the instrument one inch from the second finger. 48 OPERATIVE DENTISTRY, Fig. 55. £Ty ^'^^^^^cgj Fig. 56. xy\>-^. ">>v MANNER or HOLOINf; INSTRUMENTS. 49 50 OPERATIVE DENTISTRY. EXAMINATION OF THE MOUTH. The instruments required for examination are the mouth mirror and suitable explorers (Fig. 58), and diagram (Fig. 59) for recording. Fig. 59 is a modification of those proposed by Dr. Perry and Dr. McKellops. Listen attentively to the patient's story ; the history of a case is often important. Respect the patient's fear and dread, and avoid the sudden probing of a sensitive tooth ; make haste slowly at first. Note the age, temperament and condition of the patient. Observe the number, arrangement, form and quality of the Fig. 58. teeth, and the general condition of the gums and mucous mem- brane and the appearance and reaction of the saliva. Notice any existing complication, as local inflammation, ulceration, abscess or tumors. Record all the facts observed briefly, but accurately, for future reference. Finally, examine the teeth with reference to the location and extent of caries or other defects and operations needed. The results of the examination may be indicated by marks and abbreviations, and such remarks as may be necessary to a complete understanding of the case. Some system should be adopted in order that the examina- tion may be made complete in the shortest time, and it is EXAMINATION OF TIIK MOUTH. Flii. Sy. 5' 52 OPERATIVE DENTISTRY. recommended to begin with the posterior tooth of the upper jaw on the right side and pass around to the same position on the left side, then commence on the lower jaw and examine the lower teeth from the left around to the right. It will be found best to examine all the surfaces of each tooth before passing to the next. On all surfaces except the proximal the sight will assist the touch in detecting cavities of decay. For proximal surfaces the pair of instruments above named should be used, pass- ing the instrument between the teeth near the necks and turning the point toward the grinding surface and against the tooth to be examined, where it may be made to enter any cavity upon that surface. For the contiguous surface of the next tooth the other instrument should be used in like manner. DEPOSITS ON THE TEETH. Those of importance are salivary calculus, sanguinary or serumal calculus and green stain. The elements of salivary calculus are present in the saliva of every person. Calculus collects upon the teeth of some in large quantities, while on others it is scarcely perceptible. It is composed of earthy salts and animal matter. The salts are principally phosphate and carbonate of lime and mag- nesia. The animal matters consist of fibrine, fat, epithelial scales, food and saliva. The proportions of constituents vary so that no two analyses give the same result. Berzelius gives : — Phospliate of lime and magnesia 79 Salivary mucus and salivine 13.5 Animal matter 7-5 loo.o The analysis of Vauquelin and Langier gives: — Phospliate of lime and a little magnesia 66 Carbonate of lime 9 Salivary mucus, including plyalin 13 Animal matter 5 Water and loss 7 100 DKPOsrrs ON thk tf.eth. 53 Bacteria, also, are Ljencrally present. Calculus varies much in color, being sometimes white or yellowish, at other times of a pale or dark brown color, and in some instances black. The color and hardness have a direct relation to eacli other; the white is very soft and easily removed, the black is the hardest and adheres to the teeth with great firnmess. Salivary calculus is a deposit from the normal secretions of the mouth, and is in no sense a pathological production; but if allowed to remain on the necks of the teeth it will produce changes of a serious nature in the adjacent tissues. This deposit collects in the greatest quantities on the lingual surfaces of the inferior incisors and the buccal surfaces of the superior molars, these localities being near the openings of the ducts of the salivary glands. It collects on all the teeth and upon every part of crown and root, even to the apex of the root, and causes neuralgic pain by its constant irritation of the nerves of the pericementum, or by impinging on the nerve of the pulp at the foramen. If not removed it will accumulate in great quantities, sometimes nearly covering the teeth from sight. Calculus has no effect upon tooth substance, but to the gum with which it is in contact it is very irritating, causing inflam- mation which extends to the pericementum and implicates the alveolar process, causing its absorption. It produces a morbid condition of the fluids of the mouth and causes fetid breath. A green or brown stain collects on the labial surfaces of the teeth near the gums, especially on the superior incisors of children and young persons. The surface of the enamel under this is generally found rough and imperfect. The cause and nature of this stain are uncertain, but it is thought by Wedl and others to be a fungous growth, the result of neglect of the teeth. The hard, dark deposit found upon any portion of the roots of teeth is described as sanguinary or serumal calculus. This is the result of inflammation, and is deposited from the serum 54 OPERATIVE DENTISTRY. of the blood and colored with the hematin. It contains a larger proportion of mineral matter than any other, and is, consequently, the hardest. CLEANSING TEETH. Cleansing teeth consists in the removal of calculus, stains and any other foreign matter from the teeth, leaving the sur- faces polished. Calculus is removed with sharp steel instruments, so formed as to be readily applied to every part of each tooth. In their use care should be taken to avoid scratching the surfaces of the teeth. The square edge of the hard bit is particularly well adapted to this purpose ; it is very effective and safe and is utilized in many of the scalers used. The instrument is held firmly against the tooth and carried along parallel with the surface, the edge clearing the calculus before it. The scalers described in the chapter on instruments will prove excellent in skillful hands. Dr. Abbott's set is well adapted for general practice, as they are capable of so wide a range of motion and application. Dr. Cushing's set, especially arranged for the application of the pushing force, is effective. Dr. Harlan's set is also used with the pushing force, and are effective instruments. A Riggs scaler with the edges of the hard bit is an admi- rable instrument, and will be found an effective auxiliary to any set. To remove calculus from the roots of teeth, pass a thin, hoe-shaped instrument under the gum beyond it, and drawing toward the crown of the tooth bring the deposit with it, or, using instruments constructed for the pushing force, hold the instrument firmly against the root and press toward the apex until the deposit is loosened. A second or third sitting is advisable, as some particles of calculus are liable to be left, and unless removed at a subse- CLEANSING TEETH. 55 quent sittinf^, will form a nucleus for further deposit. These will be readily detected after the bleeding has ceased and the gum healed. At the subsequent sittings, whenaver a red or blue spot or line remains upon the gum, a speck of calculus will be found beneath it. After the calculus is removed, polish with powdered pumice applied on an orange-wood stick, or wood point, or soft rub- ber disk in the engine, followed by polishing putty (oxide of tin) or chalk. To remove the green and other stains from the teeth, apply tincture of iodine freely and then polish as before. The iodine acts upon the stains and they are then easily removed. Nothing will affect the stain of tobacco smoke. It can be removed only by means of instruments and polishing. After the cleansing, the patient should be advised to use tooth powder with the brush at least once a day, and to use the brush after each meal, brushing not across, but always , lengthwise of the teeth from the gums. The brushing after meals may be omitted without serious results if the toothpick is used, but brushing the teeth in the morning and on retiring is essential to the welfare of the organs. The use of the toothpick after a meal is advisable to remove particles of food from between the teeth. Care should be exercised to avoid crowding the pick between the necks of the teeth and thus injuring- the gum. The ubiquitous wooden toothpick is objectionable on account of its great size, which renders it liable to injure the gum, and the liability to break, leaving pieces to irritate the gum. A quill sharpened and scraped rather thin is undoubtedly the best. Dental floss silk is useful and effective, but great care is needed not to carry it too far under the gums and injure them. Properly waxed, it is a very convenient article for the purpose. Mastication has great influence on cleanliness. People often form a habit of chewing on one side of the mouth exclusively, which is quickly shown by the decided uncleanliness of the 56 OPERATIVE DENTISTRY. neglected side and the nicely polished appearance of the oppo- site side. They should be advised to correct the habit and use both alike, SEPARATING TEETH. Its object is to afford room for examination or operation. This may be accomplished by wedging the teeth apart or by removal of substance. The wedging may be done by wood, tape, raw cotton, silk or linen thread, rubber, wedge forceps or screw separators. The wood, tape or cotton is used by first inserting a thin portion and exchanging at intervals of twelve or twenty -four hours for thicker, until the desired space is obtained. Cotton is more applicable where a cavity exists. In using thread, tie a knot in it and pass the knot between the teeth and tie the thread around the point of contact, drawing the knot between. This method is suitable only v/hen the teeth are but little de- cayed. For separating with rubber take fine quality French rubber tubing or the ordinary rubber bands, cut a piece from one-sixteenth to one-fourth of an inch in length, according to force required, slit the tubing, stretch the piece between the teeth and cut off the free ends. The elasticity of the rubber will, in twenty-four hours, separate the teeth sufficiently for ordinary purposes. If the teeth are in very close contact a piece of rubber dam may be first used.. Any sharp edges which cut the rubber must be smoothed. Use thin rubber and a narrow piece, to avoid soreness. Maintain the separation with cotton until the tenderness, if there be any, disappears, before operating. With the screw separators or the wedge forceps the separa- tion may be made in from five to thirty minutes. In using the former, apply and turn the screws until they press firmly, and after waiting a few minutes repeat until sufficient space is obtained. Figs. 60 and 61 show Perry's two-bar separators with wrench for turning bars. These separators allow the light to be thrown unobstructed Fig. 6o. SEPAKATINd TKIvTII. Kit;. Ci. 57 upon every part of the separated surfaces. Little arrows stamped upon the bars indicate the direction in which they are to be turned to spread the sepa- rators. The wrench for operating them is double- end, one end straight and the other bent at an angle to give greater facility for turning the bars in different positions. Fig. 62. Fig. 62 shows the separator applied. When there is a tendency, as with teeth of narrow necks, to slip toward the gum, wood or gutta-percha props are to be put on the adjacent teeth, under the bows, to prevent them from tilting, and to keep 58 OPERATIVE DENTISTRY. the points from being forced under the gums while the teeth are being separated. Fig. 63 shows Parr's universal screw separator and wrench. The cut explains the manner of application. In the use of the wedge forceps the same principle should be observed, of waiting for the teeth to yield to the pressure already applied. In rapid wedging the only space that can be obtained safely is by compressing the pericementum. For immediate separation with wedges a thin piece of wood or quill is introduced between the teeth, to protect the gum. Fig. 63. Ml Q i' and next to this a narrow wedge of orange, hickory or box- wood, so formed as not to interfere with the wall of the cavity. These are allowed to remain during the operation, being driven to hold the space gained by a wedge introduced between the points of contactor near the cutting edge, by hand pressure or mallet force, or with wedge forceps. The wedging should be gradual, to allow the tissues to yield to the pressure. After gaining the space required, the separating wedge should be removed and the projecting portions of the others cut off. If the space should be required for another sitting, remove the wedges and maintain it with cotton and sandarac varnish, or OI'ENlN'f. CAVITIES. 59 gutta-percha. Teeth which have been wedged apart soon return to their normal positions when left to themselves. Separating by cutting away the tooth substance may be done with chisels or " hard bits," and when this is resorted to the teeth should be cut away toward the inside of the mouth, so as not to disfigure the external surfaces. Separation in this manner is applicable to the six anterior teeth of the upper jaw, and is recommended for them only. It is not necessary nor wise to cut away enough to expose or endanger the dentine. As the normal point of contact near the cutting edge is left undisturbed, the separation is made permanent, leaving a surface which is self cleansing and which causes the filling in proximal cavities to present within the mouth, subject to examination. (Fig. 64.) This separation is produced by dressing away the proximo-palatal angle of the tooth, but not sufficiently to interfere with the front. OPENING CAVITIES. This consists in enlarging the orifice of a cavity of decay so as to render accessible all parts of the cavity. It is done by cutting down the enamel walls, and by removing sound dentine when necessary. The instruments most suitable for opening crown cavities are chisels, burs and excavators ; for buccal cavities, excavators and burs, and for proximal cavities hard bits, chisels and burs. * The artist has exaggerated this somewhat. It indicates too much cutting away. 60 OPERATIVE DENTISTRY. Ill opening proximal cavities in superior incisors and cus- pids, cut away the palatal wall till every part of the cavity can be seen by direct sight or in the mirror. A few prefer to cut away the labial portion of the enamel and expose the cavity to direct sight, so that it may be filled from the front and with- out the aid of a mirror. Open proximal cavities in inferior incisors and cuspids from the labial surface, but distal cavities in inferior cuspids may sometimes be opened from the lingual surface. After the teeth are separated proximal cavities in bicuspids and molars should be opened toward the grinding surfaces, except when small and near the gum. In such cases it may be better to open from the buccal surface. If decay is far advanced, the grinding surface should be cut through. When full contour is desired, separate by wedging, open the cavities as in other cases, and restore the contour by filling. REMOVAL OF DECAYED DENTINE. This is accomplished by means of excavators, chisels and burs of various forms and sizes, cutting, whenever possible, in a direction from the pulp, as this causes less pain. In deep cavities, allow a thin layer of decalcified dentine to remain, to protect the pulp, but remove all softened tissue from the borders of cavities, and all discolorations from the enamel or near it, whenever possible, and from any connecting grooves, especially in bicuspids and molars. The deep portions of such cavities should be thoroughly disinfected. FORMATION OF CAVITIES FOR FILLING. As a rule, remove all frail and overhanging walls. Some- times when it is desirable to save them, as in presenting sur- faces, they may be strengthened by lining with cement. Remove all unsupported enamel from the cervical wall. This wall .should be at right angles to the surface of the tooth. FORMATION OK CAVITIES TOR FILLIN(;. 6l Make the lateral walls of cavities in incisors and cuspids of such form as they will most conveniently take, and make a well-defined undercut at the cervical wall, and also at the part next the cuttin<^ edge, to retain the filling. The lateral walls of proximal cavities in bicuspids and molars should generally be undercut or grooved, and if the grinding surface is not cut through, this also should be slightly undercut. If this surface is cut through, the grooves of the lateral walls may extend through the opening, thus presenting a dovetailed outline (Fig. 65), or the opening maybe left as in Fig. 66. For making these grooves use a small bur, hoe or chisel. If the cavity is of considerable size, the lateral walls should be cut away, as shown in Fig. 67, so that when filled, the filling Fig. 65. Fig. 66. Fig. 67. only will come in contact with the adjoining tooth, leaving the margins free. Let all angles be rounded and smooth. For filling with cohesive gold, retaining pits are usually made in which to start the filling. Use a small, flat, square-pointed drill, and drill the holes in the dentine near the enamel, and generally parallel with the long axis of the tooth. Avoid drilling toward the pulp. A depth equal to the diameter of the drill is sufficient. Retaining pits are condemned by many as unnecessary and a source of danger to the pulp. In bicuspids one retaining pit is usually sufficient, and is better made at the middle jiortion of the cervical wall, as the dentine is thickest at this point. These are not needed for non-cohesive gold or for plastic fillines. 62 OPERATIVE DENTISTRY. In grinding surfaces the walls of the cavity should be nearly- parallel, with slight undercuts at opposite points. The same rules apply to the formation of cavities on buccal, palatal or lingual surfaces. For the formation of these cavities various forms and sizes of burs are best suited, but the work may be well done with excavators and chisels. EXCLUSION OF MOISTURE. To obtain the best results, the cavity must be kept dry during the operation of filling. For this purpose use napkins, bibulous paper, the saliva-pump or rubber dam. Napkins from three to six inches square, folded into a small compass and held over the openings of the ducts of the salivary glands, and each side of the tooth to be operated upon, will exclude all moisture long enough for an ordinary operation, and if a saliva-pump be also used the cavity may be kept dry for an in- definite time by an occasional change of the napkins. Snow's saliva-pump is effective, but where water pressure can be ob- tained, the saliva ejector is the most desirable and efficient. The rubber dam properly adjusted is the most perfect means for the exclusion of moisture. Take a piece of strong rubber dam of medium thickness, about seven inches square, and for application to the upper teeth punch some holes about one and a half inches from the edge and one-eighth to one-fourth of an inch apart, generally on a line parallel with the edge of the rubber. For lower teeth punch the holes toward the lower part of the rubber, and not less than two inches from either edge. The rubber may be placed upon the face, and the points for the holes indicated by marking over the tooth or teeth when the rubber is carried to place. The rubber should be supported upon the face with the holder before stretching it over the teeth, as thus the edges are prevented from folding over and interfering with the applica- tion of the rubber and the ligature or clamp. EXCLUSION OF MOISTUKK. 63 For cavities in the cutting edges or grinding surface fre- quently only one tooth will need to be exposed, but if proxi- mal fillings are to be made, two teeth at least must be exposed. To suj)port the rubber dam upon the face, use a rubber dam holder — one made from a pair of ordinary sleeve catches connected by elastic braid is convenient and effective. (Fig. 68.) A good form, also, is Cogswell's holder, shown in Fig. 69, also Perry's, Fig. 70. Before applying the rubber, prove by passing silk between the teeth, that there are no sharp edges to interfere with its Fig. 68. passage. For this purpose and for ligatures, floss silk, not too coarse, well waxed, is best. Binding-wire makes an excel- lent ligature in many instances, especially when the cavity is at or below the margin of the gum. Fasten the dam-holder to each upper corner of the rubber, carry the elastic around the head and tighten it, bringing the upper edge of the rubber across the upper lip (Fig. 71), then with the forefinger of each hand stretch the rubber over the teeth. If the teeth are too close together for the rubber to pass easily, apply a little soap, and it may then be readily car- ried up with the ligature. The ligature should be passed 64 OPERATIVE DENTISTRY. twice around the tooth and drawn only closely enough to turn the edges of the rubber upward on the neck of the tooth, thus avoiding pain as much as possible, tying firmly with a square or a surgeon's knot. Should the ligature be impracticable or inconvenient, apply, Fig. 69. with the clamp forceps, one of the numerous rubber-dam clamps. To confine the lower portion of the rubber, attach a second dam-holder to the lower corners, allowing the band to pass EXCLUSION OF MOISTURE. 65 around the back of the neck, as in Fil,^ 72. Weights are also used for this purpose. Having the rubber dam thus adjusted, place in ])osition the mouth-piece of the saUva-pump, and the work will be kept dry and the patient comfortable. Fig. 70. In some cases the clamp may be applied to the tooth first and the rubber stretched over it and the silk applied. This may be readily done if the hole in the rubber is made a little larger than usual. 66 OPERATIVE DENTISTRY. An assistant, if at hand, may, with an instrument, hold the rubber down on the neck of the tooth while the silk is applied. When the silk is to be applied far back in the mouth, it Fig. 71 //j/h ■r^ij ^^ ^Adjustment of rubter'dam //'///>!/ /r,/iu- to upper teeLli, ' ^'^ JJ/' plfl'ii ^""mm„pnf^ EXCLUSION OF MOISTURE. 67 may be wound around the little fin<^er of each hand and with the forefingers carried back and pressed down between the teeth. Fig. 72. Adjustment of rubber dam to under teetk. 68 OPERATIVE DENTISTRY. GOLD FOR FILLING. Gold is the most elegant material for filling teeth that we possess, and for most cases it is the best. Though not the color of the tooth, it receives and retains so fine a polish that it is less objectionable than any other material. Gold is prepared in two forms — foil and crystal or sponge gold. Foil is used cohesive and non-cohesive. Non-cohe- sive foil is so prepared that it will not cohere when the surfaces are brought in contact. Cohesive foil is prepared by annealing so that the particles will cohere when the surfaces are brought in contact, and it may thus be welded into a solid mass while cold. For instance, two sheets of foil, well annealed, laid together and pressed by passing over them a paper-folder, become united as one sheet. Most of the non-cohesive foil now made may be rendered cohesive by annealing. A sheet of gold foil is four inches square. It is numbered according to its weight, a sheet of No. 3 weighing three grains ; of No. 4, four grains, etc. A book is one- eighth of an ounce. Foil is used of various thicknesses, from No. 2 to No. 120, or thicker. Gold in Nos. 20 to 240 is prepared by rolling, while foil thinner than No. 20 is made by beating the rolled gold to the required thinness. Gold foil may be prepared for use in various forms, as the rope, the tape, the mat, the compact and the loose block, the compact and the loose cylinder, and the ribbon. For use cohesively, cut the foil into strips of one-fifth or one-fourth of a sheet, and roll into ropes with a napkin, or, better, with the Adams roller, then cut into pieces one-fourth of an inch or more in length, according to the convenience of the operator and the requirements of the case. For rolling the foil, take a large napkin or fine towel and fokl lengthwise to a width of four or five inches, then fold this once upon itself, and, placing the strip of foil in the fold, by a dexterous movement of the upper portion of the napkin upon the lower it may be rolled into a rope. GOLD FOR FILLING 69 The Adams Roller consists of two plates of tin, three and a half by five inches, with the edges turned over and a small handle attached to the outside of each plate and a piece of thick rubber dam of the same size. The edges of the rubber are confined to the upper edge of each plate by folding the tin upon itself and hammering it down closely upon the rubber. (Fig. 73.) The rubber should first be thoroughly washed, and when- ever the gold has a tendency to stick to it the washing should , be repeated. In the use of this the rubber is folded upon itself, the strip of gold laid within it, crumpled a little endwise with pliers, and then dexterously rolled into a rope. The following excellent directions for preparing gold in various other forms are given by Dr. Jack, in the " American System of Dentistry " : — " The tape is made by folding any portion of a sheet over and over again until a desired width and thickness is pro- duced. It is not, however, considered advantageous to have the number of folds in each tape greater than eight, which, when the gold is No. 4, makes the tape equal to No. 32. If 70 OPERATIVE DENTISTRY, the tape is to be used in this form by folding it into the cavity, as will be described later, it should be of non-cohesive gold, since otherwise the adherence of the folds, as they pass and touch each other, becomes an impediment to consolidation. The tape is most conveniently formed by laying the suitable portion of the sheet upon a clean napkin or a piece of amadou, and after placing the edge of the gold spatula in the middle, the napkin and spatula are laid over to one side; this is done .three times successively. By this means the gold is formed into a tape without the fingers having come in contact with it, which is a point of considerable importance, since the cleanest fingers will impart some soil to the foil." " The Mat. — If it is desirable for any reason to use small portions of the tape, it is cut transversely in small pieces, which are called mats. These, when of non-cohesive gold, are of considerable use in very small cavities, and are also of use in large fillings when made of semi-cohesive gold. One form of tape is made by a tool which compresses the gold into this shape ; if from this kind of tape mats are cut, they may be used with advantage if of very cohesive gold. The mat is of most service in proximate cases when there may not be sufficient room to introduce larger and thicker pieces of gold. These can be inserted edgewise between the teeth, and after- ward be carried into place and consolidated according to the method of packing employed at the time. The mats of non-cohesive gold are frequently of service in filling the smaller sulci, particularly of bicuspids. In introducing cohe- sive-gold mats, the best results are produced by making thin layers of gold, since the force employed is more effective in producing thorough consolidation. If thick masses, like pel- lets, arc employed, much of the force is distributed in over- coming the impediment presented by the corrugations. "The Block. — The compact block is formed by folding a tape on itself a number of times, which is done by seizing it in the pliers and making turns of any desired size, either square or narrow. This form should be composed of non-cohesive GOLD FOR FILLING. J \ gold, as Otherwise a mass of so compact a nature would become unmanageable by the cohesion of the layers. These blocks are useful in commencing large proximate cavities, they being used upon the cervical wall. Their form, the parallel direc tions of their layers, the plastic nature of the arrangements of the layers, and the softness of the gold comprising them, enable this part of the filling to be easily started. They are also excellently adapted to simple crown cavities where it is not difficult to effect their placement. This form of block has sometimes been erroneously styled a cylinder. "The Loose Block is composed of cohesive gold, and is gen- erally made of what is called corrugated gold, the purpose of the employment of the latter being to prevent the layers from touching at more than a few points. This form of block is made by laying sheet upon sheet until a number of layers are so placed, when the mass is cut into squares with a razor-like instrument. These blocks are useful only in building up gold upon a previously-established foundation of cohesive gold. "The Compact Cylinder. — This form is made by rolling a tape of non-cohesive gold on a fine brooch, commencing at one end of the tape and continuing the movement until the desired size is reached, by which means the cylinders may be made very compact. "The Loose Cylinder bears some external resemblance to the previous kind, but is in all other respects very different. Cylinders of this form can be made only by manufacturers. They are composed of several sheets laid one upon the other, and are then wrapped loosely upon a needle-like piece of steel. When the brooch is removed, they are cut into definite lengths by a sharp tool, and are di.stributed in assorted sizes. They are usually made of corrugated, cohesive or semi-cohesive gold, and they complement the loose block. " They are employed in the commencement of fillings, for which purpose they are not usually annealed, and are recom- mended on account of the facility with which they can be packed. There is, however, considerable loss of force in 72 OPERATIVE DENTISTRY. overcoming the corrugations of the foil of which they are composed. Still, there is no question that there are certain advantages possessed by these cylinders, as, when they are fixed at one end there is less danger of displacing this fixed portion when force is applied to the other end, for the reason that the corrugations permit some movement to take place in the unconsolidated part without disturbing the part first secured. Probably on account of the impediment offered by the corrugations, they are not well adapted to building out in Fig. 74. contour operations, and other forms should be substituted when this portion of the operation is reached. "The Ribbon is formed of whole sheets, and, in some cases, of two sheets of fiat cohesive foil, folded like a tape, three times, which produces No. 32 when one sheet is taken. The folding should be loosely done. These ribbons are shown at Fig. 74. The ribbons are taken up with delicate foil-pliers and cut across into little strips, represented at d and c, care GOLD FOR TILLING. 73 being taken to protect them from injury, the width of these strips being varied with the size of the case. Each of the strips is afterward taken up by pliers and heated to redness at the moment of using. It was with this form of gold that the beautifully-executed operations of Dr. Webb were generally performed. "This form of gold is properly adapted only for building out teeth beyond the confines of the cavity, and for entirely filling such cases as depend for their support and retention upon a few retaining points or imperfect grooves yvhich have been formed in weak margins. It is also the form of gold best adapted to the use of the electro-magnetic mallet, for the reason that, as that instrument is efficient only through insen- sible distances, it is important not to have much bulk of gold beneath its points, " Rolled Gold. — Several thicknesses of heavy gold have been recommended, in some instances as high as No. 160 having been used. Reasonable practice in this respect has settled that Nos. 20 to 30 are the proper limits of heavy foil. Pure gold, prepared by rolling, has a remarkable degree of softness and toughness, and when made cohesive, manifests this quality in a higher degree than the same gold would if beaten into foil. When made of cohesive gold, and this property fully developed by heat, the adhesion is exceedingly tenacious, which adapts the gold for building out cases, and for surface fillings when it is important to produce a homogeneous ap- pearance of the surface. When made of non-cohesive gold, narrow strips may be inserted along the margins of stoppings packed by hand pressure, and they may also be used for filling the pulp-canals. In this form it is not difficult to jiack it into fine roots, and in this situation it will also well bear malleting." The methods of packing non-cohesive and cohesive gold are essentially different. Non-cohesive gold should be packed wholly by the wedging process, Pluggers for packin . . iK Auidrachms. Cocaine (alkaloid) . 10 grains. Mix. The galvano-cautery is said to be efficient and is worthy of trial. It should be passed quickly over the surface. Arsenions acid should never be used as an obtundent of sensitive dentine, unless it is determined to devitalize the pulp, as this result is sure to follow. If used, the pulp should be exposed and removed at once, or as soon as possible, to avoid discoloration of the tooth. SECONDARY DENTINE. Dentine which is formed by the pulp after the tooth is fully developed is called secondary dentine. It differs in its struc- ture from true dentine, the tubuli being more like the canaliculi of bone. The tubuli are very irregular, without any centre of radiation, as is the case in normal dentine, the tubuli of the latter radiating from the pulp cavity. The tubuli of secondary dentine are completely filled with calcific material, hence it is very translucent. It is formed as a continuation of primary dentine, sometimes to such an extent that the pulp is nearly obliterated. In other cases it is deposited in isolated nodules, or in a granular form in the pulp tissue. When formed as a covering for a receding or nearly exposed pulp it cannot be considered pathological. It is then called protective dentine, or dentine of repair, but when it is produced SECONDARY DENTINE. 93 in SO great quantities as to cause pressure upon the pulp, or in irrc'ing it out. EXTRACTING ROOTS. Decidedly the best instrument for extracting roots is the universal spicular root forceps, Fig. 98, p. 129. The beaks, being narrow and sharp, pass easily beneath the gum and effectually seize the root, rendering the use of the gum lancet unnecessary. The forceps should be pressed upward with a rotating motion till the connection between the root and the jaw is entirely broken. In the case of recently-fractured teeth it may be necessary to cut through the alveolus, for which purpose this same for- ceps may be used for the ten anterior teeth, or the alveolar forceps, Fig. 100, p. 130, for the upper jaw, and Fig. loi, p. 131, for the lower. Roots of upper molars, when firm in the jaw, may be best removed with the cowhorn forceps, placing the inner beak over the palatal root so as to get a firm support, and the cow- horn placed immediately over one of the buccal roots, clos- ing the instrument the cowhorn will pierce the alveolus and impinging upon the root will easily start it from its socket. Without removing the instrument open the beaks and repeat the operation on the other buccal root. Remove the instru- ment from the mouth, and with the spicular forceps remove the loosened buccal roots and extract the palatal root. In case of necessity the inner beak may be placed far up on the palatal surface of the gum, and the cowhorn used as before described. The instrument being carefully removed leaves only a simple wound of the gum, which readily heals. Roots of lower molars may generally be successfully re- moved with the lower cowhorn, Fig. 95, p. 127. Place the inner horn of the instrument on the gum, well down over the 136 OPERATIVE DENTISTRY. alveolus, then use the outer horn upon the root, as described for the use of the cowhorn on the upper molar roots. The alveolar forceps may also be successfully used for removing these roots. Special directions for extraction of the tempoi^ary teeth need not be given, as they offer no peculiar difficulties, but caution should be exercised not to injure the succeeding per- manent teeth. The English forceps * are much smaller than the American make. They are strong, and peculiarly well adapted to the purpose for which they are made. The following figures show some of the more important and characteristic forms — Fig. 102. Upper Incisors and Cuspids. ^ Fig. 103. Lower Incisors and Cuspids. * The cuts of these were furnished by Claudius Ash & Sons, London. EXTRACTING ROOTS. Fig. 104. 137 Upper Bicuspids. Either Side. Fig. 105. Lower Bicuspids Fig. 106. Upper Molar. Right Side. Fig. 107. Upper Molar. Left Side. 138 OPERATIVE DENTISTRY. Fig. io8. Upper Third Molar. Either Side. Fig. ic Lower Molar. Either Side. Fig. iio. Upper Root. ELEVATOR. 1 39 Fit.. Ill, Lower Root. ELEVATOR. An elevator is sometimes very useful for the removal of roots of teeth, but since so great improvement has been made in the construction of forceps it is not so much used as for- merly. The Cooledge elevator with two blades, formed like Fig. 112, is of universal application, and will serve all pur- poses for which an elevator may be required. The elevator is used by passing the blade down by the side of the tooth, using the edge of the alveolar process as a fulcrum for prying it out. Sometimes the adjacent tooth may be used as the fulcrum. The Key. — Since the perfection of the forceps, the key has fallen into disuse, and it i;? severely criticised and condemned by most of the profession. A few operators have continued to use it, and find in it such merit that a description of its use is with propriety included in this chapter, and each teacher and practitioner will judge it on its merits. This instrument, used with skill, extracts many teeth with great ease for the operator and little pain for the patient. It is especially adapted for the removal of the eight bicuspid teeth and roots. The fulcrum should be round, about three- fourths of an inch in length from centre of shaft and one-lialf inch in thickness. The hook must be long enough to reach well down on the outside of the jaw, and well curved so as not I40 OPERATIVE DENTISTRY. to be thrown off by contact with the crown of the tooth when force is appHed to extract it. The hook should have but one Fig 112. Fig. T13. Fig. 114. point, sharp and well tempered, shown in Fig. 113. Pad the bulb with wet cotton, tied on, or a small napkin wound around it — a permanent pad becomes foul. Fig. 114 shows the fulcrum and hook properly con- structed. Place the fulcrum on the inside of the jaw opposite the tooth to be extracted, and rest it on the edge of the gum well up on the neck of the tooth. If placed down on the gum the force is exerted too much laterally, and fracture of the tooth is likely to result. If the topth be strong, place the point of the hook on the neck at the buccal side of the tooth, pressing down the gum a little, but not sufficient to wound it. When adjusted, as in Fig. 115, rotate the shaft inward gently until you feel that the hook is fixed, when a quick, resolute turn of the hand will extract the tooth instantly, and in almost every case to the great surprise of the patient that it hurt so little. The natural inclination inward of the bicuspids (see Fig. 115), the taper of the THE Ki:V. 141 root toward the apex, the extreme thinness of the outer wall of bone, and the substantial thickness of the inner plate, render the direction of the force exerted b\- the key extremely favorable. If the crown be gone below the margin of tiiegum, the ful- crum must be placed a little further down on the jaw, and the hook placed well down on the gum, even one-third of an inch from the margin, as in Fig. 116. Then apply force as before, and the hook will penetrate the gum and alveolar wall, catch the root and remove it with great facility, making a clean cut Fic:. 115. Fig. 116. S, SHAFT OF KEY. P, — PAD. A, ALVEOLAR WALL. J, JAW. P, PAD. A, ALVEOLAR WALL. through to the edge without lacerating the gum or fracturing the bone. If properly used, the fulcrum will not bruise the gum at all. Some operators strenuously advocate its use for extraction of the molars, especially of the lower jaw. In these cases the fulcrum may be placed either on the lingual or buccal side of the tooth, preferably the latter, as the force thus applied acts more in accordance with the anatomical construction of the parts. 142 OPERATIVE DENTISTRY. As forceps are numbered by the hundreds, it is impossible and undesirable to describe them all in this work. When the operator shall have learned Avell to use those already men- tioned, he will then be able to select such additional instru- ments as shall suit his individual taste. AN.^^STHESIA. AncBStliesia is a state of insensibility, induced by any means or conditions whatever. As used in dental practice, it means a state of insensibility induced at the will of the operator by the administration of medicinal agents, usually by inhalation. Ether, nitrous oxide gas and chloroform are the only agents in general use for this purpose. Their effect is produced by their action upon the brain, the parts of which are affected in the following order : — First. The cerebrum, benumbing sensation and volition. Second. The cerebellum, affecting the coordinating power. Third. The medidla oblongata, depressing the powers of organic life, viz., circulation and respiration. Anaesthesia may be divided into three stages, although no marked line of division appears : — First. Stimulation. The patient is more quiet, the pulse is stronger and beats more regularly. Second. Excitement. Consciousness begins to be lost, the pulse is quickened, the face flushes, the patient is easily frightened, sounds are exaggerated, muscular movements are irregular and often violent, owing to loss of coordinating power, and soon become spasmodic. The amount and dura- tion of the excitement depend largely upon the mental condi- tion of the subject when commencing to inhale, and upon the degree of mental control exercised by the operator, and the quiet and order around. Third. Profo2ind insensibility. The muscular system becomes relaxed, the skin is insensible, the eyelids do not AN.KSTHKSIA. 1 43 respond if the lashes be touched, the conjunctiva is insensible to touch of the finger, the \n\p'i\ is dilated. Still more pro- found insensibilit)- is indicated by relaxation of the sphincter muscles, the sphincter ani being the last to succumb, by stertorous breathing, slowing and weakening of the pulse, shallow breathing and profuse sweating. In typical anaesthesia as produced by ether, especially when rapidly inhaled, sensibility to minor operations is entirely lost before other powers are sensibly affected, and at this point a single tooth may be extracted, or a single incision made, without any pain being felt, although the patient may be quite conscious of all that is being done. This condition is indicated by insensibility to pinching of the skin, and by the dropping of the hand, which was voluntarily held up by the patient at the beginning of the inhalation. Next consciousness is overcome, and by this time the coordinating power is considerably diminished and very soon lost, and loss of all muscular power quickly follows. This stage may be maintained for a long time without the circulation or respiration being sensibly lessened, and severe and prolonged operations performed. If anaesthesia be pressed further, the pulse, which at first is full, strong and quick, becomes weak and less frequent, and the respiration more shallow, showing that the medulla is affected. Auctsthesia that is produced quickly passes off quickly. It is quite practicable to induce anaesthesia, perform an operation and have the patient recover, without apparently affecting the medulla at all, consequently no nausea follows. It is prolonged anaesthesia that produces nausea. The medulla seems to be affected in proportion to the length of time that the agent is inhaled. Nitrous Oxide. — Relaxation of the muscles is not constant nor common in anaesthesia produced by nitrous oxide gas. Contraction instead of relaxation is likely to follow, and a spasmodic twitching of the muscles takes place, an interrupted, jcrk\- inspiration, and a turning inward of the thumbs toward 144 OPERATIVE DENTISTRY, the palm of the hand. Beyond these indications it is not safe to affect the patient. Nitrous oxide gas is the agent par excellence for the dentist's use. It is a stimulant to the heart, and is as safe as anything producing such results can be. Deaths reported do not ex- ceed one in one hundred thousand administrations, and in all fatal cases reported the cause of death has been somewhat in doubt. If the gas is pure, unpleasant results seldom follow its use. It is nearly odorless, so is not unpleasant to have about the office ; it is non-irritating, hence not disagreeable for the patient to breathe ; it acts quickly, produces a profound narcosis and passes off very rapidly, leaving the patient with a clear head and full pulse, ready to go on his way by the time the blood is sufficiently staunched to permit it. If impure, as gas manufactured in a dental office is likely to be, unpleasant effects, such as nausea, dizziness, lassitude and headache, may follow and persist for several days or weeks. When administering the gas the supply should be abundant and free. All air must be excluded, as a very small per cent, mixed with the gas will prevent its narcotic effects An inhaler with a rubber face-piece covering the mouth and nose, and a double-acting valve is much to be preferred. Apply the inhaler to the face, having put a prop between the teeth, and allow air to be breathed until respiration is regular, then with the consent of the patient change the valve and admit the gas. The substitution will hardly be noticed, and in from one to two minutes, rarely three, anaesthesia will be produced, lasting long enough to extract from one to twenty teeth, according to the susceptibility of the patient, the dexterity of the operator, and the difficulties of the operation. The narcosis will last as long as that of any other agent which will produce it as quickly. Inhalation of gas may be repeated, anaesthesia having been induced as many as four times at one sitting. The gas may be allowed to escape from the cylinder into a AN.KSTHESIA, 145 ba^ from wliicli it is breathed, or better, into a gasometer holdiiii^r from twenty to thirty <^allons, and breathed through a tube from this. This insures an abundant supply and pre- vents waste of gas. Any inhaler which compels the reinhalation of expired gas should be condemned. The mode of death from inhalation of gas is from failure of respiration, the irritability of the heart persisting for some time after respiration has ceased. Ether. — Ether is a safe and effective anaesthetic, and is cspeciall)- suited to prolonged operations on account of its cheapness, manageableness, and its power to relax the mus- cular system. It also stimulates the heart. Its odor is very disagreeable, penetrating and persistent. It passes out of the system slowly. In full strength it is at first irritating to the air passages and produces coughing. The ordinary way of giving ether is by holding a towel folded several thicknesses over the face and pouring ether upon it, or a large cone sponge over the face without covering. These means are effectual, but wasteful of ether, allowing much to escape and fill the apartments with the vapor. A more economical and perhaps neater way is to use a wire framework lined with lint, or a cone sponge, and over it a towel pinned closely; over this may be folded a paper cover- ing, as there will be no trouble about letting the patient have air enough. Have the size and form to fit the face without the sponge or lint coming in contact with it. Have the sponge or lint wet with water, as ether does not evaporate well from a dry surface. When everything is in readiness, pour on to the inhaler at first sufficient ether to produce the anaesthesia (one or two ozs.), as removing it to add more prolongs the operation very much. Let the patient inhale a very dilute vapor at first until the membrane of the air cells and tubes becomes somewhat affected and a state of tolerance induced; gradually approach the inhaler, withdrawing a little if the patient chokes or 146 OPERATIVE DENTISTRY. coughs, until the full strength can be borne, which will usually be after about half a dozen inhalations ; then crowd the inhaler close, so as to shut out nearly all air, and narcosis will be very quickly induced — in from two to four minutes. If the patient suffers for want of air, more must be admitted ; but admit no more than is necessary, for, by exclusion of air, narcosis is much more quickly produced. Remove the inhaler and perform the operation. If the patient is anaesthetized in this way and then allowed to come to at once, nausea will seldom be experienced. Ether narcosis should not be repeated at the same sitting, as it is almost sure to produce sickness. Conditions Unfavorable to Anaesthesia. — Alcoholism is a condition unfavorable to the production of anaesthesia. It is generally difficult and often impossible to produce it, and it is attended with unpleasant symptoms. There is no danger in attempting it, but if unfavorable symptoms appear the attempt should be abandoned. Advanced heart disease is an unfavorable condition, as enlarged heart with atrophied walls, valvular disease or fatty degeneration ; but in these cases the narcosis is no more dangerous than the shock of the operation. If a patient is able to come to an office without distress or inconvenience on account of heart trouble, the operator may feel well assured that any disease of the heart is not far enough advanced to render the narcosis at all perilous on that account. Diseased lungs or general debility, if not too pronounced, do not forbid. If physical depression follows the use of an anaesthetic, it is much more likely to be the effect of shock than of the narcosis. In ether narcosis death follows from failure of respiration. Chloroform. — Chloroform has a direct depressing influence on the heart's action. It is also a very powerful agent, and consequently is very dangerous to use. So many fatal results have followed its use in dental practice, that to continue it seems to be wholly inexcusable. If this agent be given, the atmosphere to be breathed should not contain more than two to four per cent, of chloroform AN.KSTIlIiSIA. 147 vai)or ; six per cent, is not safe, ei^ht per cent, is decidedly dangerous, and twelve per cent, is likely to prove fatal. Its odor is agreeable, hence it is pleasant to take, and the tempta- tion to use it is great. Death occurs from failure of the heart, and it is likely to occur in the early stages, often before con- sciousness is lost. A single inspiration of strong vapor may produce the fatal result. An inhaler should be used which absolutely controls the strength of the atmosphere. The ready method of napkin or handkerchief should never be adopted. Chloroform narcosis is usually easy, pleasant and prolonged, and its after-effects not disagreeable. Rapid Breathing as a Pain Obtunder. — Place the patient in a reclining position upon the side. Place a handkerchief o\'er the face to produce quiet ; have the patient breathe rapidly — about one hundred times a minute, rapidly expiring. In two to five minutes partial or entire insensibility is obtained. This is more applicable to women than men, and is not appli- cable to children. Local Anaesthesia. — Of the various means to produce local anaesthesia, the spray of ether or rhigolene applied by the atomizer is the most convenient and effective. The teeth and contiguous parts must be made dry and kept so, and the spray directed upon them gradually, that the patient may bear it without shock from the sudden cold. In from thirty to sixty seconds the full effect will be obtained, when the teeth may be extracted.*' Too great or long continued cold must be avoided, as slough- ing may result. This method is now little used, the cold being so painful. Ether or chloroform applied on cotton to the gum around the tooth for one or two minutes will lessen the sensibility in a marked degree. Unfavorable Symptoms. — When giving gas, the face of the patient sometimes becomes quite livid. This is due in part to asphyxia and in part to nervous conditions, bringing the venous blood to the surface, but more largely to impurities 148 OPERATIVE DENTISTRY. in the gas. The symptom has become much less frequent since the introduction of hquid gas. This is not to be con- sidered an alarming symptom, and absolute purity of the gas will prevent it. Nausea occasionally follows, but is only the result of pro- found anaesthesia, and soon passes away, requiring no treatment. In a few instances suspension of respiration has occurred, for which a sudden shaking or a slap upon the back has proved a sufficient remedy. The mode of death from gas is by failure of the respiration, and if suspension of the respiration continues, the patient should be laid upon the floor and artificial respira- tion be resorted to as long as irritability of the heart exists, which may be for an hour or more. The unfavorable symptoms of ether narcosis are, occasionally an extreme paleness. The remedy for this is the temporary suspension of the inhalation, and the administration of some alcoholic stimulant. Muscular contractions with irregular positions and motions of the eyes, indicating an undue disturb- ance of the nervous system, is an annoying, if not a danger- ous symptom, and demands prudence and moderation in the administration of the anaesthetic, if not an entire suspension. Nausea and vomiting are sometimes persistent and distress- ing. Bromide of potassium in doses of fifteen to thirty grains, repeated if necessary, is a good remedy. The mode of death from ether being by failure of respira- tion, if danger appears from this cause, resort at once to artificial respiration. The unfavorable symptoms attending the administration of chloroform are due to its action on the heart. Its less serious effects are indicated by an ashy paleness of the patient, its more serious and dangerous effects by a weakening of the pulse, or sudden and entire failure of the circulation. The remedy for the first symptom is a suspension of the inhalation and a free supply of air. For the second, promptly lower the head and shoulders, elevate the limbs and employ artificial respiration. The prospects for resuscitation in such cases are not favorable. CROWN WORK. 149 CROWN WORK The mctliods of attachini^ porcelain crowns to natural roots are very numerous and varied. The following directions will serve for mounting a number of kinds of serviceable crowns. For an exhaustive discussion of the subject, the student is referred to the files of the Cosmos and other dental journals and to the " American System of Dentistry," Vol. II. It is presumed that the operator understands metallurgy, including the working of metals, and that he has a reasonable conception of the principles of mechanics and the ability to apply them. A student is not expected to comprehend all the details of Crown and Bridge work without an instructor, for it is not possible to illustrate and describe every point so as to be fully understood by a novice. The following list contains the most of the instruments needed for this work : — Fig. 117. A clasp bender. Fig. 117. Contouring pliers. Fig. 118. Long pliers for soldering. Fig. 119. Small pliers for handling solder, Fig. 120. Fig. iiS Fig. 119. Fig. 120. 150 CROWN WORK. I^I Jack's hard bits, Nos. 13 and 14. (Fig. 12, p. 32.) Bennett's cliiscl excavators, Nos. 5 and 6. A hoe-shaped cutter. Excising forceps, Fig. 121. Fig. jzi. Scissors. Fig. 122 is a pair of surgical scissors for cutting plate. Fig. 122. 152 OPERATIVE DENTISTRY. Hand and engine drills, Nos. 14 and 15, standard wire gauge, for pulp canals. Corundum disks, stones and points for engine. Soldering clamps. Engine burs — round and barrel, Nos. 10 and 12, and wheel, Nos. 18 and 20. Bunsen burners, one with stand for drying and heating cases and for soldering. One mouth blow-pipe. A Knapp nitrous oxide compound blow-pipe is an excellent addition. Copper plate, No. 32. Pattern tin. Excavators — hatchets and hoes. Pliers, Fig. 123. Fig. 123. Cutters, Fig. 124, for trimming plate. Investment material, equal parts plaster and marble dust or sand or asbestos. Die metal, melts at 176° F. Bismuth, 20 parts. Lead, 12 " Tin, 7 " Mercury, 4 " CROWN WORK. 153 Or die metal, melts at 151° F. Bismuth, 7j4 parts. Lead, 4 " Tin, i^ " Cadmium, 2 " Or die metal, melts at 212° F Bismuth, 2 jiarts. Lead, i " Tin. I " Fig. 124. Oxyphosphate cement, slow-setting. Gutta-percha, soft-working. Finishing and polishing instruments and materials. Straight-grained wood ; birch is best. Cement wax — beeswax and resin, equal parts. Iron binding wire. No. 27. Pure gold plate, No. 31. Twenty-two-carat gold plate, coin, No. 31. Gold, 22, 1 0 M ;o D D o J M 00 M M (]_ o 170 THK MANDREL SYSTEM, 171 applied to the inner circumference of the collars, while the contractor must admit the collars themselves, the short taper of the holes in the contractor necessarily covers a greater ransfe of size than is shown in the mandrels. With this Fig. 140. appliance collars can be evenly and accurately reduced in size at the edges, without burring or bucking. The illustration is actual size. "The collar-pliers (Fig. 141) arc for contouring the collars Fig. 141. to shape, one beak being made convex, and the other con- cave to correspdnd. With this appliance the slightest changes required in the contour in the collar are easily made. About a half inch from the extremity of the concave beak a small 1/2 OPERATIVE DENTISTRY. bar of flat steel is attached to it by means of a screw. The free end of the bar has a minute projection upon one face, the other being reinforced to fit into the concavity of the beak. In the centre of the face of the convex beak is a depression, into which the projection on the steel bar strikes, making a very efficient punch for forming guards or stops to prevent the collars from being forced too far under the gum. The depression in the convex beak being slightly larger than the projection or punch, the metal is not cut through, but merely raised on the side oppo- site to the punch. The punch attachment being pivoted, can be swung to one side when not in use. " Fig. 142 is a mallet or hammer with a steel face and horn peen. The handle is nine inches long. "One of the appliances required is a lead anvil, which being Fig. 142. only apiece of soft lead, say two by three inches, and an inch thick, is not illustrated. The female die of an ordinary case will answer very well. "To illustrate the uses of these appliances, take a case in which the two inferior bicuspids of the left side are missing, and the crowns of the cuspid and first molar so badly decayed that the probabilities are that they will soon fall victims to the forceps. The old-time way would have been to extract the molar and cuspids and make a partial plate. Examination, however, shows that the roots of these two teeth are in good con- dition, affording an excellent opportunity for the construction of a piece of bridge-work. " With a corundum point or rotary file cut off the remain- THK MANDKKL SYSTKM. 173 iji<^ portions of the crowns level with the ^um-margins. Prepare the roots in any of the well-known ways, thorou^hl)- cleansing the apical portions, and filling them with what- ever material is desired, being careful only that the work- is well done. h'or the better retention of the filling ma- terial to be placed in the pulp-chamber, retaining grooves can be made, or retaining-posts inserted. Take a piece of binding wire (No. 26, American gauge), say two and a half inches long, pass it around the neck of the molar stump, cross the free ends, and, holding the wire in place with one finger, twist the ends with a pair of flat-nosed pliers until the wire clasps the neck closely at every point (Fig. 143). When there are any irregularities in the contour of the tooth, it is necessary to press the wire into them with a proximal burn- FlG. 143. Fig. 144. isher. It is obvious that the ring thus formed will show the exact size and shape of the neck of the tooth. Remove the ring carefully, lay it on the lead anvil, put over it a piece of flat metal, and with a smart blow from a hammer drive the wire into the lead (Fig. 144). Upon removing the wire an exact impression of the ring will be left in the lead anvil. (This part of the work, as indeed all others, should be done carefully as described. The wire ring may be driven into the lead by a direct blow of the hammer face, but the blow might not strike equally, and the interposition of the flat metal held level ensures an even impression. A piece of an old file is best, as the file cuts keep the wire from slipping.) " Next cut the wire ring at the lap, straighten out the wire, 174 OPERATIVE DENTISTRY. and select a. suitable collar by comparing the length of the wire with the straight lines in the diagram (Fig. 139, p. 170), which show the inside diameters of the various sizes. Should none of these correspond exactly, take preferably the next size smaller. It will be remembered that the collars are No. 30 in thickness, while the wire with which the conformation is secured is No. 26. This difference permits the collar when contoured to shape to enter the lead impression readily — a decided advan- tage in fitting. Having selected the collar, fit it to mandrel No. I with the peen of the hammer, holding it upon the lead anvil and using a slight pushing force to help in stretching Fig. 145. Fig. 146. and forming it (Fig 145). Having driven the collar to form, remove it from the mandrel and try in the lead impression. If it does not fit exactly, return it to the mandrel and stretch it a little, when it will usually fit perfectly, as the mandrels have been designed carefully to the average shapes which obtain in the great majority of tooth-necks. In the exceptional cases where the collar does not fit, it can be readily contoured to the exact shape with a pair of flat-nosed pliers. Of course, if it fits the impression in the lead it will fit the neck of the THE MANDREL SYSTEM. 175 tooth, always proxided the measurement and the impression have been carefully made. " If the collar or band has been accidentally stretched too much, or if, for any reason, when brought to shape, it is too large, its root-end can easily be reduced to the proper size by the use of the contractor. Place the edge of the collar which is to fit the root in the proper hole ; hold it level with a piece of file, as in taking the lead impression of the ring, and tapping lightly on the file, drive the collar into the plate (Fig. 146), until the proper reduction is made. The collar is next ' festooned ' to correspond to the shape of the maxillary ridge. Fig. 147- Fig. 148. Lay it, gum edge up, on the lead anvil, and with the piece of flat file and the hammer drive it into the lead. A few cuts with a half-round file across the proximal diameter will con- form the edges to the surface of the ridge (Fig. 147). Then place the collar in position, and having ascertained just how far it should go down on the root, remove it, and with the small spring punch on the collar-pliers form projections on the inside of the band at the proper points to serve as stops, which resting on the top of the root will prevent the collar from being forced further down upon it than is desirable *(Fig. 148)." * Cosmos, XXVIII, 478. 1/6 OPERATIVE DENTISTRY. This collar may support a porcelain crown or an all-gold cap, and upon these, for abutments, a bridge may be adjusted if needed. Crown with Metal Post without Band. — The crown Fig 149 shown in Fig. 149 is simple, easily made, and when well adjusted, perfect in appearance. For this crown the root should be cut off a little below the margin of the gum, and hollowed to corre- spond to the festoon. This may be done with an oval file, or better, with engine burs, barrel or round. Drill the canal as before described, insert the wire for the post, and cut it off so that it projects one-eighth of an inch. Take a piece of platinum plate about the size of the end of the root, thickness No. 33, place it over the end of the root, and with the finger obtain the imprint of the wire. Punch a hole in the plate large enough to admit the wire, place it over the pin on the root, and with burnishers bend to the form of the end of the root. Remove plate and pin together and fasten with strong wax, replace on the root to insure accurate position, remove carefully, invest in mixture of equal parts plaster and sand or pumice stone. Warm the piece slightly and remove the wax, or use boiling water. When dry, solder with 20-carat solder, using only enough to unite the two pieces, then insert and burnish every portion to fit the root. The outline of the root will be marked upon the plate ; remove and cut away to the exact size of the root. Reinsert, and be sure that the labial edge of the root is short enough to allow the margin of the gum to completely cover the joint, and with No. 2 modeling composition get a correct impression of this and the adjoining teeth. Place the cap in its position in the impression and make a plaster model. Grind a tooth, previously selected, of proper color and form to fit this model. Fasten the tooth to the cap with strong wax and try in the mouth to prove the position and occlusion, then invest, back the tooth with No. 28 22-carat gold plate, and solder and finish. Barb the pivot wire with a sharp knife, and the piece is ready for insertion. iiiE i,()(;an ckown. 177 Protect the root from moisture, dr)- the canal thorouglily, and in it place a moderate amount of easy-working gutta- percha. Hold the pin in the flame of the alcohol lamp until it and the tooth are quite hot, then carry it slowly and firmly to place. The hot pin softens the gutta-percha and the firm pressure expresses the surplus. When cool, cut away the sur- plus with a sharp instrument, and smooth the edges with chloroform or oil of cajeput. Oxyphosphate of zinc also makes a good setting for these crowns. The Logan tooth-crown is porcelain, with the post baked Fici. 150. P"k;. isi. Fig. 152. Fig. 153- into the end of the crown. The post is widened at the cervical portion. Dr. W. Storer How gives the following illustrated descrip- tion oC the best methods of mounting them ; — the root is presumed to be suitably prepared. Fig. 150 shows a superior right central root, an end appear- ance of the same, and a Logan crown, front view. Fig. 151 exhibits, at a right angle to the plane of the first figure, the same root, its end; and the Logan crown, side view. In both figures the pulp-canal is supposed to have been first drilled to a gauged depth with an engine twist-drill, No. 151, and then 178 OPERATIVE DENTISTRY, enlarged by means of a fissure-bur, No. 70, to the tapering form shown ; the walls being subsequently grooved with an oval bur, No. 90. The enlarged section, Fig. 152, shows the crown adjusted on the root by means of cement or gutta- percha, which surrounds the post and fills all the spaces in the root and crown. Fig. 153 shows the completed crown. Fig. 154 exhibits a bifurcated bicuspid root, its end appear- ance, and a Logan crown adjusted to the root. Fig. 155 Fig. 154. Fig. 155. Fig. 156. III 1 ! Fig. 157. Fig. t = Fig. 159. Fig. i6j. Fig. i6i. illustrates the best manner of bending the post. Fig. 156 shows a split post, and its adaptation to a bifurcated bicuspid root is seen in Fig. 157. Figs. 158 and 159 exhibit the mode of mounting the Logan crown on a superior molar root, and Figs. 160 and 161 the same crown in its relations to an inferior molar root. The suitable preparation of the bifurcated roots of some bicuspids and of all the molars is a matter involving difficulties THE LOGAN CROWN. 1 79 of an unusual cliaractcr and rcquirinj^ ^food jud^nnent. The feasibility of splittin^tj the post of a Loj^an crown to adapt it to the bifurcated root of a bicuspid is shown by Figs. 156 and 157. Tliis example directs attention to the peculiar shape of the new post, in which there is effected such a distribution of its metal tiiat its greatest strength is in the line of the greatest stress that will in use be brought to bear on the crown, while the least metal is found at the point of the least strain ; the applied part of the post being in outline nearly correspondent to that of the root itself The pulp- canal is likewise conformably enlarged to receive the largest and stiffest post which the size and shape of the root will permit. The fitting of a Logan crown to a root is best done by the use of a wet stump wheel in the engine hand-piece, a method which affords the greatest facility for the slight touches required to abrade the thin cervical borders of the crown, which may by this means be done without encroachment on the post. The recess in the Logan crown provides a receptacle for a considerable interior body of cement that will be deep enough to be self-sustaining internally, and yet allow the peripheral portions of the root and crown to approach each other so closely that, though only a film of packing remain, it will still be strong enough to insure the persistent tightness of the joint. This annular boss if formed of amalgam also adds strength in some cases to the mount. When enough of the natural crown remains, it is well to leave standing some of the palatal portion, and cut the root under the gum margin at only the labial part, as shown by Fig. 164. Thus the labial joining of the root and crown will be concealed, and the other parts of the joint will be accessible for finishing and keeping clean. The Logan crown may be ground until a large part shall have been removed for adapta- tion to the occluding tooth or teeth without serioush' impairing its streniTth. This crown also in such cases maintains the l80 OPERATIVE DENTISTRY. translucency which is one of its pecuhar excellences, owing to its solid porcelain body, and the absence of a metallic backing or an interior largely filled with cement or amalgam. The distal buccal root of the natural superior molar is nearly always too small to receive a post of any useful diameter, and therefore the Logan superior molar crown has but two posts, which like those of the inferior molar crown are square, and thus may be easily barbed, as may also the ribbed posts of the crowns for the anterior tooth-roots. These posts are large enough in all the Logan crowns to answer in any given case, and can of course be easily reduced to suit thin or short roots. Any of the cements or amalgams may be used in fixing these crowns, but good gutta-percha, softened at a low heat and quickly wrapped around the heated crown-post, which is at once seated in the root, forms the best mounting medium, and has the great advantage ^f permitting a readjustment, or if need be the ready removal of the crown by grasping it with a pair of hot pliers or forceps, and holding it until the gutta- percha is sufficiently softened. An excellent combination for some cases is accomplished by fitting a narrow seamless gold collar over the neck of a root prepared like that of Fig. 155, and then adjusting and mounting a Logan crown in the manner described above, with the result shown by Fig. 164. This collar combination is available in very difficult cases, as for instance when a root is de- F,c. Z62. Fig. 163. f:g. 164. ^^yg^ f^j- bcncath the gum, as seen in Fig. 162. Such an operation when completed would appear in vertical section like Fig. 163, and a view in perspective would resemble Fig. 164. The collar is also very useful whenever the root and crown are not flush and smooth at every point, as, if possible, they should always be made. In all cases it is of great importance that the root should THK TARMLV BROWN CROWN. 18I be thoroughly dried with alcohol, or ether and hot air, in order that the cement or gutta-percha may if possible adhere to the walls of the root to exclude moisture and insure the Fic;. 165. Fig. 166. Fir,. 167. Fk;. 168. Fi<;. 169. stabilit}' of the crown ; the stiff post of w hicii will successfully resist any normal .,^ strain, as is made obvious by the enlarged II \ views which in Fig. 165 exhibit the struc- I ture and relative capacity for resistance / inherent in this form of post.* / The Parmly Brown Crown. — Fig. 169 is a lateral view of a porcelain crown with a platino-iridium pin baked in posi- tion. The pin has great strength at the neck of the tooth, where the strain is greatest, the porcelain of the tooth ex- tending upon the pin, to increase the strength. Fig. 168 is a front view of the same crown, showing by dotted lines the form which the metal occupies in the crown to increase the strength of the attachment and prevent the pill from approaching the surface in thin teeth. Fig. 167 is a view of the two-pin bicuspid crown, which affords a pin for each root of a two-rooted bicuspid, the staple form of the pin shown, by dotted lines, being a feature of strength. * Cosmos, xxvui, 500. l82 OPERATIVE DENTISTRY. Fig. 1 66 is a view of a bicuspid crown with the two pins pressed together, making a single pin for the one root. The double pin in the bicuspid crowns prevents the loosening of these teeth by the rotary movements of mastication, which, by means of the two cusps exert such leverage as to turn and break down the ordinary crown where only one pin is used." * The Collar Crown. — " The process to be described reduces destruction of tooth-substance to the minimum. Instead of cutting the palatine wall of the tooth down to the gum-margin, the greater portion of it is carefully conserved, its presence, while not indispensable to a successful result, being in the highest degree desirable. How much of this portion of the Fig. 170. Fig. lyr. tooth can be retained will depend upon the nature of the occlusion. " In Fig. 170 the dotted line from C to D represents the point to which the tooth is cut away in the older methods of ' pivoting ;' the dotted line from A to B, the line of abscission practiced by the writer. "As will be seen by reference to Fig. 171, the face of the tooth thus prepared presents a gradual slope from the palatal surface to the labio-cervical margin. At the latter margin the root should be cut down with suitable burs, etc., to a point a little beneath the edge of the gum, in order that the porcelain * Cosmos, xxvHi, 583. THE COLLAR CROWN. I 83 tooth in front may pass up under the gum-mar<^in and tlie joint between root and tooth be concealed. At this point tooth-substance may be sacrificed, as it does not materially diminish the strength of the root. " The several parts employed in making the collar crown are a plain-plate porcelain tooth or facing, a platinum-iridium retaining-pin, and a backing, base-plate and collar, made either of platinum, pure gold, or twenty-two carat gold, either metal being made in thickness about No. 30, American gauge. When j)latinum is used coin gold or twenty-carat gold, alloyed with copper or silver only, should be employed as a solder and covering. Twenty- carat gold may be used as a solder when pure gold is employed, while eighteen-carat gold will solder the twenty -two-carat plate. " In shaping the pulp-canal for the reception of the rctain- ing-pin, care should be taken not to weaken the root by an unnecessary enlargement of the caliber of the canal. The platinum-iridium pin need not be more than No. 14, American gauge, in thickness at its point of greatest diameter near the free surface of the root, where all the strain, if an)', falls : from this point it should be made a gentla taper correspond- ing to the natural shape of the space it is to occupy. Half an inch in length is ample ; even less will serve. "The retaining-pin being shaped and adjusted in the root, care being taken to leave an excess in length at the free end for convenience in subsequent manipulations, the next step in the process is the making of the base-plate and its attachment to the pin. A strip of platinum or gold of suitable size is pressed upon the face of the root with broad-pointed, serrated instruments until it is in close adaptation to the surface at every point. This base-plate is allowed to project beyond and o^>.'crha)ig\}[\^ palatine portion of the root, but should not come quite to the labial edge. " Adaptation being secured, an opening is made in the base- plate where it covers the pulp-canal, through which opening the retaining-pin may be pressed up into position in the root. 184 OPERATIVE DENTISTRY. Pin and base-plate are then removed from the mouth, dried and cemented with a brittle resinous cement, and then, while the cement is still plastic and yielding from heat, placed again in position in and upon the tooth, and perfect adaptation secured. Then, while still in position in the mouth, throw upon the cement a stream of very cold water, so that it may be made brittle and incapable of bending. Then remove from the mouth and invest in a mixture of equal parts of plaster and pulverized marble, with enough water to make a thick paste. After this investment has set, solder the retaining-pin and the base-plate together. " To make the collar, a somewhat crescent-shaped piece of platinum or gold of suitable size is prepared and pressed into shape upon the palatine and palato-proximal face of the tooth ; little slits may be cut in the collar with a delicate pair of scissors, to make easier this adaptation ; care should be taken not to push the collar up under the gum at any point, pro- vided the palatine wall of the tooth, which had been allowed to remain standing is at all ample in height — say one-tenth of an inch ; if less than this the collar may pass under the gum for a short distanoe, as will be shown subsequently. In the average case this collar will not quite one-half encircle the tooth. Fig. 172 shows the collar curved to the outline of the gum- margin and shaped to the contour of the palato-proximal wall of the tooth. At G are the slits cut in the platinum to allow overlapping in shaping to contour. " In order to strengthen the collar and facilitate its attach- ment to the base-plate, cut a series of slits in that portion of the base-plate which has been made to project beyond the palatine wall of the tooth, and the base-plate, with its now attached pin, being placed with the collar in position in and upon the tooth, the little strips of metal into which the over- hanging edge of the base-plate has been cut are pressed, one after the other, down upon the collar, and carefully moulded to its surface, so that the collar will no longer consist of a THE COLLAR CROWN. 185 single thickness of metal, but will be reinforced by these additional thicknesses of base-plate thus pressed upon it. " Fi^. 173 shows this cjuite perfectly: H is the free end of the retaining pin which is to be cut off when the porcelain tooth is mounted. I is the base-plate, with its overhanging palatine margin cut into strips, J, which are being pressed down upon the collar, F, by the broad-surfaced and serrated instrument, K. This being accomplished, remove the several pieces from the mouth, carefully cement the collar in its proper position relative to the base-plate, which will now form a sort of matrix for it; again place in the mouth, readjust, harden the cement, remove from the mouth, invest as before, and solder the collar and base-plate together, using a considerable Fig. 173. Fig. 172. Fig. J74. excess of solder for covering, so that the collar may be still further strengthened and its surface be made uniform. " In cementing the collar to the base-plate, one precaution is imperative — namely, not to allow a film of cement to get between the collar and the tooth. If this is done and the investment poured in upon this film of cement, the latter will immediately burn out as soon as heat is applied, leaving a space between the collar and the investment into which the gold solder will flow, and thus interfere with that perfect adaptation of the appliance to the tooth which is necessar)' to a successful result. " The mounting of the facing next demands attention. As 13 I 86 OPERATIVE DENTISTRY. already stated, a plain-plate porcelain tooth is used. This .must have what are technically known as cross-pins ; that is, pins placed at right-angles with the long axis of the tooth. They must also be placed well up toward the cutting edge. If they are too near the neck, they will inevitably be cut out in fitting the tooth to the slope of the base-plate on which it must be mounted. " Fig. 174 shows the form of the facing, and indicates the slope given it in fitting. The fitting process does not differ from that ordinarily employed with porcelain teeth ; an impression may be taken and the work done on a cast, or the facing may be fitted to the mouth. In either case it is in the mouth that the finer and final adjustments as to height, con- tour, alignment, etc., must be perfected. " This being done and the facing backed, tooth and breast- plate are cemented together, restored to the mouth, finally adjusted, removed, and soldered as before, as much gold being flowed into the angle between the backing and the base-plate as occlusion will permit. " This artificial crown being properly finished and cemented into position in and upon the tooth, makes what the writer, from several years' experience in its use in a large number of cases, has found to be an appliance which will remain for an indefinite period without the slightest deviation from position and alignment, and which, in many respects, is almost as. strong as the natural tooth, because its point of greatest resistance to pressure is placed where Nature anchors her enamel walls — namely, upon the outside and not upon the inside of the walls of dentine, so that in the act of occlusion the force applied by the lower incisors as they come up in position inside the upper incisors falls upon the ivJiole thick- ness of the root through the collar, and not upon less than half its thickness through a centrally-anchored pin — a pin, too, prolonged into a lever of enormous power by jts attachment to the porcelain tooth. " In this respect there is a manifest weakness in all methods THE COLLAR CROWN. 187 of mounting artificial crowns which depend for their stabihty solely upon the central pin. Ultimate failure throu<^h splitting of the root is the frequent result, and the larger and stronger and more deeply anchored the pin the more certain this result, because a large pin necessitates a large opening for its re- ception, and a corresponding weakening of the root, upon which the strain must ultimately fall : the lever is strengthened and the point of resistance weakened. " The only safety for the usual form of ' pivot-tooth ' is, either that the occlusion shall be slight, the root very strong, or the ' pi\'ot ' very flexible or elastic. This elasticity of the old hickory * pivot ' was one of its chief excellences ; roots were much less likely to split than with a rigid, unyielding metallic pin. In cuspids or incisors, however, metallic pins, unless enormously large or thickly packed around with amalgam, will very often bend outward, thus allowing a slight displacement forward of the artificial crown, and to that ex- tent relieving the root from strain. "Fig. 175 gives a sectional view of the collar-crown in posi- tion, the lower incisor being in occlusion. L is the . . . . Fig. 175. porcelain facing. H is the pin attached to I, the base-plate. M is the backing and solder. N is the lower incisor, and F the collar. It is clearly evident that here the force of occlusion falls upon the palatine wall of Ijie natural tooth at O, through the collar F, and not upon the pin at the point of its attachment to the base-plate H, and through the pin upon the thin outer shell of the root. " In cases frequently met with, where the en- tire crown of the tooth has been removed, the collar, as before described, can be adapted to the palatine face of the root, provided the latter be not decayed away up to the alveolar margin. Usually, however, there is a considerable space between the I 88 OPERATIVE DENTISTRY. free edge of the root and the alveolus, and here, running up to the alveolus, the collar must be placed. " The dotted line E in Fig. 171, p. 182, indicates a collar so placed. All the steps in the process are essentially the same as before described. Adapting the collar to the surface of the root beneath the gum is somewhat painful, but not excessively so, and in the wearing the irritation caused by its presence is very slight and transient in character, assuming, of course, that care has been taken to leave upon it a smooth, thin, and well-polished edge. " The objection may be urged that this form of crown re- sists pressure only in one direction, from within outward, and does not provide for lateral pressure or pressure from the front. As a rule, the latter can occur with any force only as the result of accident, while if the crowned tooth is in normal relation with its fellows, and the artificial crown be closely fitted between them, they will fully sustain lateral force. " When such lateral support is wanting, through isolation of the tooth, the collar must be extended into a ring or ferrule completely encircling and grasping the root, and thus affording support on all sides. The ring, however, is more troublesome to make and more painful to apply, and generally shows a line of gold in front. In the average case the simple collar gives all requisite strength. " In mounting crowns upon bicuspid and molar roots, how- ever, the ferrule principle is often essential to stability; especially is this true of lower bicuspids and molars ; as here the forces applied in mastication are as erratic in direction as they are powerful in character, and the root must be guarded at every point against their violence. " In fixing in position the artificial croMais just described, the writer prefers to use a gutta-percha cement, adhesive in character, which will not strip from the pin when the crown is forced into position. THE COLLAR CROWN. 1 89 " The apical foramen is closed, the pulp-canal ^n-oovcd and thoroui^hh' dried, the central pin is barbed, and the pin and inside of the collar and under surface of the base- plate are thickly coated with gutta-percha ; the entire appliance is then heated to a temperature sufficient to thoroughly soften the gutta-percha, and firmly pressed up into position ; the excess of gutta-percha will ooze out at all free margins, and may be subsequently removed with suitable instruments. " A good gutta-percha cement will hold firmly in a great majority of cases, but when, as in a small lateral incisor, the retaining-pin is necessarily small and short, and the collar not as ample as could be desired, an oxychloride or oxy- phosphate cement, mixed thin, will be found to give greater stability. When these cements are used, however, it will be found very difficult to detach the artificial crown from the root, should it for any reason become necessary to do so ; whereas, a little heat will quickly soften a gutta-percha packing and permit the entire appliance to be withdrawn without difficulty. " There are various methods of mounting artificial plate teeth in natural roots, in which the dowels are used simply as a means of holding the tooth in place while gold or amalgam is packed into the root and built up to form the palatal surface of the fixture, this being mainly relied upon to support the tooth in position. " These operations, especially if done with gold, are exceed- ingly difficult and tedious. When we consider this in connec- tion with the fact that in case the porcelain crown is accident- ally fractured, there is no way of repairing the injury without destroying all that has been done, and redoing it, I consider them of doubtful value. " The probability of accident is always present ; I there- fore regard facility of repair as practically an important consideration in estimating the relative value of any 1 90 OPERATIVE DENTISTRY. method of replacing, by artificial substitutes, these im- portant organs." * The Bonwill Crown. — " This consists of an all porcelain crown with a hole through it and countersunk in the outer surface, Fig. 178 and 179 showing the molars. " Fig. 176. Sectional view of an incisor crown as now made, from mesial side, showing the under-cut at the point opening on palatal surface, the conical base and the opening from the same to the retaining grooves, with the exact relations. " Fig. 177. Palatal view of the same tooth : a is the external opening for egress of alloy and for packing around the piri ; the dotted hnes around a show the recess or under-cuts on the mesial and distal sides and near the point, for retaining the crown, and its relation with the conical base. Fig. 179. " Fig. 178. Grinding-surface view of a superior molar, with the countersunk pin holes on the buccal and palatal sides. "Fig. 179. Same view of an inferior molar with the pin- holes on the mesial and distal sides. " Fig. 180 and 181. Sectional view of a molar and bicuspid crown, showing the countersinks and their relations with the conical base. "Fig. 182. Sectional view of an incisor root, showing the retaining cuts made by the wheel bur shown in Fig. 189. " Fig. 183. End view of a canal prepared for the improved combination metal-pin. *" Am. Syst.Dent.," 11, 807. THE DONWILL CROWN. 191 " I'i^. 184. End view of same canal as in Fi^. 183, prepared for a triangular pin, showing how nuich more of the mesial and distal surfaces have been cut away from it than in Fi^. 183 for the improved pin. " Fi<^. 185. Sectional view of an incisor crown and root, w ith the improved pin in its relative position to each, with the depressions made by wheel bur. " Fig. 186. Sectional view of a superior molar, with the large angular pin in palatal root and two square pins in the buccal roots, one being shorter and not passing through the crown. "Fig. 187. Block of a molar and bicuspid, showing the countersunk holes for pins in the molar and the hole in the Fig. 183. ©c Fig- 184 Fig. 185. Fig. 186. Fig. 187. Fig. 188. Fig. 18 mesial side of the second bicuspid where a pin is alloyed in and set into a decayed cavity in the distal surface of the first bicuspid, being held upon the molar roots and attached to the bicuspid by the alloy. " Fig. 188. Side and end view of the largest size angular combination metal pin with the stamped serrations. The square pins are without serrations and double pointed, made of same metal and of equal thickness throughout. All the pins as now made are without serrations and of double thick- ness. "Fig. 189. The smallest-sized wheel-bur for grooving the canals for anchoring the pin and alloy. No need of more than one wheel on each shaft. 192 OPERATIVE DENTISTRY. " The pins are made of platinum-iridium alloy, and barbed, to hold more firmly. " Later pins of hard metal, an alloy which will amalgamate. These do not need to be barbed, and can be pulled out more easily, if need be. " The natural tooth is cut and ground off a little below the margin of the gum. The porcelain crown is then ground to fit the surface of the root and the occlusion of the opposing tooth. " The root canal is enlarged, and the pin of proper size adjusted to it. " The pin is cut the right length and bent, if need be, to sup- port the crown in position. The walls of the canal are grooved with a wheel bur, as shown in Fig. 182. " To set the crown the canal is partially filled with amalgam and the pin forced to place with a pair of pliers ; then addi- tional amalgam is packed around the pin until the canal is full. Then cover the pin with soft gutta percha to protect the tongue, and dismiss the patient. " At a subsequent sitting the crown may be set, placing some amalgam on the root and forcing the crown to place, and packing additional amalgam around the pin through the hole in the crown, and filling the countersink. Smooth off the amalgam at the joint under the gum, leaving it just flush. " A quick-setting amalgam made purposely for it is the most suitable, and should be prepared quite soft. " The color of the amalgam darkens the tooth crown some- what, and often produces a blue line at the joint under the gum. " The use of oxyphosphate cement avoids this, and also sets the crown very firmly. In case the root is frail, a band may be fitted and put on, and the crown fitted into it. It, in such cases, adds greatly to its strength." * * "Am. Syst. Dent.," n, 813. THE HOW CROWN. 1 93 Figs. :qo, 191, k 192 Fig. 193. Fig. 194. Fig. 195. Fig. 196. Fi(;s. 197, 198, 199, k joj. iJ IJ an 1 The How Crown. — The How artificial tooth- crown is described by Dr. W. Storer How as fol- lows : — " I. When the root is in proper condition for mounting, measure the depth of the canal by means of the canal plugger (Fig. 190) and its flexible gauge (Fig. 192), and fill the canal at and a short distance from the apex of the root, keeping the gauge at position to show the full length of the canal, and also the distance to which it has been filled. " 2. Cut off the root-crown with excising forceps, No. 31, and a round file, down to the gum margin, and, with barrel bur No. 241, cut the labial part of the root fairly under the gum without wounding it. " 3. Set gauge (Fig. 192) on a Gates drill (Fig. 191) to one-half the gauged depth of the canal, and drill to that depth. " 4. Set the twist drill (Fig. 195) in its chuck (Fig. 199) to project the same length as the Gates drill, and turning the chuck with thumb and finger, drill the root to exactly that depth. " 5. Enlarge the mouth of canal one-sixteenth of nch deep all around to near the margin of the root, using 194 OPERATIVE DENTISTRY. square-end fissure-bur No. 59, and then with oval, No. 94, under-cut a groove at sides and hngually, as shown in Fig. 196. " 6. If the rubber dam is to be used for a gold or plastic backing, put it now over the root with Hunter's root clamp, also over the adjacent teeth, and thoroughly dry the canal. " 7. Set the tap (Fig. 197) in its chuck (Fig. 200) a trifle less in length than the drill, and carefully tap to the gauge depth. " 8. Insert the post in its chuck (Fig. 198) to the exact gauge of the tap, and turn the thumb-screw down hard on the end Fig. 201. Fig. 204. Fig. 207. of the post ; then screw the post into the root, release the thumb-screw, unscrew the chuck a half turn, bend the post until the chuck stands in centre line with the adjoining teeth, and unscrew the chuck. ' "9. Slit the rubber back from adjacent teeth, tucking the flaps out of the way, so that occlusion may be tried, and the post excised and ground off until the teeth close clear of the post. " 10. Try the crown on the post, and with an F disk, dry, THE HOW CROWN. 1 95 grind the rib between the neck pins until the crown is labially flush with the root margin, cutting a Httle at a time until exactly flush. "II. Take the crown and place the mandrel (Fig. 201) between the pins just as the post is to be, and with the pliers (Fig. 202) bend the pins carefully over the mandrel, cutting off" the pins if too long to be pinched in on the mandrel at the sides, observing that the pin nearest the cutting-edge is first to be bent (Fig. 204), and the opposite pin bent below it on the mandrel, and so with the others (Fig. 205). " 1 2. Slip the crown over the post, try occlusion, and with the post-chuck bend the post until the crown is properly aligned with the teeth ; then with a stump corundum wheel No. 3 grind the neck of the crown to a close labial fit with the root, fitting only the portion to be concealed by the gum, leaving narrow gaps at the sides to be filled by the backing between crown and root (Fig. 206). " 1 3. Grind cutting-edge for relation to the other teeth, being sure that opposing tooth does not strike crown, or post, or pins. " 14. Fix crown on post by pinching the pins into the screw- threads of the post with special pliers. (Fig. 202 or 203.) " 15. Finally, pack the backing of gold, or cement, or amal- gam, or — for temporary backing while treating abscess — gutta- percha, into all the crevices around the post and behind and under the pins, and between the crown and the root ; contour and finish thoroughly, so that no ledge or other imperfection can be found. " Fig. 207 shows in vertical mid-section an incisor crown mounted ; the blackened portions of the backing defining the locking-hold of the backing on the post, the crown-pins, and the root recess. " Fig, 208 shows in perspective a cuspid crown ready to be slipped over its post, and also a cuspid crown ready for its post in the bicuspid root, which has its lingual cusp remaining. 196 OPERATIVE DENTISTRY. and Fig. 209 shows the crowns on their posts awaiting the contour-backing. " In mounting a crown on the bicuspid root (Fig. 208), the chucks will not pass the natural cusp, and hence both the drill and the tap must project the cusp's length in addition to the gauge length. Observe also if the space between the tap and the cusp is wider than the thickness of a crown-pin, and if not cut the cusp vertically with a large fissure-bur, so that the space shall be wide enough before setting the post, else the bent pins will not pass between the post and cusp. Grind the rib — see step 10 — quite down to the floor of the crown; take steps II, 12 and 13, and if the occlusion necessitates grinding the Fig. 208. Fig. 209. crown so as to destroy one pair of pins, invest the crown, and solder the pins at the lap, taking step 15 for completion. " When it is desired to contour the backing of a cuspid crown to form an inner cusp, or to adapt a cuspid or incisor crown for masticating uses, the pins may be twisted together over the mandrel, and again twisted tightly over the post, as in Fig. 210; but in some cases it maybe better to bend the neck-pins, as in Fig. 21 1, instead of twisting them. In all cases the bent pins are to be pinched quite hard over the mandrel and post, so that the serrations of the pliers will roughen the pins, to prevent their being pulled through the backing, which should also be condensed around the pins and po.st. " If the root is not ready for permanent mounting, use a THE HOW CROWN. 197 tubular post, or in the absence of a threaded tube, take the successive steps up to 13; then back temporarily with wax, rubber, or gutta-percha, awaiting the next sitting, when the crown may be taken off, the post unscrewed, and the remedy applied. Thus the root may be alternately medicated and mounted until ready for the permanent crown. " When the root is much decayed, the bottom of the cone- shaped cavity may be drilled and tapped to the depth of a sixteenth of an inch, and the post, thus anchored, may be further secured by cement in the grooved walls of the cavity and around the post (Fig. 212). " TheSe crowns afford unusual facility for mounting by any Fig. Fig. 211 Fig. 212. Fig. 213. of the well-known methods of inserting the post, after solder- ing it to the crown. They are also adapted for use in cellu- loid and rubber work, especially in cases of single teeth. The several long pins, having their ends bent with pliers at a sharp angle (Fig. 213), may be so arranged as to both strengthen the shank of the plate and hold the crown very firmly in position. " The screw-posts are made of crown metal, an alloy devised for the purpose in order to obtain a stiff post that will permit the cutting of the peculiar and extremely accurate thread formed upon it, and which will not amalgamate or be other- wise affected by any backing-material that may be used. Of 198 OPERATIVE DENTISTRY. course platinum or platinum alloyed with iridium may be employed for posts, but the crown metal is in every way superior. " There are some cases of a class which has hitherto pre- sented difficulties that may not be easily overcome by grind- ing the post flat on the crown side after it has been set and bent in the root (Fig. 214), so as to be clear of the occluding tooth ; and then the crown-pins may be bent over the reduced post, the crown fitted and ground to clear the opposing tooth (Fig. 215), and the backing added. "A similar case, in which the opposing tooth and a proper Fig. 214. Fig. 215. Fig. 216. Fig. 217. Fig. 21 alignment require an oblique bending of the pins, is seen in Fig. 216, while the reverse arrangement of parts is shown in Fig. 217. The crown is thus seen to be adapted to a wide range of adjustments because its point of contact with the root is at the labial portion of the neck, on which as on a hinge the crown may be swung out or in (Fig. 218, dotted lines), over an arc of at least sixty degrees, at any point of which it may be quickly and firmly fixed. The labio-cervical junction is made just under the gingival margin, and I usually interpose a thin layer of cement, amalgam, or gutta-percha, or a narrow ribbon or several large blocks of soft gold; the joint always I5ALDWIN S CROWN. I99 to be made smooth, and hid from view under the free margins of the gums. " The obviously great advantages of such a plan led to the adoption of a single size for post and appliances, but a second size has been proved to be a necessity, and hence the B size is now designed for superior centrals, and cuspids, while the A size is used for laterals and bicuspids, as also for all the inferior roots anterior to the molars. The handles of the tap-chucks and post-chucks are made of small diameter to insure that too great force shall not be used with the thumb and finger in turning in the tap and the post; and it is enjoined upon the operator to remove the tap when it begins to turn at all hard, and repeat the removal until it has been easily turned down to the gauge depth. The cuttings must then be care- fully blown or wiped out, so that the post may be easily turned down to the bottom of the hole without risk of splitting the root, as there is danger of doing with too great force acting on the debris as a wedge — hence this caution to employ only a reasonable amount of force and to do thorough work. The disk for grinding the crown-rib is an essential part of the equipment, and when the engine is not at hand, may be used in the lathe by means of lathe-chuck No. 8." Baldwin's Crown. — "The modus operandi is as follows : Select a Logan crown slightly shorter than would be used for setting without a ferrule. Countersink, and prepare the inside of a root as for a Bonwill or any ordinary crown. If the out- side of the root at the margin of the gum presents an irreg- ular surface, then with Dr. Walter Starr's reducers shape it to such a size that the ferrule may be perfectly adapted to all parts. Then take an impression, and produce in zinc or Bab- bitt metal a die, to form which take a plaster model of the root end an eighth of an inch long, and shellac it to the point of a cone, which can be easily made by turning down a large spool, thus making the deep mold in sand, into which the metal is poured. With this die strike the gold (twenty-two carat, No. 30 gauge, is most commonly in use) laid upon soft lead. A 200 OPERATIVE DENTISTRY. few blows will produce a seamless and perfectly-fitting cover and ferrule. After trimming this to fit the festoon of the gum, drill in it from the lower side a hole for the pin of the crown, leaving the ragged edge produced by the drill. Then fill the countersunk portion in the porcelain crown with oxyphos- phate of zinc, and with the gold ferrule or cap in place adjust the crown as you would wish it when completed. When the oxyphosphate is hard, you will find the ragged edge on the upper side of the cover will materially aid in removing and keeping the cap where it belongs. Unite the cover to the platinum pin in the crown with a small amount of soft solder Fig. 2ig. Fig. 221. Fig. 220. g\ — tin and lead — using muriate of zinc as a flux, a few blasts from the blowpipe being all the heat required. Then fill the root with oxyphosphate and firmly press to place. These caps might be made up at leisure, providing a few variations for double and single-rooted teeth. When a case is met that you cannot fit from your stock, choose a cap larger than the end of the root, and with a single clip of the shears cut to the centre of the cap, and with pliers spring together and lap the edges until the size required is obtained. Solder with gold solder by holding over the spirit lamp and proceed as before. Fig. 219 shows a root cover and Logan crown ready to be low's crown. 20 1 assembled for the soldering of the crown-pin to the cover; Fig. 220 shows the cap cemented and soldered to the crown ; and Fig. 221 the completely crowned root." * Low's Crown, — In our first cut, Fig. 222, we present seven instruments. No. i, the smallest, will be used most frequently. * Cosmos, XXIX, 19. 14 202 OPERATIVE DENTISTRY. Any tooth generally considered beyond restoration can be crowned with this instrument. " We now have before us in Fig. 223 a central incisor badly decayed. There is little tooth-substance exposed below the margin of the gum, the little remaining being the outer walls. The first step to be taken to place on this root a strong and serviceable crown is to cut or grind even with the gum what tooth-substance remains. We start off with the supposition that the root is in a healthy condition ; if not, it must first be treated and made so, as this is*the first consideration in the final result of a successful operation.' The next step is to select the instrument in accordance with the size of the opening in the root to be crowned. The larger the opening in the root the larger the inside or centre cutters must be, and the narrower the cutters that bevel and prepare the end of the root. The reason for this is that the space is nearly all taken by the inside cutters in order to reach and cut away the decayed tooth-substance, and prepare the root to properly receive the step-plug with bevel cap which covers the end. " We have seven sizes of instruments, and if the right one is selected, no tooth-substance will be removed that ought not to be, cutting, as it does, the least where the tooth is smallest, or, in other words, we cut the opening in the tooth tapering to the shape of the root. " These cutters leave the root in the shape of Fig. 224, with graded steps. " We next select the graded step-plug seen in Fig. 225. " This is the same size as the instrument, and will perfectly fit the opening and cover the end in a beveled saucer shape, and by its attachment to the inside step-plug when cemented make a combined union of great strength, and so made as to be impossible for the root to split. Fig. 226 shows the step- plug placed in position. " After placing the plug in position, an articulation of wax and impression of the space to be supplied and of the adjoin- ing teeth are taken in plaster-of-Paris. Before taking the LOW S CKOWN. 203 impression be careful that the pin which extends from the cap of the stcp-plui,f for purpose of removing is free from all rough- ness (a roughness that is sometimes left in the cutting of the plug), as this is liable to break the plaster when removing the impression. I generall}' fill the step-plug on a slant from the labial side to the centre, so that there shall be no mistake in replacing the step-plug in its proper place in the impression. " After placing the plug back in the impression, if necessary, take a thin, heated spatula and stick the plug fast with a little hard wax on the outer edge so that it may not be disturbed in pouring. Fig. 223. Fig. 224. Fi<;. 225. Fig. 226. Fig. 227. Fig. 228. Fig. 229. " Be careful not to get any wax on the part of the plug where you do not want solder to flow in. Now varnish the cast as usual, but do not touch the plug with varnish. Next pour with plaster and sand, asbestos or pulverized pumice-stone, any one of which will do. After the plaster is thoroughly hardened, cut it away in the usual manner. Place the articu- lation in the articulator and pour in the usual way. The tooth is selected, and we proceed to back it in the following manner : First grind and fit the tooth to the cast and cap to suit you ; then cover this entire inner surface with thin platinum, the thinner the better. Burnish close to the surface of the tooth. Then use 28-gauge platinum for a backing down to where the 204 OPERATIVE DENTISTRY. tooth is ground out to fit the step-plug, and bend the pins down to hold the two pieces of platinum tight to the tooth. We now have Fig. 227, representing the tooth as it appears backed ready to place in position. " Next place the tooth in position, in the cast, cover with plaster and sand and solder with coin gold. After finishing and polishing the crown is ready for adjustment. Moisten the step-plug and cap with cement, as in Fig. 228, and with the little roller, seen in Fig. 229, gently press the crown up in position, and we have the crown completed as seen in Fig. 228. " If you desire a cheap crown, solder with block tin. After experimenting with various metals, I have succeeded in mak- ing a step-plug — or tip, as I usually call it — of platinum and nickel, that is as strong as steel, and cannot be melted. " If I perfect the crown myself, I take a shorter way : After preparing the root with the instrument, and placing the step- plug in position, my tooth is selected, ground and arranged in the mouth, after which I back the tooth as before de.scribed. I warm and stick to the backing of the tooth a small amount of sticking-wax, made of rosin, gutta-percha and beeswax, and place the tooth in position in the mouth, perfectly imbed- ding the top of the step-plug in wax. Great care must be exercised to have the tooth in the position desired, and in pressing the tooth and wax against the plug. I next carefully remove the wax and tooth, and with pliers remove the step- plug and place in the impression just made. Then with a heated spatula I stick the tip and wax together, pour in the usual way, and in a few moments it is ready to solder. Thus a tooth can be set easily in one hour's time. " To crown a bicuspid or a molar, your first step is to grind the tooth-substance even with the margin of the gum, and then use your drill. In drilling, instead of following the nerve-cavity direct, which would leave the instrument a little diagonal, hold the instrument perpendicular. This leads the upper portion of the drill to the outer wall of the root and brings the lower portion of the drill to the inner side of the root. LOW S CROWN. 205 " You would puncture the wall of the root if you went deep enough, but there is no need of going to such a depth. Next take No. i cutter, which will invariably be the instrument to operate on all the bicuspid and molar root-canals, and after carefully cutting to the depth desired, the root is ready for the introduction of step-plug of same size. We now drill one other root in the same manner, and after placing the step- plugs in position, take an articulation and impression, remove the plugs and place in the impression, pour and separate and place in the articulator as before described. We have tvith the adjoining teeth an exact impression of the root to be crowned. " Next take a thin piece of platinum and make two perfora- tions for the pins on the end of the step-plugs to enter, press the platinum down over the root and burnish close to it ; then remove and trim by the marks made in burnishing to the exact shape of the root. " Place the platinum on the root again, and we are ready to select our tooth. This should be made the same as is used for bridge-work, with gold cusps, so no breakage can possibly occur. Place the tooth in position in the articulator and hold in place with wax. Encase in plaster and sand, and fill in and solder with coin gold, or, if you choose, block tin can be used. After polishing and burnishing, you have a strong, durable crown, ready to be adjusted, only equalled by the natural tooth. " In setting a bicuspid, we seldom use more than one step- plug, and the process is similar to setting a molar. " Fig. 230 shows the root cut ready to receive the step-plug. Fig. 231 shows us the step-plug with the platinum covering the entire tooth-surface. In Fig. 232 it will be seen that the cap to the step-plug goes below the surface of the tooth, leaving tooth-substance all the way round, but the platinum that is soldered, to the step-plug rests on the tooth-surface. In Fig. 233 we see the crown ready for adjustment. Fig. 234 is the tooth after it has been adjusted. 2o6 OPERATIVE DENTISTRY. " These plugs can be used to great advantage in varied dental operations. There is nothing equal to them for restor- ing broken and decrepid teeth to their original shape, appear- ance and usefulness. I use them exclusively in bridge-work. They make a firmer, stronger and more durable ground- work for bridging than any other method I have ever discovered. " In badly decayed molars, where there is not sufficient tooth- substance to hold a gold crown for a bridge, I always stick one 'of these plugs in the root to constitute a solid foundation. If the pin on the end of the plug for removing is not long enough, it can be very readily lengthened by soldering a piece to it, and this without danger of injuring or melting. The plugs are made of a perfectly non-corrosive metal, Fig. 230. Fig. 231. Fig. 232. Fig. 233. Fig. 234. though the color might indicate otherwise. They are strong as steel, and cannot be melted by any heat from an ordinary blowpipe."* The Improved Richmond Crowns. — " The pivot is baked into the crown. Prepare the root and adjust the tooth-crown to place. Fill the root with cement and insert the pin of the crown, leaving an open joint. Pack amalgam between the crown and root, making a perfect joint. " Another. Combine with the band and cap a tube, which are secured to the root with cement; into this tube the pin of the porcelain crown is cemented with gutta-percha dissolved in ether. This may be used for bridge-work. The supporting *" Am. Syst. Dent.," IT, 905. MERIAM CROWNS. loy roots are fitted with bands, caj).s and tubes the same as for a single crown. "A pin is attached to each end of a bridge-piece, and these pins are slipped into the tubes and cemented with gutta-percha, or ma\- be inserted without cement. Such cases are easil\- removed."* Meriam Crowns. — Dr. II. C. Meriam constructs an all porcelain crown similar to the English tube teeth shown in Figs. 235 and 236. Fir,. 235. Kir.. 7-/. They are much stronger than those customaril)^ used. He sets them in a band which is fitted to the root and crown, and dowels may or may not be used in the root. Gutta-percha or cement may be used to set them. " The band is fitted to the root and the crown ground into the band after proper occlusion with its antagonist has been obtained. If a molar, a fine groove is ground around it, and the band, after being corrugated on its inner surface with a small bur, is placed on a lead anvil and the tooth driven into * Cosmos, XXVI, 369. 208 OPERATIVE DENTISTRY. it, thus partially securing the advantage of union by gom- phosis. The common glass stopper is a good illustration of how little more than its fit would be required to retain it firmly in place. For this little I have drawn on the tube-teeth work- ers of England. A few small pieces of sulphur are then placed inside the band and all held over a small flame until the sulphur melts and flows into the groove between the band and the crown. Zinc phosphate may be used before the crown is forced in, or some flux, borax, for instance, which melts at a low temperature, though this would probably require invest- ing. We then have a crown which, if a molar, I do not fear to attach with gutta-percha without dowels ; but others may not have this confidence, and dowels may either be put into Fig. 237. Fig. 238. Fig. 239. Fig. 240. the roots or be set in the crown with cement, and afterward screwed to their places in the root as usual (Fig. 237). It is evident that if cement is strong enough to hold a dowel, it must be equally serviceable in securing the crown to the dowel. If greater security is desired, a fine platinum or pure gold wire may be fitted into the groove around the crown (Fig.. 238). Drive in as before ; invest and solder (Fig. 239). For the incisors the groove should not run around the anterior face of the crown, and I have not soldered those teeth in (Fig. 240). I have entire confidence in any form for the incisors and bicus- pids where the root is well banded, the dowel put into the centre, and the crown forced into place in gutta-percha (Fig. 241); while for the molars, if quite short I do not care for the MERIAM CROWNS, 209 dowels. You will notice that this method does away with much of the showing of gold in molars where such a result is desired (Fig. 242). " Another form for molars, although it shows more gold than the others, is perhaps stronger. The band is made full width down to occlusion, and any large, strong tooth is ground to fit the space in the arch. This is driven into the band so as to be even with its edge, and cemented with sulphur as before (Fig. 243). " Settini!^. I first xarnish the band inside with Canada balsam dissolved in ether; then fill the crown with gutta-percha and crowd it up against the root several times to get an impression. Fic. 241. Fir.. 242. Fig. 243. When sure that I have the right amount of gutta-percha, I place the dowels in the root (if I am to use them), heat the crown, dip it into cajeput or any essential oil, and crowd it to place. The dowels I fit in the same way, wrapping them with gutta-percha and working up and down in the root until I get the impression before the final forcing to place. I thus have the advantage of the dowel and hard centre of gutta-percha to act as a plunger, and the soft semi-dissolved gutta-percha comes back on the outside of the mass, forming, I think, the tightest root-filling known. I fill roots in this way with gutta- percha points when I do not use a dowel. The dowels used are made by wrapping a piece of platinum and iridium wire with about one-third of a sheet of gold-foil, which is melted 2IO OPERATIVE DENTISTRY. on, and the combination made true by being drawn once through a wire-gauge. A piece of piano-wire is then wound around it three or four times to serve as a guide, and a fine platinum wire, previously drawn square, is caught and turned through the wire-guide a few times, when the winding may either be finished by hand or the end, after being started, may be placed in a lathe-chuck and wound up at once (Fig. 244). A piece of gold foil is then wrapped around the whole and the fine wire soldered on. A dowel made in this manner is not strained by having its thread cut, and the thread being square Fig. 244. and coarse or fine, as you wish, is strong and possesses plenty of grip. " When a root has broken off far under the gum, it should be filled with gutta-percha and a temporary plate worn — if the loss be in the front of the mouth — until it works down, when it may be crowned and the plate given up. " In preparing roots after a large portion of the crown is broken away, I enlarge the pulp chamber with a large, round bur, and, when even with the ffum, follow with the revolving saw here shown (Fig. 245). With this saw I often cut off the THE MATTISON CROWN. 21 I remnants of a crown from the inside without woundin<; the gum or drawing a drop of blood, and am saved the unpleasant- ness of running a stump corundum wheel in the mouth. Fir.. 245. Fig. 246. " The outside of the root can sometimes be formed with the instruments here shown "* (Fig. 246). The Mattison Crown. — "The root upon which the crown is to be mounted should be placed in a healthy condition, with the pulp-canal filled at the apex, the end ground off below the free margin of the gum in front and within an eighth of an inch of the gum on the inner or lingual surface, the end of the root countersunk, and the pulp-canal enlarged sufficiently to receive a platinum wire — No. 18 or 20, standard plate gauge — with a screw-thread cut thereon. This should fit tightly enough to take firm hold. Further, enlarge one-half the length of the pulp-canal with a cone-shaped bur with its base toward the apex, as represented in No. i (Fig. 247). Previous to grinding the end of the root below the gum in front, with fine binding wire take a measurement of the cir- cumference of the root at the marsfin of the crum. Cut across * See Cosmos, xxvni, 493. 212 OPERATIVE DENTISTRY, at intersection, and carefully remove the wire ring thus formed, without changing its shape. Take an impression of its form, by placing it between a sheet of writing paper and a smooth surface, and by rubbing the end of a finger thereon the out- line will appear. This is the outline of the end of the root ; from this cut a pattern. Dissect the gum from the end of the Fig. 247. root up to the alveolar process. Select a die (forms shown in Fig. 247) similar in shape to the root you wish to reproduce. Make a pattern of the shell by pressing between the dies a piece of pattern tin, leaving an opening in front as represented in No. 3 (Fig. 247), the cut being on a line with the edge on one side. Remove this pattern and press into as plain a surface as possible without .stretching the margins. THE MATTISON CROWN. 21 3 "Cut the ^old-and-platinum plate to pattern, making it wider or narrower as the wire measurement of the end of the root compared with the pattern indicates. Anneal and place the plate in the same position between the dies as that previously occupied by the pattern, and press into form ; remove, bring the edges together without lapping and solder with pure gold. The shell may be made longer or shorter, wider or narrower, than the die upon which it was made, as the case demands. 1^'it the shell to the root ; trim the root end of the shell until it occupies its proper position and the articulation is correct, which is determined by the patient closing the teeth. The corners at the cutting edge and sides should be cut and the edges brought together without lapping, and also soldered with pure gold. Then from platinum plate. No. 28, cut the ring, No. 4 (Fig. 247), to the proper pattern. This forms the shoulder within the shell (the opening in the ring may be cut out with a plate punch). Place the shell in position on the root, the teeth closed ; insert the ring, which should rest upon the end of the root midway the width of the band in front, and should fit the shell so tight that both can be removed without chang- ing their relative positions. Remove from the root, and with a fine camel's-hair a'pply borax finely ground in water. At the junction of the two pieces place a small piece of twenty-carat solder on the inner surface, /. e., toward the cutting edge of the shell, to prevent an excess of solder flowing between the shoulder on the end of the root upon which it will rest. Flow the solder, which should merely tack the ring in place at the front. Try upon the root to make sure of its being correct ; remove and complete the soldering. "The shell may be strengthened by flowing inside a lower grade of solder than previously used at such places as desired. "Select a plain rubber tooth and fit it to the opening in the shell (which may be removed for the purpose), and with a corundum wheel and disk grind a dovetailed slot in the back (see No. 5, Fig. 247), running lengthwise, and sufficiently 214 OPERATIVE DENTISTRY. deep to permit the platinum screw to extend two-thirds the length of the crown without interference. " To Anchor the Croivn to the Root. — Place the shell in posi- tion ; apply the rubber dam over it and the adjoining teeth, turning the edges well under the gum; remove the shell; the dam will remain in position. " Dry the pulp-canal, insert the wire screw, cut it off the required length, and with amalgam mixed hard fill around the screw in the root, and covering the end, again replace the shell on the root (the end of the screw should be bent against the inner wall of the shell when the teeth are closed, so as to fall into the dovetailed slot in the porcelain front when that is inserted). Continue the amalgam filling through the opening in the front of the shell, around the screw and over the shoulder, as represented in No. i (Fig. 247) ; and with oxy- phosphate cement complete by filling around the wire and in the slot of the front, which is then inserted and pressed into position between the thumb and finger-, the excess escaping at the edges. " Burnish the edges of the shell around the neck of the root and porcelain front. Instruct the patient not to disturb for from four to six hours." * Dr. Kirk's Crown. — "The root is prepared in the usual manner by carefully closing the apical foramen with gold or gutta-percha, and removing all softened dentine from the canal, which is then undercut or roughened with -a wheel- bur. The apical end of the pulp-canal is enlarged by a drill, and a thread cut in the dentine by means of one of How's drill taps. Only a small portion of the upper end of the canal is so tapped, just sufficient to engage from a sixteenth to an eighth of an inch of the end of the screw-post, as dependence is placed mainly upon the cement lining for anchorage. A collar of 22-carat gold. No. 30, having its edges smoothly bevelled, is accurately fitted to the end of the * " Am. Syst. Dent.," 11, 932. DK KIRK S CROWN, 215 root and driven ti^^htly on to it, until it extends somewhat over one thirty-second of an inch under the J^um. The collar is cut short upon the labial side and left lon^ upon the lin<;u;il side, so that it extends nearly to the grinding surface of the lingal cusp of the finished crown, but is visible only as a nar- row band upon the buccal surface at the gingival margin. " When the band has been satisfactorily adapted in the manner described, a Foster crown, which has been previously adapted to the end of the root by careful grinding, is adjusted inside the root-collar. The crown selected should have a greater circumference than the end of the root, so that by grinding it down somewhat conically on its lingual and proxi- mal surfaces, it can be tightly adjusted to the collar. " If a crown smaller than the collar is taken a tight joint cannot be made. When the crown has been carefully fitted to its place, a tight joint secured, and the proper occlusion obtained, a gold screw with a head upon it, similar to the ordi- nary gimlet-pointed wood screw, is passed through the central opening in the crown, carried up until it engages in the den- tine at the apical end of the root, and driven home with a small screw-driver, and its proper length adjusted so that it firmly holds the crown and band in their proper relations to the root, as seen in Fig. 248. " When all has been satisfactorily adjusted, the screw and crown are removed, and the root-canal, band and surrounding parts thoroughly dried ; the crown is to be permanently 2l6 OPERATIVE DENTISTRY. attached by filling the root full of slow-setting oxyphosphate of zinc mixed rather thin ; the crown is then pressed firmly into its place, when the excess of cement will flow through the central opening in the crown ; the gold screw is then to be pressed through the crown and driven quickly to its seat by the screw-driver, all excess of cement passing out as before through the central opening of the crown and alongside the screw. " After the cement has hardened, all excess is cut from around the screw head by means of an excavator, after which the screw-head is covered and the countersunk opening in the crown filled with gold, anchorage for the fitting being obtained by cutting a groove around the base of the screw-head by means of a small wheel-bur. The completed operation is shown in Fig. 249."* The Leech Crown. — "Prepare the root with a stump corundum wheel, and drill it out three-eighths of an inch in depth, of a diameter of about No. 16 standard wire-gauge, enlarging it at the bottom, as shown in Fig. 250. Now fill the canal in the root with gutta-percha or oxychloride of zinc. Fig. 250. Fig. 251. Fig. 252. Hi make a gold tube to fit nicely the aperture in the root, about three-quarters of an inch in length, so that it can be more easily handled subsequently ; adapt a plate of gold or platinum to the face of the root ; cut a hole in it to correspond to the * " Am. Syst. Dent.," 11, 774. THE STOWELL CROWN. 2 1/ size of the tube ; insert the tube ; set the plate over it ; adjust it to the face of the root ; hold it in position by any suitable cement ; remove the tube and plate and unite them by solder ; insert again in the root, and adapt a plain plate tooth, w ith a j^old backin^f, holdinLj it in position with a little wax or cement. Now remove the tube, plate and tooth to<^ether and solder the tooth in place, as shown in Vlij;. 25 i. Then, with a small sepa- rating file or saw slit the tube in two or more places for about two-thirds of its length ; finish up the back of the tooth, cutting away the superfluous tubing. Now place a thin sheet of gutta-percha on the upper surface of the plate — that which is adapted to the face of the root ; warm the tooth and plate over a spirit lamp, and press it up against the root. The gutta-percha will thus hold the artificial crown temporarily in position, and, covering the whole face of the root, make a per- fect joint, shown as completed in Fig. 252. With a straight plugger fill the tube with gold or tin foil, condensing it so as to spread the split tube to correspond with the cavity in the root. The tooth is thus dovetailed into the cavity, so that it is almost impossible that it should become loosened, the filling of the tube making it almost equal to a solid gold wire. " The advantage of this method consists in the certainty which attends each stage of the operation, no guess work about it, no screws to become loose. The tube so fills the entire cavity of the root that there is no waste motion, allow- ing it to work loose."* The Stowell Crown. — I countersink the end (Fig. 253), using for that purpose a large, round bur in the engine. I now make a closed cap, using the combination crown metal, and place it upon the root. The cap is then perforated and the root reamed for the dowels. The bite in wax is now taken, after which the cap is burnished into the countersunk end of the root (Fig. 254). The dowels of platinum and iridium wire are now set in their places, being allowed to pro- * Cosmos, XXI, 232, IS 2l8 OPERATIVE DENTISTRY. ject one-fourth of an inch, so that they may adhere to the impression of plaster, which is then taken. From this a cast is made, of investing material — calcined marble-dust and plaster is preferable, though fine moulding sand will do. The dowels are now cut off even with the top of the cap (Fig. 255). The tooth to be used may be a Logan or an E. Family Brown crown, or a common countersunk tooth, but I would in most cases recommend the Logan crown. As the case in question is a bicuspid, I have selected for it a J^ogan crown. First, I cut off the pin, and then the tooth is ground into posi- tion on the cap, grinding the stump of the pin and porcelain alike evenly and smoothly. The stump of the pin is now ground, with a small wheel, below the surface of the porcelain Fig. 253. Fig 254. Fig. 255. Fig 256 Fig 257. Fig. 258. Fig 239 Fig 260. (Fig. 256). The tooth is now invested (Fig. 257), and pure gold fused on to the platinum pin, and while in a fluid state it is with a wax spatula spatted down flat (Fig. 258). The gold is now filed or ground down even with the porcelain, and at the palatal border the tooth is ground to bevel back until the gold is reached (Fig. 259). The tooth is now fastened in place on the cap -with wax cement (Fig. 260), the cast cut away, and the case invested in asbestos and plaster (Fig. 261). This is used because of the fibre of the asbestos, which pre- vents the separation of the crown and cap. The case is now heated until the wax has melted and burned out ; a small clip- ping of thin platinum plate is crowded into the opening (Fig. 261) caused by the grinding of the bevel on the crown. The clipping of platinum serves as a lead for the solder, which THE STOWKLL CROWN. 219 follows it down into the countersunk cap, around the ends of the dowels, and finally attaches itself to the pure <^old alread\- firmly attached to the stump of the platinum pin. When cool the case is removed from the investment, dressed and polished, and the work is done (Fig. 262). A sectional view of a like tooth (Fig. 263) shows the organization in detail. I'^ig. 264 shows a central incisor root on which a Logan crown is used after nn- method, h'ig. 265 shows how delicate an operation of this kind may be performed upon an inferior central incisor, b\' the use of the countersunk tooth crown, which is shown as it appears before gold has been melted in its cup around the pin, a, when the cup has been filled with gold, H, and after the crown has been ground and beveled, c. Fig. 261. Fig. 262. Fig. 263. Fig. 264. Fig. 263. Fig. 266. A countersunk molar crown is shown as likewise mounted on the roots of a superior left second molar (Fig. 266). The cuts are made from photographs of prepared specimens, the natural roots of which \-ary in the several figures, and in the section (Fig. 263) the continuation of the pulp canal does not appear, because obliterated in preparing the section. The claims for this method of crown work are as follows : The combination of an all-porcelain crown with a closed cap and dowels, the adajitation of which crown and its final attach- ment to the root can be made perfect. The dowels may be set at any angle that the direction of the root canal may indicate, using one or more dowels as the case may require, and when the root has to be cut off much 220 OPERATIVE DENTISTRY. below the gum, and a collar cannot be placed, a platinum disk floor on the root end is the preferable plan. The well- known and easily detected plate-tooth having a gold backing which renders the tooth dull in appearance is thus made obso- lete, for this crown possesses the translucent appearance of the natural organ. Best of all, the glaring gold of which some so-called beautiful crowns are almost entirely composed is by this means superseded. I hereby refer to gold bicuspids and molars, more especially to the former, which have always been an eyesore to me, and it was the unsightly appearance of these which first led me to try and improve on them. * Cosmos, XXIX, 642. BRIDGE WORK. 221 BRIDGE WORK Bridge work seems to have passed the stage of experiment and to liave been established as one of the useful and desira- ble operations in dentistry. It consists of false crowns sup- ported in the place of extracted teeth, independent of the gums, by roots adjoining the space to be filled. The supports, properly called abutments, may be on the back teeth, cap crowns, or a bar fitted into a cavity of the tooth and secured by filling ; if a front tooth, a Richmond collar crown, t)r an open cap, as in Fig. 267, made by cutting out the front Fir.. 267. of a cap, leaving only a narrow band at the neck. This, if skillfully adjusted and finished, closely resembles a gold filling. Such caps may be applied with success to bicus- pid and cuspid teeth. They are oftenest required on the cuspids. The cuspid crown should be dressed down until of uniform size with the neck of the tooth. Fit a band, as wide as the length of the crown, of 20-carat No. 31 gold, closely to the neck of the tooth, and solder. The palatine portion will stand away from the tooth ; into this space place a piece of No. 31 pure gold and fit it to the palatine surface of the tooth, secure it with wax cement, then invest and solder to the band. Grind off the surplus from the palatine surface, and cut out the labial surface as directed, when it will be found to fit very per- fectly if carefully done. The band may be made of pure gold, thin, and fitted with 222 OPERATIVE DENTISTRY. • the pliers and burnishers to the crown, carefully removed and filled with strong investment, and then covered with a second layer of gold of coarser grade, and soldered. Very thin platinum may be thus used, and a very perfect fit obtained. Some obtain an impression of the crown by use of the thin plati- num, and from this make a metal die and strike up a cap upon it. Skilled operators obtain very accurate fits in this way. Bicuspid teeth may be neatly fitted with an open cap, and have the lingual cusp covered with pure gold. When the cap is finally adjusted with the cement, the edge of pure gold may be burnished down to the surface of the tooth, and it will remain in perfect adjustment. The cusp and that of the opposing tooth may be ground a little to compensate for the thickness of the gold. In the cases above described the bands are expected to be accurately fitted to the festoon of the gums, and to pass a little way under, so the gum will completely cover the edge. Sometimes it is more desirable to cap the teeth without dressing down, and also not to have the cap reach the gum, leaving the neck of the tooth fully exposed. Many patients will avail themselves of the benefits of bridge work, if they do not have their teeth ground away, who would not otherwise do so. For such a case, make a band of pure gold, reaching nearly down to the gum, cover the grinding surface, as in other cases, and a band of thin 22-carat gold outside the pure gold band, but narrower, leaving a free edge of pure gold, which may be burnished down around the crown when it is finally adjusted with the cement. C^fm .5 Fig. 268 shows such a cap, a being the pure |jnp|gy[ a gold and, b the thickened portion of the cap. The bar anchorage is made as follows : " A slot for the bar must be cut in the grinding surface of the crown. In a large percentage of cases a crown cavity will be found in molars ; this affords a convenient point for starting the slot. Frequently, but little more is necessary than the HRinOE WORK. 223 enlarf^cmcnt or elon<:jatic)n of the cavity in the mesial direc- tion. Wlien it is necessary to start the excavation dc novo, it is best accomplished by means of a small corundum disk, which will rapidly make an elongated cut through the enamel, thus rendering the subsequent cutting comparatively easy. The slot need not necessarily be more than one-eighth inch long, although one-fifth inch is a better length ; its depth will depend upon the position of the pulp chamber, the sensitive- ness of the tooth, the strength of its walls, and the nature of the occlusion. Its width should not exceed one-tenth of an inch, and may be less. The lower second molar tooth is fre- quently so much tilted in a forward direction that there is quite a considerable space between it and the mesial portion of the grinding surface of the antagonizing upper molar. In such cases quite a thick bar can be placed in position and allowed to rise above the general level of the tooth upon which it rests, the slot being made only deep enough to secure its proper anchorage. Where the bite is very close at all points, the slot and bar must be sunk deeper. The slot should . be dovetailed and undercut, as seen in Fig. 269. The anchor- age-bar should be made of platinum alloyed with iridium, and should corres- "^" ^^" 'c-^yo- pond in shape to the slot, but be made as much smaller as may be necessary to afford space for packing around it, with very fine instruments, either foil, amal- gam, or cements for anchorage purposes. I"ig. 270 shows a desirable shape for the anchorage-bar in the case under stud\'. The notch on its surface, filled in with a strong packing, will fully counteract any tendency to movement in a forward direction which might otherwise be manifested in wear."* Another manner of connecting false crowns, when a natural tooth intervenes, is by co/niccting bands. They are made as follows : — * " Am. Syst. Dent.,*' Vol. u, p. 846. 224 OPERATIVE DENTISTRY. Fig. 271 illustrates this device for obviating the neces- sity for removing the crowns of natural teeth in prepar- ing the mouth for bridge work. Crowns are fitted in the mouth to the points of attachment in the usual manner. An impression is taken, bringing the crowns away in their proper positions. From this the cast or model is obtained. Heavy bands of half-round gold or platinum bars are now fitted around the necks of the natural teeth, on their lingual sur- faces. These bands being waxed in position, serve to connect the different parts of the bridge, uniting them in one piece without the loss of any of the natural crowns. I have found this a highly satisfactory method of inserting extensive pieces Fig. 271. of the work. Fig. 272 shows the mouth as presented, for which the piece shown in Fig. 271 was constructed. Fig. 273 shows the piece in position." * The false crowns, more frequently called dummies, are so made as to present only an edge toward the gum while having a full grinding surface presenting to the opposing tooth. The common way of making them is to select a suitable porcelain face, grind the neck thin so that only an edge will come in contact with the gum, and grind the cutting edge square, a little shorter than the occlusion requires. Take a * Cosmos, xxvn, 712, BRIDGE WORK. 225 piece of pure gold, struck to the form of the grinding surface of a corresponding tooth by a die previously prepared, or formed to the occluding surface of the opposing tooth, melt Fig. 272. coin gold into the concave surface of this, file or grind this surface smooth, and fit it to the porcelain face already pre- pared and backed with pure gold. Fi< When fitted and secured in position with wax cement, place upon each side of the crown a triangular piece of pure gold or platinum closely adjusted to the sides of the porcelain, and 226 OPERATIVE DENTISTRY. secure them in position. Invest this, wash out the wax, and this will expose a triangular box into which should be flowed coin gold or No. i solder. Fig. 274 shows different views of these crowns completed. An excellent molar or bicuspid crown for bridge work may be made by using a common rubber tooth, grinding off the shoulder a little, and cutting off the heads of the pins and wrapping it with pure gold No. 30 or 31, as in Fig. 275. To do this, take some thick pattern tin and punch holes for the pins and fold it around the tooth, overlapping a little at some point. Cut out the grinding and buccal surface of the crown, leaving a band at the cervical portion, remove the tin and spread it out. It will be a correct pattern, by which to cut the pure gold, which will be found to fit correctly, when the Fig. 274. tooth may be invested and soldered with 18 k. plate. Be sure the gold is burnished down to contact with all parts of the tooth. Special care should be taken in heating and cooling when soldering these crowns, to avoid fracture of the porce- lain. If great strength is required, the neck of the tooth may be shortened and additional thickness of gold added. Crowns thus prepared and placed in position, and a bar of gold added to the lingual surface to strengthen them, and all well soldered, make work of superior excellence. It avoids the unsightly and glaring gold crown, and affords a porcelain biting surface, which is very much more agreeable and serviceable to bite upon. The English tubs teeth can generally be used for the .same object, by first making the bridge frame and soldering a BRinOE WORK. 227 pin in position and slippin<^ on one of these teeth ground to a proper length, and secured by gutta-percha or cement. When all parts are made to fit their places, one or two false crowns may be attached by wa.x cement to the adjoining abutment, placed in the mouth and accurately adjusted to position and occlusion, and then removed, invested and sol- dered. This may be done on each enil, so the bridge will con- sist of only two parts. When this is done, place the two parts in position, have the patient close the teeth and hold the parts to a correct occlusion. Mix some investment to set quickly, draw away the lips and cheek and cover the outer surface of the bridge with the investment. When firmly set, remove it. This will be a matrix, into which the pieces of the bridge may be placed in correct relation to each other. Secure by a little wax at a few points, to insure against moving. Place around this more investment, then gold plate may be added as is needed to strengthen the bridge, and the case soldered and finished, and adjusted. The method of making the artificial crowns for the bridge is given in the following description of a case taken from Dr. Litch's excellent article in the "American System of Den- tistry." " The anchorage being now fully prepared, the cuspid and molar caps are placed in position, and with plaster an impres- sion of the mouth is taken. If the caps do not come away with the impression, they are withdrawn from the mouth and placed in their proper position in the impression, which is then varnished or oiled, or both, and a cast run after the usual manner. After removal of the impression the caps will be found implanted in their proper positions upon the cast, as seen in Fig. 276. To facilitate the subsequent removal of the cuspid caps, the inner and the outer surfaces of the ferrule portions and the sides of the retaining-pins should be coated with a thin film of paraffine and wa.x, which by the applica- tion of a little heat will readily soften and permit the with- drawal from the cast. After the wax film has been removed, 228 OPERATIVE DENTISTRY. the caps can be replaced in and withdrawn from their places on the cast at pleasure. A similar method should be adopted with the molar caps. Enough wax should be placed upon its inner surface to fill out the curvatures and make its walls par- allel with the long axis of the tooth. Covering with wax the under surface of the crown-plate should, however, be avoided, as it is desirable to have that rest firmly upon the column of plaster which will be found as a part of the cast after the wax has been softened and the cap withdrawn. Fig. 276. " Upon the cast thus prepared a rim of wax attached to a paraffine and wax base-plate is modeled preparatory to taking the articulation. The details of this method do not at all differ from the methods described elsewhere in this work. "The base-plate and wax rim are made to rest upon the cuspid caps, both when they are on the cast and when in the mouth, to which they are restored when the bite is taken. " At the point where the wax rim rests upon the cuspid caps, it should not extend beyond their labial edge. The articulation and an impression and cast of the lower antago- BRIDGE WORK. 529 nizing teeth being secured, tlie cast is properl)- mounted upon an articulating frame. "Suitable porcelain teeth are now to be selected and mounted. For the incisors and cuspids plain plate teeth are usually selected ; they should be strong and well made. The molars and bicuspids are built up almost entirely in solid gold, and are sometimes made throughout of that metal ; but usu- ally porcelain facings are employed, which at least serve to protect the gold from view, its conspicuousness being objec- tionable. " F'or bicuspid facings cuspid teeth strongly made and with heavy pins may be used. In fitting, only the outer edge of the necks of the teeth should be allowed to rest upon the gum. The teeth should be so spaced that the cuspids will come into proper position upon the caps prepared for them. In fitting them to the caps the utmost nicety should be observed, so that there may be no space left between the tooth and the cap. " If the front of the cap is above the level of the gum, and thus e.xposed to view, it can often be concealed by bringing the neck of the porcelain tooth over it, using very small corundum wheels to grind out on the under surface of the porcelain a concave space adapted to the conve.xity of the cap; by this means the cap can often be perfectly concealed from view by a film of porcelain which, although thin, will in that position rarely be fractured. "The teeth being fitted into position on the model, a matrix in two sections is run over their outer surface, and upon the outer face of the cast, on which, as guides, conical depressions are previously cut. The matrix is seen as D in Fig. 277. The teeth can be taken from it and returned to it at pleasure — a great convenience in subsequent processes. "As molar and bicuspid facings are subjected to great strain when mounted upon a rigid and unyielding piece of bridge work, it is generally desirable to shield them from pressure by a heavy gold crown plate; this can be made in precisely the same manner as previously directed for making the crown 230 OPERATIVE DENTISTRY. plate for the molar caps. As the shell of the crown plate fol- lows the dimensions of a natural tooth, and molar facings are usually much narrower, it is necessary to make the shell and facing correspond in width ; this is readily accomplished by bending in the edges of the shell to the necessary extent with a pair of pliers. The palato-buccal diameter of the shell should also be reduced, as it is rarely desirable to make arti- ficial molar teeth of any kind the full size of the natural organs. The shell, being thus prepared, is filled with i8-carat gold and a box plate attached precisely as previously described for the crown plate of the molar tooth. Fig 277. ",The porcelain molar-facing upon which it is to rest is then ground away sufficiently to allow the crown plate to slip in between it and the occluding teeth, as seen in Fig. 280. " Letter A is the porcelain face cut down at B to admit crown plate C, which is being passed into position between the porcelain face and the occluding tooth ; it is the plaster matrix which holds the teeth in position upon the cast when the articulating frame is reversed. As represented in the cut they would drop out. " Too much care cannot be exercised in making the joint ' HKIIXiK \Vf)KK. 231 between the porcelain facing and the crown plate a perfect one. For artistic effect, and also for cleanliness, there should be absolutely no space at any point. To secure this result, it is well, after all but the finest irregularities have been removed by the corundum wheel, to place a little wet pulverized corun- dum between the two surfaces and rub them together. This, if skillfully done, will make an almost impermeable joint. In fitting to position allow the crown plate to project a very little beyond the buccal surface of the porcelain facing. This projection is to be cut awa\' in finishing, and gives a little margin for perfecting that process. "After the same manner crown plates are prepared for the other molars and bicuspids, which teeth are then removed from their matrices and backed with platinum No. 27 standard gauge. Each backing is made to extend from the grinding surface, when it is brought in close contact with the crown plate, to the extreme edge of the neck, and to cover the entire inner surface of the tooth from side to side. It must be adapted to the porcelain surface with the utmost nicety. The platinum being pliable, can be bent and burnished into the closest contact; so that the joint shall be impermeable. The proximal and cervical margins are bevelled down to a feather edge ; the coronal margin is left square. (The facing as thus prepared, with its crown plate and backing, is seen in Fig. 278.) Cement is then placed between the crown plate and backing and the tooth invested in the marble-dust and plaster mixture already recommended, preparatory to soldering the platinum pins of the porcelain facing to the backing and the backing to the crown plate, at the same time filling in solidly, with metal, the angle between the latter two. It is an economy of time and labor to place three or four teeth in the same inx^estmcnt, taking care that sufficient space is left between them to prevent union. Invested in this manner the teeth will present the appearance presented in Fig 279. The dotted lines seen in Fig. 280 indicate the surface to which the gold is extended in the soldering process. 232 OPERATIVE DENTISTRY. " In soldering great care must be taken to secure a uniform temperature throughout the investment and its enclosed teeth ; such large masses of metal are to be imposed upon the porce- lain facings that unless the utmost caution is observed there is great danger of fracture. The safest plan is to heat the investment to a dull-red heat over a gas-stove or other suit- able heating apparatus, and then transfer it to a hot bed of charcoal in the soldering furnace ; by this means the heat can be raised gradually and uniformly and be maintained at the required point throughout the soldering process. " If the blowpipe flame alone is depended upon, there is always the danger that the face of the porcelain teeth next to Fig. 278. Fig. 28 the metallic backing will be heated to a much higher point than that in contact with the investment, unequal expansion, followed by fracture, being pretty sure to result. With single teeth fracture in soldering does not usually depend upon too rapid heating or too rapid cooling, but rather upon unequal heating and cooling. A good porcelain single tooth protected from direct contact with flame by a suitable investment can be .safely raised to a full red heat in five minutes, and cooled to the temperature of the air in as many more, provided that care be taken to make the application of heat uniform and progres- sive. If a pointed blowpipe flame at perhaps the tempera- ture of 2000° F. is thrown upon that face of the porcelain BRIDGE WORK. 233 covered by the backing, while the other, covered by a thick investment, remains at a temperature not much, if at all, above 212° F., as indicated by the still-escaping steam from the plas- ter, fracture is sure to result. The thicker the investment the more difficult does it become to equalize the temperature on both sides of the porcelain tooth. For this reason it is rarely desirable to make the investment more than half an inch in thickness. " The description just given of the methods of making molar and bicuspid bridge-teeth must be slightly modified for the left molar bridge-tooth, to which the bar already shown (Fig. 270) is to be attached. " To this molar the mesial end of the bar is cemented, the Fig. 281. Fig. 282. bar being placed against the backing and beneath the crown- plate, as seen in Fig. 281. " The angle between the backing and crown-plate being filled with wax-and-rosin cement, the bar will be strongly held, and while the cement is still plastic the tooth and bar are conveyed to position in the mouth and the adjustment of the bar to the slot, and, at the same time, of the crown-plate to occlusion, is preferable. The cement is then chilled and the tooth invested and soldered as before described. The investment grasps the distal end of the bar and holds it in position after the cement has melted, while the gold solder takes the place of the cement and holds the bar firmly and rigidly in place. " Fig. 282 gives a sectional view of the completed typical bridge-tooth, porcelain seen in Fig. 281 having been filed 16 234 OPERATIVE DENTISTRY. away to a level with the buccal surface of the facing. The relation to the alveolar ridge of the cervical edge of the bridge-tooth when in position is shown in the diagram. All exposed surfaces, except the coronal, form inclined planes, upon which it is impossible for food to lodge or remain. "As the contracted cervical edge barely, if at all, touches the gum, it affords no obstacle to the flushing effect of water held in the mouth and washed to and fro under the denture. All the broader surfaces are readily accessible to a properly-con- structed brush. The molar and bicuspid bridge-teeth being completed, the cuspids and incisors also, are to be backed and soldered. Platinum backings should be used for each, and the solder should be i8-carat gold plate. In soldering the cuspids the palatine surface should be filled out to contour, as seen in Fig. 283. The two cuspids may be soldered in one investment, and the four incisors in another. Upon the back- ing of each incisor a large excess of gold should be flowed, as seen in Fig. 284, where it is made about the twelfth of an inch in thickness. If it is found desirable to have a shoulder upon the inner edge of the incisor for occlusion with the lower teeth, this can readily be secured by cementing a strip of 22- carat gold at the proper point transversely across the backing, as seen in Fig. 285, and flowing in gold up to the dotted lines. The several pieces of the bridge being now completed, all that remains is first to unite them into sections, and then join the sections, thus constituting a continuous arch. The first section will be composed of the right cuspid and molar abut- ment-teeth and the three intermediate bridge-teeth. The BRIDGE WORK. 235 second section will be formed of the left cuspid, the left molar, with the anchorage-bar attached and the intervening bicuspids. The third section will consist of the four incisors only. "To build the sections, the teeth composing them are re- stored to their several positions in the matrix upon the cast, the sides of the crown-plates and metallic backings, if redun- dant, being cut down sufficiently to allow the teeth to rest side by side in the matrices. It is desirable that the edges of the crown-plate should be fully in contact, but that the back- ings should touch only toward the buccal surfaces of the several teeth, from tliose points to the palatine edges of the backing narrow V-shaped spaces should be left, into which the solder will readily flow and thus ensure the effectual filling up of the joint, and consequently the firm and strong union of the several teeth and caps Avhich compose the section. After being satisfactorily arranged in the matrix, the teeth and caps are strongly cemented together with a brittle wax-and-resin cement, and transferred to position in the mouth when the final adjustments are perfected. " The cement is then chilled. In this state it should be quite strong enough to hold together the several parts of the sec- tion. But, usualh\ such cements are not strong enough to withstand the strain necessarily put upon them in withdraw- ing tightly-fitting caps from anchorage-teeth. In such cases a thin matri.x should be moulded over their buccal surfaces as, held together by the cement, they stand in position in the mouth. This matrix should be made of a quickly-setting plaster mixed to a thick batter. It is to be spread by a spatula over the entire front of the section, that surface of each tooth and cap composing it being fully covered, the plaster at the same time being run well into the interspaces. After the plaster has hardened, the matrix is removed from the mouth, as also are the teeth and caps. These, on being replaced in the section matrix, are there held in precisely the same relative position which they occupied in the mouth. 236 OPERATIVE DENTISTRY. " Bridge-teeth and anchorage-caps are then very strongly cemented together and the cement thoroughly chilled, to avoid the possibility of bending. The section is then care- fully lifted from the matrix, invested, grinding surfaces down, in the marble-dust-and-plaster investment, and soldered with the zinc alloyed i8-carat solder previously recommended. " Fig. 286 shows the right section thus invested. The same methods are to be employed in forming the other sections. " Finally, the three sections must be joined, to form the con- tinuous arch. The point of junction will be between the cus- FlG. 286. pids and laterals of either side. These two points must first be strongly cemented. This is best accomplished by thor- oughly drying the right and left sections, and then placing them in position in the mouth, where, by means of napkins, they must be carefully protected from moisture. The incisor section is then also dried and slightly heated. The distal sur- faces of the lateral incisors is covered with quite a thick layer of the wax-and-resin cement, and while this is still soft and adhesive, the section is carried to the mouth and pressed into place, where the cement serves to attach it to the other sec- tion. If the adhesion is not satisfactory, it can be improved BRIDGE WORK. 237 by rcmelting the cement with a liot iron, at the same time the surfaces to be joined. The cement siioukl then be chilled. " A matrix is then made somewhat after the manner of taking an impression, the plaster being allowed to cover the teeth, previously slightly oiled, for about one-third their length above the cutting-edges and grinding-surfaces, as seen in Fig. 287. The impression-tray is shallow and need contain only a small amount of plaster. Fig. 287. "The matrix must be trimmed away until the bridge-piece can easily be detached and be replaced or withdrawn with perfect freedom. If the cement between the cuspids and laterals has been fractured,, it must be again restored and hardened. The case is then, with the most scrupulous care and delicacy of manipulation, lifted from its place in the matrix and transferred, crown side up, to the investment-slab seen in Fig. 288, which is designed to give a rigid and fixed 238 OPERATIVE DENTISTRY. support to the bridge-piece and its investment, and thus pre- vent warpage of the one or fracture of the other during the soldering process. "The investment-slab is made of fireclay, about one-fifth of an inch in thickness, its other dimensions corresponding to those of the case to be invested. On its outer circumference are placed dovetailed notches, made larger on the under than the upper surface of the slab. These serve as anchorage for the investment and prevent its breaking away from the case or Fig. 28 from the slab. In investing, those notches are filled with the investment mixture (beach-sand and plaster-of-Paris, equal parts), and at the same time a sufficient amount of the material is heaped up upon the slab (previously placed upon a flat, smooth surface) securely to imbed the bridge-piece as it is transferred from the matrix. "All parts of the case, except immediately around the sur- faces to be soldered, are covered with the investment, which, as already stated, need at no point be more than half an inch in thickness. BRIDGE WORK. 239 " Fi^. 289 shows the iiucstcd case, a is the in\'estiiient ; li, the iinestinent-slab ; c, c, tlie joints to be closed. It need liardl}' be stated that in this final soldering the same care in regulating the temperature should be observed as has been Fk: previously directed. In this soldering the zinc-alloyed gold solder should be used and the joint between the laterals and cuspids on either side should be fully filled. After cooling, the case is then ready for the final finishing processes and for adjustment in the mouth. Fig. 290. " Fig. 290 shows the completed case detached and in Fig. 291 it is seen in position. " If the directions gi\'en for the construction of the cases of bridge-work have been carefully followed, the denture, after 240 OPERATIVE DENTISTRY. the final soldering and finishing, should pass up into position in the mouth and fit with perfect accuracy. " Any warpage indicates defective manipulation. This fault is readily detected by testing the case in the final matrix (Fig. 287), in which it should fit as perfectly after as before invest- ment and soldering, except that a little excess of solder in the joints between the incisors and cuspids may cause a mal- adjustment at those points — a fault, however, easily discovered and remedied, either by removal of the solder or by scraping Fig. 2QI. away the plaster of the matrix; which being done the case will go fully into place. " In placing the completed arch upon the anchorage-teeth some difficulty may arise in consequence of a want of coinci- dence in their respective angles of inclination. This is a detail which must be looked to before determining the plan of the bridge, and the case should, as far as possible, be con- structed with a view to avoiding the complication, such anchorages being selected as will accomplish this end, and at the same time be satisfactory in other respects. LOW i5KID<;k. 241 " With every care, however, it may sometimes happen that while the individual sections are readily adjustable to their respective anchora;j^es, they, when united, interlock in such a way that either removal or replacement is difficult or imprac- ticable. This is a point which b\' the aid of the final matrix can and should be fully tested before the sections are united by solder ; for the plaster of the matrix holds them firmly together, and if while thus held in contact they cannot be withdrawn from their respective anchorages, or, being sepa- rately withdrawn and restored to their relative positions in the matrix, they cannot be replaced upon the anchorage-teeth, it is entirely inadvisable to proceed farther until the difficulty is remedied. "Usually, this can readily be accomplished by cutting away that face or angle of the anchorage-tooth or root which is the point of difificulty. Sometimes the simple shortening of the retaining-pins, or the enlargement in a given direction of one or more of the pulp-canals, will overcome the trouble. To precisely locate the points of interference, the surface of the implicated teeth or roots may be covered with a thin film of wax, or the edge and inner surface of the ferrules may be covered with a layer of rouge or plumbago, which will leave a distinct mark upon the anchorage-teeth at whatever points pressure is- most considerable, which points being then cut away, the denture may readily pass into place. All remedial measures of this kind failing, some modification of the plan of construction of the denture, of a nature to simplify its anchor- ages, will be necessary."* Low Bridge. — " For the first illustration, as seen in Fig. 292, we have a case where all the teeth have been extracted except the two cuspids and two second molar roots. " We first proceed to prepare the roots by crowning. I use gold crowns on the molar teeth and the Low crown on the two cu.spids. *" Am. Syst. Dent.," II, 846, 242 OPERATIVE DENTISTRY. " The preparation of the two cuspids consists in making the crown read}' for adjustment. I always measure the tooth to be crowned with gold with a strip of block tin, about 35 Stub's gauge. Place the tin around the tooth, and with pliers care- fully measure the full size of the same. " Should you be measuring a tooth or part of a tooth on which there are projections, take the engine and with a stone grind off the same, making a smooth surface, so there will be nothing to interfere with the proper fitting of the bands. After cutting the tin measures by the marks made by the pliers, you Fig. 292. have the measures ready to make the gold bands by. Cut the bands and bevel the edges and solder together, and you are ready to fit. After fitting all the bands and finishing the crowns in the usual way, I place each in position in the mouth, having previously regulated the articulation of each crown as desired in the process of making. I now take a deep articula- tion in wa.x and impression in plaster of Paris ; remove before it gets too hard, and place all the crowns in their positions in the impression; varnish, oil, and pour in the usual way; separate the cast from the impression and place in the ar- LOW HRinCE. 243 ticulator. Then pour plaster. After the plaster has hardened, remove the wax, and we have the articulation proper and are ready to select and grind our teeth, having previously selected our shade. My experience has long ago taught me that no porcelain teeth can stand the pressure for bridge work, the strain on them being twice as great as with teeth on plates, which rest on the gums, that gi\e to pressure. In order to prevent breakage of teeth and give strength, I have for many years been making a tooth with gold cusps. I will here describe my manner of doing so. " I had some shells of bicuspids and molars made, or rather teeth, without the crown. They can now be found in some of the depots. For the first step I use 28-gauge platinum for a covering of the inside of the shell, or just where you wish gold to flow. Then I bend the pins down to hold the pla- tinum in position, and with a file remove all overlapping pla- tinum to prevent breaking of our teeth in heating. The tooth is made flat on the crown surface with the express intention of restoring with a gold crown. The crown need not be very thick, but should perfectly resemble the cusps on the natural tooth for the purpose of mastication. As these cusps are not on the market, and every dentist making bridge work cannot make it in a way to stand without putting gold cusps on the grinding surface of the bicuspids and molars, I will here describe, for the benefit of those who do not know how to make them, how they can be made with very little trouble. Pick out a natural tooth with cusps the exact shape you wish to have your gold cusp; mix some fireclay in a thick paste, then press your tooth into it a little deeper than you wish the cusps. Having made the proper impression, remove the tooth, and set the impression over the gas stove to dry. After it is dried and reasonably hot, lay your pieces of gold in the impression and with a blowpipe melt them. When melted, press with a piece of steel on the gold till cool. This mould will do to make many from. If you have not the fireclay, and can get charcoal that is burned from fine-grained wood,. and is 244 OPERATIVE DENTISTRY. soft, you can simply press your tooth into the charcoal and melt in the same way, or you can carve your teeth as you desire in a block of carbon. Of course, the little steel dies are handier, as we can swage up our gold cusps in them, either solid or thin. " Having described our manner of making the cusps, we will now return to the manner of finishing our tooth. I left off by saying we covered the inside and bent down the pins and filed off the overlapping platinum. We now place the cusp on the top of the tooth, and place in the position desired, holding it there with wax, and with a spatula trim the wax the exact shape we wish our tooth to be — V shape, tapering from the crown down. We now encase in plaster and sand, which gives Fig. 293. Fig. 294. US a box. When hard remove the wax and place over the stove, and when sufficiently dry, fill in with coin gold, using the blowpipe to melt it in a solid mass, and then our tooth is ready to fill up and place in position on the articulator. Fig. 293 shows the tooth in this condition. "After our teeth are all arranged we hold the same in posi- tion with wax, remove from the articulator, encase with plaster and sand or asbestos in the usual way. That we may have a strong case, I always use platinum wire between all the teeth, and then proceed to heat and solder. Be sure all the gold cusps are so arranged that you can get all soldered together, as this gives us great strength. My formula for solder, which I have used for many years, and which will be found very easy LOW I5KIDGE. 245 flowing aiul almost the exact color of the gold you are using, is as follows (always figure fiom the carat of gold you arc working) : Take one pennyweight of coin gold, two grains of copper, and four of silver. We now have our case soldered; after filling' as desired, commence to finish with felt wheels and pumice-stone, after which use rough buff wheels. We are now ready to adjust in the mouth. In Fig. 294 we see the case ready for adjustment. " Have the assistant dry all the teeth or roots to be operated upon while you are mi.xing the cement. Be sure and use a kind which does not harden very rapidly, or your cement will set before you get your teeth adjusted. Use sufficient cement Fig. 295. to fill all the gold crowns perfectly when the case is driven to place. Moisten the step plugs and cap with cement, touching every portion, and with an instrument place a little cement in the bottom of the cavity. We now adjust our case, using the little rotor for the Low crowns and a piece of ivory for driv- ing on the gold crowns. Fig. 295 represents the case when in position. " It will be seen by looking at Fig. 294 that the teeth after having been soldered are all spaced fully one-third of the dis- tance from the place of contact with the gums and the grinding surface of the teeth, so that the secretions could not possibly lodge there. I have given you a description of my manner of 246 OPERATIVE DENTISTRY. making a full upper case of bridge work where there are roots to be crowned to support the bridge. I will now describe my manner of operating upon a case where the four centrals are missing, as seen in Fig. 296. To supply these four teeth where the cuspids are intact, I use a gold band. I first measure the tooth with strips of tin, and make the gold bands, as before described, and cut out the outside lower portion ot the band before beginning to fit. In fitting, as the band is being driven down, cut away any of the band that touches the gum before all touches ; never drive the band under the gum, as inflammation would probably follow. Fig. 296. " I mention this as I have seen many attempts to get rid ot the bands by driving up under the gums and cutting them out on the front, until they were too narrow for strength. It is hard work to make something out of nothing. The bands should be heavy and strong, and the patient made to under- stand that if he expects to get rid of the annoyance of the plate he must sacrifice his dislike to showing gold. After driving the bands up close to the margin of the gums, as the cuspid teeth are very tapering, the bands will have to be taken in at the bottom. To do this, I slit the band about a third of its length up, then place it on the tooth again, lap it I.oW liKllXiE. 247 over enough to biiiiL^ it to a close fit, and then take it off and solder, " Continue taking it in wherever it does n(jt perfectly fit the tooth, and after a good fit is obtained, j)roceed as before described, by taking an articulation and impression. In adjust- ing, first try the case on to see that it fits, and that the articula- tion is all right. Fig. 297 shows the case ready for adjustment. " Next have the assistant dr\' the teeth ui)on wliicli the bands are going, and then mix )'our cement. This should be mixed to about the consistency'of thick cream. It must be neither too thick nor too ^^m» IL thin, or the adhesion will not be strong enough to hold. Cover your ^teeth with cement, and then the inside of the bands. Place these on the teeth and carefully mallet up into position. For this purpose I use a steel instrument with a crease or groove in the end. The teeth must be kept dry after the case is in position until the cement is well set. After this is done, Fig. 297. Fig. 298. bevel the edges of the bands and burnish close to the teeth, and if properly done they will be made to resemble gold fill- ings. In Fig. 298, we have the case completed. 248 OPERATIVE DENTISTRY. " I am aware that in a case like this, porcelain crowns instead of gold bands could be used, and I should consider it much preferable to do so where we have roots or unsound teeth to operate upon ; but I do not advise the destroying of nerves, where the teeth are intact, to supply such a case with crowns, as the bands will answer every purpose for many years. " If they should give out in after years, the roots can then be crowned. I have many of these cases that have been in use seven and eight years, some of which have never loosened, and some I have reset nearly every year. I always impress upon the patient the necessity of having them reset immedi- ately should they become loose, and advise them to have their cases examined at least once a year. Should parties insist upon having crowns used to supply a case like the one just described, on perfectly sound teeth, I should begin by using an aluminum disk with corundum, cutting deep as possible both on the labial and lingual sides, and then use the excising for- ceps. This can be done under the influence of an anaesthetic or otherwise. It is not by any means so painful an operation as one would think. If the nerve does not come out with the piece of tooth cut off, I take a piece of orange-wood, which I have previously cut the proper shape, to drive into the nerve canal. I place it in creasote and let it soak a few minutes before beginning to operate. Immediately after severing the tooth drive this into the canal, then remove and dip in crea- sote, and drive in again. This will perfectly fill the nerve- canal; all sensitiveness will disappear, and you can begin to operate at once. I do not recommend this treatment for sound teeth, but I have treated many exposed nerves in this way, also many teeth broken by accident, and think this the most satisfactory way to dispose of such cases. I have never had any unfavorable results follow after operating upon teeth in this way, and I can hardly say as much in favor of any other treatment. I speak of this manner of treating exposed nerves as one of the operations that sometimes become necessary in LOW IfKinOE. 249 adjusting a bridge properly. I do not claim any originality in this mode of treatment. I know several dentists who u.se this method, all of whom report satisfactory results. We now have Fig. 299, showing the roots prepared to receive the case. I'll.. J'm. " I have many of these cases in use that arc giving entire satisfaction. The instrument selected for preparing these roots should be one with small inside cutters and large bevelers, so as not to cut away any more tooth substance than possible. Fig. 300 "Fig. 300 represents the case ready for adjustment. 301 represents the case after adjustment. 17 Fig. !50 OPERATIVE DENTISTRY. "In this article I have described my manner of making teeth for bridge work. I am now having made a tooth ex- pressly for bridge work, which I hope to be able to place on the market soon. I have been using these teeth, but have not perfected my shells and moulds sufficiently to enable me to get them out in large quantities. " Fig. 302 shows us a socket. This I propose to have ready made in various sizes in bicuspids and molars, with corre- sponding shells. Figs. 303 and 304 represent the shells placed in sockets. Fig. 303 is a molar tooth showing the shell in position, and Fig. 304 is a central reversed. Fig. 305 repre- sents the socket as made for the four central and two cuspid teeth. The advantage of these teeth can readily be seen, not only for bridge work, but all gold plates. A tooth, if broken, can readily be replaced without removing the bridge or crack- FlG. 302. Fig. 303. Fig. 304. Fig. 305. ing by soldering, and with only a small expense. Fig. 306 represents the shell placed in position in the socket, which can be used for bridge or crown work, and will greatly reduce the labor in making either."* Parmly Brown Bridge. — " This system has the metal baked invisibly through the body of the teeth. No metal shows either inside or outside of the dental arch. The six anterior teeth are riveted to the platino-iridium bar by the ordinary pins of plate teeth, which are the teeth used for this work. The bicuspids and molars are prepared by grinding a slot on the palatal surfaces of the teeth. 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The object held in view in the preparation of this Series was to make books that should be concise and practical, not burdened by useless theories and discussions, but containing all that is needed or necessary for the student and practitioner. No pains have been spared to bring them up to the times, and the very low price at which they have been published is an additional point in their favor. Full circular, descriptive of the Series, will be sent upon application. WALSHAM'S PRACTICAL SURGERY, A Manual for Students and Physicians. By Wm. J. Walsham, M.D., Asst. Surgeon to, and Demonstrator of Surgery in, St. Bartholomew's Hospital; Sur- geon to Metropolitan Free Hospital, London, etc. With 236 Illustrations. 656 pp. Cloth, ^3.00; Leather, ^3.50 YEO'S MANUAL OF PHYSIOLOGY. Third Edition. A New Text-book for Students. By Gerald F. Yeo, m.d., f.r.c.s.. Professor of Physiology in King's College, London. Over 301 Illus- trations and a Glossary. 758 pages. Cloth, ^3.00; Leather, ^3.50 PARVIN'S-WINCKEL'S DISEASES OF WOMEN. A Treatise on the Diseases of Women. By Dr. F. Winckel, Professor of Gynsecology and Director of the Royal University Clinic for Women, in Munich. Translated from the German by Dr. J. H. Williamson, Resident Physician Allegheny Gen- eral Hospital, Allegheny, Penn'a, under the supervision of, and with an Introduction by, Theophilus Parvin, M.D., Professor of Obstetrics and Diseases of Women and Children in Jefferson Medical College. Illustrated by 117 fine Engravings on Wood, most of which are new. 674 pp. Cloth, ^3.00; Leather, I3.50 POTTER'S MATERIA MEDICA, PHARMACY AND THERAPEUTICS. A Handbook of Materia Medica, Pharmacy and Therapeutics, — including the Physiological Action of Drugs, Special Therapeutics of Diseases, Official and Extemporaneous Pharmacy, etc., etc. By Sam'l O. L. Potter, M.A., M.D., Professor of Practice, Cooper Medical College, San f>ancisco; Author of " Quiz Compends " of Anatomy and Materia Medica, etc. With 600 Prescriptions and an Appendix containing numerous Tables comprising doses, diagnosis, Latin terms, formulae for hypodermics, metric equivalents, specific gravities and volumes, and obstetric memoranda — together with Notes on temperature and the clinical thermometer, poisons, urinary examinations and patent medicines, etc. 830 pages. Cloth, ^3.00; Leather, ^3.50 GALABIN'S MIDWIFERY. A Manual of Midwifery. By Alfred Lewis Galabin, m.a., m.d., Obstetric Physician and Lecturer on Midwifery and the Diseases of Women at Guy's Hospital, London ; Examiner in Midwifery to the Conjoint Examining Board of England. 227 Illustrations. 753 pages. Cloth, ^3.00; Leather, ^3.50 GOODHART AND STARR, DISEASES OF CHILDREN. By J. F. Goodhart, m.d.. Physi- cian to the Evelina Hospital for Children; Assistant Physician to Guy's Hospital, London. American Edition. Revised and Edited by Louis Starr, m.d.. Clinical Professor of Diseases of Children in the Hospital of the University of Pennsylvania, and Physician to the Children's Hospital, Phila. With many new Prescriptions and over 50 Formulae, conforming to the U. S. Pharmacopoeia, and Directions for making Artificial Human Milk, for the Artificial Digestion of Milk, etc. 738 pages. Cloth, ^3.00; Leather, ^3.50 RICHTER'S ORGANIC CHEMISTRY. By Prof. Victor von Richter, University of Breslau. Authorized translation. First American, from the Fourth German Edition. By Edgar F. Smith, M.A., PH.D., Translator of Richter's Inorganic Chemistry; Prof, of Ciiemistry in Wittenberg College, Spring- field, Oiiio; formerly in the Laboratories of the University of Pennsylvania; Member of the Chemical Societies of Berlin and Paris, of the Academy of Natural Sciences of Philadelphia, etc. Illustrated. 710 pages. Cloth, ^3.00; Leather, ^3.50 REESE'S MEDICAL JURISPRUDENCE AND TOXICOLOGY. By John J. Reese, m.d.. Professor of Medical Jurisprudence and Toxicology in the University of Pennsylvania; late President of the Medical Jurisprudence Society of Philadelphia; Physician to St. Joseph's Hospital; Member of the College of Physicians of Phila ; Corresponding Member of the New York Medico-Legal Society, etc. 2d Edition. Revised and Enlarged. 654 pages. Cloth, ^3.00; Leather, ^^3.50 WARING'S PRACTICAL THERAPEUTICS. Fourth Edition. A Manual of Practical Thera- peutics, considered with reference to Articles of the Materia Medica. Containing, also, an Index of Diseases, with a list of the Medicines applicable as Remedies, and a full Index of the Medicines and Preparations noticed in the work. By Edward John Waring, m.d., f.r.c.p., f.l.s., etc. 4th Edition. Rewritlen and Revised. Edited by Dudley W. Buxton, m.d., Asst. to the Prof, of Medicine at University College Hospital ; Member of the Royal College of Physicians of London. 666 pages. Cloth, #3.00; Leather, ^3.50 *^* These books may be obtained from booksellers, or, upon receipt of price, any book will be sent, postage prepaid. Full catalogues upon application. JUST PUBLISHED. SECOND EDITION. HUMAN PHYSIOLOGY. By LANDOIS and STIRLING. Wifh nearly 600 lllustraiions. SECOND AMERICAN, FROM THE FIFTH GERMAN EDITION. A Text-Book of Human Physiology, including Histology and Microscopical Anatomy, with special reference to the requirements of Practical Medicine. By Dr. L. L.ANDOis, Professor of Physiology and Director of the Physiological Institute, University of Greifswald. Translated from the Fifth German Edition, with addi- tions by Wm. Stirling, m.d., sc.d., Brackenburg, Professor of Physiology and Histology in Owen's College and Victoria University, Manchester; Examiner in the Honors' School of Science, University of Oxford, England. Second Edition, revised and enlarged. 583 Illustrations. "A BRIDGE BETWEEN PHYSIOLOGY AND PRACTICAL MEDICINE." One Volume. Royal Octavo. Cloth, $6.50 ; Leather, $7.50. From the Prefaces to the English Edition. The fact that Prof. Landois' book has passed through four large editions in the original since 1880, and that in barely six months' time a second edition of the English has been called for, shows that in some special way it has met a want. The characteristic which has thus commended the work will be found mainly to lie in its eminent practicability; and it is this consideration -vhichhas induced me to undertake the task of putting it into English. Landois' work, in fact, forms a Bridge between Physiology and the Practice of Medicine. It never loses sight of the fact that tlie student of to day is the practicing physician of to-morrow. In the same way, the work offers to the busy physician in practice a ready means of refreshing his memory on the theoretical aspects of Medicine. lie can pass backward from the examination of patho- logical phenomena to the normal processes, and, in the study of these, find new indications and new lights for the appreciation and treatment of the cases under consideration. With this object in view, all the methods of investigation which may, to advantage, be used by the practitioner, are carefully and fully described. Many additions, and about one hundred illustrations, have been introduced into this second English edition, and the whole work carefully revised. PRESS NOTICES. "Most effectiv;ly aids the busy physician to trace from morbid phenomena back the course of divergence from healthy physical operations, and to gather in this way new lights and novel indications for the comprehension and tkeatment ot the maladies with which he is called upon to cope." — American Journal (jf Uledical Sciences. " I know of no book which is its equal in the applications to the needs of clinical medicine." — Pro/. Harrison Allen, lai* Professor ff Physioloi^y, University of Pennsylvania. " We have no hesitation in saying that this is the work to which the Practitioner will turn whenever he desires light thrown upon ilie phenomena of a complicated or important case." — Edinburgh Medical Journal. " So great are the advantages oflfered by Prof. Landois' Text- Book, from the exhaustive and bminrntly practical manner in which the subject is treated, that it has passed through four large editions in the same nuniber of years. . . . Dr. Stirling's annotations have materially added to the value of the work. Admirably adapted for the Practitkinkr. . . . With this Text-book at command, NO Student could fail in his examination." — The Lancet. "One of the mkST practical works on Physiology ever written, forming a ' bridge ' between Physiology and Practical Medicine. . . . Its chief merits are its completeness and conciseness. . . . The additions by the Editor are able and judicious. . . . Excellently clear, attractive and succinct." — British Medical Journal. " The great subjects dealt with are treated in an admirably clear, terse, and happily illustrated manner." — Practitioner. "Unquestionably the most admirable exposition of the relations of Human Physiology to Practical Medicine ever laid before English readers" — Students' Journal. " As a work of reference, Landois and Stirling's Treatise ought to take the foremost place among the text- books in the Engli'^h language. The wood-cuts are noticeable for their number and beauty." — (^last^tnn Medical Journal. " Landois' Physiology is, without question, the best text-book on the subject that has ever been written." — Neiu York Medical Record. " The chapter on the Brain and Spin.-il Cord will be a n"ost valu.able one for the general reader, the tran!;l:itor's notes adding not a little to its importance. The sections on Sight and Hearing are exhaustive. . . . The Chemistry of the Urine is thoroughly considered. ... In its present form, the value of the original h.is been greatly increased. . . . The text is smooth, accurate, and unusually fiee from tjermanisms ; in fact, it is good English." — Ne-w York Medical Journal. " It is not for the physiological student alone that Prof. Landois' book possesses great value, for tt has bfen addresskii TO the practitioner of medicine as well, who will find here a direct application of physiological to pathological processes." Af-dical liulletin. P. BLAKISTON, SON & CO., Publishers, 1012 Walnut St., Philadelphia. JUST READY. A TEXT-BOOK OF DISEASES OF THE EYE. BY DR. EDOUARD MEYER, Prof, i V Kcole Pratique de la Faculte de Medecine de Pai'is ; Chevalier of the Legion of Honor, etc. AUTHORIZED TRANSLATION BY FREELAND FERGUS, M. B., Assistant Surgeon, Glasgow Eye Infirmary. COLORED PLATES PRINTED UNDER THE DIRECTION OF DR. RICHARD LIEEREICH, M. R. C. S., Author of the "Atlas of Ophthalmoscopy." WITH COLORED PLATES AND 267 ENGRAVINGS ON WOOD. Octavo. 650 Pages. Cloth, $4.50 ; Leather, $5.50. Synopsis of Contents. — Diagnosis and Treatment of Ocular Affections. Diseases of the Conjunc- tiva. Diseases of the Cornea and Sclerotic. Iris — Ciliary Body — Choroid. Glaucoma. Diseases of the Optic Nerve and Retina. Amblyopia and Amaurosis. Diseases of the Vitreous Body. Diseases of the Crystalline Lens. Refraction and Accommodation. The Muscles of the Eye. Diseases of the Eyelids. Diseases of the Lachrymal Passages. Diseases of the Orbit. Table of Dioptrics. Index. Fig. 27.— Pterygium. Forming a complete systematic Manual of Ophthalmology. The translating and editing have been done with the assistance of the author. The illustrations, which will be found of great help in diagnosis, have been care- fully engraved ; the colored plates, being re- duced from Liebreich's Atlas of Ophthalmology and printed under the direction of Dr. Liebreich, are accurate and faithful representations of their subjects. Treatment and Diagnosis receive full share of attention. Refraction and accommodation (Attention is called to the help in diagnosis of a occupy a scction of ovcr sixty pagcs, being cut of this character. It is followed by three en- handled in a practical, concisc way that will gravings showing the operation for Pterygium.) . , , . commend itself specially to students and physi- cians who have given the subject but little attention. The chapters describing the subject of general diagnosis and the proper instruments to be used, are thorough and well illustrated. Dr. Swan M. Burnett, reviewing the book in Tke Archives of Ophthalmology, says : " The cause of its popularity is not far to seek. It is clear, concise, conservative and eminently practical." This book has gone through three French and four German Editions, has been translated into Italian, Spanish, Polish, Russian, Japanese — this, the English Edition, making the eighth language in which it has been published. P. Blakiston, Son & Co., Publishers, 1012 Walnut Street, Philadelphia. COWERS' DISEASES OP THE NERVOUS SYSTEM. Complete in One Large Octavo Volume. 1360 Pages. 341 Illustrations, con- taining over 700 Figures. Price in Cloth, $6 50 ; in Leather, $7.50. A COMPLETE TEXT-BOOK. By William R. Gowers, m.d., Professor Clinical Medicine, University College, London, Physician to University College Hospital and to the National Hospital for Paralyzed and Epileptic, etc. Published by special arrangement with the author, and containing all the mate- rial in the two-volume English edition, with some corrections and additions. This is probably the most exhaustive book ever published on Nervous Diseases. The author's breadth of scope, systematic and interesting style, combine to make his work one of the most useful that has been published in any branch of medicine. " The work, therefore, while serving to initiate the general reader in the elements of that science, ranks higher than a more textbook on the subject. The author's object has been, in our opinion, skillfully and successfully carried out, and a perusal and study of this will place the student and practitioner in possession of all the leading and essential facts necessar>' to investigate and treat diseases of the nervous system according to the most recent improvements of our knowledge at the present day." — British Medical Journal. "It maybe said, without reserve, that this work is the most clear, concise and complete text-book upon diseases of the nervous system in any language. And when the large number of such works which has appeared in Ger- many, France and England within the past ten years is considered, this implies high praise." — American Journal Medical Science , June , iSSS. " It would be invidious to praise one part more than another, where all is so good. Brevity and conciseness, combined with completeness and the most absolute clearness, are the characteristics of the work. T.iken as a whole, it promises to be the most useful work on diseases of the nervous system which we possess." — Dublin Journal 0/ Medical Sciences. "The student and practitioner will find in it a true friend, guide and helper in his studies of the diseases of the nervous system. It is a most complete manual, presenting a thor',ugh reflex of the present state of know- ledge of the diseases of the nervous system. The care and thought that have been bestowed on its production are evident on every page. In the presence of such ability, learning and originality, criticism can only take a favorable direction. The style and manner are accurate, studied and adequate — never diffuse. The illustrations call for special notice. They are numerous, new and original. No better manual on nervous disAses has been presented to the medical profession." — London Lancet, " From a small beginning a great work has gradually been evolved. Less than ten years ago Gowers put out a very modest little book on the ' Diagnosis of Diseases of the Spinal Cord,' which was soon followed by an equally modest treatise on ' Diseases of the Brain.' Two years ago the first half of this manual appeared, com- prising Diseases of the Spinal Cord and Nerves, and now this manual of Diseases of the entire Nervous System is placed before us. Cowers' manual is herewith recommended to the general and to the special student. It is not too detailed for the former, while for the specialist it is explicit enough as a first-class book of reference. It is, on the whole, an admirable treatise." — journal of Nervous and Menial Diseases, Netv York, May, jSSS. * * * " The contents is so vast as to make it impossible, in a review, to enumerate the subjects handled by the author, far less to attempt an analysis and discussion of the views held by him on the numerous problems with which he has to deal. We shall limit ourselves, therefore, almost entirely to a statement of the leading features of this manual, that characterize it as one of the very best published in any langu.ige. * * • What we admire, first, is the clearness of thought and language in the exposition, even in the most difficult portions of the subject. It is not every one who, being a master, is at the same time a skillful expounder, and knows how to elucidate, whilst condensing, his theme. Secondly, we find the evidence on every page of the book of the author's individual familiarity with the topics he is discussing. • • • Finally, we note the thorough mas- tery of the author of the most recent researches."— .5rai«, Lyndon, /SS3. P. BLAKISTON, SON & CO., I>ul>lislier8, 101X3 "W^alnut Street, PbUadelpliia, I»». A NEW^ TEXT-BOOK JUST PUBLISHED. DISEASES OF THE SKIN. BY T. MCCALL ANDERSON, M.D., Professor of Clinical Medicine in the University of Glasgow. ASSISTED BY Dr. James Christie, Sec'y London Epidemiological Society for Indian Ocean and East Africa ; Mem. Medical Soc. of Bombay, etc. Dr. Hector C. Cameron, Surgeon and Lecturer to Western Infirmary, Glasgow; Surgeon to Glasgow Hospital for Children, etc. William Macewen, m.b., m.d., Lecturer on Systematic and Clinical Surgery, Royal Infirmary ; Surgeon to Royal Infirmary and Children's Hospital, Glasgow, etc. WITH COLORED PLATES AND NUMEROUS WOOD ENGRAVINGS. Octavo. 650 Pages. Cloth, $4.50 ; Leather, $5.50. A treatise on Diseases of the Skin, with reference to Diagnosis and Treatment, including an Analysis of 11,000 Consecutive Cases. Thoroughly illustrated by new and handsome wood engravings, and several colored and steel plates prepared, under the direction of the author, from special drawings by Dr. John Wilson. PARTICULARLY STRONG IN TREATMENT. B@°" Special attention is given to the Differential Diagnosis of Skin Diseases and to the treatment. There are over 150 prescriptions, which will serve as hints to the physician in dealing with obstinate and chronic cases. There has been no complete treatise on Dermatology issued for several years ; Professor Anderson has, therefore, chosen an opportune time to publish his book. Illustrating one of the Diseases of the Hair (See Fig, b,^age 7). For nearly twenty-five years Professor Anderson has been a general practitioner and a hospital physician, with unusual opportunities for the study of this class of diseases, though not a "specialist," as the term is understood. His experience is, therefore, of great value, and the physician will feel that, in consulting this work, he is reading the expe- riences of a man situated as himself — with the same difficulties of diagnosis and treatment, and who has surmounted them successfully. We believe this to be a valuable feature of the book that will be recognized at once ; for it is undoubtedly a fact that a work like the present contains much practical information and many hints not to be found else- where. Professor Anderson is particularly happy in illustrating the impor- tant relations subsisting between the general economy and its covering, and his ideas of pathology and therapeutics, including a consideration of all the general, and local manifestations of the common diseases of the economy which are manifested upon the surface, will find many appreciative readers. Diseases of the hair receive full systematic treatment. " We welcome Dr. Anderson's work not only as a friend, but as a benefactor to the profession, because the author has ; stricken off mediaeval shackles of insuperable nomenclature and made crooked ways straight in the diagnosis and treatment of this hitlTierto but little understood class of diseases. The chapter on Eczema is, alone, worth the price of the book." — Nashville Altdical News. ^ P. Blakiston, Son & Co., Publishers, 1012 Walnut Street, Philadelphia. JUST READY. THE SEVENTH REVISED AND ENLARGED EDITION OF ROBERTS' PRACTICE. THE THEORY AND PRACTICE OF MEDICINE. By Fred. T. Roberts, m.d., k.r.c.p., Professor of Materia Mcdica and Therapeu- tics at University Hospital, Physician to Univcrs-.*^ College Hospital, etc. Seventh Edition. Revised and Enlarged. One vo.."'nr>e, 8vo., with nu- merous Illustrations. Cloth Binding, $5.50; Leather, $6.50 The present edition has been fully revised throughout, and in some parts rewritten or re- arranged. While an endeavor has been made to bring every subject up to date in all its aspects, special attention has been given to the questions of treatment, with the view of bringing into notice important therapeutic agents or methods which have been recently introduced. The unexceptional large and rapid sale of this book, and the universal commendation it has received from the profession, seems to be a sufficient guarantee of its merit as a Text-book. The publishers are in receipt of numerous letters from professors in the medical schools, speaking favorably of it, and below they give a few extracts from the medical press, American and English, attesting its superiority and value to both student and practitioner. The present edi- tion has been thoroughly revised and much of it re- written. " The best Text-book for students in the English language. We know of no work in the English language, or in any other, which competes with this one." — Edinburgh Medical Journal. " Dr. Roberts' book is admirably fitted to supply the want of a good Handbook, so much felt by every medical student." — Student's Journal and Hospital Gazette. "There are great excellencies in this book, which will make it a favorite with the student." — Richmond and Louisville Journal. " We heartily recommend it to students, teachers, and practitioners." — Boston Medical and Surgical Journal. " It is unsurpassed by any work that has fallen into our hands as a compendium for students." The Clinic. " We particularly commend it to students about to enter upon the practice of their profession." — St. Louis Medical and Surgical Journal. " If there is a book in the whole of medical literature in which so much is said in so few words, it has never come within our reach." — Chicago Medical Journal. BY THE SAME AUTHOR. NOTES ON MATERIA MEDICA AND PHARMACY. ESPECIALLY ARRANGED FOR THE USE OF STUDENTS. 16mo, Cloth, $2.00. For sale by all Booksellers ; or will be sent by mail, postpaid, on receipt of price by the Publishers, P. BlakIston, Son & Co., 1012 Walnut Street, Philadelphia. PERIODICALS PUBLISHED BY P. BLAKISTON, SON & CO. THE POLYCLINIC. Vol. VL A Monthly Journal of Medicine and Surgery. Doubled in Size Without Increase of Price. $i.oo PER ANNUM. SAMPLE COPIES FREE. EDITOR-IN-CHIEF, HENRY LEFFMANN, M. D. Tlie Polyclinic contains More original and clinical articles prepared especially for it by prominent writers than any other Medical Journal of its size and price. Arrangements have been made to secure reports of clinics by well-known lecturers in New York, Chicago and other cities, as well as in Philadelphia. A special department of Therapeutics has been added, in which will be described the action of new remedies and newly-discovered action of old drugs; also a department of Clinical Ab- stracts from foreign journals. Both departments are in charge of men selected for their special fitness for the purpose. REGULAR CONTRIBUTORS.— Chas. H. Burnett, m.d. (Oio/ogy), Arthur Ym Har- lingen, m.d. {Skin Diseases), John B. Roberts, m.d. {Surgery), Thos. J. Mays, M.D. {Therapeu- tics), J. Henry C. Simes, m.d. {Surgery), Chas. K. Mills, M.D. {Nervous Diseases), and others. Clinical Lectures, Papers and Original Articles appeared by the following gentlemen during 1887:— Goodell (Prof. Wm.), Univ. of Penna. Meigs (Dr. A. V.), Phys. to Penna, and Child. Hosp. Osier (Prof. Wm.), Univ. of Penna. Willard (Dr. DeForest). Mittendorf (Dr. VV. M.), Surg, to N. Y. Eye and Ear Infirmary. Sinkler (Dr. Wharton), Phys. to Orth. Hosp. Browne (Lenno.x, f.k.c s.), London. Brubaker (Dr. A. P.), Dera. of Physiology, Jefferson Med. Coll. Steele (D. A. K., m.d.). Prof. Orth. Surg., Coll. Phys. and Surg., Chicago. McMurtrie (Dr. L. S.), Danville, Ky. Tyson (Dr. Jas.), Prof. Pathology, Univ. of Penna. Hartshorne (Dr. Henry). DaCosta (Dr John C ), Gynjecologist to Jeff. Med. Coll. Hosp. Henry (Dr. F. P.), Phys. to Episcopal Hospital, Phila. A. SPECIAL OFFER. '^^ &^ch. new subscriber, who remits one dollar, in I - .1 advance, we will send The Polyclinic for one year and A copy of either of the following books : — Urinary and Renal Derangements and Calculous Disorders, with Hints on Diagnosis and Treatment, by Lionel S. Beale, m.d., i2mo, 356 pages; Roberts' Materia Medica, i6mo, 388 pages; or Thompson's Surgery of the Urinary Organs, 8vo, 150 pages. The Journal of Laryngology and Rhinology. An Analytical Ra«i»rd of Current Literature Relating to the Throat and Nose. Edited by MORELL MACKENZIE, M.D., Lond., and R, NORRIS WOLFENDEN, M.D., Cantab. With the Co-operation of Dr. Fauvel (Paris), Dr. Joal (Paris), Prof. Massei (Naples), Prof. GuvE (Amsterdam), Dr. Capart (Brussels), Dr. Hunter Mackenzie (Edinburgh), Dr. Michael (Hamburg), Dr. Ramon de la Sota y Lastra (Seville), Dr. John N. Mackenzie (Baltimore), Dr. Holger Mygind (Copenhagen), Dr. Smyly (Dublin), and Dr. Greville Macdonald (London). PUBLISHED MONTHLY. PER ANNUM, $3.00. SAMPLE NUMBERS 25c. "the ophthalmic reviewT A Monthly Record of Ophthalmic Science. Edited by JAMES ANDERSON, M.D., London ; KARL GROSSMANN, Liverpool; PRIESTLEY SMITH, Birmingham, and JOHN B. STORY, M.D., Dublin. MONTHLY. SUBSCRIPTION PER ANNUM $3.00. The Ophthalmic Review is the only Journal devoted to this special branch of medicine that is published in Great Britain, and therefore represents the advances made in that country as no other periodical can. Sample numbers 23 cents. Bantock (Geo. Granville, f.r.c.s.), London. Pepper (Wm., m.d.). Prof. Pract.of Med.,Univ. of Pa, Carter (Dr. Landon Gray), Prof, of Men. and Nerv. Dis., N. Y. Polyclinic. Robison (Dr. John A.), Rush Med. Coll., Chicago. Pavy (F. W., f.r.s.)", London. Price (Dr. Joseph), Phys. to Preston Retreat, Phila. Longstreth (Dr. Morris), Pathologist to Jefferson Med. Coll. AVhite (Wm. Hale, m.d.), Guy's Hospital, London. Ashhurst (John, Jr.), Prof. Clin. Surg., Univ. of Pa. Packard (Dr. John H.), Surg to Penna. Hospital. Parvin (Theophilus), Prof. Obst. and Dis. of Women, Jefferson Med. Coll. Wyeth (John A.), Prof, of Surg., N. Y. Polyclinic. Reese (Dr. John J.), Prof, of Med. Jurisprudence, Univ. of Pa. Spender (John Kent, m.d.), Bath, England. COLUMBIA UNIVERSITY LIBRARY j This book is due on the date Indicated below, or at the j expiration of a definite period after the date of borrowing, i as provided by the rules of the Library or by special ar- \ rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE i^H ^i ^^^^^^H C28(239)MI00 RKFOl -^illebrowri i:OLUMBIA UNIVERSITY LIBRARIES (hsl.stx) RK 501 F48 C.1 A text book o( operative dentistr