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diff --git a/old/52720-0.txt b/old/52720-0.txt deleted file mode 100644 index d7323b6..0000000 --- a/old/52720-0.txt +++ /dev/null @@ -1,2901 +0,0 @@ -The Project Gutenberg EBook of Extraction of the Teeth, by J. F. Colyer - -This eBook is for the use of anyone anywhere at no cost and with -almost no restrictions whatsoever. You may copy it, give it away or -re-use it under the terms of the Project Gutenberg License included -with this eBook or online at www.gutenberg.org/license - - -Title: Extraction of the Teeth - -Author: J. F. Colyer - -Release Date: August 4, 2016 [EBook #52720] - -Language: English - -Character set encoding: UTF-8 - -*** START OF THIS PROJECT GUTENBERG EBOOK EXTRACTION OF THE TEETH *** - - - - -Produced by deaurider, Chuck Greif and the Online -Distributed Proofreading Team at http://www.pgdp.net (This -file was produced from images generously made available -by The Internet Archive) - - - - - - - - - - - EXTRACTION OF THE TEETH. - - - - - EXTRACTION OF THE TEETH - - - BY - - J. F. COLYER, L.R.C.P., M.R.C.S. L.D.S. - - -_Dental Surgeon and Lecturer on Dental Surgery to Charing Cross Hospital: - Assistant Dental Surgeon to the Dental Hospital of London_ - - - London: - CLAUDIUS ASH & SONS, LIMITED, - 5, 6, 7, 8 AND 9, BROAD STREET, GOLDEN SQUARE, W. - - 1896 - - - - -CONTENTS. - - -CHAPTER I. PAGE - -THE GENERAL PRINCIPLES OF EXTRACTION OF THE TEETH 1 - - -CHAPTER II. - -THE EXTRACTION OF INDIVIDUAL TEETH 19 - - -CHAPTER III. - -THE EXTRACTION OF MISPLACED TEETH 46 - - -CHAPTER IV. - -THE USE OF ANÆSTHETICS DURING EXTRACTION OF THE TEETH 56 - - -CHAPTER V. - -DIFFICULTIES, COMPLICATIONS, AND SEQUELÆ OF EXTRACTION OF THE TEETH 63 - -INDEX 96 - - - - -EXTRACTION OF THE TEETH. - - - - -CHAPTER I. - -The General Principles of Extraction of the Teeth. - - -As an operation, extraction of teeth is fortunately becoming more rare, -but even now large numbers are needlessly sacrificed, in many cases -owing to ignorance on the part of the patient of the value of the teeth, -at times to lack of knowledge on the part of both operator and patient -of the modern methods of conservative dentistry. With the assistance of -antiseptics in the treatment of root-canals, and the increase in -knowledge of the methods of filling and crowning teeth, it is now -possible to retain many which would in former days have been -extracted--indeed it may be said with truth that all teeth and many -roots are capable of being saved and rendered useful, with the exception -of-- - -(1) Those teeth whose roots are much shortened by absorption. - -(2) Those teeth from which the alveolar process has disappeared to such -an extent as to leave them quite loose; and - -(3) Those teeth attacked with chronic periodontitis, which, in spite of -treatment, tends to become worse. - -Special circumstances naturally alter cases; for instance, with patients -the subjects of nervous prostration, or feeble in health, a lengthy -operation is often contra-indicated, and under such conditions -extraction may be preferable to the lengthy and tedious processes of -conservative treatment. Another indication for extraction is in cases of -teeth setting up or aggravating ulceration of the tongue, lips, or other -soft parts of the mouth. Teeth fractured in a longitudinal direction -should generally be removed, and the same rule applies to those which -are so misplaced as to be incapable of being brought into the normal -arch. In crowded conditions of the teeth extraction is often called for, -and under such circumstances is really conservative treatment. - -If extraction be determined upon, _a careful examination of the tooth_ -to be removed should be made. This will allow some idea to be formed of -the amount of sound tissue present, and also of the force which will be -necessary for the dislodgment of the tooth. In the case of roots, the -edges must be defined, and for this purpose a blunt probe, similar in -pattern to that shown in fig. 1 will be found useful. - -[Illustration: FIG. 1.] - -=Instruments.=--The instruments in general use for the removal of teeth -are forceps and elevators. _The Forceps_ is an amplified pair of pincers -or pliers. It is made up of three parts, namely, the blades or portions -beyond the joint which are applied to the tooth, the joint itself, and -the handles. Forceps should be made of fine steel, should be light and -yet strong enough to withstand without bending any strain that may be -put upon them.[1] The blades should be shaped to fit the tooth they are -intended to remove, and they should be clear of the crown when applied. -On longitudinal section a blade should present a thin wedge-shaped -appearance. Two kinds of joints are met with. In the first variety one -half of the forceps passes through a slot in the other, the two being -held together by a rivet passing through the centre (fig. 2). In the -second variety (fig. 3) the two halves are held together side by side by -a screw or pin which takes the entire strain. Most forceps of English -manufacture are made on the latter plan, which has the advantage of -permitting the instrument to be easily cleaned; it also allows a slight -lateral movement of the two halves--a point of some practical -importance. It is urged against this style of joint that it is weak; in -practice, however, this is not found to be the case. - -[Illustration: FIG. 2.] - -[Illustration: FIG. 3.] - -The handles should be of a size and shape to lie comfortably in the palm -of the hand, and should be in such relation to the blades that when the -latter are applied in the direction of the long axis of the tooth, the -handles clear the lips. - -As a general rule, in forceps designed for the removal of the anterior -teeth in the maxilla, the blades and handles are in the same line (fig. -4), - -[Illustration: FIG. 4.] - -[Illustration: FIG. 5.] - -while for the upper back teeth the handles form a curve of greater or -less extent with the blades (fig. 5). In forceps for the lower teeth the -blades are bent down from the handles to an angle of nearly ninety -degrees. In one class, namely, the hawk’s-bill, when the blades are -applied to the tooth the handles are at right angles to the line of the -arch (fig. 6), while in other classes the handles are in line with the -arch (fig. 7). - -[Illustration: FIG. 6.] - -[Illustration: FIG. 7.] - -The manner of holding forceps is shown in figs. 8, 9, 10. The handles -should rest comfortably in the palmar surface of the hand, and in such a -manner that the end of one handle rests between the thenar and -hypothenar eminences--a portion of the hand where force can be applied -with advantage. - -The thumb placed between the handles acts as a regulator to control the -amount of pressure of the blades upon the tooth. As a precaution it is -well to have the ball of the thumb well between the handles, so that the -pressure is counteracted not only by the soft tissues, but also by the -terminal bony phalanx of the thumb. If this precaution be not observed, -any sudden crushing of the tooth may be accompanied by a severe and very -painful contusion of the operator’s thumb. - -[Illustration: FIG. 8. - -Mode of holding forceps for the removal of upper teeth.] - -_The Elevator_ consists of two parts--the handle and the blade. The -former, usually made of wood or ivory, is about four inches in length -and of a shape suitable to allow a firm grip being obtained of it by the -hand. The blade is made of fine steel, and is about two inches long. -Elevators are of two varieties, straight and curved. In the first form -the blade is thin, about one-fifth of an inch in breadth, one surface -being made convex and the other flat. The point of the blade may be -rounded as shown in fig. 11, or spear-shaped, as shown in fig. 12. - -[Illustration: FIG. 9. - -Mode of holding lower “hawk’s bill” pattern forceps.] - -[Illustration: FIG. 10. - -Mode of holding forceps of pattern shown in fig. 30.] - -In the curved variety, the terminal half inch of the steel portion of -the instrument is bent at an angle with the shaft of the instrument -(fig. 49). The edge of the blade of an elevator should always be kept -sharp. - -The method of holding an elevator is shown in fig. 13. The handle should -rest comfortably in the palm of the hand, the first finger lying along -the blade and being brought near the point so as to prevent the -instrument slipping. When using the elevator for the removal of teeth on -the right side of the mandible, the finger should lie along the curved -side of the blade, and on the flat side when extracting teeth on the -left side. - -[Illustration: FIG. 11.] - -_The Screw_ (fig. 14) is an instrument which on rare occasions is useful -for the removal of deep seated roots. - -[Illustration: FIG. 12.] - -After being used, instruments of every kind should be freed from all -foreign matter and then carefully sterilised. - -The next point which demands attention is the =position of the operator -and patient=. The chair should be placed before a good light, and if a -proper dental chair is not to hand an ordinary arm chair may be -utilised; failing this, two ordinary chairs may be placed back to back, -on one of which the left leg of the operator should be raised to form a -rest for the patient’s head. The patient should be placed in such an -unconstrained position as will allow the operator to exert all necessary -movements with freedom. - -[Illustration: FIG. 13.] - -[Illustration: FIG. 14.] - -The operator should place himself so as to use his force to the greatest -advantage. His left arm may be utilised, if necessary, for steadying the -movements of the patient’s head, while the fingers of the left hand can -be employed-- - -(1) To keep the cheek and other soft parts away so as to obtain a clear -view of the tooth to be extracted and its immediate neighbours; - -(2) To support the mandible; - -(3) To grasp the alveolus and so allow some idea to be gained of the -effect of the force employed. - -The special positions for the removal of different teeth will be -described in chapter ii. - -It may be advantageous, before describing the steps of the operation of -extraction, to refer briefly to a few =points in the anatomy of the teeth -and jaws= which have a direct bearing upon the manner of carrying it out. - -If the teeth be examined it will be noticed that they are capable of -division into-- - -(1) Teeth with single, rounded tapering roots; - -(2) Teeth with single roots more or less irregularly flattened or -curved; - -(3) Teeth with multiple roots. - -Under (1) are included the upper incisors (temporary and permanent) and -the lower bicuspids; (2) the lower incisors and canines (temporary and -permanent), and also the upper canines and bicuspids; (3) the upper and -lower molars (temporary and permanent) and frequently the first upper -bicuspids.[2] - -The shape of the roots, as we shall subsequently find, has an important -bearing upon the manner in which force is to be applied when severing -them from their attachments. - -A correct acquaintance with the disposition of the alveoli of the teeth -is of importance for skilful and successful operating. Fig. 15 gives a -general idea of the appearance of the alveoli, but it is needless to say -that a full knowledge can only be really obtained by a careful study of -the bones themselves; by this means, too, some idea of the strength of -different portions of the alveolar borders can be obtained--a matter of -some moment when applying force in the process of removing a tooth from -its socket. The points to be specially noted in the maxilla are the -thinness of the outer alveolar wall as compared with the inner, the -prominence of the canine socket, and the cancellous character of the -bone in the region of the third molar. In the mandible the outer -alveolar border will be seen to be thinner than the inner, with the -exception of that portion in the region of the - -[Illustration: FIG. 15. - -From the “American System of Dentistry.”] - -third, and often of the second molar; another fact worthy of attention -is that at the posterior portion of the socket of the third molar the -bone is moderately dense. - -=When performed with forceps the operation of tooth extraction may be -divided into three stages:--= - -(1) Adaptation of the forceps to the tooth. - -(2) Destruction of its membranous connections with, and dilatation of, -the socket. - -(3) Removal of the tooth from the socket. - -In the initial stage the _first step_ is the application of the blades, -and, in this connection, care must be taken to see that the points pass -between the gum and the tooth, and also that they are applied parallel -with the long axis of the root. It is, as a rule, best first to apply -the blade on the side of the tooth most obscured from view, and then -lightly to close the other upon the opposite side. The blades should -then be forcibly pressed upwards or downwards, as the case may be, in -the direction of the apex of the root; a slight rotary or wriggling -motion will often be found of assistance in the process. This “pressing” -movement should be continued until a firm hold of the root has been -obtained--a point of great importance, as upon it the successful removal -of the tooth in a large measure depends. The handles should next be -firmly closed, so as to give the blades a good grip, and the amount of -pressure applied should be such, that when movement has commenced the -blades do not ride upon the surface of the root. The amount of pressure -to be applied must naturally vary according to the character of the -tooth to be removed, and the resistance offered by the alveolar process. -The thumb placed between the handles of the forceps, as previously -pointed out, should counteract the pressure applied to the root and -prevent crushing, which, should it occur, may make the subsequent -removal very difficult. - -The _second stage_--the destruction of the membranous attachments and -dilatation of the socket--is accomplished by employing force in either a -rotary or a lateral direction. The movement to be employed depends upon -the form of the root or roots to be removed and the resisting strength -of the surrounding hard structures, and at this point it need only be -remarked that rotary motion is alone admissible in the case of teeth -possessing a single conical root. - -The _final stage_ is carried out by exerting extractive force in the -direction of the long axis of the tooth, and also in that of least -resistance; the latter is determined by a knowledge of the anatomy of -the alveolar border, and by the sensation conveyed to the hand through -the forceps. - -=The removal of a tooth with a straight elevator= is accomplished in the -following manner. The blade, with the flattened surface towards the -tooth to be removed, is inserted between the root and the alveolus, the -instrument being kept as far as possible parallel with the anterior -surface of the crown. The blade is then forced downwards so as to reach -the root at as low a point as possible; the handle of the elevator is -then rotated away from the direction in which the tooth is to be -removed. This has the effect of both raising the tooth in its socket and -displacing it in the required direction. One such movement of the -instrument rarely suffices for the removal of a tooth, a second, and -sometimes a third grip, each time nearer to the apex of the root, having -to be obtained. - -The method of using a curved elevator will be described in dealing with -the removal of the roots of lower molar teeth. - -=The wound resulting from the removal of a tooth= is a lacerated one, and -heals by “granulation.” The socket immediately after the operation -becomes filled with coagulated blood, which is eventually replaced by -granulation tissue, followed at a later period by the formation of loose -cancellous bone. - -A varying amount of absorption of the alveolar border always follows the -removal of a tooth, the continuity in the surface of the gum being -restored by ordinary cicatricial fibrous tissue. - -The wound is best treated by keeping the parts carefully cleansed as far -as possible from all foreign matter, and for this purpose an antiseptic -mouth-wash[3] should be used several times a day. From the wound -resulting from the extraction of an upper tooth the discharge drains -away in a natural manner owing to the orifice being the most dependent -part. From the wound caused by the removal of a lower tooth such is not -the case, and should suppuration take place the socket must be -frequently syringed with some antiseptic solution, and if necessary, -packed. - -=The Extraction of the Temporary Teeth.=--Although the actual details of -the extraction of the temporary teeth do not differ from those of the -permanent teeth, there are, nevertheless, one or two points to which -attention may with advantage be directed. First and foremost, a child -should not be deceived, and if it is necessary to extract a tooth, the -child should be told and not taken unawares. When, too, a child resists -having a tooth removed, the operation must not be forcibly carried out, -for by a little patience and moral suasion on the part of the operator, -the better side of a child’s nature can generally be gained. It should -also be remembered that anæsthetics are quite as needful for the -extraction of the temporary as the permanent teeth, the pain to be borne -by a child being quite as great as that to be endured by an adult. - - - - -CHAPTER II. - - -The Extraction of Individual Teeth. - -(1)=UPPER TEETH.=--For the removal of teeth in the maxilla the patient -should be placed at such a level that the arm of the operator can, if -necessary, embrace the head of the patient with comfort. The operator -should stand at the right side of the patient, and slightly in front, -the first finger and thumb being placed on either side of the alveolus -(fig. 16). In the event of the patient becoming restless, the arm should -be shifted so as to encircle the head and hold it firmly. - -(_a_) =Upper Incisors.=--The roots of both the upper central and lateral -incisors are usually cone shaped, the anterior surface being the arc of -a greater circle than that of the posterior. Forceps for the removal of -these teeth ought therefore to have the blades made in a corresponding -manner (see fig. 17). The lateral incisor is smaller than the central, -and has at times a root somewhat flattened. In removing upper incisors -the posterior blade is applied first, care being taken to - -[Illustration: FIG. 16.] - -see that the edge of the instrument passes between the gum and the -tooth. To dislodge these teeth a firm inward movement should be made in -a direction towards the palate, this movement being followed by one in -an outward direction. If this fails to dislodge the tooth from its -attachments, a firm rotary motion, first to the right and then to the -left, may be tried (the amount of rotation necessary being only about an -eighth of the circle represented by the circumference of the root). -Rotation is generally recommended in the first instance for the -extraction of these teeth, but the inward movement is, I think, best, -the teeth yielding more readily and with less laceration of the soft -tissues. - -The extraction of the roots of these teeth does not as a rule present -much difficulty. When moderately sound the instrument shown in fig. 17 -may be used, but in those instances where the root is much decayed, and -lies well below the gum margin, a rather finer pair will be found more -serviceable. The manner of removal is similar to that used when the -crown is standing. - -[Illustration: FIG. 17.] - -(_b_) =Upper Canines.=--These teeth, like the incisors, are single rooted, -but the difference between the curve of the anterior and posterior -surfaces is greater. The roots too are much longer, more firmly -implanted, and hence require more force in their removal. Forceps -similar in pattern to those used for incisors may be used, the severance -of the tooth from its attachments being brought about by force applied -in an inward, followed by an outward, direction. The root being more or -less three sided, rotation cannot well be adopted. - -The roots of canine teeth are to be removed in the same manner as that -adopted for the whole tooth. - -(_c_) =Upper Bicuspids.=--The first bicuspid has usually one root -flattened and more or less longitudinally grooved on its mesial and -distal surfaces. If this grooving is much marked, it results in a -greater or less division of the root into two slender terminations. -Whether such bifurcation exists or not can seldom be determined before -operation and would not modify the method adopted, but the tendency to -this variation should be borne in mind and the lateral movement be very -gently applied. The internal and external surfaces of the root are for -all practical purposes of equal curvature. - -The second bicuspid has usually only one root, which is not so flattened -in the antero-posterior diameter as the first. There is also not the -same tendency to grooving or bifurcation of the root as there is in the -first bicuspid. - -The blades of forceps for the bicuspids should be equal segments of the -same circle; they should also be bent at an angle with the handles, so -that the latter may clear the lower lip. The forceps shown in fig. 18 is -a useful pattern. In removing an upper bicuspid, the inner blade of the -forceps should be applied first. For severing the tooth from its -attachments a slight inward movement should first be made, followed by -an outward one. If this fails to cause the socket to yield, the inward -movement may again be made, followed by an outward one, and repeated if -necessary. The removal of the tooth from its socket is to be carried out -by force applied in a downward and outward direction. It is well to -remember that the force applied to the inward should always be slight -compared to that used in the outward direction. The removal of bicuspid -roots is carried out in a manner similar to that for the whole tooth. - -[Illustration: FIG. 18.] - -(_d_) =Upper Molars.=--The first upper molar has three roots, one internal -towards the palate (palatine), and two external (buccal); of the three -the palatine is the largest, sub-cylindrical in form, and often curved. -The two buccal roots are placed in an anterior and posterior position, -the latter being in a plane internal to the anterior one; both these -roots are somewhat flattened, and of the two the anterior is the larger. -The roots of the second molar are similar in shape to the first, but are -usually smaller. The third molar, when normal, has three roots, but very -frequently these are all fused together so as to form an abrupt tapering -cone, the point of which is often curved. - -[Illustration: FIG. 19.] - -Owing to the disposition of the roots different forceps will be required -for the removal of upper molars on the right and left side. Of the -blades, the outer or buccal should possess two grooves, the anterior -being the broader and placed in a more external plane. This blade should -also have a slight projection between the grooved surfaces to adapt -itself to the space between the buccal roots. The inner or palatal blade -should possess only one groove. A well-made pair of upper molar forceps -should fit the neck of a first upper permanent molar accurately. The -blades should be bent at an angle with the handles, so that when in use -the latter may clear the lower lip (fig. 19). The palatine blade should -be applied first, and in bringing the outer blade into place the point -should be kept over the groove on the buccal side of the tooth, as this -groove is a guide to the space between the outer roots. To sever these -teeth from their attachments force must be applied first slightly -inwards and then outwards, the movements being repeated if necessary, -the removal of the tooth from the socket being carried out by exerting -force in a downward and outward direction. Too much outward movement -leads to undue bending or fracture of the external alveolar plate. - -[Illustration: FIG. 20.] - -In removing the third molars it is advisable not to have the patient’s -mouth opened to the fullest extent, as the tension of the tissues of the -cheek will thereby be lessened and a clearer view of the outer side of -the tooth thus gained. The application of the forceps is of the utmost -importance, as one is liable, unless care is taken, to include some of -the soft tissue between the blades and the tooth and so cause a painful -laceration. Force applied inwards and then outwards is generally -sufficient to loosen these teeth, their removal being carried out by a -downward and outward movement. - -Forceps similar to those shown in fig. 19 may be used for the removal of -the third molars, but most operators use patterns the blades of which -are similar segments of the same circle (fig. 20). - -[Illustration: FIG. 21. - - (_a_) Normal upper first permanent molar. - (_b_) Oblique rooted upper first permanent molar. - (_c_) Normal upper second permanent molar. - (_d_) Oblique rooted second permanent molar.] - -There is _an abnormality of the upper molars_ which may with advantage -be mentioned here. In this deformity the posterior buccal root is -situated in a plane much internal to the anterior--in other words, it is -an exaggeration of the normal arrangement. Such teeth have been termed -by Mr. Booth Pearsall “_oblique rooted_” (fig. 21). The abnormality is -met with most frequently in the third molar, sometimes in the second, -rarely in the first. The difficulty encountered in extracting these -teeth is that the outer blade of the forceps tends to slip round. -Oblique-rooted teeth can at times be diagnosed by noting an undue -prominence of the alveolus over the anterior buccal root, and are best -removed with forceps similar to that shown in fig. 20. - -_In cases where a portion of the crown remains and the decay extends -well below the gum_ on either the palatal or buccal side, ordinary molar -forceps should be discarded and root forceps employed; useful patterns -are shown in figs. 18, 22 and 23. The removal of teeth in this condition -is carried out as follows, and for the sake of description it will be -supposed that the decay extends deeply on the palatine side. One blade -of the forceps should be first applied to the buccal side of the tooth -and to the root which is considered the stronger; the inner blade should -then be applied to the palatine root care being taken to insinuate it -between the alveolus and the root. The forceps should then be pushed -well upwards until a firm hold of the root is obtained. A firm inward -movement should then be made, as this will allow the inner blade to pass -still higher up the palatine fang and insure steadiness should the -blades tend to ride upon the surface of the root. An outward movement -should next be made, but to nothing like so great a degree as that used -in extracting molars with the whole of the crown standing. This inward -and outward movement is to be repeated until the tooth is freed, the -force being principally applied in the inward direction. - -[Illustration: FIG. 22.] - -[Illustration: FIG. 23. - -For the removal of roots towards the back of the mouth.] - -When the more extensive decay has taken place on the buccal side the -order of proceeding is slightly different. The first blade to be applied -should be the palatine, the outer blade being closed upon whichever of -the buccal roots is considered the stronger. - -The extractive force should be applied first outwards and then inwards, -these movements being repeated if necessary, the principal force being -outwards, as the object in view is to prevent the instrument slipping -off the more decayed side. - -_When a molar is so decayed that but little of the crown remains, but -all the roots are still united_, root forceps are indicated. In such a -case the inner blade is to be applied to the palatine root first, the -outer blade being closed upon the stronger of the buccal fangs. Inward -followed by outward movement should be employed, the point to bear in -mind being to use force towards the side of the tooth which is -considered the weaker. In the majority of such cases the three roots -come away together, but even if this does not happen, one or perhaps two -will be removed, the remainder being subsequently removed with but -little difficulty. - -_In cases where the resistance presented by the roots is very great_ and -an unsuccessful attempt has been made with ordinary root forceps, an -instrument with a buccal blade similar to that shown in fig. 24 may be -used. The inner blade is first applied, the outer one being brought so -as to come, if possible, into the space between the buccal roots. A -firm hold of the roots having been gained, an attempt to extract should -be made by force applied in an inward and outward direction; this -failing, sufficient pressure should be put upon the handles to split the -roots asunder. The sharp outer blade of the forceps will then pass -between the divided buccal roots on to the palatine root, which can thus -readily be brought away. A pair of ordinary upper root forceps should be -employed for removing the buccal roots. - -_If all the three roots of a molar are separate_, their extraction -presents but little difficulty, a slight rotary movement generally -sufficing. - -In all cases where there is a fear of a molar fracturing, root in -preference to ordinary forceps should be used. - -[Illustration: FIG. 24.] - - -(2) =LOWER TEETH.=--For the removal of lower teeth the patient should be -placed on a low level, the head being kept a little forward and the chin -depressed. The position of the operator will naturally differ with the -tooth to be removed - -[Illustration: FIG. 25.] - -and also with the instrument to be used. With teeth on the right side, -when hawk’s-bill pattern forceps or elevators are used, the operator -should stand behind and to the right of the patient, the left arm being -brought round the patient’s head. The thumb of the left hand should be -placed on the inner side and the first finger on the outer side of the -alveolus of the tooth to be removed, and the three remaining fingers -under and supporting the chin. In placing the fingers in the mouth, -care should be taken to keep the wrist well down so as not to impede the -entrance of light (fig. 25). - -[Illustration: FIG. 26.] - -When removing the anterior teeth or those on the left side of the mouth, -the operator should stand on the right side and slightly in front of the -patient. The left hand should be placed as follows: the second finger -on the lingual side, and the first on the labial side of the alveolus of -the tooth to be extracted, the thumb being placed under the chin (fig. -26). - -When employing forceps of the straight pattern shown in fig. 30, the -operator should stand as shown in fig. 26, but it will be found -difficult to place the fingers of the left hand on either side of the -alveolus, indeed they can only well be used for retracting the cheek and -supporting the jaw. - -In removing teeth from the lower jaw, the operator should be careful, in -raising the tooth from the socket, to guard against a sudden separation -of the tooth from its attachments which might result in damage to the -upper teeth. - -[Illustration: FIG. 27.] - -(_a_) =Lower Incisors.=--These teeth each have a single root which is much -flattened laterally. For their removal, forceps similar to those shown -in fig. 27 should be used, the blades being equal segments of the same -circle. The lingual blade should be applied first, the loosening -movement being made by taking the tooth slightly inwards and then -outwards, the final extractive force being upwards and outwards. - -The removal of lower incisor roots is carried out in a similar manner. - -(_b_) =Lower Canines.=--The lower canines have normally one root, which is -flattened laterally. In comparison with the incisors, the root is -stronger and longer. The removal of a lower canine is carried out in a -manner similar to that employed for a lower incisor, but as the tooth -presents more resistance, a greater amount of force is usually required. - -(_c_) =Lower Bicuspids.=--The lower bicuspids have normally one root which -is conical in shape. In the first bicuspid the conical shape of the root -is not so marked as in the second, the outer aspect being the arc of -rather a larger circle than the posterior. Forceps similar to those -shown in fig. 27 may be used, the blades for all practical purposes -being equal in size and shape. The lingual blade of the instrument -should be applied first, the severing of the tooth from its attachments -being carried out by a slight rotary movement around the long axis of -the tooth first in one direction and then in the other; should this not -succeed, a slight inward followed by an outward movement may be tried, -the tooth being raised from its socket by force applied in an upward and -slightly outward direction. - -The roots of lower bicuspids are to be removed in a manner similar to -that required for the extraction of a whole tooth. When the root lies -much below the level of the gum the extraction is often troublesome -owing to the difficulty in gaining a hold with the blades of the -forceps; in such cases, if an attempt with forceps has failed, the -straight elevator may be employed. - -[Illustration: FIG. 28.] - -(_d_) =Lower Molars.=--Lower molars have two roots, placed anteriorly and -posteriorly. The roots are much flattened and have a tendency to curve -backwards, this being well marked in the second and especially so in the -third molar; a fusion of the two roots is at times met with in the -second and frequently in the third molar. A section of a lower molar at -the neck shows both the buccal and lingual aspects to be composed of two -segments of a circle touching each other at one extremity; the anterior -segment being slightly the larger (fig. 28). Each blade of the forceps -used for these teeth should possess two grooves, - -[Illustration: FIG. 29.] - -[Illustration: FIG. 30.] - -separated by a projection which fits into the division between the -anterior and posterior roots; for all practical purposes the blades may -be made of the same size, so that one instrument will suffice for both -sides of the jaw. The instrument best adapted for the removal of these -teeth is shown in fig. 29, though some operators prefer the shape -illustrated in fig. 30. The advantages of the former over the latter -may be briefly summed up as follows: - -(1) A clear view of the tooth and its surroundings can be obtained -during the whole period of removal. - -(2) Force can be applied with greater advantage. - -(3) The alveolus can be easily embraced by the fingers, or by the finger -and thumb of the left hand. - -(4) In removing the tooth from the socket a slight backward movement can -be employed. - -One disadvantage of shape fig. 29 is that it is difficult to employ much -inward movement, and therefore, for teeth lying inwards, namely, with -the crown directed towards the tongue, hawk’s-bill-shaped forceps cannot -easily be used. - -Another disadvantage is that the extent of inward movement is limited by -the proximity of the upper teeth, and in case of trismus it is often -better to use straight forceps (fig. 30). In cases where there are also -much swelling and rigidity of the cheek the straight forceps cause less -inconvenience to the patient. - -In removing lower molars with forceps, the inner blade should be first -applied and then the outer, care being taken to get the points of the -blades between the interspace of the roots. For severing these teeth -from their attachments, a slight inward movement should be first made, -followed by one well outwards, this inward and outward movement being -repeated if necessary. The removal of the tooth from its socket is -carried out by force used in an upward and outward direction. The upward -force exerted upon lower teeth should always be well under control, as -not infrequently the resistance is very suddenly overcome, and, if such -precaution is not taken, there is danger of striking the upper teeth -with considerable force. - -[Illustration: FIG. 31.] - -As previously pointed out, the roots of these teeth are at times curved -a little backwards so that it is often needful in removing the teeth -from their sockets to twist the forceps in a curved direction backwards. - -In the removal of the second molar too much outward movement is not -permissible, as the outer alveolus is often very dense. - -The third molar is best removed with a straight elevator. A glance at -the illustration of this tooth (fig. 31) will show that the roots have a -well-marked curve backwards, in addition to which the bone forming the -socket of this tooth is stronger than is the case with the anterior -molars. The removal of the third molar has therefore to be accomplished -by using force in a direction upwards and backwards, in other words, in -a curve similar to the arc of the circle formed by the roots. This -movement cannot well be carried out with forceps, but is easily -accomplished with the elevator as follows (it being assumed that the -second molar is in place):--Hold the elevator as shown in fig. 13, and -insert the blade between the anterior surface of the root and the -alveolus, keeping the flattened side of the instrument as far as -possible parallel with the root surface. Then force the blade downwards -in a direction towards the apex of the root; following this, rotate the -handle away from the direction in which the tooth is to be moved. This -has the effect of both raising the tooth in its socket and displacing it -backward. The edge of the elevator which is to be brought into contact -with the surface of the root should be sharp so as to cut somewhat into -the cementum. Should this prove insufficient the handle should again be -raised and the flattened surface of the instrument brought parallel with -the anterior surface of the root and the extractive movement repeated -until the tooth is completely raised from its socket. - -In using the elevator, especial care must be taken to protect the tongue -with the fingers or thumb of the left hand, so as to prevent a slip, -which might result in puncture of the tongue, or of the operator’s -finger. - -With the third lower molar there is a tendency for the gum to adhere -tenaciously to the posterior part of the neck of the tooth. When this -happens it is better to simply raise the tooth from its socket with the -elevator or forceps, as the case may be, and then cut the gum away with -a curved pair of scissors. By this method a severe laceration of the gum -may at times be avoided. - -When the third molar is isolated owing to the absence of the second -molar, the elevator may still be employed for its removal, on the right -side the first finger, and on the left side the thumb of the left hand -being used as the fulcrum. In such cases, however, many operators -prefer to use ordinary lower molar forceps. - -_The removal of lower molars when a portion of the crown is standing, -but the decay has progressed below the gum_ on either the buccal or the -lingual aspect, is carried out with root forceps of shape shown in fig. -27. A condition similar to this in upper molars and the method indicated -for their removal were referred to on page 27. The principles enumerated -there apply equally to the removal of lower molars, so that it will not -be necessary to repeat them. The main points to bear in mind are, to -apply the blades of the forceps to the stronger root, and to use the -principal force in the direction of the weaker wall. - -_Where the roots of molars are still united_, root forceps should be -used, the blade being first applied to the lingual surface of the -stronger root. A firm hold having been obtained, the root may be removed -by employing force in a manner similar to that employed with ordinary -molar forceps. In this way both roots will usually come away together. -If, however, only one root is extracted, the remaining one can easily be -removed, either with the same forceps or a curved elevator. The curved -elevator (fig. 49) may be employed either by placing it against the -root, and so forcing it into the socket of the root already removed, or -by placing the blade in the socket of the extracted root, forcing the -point of the instrument through the intervening bone and then elevating -the remaining root. - -_With roots of lower molars which present great resistance_, forceps -with cutting blades may be used (fig. 32). The blades are inserted on -the lingual and buccal aspects of the arch in such a manner that the -points pass into the space between the roots. The handles are then -closed and an attempt is made to remove the roots in the ordinary way, -but should this prove unsuccessful the handles must be forcibly closed, -so as to divide the roots which can then, as a rule, be removed with -ordinary root forceps. - -The value of splitting roots in a case similar to that shown in fig. 33 -is apparent, for, as will be seen, it allows each root to be removed in -the line of its inclination. - -[Illustration: FIG. 32.] - -_In those cases where the roots are separated_ their removal is carried -out with root forceps, an inward and outward movement being usually -sufficient. - -The roots of third molars are best removed with a straight elevator. -The _modus operandi_ is similar to that used in extracting the whole -tooth. - -[Illustration: FIG. 33. - -(_a_) Lower molar with divergent roots. (_b_) The dotted lines show the -direction in which the root can be removed if the tooth is divided as -suggested in the text.] - -_At times the lower molar teeth are much tilted in such a way that the -crown surface stands towards the tongue._--Under such conditions their -removal is best carried out with instruments of the pattern shown in -fig. 30, since the handles of forceps of the hawk’s-bill pattern when -applied would come in contact with the upper teeth, and thus impede the -inward movement which is so necessary for the removal of teeth in this -position. - -=The Temporary Teeth.=--For the removal of upper incisors and canines, a -small pair of straight forceps of the pattern shown in fig. 34 should be -used. The first upper temporary molars are best removed with a pair of -forceps like fig. 35. - -The lower incisors and canines require a small pair of hawk’s-bill -forceps similar to the shape shown in fig. 27. For the lower temporary -molars, a small pair of forceps similar to that illustrated in fig. 29 -should be used. - -[Illustration: FIG. 34.] - -[Illustration: FIG. 35.] - -In removing the temporary teeth, care must be taken not to drive the -forceps up too high, for fear of injuring the permanent teeth; this is -more especially to be noted in connection with the temporary molars, as -the roots of these teeth practically embrace the crowns of the -bicuspids. Generally speaking, if a temporary molar fractures in the -attempt to remove it, the portion of tooth remaining in the jaw should -be left alone unless it can be brought away quite easily. - -[Illustration: FIG. 36.] - -Roots in the condition shown in fig. 36 are best removed with an -elevator as follows: the thumb of the right hand being placed on an -adjacent tooth so as to gain a hold, the point of the elevator should be -placed below the end of the root and force applied. In a few cases it -may be necessary to cut the gum with a lancet before using the elevator. - -Small pieces of the temporary teeth which persist and become wedged in -between the permanent teeth can be best removed with an excavator or a -similar suitable instrument. - - - - -CHAPTER III. - -The Extraction of Misplaced Teeth. - - -Nothing, perhaps, tests the skill of a good operator more than the -extraction of a misplaced or impacted tooth, and although it is -impossible to give anything like a complete list of the various -malpositions met with, those most commonly seen will be mentioned, and -the usual method for removing such teeth indicated. - -[Illustration: FIG. 37.] - -(_a_) =Upper Central Incisors.=--An irregularity of this tooth calling for -removal is shown in fig. 37. - -The extraction is best carried out with an instrument similar to that -shown in fig. 38, the fine inner blade being applied on the palatal side -and the broad blade on the labial. Extractive force should be applied -principally in the outward direction, and if this is not sufficient, -slight rotary movement should be tried. In cases where there is less -room between the approximal teeth, the projecting tooth may be removed -with a pair of straight forceps (fig. 17), the blades being applied to -the mesial and distal aspects of the root. The blades should not be -driven very far up, and the loosening of the tooth should be -accomplished by slight rotary motion, in using which care should be -taken to avoid loosening the approximal teeth. - -[Illustration: FIG. 38.] - -(_b_) =Upper Lateral Incisors= lying internal to the arch, as shown in -fig. 39, can be removed with the forceps shown in fig. 38, by placing -the fine blade on the labial and the broad blade on the palatal side of -the tooth. Extractive movement should be made inwards, followed by very -slight outward movement; this failing, rotation should be tried, but as -pointed out on a previous page, this form of movement is not so suitable -for lateral incisors as for centrals. - -[Illustration: FIG. 39.] - -(_c_) =Upper Canines= placed high in the arch, as shown in fig. 40, may be -extracted with a straight pair of forceps (fig. 17), the blades being -placed on the mesial and labial aspects of the root. Extraction of such -teeth is very difficult. Slight but firm rotation may first be tried; if -this fails to loosen the tooth, slight lateral movement may be -attempted, the force being applied towards and then away from the median -line of the mouth. - -[Illustration: FIG. 40.] - -[Illustration: FIG. 41.] - -(_d_) =Upper Bicuspids= misplaced, as shown in fig. 41, can be removed -with forceps, as shown in figs. 18 and 22, the blades being applied on -the anterior and posterior aspects of the tooth. Force should be applied -in a backward and forward direction, the movements being repeated and -persevered with until the tooth is loosened in its socket. - -[Illustration: FIG. 42.] - -[Illustration: FIG. 43.] - -A bicuspid placed as shown in fig. 42 can be removed with forceps -similar in form to those depicted in figs. 18 and 22, with the outer -blade strong but narrow. The extractive movement should be made mainly -in an inward direction. - -[Illustration: FIG. 44.] - -(_e_) =Lower Central Incisors= placed similarly to that shown in fig. 43 -may be removed with ordinary lower root forceps (hawk’s-bill pattern), -the blades being placed on the mesial and distal surfaces of the root, -and movement applied in a direction to and away from the median line of -the mouth. When the crowding is not so extreme as shown in fig. 44, -forceps of the hawk’s-bill pattern with a strong but narrow inner blade -should be used (fig. 45), and the principal extractive movement made in -an outward direction. For an incisor placed as shown in fig. 47, the -narrow blade should be the outer one (fig. 46), and the principal force -should be applied in an inward direction. - -(_f_) =Lower Bicuspids= placed as in fig. 48 are - -[Illustration: FIG. 45.] - -[Illustration: FIG. 46.] - -most difficult teeth to remove. One of the most useful instruments for -their extraction is a pair of upper root forceps (Read’s pattern, fig. -22), which should be held so that the curve of the blades is downwards. -The blades should grasp the root on its anterior and posterior surfaces. -Slight rotary movement may first be attempted, followed by lateral -motion. These movements may be persevered with until the tooth is found -to yield. Too much haste may lead to a fracture, which would be -extremely difficult to deal with. - -[Illustration: FIG. 47.] - -[Illustration: FIG. 48.] - -In cases where the crowding is not so great, and the tooth is more in -the normal line of the arch, a forceps with a narrow outer blade will -suffice (fig. 46). Extractive force should be used principally towards -the median line of the mouth, and this may be combined with slight -rotary movement. - -[Illustration: FIG. 49.] - -(_g_) =Impacted Lower Third Molars= are amongst the most difficult teeth -to extract. Where the tooth is deep-seated, the gum should be pushed -aside by careful packing, and as clear a view of the tooth as is -possible obtained. For removing these teeth it is difficult to give any -rules, as each case must be treated on its own merits. - -As useful an instrument as any for their removal is a curved elevator -(fig. 49), the blade of which can often be inserted under the crown, and -assuming that good leverage is thus obtained, the tooth can be prised -up. Sometimes the tooth is firmly embedded in the bone. In such cases a -clear view of the tooth may be obtained by gradually packing the soft -tissues apart, the periosteum covering the alveolus should then be -raised, and the bone surrounding the tooth cut away with suitable -instruments. The tooth, when freely exposed, should be removed with an -elevator or forceps. - -The wound resulting must be carefully packed and treated as described on -page 85. - - - - -CHAPTER IV. - -The Use of Anæsthetics during Extraction of the Teeth. - - -The anæsthetics used during the extraction of teeth may be divided into -two classes, viz.:--general and local. It is not proposed to make any -allusion to the methods of administering general anæsthetics, as they -hardly fall within the scope of this volume. There are, however, a few -points which the operator should bear in mind when employing them and -which may with advantage be briefly dwelt upon, but before considering -these, a word or two may not be out of place with regard to the choice -of the anæsthetic. In dental practice three agents are generally used, -nitrous oxide alone or in combination with air or oxygen, ether and -chloroform. - -In the very large majority of dental operations nitrous oxide is to be -preferred to ether and chloroform, and possesses the great advantage -over them of being practically safe. In addition, the administration of -nitrous oxide occupies a shorter period, and the recovery is rapid and -complete. Within the last few years, combinations of nitrous oxide with -oxygen and with air have been introduced by Dr. Hewitt and Mr. Rowell -respectively, and both combinations possess advantages over nitrous -oxide used alone. - -_The advantages of nitrous oxide and oxygen over nitrous oxide alone -are_:-- - -(1) The anæsthesia is quieter. - -(2) The mucous membranes of the mouth do not swell to the same extent, -and the operator therefore gains a clearer view of the tooth. - -(3) The period of anæsthesia is lengthened, perhaps by only a few -seconds, but the quieter condition of the patient assists indirectly in -prolonging the period for operating. - -_The advantages of nitrous oxide with air over nitrous oxide alone_ are -somewhat similar to those of nitrous oxide and oxygen, though less -marked. - -_For operations requiring a long anæsthesia_, such as the extraction of -a difficult third molar, ether should be used, the administration being -commenced with nitrous oxide. In such cases many operators prefer to use -chloroform, but the regular employment of this agent in dental surgery -is to be severely condemned, and the cases are rare indeed in which its -use is called for. A most careful inquiry into this important subject -has been made by Dr. Hewitt, and the results of his work were -communicated in an exhaustive paper published in the _Journal of the -British Dental Association_ for November, 1895, which is well worthy the -perusal of all those who are in the habit of administering chloroform. - -Whenever a general anæsthetic is given for the removal of teeth, two -people should always be present, one to confine his attention solely to -the administration of the anæsthetic, the other to the removal of the -tooth, as it is impossible for one person to operate and at the same -time to observe the condition of the patient during the anæsthetic -period. This rule should be strictly adhered to. - -For extraction under nitrous oxide, and also to a great extent under -ether, the positions of the patients should differ but little if at all -from those already advocated, with this exception, it is advisable not -to have the head too far back. Before the administration of the -anæsthetic is commenced, any removable artificial teeth that may be in -the mouth should be taken out; the operator should decide exactly what -he intends to do; at the same time it is well not to attempt too much -and to avoid pricking the gum during the examination of any roots that -it may be necessary to extract. The prop should be placed on sound firm -teeth in such a position that the operator can work without being -hindered by it, and a final view of the mouth should be taken. Where -several teeth have to be extracted at one sitting, their order of -removal should be decided upon before the operation is commenced, and if -any particular tooth is causing pain, it should be extracted first. The -order of removal should also as far as possible be arranged so that -changes of instruments are reduced to a minimum. As a rule, lower teeth -should be extracted before upper teeth, because if the latter are -removed first, the blood may pass down and so obscure the lower ones. -Roots should be removed before whole teeth for the same reason. Each -tooth or root must be cleared from the mouth before any attempt is made -to remove another except in cases where the gum is thoroughly adherent; -under this condition the tooth or root may be left and freed from the -gum when the patient has recovered. With teeth which have a liability to -slip out from between the blades of the forceps, it is well as a -precaution to keep a finger of the left hand behind the blades to -prevent the tooth passing backwards should it slip out. - - -LOCAL ANÆSTHETICS. - -(_a_) =Cocaine.=--The most efficacious of the local anæsthetics in use is -cocaine. It is an alkaloid obtained from the dry leaves of Erythroxylon -Coca, and in practice the hydrochlorate form is generally used. For the -removal of teeth it is necessary to inject a solution of the drug into -the tissues, a simple application to the gum being of little use. -Cocaine has the reputation of not being thoroughly reliable in its -action, but this in a great measure often arises from want of care in -injecting it. Not more than half a grain should be injected for the -removal of a tooth, and even then with people of feeble health, untoward -symptoms may supervene. - -_Mode of Employment._--A fresh solution of the drug should be made each -time its use is called for, by dissolving a tabloid weighing half a -grain in 5 minims of distilled water. Half of the solution should be -injected into the gum on each side of the alveolus. The gum being such a -dense tissue, the solution should be injected slowly, otherwise the bulk -of it will escape by the side of the needle into the mouth. As there is -always a tendency for this to happen even when the solution is slowly -injected, it is well to keep a finger of the left hand pressed on the -gum where the needle is inserted. - -Speaking personally, I usually occupy about eight minutes over the -injection, and wait for four or five minutes after its completion before -operating. As a local anæsthetic I have generally found cocaine -satisfactory, so far as its anæsthetic properties are concerned, but the -occasional appearance of toxic symptoms, especially in those of feeble -health, should not be lost sight of. Tropacocaine has been recommended -as possessing the anæsthetic properties of cocaine without giving rise -to toxic effects, but in practice I have not found these statements -fully borne out. - -_Toxic Effects._--The administration of cocaine, especially if given in -large doses, may be followed by well-marked toxic effects of which the -following are cited by Dr. Hewitt.[4] - -“Headache; vertigo; pallor; a cold, moist skin; a feeble, slow, or rapid -pulse, becoming imperceptible in grave cases; incoherence of speech; -nausea; vomiting; unconsciousness; trismus and other muscular spasms; -epileptiform attacks; dilated or unequal pupils; and disturbances of -respiration, culminating in dyspnœa and asphyxia.” The treatment of -cocaine poisoning should be directed first to restoring the circulation -by the administration of a rapidly acting stimulant, such as -sal-volatile, brandy, or the hypodermic injection of ether. The patient -should be placed in the horizontal position, and the respiration watched -for; should this tend to fail, artificial respiration must be -immediately resorted to. - -(_b_) =Freezing Agents.=--This group includes such preparations as -_chloride of ethyl_, _coryl_ (a mixture of chloride of ethyl and -chloride of methyl in such proportions that the mixture boils at 0° C.) -and _anestile_. Generally speaking, the anæsthesia produced is by no -means satisfactory, and to use them to the greatest advantage, attention -must be given to the following points:-- - -(1) The gums must be well dried, and as far as possible all neighbouring -regions, such as the cheeks or tongue, protected by napkins or other -suitable material. - -(2) The gums must be thoroughly frozen before commencing to operate. - -(3) The extraction must be carried out as quickly as is consistent with -thoroughness. - -(4) If possible the spray should be continued during the operation. - -(5) Too great a jet should not be used. - -Freezing agents can be employed much better for front than for back -teeth, in fact it is found at times difficult to freeze the gums at all -satisfactorily at the back of the mouth. - - - - -CHAPTER V. - -Difficulties, Complications and Sequelæ of Extraction of the Teeth. - - -Like all other surgical operations, the extraction of teeth is at times -attended with certain difficulties, complications and sequelæ which for -the sake of description will be considered under the following headings: - -(1) Difficulties, complications and sequelæ connected with the teeth -themselves. - -(2) Difficulties, complications and sequelæ connected with the jaws. - -(3) Difficulties, complications and sequelæ connected with the soft -parts. - -(4) Difficulties, complications and sequelæ arising during extraction -under anæsthetics. - -(5) Miscellaneous complications, difficulties and sequelæ. - - -(1) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ CONNECTED WITH THE TEETH -THEMSELVES. - -(_a_) =Undue Resistance of the tooth and= =alveolus.=--Considerable -resistance to our efforts to remove a tooth at times occurs. This is -naturally most often, though by no means always, met with in those of -strong physique. Teeth isolated are always firmer than those in series; -this is accounted for by a consolidation of the bone around them. -Experience will act as a guide, and it is to a certain extent possible, -after a little observation, to gather from the general appearance of a -tooth if it will give more than normal trouble in removal. Should undue -resistance be met with, steady attempts to move the tooth slightly in -different directions should be made and persevered with; if this -precaution is not taken and too much force is used in any one direction, -fracture of the tooth or alveolus is sure to result. It may, perhaps, be -found impossible to remove the tooth; when this is the case it is best -to dismiss the patient and to make a fresh attempt two or three days -later; the tooth will then probably be loose, as a result of the -inflammation which has been set up by the previous attempt at -extraction, and can be easily removed. - -The causes of undue resistance are:-- - -(i.) Abnormal density of the alveolar process. - -(ii.) Divergent and twisted roots. - -(iii.) Alteration in the shapes of the roots brought about by -periodontal inflammation (exostosis). - -(_b_) =Fracture of the tooth.=--The principal causes of this accident -are:-- - -(i.) The use of badly fitting forceps. - -(ii.) The use of unnecessary or wrongly applied force in attempting to -loosen the tooth in its socket. - -A tooth having been fractured, the patient should be made to rinse the -mouth until the bleeding has ceased, the socket should be dried with -cotton-wool, and the position and edge of the root defined with a probe -before attempting to remove the fractured portion. It is neglect of -these steps that so often leads to failure to remove the remaining -portion of a fractured root. Too many attempts to remove a fractured -root should not be made; if a second endeavour proves fruitless, the -patient should be dismissed and a fresh attempt, if necessary, made -after a period of one or two days, as the tooth will probably then be -looser from inflammatory trouble, moreover, the hæmorrhage having -ceased, it will be possible to obtain a clearer view of the root. -Before, however, dismissing the patient, an anodyne mouth wash should be -prescribed, and the pulp if exposed touched with carbolic or nitric -acid. The lower third of a root may generally be left without fear of -unpleasant consequences; but it is always well to inform the patient -when any portion of a tooth is allowed to remain in the jaw, as such -knowledge may be of assistance should any trouble arise at a subsequent -date. - -(_c_) =Crowded and irregular teeth.=--The removal of these has already -been referred to in Chapter III. - -(_d_) =The Removal of the wrong tooth.=--The removal of the wrong tooth -may occur and is naturally due to carelessness on the part of the -operator. Should this accident arise, the tooth must be immediately -replaced and if necessary secured with a ligature. If the pulp -subsequently shows signs of degeneration or inflammation it should be -removed and the canal treated and filled. - -(_e_) =Removal of a neighbouring tooth.=--This may occur and is generally -due to a crowded arrangement of the teeth. The accident seems to occur -most frequently with the removal of the first permanent lower molar, the -neighbouring tooth usually involved being the second bicuspid which is -simultaneously dislocated from its socket. This accident can be avoided -by placing the thumb on the tooth which shows a tendency to move, and -exerting only as much force in the removal of the tooth which is being -extracted as can be controlled by the thumb. If a neighbouring tooth is -removed it must be replaced and treated in the same manner as described -above. - -(_f_) =Removal of an unerupted bicuspid.=--This may be an avoidable or an -unavoidable accident. At times the developing bicuspid is so firmly -embraced by the roots of the deciduous molar that during the extraction -of the latter tooth the bicuspid is removed--such an accident cannot be -avoided. It is an avoidable accident when it occurs during the -extraction of the roots of a temporary molar and arises from using too -much force. As previously pointed out it is best to leave the fractured -roots of temporary molars alone unless they can be easily removed. - -(_g_) =Breaking one tooth in extracting another.=--In the extraction of -lower teeth with hawk’s-bill forceps the upper teeth may be fractured. -This accident is most likely to occur to the inexperienced, and arises -from the tooth leaving its socket suddenly, due frequently to the -extracting force being used in an upward rather than an outward -direction. It may, however, occur when a lower tooth has been more than -normally resistant. In all such cases it is well for the operator to be -on guard by keeping the thumb or a finger of the left hand over the -joint of the forceps. - -Also in using the elevator an adjacent tooth may be fractured. - - -(2) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ CONNECTED WITH THE JAWS. - -(_a_) =Fracture.=--The fracture and removal of a small piece of the -alveolus is not an unfrequent accident which is fortunately by no means -serious. It is sometimes unavoidable but at other times is due to -getting the blades of the forceps on the outer sides of the alveolus -instead of between the bone and the root of the tooth. - -Extensive fracture is sometimes seen, for instance in a case that came -under my notice at the Dental Hospital of London an unqualified person -in removing the first lower right permanent molar fractured the bone in -a horizontal direction so that the second and first bicuspids with the -canine were completely separated from the body of the bone. Mr. -Salter[5] gives an account of an extensive fracture of the jaw which -occurred in a lady æt. 35. The fracture occurred in connection with the -removal of the superior central incisors. The right central incisor -required some force for its removal, and when it came away the whole of -the front of the alveolus was firmly attached to the root. In removing -the left central incisor considerable force was required during the -exertion of which the bone was fractured. On examination of the parts -the mass of bone corresponding to the intermaxillary bone was found to -be merely held in place by the soft tissues. “A vertical fracture -extended from the side of the canine up to the root of the nose, then -nearly horizontally across to the opposite side, being connected there -with another vertical fracture. The lesion passed completely through the -jaw from before backwards, and there was a wound in the palate three -quarters of an inch from the alveolar border, through which was -considerable hæmorrhage.” A still more severe example of fracture during -extraction of teeth is recorded by Mr. Cattlin,[6] where in an attempt -to remove a third upper molar with an elevator the tuberosity of the -maxilla, a portion of the floor of the antrum and part of the sphenoid -were fractured. - -Fracture of the maxilla tuberosity may occur during the removal of the -third upper molar, and Mr. Nicol[7] records such an accident during the -removal of the second upper permanent molar. In a case recorded by Mr. -L. Matheson[8] a transverse fracture of the maxilla occurred in a line -between the first and second permanent molars during the removal of the -first-named tooth. - -Direct transverse fracture of the horizontal ramus of the mandible due -to extraction of the teeth has also been recorded. - -_Treatment._--In fracture of small portions of the alveolar process, no -special treatment is called for except that all loose fragments should -be removed. When the fracture is of a more extensive character, the -fragments must be retained in position by a suitable form of splint, a -description of which will be found in most works on dental surgery. - -(_b_) =Necrosis= of the alveolus may result from extraction and is -generally the result of undue violence or of some septic process -occurring in the wound. The _treatment_ to be followed consists of the -use of antiseptic and deodorant mouth washes; the necrosed bone when -quite separated from the living tissue should be removed with a pair of -suitable forceps. - -(_c_) =Dislocation of the mandible.=--The use of too much force in -extracting a lower tooth and not at the same time counteracting the -force by supporting the chin, may lead to unilateral or bilateral -dislocation of the mandible. This accident may also be brought about by -forcing the mouth open too much with a Mason’s gag during the -administration of an anæsthetic. It may likewise occur without the -employment of undue force in those who have previously met with or are -liable to dislocation. - -_Reduction_ may be brought about by placing the thumbs, carefully -wrapped in a napkin, on the molar teeth and the palmar surfaces of the -fingers below the chin. If downward pressure is then made with the -thumbs, and upward pressure with the fingers, the condyles of the -mandible will generally pass back easily into the glenoid cavity. In -cases where more difficulty than this is experienced, the patient should -be placed in a recumbent position, and corks should be inserted between -the back teeth. Upward pressure should then be applied on the under -surface of the chin. It is advisable, after reduction, for the patient -to wear a four-tailed bandage for about a week. - -(_d_) =Forcing a root into the antrum.=--This accident occurs mostly in -connection with the extraction of the second upper bicuspid root and -buccal roots of the first upper permanent molar. If a root has been so -dislocated into the antral cavity as to still partly remain in its -socket, the best course to pursue is to leave it alone and not to -attempt removal as the attempt might only result in complete dislocation -of the root into the antrum. The socket should be kept quite clean by -the continual use of antiseptic washes. As a rule the root gives rise to -no subsequent trouble. - -When a root has been forced completely into the antrum, the latter -should be enlarged and the antral cavity thoroughly syringed. For this -purpose it is well to use an aural syringe of five or six ounce -capacity. The rationale of this form of treatment is that the root may -pass out with the return current from the antrum. If this treatment -fails, an attempt may be made to remove the root with a little scoop of -gutta-percha fixed on to a flexible wire. When it cannot be removed in -this manner, the cavity should be thoroughly irrigated with an -antiseptic solution and the root left alone, as it will in all -probability become encysted and not give rise to any subsequent -trouble. If, however, the patient has a history of epitheliomatous -disease of the jaws further attempts should be made to remove it. A case -where a tooth was forced into the antrum in a patient with a family -history of epithelioma of the jaw is recorded in the Transactions of the -Odontological Society, vol. ii., page 15, old series. - -(_e_) =Forcing a tooth into an abscess cavity.=--This accident may occur; -if it does, it requires similar treatment to the accident just described -in connection with the antrum. - -(_f_) =Trismus.=--Inability to open the mouth naturally renders extraction -of the teeth more difficult than usual. When, however, the closure is -the result of inflammatory trouble in connection with the lower molars, -an anæsthetic should be given and the mouth opened forcibly with a -Mason’s gag. If the trismus is the result of tonic contraction of the -muscles closing the jaw, ether should be used in order to overcome the -resistance of the muscles, as nitrous oxide would not have the desired -effect. - - -(3) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ IN CONNECTION WITH THE SOFT -TISSUES. - -(_a_) =Extensive laceration of the gum.=--In cases where a tooth has given -rise to much trouble in removal, the soft tissues naturally suffer, but -apart from this they may be severely lacerated when the gum is more -than usually adherent to a tooth. This is most frequently seen in the -removal of the lower third molar, but it is also sometimes met with in -the removal of loose teeth. When the gum is found more than usually -adherent the tooth should be left in the socket until the gum attachment -has been divided with a pair of scissors or a lancet. Continued attempts -to remove the tooth with the forceps before the gum has been divided -will only lead to undue laceration. - -In all cases where the gums have been badly lacerated, an anodyne mouth -wash should be prescribed. - -(_b_) =Wounding the tongue.=--This is most likely to occur under nitrous -oxide, as the tongue during anæsthesia is generally swollen, and is, -moreover, not under the control of the patient. Wounding the tongue is -nearly always due to carelessness, and arises generally in using the -elevator. When the tongue is _much lacerated_, the overhanging portions -should be trimmed off with scissors and the surface kept clean with -antiseptic mouth washes. If the _tongue is punctured and the wound does -not involve a large branch of the lingual artery_, but yet bleeds -freely, the tongue should be drawn forward; if this does not prove -successful the insertion of a stitch will generally cause the hæmorrhage -to cease. _If the tongue is punctured and a large branch of the lingual -artery is involved_, the finger should be placed on the back of the -tongue and the organ drawn forward; this compresses the lingual artery -against the hyoid bone. The bleeding point must then be sought for and, -if found, an attempt made to twist the wounded vessel. If this fails -cauterisation may be tried, and as a last resource, if cauterisation -does not stop the bleeding, the lingual artery must be tied. - -(_c_) =Bruising the lower lips.=--This may occur in the removal of upper -bicuspids and molars, and is due to having the mouth insufficiently -opened, and using forceps of too straight a pattern. - -(_d_) =Injury of the mandibular nerve.=--The mandibular nerve may be -injured during the removal of the lower molars and bicuspids. Loss of -sensation over the parts supplied by the nerve, with dribbling of -saliva, generally follows the accident. Sensation is, however, usually -restored, and in cases of laceration the nerve generally unites. - -Mr. Sewill records a case in which “the roots of a lower wisdom tooth -contained a groove and a foramen, through which the inferior dental -nerve had evidently passed.” - -(_e_) =Hæmorrhage following tooth extraction= is a most important -complication, and one which needs prompt treatment. Hæmorrhage is -predisposed to by a diathesis known as hæmophylia. Of its pathology but -little seems to be definitely known. The blood in this condition is said -by Walsham to be deficient in fibrin. Hæmorrhage may occur in people not -predisposed to the above-named diathesis; in some instances it is -probably due to pathological changes in the artery supplying the tooth, -these changes being frequently induced by inflammation around the apex -of the root, and the vessel becoming adherent to its bony surrounding, -and thus prevented from contracting. Another condition, which may or may -not have any practical bearing, is the occurrence of hæmorrhage during -the menstrual period. I have, on two occasions, had under notice -patients for whom teeth have been extracted during this period, and in -whom hæmorrhage followed, but ceased at the termination of the period. -Teeth had been extracted for both these patients on previous occasions, -without undue hæmorrhage following. - -Hæmorrhage is generally divided into three stages, viz.:--primary, -intermediate and secondary. In the mouth we often find the primary -running into the intermediate. The treatment of primary hæmorrhage, or -that occurring at the time of the operation, is not of serious import. -If it is at all sharp a useful plan is to give the patient some tincture -of hamamelis in the water used for rinsing the mouth. At the same time -about fifteen grains of gallic acid[9] should be given, and the patient -should be ordered to take a similar quantity every two or three hours -until the hæmorrhage ceases. The socket should also be loosely plugged -with cotton-wool dipped in some styptic, such as gallic acid. - -Intermediate and secondary hæmorrhage is of a more serious nature, and -generally sets in at night. When a case of intermediate hæmorrhage is -first seen, these two important points should be ascertained before -treating it:--first, whether the bleeding is coming from the gums or the -socket of the tooth; secondly, whether the blood shows a tendency to -coagulation. The latter point will act as a guide in the choice of drugs -for internal administration. - -In hæmorrhage from the gum search should be made for any small vessels -that may be the cause of it, and if found they should be twisted or -compressed. If the vessel is only partially divided it should be -completely severed, as this will probably allow contraction to take -place. If the bleeding is capillary in character, a pad of gutta-percha -lined with lint dipped in some styptic and applied with firm pressure is -usually sufficient to stop it.[10] - -When the bleeding proceeds from the socket the following mode of -procedure is adopted: some small cone-shaped pieces of non-absorbent -cotton-wool are prepared (each about ⅓ to ½ inch long and ¼ inch broad -at the base), also a pad of lint and a four-tailed bandage; a syringe, a -pair of conveying forceps, some cold water and the chosen styptic are -likewise placed ready for use. The socket is first freed from clot, then -syringed, then dried out with a pledget of cotton-wool, and directly -afterwards one of the cone-shaped pieces of cotton-wool dipped in the -styptic (the most useful being tannin) is placed in the socket and -forced to the apex, with a fair amount of pressure; the hæmorrhage is -arrested far more by pressure than by the styptic. More pledgets of wool -are inserted until the socket is quite full; a plug of lint is then -placed over all and kept in position by antagonism with the upper teeth, -a four-tailed bandage being used for this purpose. An excellent method -of keeping the plug in the socket if the approximal teeth are standing -is to wedge a piece of wood between them. Excellent as this plan is, -however, if the hæmorrhage is at all sharp it is better to use the -four-tailed bandage to make more certain of retaining the plug in -position. The number of pledgets of wool inserted in the socket should -be counted. - -The general directions to be given to the patient, though apparently -trivial, are most important and should never be forgotten. He or she -should be advised to go home very quietly, to avoid all forms of -excitement, to assume the sitting position usual during the day, and to -use a high pillow at night. The patient should be fed through a bent -tube, and all fluids should be given cold. - -In addition to plugging the socket, hæmostatics should be administered -internally. - -In _cases where there is_ a thin watery blood and _no tendency to -coagulation_ it may be fairly assumed that the cause of the hæmorrhage -lies in the blood, and such drugs as gallic acid[11] and perchloride of -iron[12] are indicated, _but when the blood shows a marked tendency to -coagulate_ in the mouth, as often happens, and the bleeding still -continues, such drugs as ergot[13] are indicated; in this latter -condition it may be assumed that the cause of the hæmorrhage lies in -some want of contractility of the vessel wall, and ergot causes -contraction of unstriped muscular tissue. - -At the time of plugging the socket a dose of gallic acid, perchloride of -iron or ergot should be given, and its administration continued at -intervals until the bleeding ceases. Mr. Morton Smale prefers a -hypodermic injection of ergotine.[14] - -The patient should be seen within twenty-four hours after treatment, and -if the bleeding has ceased the plugs may be removed and an antiseptic -mouth wash prescribed. This course is not recommended when the -hæmorrhage has been severe; under such circumstances the plugs should be -allowed to work themselves out. If the hæmorrhage has not then ceased, -the socket should be replugged tighter than before with a plug of wood -wrapped in non-absorbent cotton-wool. Should this prove of no avail the -actual cautery may be tried; if this fails, and the bleeding is from the -mandible, the canal should be trephined and a plug of ivory inserted, -so as to compress the artery against the inner plate of the bone. In -uncontrollable hæmorrhage from the maxilla digital pressure on the -common carotid opposite the transverse process of the sixth cervical -vertebra may be tried; should this fail to stop the hæmorrhage, ligature -of that vessel must be resorted to. - -In one case of hæmorrhage from the region of the third right lower molar -Mr. Boyd[15] divided the lip in the median line and reflected the cheek -from the jaw. The mandibular canal was then laid open by excising the -outer plate of the bone, and the bleeding was arrested by plugging the -mesial and distal ends of the canal. - -_In extreme cases, with sign of collapse_, normal saline solution[16] -must be infused into the median basilic vein. - -In _patients predisposed to hæmorrhage_ extraction should be if possible -avoided; but, if the removal of the tooth be absolutely necessary, -prophylactic treatment should be pursued for three or four days previous -to the operation by the administration of one or other of the remedies -previously mentioned. - -A new styptic, consisting of fibrin ferment 1 to 10 to which 1 per cent. -of calcium chloride has been added, is said by Walsham to act only on -the blood, not on the tissues, and to be perfectly aseptic. It was found -to be effectual in arresting hæmorrhage after the division of all the -veins except the common jugular in a dog’s neck. - -The tooth should be extracted in the early morning, as we then have the -day before us should hæmorrhage occur. Some hæmostatic should be -administered at the time of the operation and the socket plugged at -once; for it is most important to remember that in these cases it is far -easier to prevent the hæmorrhage occurring than to arrest it when once -it has commenced. The subsequent treatment will consist in the continued -administration of hæmostatic drugs. - -(_f_) =Injury of the arteries in the neighbourhood of the teeth.=--Wound -of the _lingual_ artery has been referred to under the heading of -injuries to the tongue. Laceration of the _ranine_, _anterior and -posterior palatine_ arteries may also occur. Such accidents are usually -the result of the forceps slipping and are therefore avoidable. -Treatment consists in pressure or in twisting or tying the divided -vessel. In the case of the _anterior or posterior palatine artery_ it -may be found necessary to plug the foramina which give passage to these -vessels. - -(_g_) =Pain following tooth extraction.=--The causes giving rise to pain -following the extraction of a tooth are:-- - -(1) _Incomplete extraction of the tooth_, more especially when the -remaining portion contains an exposed pulp. - -(2) _Too rapid healing of the orifice of the socket._--It sometimes -happens that the margins of the wound left after extraction unite very -early, and when this occurs the discharges which naturally come away -from the granulating surface at the base of the socket, have no exit; -the consequence is that they are retained and set up a local traumatic -inflammation, leading to swelling of the surrounding tissue. - -(3) _Suppuration in the tooth socket._--This may be due in the first -instance to the use of dirty forceps, and under such circumstances it -may be classed as a poisoned wound. An examination will reveal the -presence of greenish putrid pus, while the tissue around will be much -inflamed, and the portion immediately bordering the wound will have a -tendency to slough. A condition of this kind is often seen in hospital -nurses and medical students and is no doubt due to infection met with in -their daily duties. - -Suppuration in the socket may be due to a lowered vitality of the -tissue, produced by some such local causes as acute or chronic -inflammation, and is especially well seen in cases of extraction for -the relief of periodontitis, or where the operation has been performed -in patients suffering from general debility, syphilis, struma or in fact -any of those systemic diseases which tend to lower the vitality of the -organism. - -(4) _Extensive laceration of the hard and soft tissues_ in the -neighbourhood of the socket; and - -(5) _Necrosis of the socket of the tooth_ are also fruitful sources of -pain following tooth extraction. - -(6) _The presence in the wound of a foreign body._--A curious example of -this came under notice a few years ago. A patient applied for the -extraction of the left first permanent molar. During the operation a -portion of one of the cusps disappeared; a search was made for it but, -as it was not found, the natural supposition was that it had been -removed in rinsing the mouth. The patient for the next three weeks -complained of slight pain in the socket for which remedies were tried -but proved of little use. Eventually the patient discovered the cusp on -the top of the granulation tissue which had filled up the socket. In -another case of the same character which came under notice, the -offending material was a piece of an amalgam filling. A fractured blade -of forceps may likewise act as the offending body. - -(7) _Injury to the nerve._--Direct injury to the trunk of the nerve is -more likely to occur during extraction of the lower third molar than -with any other tooth. It is more than probable that many obscure cases -of pain following tooth extraction are due to exposure and irritation of -the nerve at the apex of the socket. An interesting case of this -character was lately reported by Mr. Storer Bennett.[17] The patient, a -lady æt. 23, had had the third upper molar dislocated through the use of -a Wood’s gag, and, as it was considered hopeless to restore the -dislocated tooth, it was extracted without difficulty. The socket in -spite of treatment remained painful for the next twelve days, but in the -meanwhile granulated healthily, except at its apex, where by the aid of -a mirror and probe a spot about the size of a pin’s head was noticed -which caused the greatest agony on being touched. Incision of the nerve -produced permanent relief. - -_Treatment._--The treatment naturally depends very much upon the cause. -A thorough examination of the socket should be made with probe and -mirror. When due to incomplete extraction, another attempt, if -considered advisable, may be made to remove the tooth. This proving -unsuccessful, the socket should be swabbed with an anodyne drug and, if -there is an exposed pulp in the remaining portion of the tooth, the pulp -should be touched with fuming nitric acid or strong carbolic acid. The -patient should also be advised to use some poppy head fomentation.[18] - -In _too rapid healing of the orifice of the socket_, the freshly healed -surface must be separated, the socket syringed out, and a small tent of -lint allowed to remain in the orifice for about twelve hours. An -antiseptic mouth wash should also be prescribed. - -In those cases _where the pus is putrid_ and there is reason to suspect -infection, the socket should be thoroughly syringed with some antiseptic -such as hyd. perchlor. 1 in 1,000, carbolic acid 1 in 40; following this -the parts should be carefully dried with cotton-wool. A small piece of -chloride of zinc should then be introduced and allowed to dissolve in -the socket, which must be subsequently kept aseptic by constant -irrigation with some antiseptic solution. - -Suppuration is most frequently seen after extraction of the lower teeth -owing to the fact that drainage is less easily effected than in the -upper, owing to the dependent position of the socket. In many cases it -will be found necessary to plug the socket tightly with non-absorbent -cotton-wool dipped in an antiseptic solution; this prevents the -accumulation of _débris_ which would act as an irritant. In cases of -_suppuration occurring in patients of diminished vitality_ a tonic form -of treatment should be prescribed;[19] the dressing in the socket should -be removed two or three times a day and the socket syringed. - -Care must be exercised in applying escharotics to sockets to which the -nerve may be in close proximity; this is especially necessary in dealing -with impacted lower third molars. Two cases illustrating this point have -come under my notice. In the first a second lower bicuspid with a long -standing chronic abscess had been removed. The patient complained of -pain, the socket was syringed out and a small piece of chloride of zinc -inserted. Intense agonizing pain followed which all local anodynes -failed to relieve. In the second case an impacted right lower third -molar had been removed. The socket suppurated, and the pain although -severe was not intense. Treatment similar to that used in the first case -was adopted with similar results. Since then in all cases where it is -possible that the trunk of the nerve may be in close proximity to the -socket, I have used non-irritating antiseptic injections and plugged -the socket with cotton-wool dipped in tincture of opium with much more -satisfactory results. - -It is advisable to inform the patient of the possibility of pain -following the extraction of a tooth, especially after periodontitis, and -in all cases where a large number of teeth have been extracted a -mouth-wash[20] should be prescribed; for, even if there is no pain, it -will prevent the discharge from the sockets of the teeth undergoing -putrefactive changes. - -_In pain due to necrosis of the socket_ deodorant antiseptic injections -must be used, while in extensive laceration of the soft and hard parts -an anodyne mouth-wash[21] may be tried. In all _obscure cases_ an -application should be made to the socket of some local anodyne such as -tincture of opium or cocaine, and a mouth wash having similar -properties should at the same time be prescribed. - - -(4) DIFFICULTIES, COMPLICATIONS AND SEQUELÆ ARISING DURING EXTRACTION -UNDER ANÆSTHETICS. - -(_a_) =Tongue slipping back.=--During extraction under anæsthetics the -tongue not being under control may slip over the larynx, or may be -forcibly pushed back by the fingers of the operator. Symptoms of -difficult breathing or even arrest of respiration will follow this -accident. It is not enough to watch the chest walls, as respiratory -movement may continue without air entering the lungs. Treatment consists -in pulling the tongue forcibly forward with a suitable instrument and -forcibly extending the head on the spinal column. - -(b) =Forcing out a tooth with a prop or a Mason’s gag.=--With a prop this -accident may arise from resting it upon teeth which are loose or from -placing it in such a way that undue leverage is brought to bear on the -teeth. It is an accident most likely to occur when the prop is fixed on -the front teeth and the mouth opened to its widest extent. Under such -conditions undue leverage at right angles to the long axis of the tooth -is brought to bear upon the palatal surfaces of the upper teeth and they -are consequently forced outwards. With a Mason’s gag the accident is -due at times to clumsiness; great care should therefore be exercised -when using this very powerful instrument. If a tooth is forced out it -should if possible be immediately replaced. - -(_c_) =Passage of a foreign body through the isthmus of the fauces.=--A -foreign body, such as a tooth, a broken piece of forceps or a prop, -passing through the isthmus of the fauces may become impacted in either -the air or food passages. - -In the air passages it may lodge (1) over the entrance of the larynx, -(2) in the larynx, (3) in the trachea or bronchus. - -In the food passages it may lodge (1) in the pharynx, (2) in the -œsophagus, (3) at the pyloric opening of the stomach. - -_In the air passages._--Should the foreign body lodge _over the entrance -of or in the larynx_ the patient will be seized with a violent fit of -coughing which may expel it; but, should this not happen, symptoms of -asphyxia will supervene. With regard to treatment; the head should -immediately be brought forward and the finger inserted along the side of -the mouth into the pharynx, and then given a forward sweeping movement; -by this means the foreign body, if lodged at the back of the tongue, -will probably be removed. This failing, the patient must if possible be -inverted and a forcible slap given on the back. If the foreign body is -not dislodged by this method, laryngotomy should be immediately -performed. There must be no hesitation about the performance of this -operation and it must be carried out promptly, for the longer it is -delayed the less becomes the chance of saving the life of the patient. - -_A foreign body in the trachea or bronchus_ may give rise to no -immediate symptoms, but generally a violent fit of coughing, with signs -of impending asphyxia, takes place at the time of the accident. These -signs pass away, to be followed at intervals by fresh attacks of -coughing and eventually by symptoms of collapse of the lung or lungs. - -In a case recorded by Sir William MacCormac,[22] during the removal of -an upper bicuspid the palatine blade of the forceps snapped off close to -the joint and disappeared. The patient immediately suffered from great -dyspnœa and appeared to be dying. The symptoms passed away, and for the -following six weeks the patient’s condition gave no great cause for -anxiety, although she suffered from a constant hacking cough accompanied -by bloody expectoration. Seven weeks after the accident she was admitted -into St. Thomas’s Hospital, the foreign body was with difficulty removed -from the right bronchus, and the patient made an excellent recovery. - -_The diagnosis of a foreign body in one bronchus_ is made by an absence -of signs of respiration over the whole or part of the lung on that side, -with exaggerated sounds (puerile breathing) over the opposite side. -Treatment consists in performing tracheotomy and removing the foreign -body. - -_In the food passages._--_A foreign body impacted in the pharynx_ will -give rise to pain, symptoms of dysphagia and dyspnœa. A hacking cough is -generally present. - -Should a foreign body be suspected in the pharynx, its presence can -usually be ascertained by digital exploration; this failing, the cavity -should be examined by the aid of a laryngoscope. - -An attempt should first be made to remove the body with the fingers, and -if this is unsuccessful pharyngeal forceps must be called into use. In -some cases where the impaction is very firm it may be necessary to -perform pharyngotomy. - -_A foreign body in the œsophagus_ will cause dysphagia, and will -probably give rise to constant pain; if it is situated in the upper part -it will in all probability give rise to dyspnœa. On applying the -stethoscope over the region of the œsophagus, a gurgling sound will be -heard when the patient swallows fluids. The presence of a foreign body -may be definitely ascertained by passing a bougie; this step will also -enable the surgeon to determine the position in which the foreign body -is lodged. - -_If impacted in the upper part of the œsophagus_, an attempt may be made -to remove the impacted body with forceps; this failing, œsophagotomy -must be performed. - -_If lodged near the cardiac end of the œsophagus_ an attempt may be made -with a bougie to push the foreign body into the stomach; this failing, -gastrotomy should be performed. - -_If a foreign body becomes impacted at the pyloric opening_ of the -stomach, it will give rise to gastric dilatation. Under such -circumstances the stomach must be emptied of its contents, and -gastrotomy then performed. - -A foreign body going through the isthmus of the fauces will as a rule -pass into the œsophagus, then into the stomach, and will give rise to no -trouble. - -The details of such operations as gastrotomy, œsophagotomy, &c., do not -lie within the scope of this book, and should be sought for in works -dealing with general surgery. - -The necessity of being ready for such emergencies as the above cannot be -too fully emphasised, and all who administer anæsthetics should be -provided with the instruments necessary to perform laryngotomy. These -should be kept in a little case, and no anæsthetic should be -administered without the case being near at hand. Adherence to this rule -is important. - - -(5) MISCELLANEOUS DIFFICULTIES, COMPLICATIONS AND SEQUELÆ. - -(_a_) =Uterine pain.=--A case is quoted by Mr. Sercombe where extraction -of a tooth was followed by paroxysmal uterine pain, followed by the cure -of an obstinate leucorrhœa.[23] - -(_b_) =Shock.=--The fact that _tooth extraction is a surgical operation_, -and may be followed by shock, is often overlooked. The amount of shock -which follows as a rule is practically _nil_, but at times, especially -in the weak, it may be well marked. This is not taken sufficiently into -account when a question arises as to the number of teeth to be extracted -at one sitting, and it should be clearly borne in mind that what a -strong, able-bodied person, can stand, one of weaker physique cannot -bear. The _wholesale extraction of teeth at one sitting_ which is -carried out by some operators is not advisable, and the amount of -prostration that follows is sometimes very severe. - -_Syncope at the time of the operation_ sometimes occurs. Should it -supervene during the extraction of the tooth the operator should -immediately desist until recovery ensues. Fainting is best treated by -bending the head down towards the knees, at the same time loosening -anything tight about the neck and applying ordinary salts of ammonia to -the nose. _In severe cases_ the patient should be removed from the chair -and laid on the floor, and the chest should be exposed and flipped with -a towel dipped in cold water. _In more severe cases_ it may be necessary -to inject ether or some other stimulant, such as brandy. _Fatal syncope_ -following tooth extraction has occurred, and a case which took place at -Marseilles in 1881 is mentioned by Tomes.[24] The patient was a female, -and an attempt was made to remove a tooth, but was desisted in owing to -alarming syncope. A second attempt was made, or rather about to be made, -when fatal syncope ensued. _Post-mortem_ examination showed nothing -beyond a slight amount of cerebral congestion. - -(_c_) =Epilepsy.=--In those pre-disposed to epilepsy an attack often -commences immediately after the extraction of a tooth. In the event of a -fit occurring the patient should be removed from the chair and placed on -the floor, the clothes being at the same time loosened, and a wedge of -wood or some suitable material placed between the teeth to prevent -injury to the tongue. - -(_d_) =Hysteria.=--Manifestations of this disorder at times follow tooth -extraction, but do not call for any special treatment beyond that -usually adopted for this disorder. - -(_e_) =Septic and infective sequelæ.=--Scattered through dental literature -will be found a large number of records of septic and infective diseases -which have followed the extraction of teeth. In many of these cases it -would be difficult to say that the infection was always the result of -the operation; in a number of them the actual cause was due to the -neglected condition of the tooth which called for extraction. Infection -can, however, at times undoubtedly be traced to the operation, and once -again attention cannot be too strongly drawn to the fact that antiseptic -precautions should be carried out as far as possible. - -Suppuration of the socket and its appropriate treatment has already been -dwelt upon (page 82). Cases of syphilis having been acquired through the -use of infected forceps are recorded, while septicæmia, sapræmia, -cellulitis, osteitis, osteomyelitis, periostitis, pyæmia, tetanus, have -all been known to follow the removal of a tooth, but the treatment of -these conditions hardly lies within the scope of this book. - - - - -INDEX. - - -A - PAGE - -Abnormality of upper molars, 26 - -ACCIDENTS UNDER ANÆSTHETICS:-- - Forcing out a tooth with a prop or a Mason’s gag, 88 - Passage of a foreign body through the isthmus of the fauces, 89 - Tongue slipping back, 88 - -Alveoli of the teeth, disposition of the, 12 - -Alveolus, fracture of the, during extraction, 67 - - “ “ “ “ treatment of, 69 - - “ necrosis of the, following extraction, 70 - -Anæsthetics, the use of, during the extraction of teeth, 56 - -Arteries, injury to the, in the neighbourhood of the - tooth during extraction, 81 - - -B - -Bicuspids, the extraction of lower, 34 - - “ “ “ “ misplaced lower, 51 - - “ “ “ “ “ upper, 49 - - “ “ “ “ upper, 22 - -Breaking one tooth in extracting another, 67 - -Bruising the lower lips during extraction, 74 - - -C - -Canines, the extraction of lower, 34 - - “ “ “ “ upper, 21 - -Central incisors, the extraction of lower, 33, 51 - - “ “ “ “ “ upper, 19 - -Chloride of ethyl, 61 - -Chloroform, the use of, during the extraction of the teeth, 56, 57 - -Cocaine, mode of employment, 60 - - “ toxic effects, 61 - -COMPLICATIONS, DIFFICULTIES AND SEQUELÆ OF EXTRACTION OF THE TEETH:-- - Complications, difficulties, and sequelæ arising during extraction, - miscellaneous, 94 - Complications, difficulties and sequelæ arising during extraction - under anæsthetics, 88 - Complications, difficulties and sequelæ of extraction of the teeth - connected with the jaws, 67 - Complications, difficulties and sequelæ of extraction of the teeth - connected with the soft tissues, 72 - Complications, difficulties and sequelæ of extraction of the teeth - connected with the teeth themselves, 63 - -Coryl, 61 - - -D - -DIFFICULTIES, COMPLICATIONS AND SEQUELÆ ARISING DURING EXTRACTION, - MISCELLANEOUS:-- - Epilepsy, 94 - Hysteria, 94 - Septic and infective sequelæ, 95 - Shock, 93 - Uterine pain, 93 - -DIFFICULTIES, COMPLICATIONS AND SEQUELÆ ARISING DURING EXTRACTION - UNDER ANÆSTHETICS:-- - Tongue slipping back, 88 - Forcing a tooth out with a prop or Mason’s gag, 88 - Passage of a foreign body through the isthmus of the fauces, 89 - -DIFFICULTIES, COMPLICATIONS AND SEQUELÆ CONNECTED WITH THE JAWS:-- - Dislocation of the mandible, 70 - Forcing a root into the antrum, 71 - Forcing a tooth into an abscess cavity, 72 - Fracture, 67 - “ treatment of, 69 - Necrosis, 70 - Trismus, 72 - -DIFFICULTIES, COMPLICATIONS AND SEQUELÆ CONNECTED WITH THE TEETH - THEMSELVES:-- - Breaking one tooth in extracting another, 67 - Crowded and irregular teeth, 65 - Fracture of the tooth, 64 - The removal of a neighbouring tooth, 66 - “ “ an unerupted bicuspid, 66 - “ “ the wrong tooth, 66 - Undue resistance of the tooth and alveolus, 63 - -DIFFICULTIES, COMPLICATIONS AND SEQUELÆ IN CONNECTION WITH THE - SOFT TISSUES:-- - Bruising the lower lips, 74 - Extensive laceration of the gum, 72 - Hæmorrhage following tooth-extraction, 74 - “ “ “ treatment of, 76 - Injury of the arteries in the neighbourhood of the teeth, 81 - Injury of the mandibular nerve, 74 - Pain following tooth extraction, 81 - Wounding the tongue, 73 - -Disposition of the alveoli of the teeth, 12 - - -E - -Elevator, 7 - -Epilepsy, attack of, following tooth extraction, 94 - -Ethyl, chloride of, 61 - -Extraction of impacted lower third molars, 54 - - “ “ individual teeth, 19 - - “ “ lower bicuspids, 34 - - “ “ “ canines, 34 - - “ “ “ incisors, 33 - - “ “ “ molars, 35 - - “ “ “ teeth, 30 - - “ “ misplaced lower bicuspids, 51 - - “ “ “ “ incisors, 51 - - “ “ “ teeth, 46 - - “ “ “ upper bicuspids, 49 - - “ “ “ “ canines, 48 - - “ “ “ “ central incisors, 47 - - “ “ “ “ lateral “, 47 - - “ “ temporary teeth, 17, 43 - -Extraction of upper bicuspids, 22 - - “ “ “ canines, 21 - - “ “ “ incisors, 19 - - “ “ “ molars, 23 - - “ “ “ teeth, 19 - - “ “ the teeth, general principles of, 1 - - “ with forceps, 14 - - -F - -Forceps, holding of, 6 - -Forceps, the, 3 - -Forcing a root into the antrum during tooth extraction, 71 - - “ “ tooth into an abscess cavity during tooth extraction, 72 - - “ out a tooth with a prop or a Mason’s gag, accidents - under anæsthetics, 88 - -Fracture of the alveolus during tooth extraction, 67 - - “ “ “ “ treatment of, 69 - - “ “ “ tooth during tooth extraction, 64 - -Freezing agents, local anæsthetics, 61 - - -G - -General principles of extraction of the teeth, 1 - -Gum, extensive laceration of the, during tooth extraction, 72 - - -H - -Hæmorrhage following tooth extraction, 74 - - “ “ “ “ treatment of, 76 - -Hewitt, Dr., on the toxic effects of cocaine, 61 - - “ “ “ “ use of chloroform in operations, 57 - -Holding of elevator, 9 - - “ “ the forceps, 6 - -Hysteria, attack of, following tooth extraction, 94 - - -I - -Impacted lower third molars, the extraction of, 54 - -Incisors, the extraction of lower, 33 - - “ “ “ “ misplaced lower, 51 - - “ “ “ “ “ upper central, 47 - - “ “ “ “ “ “ lateral, 47 - -Incisors, the extraction of upper, 19 - -Individual teeth, the extraction of, 19 - -Injury of the arteries in the neighbourhood of the tooth during - extraction, 81 - - “ to the mandibular nerve during tooth extraction, 74 - -Instruments, 3 - -Irregular and crowded teeth, difficulties during extraction through, 65 - - -L - -Laceration of the gum through tooth extraction, extensive, 72 - -Lateral incisors, the extraction of misplaced upper, 47 - -Lips, bruising the lower, during tooth extraction, 74 - -Local anæsthetics, 59 - -Lower bicuspids, misplaced, the extraction of, 51 - - “ incisors, misplaced, the extraction of, 51 - - “ “ the extraction of, 33 - - “ teeth, the extraction of, 30 - - “ third molars, impacted, the extraction of, 54 - - -M - -Mandible, Dislocation of the, during tooth extraction, 70 - -Mandibular nerve, injury to the, during tooth extraction, 74 - -Miscellaneous complications, difficulties and sequelæ, 93 - -Misplaced lower bicuspids, the extraction of, 51 - - “ “ incisors, the extraction of, 51 - - “ teeth, the extraction of, 49 - - “ upper bicuspids, the extraction of, 49 - - “ “ canines “ “, 48 - - “ “ central incisors, the extraction of, 47 - - “ “ lateral “ “, 47 - -Molars, impacted lower third, 54 - - “ the extraction of lower, 35 - - “ “ “ upper, 23 - - -N - -Necrosis of the alveolus following tooth extraction, 70 - -Nitrous oxide, the use of, during the extraction of the teeth, 56, 57, 58 - -Nitrous oxide with air, the use of, during the extraction of - the teeth, 56, 57, 58 - - -O - -“Oblique rooted” molars, 26 - -Operations requiring a long anæsthesia, 57 - -Order of removal of teeth, 59 - - -P - -Pain following tooth extraction, 83 - -Passage of a foreign body through the isthmus of the fauces, - accidents under anæsthetics, 89 - -Points in the anatomy of the teeth and jaws, 11 - -Position of the operator and patient, 10 - - -R - -Removal of a neighbouring tooth during extraction, 66 - - “ “ an unerupted bicuspid “ “, 66 - - “ “ teeth, the order of, under anæsthetics, 59 - - “ “ “ with straight elevator, 15 - - “ “ the wrong tooth during tooth extraction, 66 - - -S - -Screw, the, 9 - -Septic and infective sequelæ following extraction, 95 - -Sequelæ, difficulties and complications arising during - extraction, miscellaneous, 93 - -Sequelæ, difficulties, complications and, arising during - extraction under anæsthetics, 88 - -Sequelæ, difficulties, complications and, of extraction - of the teeth connected with the jaws, 67 - -Sequelæ, difficulties, complications and, of extraction - of the teeth connected with the soft parts, 72 - -Sequelæ, difficulties, complications and, of extraction - of the teeth connected with the teeth themselves, 63 - -Shock following extraction, 93 - - -T - -Teeth, general principles of extraction of the teeth, 1 - - “ which require extraction, 1 - -Temporary teeth, the extraction of, 17, 43 - -Tongue slipping back, accidents under anæsthetics, 88 - -Treatment of fracture of the alveolus during tooth extraction, 69 - -Treatment of hæmorrhage following tooth extraction, 76 - -Trismus, treatment of, 72 - - -U - -Undue resistance of the tooth and alveolus, 63 - -Upper bicuspids, misplaced, the extraction of, 49 - - “ canines, misplaced, the extraction of, 48 - - “ central incisor, misplaced, the extraction of, 47 - - “ lateral “ “ “ “ “, 47 - - “ teeth, the extraction of, 19 - -Use of anæsthetics during the extraction of the teeth, 56 - -Uterine pain following tooth extraction, 93 - - -W - -Wounding the tongue during tooth extraction, 73 - -Wound resulting from removal of a tooth, 16 - - * * * * * - - DISEASES AND INJURIES - OF THE TEETH, - - _Including Pathology and Treatment_, - - A Manual of Practical Dentistry for Students - and Practitioners. - - BY - - MORTON SMALE, M.R.C.S., L.S.A., L.D.S., - - Dental Surgeon to St. Mary’s Hospital; Dean of the - School, Dental Hospital of London; Member of Board - of Examiners in Dental Surgery, Royal College of - Surgeons of England. - - AND - - J. F. COLYER, L.R.C.P., M.R.C.S., L.D.S., - - Dental Surgeon and Lecturer on Dental Surgery to - Charing Cross Hospital and to the Dental Hospital - of London. - - 334 illustrations. 407 pp. and Index. 8vo, cloth. - - Price 15s. - - SUPPLIED BY - - CLAUDIUS ASH & SONS, Limited, - - 5, 6, 7, 8, & 9, BROAD STREET, GOLDEN SQUARE, LONDON, W. - - ENGLAND. - - -FOOTNOTES: - - [1] A description of the different instruments in general use for the - removal of the various teeth will be found in chapter ii. - - [2] A description of the form of each tooth, with respect to its - bearing upon the construction of forceps and its removal, will be - found in chapter ii. - - [3] The following is a useful formula:-- - - ℞ Liquoris potassæ Ʒvi. - Acidi carbolici glacialis Ʒij. - Aquam ad. ℥viii. - - _M._ One teaspoonful to be used with half a tumbler-full of warm water - as a mouth wash. - - [4] “A System of Surgery” (edited by Frederick Treves), vol. i., page - 292. - - [5] “Dental Pathology and Surgery,” page 340. - - [6] _Transactions Odontological Society_, vol. iii., page 138. - - [7] _Transactions Odontological Society_, vol. xxviii., page 3. - - [8] _Journal British Dental Association_, vol. xiv., page 727. - - [9] - - ℞ Acidi gallici Ʒij. - Ft. pulv. viij. - - One powder every two hours until the hæmorrhage ceases. - - [10] Perchloride of iron should be avoided as a styptic, it nearly - always contains some free acid, and is therefore detrimental to the - teeth; in addition to this it leads to extensive clotting in the - veins, as well as to a certain amount of sloughing of the gums. - - [11] - - ℞ Acidi gallici Ʒij. - Ft. pulv. viij. - - One powder every two hours until the hæmorrhage ceases. - - [12] - - ℞ Liq. ferri perchloridi ♏xxv. - Aquæ chloroformi Ʒij. - Aquam ad ℥j. - Mitte ℥viij. - - M. Two tablespoonfuls every three hours until the hæmorrhage ceases. - - [13] - - ℞ Ext. ergotæ liquidi ♏xx. - Acidi sulphurici diluti ♏x. - Aquam rosæ ad. ℥j. - Mitte ℥viij. - - M. Two tablespoonfuls every three hours until the hæmorrhage ceases. - - [14] Injectio ergotini hypodermica B.P.: 1 of ergotine to 2 of camphor - water. Dose 3 to 10 minims, made as required. - - [15] _Dental Record_, vol. xi., p. 425. - - [16] Common salt, Ʒj., water 0j. at 99° F. - - [17] _Transactions of the Odontological Society_, vol. xxvii., page - 123. - - [18] Two ounces of poppy heads should be placed in one pint of boiling - water, the water being boiled down to half a pint. - - [19] - - ℞ Ferri et quiniæ citratis gr. vi. - Aquæ chloroformi Ʒij. - Infusum quassiæ ad. ℥i. - Mitte ℥viij. - - M. Two tablespoonfuls three times a day after meals. - - [20] The following will be found useful:-- - - ℞ Boro-glyceride (Barff) } - Eau de Cologne } aa. Ʒiv. - Tinct. krameriæ } - Spirit vini. rect. ad. ℥iv. - ♏ Fiat lotio. - - To be used with water as a mouth wash. Shake before using. - - [21] - - ℞ Zinci sulphatis gr. viij. - Zinci chloridi gr. vi. - Morphinæ acetatis gr. ij. - Aquam ad. ℥viij. - ♏ Fiat lotio. - - To be used with an equal quantity of water as a mouth-wash. - - [22] _The Journal of the British Dental Association_, vol. vii., page - 32. - - [23] _British Journal Dental Science_, vol. iii., page 221. - - [24] “A System of Dental Surgery,” 3rd edition, page 626. - - - - - - - - -End of Project Gutenberg's Extraction of the Teeth, by J. F. 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