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THE GENERAL PRINCIPLES OF EXTRACTION OF THE TEETH 1

THE EXTRACTION OF INDIVIDUAL TEETH 19

THE EXTRACTION OF MISPLACED TEETH 46

THE USE OF ANAESTHETICS DURING EXTRACTION OF THE TEETH 56

DIFFICULTIES, COMPLICATIONS, AND SEQUELAE OF EXTRACTION OF THE TEETH 63

INDEX 96

EXTRACTION OF THE TEETH.

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--

Those teeth whose roots are much shortened by absorption.

Those teeth from which the alveolar process has disappeared to such an extent as to leave them quite loose; and

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.

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 ,

while for the upper back teeth the handles form a curve of greater or less extent with the blades . 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 , while in other classes the handles are in line with the arch .

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.

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 . 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.

After being used, instruments of every kind should be freed from all foreign matter and then carefully sterilised.

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--

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;

To support the mandible;

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.

If the teeth be examined it will be noticed that they are capable of division into--

Teeth with single, rounded tapering roots;

Teeth with single roots more or less irregularly flattened or curved;

Teeth with multiple roots.

Under are included the upper incisors and the lower bicuspids; the lower incisors and canines , and also the upper canines and bicuspids; the upper and lower molars and frequently the first upper bicuspids.

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

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.

Adaptation of the forceps to the tooth.

Destruction of its membranous connections with, and dilatation of, the socket.

Removal of the tooth from the socket.

The method of using a curved elevator will be described in dealing with the removal of the roots of lower molar teeth.

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 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 Individual Teeth.

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 . 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.

The roots of canine teeth are to be removed in the same manner as that adopted for the whole tooth.

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.

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 . 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.

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 .

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.

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