Read Ebook: Extraction of the Teeth by Colyer Frank

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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.

In all cases where there is a fear of a molar fracturing, root in preference to ordinary forceps should be used.

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 .

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 .

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.

The removal of lower incisor roots is carried out in a similar manner.

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.

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:

A clear view of the tooth and its surroundings can be obtained during the whole period of removal.

Force can be applied with greater advantage.

The alveolus can be easily embraced by the fingers, or by the finger and thumb of the left hand.

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 . 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.

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 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 :--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.

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 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.

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.

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.

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.

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.

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 , 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.

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.

most difficult teeth to remove. One of the most useful instruments for their extraction is a pair of upper root forceps , 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.

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 . Extractive force should be used principally towards the median line of the mouth, and this may be combined with slight rotary movement.

As useful an instrument as any for their removal is a curved elevator , 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.

The Use of Anaesthetics during Extraction of the Teeth.

The anaesthetics 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 anaesthetics, 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 anaesthetic. 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 anaesthesia is quieter.

The mucous membranes of the mouth do not swell to the same extent, and the operator therefore gains a clearer view of the tooth.

The period of anaesthesia is lengthened, perhaps by only a few seconds, but the quieter condition of the patient assists indirectly in prolonging the period for operating.

Whenever a general anaesthetic is given for the removal of teeth, two people should always be present, one to confine his attention solely to the administration of the anaesthetic, 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 anaesthetic 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 anaesthetic 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 ANAESTHETICS.

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 anaesthetic I have generally found cocaine satisfactory, so far as its anaesthetic 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 anaesthetic properties of cocaine without giving rise to toxic effects, but in practice I have not found these statements fully borne out.

"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 dyspnoea 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.

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.

The gums must be thoroughly frozen before commencing to operate.

The extraction must be carried out as quickly as is consistent with thoroughness.

If possible the spray should be continued during the operation.

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.

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