Principles and practice of filling teeth

Front matter

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Preface To The Fourth Edition

For the Fourth Edition of this work a more extensive revision has been made than for any previous issue. This has been rendered necessary by the very considerable change in ideas regarding some of the modern methods of practice. In recent years the cast gold inlay has assumed a definite status in our daily work, and accordingly the chapter on this subject has been entirely re-written. Root canal work is claiming unusual attention by the profession, and this therefore has been considered in some detail. The subject of oral prophylaxis is an increasingly important one, with great possibilities for future usefulness, and it has been deemed necessary to go into it with some care. Little change has been made in the Chapters on Cavity Preparation, this work having been standardized and placed on a stable basis year's ago.

The rapid evolution of ideas in many of the lines of practice in operative dentistry renders constant revision necessary in a work of this kind, and the author can only hope that this edition may prove satisfactory to his readers. If they are as charitable of the limitations of the present volume as they have been of the previous issues, it is all that he can ask.

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CHICAGO.

Contents

RIE Res. 5, 6 sce ake CAE ee ta EE ES is CPU aR a AS

Deposits ON THE TEETH. Kinds of Deposits.—Salivary Cal-

culus.—Serumal Calculus.—Stains on the Teeth. Removat oF

Chapter I Deposits On The Teeth

_ The first duty of the dentist when a patient applies to him for attention to the natural teeth is the thorough removal of all deposits, provided the patient is not suffering pain. In every instance where there is suffering the manifest duty of the professional man is to relieve it at once if possible, no matter in what form it may present itself; but after this is accomplished, and before any filling operations are undertaken, the mouth should be put in as nearly a hygienic condition as may be secured by the utmost cleanliness. It is too often the case that operators—some of them with a brilliant reoord as skillful manipulators—seem to ignore this important procedure, and hasten to the insertion of fillings in teeth covered with calculus. It matters not how beautiful or how perfect an operation may be under these conditions, the work should never be considered as ideal dental service. No successful architect ever builds a house without first looking well to the foundation, and no surgeon of repute will proceed to operate upon a wound without at least making the surrounding parts as healthy as may be in advance. Dentists _are not living up to the highest possibilities of their art when they fail to consider the importance of maintaining the tissues around the teeth in a state of health, and this cannot be done short of a ’ careful removal of all extraneous material which may be found adherent to the teeth. It would seem that sufficient emphasis had been given this matter by writers in the past, but the fact remains that with all that has been said the profession are most lamentably lax when it comes to the observance of true hygiene of the mouth. It is not here intended to make an unjust arraignment of the profession nor charge its members with willful neglect, but the persistent ignoring of this important phase of practice on the part of many otherwise excellent operators constitutes a grave 1 reflection on their professional integrity and correspondingly lowers the standard of dentistry. The people can be educated in this matter only by the most conscientious and earnest effort of their dental advisers, and no man practising dentistry is doing his full duty unless his patients are constantly being schooled into the necessity for painstaking care in cleanliness of the mouth. It is not within the province of the present work to go minutely into the pathology of this subject, and yet it would seem desirable to briefly indicate some of the deleterious effects produced by deposits when allowed to remain.

The encroachment of calculus along the neck and root of a tooth, if left unchecked, results in an absorption of the gum, the peridental membrane, and even the alveolar process, so that finally the support of the tooth is destroyed, and it is allowed to topple over and fall out. It is estimated by many observant practitioners that more teeth are lost as the result of diseased conditions in the tissues surrounding them than from decay of the teeth themselves; and, if this be true, it is very important that dentists should pay especial attention to the agencies calculated to bring about such conditions. It is undeniably a fact that calculus in a mouth subject to its continual formation will, if allowed to accumulate, sooner or later work the destruction of the teeth.

WEG, sds Fie. 2. Fig. 3.

Figs. 1, 2, 3, 4, and 5 illustrate some extreme cases of calculus formation about the teeth. Figs. 1 and 2 show the mesial and distal aspects of two lower incisors with calculus attached, actual size. Fig. 3 is a mass of calculus detached from the buccal surface of an upper molar. The patient applied to her dentist for examination relative to some “growth” which she said was forming in her mouth, and the result was the removal of this piece of calculus, here reproduced in two views, actual size. Figs. 4 and 5 are specimens of calculus attached to teeth, one a lower cuspid, the other an upper molar. It must be apparent that in the specimens shown the teeth need not necessarily have been lost if early attention had been given to these deposits. There was not the slightest indication of caries upon any of them, and it is safe to

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conclude that had the patients sought and obtained proper dental service in the initial stages of the affection the teeth might have been preserved for many years of usefulness. It is true that in these particular cases the patient had failed to apply to the dentist in time to accomplish anything, through an ignorance of the significance of the deposits, and yet there would seem to be

Fie. 5.

many instances where the neglect is not entirely traceable to the patient. It should be the office of the dentist not only to perform operations on the teeth, but to so educate those who come under his charge that the general public shall be made familiar with conditions so readily understood.as these, and so manifestly self-evident when attention is once called to them.

KINDS OF DEPOSITS

Deposits are usually classified under three kinds, salivary calculus, serumal calculus, and green stain, though from an operative point of view the latter would seem to be widely distinguishable from the other two. It is not a deposit of appreciable bulk, and it is entirely different in character, both as regards its deleterious effects and the methods to be employed in its removal. Nor wee it seem to be altogether appropriate to limit the term to

‘“‘oreen’’ stain. There are other stains on the teeth besides those of a green color, and they should not be ignored in Rta the subject.

Salivary Calculus

This, as its name implies, is chiefly a deposit from the saliva. The solid constituents of this secretion, which are normally held in solution during its progress from the gland to the mouth, become'so affected by the change of environment on entering the oral cavity as to be precipitated in the form of caleulus on the teeth. This being true, we should naturally expect to find the . most extensive deposits upon the surfaces of the teeth lying nearest to the openings of the salivary ducts, a fact borne out by clinical observation. The usual points of initial deposit of salivary calculus are upon the lingual surfaces of the lower incisors, opposite the openings of the ducts from the sublingual and submaxillary glands, and upon the buccal surfaces of the upper molars, which are copiously bathed in the parotid saliva. This must not imply that these are the only surfaces subject to the deposition of salivary calculus. There is no surface of any tooth exposed to the fluids of the mouth which may not accumulate this deposit, provided there is an absence of friction on that

surface.

The full function of mastication would seem to be one of the most effectual natural processes in limiting the deposition of salivary calculus, it being plainly evident to an observant operator the moment he looks in a mouth where mastication is confined to one side. It will invariably be found that the teeth on the unused side will present an altogether neglected appearance, and if there is a predisposition to the formation of calculus they will be almost completely covered with it, even over the occlusal surfaces. A striking object-lesson may be given patients as to the necessity of keeping the teeth in active and uniform service by calling attention to the difference in appearance of the teeth on the two sides, and impressing them with the fact that whereever, for any reason, thorough mastication is impracticable the deficiency should be supplied by substituting artificial friction with the tooth-brush. The demand for friction relates as well to the gums as to the teeth, it being very exceptional to find a healthy condition of the gums in any locality not subjected to full functional use.

This question of giving the teeth and gums adequate employment should be carefully studied by operators, and its necessity forced upon the attention of patients. It is the keynote of health in the mouth, as elsewhere in the human body, and it should be the prime function of the dentist to keep the oral tissues healthy. It is infinitely a higher aim to prevent disease than to cure it, and if dentists take this matter seriously to heart they can accomplish much in this direction. A critical study should be made of the conditions present in every mouth coming under the operator’s attention, and a careful note made of the various landmarks of neglect. The results of this neglect must invariably be pointed out to the patient, and an impression made in such a manner that it cannot be ignored. If the dentist thereby fails to enlist the co-operation of his patient, it is only common justice to at once absolve himself from responsibility for the ultimate saving of the teeth. This will usually bring the patient to a proper realization of the true relation existing between operator and patient, and will at least eerptel an intelligent understand- ‘ing between them.

In character salivary ‘eaiculin may vary from a soft granular mass, easily removed and disintegrated with an instrument, to a hard, dense, and almost flint-like consistence. This difference in density relates chiefly to the rapidity with which it is formed and the length of time it is allowed to remain in the mouth. When it is rapidly deposited and of recent formation it is comparatively soft, but seems to grow progressively harder if left undisturbed. The color also varies materially in different specimens, from a yellowish gray to a black, the former usually being associated with rapid and recent formations, while the latter is ordinarily confined to cases of long standing. In some mouths the yellowish gray remains almost indefinitely, so that the question of color is not entirely one of age; and yet in specimens of extensive accumulation, such as those illustrated, it will usually be found that the portion nearest the tooth, and also that immediately overlying the gum-tissue, and which accordingly has been longest in place, is much darker than that more recently formed upon the surface.

The present reference to color relates to a staining of the caleulus itself, and not to a surface deposit of black such as is commonly found in the mouths of smokers. The latter is a characteristic jet-black discoloration, unmistakably from tobacco smoke, while the former is less intensely black, with sometimes a greenish tinge—especially where it has been long in contact with the gum—and its source is not so apparent.

Serumal Calculus

This deposit is distinguishable from salivary calculus in several particulars, but chiefly in its initial point of location on the tooth. Salivary calculus finds its lodgment on that portion of the tooth which is bathed in saliva, and therefore becomes adherent to the crown or neck of the tooth, the part not covered by the gum. It may advance and force the gum and adjacent tissues back so as to follow the root to the apex, as in Fig. 1; and yet it begins not under the gum, but crownwise of it. Serumal calculus, on the contrary, attaches itself to the root of the tooth, or to that portion of the neck which is covered by the gum. The source of this deposit is therefore different from salivary calculus, and, as its name implies, it is supposed to be from the serum of the blood. In fact, it has sometimes on this account been termed sanguinary calculus, though it would appear that there are certain formations of this deposit which cannot well be considered as coming directly from the blood. In chronic alveolar abscess we often find upon the apex of a root which has been for some time constantly bathed.in pus the characteristic serumal deposit. But it at least may safely be stated that serumal calculus is a deposit from the fluids which surround the root of the tooth, while salivary calculus is deposited from the fluids in contact with the crown.

Another point of distinction between the two is found in the relative bulk of the deposit. Salivary calculus, as we have seen, - may assume extensive proportions, while serumal calculus, on account of its environment, is restricted in growth, and is usually found in the form of small nodules, narrow bands, or thin scales (Figs. 6 and 7). These are ordinarily attached quite firmly to the surface of the root, and require considerable force to dislodge them. It is probable that the irritation produced by serumal calculus under the gums is accountable for many of the diseases to be found in the surrounding tissues, and which frequently lead to loss of the teeth, it being impossible to conceive of gums remaining healthy with any considerable deposit of serumal calculus under them.

The color of serumal calculus is usually darker than that of salivary calculus, and quite commonly has a greenish tinge running through it. It is also dense in structure, and is probably formed more slowly than salivary calculus. It may be found in some instances deposited in a thin scale along the side of the root where the pericemental membrane has been lost, or it may occur as small nodules, particularly at the apex of a root, as the result of chronic alveolar abscess. In other cases, where the attachment of the pericemental membrane to the root seems perfect from the apex to near the alveolar border, but where the free margin of the gum is congested and puffed, a narrow band of calculus may be found encircling the neck of the tooth in its entire circumference just under the gum. ‘This is sometimes so near the margin of the gum that it may readily be seen by forcing the gum back with a pledget of cotton. In any pocket formed between the gum and the root as the result of the loss of that portion of the pericemental membrane, we may ordinarily expect to find more or less of a deposit of serumal calculus, and we need not hope to see the gum-tissue overlying this become healthy so long as the deposit is allowed to remain.

Stains on the Teeth

These may present themselves in varying degrees of extent and intensity, and in varying shades of color. The one claiming most attention from the profession in the past is green stain, which seems to occur with the greatest frequency on the labial surfaces of upper incisors in young patients. It may also be found in certain instances coating the entire buccal and labial surfaces of all of the teeth in adults, though this is comparatively rare. It would appear strange that so much prominence has been given green stain to the almost complete ignoring of the other varieties. In point of frequency the brownish stains are more prevalent, and they are found occurring at all ages and upon any of the surfaces of the teeth not subjected to considerable friction, but it should be stated in this connection that many of these brown stains will exhibit a greenish tinge when examined with a magnifying glass.

All of the stains seem to form with the greatest intensity near the gum-margin, and gradually shade away toward the occlusal surface, though in some instances they constitute a more or less well-defined concentric band near the gingival line, following the curvature of the gum, and including the lingual as well as the labial surfaces. There is a wide variation in the degree of tenacity with which these stains adhere to the surfaces of the teeth; in some instances the slightest friction being all that is necessary to remove them completely, while in others they seem almost part and parcel of the enamel itself. The green stains are usually more adherent than the brown, and in cases of great intensity of stain the surface of the enamel is disintegrated and roughened after its removal. The indications in every instance are for the perfect polishing away of all such stains upon the teeth, the fact of their unsightliness being an all-sufficient reason for such a procedure aside from the somewhat undetermined point as to their possible deleterious effect upon the enamel.

Another variety of discoloration upon the teeth may be -mentioned as being distinct from the green and brown stains, and of a character entirely peculiar to itself. This is the black deposit caused by tobacco smoke. It may be found adherent to the teeth of smokers much the same as the other stains, except that it is more prevalent on the lingual surfaces, and it has more appreciable bulk. It may be scraped away with instruments, leaving the enamel apparently unaffected under it; but it does not accumulate like salivary calculus, so as to impinge upon the gum or cause irritation to the surrounding parts. In instances of the long-continued use of tobacco the structure of the teeth themselves may become so stained as to permanently remain so, particularly where the enamel is gone and the dentin is exposed to the smoke. ;

REMOVAL OF DEPOSITS Removal of Salivary Calculus

There are two principal plans of manipulative procedure for the removal of salivary calculus, the push-cut method and the draw-cut method, each having different forms of instruments adapted to its use. By the push-cut method the blade of the scaler is brought to bear upon the calculus at the point nearest the occlusal surface of the tooth, and the mass dislodged by forcing the scaler between the calculus and the enamel in the direction of the root. By the draw-cut method the scaler is placed rootwise of the deposit, and force applied by pulling toward the occlusal surface. Each method has its advocates in the profession, and each is applicable to certain conditions, the best practice probably being to use them interchangeably, as circumstances suggest. The limitations of the draw-cut method relate to the fact that to force an instrument of sufficient size for the removal of salivary calculus far enough rootwise to seize the deposit frequently involves considerable impingement on the gum, with consequent laceration; while by the skillful use of the push-cut instrument the deposit may often be forced away without touching the gum at all. On the other hand, the push-cut method invites a certain danger which is never present with the draw-cut. The application of force directly toward the gum carries with it the constant possibility of the instrument slipping and wounding the gum, while a slip of the draw-cut instrument is comparatively harmless. The element of apprehension on the part of the patient when the push-cut is being used is sometimes a menace which invites accidents from the patient flinching on the application of force, thus causing the instrument to glide into the gum.

To avoid accidents of this nature, and to carry assurance to the mind of the patient, it is always necessary before applying any force. with the scaler to so guard the hand of the operator against undue movement that the instrument, in case it does slip, will not be carried into the gum. This can be done by bracing the unused fingers—the ones not grasping the scaler—firmly against the occlusal surfaces of the teeth before applying the scaler to the deposit. By this means a perfect control may be maintained over the instrument, and a sense of security imparted to the patient, which usually results in a reasonable degree of confidence during the operation. This matter of creating confidence on the part of the patient is an important element in conducting a successful practice in all lines of procedure, and the operator should study the manipulation of instruments to this end. The cardinal principles in operating should be precision of methods, firmness of control, and delicacy of execution. Patients are more susceptible to impressions made upon them through manipulative procedure than the average operator would seem to conceive of. They are quick to recognize superior skill in an operator by reason of his mastery of instruments and the apparent intelligence with which he approaches his work, and there are few operations in dentistry calling for a more diversified order of skill than the successful removal of calculus from the teeth.

The cases are so varied in their nature, both as regards the extent and location of the deposit and also the character of the teeth and their position in the arch, that it may almost be said that each case constitutes a law unto itself, and must be approached in accordance with its individual requirements. And yet it would seem desirable to formulate so far as possible definite rules of procedure in this as in all other operations on the teeth, though the fact must constantly be borne in mind that in any formulation of this nature the element of personal equation must necessarily enter conspicuously into it and largely influence its details. No two men need be expected to approach this work in precisely the same way, though each should at least study out some systematic order of procedure for his own guidance, so as to accomplish the result in an orderly sequence, rather than by haphazard and slip-shod methods. Lack of system in the performance of our work has been one of our chief limitations as operators, and it is accountable for a grievous waste of time both to practitioner and patient.

The methods here suggested are not applicable to all cases, nor will they probably appeal to all operators; but it is confidently hoped that they may at least prove helpful to those who in the past have not thought it necessary to employ any particular method in these operations.

Instruments for the Removal of Calculus

The instruments here illustrated are largely adaptations from or modifications of the forms long since introduced to the profes-

DEPOSITS ON THE TEETH 1l sion by various operators. Fig. 8 is a somewhat sickle-shaped contra-angle instrument, having three sides for cutting. It may therefore be used interchangeably as a push-cut or draw-cut instrument, though the sharpest or most acute edge being along the extremity of the instrument gives it greater efficiency as a push-cut than as a draw-cut. Its uses will be indicated hereafter. Fig. 9 is an ordinary direct push-cut scaler, with the curvature somewhat nearer the cutting-edge than usual; while Fig. 10 is a long, slender, delicate instrument for reaching places inaccessible to Fig. 9. Figs. 11, 12, 13, and 14 are hooked instruments of

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varying forms for draw-cut work along the roots of teeth in pockets under the gum, the two former being from the Mawhinney set. One precaution should be taken with all instruments used for this purpose. Ordinarily the back of the scaler— the side coming in contact with the gum in passing between it and the root—is left with sharp angles and corners, which inflict unnecessary discomfort on the patient by lacerating the gum. ‘These angles should be rounded off, so as to leave a smooth back to the instrument, which may be insinuated under the gum and along the root without serious disturbance to the patient. Fig. 15 is merely a short-bladed hoe excavator, while Fig. 16 is a delicate hatchet excavator, the uses for which will be considered later. Fig. 17 is a curved wide push-cut scaler for passing over the surfaces of teeth where the bulk of the deposit has already been removed, and scraping off any small’ particles that may have been left. Fig. 18 is a long-reach push-cut scaler for approaching localities in special cases inaccessible to the ordinary instruments.

Technique of the Operation

In the examination for calculus on the teeth probably nine out of ten operators will instinctively place the mouth-mirror between the tip of the tongue and the lower incisors, and reflect the light upon the lingual surfaces of these teeth. It is therefore natural that the removal of the deposits should begin at this point, and there is also another minor reason why it is well to start where there is considerable material to be removed. It makes an instantaneous impression on the mind of the patient as to the extent of the deposit present, and arouses an interest in the work which nothing else will. It is seldom that a patient realizes just how much calculus there is upon the teeth, due to its gradual formation and the fact that the tongue becomes accustomed to its presence. But if, on the first introduction of the scaler, several large pieces are flaked off and allowed to fall into the floor of the mouth, the patient is startled into a realization of what has been going on, and is impressed with the importance of proper attention to the matter in the future. The same impression never seems possible later on in the operation if the large masses are left till the last.

For the removal of salivary calculus from the lingual surfaces of the lower incisors in ordinary cases the scaler illustrated in Fig. 8 is admirably adapted. (It need not here be urged that all sealers should be keenly sharp in whatever location they are used.) With the mouth-mirror in the left hand, and held in such a position that the tongue is kept well away from the lower incisors and the light thrown upon the deposit, the first movement of the operating hand should be to firmly brace the end of the third finger against the occlusal surfaces of the adjacent teeth in such a manner that the patient must at once realize that the operator has complete control of the instrument against slipping. This accomplished, rapid work is possible. A push-cut should be used along the disto-lingual surface of the right lower lateral, and the deposit dislodged. Immediately this is done the point of the instrument should be turned rootwise of the deposit on the mesio-lingual surface of the same tooth, and a draw-cut given to flake it off along that surface. Thus with two movements, one downward and the other upward, the large bulk of calculus from that’tooth has been dislodged in the most expeditious manner. ‘The same plan should be followed successively with the other teeth in line as far as the left cuspid, when the sickle-shaped scaler should be exchanged for Fig. 17. With this the entire lingual surfaces of these teeth should be scraped to remove any small particles of deposit which may have been left by the other scaler, and, following this, attention should be given to the lingual surfaces of the left lower bicuspids and molars. Beginning with the mesio-lingual aspect of the first bicuspid, these surfaces should be followed in regular order to the distal surface of the left lower third molar, the instruments usually best adapted for this work being either the hoe or hatchet forms, Figs. 15 and 16. The lingual surfaces of all of the lower teeth to the left of the right cuspid have now been covered. To reach the lingual surfaces of the right cuspid and the teeth posterior to it the operator should step slightly forward and face his patient, so as to look along these teeth. Then, with the hatchet instrument held in the palm and the thumb braced against the

teeth, the deposit may be lifted from the necks very expeditiously. After the lingual surfaces are attended to, the buccal and labial surfaces may ordinarily be reached with the hatchet instrument, using the pen grasp for the right side of the mouth as far forward as the cuspid, and then changing to the palm grasp for all the teeth to the left of that. These surfaces should be followed successively from one third molar to the other. As the deposit is being lifted from the labial aspect of the lower incisors, care should be taken that the pieces of calculus do not fly into the operator’s eyes. The force is necessarily exerted directly toward the operator, and the particles sometimes snap off with considerable momentum, so that accidents of this nature are not uncommon.

When large masses of calculus are found on any of these surfaces, it may be removed with the push-cut instruments, Fig. 8 or 17. In cases of great recession of the gum and extensive deposits along the exposed portion of the roots, particularly if the teeth lean in toward the tongue, so that they stand obliquely in the arch and are very long, the lingual surfaces can only be reached to good advantage with an instrument like Fig. 18. In using this on the lower incisors or right cuspid, bicuspid, or molars it will be found better to pass to the left side of the patient and throw the light down into this secluded locality with the mouth-mirror in the left hand. The right hand, grasping the scaler, may pass around the patient’s head to the right angle of the mouth, so that the end of the third finger rests on the occlusal surfaces of the teeth in the region of the right lower cuspid or first bicuspid. Braced in this way, effective push-cutting may be done without impingement of the gum.