A practical treatise on operative dentistry

Preface

The exigences of the Profession seemed to require, for the department of Operative Dentistry, a work that should contain all that is known in this branch of the science. To answer that requirement, the author of the present work has aimed to furnish, in as compact a form as possible, the Principles of the Science, properly digested, the Experiments Detailed, the Manipulations Described, and the whole methodized and thus made available to the Student and the Practitioner. In the accomplishment of this object, he has, he believes, included everything meritorious or important in this department of Dental Stud}-.

To the dental writers whose labors have lightened, in any degree, the toil of this undertaking, the intelligent reader will ascribe the credit due; and to the members of the profession, whose suggestions have found place in various parts of the volume, the author gratefully acknowledges his obligations.

J. TAFT.

Cincinnati, July 1, 1859.

A*

Chapter I. Paoe

Introduction, . . . . . . .17

Origin of, ..... 19

Points of Deposit, ...... 20

Method of Removing, . . . . .22

Green Tartar, ...... 24

Treatment of, . . . . . . 26

Irregularity, . . . . . . .27

Chemical Abrasion, ...... 36

Necrosis of the Teeth, ...... 38 xu

CONTENTS.

CHAPTER H.

Caries of the Teeth, ....

Causes of Caries, .

Predisposing causes of Caries, Exciting causes of Caries,

Comparative liability to Decay,

Consequences of Caries,

Treatment of Caries,

CHAPTER III. Various Preparations of Gold, . . .85

Nonmetallic Materials, . . . . . 91

CHAPTER IV. Heavy Cutting Instruments, .... 94

Bur Drills, ...... 96

Common Drills, . . . . . .98

Drill Stocks, ...... 100

Manufacture of Excavators, . . . .105

PAGE

41 51 51

55 62 63 66

CONTENTS. Xlll

PAGE

The File, ....... Ill

Use of the File, ..... 113

Mode of using the File, . . • • .114

Chapter VI

Filling of Teeth, Examination, Opening Cavities, Removal of Decay, .

Forming Cavities, Drying Cavities, Introducing the Filling, Block Filling,

Forming Blocks, .

Introducing the Blocks,

Pellets,

Adhesive Foil, .

Crystal Gold, Finishing Fillings, .

. 124

125 . 126

128 . 131

139 . 142

148 . 149

151 . 154

154 . 158

CHAPTER VII. First Class, . . . . . 168

Filling with Foil, . . . 173

Adhesive Foil, ..... 175

1st Modification, . . . . .177

2d Modification, . . . . . 179

Second Class, . . . . . .180

1st Modification, ..... 181 xiv

CONTENTS.

PAOE

Third Class, . . . . . .183

2d Modification, ..... 186

Fourth Class, . . . . . .187

1st Modification, . . . . . 191

2d Modification, ...... 193

3d Modification, ..... 194

4th Modification, ..... 195

Fifth Class, . . . . . . 197

Special Cases, ..... 199

The Palatal portion of the Crown broken away, leaving the outer portion standing — nerve not exposed, ..... 200

Filling large Cavities on the Labial Surfaces of

the Superior Incisor, .... 204

Chapter VIII

Treatment of Inflamed Dentine, Tannin, or Tannic Acid, Creosote, or Carbolic Acid, Nitrate of Silver, Chlorid of Zinc, Terchlorid of Gold, Arsenious Acid, Alkaline Caustics, .

CHAPTER IX. Exposed Pulps

Treatment of Exposed Pulps, Destruction of the Pulp, Actual Cautery, Potential Cautery, .

Arsenious Acid, Application of,

206 . 210

213 . 214

214 . 216

217 . 218

. 221 223

. 231 236

. 237 237

. 239

CONTENTS. XV

PAGE

Filling Pulp-Cavities and Canals, .... 244 Preparing the Teeth for Filling, . . . .251

Treatment of, . • • • .261

CHAPTER X. Fitting the Crown, ...... 272

Attachment of the Crown, . . . . . 275

CHAPTER XI. General Remarks, ...... 285

Indications for Extraction, ..... 292

Extracting Instruments, ..... 294

The Key, 295

Modus Operandi, ..... 296

The Forceps, ...... 299

The Gum-Lancet, . . . . . 315

Method of Lancing the Gums, . . . . .317

Extraction of the Teeth, . . . . . 319

Superior Incisors, . . . . . .319

Superior Cuspids, . . . . . 321

Superior Bicuspids, ..... 323

Superior Molars, . . . . . 326

Extraction of Roots, . . . . .327

Removal of the Dentes Sapientise, . . . 329

Extraction of the Inferior Incisors, . . .331

Inferior Cuspids, . . . . . .332

Inferior Bicuspids, ..... 334 xvi

CONTENTS.

PAGE

Inferior Molars, ...... 335

Inferior Dentes Sapientiae, .... 339

Extraction preparatory to the Insertion of Artificial Dentures, ...... 340

Conditions to be observed in the Extraction, . . 342

CHAPTER XII. Treatment, I 350 Fracture of the Alveolus, . . . . .358

Laceration of the Gums, . . . . . 360

Breaking the Teeth, . . . . . .361

Removal of a Wrong Tooth, . . . . 362

Dislocation of the Inferior Maxillary, .... 363

CHAPTER XIII. Ether — Chloroform, . . . . 368

Local Anesthesia, . . " . . • 372

Congelation, ...... 373

Extraction by Electro-Magnetism, .... 375

Application, . . . . ■ . 377

OPERATIVE DENTISTRY.

Introduction

As introductory to the following treatise, a cursory consideration of those conditions and diseases of the tee tli which demand the aid of dental surgery, would seem appropriate. To refer, however, to all of these, or to remark extendedly upon any of them, would not be consistent with the design of this work, or necessary to a proper understanding of the subjects proposed. Only those affections which pertain to the teeth directly, and which, for the most part, are confined to the tooth-substance itself, will here require attention. Nor will the pathology of contiguous parts be introduced ; for the appropriate treatment of these, being mainly therapeutic rather than surgical, would involve a discusssion of questions not within the scope of the present volume. Indeed, it is pro-

B

INTRODUCTION.

posed merely to speak of those affections of the teeth, which generally suggest surgical remedies, and which are implicated more or less in the operations described in the following pages ; and first, of

DEPOSITS.

In this term are included those calcareous formations commonly called tartar, a certain coloring matter denominated green stain, and such other impurities on the teeth as result from neglect, the use of tobacco, and like causes. The word

Implies all calcareous deposits upon the teeth. Of this substance there are several varieties, the more obvious of which have respect to color and consistence. In color, there are all shades, from a white as light as that of the tooth, or even lighter, to a jet black ; and in consistence, all degrees, from a thick, gummy mucus, to the density of the dentine itself. The color will, in most cases, be indicative of the density, the lightest shade corresponding with the softest, and the darkest with the hardest consistence. The tenacity to the teeth is also in proportion to the density, the dense and dark adhering most firmly. The density of the deposit, too, is generally indicative

TARTAR.

of the rapidity of its formation, being in an inverse ratio to this.

All the varieties of tartar are composed principally of the same elements, — phosphate of lime, fibrin, fat, and animal matter being contained in them all, though in various proportions. The fact that some varieties are soluble in acids, and others not, has been adduced to prove that they are entirely different in their composition. This, however, is accounted for on an other hypothesis : in the softer varieties, the phosphate of lime is so protected by the fat and the animal matter that, under ordinary circumstances, acid can not come in contact with it; but the dense varieties are very soluble, because the acid readily comes in contact with the calcareous portion.

Its origin. — It is a precipitate of the saliva, — or at least the phosphate of lime, and probably the fibrin, comes into the mouth with the saliva ; while perhaps the fat and other animal matter are deposited from the mucus. In all cases in which this substance is formed upon the teeth, the saliva has a very definite alkaline character, holding in solution the phosphate of lime, which, by the action of the acid mucus upon the saliva, is precipitated.

Persons of a lymphatic temperament, or a tendency toward it, with muscles of a soft, flabby texture, hair light, teeth of a rather inferior quality,

INTRODUCTION.

and a free flow of saliva, are most subject to the deposition of tartar ; yet there are conditions of almost all constitutions, in which it is freely eliminated. That it is precipitated from the saliva, is a fact so easily demonstrated and so generally admitted, that it need not here be considered.

Points of Deposit. — The points at which it is deposited in the greatest quantities upon the teeth, are in the vicinity of the orifices of the salivary ducts ; and hence it is found most abundant on the inner portions of the inferior anterior teeth, and on the buccal surfaces of the superior molars. Frequently, also, it collects in considerable quantities upon the external surfaces of the inferior front teeth. The points upon the teeth to which it most readily attaches, are at the necks, immediately beneath the free margin of the gum, and at the termination of the enamel. A nucleus once formed, and it encroaches upon the crown of the tooth, if no means are employed to prevent its lodgment, at a rate determined by the condition of the saliva.

It is deposited first and most abundantly on the necks of the teeth, because here the saliva first comes in contact with these organs, and here remains for the longest periods and in the largest quantities. That it is precipitated very soon after the saliva enters the mouth, is evident from the fact that it is found collected upon the superior molars, just in the

TARTAR.

vicinity of the orifices of the ducts-of-Wharton, where the saliva cannot be retained for any considerable time, by reason of the position, but must very soon pass along upon the surfaces of the contiguous teeth, on which we generally find it deposited in much smaller quantities. Indeed, this calcareous deposition has been sometimes found in the salivary ducts themselves.

Its Effects. — It exercises no directly injurious influence upon the substance of the teeth ; but it is highly prejudicial to the parts immediately in connection with them, upon which they depend for support. It encroaches upon the gums and alv^pli, and causes an absorption of these important surroundings; and as they become absorbed, its encroachments are accelerated. In some constitutions this process goes on with little or no annoyance to the patient ; while in others, irritation, inflammation, and even suppuration of the gums occur; and thus their destruction is effected in a twofold manner. This irritation and inflammation may extend to the mucous membrane, and involve all the adjacent parts. The dental periosteum, also, if susceptible, as in many cases it is, will become implicated in the difficulty; periostitis will ensue, and often suppuration, thus breaking up the attachments of the teeth even before the surroundings are removed. The alveolus, too, becomes diseased, and in some instances its death and exfoliation result.

INTRODUCTION.

Salivary calculus, however, never induces caries of the teeth, nor even favors it. On the contrary, we frequently meet with instances of decay entirely arrested by a deposit of tartar in the cavity.

Persons of all ages are subject to this affection; those past middle life being most so, and those advanced in years sometimes having teeth nearly covered with tartar. There are some constitutions whose diathesis is favorable to a deposition of salivary calculus through life. Others, again, will be perfectly exempt from it till some peculiar constitutional change intervenes, when it will begin to be rapidly eliminated.

Method of removing It. — The removal of salivary calculus is an operation that does not involve a great amount of skill, but, with suitable appliances, is easily performed. There are two methods of effecting it; the one, that of scaling and scraping, and the other, that of decomposing the deposit by the application of an acid. The former is always to be preferred ; for, in the latter, the chemical action of the acid does not stop with a decomposition of the deposit, but, by the same affinity, attacks the tooth itself. For the successful accomplishment of the operation, instruments of various forms and curves will be necessary, adapted and adjusted to the various shapes and situations of the surfaces to be operated upon. The most common forms are repre-

TARTAR.

sented in the following figure. The blade of the instrument should be applied at a slightly obtuse angle with the surface of the tooth, just beyond the edge of

Fig. 1.

the deposit next the gum, and thus slid under the tartar, scaling it off to the point, in such a manner as not to roughen up or abrade the enamel. Deposits of this substance on proximal surfaces of the teeth are to be carefully observed, and removed with instruments of attenuated blades. When the thick incrustations have been thus removed, the surface should then be gently scraped, so as entirely to clean off all remaining portions, and afterward thorough!}" polished with fine pumice, or Arkansas- or rotten-stone, and finished by burnishing. During the operation, a frequent employment of the toothbrush with water will be required, to cleanse the mouth of the detached deposits and the increased secretions; and, in general, the completion of the process will occupy more than one sitting. Since this deposit often extends beneath

INTRODUCTION.

the free margin of the gum, much care is necessary to see that it all be removed.

GREEN TARTAR.

This deposit has been so referred to by writers, as to convey the impression that it is of the same generic character as salivary calculus. Such a misapprehension is hardly pardonable. The teeth of young persons only are subject to this affection, it being often found on those of children three or four years old. It almost always appears on the labial surfaces of the superior front teeth, and in largest quantity near the margin of the gum. It is seldom seen on the inferior teeth, and only on the anterior surfaces of the superior. The color of this deposit is very dark, inclining to green. Wherever it attaches, the surfaces of the teeth are abraded, and when it is of long standing, the entire enamel beneath it is destroyed, and the dentine is gradually involved in the dissolution. This effect upon the teeth is not produced by the coloring matter observed upon them, but by an acid in combination with this material before it is deposited. The stain is a precipitate from this compound, and the acid, leaving this, combines with the calcareous ingredients of the teeth, to their detriment as above; but the precipitate is entirely innocent.

GREEN TARTAR.

Its Origin. — Green tartar, or green stain, doubtless lias its origin in the mucus, when this is in a particular acid condition. That it does not proceed from the saliva is proved by the fact that it is never found where there is a free flow of saliva, or where this has free access ; but the point of its deposit is where the saliva is least frequently present, being most abundant in cases in which there is a large relative amount of mucus, and this in a very acid condition. But the query might arise here, if the mucus of the mouth were wholly in that condition, why would not the teeth suffer from it elsewhere. Because, on the masticating surfaces of the teeth, the friction of the food will prevent it, and on the inner surfaces, the friction of the tongue ; besides, wherever there is a free flow of saliva, this will have a counteracting , effect. Decay goes on very rapidly, after it has once commenced, upon teeth affected by this deposit.

There are points of dissimilarity between this green tartar or stain and salivary calculus, that it may be well to notice. The latter is from the saliva; the former from the mucus; and hence the one exists where there is an abundant flow of saliva, and the other where the relative quantity of this is small. The calculus is deposited when the saliva is in an alkaline condition; the stain, when the mucus is very acid. The former is deposited in large quantities and thick incrustations, and upon the surfaces of

INTRODUCTION.

the teeth, and is easily removed without detriment to their substance ; whereas the latter is a thin film, barely sufficient to stain the surface, and yet it enters into the tooth-substance itself, and cannot be removed without detaching some portion of the tooth with it. The one seems rather preventive of caries, which does not occur beneath it; but the other is highly promotive of decay. With these marked features of difference, it is surprising that the two should ever have been confounded, since it is so important that the distinctive character of each be understood, in order to its correct treatment.

Treatment.— In order to a perfect and final remedy for green stain, therapeutic treatment must be combined with the operative ; but only the latter will be here described, which has for its object the removal of the deposit, and the rendering of the eroded surface smooth and polished. There are two or three methods of accomplishing this object. When the erosion is but slight, it will be effected with pulverized pumice or Arkansas-stone, applied with water till the stain disappears, and with the subsequent use of the burnisher with a solution of soap. But when the erosion is too extensive to be thus reduced, it must be cut down with a file, and then finished with stone and burnisher, as before. And when the erosion is extreme, a cutting-instrument must precede the file.

IRREGULARITY.

IRREGULARITY.

By this term we imply those variations from a beautiful and natural position, in which the teeth are so frequently found. The principal cause of irregularity is a disproportion between the actual size of the arch, and the size required for the accommodation of the teeth. When this disproportion exists, the teeth which are first irrupted, occupy very nearly their proper position ; but those which come in afterward, are more or less disarranged, in proportion to the preoccupation of the space. There are cases in which the roots of the temporary teeth* are not absorbed, and the permanent teeth are irrupted out of their true position, even when there is room enough for them were the former removed. Irregularity is mainly confined to the front teeth, and consists in either an inward or an outward inclination, and, in some instances, both. Sometimes the incisors are turned round in the socket, so that the edge stands at a very considerable angle with the proper position.

The upper teeth are oftener materially disarranged than the lower, though the latter frequently exhibit some irregularity in front, in consequence of a crowded condition. The teeth most liable to be out of position are the cuspidate. These, of the teeth of replacement, are the last in their irruption ; and it often occurs that the arch is previously wellnigh oc-

INTRODUCTION.

cupied; in which case they are thrown outward. When there is any irregularity of the bicuspids, it is that of an inward inclination. The first and second molars are very seldom out of proper position. The third molars, however, for want of room, are sometimes thrown out toward the cheek, or even prevented from coming out at all in any direction.

Effects. — In all cases, irregularity is favorable to decay. It is even maintained by some that the organic structure of irregular teeth is less perfect than that of regular, because the former are impeded in their irruption, and thus impaired. But this, to say the least, is questionable ; for it will be remembered that the crowns of the teeth are formed and completely ossified before they can be affected by a crowded state ; and it is hardly probable that they could be materially modified in their structure after this period. The crowns of the teeth are never deformed by a crowded condition. The principal cause of the liability of irregular teeth to decay, is the facility they furnish for the lodgment of foreign substances about them, and the difficulty they present to its removal. And again, in irregular teeth, parts are approximated that nature did not intend should be brought together. Irregularity impairs the speech, impedes the mastication, and often distorts the countenance and deforms the features.

ATROPHY.

ATROPHY.

This affection is characterized by defective spots in the enamel, white, chalklike— which scarcely ever penetrate the dentine. In these spots there is nothing of that organic structure exhibited by well formed enamel. They are in all cases quite small, but vary greatly in number. They are often found arranged in transverse rows across the tooth affected. The superior incisors are most frequently found with atrophy, though the bicuspids and molars sometimes exhibit it. The front upper teeth are attacked by it only on the anterior surfaces.

Instead of the spots, we sometimes find pits, or indentations, into or through the enamel, which occasionally run together, so as ultimately to form transverse grooves of considerable extent upon the teeth. In many cases, where on the irruption of the teeth the spots only are presented, the organs are not injured, except in appearance, the spots retaining the smooth, enamellike surface during life. In other cases, the spot is of such a soft, friable texture, that it early crumbles out, leaving the little pits above referred to. These indentations, however, sometimes exist at the first appearance of the tooth, but more frequently afterward, being formed by the crumblingaway of the defective portion.

Atrophy usually occurs on teeth of good structure,

INTRODUCTION.

short, thick crowns, and rather yellowish color. The long, thin, white tooth, of imperfect organization and insufficient density, seldom or never presents an atrophied condition.

The Cause. — It may be difficult to point out the precise cause of this affection, but some facts in regard to it are very obvious. There is, in every case, an obstruction in the development of the enamel at the point of defect, and at the time of its origination. In some cases, doubtless, there are a deficient amount and an inferior quality of the material elaborated for the upbuilding of the structure; and this is probably the case when the pits exist at the irruption of the teeth. In other instances, the requisite quantity of material may be elaborated, and yet the vital energy be insufficient to organize it, as in the case of the spots referred to. The latter condition is more frequent than the former, as is evidenced by the more frequent appearance of the spots than of the £>its. We are led to infer, then, that the origin of this affection is for the most part constitutional, and not local. There are commonly found traces of it on all the teeth whose enamel was in process of formation at the time of the interruption.

Any general disturbance, such as to interrupt the assimilative process, would be detrimental to the perfect formation of the tooth. Again, some affections may materially affect the organizing power of the

EXOSTOSIS.

system, without interfering with the assimilative power. Any disease that should interrupt the functions of the digestive apparatus, would be prejudicial to the process of assimilation ; whilst other diseases, such, for instance, as those of a febrile character, would diminish the vital power, and consequently the ability to build up organic structures, without interrupting in any special manner the process of assimilation. These things are referred to here for the purpose of showing under what circumstances atrophy of the teeth may occur.

Effects. — In the best formed teeth, there are no unpleasant results from atrophy, other than its detraction from their beauty. The spots are unsightly, and when the pits are present, they become dark, and sometimes black, from deposit ; which, by ordinary means, is difficult of removal. In teeth of inferior structure, decay often supervenes in these pits, and, extending thence, involves the other parts ; and anything that will affect the tooth-substance, will affect the spots in a greater degree.

EXOSTOSIS.

This term, critically defined, implies outgrowth from a bone; but, as applied to the bones generally, and particularly to the teeth, it probably conveys the idea of growth upon a bom. The affection thus denomi-

INTRODUCTION.

nated is common to all the bones; some, however, being more frequently attacked by it than others. It occurs upon the roots of the teeth, but is never developed where there is no periosteum. The manner of its deposit is not uniform ; but it is commonly in an enlargement on the point of the root, or from the point some distance toward, and occasionally all the way to, the neck of the tooth. In some cases, it extends entirely round the root, and in, others, is confined to one side. It sometimes results in such an enlargement of the root, especially if it is near the point, as to render the tooth very difficult of removal. When it is bulb-form, the entire attachment of the tooth may be broken up, so as to allow this to rotate in the socket, and yet the tooth be very difficult to remove ; indeed, in some instances, impossible, without cutting away a portion of the process.

The density of the deposit is usually greater than that of the root on which it is found ; though in this respect there is considerable variation : in a few instances we have found it softer than the root proper. The surrounding parts are absorbed for its accommodation. The color of the substance is slightly yellow, not differing much from that of the root itself; and frequently it exhibits a semitranslucent appearance. The rate of its formation varies considerably, sometimes increasing so rapidly as to occasion much difficulty, and at other times seeming to advance very

EXOSTOSIS.

slowly; and frequently it is arrested altogether. Roots are often found affected with exostosis, that have been dead and crownless for a number of years, and yet have never, so far as known, given any trouble because of the affection ; and teeth perfectly healthy in other respects may be thus affected.

Its Effects. — It always increases the difficulty of removing the tooth, either by enlargement of the point of the fang, or by deposit upon one side of it, causing it to curve ; in which latter case the difficulty is all the greater, from the impossibility of determining the direction of the curve. It sometimes produces a diseased condition of the surrounding parts — in some instances chronic inflammation — that will continue as long as the tooth remains. Nervous affections often result from exostosis, either through irritation caused by pressure on the nerve, or through the diseased condition of the surrounding parts. The floor of the antrum is sometimes absorbed away, in consequence of the enlargement of the point of the fang; and then disease of the lining membrane of that cavity generally ensues.

The Cause. — The cause of this affection is not well understood. It is most probably deposited by the periosteum when this is in an abnormal condition ; but what peculiar condition, it is not clearly ascertained, though some have supposed it to be inflammation. It is patent, however, that something more than a

INTRODUCTION.

state of simple inflammation exists ; for there is inflammation in numerous instances without this deposit. Again, in all cases where there is periostitis, that state is definitely indicated by percussion upon the affected tooth; indeed, in the occlusion of the jaws, pain is usually experienced. Yet there are found many teeth whose roots are subjects of this deposit, that have never given any indications, either by pain or otherwise, of a diseased condition.

This subject is one in which there is room, at least so far as dentists are concerned, for extensive observation.

DENUDING.

This consists in a wasting-away of the enamel of the anterior teeth, from the points toward the necks. The affection, however, is of too rare occurrence to demand extended consideration. The color of the enamel is not changed by this process, nor is its natural polish impaired by any abrasion. The dentine, on becoming exposed by this removal of its natural protection or covering, is perfectly smooth, but of a yellowish cast, in some cases inclining to brown. When the enamel is removed, there seems to be a cessation of the destructive process ; for the crowns of such teeth will, in many instances, endure

DENUDING.

for a long time— indeed, till they are worn down by the friction in mastication.

This wasting process usually begins at the points of the teeth, and proceeds toward the necks, on all sides, till the enamel is entirely destroyed. Sometimes, however, it commences on their labial surfaces ; this is particularly the case with the superior anterior, but very seldom with the inferior teeth. The affection, however, attacks the inferior more frequently than the superior teeth ; yet it is often found assailing both with about equal energy.

The cause of the disease is not well understood, though it is generally conceded to be the operation of an acid contained in the mucus. Doubtless, the agent producing the affection is contained in the mucus ; for it usually occurs where there is a large relative amount of this secretion ; but that it is an agent of a very decided acid character, we are not prepared to affirm. Decay of the teeth does not seem to progress with greater rapidity while this affection exists, than at other times; and again, the enamel does not present the roughened, abraded appearance we find resulting from the operation of any ordinary agent. With these apparently incongruous facts, it is rather difficult to arrive at a definite conclusion as to the precise manner in which this condition is produced, or the exact character of the agent instrumental in its production.