A manual on extracting teeth

Front matter

ROBERTSON'S

MANUAL ON EXTRACTING TEETH

Lindsay & Blakiston also Publish :

Preface

The operation of extracting teeth being at best a painful cne, and one to which almost every individual of the more than thirty millions of inhabitants of this country, as well as a large share of the remaining one thousand millions of the human race are necessarily subjected, and millions of them many times each ; the interests, the comfort of humanity demand that those who perform the operation should be so instructed as to be able to do it in the most skilful manner. And, strange as it may seem, the author of this is not aware that there is any work, in any language, devoted exclusively to that subject. All, so far as he knows, that has

PREFACE.

been written on the subject, being comprised in a few minor articles in the dental journals, and an occasional chapter in treatises on practical dentistry — works but little likely to fall into the hands of the great mass of those whose duty requires them to perform this operation.

Having for a long time felt the necessity of such a work, by having seen the evil consequences to patients for want of skill on the part of the operator: and having often experienced, in his early career, the anxiety and trepidation of being obliged to perform operations in the principles of which he was not fully instructed, the author, after an experience of many years, has, in this little manual, undertaken to set forth, as clearly as possible, all the principles involved in the operation ; as well as the necessary manipulations required ; founded on the anatomy of the parts concerned ; the proper construction of the appropriate instru-

PREFACE. XI

merits to be used ; and the best means of retrieving the accidents liable to occur in performing the operation.

If in this undertaking it shall prove that he has contributed something toward the relief of the pains and sufferings of humanity, he will congratulate himself with the belief that he has not lived and labored in vain.

Abr. Robertson.

A TREATISE

EXTRACTING TEETH,

Chapter I. Introductory Remarks

The operation of extracting decayed and painful teeth, has been performed, in some manner, from very remote antiquity. At first, and for many ages, for want of the necessary anatomical knowledge, and probably for various other reasons, it was performed with very unsuitable instruments and in the roughest and most barbarous maimer. Justice also compels us to admit that but comparatively slight improvements had been made, either in the instruments used in the operation or in the manner of using them, till after the lapse of the first quarter of the present century, although great advances had been made in the knowledge of anatomy previous to that time. And we are compelled, in honesty and in sorrow, further to say, that very many still, who extract teeth, have made but very little advance on the most primitive instruments or the application of them, although the anatomy of the human system has now been studied, almost to the counting of the hairs and fibres of the whole organization. This may probably be accounted for from the fact that anatomy has not been studied with especial reference to this particular object. But another and a stronger reason is, that in times past, and not very remote, extracting teeth, with bleeding, cupping, and leeching, and, indeed, most other surgical operations, was consigned to the care of barbers, as not worthy the attention of learned physicians. From this degradation it has not yet altogether recovered. But, happily for humanity, it is not now generally considered beneath the dignity of the wisest and the best, to do anything that will relieve suffering mortals from the severest torments " to which flesh is heir."

But, as what has been done badly, or is badly done, has but little to do with what should be done well, or is well done, we will spend no time in describing either those primitive instruments or the primitive manner of using them. The curious can find them described in other volumes.

But, as this operation is more frequently performed than any, or all other surgical operations combined, almost every individual in this country of mature age, having been obliged to submit to it more or less repeatedly, and, as it is usually accompanied with more dread than any other operation of equal importance, and as it is always (unless anaesthetics are used) a painful operation ; and when unskilfully performed, a very painful one, and sometimes even a dangerous one, it is "therefore important that it should always be done in the most careful and skilful manner. What we now propose to do, is to describe and illustrate the instruments best adapted to the perfect accomplishment of the object under consideration, — the entire removal of every tooth and root of a tooth that requires extraction, with the least exertion, with the least amount of force by the operator, with the least possible injury to the surrounding parts, and consequently with the least amount of present pain and after-suffering to the patient, and the most appropriate methods of applying and using such instruments to effect such results.

But, before attempting to use or to apply any instruments for the extraction of the teeth, preliminary knowledge is indispensably requisite ; to wit : a distinct and definite knowledge of the anatomy of the teeth, in at least so far as their external forms and articulations are concerned, and of the jaws, their articulations and appendages. A knowledge, too, of the pathology of the teeth is no less necessary and indispensable rightly to qualify one to perform the duties of this branch of surgery.

A knowledge of anatomy can best be acquired in the dissecting-room ; and perfectly only there. The author would therefore most urgently recommend to every one who intends devoting himself to the alleviation of the pains of his fellow-beings by extracting their teeth, there to seek this knowledge ; for without it, sad mistakes and injuries are liable to be committed wiih the very best of instruments.

This knowledge is necessary, not only to enable one to know when and how to operate, and to guard against the occurrence of accidents and injuries, but if, as is sometimes unavoidably the case in the hands of the most skilful, — an accident does happen, it is still more necessary to enable him to make the best possible amends. For a knowledge of the anatomy of the parts involved, is the foundation of all surgery, and the only thing that enables one knowingly, and therefore the most effectually, to repair such accidents.

Since then a knowledge of the anatomy of the teeth is a sine qua non in even learning to extract them, and as all may not be able to study it in the dissecting-room, we will devote a preliminary chapter to that subject.

Chapter II. Anatomy Of The Jaws And Teeth

Sec. 1. The jaws are two, upper and lower (or superior and inferior). The upper jaw, entire, is composed of the two superior maxillary bones which unite at the medial line of the face. They each consist of what is called a body and four processes — the nasal, malar, alveolar, and palate processes — and give form to the anterior middle portion of the face, and help to form the nose, the orbit, the cheek, and the palate. The body of the bone is of an irregular triangular form. Its interior is hollowed into a large triangular, but in size and form irregular, cavity called the antrum maxillare, or antrum highmorianum ; on the internal surface of which are numerous small grooves, for the lodgment of the superior maxillary nerve and its branches ; and in its floor are sometimes found several conical processes, corresponding to the roots of the molar teeth, which occasionally penetrate this cavity. This bone has four faces or sides ; the external or facial, which is the

2* anterior part of the bone, the interior or nasal, the snperior or orbital, and the posterior or zygomatic.

Fig. 1.

Fig. 1. a, The body of the left superior maxilla ; b, Canine fossa; c, Infra-orbital foramen ; d, Incisive fossa; e, Harmonial suture of the two bones;/, Nasal spine; «-, Semilunar notch of anterior nares ; k, Nasal process ; i, Articulation with lachrymal bone ; j, Malar process ; /:, Tuberosity of superior maxilla; /, Cavity of the antrum ; m, Lachrymal tubercle ; n, Orbital process.

I^ear the centre of the irregular concave facial surface is a deep depression, called the canine fossa, which gives attachment to certain muscles of the mouth and nose, and immediately above this fossa is the infraorbital foramen, which transmits what remains of the superior maxillary nerve, after having supplied branches to all the teeth — a branch to each root — in the upper jaw. There are other fossse or corrugations of this face of the bone, which give attachment to other muscles ; but, as they are not important to our present purpose, we shall not describe them.

The nasal surface forms a portion of the opening of the nose, and articulates with the lachrymal, ethmoid, and palate bones.

The superior or orbital surface is thin and triangular, and forms the floor of the orbit and roof of the antrum maxillare.

The posterior or zygomatic surface is bounded anteriorly by the malar process, and interiorly by a rough rounded border, called the tuberosity, which is pierced by several small foramina, which give passage to the posterior dental nerves and the superior dental artery. The lower part of this tuberosity articulates by a rough rounded surface with the palate bone.

The four processes of this bone, as already named, are the nasal, malar, palate, and alveolar.

The nasal process forms the lateral boundary of the nose, and articulates with the nasal and frontal bones.

The malar process is large and irregular, and is at the angle of separation between the facial and zygomatic surfaces, and articulates, by a large triangular surface, with the malar bone.

The palate process projects horizontally inward

ANATOMY OF THE JAWS AND TEETH.

from the inner surface of the body of the bone. It is thick and strong, and is concave, both above and below, and forms the floor of the nares and a part of the roof of the palate.

The alveolar process forms the lower margin of the bone. Its exterior is dense and firm, its interior cellular. It contains in its whole length, a series of cells or cavities, into which the teeth are articulated, corresponding in number, size, form, and depth, to the number, size, form and length of the roots of the teeth in the jaw.

Fig. 2.

This process is much thicker where it arises from the body of the bone than at its free margins, at the necks of the teeth. Here it is thin ; sometimes very thin and sharp. The septa between the cells, containing the roots of individual teeth, and between the different teeth, are thicker or thinner according

ANATOMY OP THE JAWS AND TEETH. 21

as the roots are divergent or close, or as the teeth are near or far apart.

In the bottom of each of these alveolar cells is a small perforation, or foramen, for the transmission of a nerve and artery to, and returning vein from, the root of a tooth contained in it.

The lower jaw is the largest bone of the face ; and although it consists of two distinct symmetrical halves in the foetus, is but one bone in the adult, united by a ridge at the centre, or that part which forms the chin, which is called the symphysis. It is of a semicircular, or more nearly, of a horseshoe shape ; extends from the chin to the base of the skull, where it articulates with the glenoid fossa? of the temporal bone. It gives form to the lower part of the face. It is divided into a body and rami. The body is the horizontal portion, and on both its external and internal surfaces are various protuberances or processes, and indentations or fossae, which afford attachments to the muscles of the lips and tongue ; but as, in extracting the teeth, we have but little to do with any muscles except those which close the jaws, we shall not stop now to describe them.

About the middle of the bone, and just below the

roots of the canine teeth, are the mental — sometimes

i called the anterior mental — foramina, which afford

exit to the inferior dental nerve and artery, after each, having supplied a branch to each root of a tooth contained in the jaw. The upper edge of the jaw is

Fig. 3.

Fig. 3. Tho inferior maxilla ; a, Body of the bone ; b, Mental foramen ; c, The symphysis; d d, Alveolar processes; e, Ramus of the lower jaw; /, Its angle ; gg, Coronoid processes ; h h, Sigmoid notch ; ii, Condyloid processes ; jj, Neck of the condyles ; k, Inferior dental foramen ; /, Mylohyoid ridge.

surmounted by the alveolar processes and cells, corresponding, like those in the upper jaw, in number, size, form, and depth, to the number, size, form and length of the roots of the teeth which they contain and support. These processes are wanting, mostly, in foetal life and early infancy ; and in old age, or at an earlier period, with the loss of the teeth, are gradually wasted or absorbed away ; coming with the teeth and departing with them.

Fig. 4.

The anterior alveolar processes are thinner and higher than the posterior ; the roots of the wisdom teeth being almost entirely imbedded in the body of the bone, or having at most a very short and thick process ; a circumstance of great practical importance, as- we shall see, when treating of the extraction of the lower wisdom teeth.

The ramus of the jaw is a strong, oblong-shaped process, rising from the posterior portion of each side of the body, forming an angle more or less obtuse, according to the age of the individual ; in foetal and infantile life being very obtuse, or almost horizontal with the body of the bone. In youth, and till mature manhood, it slowly advances toward a perpendicular position, or right angle. After the

Fig. 5.

loss of the teeth, in old age, it is said again to decline. The upper portion of the ramus is divided into two processes, by a broad fissure, called the sigmoid notch. (See Fig. 3.)

These processes are called the coronoid process, and the condyle of the lower jaw. The anterior, or coronoid process, is broad at its base, rather thin, of a triangular shape, and affords attachment to the ternporal muscle. The posterior, or condyle of the jaw, is flattened from before backward, and is smooth on its top to form its hinge-like articulation.

Eear the centre of the internal surface of the ramus is the inferior dental foramen, through which the inferior dental artery and nerve enter the jaw, and are transmitted through the body of the bone below the alveolar cells (each of which, like those in the upper jaw, is perforated by a minute foramen, for the transmission of a branch of each to its contained root of a tooth, and for the egress of the recurrent vein) to the mental foramen, where they pass out to be distributed on the chin. The posterior junction of the ramus with the body of the bone forms a rough tuberosity, called the angle of the jaw.

Sec. 2. The muscles that are chiefly concerned in the extraction of the teeth, and more particularly in the accidents that may sometimes occur in connection with that operation, and therefore require our present attention, are the temporal, the masseter, and the external and internal pterygoid. These are the elevators of the lower jaw, and also give it its forward, backward, and lateral motions.

The upper jaw has no independent motion. It only moves with the motions of the whole head.

ANATOMY OF THE JAWS AND TEETH.

The masseter is a short, thick, quadrilateral-shaped muscle. It arises from the tuberosity of the superior

Fig. 6.

Fig. 6. g, Zygomaticus minor ; h, Zygomaticus major ; i, Masseter muscle ; r, Deep-seated portion of masseter.

maxillary bone, the lower margin of the malar bone, and from the zygoma, and is inserted into the ramus and angle of the lower jaw.

The temporal is a broad, radiating muscle, occupying a large part of the side of the head. It arises from the whole length of the temporal ridge, from the temporal fascia, and from the entire surface of the temporal fossa. Its fibres converge to a narrow,

ANATOMY OF THE JAWS AND TEETH.

but strong tendon, which is inserted into the apex of the coronoid process, and from some distance down its inner surface.

Fig. 7.

Fig. 7. a, Side view of the temporal muscle, exposed by the removal of the temporal fascia ; b, External lateral ligament of the lower jaw ; c, Insertion of temporal muscle into coronoid process of lower jaw.

The internal pterygoid (Fig. 8) is a thick quadrangular muscle. It arises from the pterygoid fossa, and descending obliquely backward, is inserted into the ramus and angle of the lower jaw. From its resemblance to the masseter, in appearance and direction, it has sometimes been called the internal masseter.

28 ANATOMY OP THE JAWS AND TEETH.

The external pterygoid is a short, thick, triangular muscle, being broader at its origin than at its insertion, (a, b, Fig. 8.) It arises from the pterygoid

Fig. 8.

Fig. 8. a and b, Superior and inferior portions of the pterygoideus externus ; e, Pterygoideus internus ; d, Root of zygomatic process ; e, Condj-le.

The ramus is cut away, to show the internal pterygoid muscle.

process, pterygoid plate, and the tuberosity of the palate bone. It passes backward, and is inserted into the neck of the lower jaw and its capsular ligament.

The office of the pterygoid muscles, when acting separately, is to give the lateral, or grinding, motion to the jaw. When acting together, they thrust the jaw forward, and close the mouth.

Sec. 3. Anatomy of the Teeth. — Man, in common with most other animals, is supplied with two complete and distinct sets of teeth, — a temporary and a permanent set.

In mankind, the temporary set, called also deciduous or milk teeth, consists of twenty teeth, ten in each jaw. They are of the sizes, forms and structure suited to the size of the jaws, and to the necessities of infancy and childhood. AVhcn hy the absorption of their roots they are loosened and drop out, or are removed, their places are supplied by another, a larger and a stronger set, suited to the increased size of the jaws and to the wants of mature life.

The temporary set is divided into three classes : incisors, of which there are four in each jaw; canine teeth, or cuspidati, two in each jaw ; and molars, or grinding teeth, four in each jaw.

The roots of the temporary molars are generally broader and thinner, and more divergent, according

30 ANATOMY OP THE JAWS AND TEETH.

to their size, than the corresponding permanent ones ; and as this is the only material difference between them, or any other of the corresponding classes of the two sets, except the much smaller size of the temporary, a particular description of their forms is here unnecessary.

The permanent set consists of thirty-two teeth, sixteen in each jaw. They are divided into four classes, each having very distinct and definite forms ; to wit : four incisors, two canine or cuspidati, four bicuspidati or small molars, and six molars, in each jaw. The incisors, for convenience of description, are, from their positions, subdivided into right and left, central and lateral incisors. The bicuspidati, into first and second, or anterior and posterior, right and left; and the molars, into first, second, and third, right and left molars ; always reckoning from the front backward. The third molars are also called dentes sapientiae or wisdom teeth, from their coming later in life. They vary greatly in the time of their coming ; sometimes appearing as early as sixteen years of age, and sometimes not before thirty-five.

The length, width and thickness of all the teeth, and the curvatures of the crowns of the incisors, vary materially in different individuals, according to the configurations of the persons to whom they belong. Thus, tall, slender persons, usually have comparatively long and narrow teeth, while short, thick-set persons have shorter, broader, and thicker teeth. Short thick-set persons too, usually have thicker bones and alveolar processes than those with more slender forms. Their teeth are generally more fimly set, and therefore, require more force to effect their removal.

The color of the teeth varies too, in different individuals, from an almost pearly white, to a deep tinge of yellow, brown, or blue, closely corresponding with the complexion of the individual. Their color also varies with the age of the individual, from light in youth, to dark in age.

Their density, strength and durability are also quite variable, cachectic and lymphatic persons mostly having thin, soft, frail teeth, while the robust and healthy have thicker, denser, stronger, and more durable ones. Their density varies, too, with the age of the person, being much more solid in age than in youth.

Each tooth, for convenience of description, is divided into three parts : the crown, the neck, and the root or roots. The crowui extends from the edge of the cutting, or the grinding surface, as the case may be, to the gum ; Or is that part which is exposed to view, and is covered by the enamel.

The neck is the slightly constricted portion next

ANATOMY OF THE JAWS AND TEETH.

to the crown, and extends, when the parts are in a normal condition, from the edge of the gum to the edge of the alveolus, or perhaps more strictly, from the crown to the bifurcation in the molar teeth.

The root, is that part of the tooth contained within the alveolar cell or socket, and articulates it with the jaw.

Although the crowns of the same class of teeth vary very much in form and size, in different individuals, a general outline of the description of any tooth belonging to a given class will be the same.

The superior central incisors occupy the anterior central portion of the upper jaw ; one on each side of the mesial line of the face. Their crowns are of an oblong, quadrilateral form, averaging about five

Fig. 9.

lines in length by four in width ; and usually a little wider at their free, or cutting edges', than at the gum, or necks of the teeth. Their cutting edges are nearly straight across, though their corners, and especially their outer ones, • are sometimes slightly rounded. Their anterior, or labial surfaces, are always more or less convex, while their inner or posterior surfaces are correspondingly concave ; the interior surface forming the segment of a smaller circle than the outer.

The tooth is much thicker at the gum than at its edge, and presents an appearance as if it had been formed into a wedge, by cutting away the inner surface of the tooth, and then slightly bending it inward, with a regular curve from the neck to the edge. The roots of these teeth average about seven lines in length, and about three lines in diameter. They are irregularly conical in shape, tapering, somewhat unevenly, to their points ; and the outer portion forming the segment of a rather larger circle than the inner.

The lateral incisors are next in order to the centrals. Their crowns are usually a little shorter than those of the centrals, in the same mouth, and about three-fourths their width. Their corners are more rounded than those of the centrals, and especially their outer corners, which are generally considerably so. Their roots, though slightly shorter, are very nearly of the same length as the others, but are generally considerably more flattened, or compressed, lat_ erally, than they. The outer portion, like the centrals, is larger than the inner.

ANATOMY OF THE JAWS AND TEETH.

Next to the lateral incisors arfc the cuspidati or canine teeth ; one on each side. The crowns of these are abont the same length and width as the central incisors ; bnt they are thicker at their necks, from their outer to their inner surfaces, and stronger than the incisors, and instead of being like them broad and straight across their edges, they are tapered for abont half their length to a blunt spearlike-shaped point. They are also more convex on their labial surfaces, and but slightly, if at all, concave on their internal or lingual surfaces. From their greater thickness they stand a little more prominent than the other teeth, forming approximations to corners in the dental arch. Their roots are both larger and longer than those of any of the other teeth, being most commonly a line or more longer than those of the central incisors. Their roots are also shaped differently from those of any of the other teeth, for they are not only larger at their neck, but they taper to more slender points. They are, though sometimes almost perfectly round, usually about once and a half as large in their antero-posterior diameter as in their approximal, with the appearance of having been compressed or flattened like the roots of the upper lateral and all the lower incisors. A transverse section of the root presents an ovoid form, though the outer or larger portion of the root would generally be a little larger, and the smaller or inner portion a little smaller in proportion, than a longitudinal section of an egg. The roots of these teeth are more frequently curved, in part, or all of their length, and more subject to have short crooks in them, and are generally more closely and firmly articulated with the alveolus, and therefore require more force for their removal, than any other of the single-rooted teeth.

All the incisors and cuspidati of both jaws, the second or posterior bicuspidati of the upper jaw, and all of the bicuspidati in the lower jaw, have each uniformly but one root.*

The upper bicuspidati come next in order.

Their crowns are a little shorter than the preced-

* Since writing the above, Dr. Kandall, of Farmington, President of the Maine Dental Society, has shown me a pair of upper bicuspidati, extracted by him, having two well-defined roots each, — the bifurcation extending to their necks.

ANATOMY OF THE JAWS AND TEETH.

ing, and are very nearly an ovoid shape, but somewhat compressed on their approximal sides, — the larger end representing the grinding surface of the tooth, which is furrowed in the direction of the arch of the teeth by a broad triangular groove, thus leaving two — an outer and an inner — rather blunt tubercles or cusps, and the smaller end of the egg truncated to represent its union with the neck of the tooth.

The first or anterior bicuspidatus on each side, most commonly, but not uniformly, has two roots,

Bill an external and an internal. They are small and round ; sometimes regularly and increasingly divergent from their bifurcation to their points. Sometimes they are considerably divergent for a half or

ANATOMY OF THE JAWS AND TEETH.

two-thirds of their length, and then convergent till their points nearly, or even quite, come in contact with each other. Sometimes they take a course quite close and parallel to each other, as if they had been originally hut one flattened root, simply split in two. At other times they are found having but one root, very much flattened on its approximal sides, and grooved so as to show the rudiments of two roots.

The second or posterior bicuspidati, as already remarked, have uniformly but one root each, which is always compressed or flattened and grooved on its approximal sides. Their crowns are entirely similar to those of the anterior. The roots of all the bicuspidati are of about the same length as are those of the incisors.

The upper molar teeth, three on each side, are the last in the order, and the largest of them all. Of these, the first or anterior is a little the largest, and the third or wisdom tooth is considerably the smallest.

The crowns of these teeth are nearly cubical in shape, with their corners all rounded. In size each of their surfaces or faces is about equal to or a little larger than the face of the central incisor belonging to the same set. Their grinding surfaces are of course broad, and they are furrowed or cut by several triangular grooves leaving at least four or more tubercles or cusps.

They have ordinarily each three roots. Two external or buccal, and one internal or palatal. The external roots are an anterior and a posterior. Of these two, the anterior is larger than the posterior, being indeed about twice its size ; it is broad and flat, being compressed from before backward, and stands out more prominently in the arch than its fellow. The two stand nearly perpendicular to the outside of the crown, but usually diverge more or less from each other. The internal root is generally the longest of the three. Its size is about the same as that of the anterior external root, but instead of being flattened like that, it is round or nearly so. It generally diverges considerably from the perpendicular of the crown toward the palate, but after diverging for about two-thirds of its length, the remaining portion most commonly converges toward the points of the other roots. Sometimes, and indeed not unfrequently, this and one of the other roots are united